Stephen Butler

Adverse childhood experiences influence development of pain during pregnancy

To investigate the association between adverse childhood experiences (ACE) and pain with onset during pregnancy.

Referred pain patterns provoked on intra-pelvic structures among women with and without chronic pelvic pain : a descriptive study

Objectives To describe referred pain patterns provoked from intra-pelvic structures in women with chronic pelvic pain (CPP) persisting after childbirth with the purpose to improve diagnostics and give implications for treatment. Materials and Methods In this descriptive and comparative study 36 parous women with CPP were recruited from a physiotherapy department waiting list and by advertisements in newspapers. A control group of 29 parous women without CPP was consecutively assessed for eligibility from a midwifery surgery. Inclusion criterion for CPP was: moderate pain in the sacral region persisting at least six months after childbirth confirmed by pelvic pain provocation tests. Exclusion criteria in groups with and without CPP were: persistent back or pelvic pain with onset prior to pregnancy, previous back surgery and positive neurological signs. Pain was provoked by palpation of 13 predetermined intra-pelvic anatomical landmarks. The referred pain distribution was expressed in pain drawings and described in pain maps and calculated referred pain areas. Results Pain provoked by palpation of the posterior intra-pelvic landmarks was mostly referred to the sacral region and pain provoked by palpation of the ischial and pubic bones was mostly referred to the groin and pubic regions, with or without pain referred down the ipsilateral leg. The average pain distribution area provoked by palpation of all 13 anatomical landmarks was 30.3 mm² (19.2 to 53.7) in women with CPP as compared to 3.2 mm² (1.0 to 5.1) in women without CPP, p< 0.0001. Conclusions Referred pain patterns provoked from intra-pelvic landmarks in women with CPP are consistent with sclerotomal sensory innervation. Magnification of referred pain patterns indicates allodynia and central sensitization. The results suggest that pain mapping can be used to evaluate and confirm the pain experience among women with CPP and contribute to diagnosis.

Neglect-like signs and symptoms in CRPS.

Belgium,and Switzerlandin emergency,paediatric,and post-surgery settings (validation is still underway in different environments). By publishing EVENDOL in PAIN, our aim was not only to provide information on French research on pain assessment in young children, including the psychometric validation criteria used for the instrument, it was also to make more widely available an instrument that appears relevant and useful in day-to-day practice. The long, thorough translation procedure used only bilingual and bicultural caregivers, most of whom were working in the area of pain among children. Wordings were changed a number of times in the course of numerous discussions. The back-translation enabled adjustment of certain problematic phrasings. EVENDOL nevertheless proved fairly easy to translate, because it is a clinical measure intended for use by health care professionals, so that aspects of wording acceptability and comprehensibility that are crucial in subjective questionnaires (as advocated in the Sousa guidelines) [3] are less so here. EVENDOL wordings are merely descriptive of easily detectable behaviours, avoiding any medical jargon. We contend that the thoroughness of the discussion process and the variety of expert opinions sought—not adequately set out in our article—contribute to an English-language version that is conceptually and functionally very close to the original. A back-translation was one stage in the procedure, but we consider that the decisive task upstream of this is to select appropriate wordings reflecting the actual content, which was our main focus [4]. Post-translation, validation should ideally assess the ability of the measure to distinguish levels of pain when used by caregivers in either language on a single sample of patients from the 2 countries, for example, using videos scored by caregivers from the 2 settings. To our knowledge, this has not previously been done. In some rare instances, researchers have repeated the validation studies in different countries [5]. This secondary validation, in our opinion, may be superfluous here, as manifestations of pain by young children are probably similar across cultures. Likewise, although parents and caregivers may differ culturally, it seems unlikely that this will influence the scoring of simple behavioural descriptors. When we choose to translate an instrument, it assumes that the target culture shares a ‘‘sufficient’’ number of values, representations, and behavioural manifestations to be considered ‘‘close’’. This approximation appears more readily acceptable for an instrument targeting manifestations of pain in young children, which, unlike subjective measures, should not be markedly influenced by culture. In conclusion, we contend that what underpins the validity of a translated measure is the quality of the translation and the transcultural stability of the concept measured. We consider that EVENDOL, an objective measure of behavioural signs, meets these 2 requirements. The French and English-language versions of the instrument are freely available for use in clinical settings, if the above is deemed convincing, or for validation procedures if greater assurance is desired. But maybe that would be using belt and braces?

