Management of refractory pain in Stiff-Person syndrome.

Stiff-Person syndrome (SPS) is a rare autoimmune neurological disorder characterised by episodic painful muscle rigidity and violent spasms. A significant trigger for the painful spasms experienced by patients is pain itself, making optimal pain management and avoidance a necessity. While first-line and second-line therapies for spasm prevention and termination are known, there is a paucity of evidence to guide pain management. We report the case of a 26-year-old woman with SPS referred for excruciating muscle cramping and rigidity with pain lasting beyond the episodes themselves. We report the novel use of ketamine and intravenous magnesium sulfate which may provide analgesia, spasm avoidance and early termination of exacerbations in SPS.

Immersive Virtual Reality for the Management of Pain in Community-Dwelling Older Adults.

Immersive virtual reality (VR) can provide a high level of engagement and distraction analgesia to address pain. However, community-based applications of this technology for older adults have not been studied. The objective of this study was to examine the applicability and effectiveness of an immersive VR intervention for pain, depression, and quality of life (QOL) in older adults. This pretest-posttest, mixed-methods design included senior center members ( n = 12) with pain that interfered with daily functioning. The outcomes included the Numeric Pain Rating Scale, Patient-Reported Outcomes Measurement Information System (PROMIS®) depression scale, World Health Organization Quality of Life Scale Brief Version (WHO QOL-BREF), and open-ended questions. The VR intervention (15- to 45-min sessions, 12 sessions over 6 weeks) was well accepted with no dropouts. There was a significant decrease in pain ( p = .002, d = -1.54) with no effect on depression and QOL. There were no adverse effects, and positive perceptions of VR were reported. The 6-week immersive VR intervention was applicable and effective in reducing pain intensity for community-dwelling older adults.

Arthroscopic Treatment of Hip Pain in Adolescent Patients With Borderline Dysplasia of the Hip: Minimum 2-Year Follow-Up.

PURPOSE: To examine arthroscopic treatment of hip pain in patients with borderline hip dysplasia (lateral center edge angle [LCEA] between 20° and 25°). METHODS: From 2008 to 2013, patients below 18 years of age who underwent arthroscopic hip surgery with an LCEA between 20° and 25° were retrospectively matched 1:1 to a control group without dysplasia (LCEA ≥25°) based on age, gender, femoroplasty, labral treatment, and capsular plication. Indications for surgery included failure to improve with nonoperative treatments and anti-inflammatory medications after 3 months. Patient-reported outcome data were collected using modified Harris hip score, hip outcome score-activities of daily living subscale, hip outcome score-sports-specific subscale, nonarthritic athletic hip score, and visual analog scale. RESULTS: From 2008 to 2013, 168 patients below the age of 18 underwent arthroscopic hip surgery. Twenty-one patients met inclusion criteria and were matched 1:1 to a control group. Follow-up was achieved for 17 patients in both groups (81%). Mean follow-up time, age, and LCEA were 2.19 years, 15.5 years, and 22.3° for the dysplastic group and 2.16 years, 16.0 years, and 31.2° for the control group, respectively. Preoperative patient-reported outcomes between groups were not statistically different. At the latest follow-up, both groups showed statistically significant improvement over baseline in modified Harris hip score, hip outcome score-activities of daily living subscale, hip outcome score-sports-specific subscale, nonarthritic athletic hip score, and visual analog scale (P < .001). Latest follow-up scores were not statistically different between groups. CONCLUSIONS: This study shows favorable 2-year outcomes in adolescent patients with borderline dysplasia undergoing labral treatment and capsular plication. Outcomes in the borderline dysplastic patients were as good as those of a control group. Although adolescents with borderline dysplasia have traditionally been a challenging group of patients to treat, these results suggest that an arthroscopic approach that addresses both labral pathology and instability may be beneficial. LEVEL OF EVIDENCE: Level IV, therapeutic case series.

[Levels of pain and self-efficacy of individuals with osteoarthritis]. / Osteoartritli bireylerin agri ve öz etkililik düzeyleri.

