Articles: chronic-pain.
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According to the fear avoidance model, prolonged disability among patients with chronic nonmalignant pain is due, in part, to an exaggerated fear of pain. At issue in the present study was an attempt to refine the fear-avoidance hypothesis by eliciting estimates of anticipated pain as well as anticipated injury. Along with scores on the Fear Avoidance Beliefs Questionnaire-Work (FABQ-W), a validated measure of fear avoidance, pain and injury expectancies were used as predictors of work disability in a hierarchical regression model. ⋯ After controlling for pain duration, depression, somatization, and current pain severity, pain expectancy alone accounted for 16% of the variance in patients in the chronic group (P < .001) and 33% of the variance in patients in the acute group (P < .001). Both pain and injury expectancies were associated equally with work disability for patients in the acute group (P < .001), but only pain expectancy accounted for variance in the chronic group (P < .001). Fear-avoidance beliefs, in the form of cognitive expectancies, may have as much influence on the duration of disability in patients with acute pain as they do in patients with chronic pain.
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Postlumbar laminectomy syndrome, or pain following operative procedures of the lumbar spine, is increasingly a common entity in modern medicine. Multiple causes proposed for recurrence of pain after lumbar laminectomy are: epidural fibrosis, recurrent disc herniation, instability, and facet joints. Even though the prevalence of persistent low back pain secondary to the involvement of lumbosacral facet joints has been described in controlled studies from 15% to 45%, the prevalence of facet joint mediated pain in postlumbar laminectomy syndrome has not been studied. ⋯ Results showed that the prevalence of facet joint mediated pain in non-surgical patients was 44% compared to 32% in post surgical patients determined by comparative controlled local anesthetic blocks utilizing lidocaine and bupivacaine. This study also showed a false positive rate of 36% in non-surgical group and 24% in post-surgical group. In conclusion, this study shows that facet joint mediated symptomatology in chronic low back pain is prevalent, both in non-surgical as well as post-surgical patients even though prevalence was somewhat higher in the non-surgical group compared to post-surgical group.
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Epidural fibrosis is seen as a common phenomenon among postlumbar laminectomy syndrome patients, contributing to approximately 60% of symptom recurrence. Percutaneous epidural lysis of adhesions has been described as a modality to effectively manage chronic low back pain secondary to epidural fibrosis. Forty-five patients were randomly assigned, with fifteen patients in the control group, or Group I, who were treated with conservative modalities of treatments, including medication, physical therapy, and an exercise program; and, thirty patients in Group II, who were treated with percutaneous epidural adhesiolysis and hypertonic saline neurolysis. ⋯ The study also showed that overall health status improved significantly in the treatment group in all parameters with average pain, physical health, mental health, functional status, psychological status and narcotic intake. Analysis also showed that this is a cost-effective treatment, with cost for 1-year improvement of quality of life at $2693. In conclusion, epidural adhesiolysis with hypertonic saline neurolysis performed on a 1-day basis is an effective modality of treatment in managing chronic low back pain in patients who failed to respond to fluoroscopically directed epidural steroid injections and also were demonstrated not to have facet joint mediated pain.
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The objective of this paper is to examine the outcomes of patients with intractable low-back pain treated with epidural spinal cord stimulation (SCS) utilizing paddle electrodes and a radio frequency (RF) stimulator. A multicenter prospective study was performed to collect data from patients suffering from chronic low-back pain. The study was designed to collect data from 60 patients at four centers and examine their outcomes at, or up to two years post implantation. ⋯ The majority of patients reported that the procedure was worthwhile (92% at six months, 88% at one year). No patient indicated that the procedure was not worthwhile. We conclude that SCS proved beneficial at one year for the treatment of patients with chronic low back and leg pain.
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Elan Pharmaceuticals (formerly Neurex) is developing ziconotide, a neuron-specific N-type calcium channel blocker, for the potential treatment of severe pain and ischemia. A US NDA for the use of the compound in intractable pain is under review [351606,357600] and phase III trials for ischemia are ongoing [261455,292579]. Elan received an approvable letter from the FDA for pain in June 2000, and by October 2000, was responding to questions raised by the FDA in the letter [372580,386279]. In December 2000, DRAXIS filed an NDS for ziconotide with the Therapeutic Products Programme of Health Canada [393773]. The drug has Priority Review status in Canada [387218]. PAIN: In pivotal studies, ziconotide showed a significant reduction in pain compared to placebo. In the two trials, completed by December 1999, more than 700 patients received the drug for the treatment of intractable pain intrathecally. This included patients who had failed morphine therapy, or who had become intolerant of therapy due to side-effects. The drug was safe and well tolerated over periods as long as 3 years [351606]. ⋯ Elan and Pfizer (formerly Warner-Lambert) are also developing ziconotide for the treatment of ischemia associated with head trauma and stroke [292579]. In September 1997, Neurex and Warner-Lambert restarted a pivotal phase III head trauma study with no changes in the study design. In July 1997, patient enrollment had been halted pending analysis of clinical data from earlier studies to determine the relative risk/benefits of administering ziconotide with the current protocol [261455]. By April 1999, Parke-Davis (now Pfizer) was also working on the development of nonpeptide analogs of ziconotide, with the aim of developing an orally available agent for the treatment of chronic pain [325613,324954]. In July 2000, Merrill Lynch predicted FDA approval and launch in the third or fourth quarter of 2000 [375966], but in January 2001, the prediction of approval was revised to be in 2001 [395423].