Important new insight in pain and pain treatment induced changes in functional connectivity between the Pain Matrix and the Salience, Central Executive, and Sensorimotor networks

Important new insight in pain and pain treatment induced changes in functional connectivity between the Pain Matrix and the Salience, Central Executive, and Sensorimotor networks

Identifying characteristics of the most severely impaired chronic pain patients treated at a specialized inpatient pain clinic

Abstract Background and aims Patients suffering from chronic nonmalignant pain constitute a heterogeneous population in terms of clinical presentation and treatment results. Few data are available about what distinguishes different groups in this huge population of patients with chronic persistent pain (CPP). A subgroup that is poorly studied, consists of the most severely impaired chronic pain patients. At the Uppsala University Hospital Pain Clinic, there is a specialized department accepting the most complex patients for rehabilitation. In the endeavour to improve and evaluate treatment for this subgroup, a better understanding of the complex nature of the illness is essential. This prospective study aimed to describe the characteristics of this subgroup of patients with CPP. Methods Seventy-two consecutive patients enrolled in the Uppsala programme were evaluated. We collected data on demographics, type of pain and experienced symptoms other than pain using a checklist of 41 possible symptoms. Psychiatric comorbidity was assessed by a psychiatrist using a structured clinical interview. Quality of life (QoL), pain rating and medication/drug/alcohol usage were measured by validated questionnaires: SF-36, NRS, DUDIT and AUDIT. Concerning physical functioning and sick leave, a comparison was made with data from the Swedish Quality Register Registry for pain rehabilitation (SQRP). Results The cohort consisted of 61% women and the average age was 45 (range 20-70) years. For this cohort, 74% reported being on sick leave or disability-pension. In the SQRP 59% were on sick leave at the time they entered the rehabilitation programmes [1]. On average, the study-population reported 22 symptoms other than pain, to be at a high rate of severity. Patients treated in conventional pain-rehabilitation programmes reported a mean of 10 symptoms in average. Symptoms reported with the highest frequency (>80%), were lethargy, tiredness, headache and difficulties concentrating. Seventy- six percent were diagnosed with a psychiatric disorder. Sixty-nine fulfilled the criteria for depression or depression/anxiety disorder despite that most (65%) were treated with psychotropic medication. Alcohol/drug abuse was minimal. Seventy-one percent were on opioids but the doses were moderate (<100 mg) MEq. The pain rating was ≥7 (out of a maximum of 10) for 60% of the patients. Conclusion This study describes what makes the subgroup of pain patients most affected by their pain special according to associated factors and comorbidity We found that they were distinguished by a high degree of psychiatric comorbidity, low physical functioning and extreme levels of symptom preoccupation/hypervigilance. Many severe symptoms additional to pain (e.g. depression/anxiety, tiredness, disturbed sleep, lack of concentration, constipation) were reported. The group seems hypervigilant, overwhelmed with a multitude of different symptoms on a high severity level. Implications When treating this complex group, the expressions of the illness can act as obstacles to achieve successful treatment outcomes. The study provides evidence based information, for a better understanding of the needs concerning these pain patients. Our result indicates that parallel assessment and treatment of psychiatric comorbidities and sleep disorders combined with traditional rehabilitation, i.e. physical activation and cognitive reorganization are imperative for improved outcomes.

Qualitative research in complex regional pain syndrome (CRPS)

To answer the first question, qualitative research (QualR) in edicine has a long track record although somewhat shorter in the rea of pain. A search in PubMed using the search words “qualitaive” “research” “pain” gives 3479 hits. A quick review of the first 40 rticles shows that over half actually are on clinical pain syndromes nd the process goes back several years. The structure and practice f QualR are both well established and comprehensive texts on this ave been published as the authors point out [2]. Although often considered “not scientific” by those doing quanitative research, many in quantitative research in pain use methods erived from QualR. As the authors of this paper also point out, onald Melzack began developing the McGill pain questionnaire MPQ) by talking to a patient with phantom limb pain on sevral occasions, fascinated by her descriptions of the pain [3]. The escription by Melzack of the process makes interesting reading. is background as a part time author of lay literature perhaps was ehind this interest in words but Melzack used a quasi-QualR techique and the MPQ that resulted now is routinely used in clinical ain research.

Back pain is complicated

The article by Baron et al., in this issue [1], presents a complicated approach for evaluating the effects of pregabalin in a difficult patient population – low back pain with radiculopathy where the radiculopathy symptoms are the focus. From the title, one would assume that this would be a simple study with a double blind, placebo-controlled dosing of pregabalin evaluating pain reports in some form as the primary outcome. Such is not the case and we must search for the direction of this interesting journey since no hypothesis is proposed. The primary outcome of the study found in the abstract and part 2.1 of the ”Materials and methods” states ‘‘The primary efficacy measure was the time to loss of therapeutic response or discontinuation from the study”. The course in getting there is not easy. At first glance, the design seems to be an exercise to establish a patient population where pregabalin cannot fail – take a neuropathic pain problem, exclude the placebo responders, then include only those who respond to a trial of pregabalin and use them in a head to head contest with placebo. What could be simpler? If that were truely the case, I do not think that this article would have been published in Pain. The complicated protocol is meant instead to be a real test of the efficacy of pregabalin. Pregabalin is compared with placebo in a double blind protocol where observations of decreasing effects of drug withdrawal on pain are more important as an endpoint than just pain relief. I think the intent was to see if the supposed positive effect on pain relief could be supported also by a comparison with the inevitable placebo responders during this withdrawal phase. What is somewhat surprising is that pregabalin failed to show superiority to placebo in the primary outcome and also in the majority of the secondary measures excluding effects on sleep, anxiety and depression. It was a brave act to submit this paper when many think of pregabalin as the gold standard for the treatment of neuropathic pain. Can we account for the failure in a design that at the outset looks fail proof in showing superiority for pregabalin over placebo? The authors discuss this at length and I would like to expand on just a few of their points. The choice of radiculopathy in low back pain patients presents a real challenge. The possible causes of radiating pain in this population are several, not just radiculopathy. There is evidence from both animal and human experiments that pain radiating as far as the toes can come from intervertebral disks, zygopophyseal joints, muscles, and fascia [4– 6] as well as from a radiculopathy. The cause for the radiating pain might not have been neuropathic since there was neither neuroimaging nor neurophysiological tests (except at the bedside) to establish the diagnosis. Also, as is often the case in low back pain, there was possibly more than one cause of radiating pain and the effect of pregabalin on a neuropathic component was overshadowed by the other non-responsive pains. However, we