OBJECTIVES: This descriptive study was conducted to determine pain and self-efficacy levels of individuals with osteoarthritis. METHODS: 83 patients, who were hospitalized in and admitted to physical therapy or rehabilitation outpatient clinic and had a primary diagnosis of osteoarthritis, were included in the study. The data of the study were collected by using patient information form, visual analog scale (VAS), Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC), and arthritis self-efficacy scale. Pearson correlation analysis, t-test, and one-way analysis of variance were used to assess the data. A p value less than 0.05 was considered as statistically significant. RESULTS: The most frequent complaints of 78.5% of the individuals with osteoarthritis were pain and limitation of movement. The pain experienced by 69.9% affected their daily life activities so much. VAS mean score of the participants was 5.7±2.3, their WOMAC mean score was 56.3±14.8, and their self-efficacy score was 103.7±29.5. Self-efficacy levels of those, who were men, had a higher educational level, were not housewives, were independent in daily life activities and did not have an additional chronic disease, were higher compared to the other groups (p<0.05). In this study, a negative correlation between self-efficacy scores and VAS and WOMAC scores and a positive correlation between VAS and WOMAC scores were found (p<0.05). CONCLUSION: It was determined that self-efficacy of the individuals with osteoarthritis was moderate and gender, educational level, status of independence, pain, and functional level affected self-efficacy.

[Rehabilitation for Pain Relief: Preface and Comments].

Chronic intractable pain is difficult to manage as the mechanisms of chronic pain are complicated. Recently rehabilitation is used in patients with chronic pain not responding to NSAIDs, non-opioids, anti-depressants and so on. Rehabilitation includes acute, recovery and maintained modes of rehabilitation. This review is focused on the concept of rehabilitation, rehabilitation therapy, rehabilitation during recovery period, nerve rehabilitation, music-trampoline therapy and so on.

Establishment of a liaison clinic for patients with intractable chronic pain.

BACKGROUND: A multidisciplinary approach has been shown to be effective for the treatment of intractable pain. However, few hospitals in Japan have established liaison clinics for such patients. In this study, we investigated the short-term results of a liaison clinic for patients with intractable chronic pain. METHODS: Study participants comprised 53 outpatients (20 men, 33 women) with intractable chronic pain who visited our hospital between April 2012 and March 2013. At baseline, patients completed a self-reported questionnaire and provided demographic and clinical information. Experts in various fields (anesthesia, orthopedic surgery, psychiatry, physical therapy, and nursing) conducted examinations of patients and attended a weekly conference during which patients' physical, psychological, and social problems were discussed and courses of treatment were determined. All patients were assessed using the Numerical Rating Scale (NRS), Pain Catastrophizing Scale (PCS), Hospital Anxiety and Depression Scale (HADS), and Pain Disability Assessment Scale (PDAS). Eligibility for the pain liaison outpatient clinic was evaluated using multiple logistic regression analysis. RESULTS: After a 6-month follow-up period, no significant changes were seen in scores for the NRS, PDAS, or HADS for depression. In contrast, scores for both the PCS and HADS for anxiety were significantly reduced after 6 months of treatment (p < 0.05). HADS for anxiety was identified as a factor related to patient resistance to attending the pain liaison outpatient clinic (p < 0.05). CONCLUSIONS: This liaison clinic for patients with intractable chronic pain was able to improve patient anxiety. Severe anxiety at the initial visit represented a risk factor for dropout from the clinic.

Effects of Adding an Internet-Based Pain Coping Skills Training Protocol to a Standardized Education and Exercise Program for People With Persistent Hip Pain (HOPE Trial): Randomized Controlled Trial Protocol.

