The journal of pain : official journal of the American Pain Society
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Randomized Controlled Trial Multicenter Study
Physician characteristics and variation in treatment outcomes: are better qualified and experienced physicians more successful in treating patients with chronic pain with acupuncture?
The aim of this paper was to quantify the influence of the physician's training and experience in the field of acupuncture on the outcome in patients with chronic pain. Patients visiting their physician because of chronic low back pain, headache, pain due to osteoarthritis of the knee or hip, or neck pain, were included in 4 multicenter, randomized, controlled studies. All patients received routine care; patients in the acupuncture groups received additional acupuncture treatment (on average 10 sessions). The data was pooled, and the 3-month change from baseline of the SF-36 bodily pain subscale as the main outcome defined. A total of 9,990 patients (mean age 49.6 +/- 13.6 years, 68% female) treated by 2,781 physicians (mean age 46.3 +/- 7 years, 37% female) were analyzed. The physicians had 7.3 +/- 5.2 (mean +/- sd) years of experience in acupuncture and their mean duration of formal acupuncture training had been 287 +/- 321 hours. The outcome was markedly improved in the acupuncture group. We identified only 1 physician characteristic with a significant influence on the outcome: Internists performed better (odds ratio OR = 1.49, confidence interval CI: 1.01;2.18; P = .043); orthopedists worse (OR = .79, CI: .62;1; P = .043) than the average physician. Neither the duration of training nor the duration of experience had any impact on the extent of the acupuncture effect. ⋯ In this analysis, physician characteristics such as training did not influence patients' outcome after acupuncture, suggesting that formal training parameters have only a limited influence on treatment effect. Other skills such as the therapeutic relationship, which are difficult to measure, may probably play a more important role and should be taken into consideration.
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While sex differences in pain-related coping have been widely reported, little is known on sex differences in changes in coping following multimodal pain treatment and how these changes relate to treatment outcome. The present prospective study therefore aimed to investigate sex differences in coping strategies between boys and girls with chronic pain prior to multimodal inpatient treatment and at 3-month follow-up. Sixty-four boys and 103 girls with various pain disorders were evaluated. Core outcomes (pain intensity and pain-related disability) and coping were assessed via validated questionnaires. At admission, boys and girls used similar coping strategies. Three months following treatment, boys and girls decreased passive pain coping and seeking social support while they maintained the degree of positive self-instruction. Girls displayed higher seeking social support than boys and of importance, only for girls, a reduction in seeking social support was related to decreases in pain intensity. In both groups, the changes in coping were related to positive treatment outcome. Results suggest that both groups may benefit from reductions in passive pain coping and seeking social support. The causal quality of this relationship remains to be determined in future studies. Gender-role expectations and family interactions may account for the sex differences demonstrated for seeking social support. ⋯ Boys and girls with chronic pain show profound similarities in pain-related coping strategies prior and after multimodal pain treatment. The changes in coping are related to positive treatment outcomes. Sex-specific treatment strategies for changing seeking social support may need to be developed and tested for their differential efficacy in boys and girls.
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Fatiguing exercise can affect muscle pain sensitivity and muscle hardness, as seen with work-related neck and shoulder pain. Objective methods to assess muscle pain sensitivity are important because the reliability of manual assessment is generally poor. The aim of this study was (1) to compare coexistence of tender points identified by manual palpation and pressure algometry or hardness assessments and (2) to examine the influence of exercise on muscle pain sensitivity and hardness. Fourteen sites in the upper trapezius muscle were selected for assessments in 12 healthy subjects. Pressure pain thresholds and muscle hardness were examined by computer-controlled pressure algometry at baseline, immediately after static or dynamic exercise, and 20 minutes after static or dynamic exercise. Before recording of pressure pain thresholds, the trapezius muscle was examined for tender points by manual palpation. Two sites with low pressure pain thresholds were typical locations for tender points, and these were the least hard sites. However, manually detected tender points were often (29%) not colocalized with most sensitive sites according to the pressure algometry. A heterogeneous distribution of pressure pain sensitivity and muscle hardness was found in the upper trapezius. The short duration of exercise until exhaustion did not change muscle sensitivity or muscle hardness in asymptomatic muscles. ⋯ This study confirms clinical findings with heterogeniosity in pain sensitivity and hardness across the upper trapezius muscle. Developments of new techniques that objectively can identify tender points are important, but thus far, manual palpation is best clinical practice.
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Randomized Controlled Trial
Effects of anodal transcranial direct current stimulation on chronic neuropathic pain in patients with multiple sclerosis.
Neuropathic pain in patients with MS is frequent and is associated with a great interference with daily life activities. In the present study, we investigated whether anodal transcranial direct current stimulation (tDCS) may be effective in reducing central chronic pain in MS patients. Patients received sham tDCS or real tDCS in a 5-day period of treatment in a randomized, double blind, sham-controlled study. Pain was measured using visual analog scale (VAS) for pain and the short form McGill questionnaire (SF-MPQ). Quality of life was measured using the Multiple Sclerosis Quality of Life-54 scale (MSQoL-54). Depressive symptoms and anxiety were also evaluated as confounding factors using the Beck Depression Inventory (BDI) and VAS for anxiety. Evaluations were performed at baseline, immediately after the end of treatment, and once a week during a 3-week follow-up period. Following anodal but not sham tDCS over the motor cortex, there was a significant pain improvement as assessed by VAS for pain and McGill questionnaire, and of overall quality of life. No depression or anxiety changes were observed. Our results show that anodal tDCS is able to reduce pain-scale scores in MS patients with central chronic pain and that this effect outlasts the period of stimulation, leading to long-lasting clinical effects. ⋯ This article presents a new, noninvasive therapeutic approach to chronic, central neuropathic pain in multiple sclerosis, poorly responsive to current conventional medications. tDCS is known to cause long-lasting changes of neuronal excitability at the site of stimulation and in the connected areas in healthy subjects. This led us to hypothesize that pain decrease may be the result of functional plastic changes in brain structures involved in the pathogenesis of chronic neuropathic pain.