Catastrophizing, Solicitous Responses From Significant Others, and Function in Individuals With Neuropathic Pain, Osteoarthritis, or Spinal Pain in the General Population

That certain psychological factors are negatively associated with function in patients with chronic pain is well established. However, few studies have evaluated these factors in individuals with chronic pain from the general population. The aims of this study were to: 1) evaluate the unique associations between catastrophizing and perceived solicitous responses and psychological function, physical function, and insomnia severity in individuals with neuropathic pain, osteoarthritis, or spinal pain in the general population; and 2) determine if diagnosis moderates the associations found. Five hundred fifty-one individuals from the general population underwent examinations with a physician and physiotherapist, and a total of 334 individuals were diagnosed with either neuropathic pain (nu2009=u200934), osteoarthritis (nu2009=u200978), or spinal pain (nu2009=u2009222). Results showed that catastrophizing was significantly associated with reduced psychological and physical function, explaining 24% and 2% of the variance respectively, whereas catastrophizing as well as perceived solicitous responding were significantly and uniquely associated with insomnia severity, explaining 8% of the variance. Perceived solicitous responding was significantly negatively associated with insomnia severity. Moderator analyses indicated that: 1) the association between catastrophizing and psychological function was greater among individuals with spinal pain and neuropathic pain than those with osteoarthritis, and 2) the association between catastrophizing and insomnia was greater among individuals with spinal pain and osteoarthritis than those with neuropathic pain. No statistically significant interactions including perceived solicitous responses were found. The findings support earlier findings of an association between catastrophizing and function among individuals with chronic pain in the general population, and suggest that diagnosis may serve a moderating role in some of these associations.nnnPERSPECTIVEnWhen examining persons with pain in the general population, catastrophizing is associated with several aspects of function, and diagnosis serves as a moderator for these associations. The replication of these associations in the general population support their reliability and generalizability.

Anatomical landmarks of the intra-pelvic side-wall as sources of pain in women with and without pregnancy-related chronic pelvic pain after childbirth: a descriptive study

BackgroundChronic pelvic pain (CPP) affects 15–24% of women and can have a devastating impact on quality of life. Laparoscopy is often used in the investigation, although in one third of the examinations there is no visible pathology and the women may be dismissed without further investigation. Also, the contribution of skeletal, muscular, periosteal and ligamentous tissues to CPP remains to be further elucidated. The objective of the present study was to compare pain intensity provoked from anatomical landmarks of the intra-pelvic side-wall in women with pregnancy-related CPP after childbirth and women without such pain.MethodsThis is a descriptive study of 36 non-randomly selected parous women with CPP after childbirth and 29 likewise selected parous women after childbirth without CPP. Pain was determined by questionnaire and clinical examination. The primary outcome measure was reported pain intensity provoked on 13 anatomical landmarks of the intra-pelvic side-wall. All women reported their perceived pain intensity for each anatomical landmark on Likert scales and an individual sum score was calculated.ResultsWomen with chronic pelvic pain were older than women without CPP. At several intra-pelvic landmarks high intensity pain was provoked in women with CPP compared with less intense pain provoked at fewer landmarks in women without low back or pelvic pain (pu2009<u20090.0001). The average sum of pain intensity scores was about 4 times higher in women with CPP (1.3) as compared with those without low back or pelvic pain (0.3), pu2009<u20090.0001. This association remained when adjusting for the age difference between the pain groups in linear regression analysis. In addition, reported pain intensity at worst past week was independently associated with sum of pain intensity scores. The maximum individual sum of pain intensity scores among women without CPP was exceeded by that of 85% of the women with CPP.ConclusionsParous women with CPP after childbirth had a heightened pain intensity over 13 anatomical landmarks during pelvic examination compared with parous women without CPP. These results need to be confirmed in a larger cohort with different types of CPP.

The triumvirate of co-morbid chronic pain, depression, and cognitive impairment: Attacking this “chicken-and-egg” in novel ways

The triumvirate of co-morbid chronic pain, depression, and cognitive impairment : Attacking this chicken-and-egg in novel ways