BACKGROUND: Persistent hip pain in older people is usually due to hip osteoarthritis (OA), a major cause of pain, disability, and psychological dysfunction. OBJECTIVE: The purpose of this study is to evaluate whether adding an Internet-based pain coping skills training (PCST) protocol to a standardized intervention of education followed by physical therapist-instructed home exercise leads to greater reductions in pain and improvements in function. DESIGN: An assessor-, therapist-, and participant-blinded randomized controlled trial will be conducted. SETTING: The study will be conducted in a community setting. PARTICIPANTS: The participants will be 142 people over 50 years of age with self-reported hip pain consistent with hip OA. INTERVENTION: Participants will be randomly allocated to: (1) a control group receiving a 24-week standardized intervention comprising an 8-week Internet-based education package followed by 5 individual physical therapy exercise sessions plus home exercises (3 times weekly) or (2) a PCST group receiving an 8-week Internet-based PCST protocol in addition to the control intervention. MEASUREMENTS: Outcomes will be measured at baseline and 8, 24, and 52 weeks, with the primary time point at 24 weeks. Primary outcomes are hip pain on walking and self-reported physical function. Secondary outcomes include health-related quality-of-life, participant-perceived treatment response, self-efficacy for pain management and function, pain coping attempts, pain catastrophizing, and physical activity. Measurements of adherence, adverse events, use of health services, and process measures will be collected at 24 and 52 weeks. Cost-effectiveness will be assessed at 52 weeks. LIMITATIONS: A self-reported diagnosis of persistent hip pain will be used. CONCLUSIONS: The findings will help determine whether adding an Internet-based PCST protocol to standardized education and physical therapist-instructed home exercise is more effective than education and exercise alone for persistent hip pain. This study has the potential to guide clinical practice toward innovative modes of psychosocial health care provision.

[Fibromyalgia syndrome. General principles and coordination of clinical care and patient education]. / Das Fibromyalgiesyndrom. Allgemeine Behandlungsgrundsätze, Versorgungskoordination und Patientenschulung.

BACKGROUND: The scheduled update to the German S3 guidelines on fibromyalgia syndrome (FMS) by the Association of the Scientific Medical Societies ("Arbeitsgemeinschaft der Wissenschaftlichen Medizinischen Fachgesellschaften", AWMF; registration number 041/004) was planned starting in March 2011. MATERIALS AND METHODS: The development of the guidelines was coordinated by the German Interdisciplinary Association for Pain Therapy ("Deutsche Interdisziplinären Vereinigung für Schmerztherapie", DIVS), 9 scientific medical societies and 2 patient self-help organizations. Eight working groups with a total of 50 members were evenly balanced in terms of gender, medical field, potential conflicts of interest and hierarchical position in the medical and scientific fields. Literature searches were performed using the Medline, PsycInfo, Scopus and Cochrane Library databases (until December 2010). The grading of the strength of the evidence followed the scheme of the Oxford Centre for Evidence-Based Medicine. The formulation and grading of recommendations was accomplished using a multi-step, formal consensus process. The guidelines were reviewed by the boards of the participating scientific medical societies. RESULTS AND CONCLUSION: A diagnosis of FMS should be explicitly communicated with the afflicted individual. A step-wise treatment, depending on the severity of FMS and the responses to therapeutic measures, is recommended. Therapy should only be continued if the positive effects outweigh the side effects. The English full-text version of this article is available at SpringerLink (under "Supplemental").

Psychometric properties of the Pain Attitudes and Beliefs Scale for Physiotherapists: a systematic review.

OBJECTIVE: Evidence suggests that care providers' attitudes influence their perception of patient characteristics and the way they manage their cases. Attitudes and beliefs of care providers can be measured with the Pain Attitude and Beliefs Scale for Physiotherapists (PABS-PT). This study evaluates the measurement properties of the PABS-PT. METHODS: Databases (PubMed-Medline, Embase, Cinahl and Pedro) were searched for studies on the development or evaluation of measurement properties of the PABS-PT. Methodological quality was assessed and rated using the COSMIN checklist and scoring system. RESULTS: Of the 139 identified publications, 10 met the selection criteria. Most of the included studies had fair to excellent methodological quality scores. Positive results were found for internal consistency, construct validity, reliability and responsiveness. No psychometric data were found for the content validity and interpretability of the PABS-PT. CONCLUSION: The PABS-PT is still in a developmental stage. Results for the psychometric properties are promising, but content validity and interpretability need more study. The relationship between implicit and explicit attitudes, and their influence on test scores, remains unclear.

Identification of essential elements of functioning in chronic widespread pain based on a statistical approach.

