Scandinavian Journal of Pain

HIGH risk of chronic pain in women with LOW education, LOW socio-economic status, and LOW mood

Harald Breivik — 2012-04-01

In this issue of the Scandinavian Journal of Pain Thomtén et al. publish an interesting study on chronic pain in women indicating that depressive symptoms may have a mediating role in the high risk of developing chronic pain in women with low socio-economic status . Their study confirms what Eriksen et al. have reported in their publications from the ongoing health surveys in Denmark for almost two decades : low education and depression in middle aged women are significantly associated with persistent pain conditions. We do not know what is the egg and what is the hen: does low mental mood and depression cause chronic pain ? Or does a persistent pain condition and the accompanying stress on mental energy, working abilities, social interactions and financial strain cause depression ? Or is the explanation that some unfortunate persons have a shared vulnerability to both chronic pain and mental diseases such as depression, possibly through a dysfunctional brain dopamine system as suggested by Taiminen et al. . It is not possible to successfully treat chronic pain without treating the accompanying depression as suggested by Linton and Bergbom and strongly supported by Nicholas . It is also not possible to help a complex chronic pain patient with a massive burden of socio-economic problems in addition to the pain condition without helping the patient with her (most often women) economic and social problems as emphasized by Hagelberg and Aho et al. . The study by Thomtén et al. in this issue of the Scandinavian Journal of Pain is therefore a valuable reminder that chronic pain is strongly associated with the socio-economic status of the patient and that those who try to help these unfortunate women face a complex challenge where a truly multidisciplinary team approach is necessary . The social worker, the psychologist and psychiatrist , the physiotherapist , as well as specialists in women's diseases are more important than the “pain specialist” using pharmacology and interventional techniques.

Pain among women: Associations with socio-economic factors over time and the mediating role of depressive symptoms

Johanna Thomtén, Joaquim J.F. Soares, Örjan Sundin — 2012-04-01

Highlights: ► Financial strain and low occupational level at baseline were related to incidence of pain at follow up among all women. ► Low educational level at baseline was related to worse pain outcomes among women reporting pain at follow-up. ► Symptoms of depression were associated with pain incidence and with pain and pain related disability and with lower socioeconomic status (SES). ► Symptoms of depression could be understood as a mediator of the relationship between SES and pain among women. ► Impaired coping ability might be associated with both low educational level and depressive symptoms, thereby posing a risk for pain.Abstract: Background and aims: Lower socioeconomic status (SES), based on economic situation, education and occupation, has been associated with greater morbidity and mortality in a wide range of diseases, and socioeconomic inequalities have been found in several chronic pain populations. Since women are overrepresented in several clinical pain conditions, there is a need to understand the influence of SES among women with pain. In a previous cross-sectional study, socioeconomic- and work conditions were associated with pain among women from the general population of Sweden. In the present study, based on baseline and follow-up measures from 2300 of the same sample, we examined associations between pain variables, socioeconomic status and work conditions over time by means of multiple logistic/linear regression analyses. Additionally, a possible mediating role of depressive symptoms on the relationship between SES and pain was examined.Methods: The study was a prospective panel survey with two measurements 12 months apart among 2300 women with and without pain from the general population in Stockholm (aged 18–64). Logistic and linear regression analyses were used to identify associations between SES and pain outcomes.Results: Results revealed that pain is a rather stable condition with large impact on daily functioning among many women. Certain SES variables (educational level, financial strain, occupational level) were related to pain and pain related disability prospectively. Financial strain and to be a blue-collar worker were related to the incidence of pain among all women, while educational level was related to worse pain outcomes among women with pain in terms of pain intensity, pain frequency, number of pain locations and pain-related disability. Symptoms of depression were associated with pain incidence and with pain variables (intensity, number of pain locations and pain-related disability) and with lower SES.Conclusions: Financial strain and occupational level were here identified as risk factors for the incidence of pain, and could be interpreted as increasing both physical and psychological stress and thereby work both as predisposing the individual to pain and to perpetuate the development of a pain condition. Educational level was associated with the course of pain in terms of pain duration and pain-related disability which may indicate that once affected by pain, lower educational level may be related to less functional coping strategies in the adaptation to the pain condition. Depressive symptoms could be understood as a mediator of the relationship between SES and pain among women in terms of limiting the individual's strategies to handle pain in a functional manner by increasing passive behavior patterns such as avoidance.Implications: The interplay between SES and symptoms of depression should be regarded in preventive interventions and in treatment of pain among women. An overall risk-profile in terms of psychosocial and biological factors needs to be assessed early on within pain treatment for women. Increased knowledge of socioeconomic risk factors for long term pain, e.g. low educational level, is needed on all levels among all professionals within the healthcare system in order to facilitate effective communication in the treatment of women with pain.

