Pain chronification and the important role of non-disease-specific symptoms in patients with systemic sclerosis.

BACKGROUND: Pain is a frequent, yet inadequately explored challenge in patients with systemic sclerosis (SSc). This study aimed to conduct an extensive pain assessment, examining pain chronification and its association with disease manifestations. METHODS: Consecutive SSc patients attending their annual assessment were included. SSc-specific features were addressed as defined by the European Scleroderma Trials and Research (EUSTAR) guidelines. Pain analysis included intensity, localization, treatment, chronification grade according to the Mainz Pain Staging System (MPSS), general well-being using the Marburg questionnaire on habitual health findings (MFHW) and symptoms of anxiety and depression using the Hospital Anxiety and Depression Scale (HADS). RESULTS: One hundred forty-seven SSc patients completed a pain questionnaire, and 118/147 patients reporting pain were included in the analysis. Median pain intensity was 4/10 on a numeric rating scale (NRS). The most frequent major pain localizations were hand and lower back. Low back pain as the main pain manifestation was significantly more frequent in patients with very early SSc (p = 0.01); those patients also showed worse HADS and MFHW scores. Regarding pain chronification, 34.8% were in stage I according to the MPSS, 45.2% in stage II and 20.0% in stage III. There was no significant correlation between chronification grade and disease severity, but advanced chronification was significantly more frequent in patients with low back pain (p = 0.024). It was also significantly associated with pathological HADS scores (p < 0.0001) and linked with decreased well-being and higher use of analgesics. CONCLUSIONS: Our study implies that also non-disease-specific symptoms such as low back pain need to be considered in SSc patients, especially in early disease. Since low back pain seems to be associated with higher grades of pain chronification and psychological problems, our study underlines the importance of preventing pain chronification in order to enhance the quality of life.

[Elosan therapy : A new treatment option for chronic pain]. / Elosan-Therapie : Eine neue Behandlungsoption bei chronischen Schmerzerkrankungen.

BACKGROUND: The new physical Elosan therapy is designed to provide patients with chronic pain with clear relief, improve their quality of life and reduce the consumption of painkillers. To prove the efficacy and tolerability of this new therapy, a clinical pilot study had to be carried out to certify the Elosan Therapy Cabin as a medical device, since despite extensive literature research no equivalent product or therapy could be identified. METHODOLOGY: In an open, randomized, clinical comparison study at three pain medical centers in Switzerland, a total of 39 patients with chronic pain (duration >6 months; intensity >50 mm visual analog scale (VAS) according to Borg) in two groups (21 verum, 18 control) were included in the study. The verum group received a 4-min Elosan therapy over a period of 28 days twice/week in addition to the further applied individual standard therapy. The control group continued to receive only their individual standard therapy. The primary target parameter was that the pain reduction in the verum group after 8 treatments should be at least 20 mm (100 mm partial VAS pain scale) more than in the control group. The secondary target parameters were a change in quality of life based on the Short Form (SF) 12 questionnaire and a relevant reduction in pain medication. RESULTS: The most important result was in-group pain reduction (measured VAS score), which was highly significant in the Elosan group (p = 0.001). The treatment effect corresponded on average to a pain reduction of almost 25% with simultaneous administration of standard drug therapy. Overall, 2.5 times more patients in the Elosan group compared to the control group experienced a reduction of the VAS score of more than 20 mm (= pain reduction of at least 30%). Nevertheless, statistical significance was not fully achieved in the primary endpoint (p = 0.102). The result of the SF 12 questionnaire showed efficacy in the physical area, subitem: "Physical pain", which improved significantly in the verum group (p = 0.001). The total value of SF 12 in the mental area was significantly better in the Elosan treatment group than in the reference group (p = 0.016). The improvement in pain sensation was highly significantly better in the verum group (p = 0.001). Finally, about four times more patients in the Elosan group were able to reduce their pain medication towards the end of the study.

Catheter-tip Granulomas Associated with Intrathecal Drug Delivery--A Two-Center Experience Identifying 13 Cases.