OBJECTIVE: This study aimed to study the most relevant International Classification of Functioning, Disability, and Health (ICF) categories for describing functioning and disability in patients with chronic widespread pain (CWP). The specific aims of the study are (1) to identify which ICF categories explain the most variance of the experience of health in CWP and (2) to compare the identified ICF categories to the ICF categories of the Brief ICF Core Set for CWP. DESIGN: The ICF categories entered in an initial regression model were selected according to their correlation with item 1 of the Medical Outcomes Survey 36-Item Short-Form Health Survey (SF-36). Based on an initial regression model, additional regression models were performed through systematically substituting the ICF categories included in the initial model with ICF categories from the same chapter with which they highly correlated. RESULTS: Eleven categories were identified. Six of them are included in the Brief ICF Core Set for CWP. CONCLUSIONS: Most of the categories identified in the regression models are similar to the domains identified in Outcome Measures in Rheumatoid Arthritis Clinical Trials workshops and are represented in the Brief ICF Core Set for CWP, either directly or in ICF categories from the same chapters. Based on the 11 identified categories, clinicians and health professionals can obtain an efficient overview regarding the level of functioning of their patients in those essential areas that best differentiate among various levels of functioning.

Persistent shoulder pain in the first 6 months after stroke: results of a prospective cohort study.

OBJECTIVE: To identify factors associated with persistent poststroke shoulder pain (pPSSP) in the first 6 months after stroke. DESIGN: Prospective inception cohort study. SETTING: Stroke units of 2 teaching hospitals. PARTICIPANTS: Patients (N=31) with a clinical diagnosis of stroke. INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURES: The development of pPSSP within the first 6 months after stroke. Clinical assessment of motor, somatosensory, cognitive, emotional, and autonomic functions, undertaken within 2 weeks (t0), at 3 months (t1), and at 6 months (t2) after stroke. RESULTS: Patients with pPSSP (n=9) were compared with patients without pPSSP (n=22). Bivariate logistic regression analyses showed that pPSSP was significantly associated with impaired voluntary motor control (t0, t1, t2), diminished proprioception (t0, t1), tactile extinction (t0), abnormal sensation (t1, t2), spasticity of the elbow flexor muscles (t1, t2), restricted range of motion (ROM) for both shoulder abduction (t2) and shoulder external rotation (t1, t2), trophic changes (t1), and type 2 diabetes mellitus (t0). CONCLUSIONS: These findings suggest a multifactorial etiology of pPSSP. The association of pPSSP with restricted, passive, pain-free ROM and signs indicative of somatosensory sensitization may implicate a vicious cycle of repetitive (micro)trauma that can establish itself rapidly after stroke. Intervention should therefore be focused on maintaining and restoring joint ROM as well as preventing injury and somatosensory sensitization. In this perspective, strategies that aim to intervene simultaneously at various levels of function can be expected to be more effective than treatment directed at merely 1 level.

Validity of electrical stimulus magnitude matching in chronic pain.

OBJECTIVE: To examine the validity of the PainMatcher in chronic pain. DESIGN: Comparison of parallel pain estimates from visual analogue scales with electrical stimulus magnitude matching. PATIENTS: Thirty-one patients with chronic musculoskeletal pain. METHODS: Twice a day ongoing pain was rated on a standard 100-mm visual analogue scale, and thereafter magnitude matching was performed using a PainMatcher. The sensory threshold to electrical stimulation was tested twice on separate occasions. RESULTS: In 438 observations visual analogue scale ranged from 3 to 95 (median 41) mm, and PainMatcher magnitudes from 2.67 to 27.67 (median 6.67; mean 7.78) steps. There was little correlation between visual analogue scale and magnitude data (r = 0.29; p < 0.0001). The mean sensory threshold was 3.67 steps, indicating that the PainMatcher, on average, stimulated at 2.1 times the perception threshold at matching point. CONCLUSION: Electrical magnitude matching of chronic pain intensity elicited limited activation of nerve fibres at 2.0-2.2 times sensory threshold, indicating that the induced pain was evoked by coarse nociceptive Adelta fibres. While the visual analogue scale estimates covered the whole range of the instrument, the PainMatcher readings utilized only a small part of the instrument range and, importantly, had little or no relation to the visual analogue scale estimates. The validity of the PainMatcher procedure is doubtful.