Systematic reviews—Great gains and significant pitfalls

Katri Hamunen — 2012-04-01

Systematic reviews have become very popular and productive form of publishing within medical science. They are considered the top of hierarchy of medical evidence. Systematic reviews provide clinicians with tools for evidence-based practice. They are utilized in producing national and international clinical guidelines, decision-making of reimbursement policies and other health care decisions. This places a severe responsibility to all involved in production and publication of systematic reviews since they do not come without problems and they do not provide us with the final truth – for several reasons.

Does evidence support physiotherapy management of adult female chronic pelvic pain? A systematic review

S. Loving, J. Nordling, P. Jaszczak, T. Thomsen — 2012-04-01

Highlights: ► A systematic review of the evidence for physiotherapy on chronic pelvic pain [CPP]. ► Only small and largely non-randomised studies have been undertaken in this area. ► This limits the evidence for the effect of physiotherapeutic interventions on CPP. ► Somatocognitive therapy and multidisciplinary intervention appear to be promising. ► But there is an urgent need for well-conducted randomised clinical trials.Abstract: Background and purpose: Chronic pelvic pain (CPP) is a debilitating condition among women with a major impact on health-related quality of life, work productivity and health care utilisation. The exact prevalence of chronic pelvic pain is not known, but 3.8% is commonly suggested. Musculoskeletal dysfunction is frequently cited as a possible aetiology. Physiotherapy is therefore recommended as one treatment modality. The aim of this systematic review was to source and critically evaluate the evidence for an effect of physiotherapy on pain, physical activity and quality of life in the treatment of female CPP.Methods: Electronic databases, conference proceedings, text books and clinical guidelines were searched for quantitative, observational, and prospective clinical intervention studies of female chronic pelvic pain where physiotherapy was a sole or significant component of the intervention. Trial inclusion, data extraction according to predefined criteria and risk of bias assessment were performed by two independent authors. Methodological quality of the included clinical intervention studies was assessed using The Cochrane Collaboration's tool for assessing risk of bias. Review Manager (RevMan) version 5.0 was used for data analysis. Effect estimates (relative risk, mean difference and mean change) with 95% confidence intervals were calculated for the above outcomes. For significant outcomes the numbers needed to treat were calculated.Results: The search strategy identified 3469 potential articles. Of these, 11 articles, representing 10 studies, met the inclusion criteria. There were 6 randomised clinical trials, 1 cohort study and 3 case series. Methodological quality was dependent on study type. Accordingly, level of evidence was judged higher in randomised clinical trials than in the other study types. Physiotherapy treatments varied between studies and were provided in combination with psychotherapeutic modalities and medical management. This did not allow for the ‘stand-alone’ value of physiotherapy to be determined. Heterogeneity across the studies, with respect to participants, interventions, outcome measures and times of follow-up, prevented meta-analysis. Narrative synthesis of the results, based on effect estimates and clinically relevant pain improvement, disclosed some evidence to support an effect of multidisciplinary intervention and Mensendieck somatocognitive therapy on female chronic pelvic pain.Conclusion: Chronic pelvic pain in women is a major health care problem with no specific therapies and poor prognosis. There seems to be some evidence to support the use of a multidisciplinary intervention in the management of female chronic pelvic pain. Somatocognitive therapy is a new approach that appears to be promising and randomised clinical trials are underway in order to establish its evidence base.Implications: Based on the findings of this review, recommendations for physiotherapy in chronic pelvic pain clinical guidelines, textbooks and narrative reviews should be interpreted with caution due to the lack of a sufficient evidence base. Only small and largely non-randomised studies have been undertaken of physiotherapeutic interventions and this greatly limits the available evidence on which to base clinical practice. High quality randomised clinical trials are therefore urgently needed.

Effective treatment of osteoarthritic pain, tackling the challenge with pets

Antti Pertovaara — 2012-04-01

Pain in joints is a major clinical problem. Among diseases causing chronic joint pain, osteoarthritis (OA) is a more frequent cause of pain than inflammatory joint diseases, such as rheumatoid arthritis . While OA is rarely observed in young people (prevalence<0.1% in age group 25–34 years), its prevalence is about 30% in age group 65–74 years and women are more likely to have OA than men . In addition to age, among main risk factors of OA are obesity, injury and congenital anomalies. Obesity increases mechanical stress on the weight-bearing joints, which may explain association of obesity with OA, although a contribution of atypical hormone or growth factor concentrations that affect the cartilage or bone has not yet been excluded. It has also been speculated that nutrients might play a role in OA, e.g. by influencing bone mineralization and cell differentiation in joints .