BACKGROUND: Intrathecal (IT) drug therapy with implanted pumps is an effective treatment modality for chronic pain and/or spasticity, especially after non-invasive treatment has failed. Long-term use of intrathecal opioids may cause formation of inflammatory masses at the tip of intrathecal catheters, possibly leading to neurological deficits and/or catheter revision. OBJECTIVE: We aimed to identify risk factors for catheter-tip granuloma (CG) formation. STUDY DESIGN: Retrospective study. SETTING: Tertiary Spine Centers in Germany and Switzerland. METHODS: We retrospectively reviewed data at 2 Swiss centers (Kantonsspital St. Gallen, Swiss Paraplegic Centre Nottwil) between 01/1994 and 10/2013. Collected data were age at operation, gender, smoking status, previous spinal operations, spinal level of catheter-tip, clinical symptoms, catheter testing with contrast agent, applied drugs, drug concentration, as well as cumulative daily drug dosages. RESULTS: Thirteen patients with a mean age of 52.6 years and CG formation after a mean of 6.9 years of follow-up were identified and compared to 54 patients of similar age and length of follow-up (48.6 years, P = 0.535; follow-up 5.3 years, P = 0.236) without CG. In the analysis of risk factors, catheter ending in the middle thoracic spine (Th4-8; 38.5 vs. 6.5%; P = 0.010), previous spinal surgery (75 vs. 41%; P = 0.051), and chronic pain as an underlying primary symptom for IT drug therapy (100 vs. 56%, P = 0.003) were associated with CG formation. IT drug therapy for spasticity appeared to be much less associated with CG formation (0 vs. 44%, P = .0003). As the symptomatology is closely related to the medical treatment applied, patients with CG were more likely to be treated with IT morphine (77 vs. 20%; P < 0.001), and as tendency with IT clonidine (54 vs. 26%; P = 0.092) and IT bupivacaine (46 vs. 20%; P = 0.077). Average in-pump morphine concentration (30.3 vs. 19.5 mg/mL; P = 0.05) as well as average daily dose of morphine (12.5 vs. 6.2 mg/d; P = 0.037) were significantly higher in the CG group. Smoking could not be identified as risk factor for CG formation. LIMITATIONS: Limitations include the retrospective approach, the limited group size of granuloma patients, as well as missing data in the investigated patient groups. CONCLUSION: Our patient cohort with CG differed in some features, of which some like catheter localization, choice, dosage, and the concentration of drugs are potentially modifiable. These results could contribute to the prevention of CG in the future.

Incidence of chronic postsurgical pain (CPSP) after general surgery.

OBJECTIVE: This study investigated the incidence and determinants of chronic postsurgical pain (CPSP) in a general surgical patient population. DESIGN: This is a prospective cross-sectional study at a university-affiliated clinic/level 1 trauma center. Patients were followed at least 1 year postoperatively. By surgical discipline, procedures were 50% orthopedic/trauma, 33% general (abdominal/visceral), and 17% vascular. SETTING: All patients admitted during one year (N = 3020) were eligible. Exclusion criteria were cognitive impairment, communication/language barrier, nonoperative treatment, and refusal to participate. A CPSP questionnaire was completed. Step-by-step analysis followed with a 2(nd) questionnaire to detect CPSP with numeric rating scale (NRS) pain intensity ≥3. Finally, individual follow-up examinations were performed. RESULTS: 911 patients responded (30.2%). 522 complained of pain intensity ≥3 on NRS (scale 0-10). The second step identified 214 patients with chronic pain (NRS ≥3, mean 29 months postoperatively). On final examination, 83 CPSP patients (14.8%) were identified. By surgical discipline, 28% were general, 15% vascular, and 57% trauma/orthopedic surgery. Most oftenly cited pain sites were joint (49.4%), incisional/scar (37.7%), and nerve pain (33.7%). By procedure, patients underwent pelvic surgery, colon surgery, laparoscopies, inguinal herniorrhaphies, arthroscopies, and hardware extractions. All patients in the "laborer" and "unemployed" categories reported chronic pain. CONCLUSION: Bias due to study design and/or heterogeneity of patients is possible, but there was a high CPSP rate after 2 years both generally and particularly in orthopedic/trauma (57%) patients. Both "major" and "minor" surgical procedures led to CPSP.