The journal of pain : official journal of the American Pain Society
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Observational Study
The influence of chronic pain on post-operative pain and function after hip surgery: a prospective observational cohort study.
Pre-existing or chronic pain is an established risk factor for severe postoperative pain. In this prospective observational cohort study, we investigated whether a history of chronic pain, beyond the presence of hip-related pain, affected other postoperative factors including early mobilization, function, and psychological distress after hip surgery. Patients who underwent total hip replacement surgery were observed from the preoperative day until the seventh postoperative day. Before surgery, they were characterized by their pain history, pain intensity, function, and psychological characteristics. Postoperatively, pain intensity was evaluated on day 1, 3, 5, and 7 and the analgesic consumption was recorded for each of these days. Measures of function (functional questionnaire, ability to mobilize and to climb stairs, and range of hip motion) and psychological distress were re-evaluated on day 7. A history of chronic pain was associated with slower postoperative mobilization, poorer physical function, and greater psychological distress in addition to increased postoperative pain intensity. The comorbidity of a chronic pain disorder resulted in greater pain intensity after surgery, and also impeded postoperative rehabilitation. Identification of patients with a chronic pain disorder is necessary preoperatively so that appropriate pain management and rehabilitation can be planned to facilitate recovery. ⋯ Chronic pain, beyond the presence of hip-related pain, is associated with slower postoperative mobilization, poorer physical function, and greater psychological distress after total hip replacement surgery. Identification of patients with chronic pain and establishment of multiprofessional perioperative management might improve postoperative rehabilitation of patients with chronic pain.
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Most patients who undergo surgical procedures experience acute postoperative pain, but evidence suggests that less than half report adequate postoperative pain relief. Many preoperative, intraoperative, and postoperative interventions and management strategies are available for reducing and managing postoperative pain. The American Pain Society, with input from the American Society of Anesthesiologists, commissioned an interdisciplinary expert panel to develop a clinical practice guideline to promote evidence-based, effective, and safer postoperative pain management in children and adults. The guideline was subsequently approved by the American Society for Regional Anesthesia. As part of the guideline development process, a systematic review was commissioned on various aspects related to various interventions and management strategies for postoperative pain. After a review of the evidence, the expert panel formulated recommendations that addressed various aspects of postoperative pain management, including preoperative education, perioperative pain management planning, use of different pharmacological and nonpharmacological modalities, organizational policies, and transition to outpatient care. The recommendations are based on the underlying premise that optimal management begins in the preoperative period with an assessment of the patient and development of a plan of care tailored to the individual and the surgical procedure involved. The panel found that evidence supports the use of multimodal regimens in many situations, although the exact components of effective multimodal care will vary depending on the patient, setting, and surgical procedure. Although these guidelines are based on a systematic review of the evidence on management of postoperative pain, the panel identified numerous research gaps. Of 32 recommendations, 4 were assessed as being supported by high-quality evidence, and 11 (in the areas of patient education and perioperative planning, patient assessment, organizational structures and policies, and transitioning to outpatient care) were made on the basis of low-quality evidence. ⋯ This guideline, on the basis of a systematic review of the evidence on postoperative pain management, provides recommendations developed by a multidisciplinary expert panel. Safe and effective postoperative pain management should be on the basis of a plan of care tailored to the individual and the surgical procedure involved, and multimodal regimens are recommended in many situations.
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The Brief Pain Inventory (BPI) has been psychometrically evaluated worldwide in adult patients with cancer-related and chronic pain in several languages, but never in nursing home residents with chronic pain. To address this gap, we evaluated the validity of a modified version of the BPI, the BPI for nursing home residents (BPI-NHR) in individuals who resided in German nursing homes. One analytic sample included 137 nursing home residents (mean age, 83.3 years; SD, 8.0 years) without any missing values. An extended sample also included individuals with previous missing values that were substituted with the personal mean (n = 163; mean age, 83.3 years; SD, 8.3 years). Principal axis factoring with oblimin rotation was used to compute the final 2-factor solution for the substituted sample. These factors explained 71.7% of the variance. Internal consistency was calculated using Cronbach α, and showed excellent results. Concurrent validity was tested using nonparametric correlation analyses of the BPI-NHR with the pain medication scale. The present findings support the reliability and validity of the BPI-NHR for very old nursing home residents. Further evaluation of this measure is needed to examine face validity and the effect of multimorbidity on pain interference with function. ⋯ In this article we present psychometric properties of the BPI originally developed to assess cancer pain, extended to measure chronic nonmalignant pain in younger and middle-aged patients, and now further developed to measure pain intensity and interference with function among very old nursing home residents. Thus, the BPI-NHR might assist clinicians and researchers interested in assessment of pain intensity and interference in elderly individuals who reside in nursing homes.
