Transitioning from acute to chronic pain: a simulation study of trajectories of low back pain.

BACKGROUND: Identifying how pain transitions from acute to chronic is critical in designing effective prevention and management techniques for patients' well-being, physically, psychosocially, and financially. There is an increasingly pressing need for a quantitative and predictive method to evaluate how low back pain trajectories are classified and, subsequently, how we can more effectively intervene during these progression stages. METHODS: In order to better understand pain mechanisms, we investigated, using computational modeling, how best to describe pain trajectories by developing a platform by which we studied the transition of acute chronic pain. RESULTS: The present study uses a computational neuroscience-based method to conduct such trajectory research, motivated by the use of hypothalamic-pituitary-adrenal (HPA) axis activity-history over a time-period as a way to mimic pain trajectories. A numerical simulation study is presented as a "proof of concept" for this modeling approach. CONCLUSIONS: This model and its simulation results have highlighted the feasibility and the potential of developing such a broader model for patient evaluations.

Transitioning from Acute to Chronic Pain: An Examination of Different Trajectories of Low-Back Pain.

Traditionally, there has been a widely accepted notion that the transition from acute to chronic pain follows a linear trajectory, where an injury leads to acute episodes, subacute stages, and progresses to a chronic pain condition. However, it appears that pain progression is much more complicated and individualized than this original unsupported assumption. It is now becoming apparent that, while this linear progression may occur, it is not the only path that pain, specifically low-back pain, follows. It is clear there is a definite need to evaluate how low-back pain trajectories are classified and, subsequently, how we can more effectively intervene during these progression stages. In order to better understand and manage pain conditions, we must examine the different pain trajectories, and develop a standard by which to use these classifications, so that clinicians can better identify and predict patient-needs and customize treatments for maximum efficacy. The present article examines the most recent trajectory research, and highlights the importance of developing a broader model for patient evaluation.

Use of the Central Sensitization Inventory (CSI) as a treatment outcome measure for patients with chronic spinal pain disorder in a functional restoration program.

BACKGROUND CONTEXT: The Central Sensitization Inventory (CSI) is a valid and reliable patient-reported instrument designed to identify patients whose presenting symptoms may be related to central sensitization (CS). Part A of the CSI measures a full array of 25 somatic and emotional symptoms associated with CS, and Part B asks if patients have previously been diagnosed with one or more specific central sensitivity syndromes (CSSs) and related disorders. The CSI has previously been validated in a group of patients with chronic pain who were screened by a trained psychiatrist for specific CSS diagnoses. It is currently unknown if the CSI can be a useful treatment-outcome assessment tool for patients with chronic spinal pain disorder (CSPD) who are not screened for comorbid CSSs. It is known, however, that previous studies have identified CS-related symptoms, and comorbid CSSs, in subsets of patients with CSPDs. Studies have also shown that CS-related symptoms can be influenced by cognitive and psychosocial factors, including abuse history in both childhood and adulthood, sleep disturbance, catastrophic and fear-avoidant cognitions, and symptoms of depression and anxiety. PURPOSE: This study aimed to evaluate CSI scores, and their associations with other clinically relevant psychosocial variables, in a cohort of patients with CSPD who entered and completed a functional restoration program. STUDY DESIGN/SETTING: A retrospective study of prospectively collected data from a cohort study of patients with CSPD, who completed the CSI at admission to, and discharge from, an interdisciplinary function restoration program (FRP) was carried out. PATIENT SAMPLE: A cohort of 763 patients with CSPD comprised the study sample. OUTCOME MEASURES: Clinical interviews evaluated mood disorders and abuse history. A series of self-reported measures evaluated comorbid psychosocial symptoms, including pain intensity, pain-related anxiety, depressive symptoms, somatization symptoms, perceived disability, and sleep disturbance, at FRP admission and discharge. METHODS: Patients were grouped into five severity level groups, from mild to extreme, based on total CSI scores, at FRP admission, and then again at discharge. The FRP included a quantitatively directed and medically supervised exercise process, as well as a multimodal psychosocial disability management component. RESULTS: The CSI severity groups were strongly associated with Major Depressive Disorder and previous abuse history (p<.01), which are known risk factors for CS-related symptoms and diagnoses. The CSI scores were also strongly associated with patient-reported CSS diagnoses on CSI Part B. The percentage of patients who reported a comorbid CSS diagnosis increased in each higher CSI-severity group, from 11% in the Subclinical group, to 56% in the Extreme group. The CSI severity groups were significantly related to other CS-related patient-reported symptoms, including pain intensity, pain-related anxiety, depressive symptoms, somatization symptoms, perceived disability, and sleep disturbance (p's<.001). The CSI scores, along with all other psychosocial measures, decreased at treatment discharge. CONCLUSIONS: In the present study, admission CSI scores were highly associated with previous CSS diagnoses, CS-related symptoms, and clinically relevant patient-reported psychosocial variables. All psychosocial variables, as well as scores on the CSI, were significantly improved at FRP discharge. The CSI may have important clinical utility, as a screener and as a treatment outcome measure, for patients with CSPD participating in an interdisciplinary FRP.

Pharmacological treatment of depression in geriatric chronic pain patients: a biopsychosocial approach integrating functional restoration.

INTRODUCTION: A recent literature review concluded that the comorbidity of chronic pain and depression in adults is approximately 50%-65%. Physical and cognitive declines, concurrent multiple health conditions, and complex medication regimens add to the unique and complex challenges of effectively treating pain in particularly geriatric populations. Interdisciplinary medical intervention and monitoring for psychiatric sequelae, such as depression, cognitive change, and synergistic physical side effects are necessary. Areas covered: This review covers an extensive multi-database wide search of the pharmacotherapy of pain and depression in older adults, including biopsychosocial approaches. One of these, on which this review focuses, is Functional Restoration, an interdisciplinary application of quantified physical rehabilitation, case management, and cognitive behavioral and educational therapies to achieve improved well- being and better physical functioning. The biopsychosocial model incorporates an overview of the overlapping and interactive dimensions of a patient's life and addresses them within a comprehensive plan of treatment. Expert commentary: A multifactorial, rather than a single factor approach to the treatment of complicated health care problems such as chronic pain in an elderly patient is emphasized as an important change in perspective for the health care provider.