[Cervical spine and pain]. / Omurganin servikal bölümü ve agri.

Chronic pain originating from the cervical spine, that may have diverse etiological factors, is a common condition in the clinical practice. Having distinct properties in the spine, cervical column has a wide range of motion and is commonly subject to traumatic injury. In this review, after the anatomical properties that has clinical significance and the evaluation of a patient with cervical pain are explained, the common cervical spinal pain conditions are discussed by emphasizing the therapeutic approaches in each condition.

Exposure and acceptance in the rehabilitation of adolescents with idiopathic chronic pain - a pilot study.

For chronic pain of unclear origin (idiopathic), pharmacological therapy is often insufficient. Psychological treatment strategies have been developed and evaluated for adults with chronic pain. However, few such studies are seen with youths, and to date there is limited empirical evidence regarding the effectiveness of psychological treatment for generalized musculoskeletal pain syndromes in adolescents. Acceptance and commitment therapy (ACT) is a development of cognitive behaviour therapy emphasizing exposure and acceptance. In this pilot study, 14 adolescents referred to the pain treatment service due to chronic debilitating pain were treated using an ACT-based approach. It was hypothesized that avoidance of pain and related stimuli was central to the disability seen among these patients, and that exposure and acceptance strategies could increase functioning and decrease pain. In contrast to emphasizing reductions in pain and distress, the treatment objective was to improve functioning by increasing the patient's ability to act in line with personal values in the presence of negative thoughts, emotions or bodily sensations. Following treatment, and retained at 3- and 6-month follow-up, improvements in functional ability, school attendance, catastrophizing and pain (i.e., intensity and interference) were seen. The outcome of this pilot study indicates that exposure and acceptance can been useful in the rehabilitation of adolescents with chronic debilitating pain. Randomized controlled studies are needed to empirically evaluate the effectiveness of this approach.

Is the Pain Stages of Change Questionnaire (PSOCQ) a useful tool for predicting participation in a self-management programme? Further evidence of validity, on a sample of UK pain clinic patients.

BACKGROUND: In the context of finite health resources, encouraging self-management of chronic conditions is important. Indeed, it is a key priority in the UK. An increasing number of self-management programmes are becoming available. However, patients may not always choose to participate in them. Some will prefer a more directed or medically orientated treatment. The acceptability of self-management programmes for patients suffering from chronic pain is an important issue. Few measures exist that examine the process of change to a self-management approach. The Pain Stages of Change Questionnaire (PSOCQ) was evaluated for this purpose in the present study. Hypotheses were centred around criterion and construct validity of the PSOCQ. METHODS: A sample of pain patients was surveyed about their interest in participating in a lay-led self-management programme ('the Expert Patients Programme'). In addition, participants completed two psychometric measures: the Pain Stages of Change Questionnaire (PSOCQ) together with the Chronic Pain Acceptance Questionnaire (CPAQ). This is the first study as far as we are aware to examine these two scales together. The psychometric properties of the PSOCQ were examined. Analyses focused on the associations between the PSOCQ scores and interest in participating in the self-management programme. Further associations were examined between the PSOCQ and the Chronic Pain Acceptance Questionnaire. RESULTS: The results demonstrated qualified support for the PSOCQ, in particular the Contemplation sub-scale. There was a significant positive association between interest and likelihood of joining the self-management programme and contemplation scores. The action and maintenance sub-scales appeared to be measuring a unitary dimension. The associations between the PSOCQ and the Chronic Pain Acceptance Questionnaire were in the directions predicted. The limitations of the study were discussed. CONCLUSION: The results showed some support for the PSOCQ as a potentially useful tool in assessing who may or may not be likely to join a self-management course.

Pain in patient groups frequently treated by physiatrists.

This article highlights the significant prevalence and impact of pain in persons who have disabilities and points to the need for additional research in this area. Theory-driven research examining biopsychosocial models of and treatments for chronic pain are the important next steps in this area. The extensive literature on persons in whom pain is the primary disability provides a useful basis for such research. Pain may be one of several problems facing rehabilitation professionals in their care of persons with disabilities. Nonetheless, given the suffering associated with it, pain warrants careful assessment and, as indicated, intervention.