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Health care providers use treatments whose effectiveness derives partially or completely from 'nonspecific' factors, frequently referred to as placebo effects. Although the ethics of interventional placebo use continues to be debated, evidence suggests that placebos can produce clinically meaningful analgesic effects. Burgeoning evidence suggest that patients with chronic pain might be open to placebo treatments in certain contexts despite limited knowledge of their well-established psychoneurobiological underpinnings. In this investigation we sought to examine the effects of a brief, mechanism-based placebo analgesia educational intervention on aspects placebo knowledge and acceptability. Participants with chronic musculoskeletal pain completed a web-based survey in which they rated their knowledge of placebo analgesia, assessed placebo acceptability across different medical contexts, and evaluated 6 unique patient-provider treatment scenarios to assess the role of treatment effectiveness and deception on patient-provider attributions. Using a pre-post design, participants were randomized to receive either a placebo educational intervention or an active control education. Results showed that the educational intervention greatly improved perceptions of placebo knowledge, effectiveness, and acceptability, even in deceptive treatment contexts. This was the first study of its kind to show the value of an educational intervention in increasing openness to and knowledge of placebo analgesic interventions among patients with chronic musculoskeletal pain. ⋯ In this we article highlight how patients with chronic pain might be open to placebo interventions, particularly adjunct and/or complementary treatments, when provided education on the neurobiological and psychological mechanisms that underlie placebo effects. Study findings highlight ethically acceptable ways to potentially use placebo factors to enhance existing pain treatments and improve patient health outcomes.
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Review Meta Analysis
The efficacy of movement representation techniques for treating limb pain - a systematic review and metaanalysis.
Relatively new evidence suggests that movement representation techniques (ie, therapies that use the observation and/or imagination of normal pain-free movements, such as mirror therapy, motor imagery, or movement and/or action observation) might be effective in reduction of some types of limb pain. To summarize the evidence regarding the efficacy of those techniques, a systematic review with meta-analysis was performed. We searched Cochrane Central Register of Controlled Trials, MEDLINE, EMBASE, CINAHL, AMED, PsychINFO, Physiotherapy Evidence Database, and OT-seeker up to August 2014 and hand-searched further relevant resources for randomized controlled trials that studied the efficacy of movement representation techniques in reduction of limb pain. The outcomes of interest were pain, disability, and quality of life. Study selection and data extraction were performed by 2 reviewers independently. We included 15 trials on the effects of mirror therapy, (graded) motor imagery, and action observation in patients with complex regional pain syndrome, phantom limb pain, poststroke pain, and nonpathological (acute) pain. Overall, movement representation techniques were found to be effective in reduction of pain (standardized mean difference [SMD] = -.82, 95% confidence interval [CI], -1.32 to -.31, P = .001) and disability (SMD = .72, 95% CI, .22-1.22, P = .004) and showed a positive but nonsignificant effect on quality of life (SMD = 2.61, 85% CI, -3.32 to 8.54, P = .39). Especially mirror therapy and graded motor imagery should be considered for the treatment of patients with complex regional pain syndrome. Furthermore, the results indicate that motor imagery could be considered as a potential effective treatment in patients with acute pain after trauma and surgery. To date, there is no evidence for a pain reducing effect of movement representation techniques in patients with phantom limb pain and poststroke pain other than complex regional pain syndrome. ⋯ In this systematic review we synthesize the evidence for the efficacy of movement representation techniques (ie, motor imagery, mirror therapy, or action observation) for treatment of limb pain. Our findings suggest effective pain reduction in some types of limb pain. Further research should address specific questions on the optimal type and dose of therapy.