Translational animal models using veterinary patients – An example of canine osteoarthritis (OA)

Outi Vainio — 2012-04-01

Highlights: ► Recent studies have shown that laboratory animal pain models have repeatedly failed to predict clinical analgesic efficacy and adverse side effects of potential drug molecules in humans. ► Animal models that more closely mimick clinical pain conditions has been requested. ► The clinical expression and pathogenesis of naturally occurring canine OA is considered an analogous disease to that which occurs in humans, and OA in domestic dogs is quite prevalent. ► Pain and pain-relief in canine OA in veterinary patients can be evaluated by owners and by instruments for objective gait analysis, promising improved predictability of translational OA-pain research.Abstract: Background and purpose: The use of laboratory animals in pain research has powerfully contributed to our detailed understanding of the physiological mechanisms of pain. Animal models also represent an essential tool to screen and select novel drug molecules with potentially analgesic properties. Despite of the inevitable input of laboratory animal trials, recent studies have shown that animal pain models have repeatedly failed to predict clinical analgesic efficacy and adverse side effects of potential drug molecules in human pain patients. This paper provides a review of the laboratory animal models of OA, which have been developed to test efficacy of novel analgesics. The paper also presents spontaneous OA in canine veterinary patients, and methods to observe chronic pain in nonverbal dogs.Methods: PubMed data base was searched as a reference list to locate most relevant articles. A number of 118 articles including 4 reviews were located. Web pages of 4 establishments and 2 private organizations were also accessed.Results: The clinical expression and pathogenesis of naturally occurring OA in dogs is considered an analogous disease that occurs in humans, including pain and lameness. OA may occur in any joint in dogs as well as in humans. Primary idiopathic OA in dogs is rare, but certain breeds may be predisposed to it. For the most part, canine OA is considered secondary to acquired or congenital musculoskeletal disorders. Concomitant factors, such as aging and obesity, likely accelerate progression. However, mechanical factors appear to predominate in the etiopathogenesis of canine spontaneous OA. Both subjective (validated questionnaire) and objective (gait analysis) tools are available to measure OA related pain in dogs. Information on the prevalence of canine OA is limited, but rough surveys suggest that 11 million dogs in the United States and 5 million in Europe could suffer from OA. Ethical considerations concerning the use of privately owned dogs can be resolved by a careful experimental design.Conclusions: Canine spontaneous OA could serve as a translational animal model that would more closely mimick clinical OA related pain conditions in humans. Privately owned dogs would make a solution to fix the gap between animal pain models and clinical trials when testing potential analgesic drug molecules. Close interdisciplinary cooperation would guarantee that both scientific and ethical intentions would be achieved.Implications: The predictability of translational pain research would improve by using privately owned dogs as chronic pain models when testing novel analgesics.

Pre-procedure anxiety aggravates pain—A problem also in adult patients

Harald Breivik — 2012-04-01

A nervous and tense patient expecting a procedure to be painful is guaranteed to have a much more unpleasant experience than a non-anxious patient . This is true for patients having surgery for nonmalignant conditions , but it is even more so for cancer patients having diagnostic procedures or surgery . This is a major problem for chronic pain patients . Their nervousness in relation to acute pain escalates to despair and catastrophizing thoughts when their pain condition continues into a recurring pain: “My pain condition is so complex and difficult to treat that I will never get rid of my pain”. This may become a self-fulfilling prophecy and a great obstacle to effective treatment of chronic pain .

Anxiety and pain during bone marrow aspiration and biopsy

2012-04-01

Highlights: ► Pre-procedural anxiety intensifies the pain felt during bone marrow aspiration and/or biopsy. ► Pain experienced during previous medical procedures is a predictor of anxiety and pain associated with bone marrow aspiration and/or biopsy. ► Patients who received analgesics or sedative medication did not have lower pain scores during the procedure than the rest of the patients.Abstract: Background: Previously we found that pre-procedural nervousness and tension (translated into English as “anxiety”), assessed on a non-validated five-point scale, correlated with pain intensity of the various stages of bone marrow aspiration and biopsy (BMAB). The fewer the previous BMAB procedures the stronger the pain from a repeated procedure. The primary purpose of the present observational study is to evaluate the state of anxiety just before BMAB and to find out whether it affects the pain experiences during the various stages of the BMAB procedure. We also examined whether first-timers differ from patients with previous BMAB experience in the degree of anxiety and intensity of BMAB procedural pain.Methods: A total of 166 adult outpatients undergoing the BMAB from the Helsinki University Hospital were enrolled, 48 of them being first-timers. The level of anxiety was measured with State-Trait Anxiety Inventory (STAI) and the pain experiences associated with the various stages of the procedure were evaluated on the NRS-scale (Numeral Rating Scale 0–10) and using the Finnish pain vocabulary. BMAB was planned to be performed under lidocaine infiltration anaesthesia but, on request, patients were allowed to receive premedication with diazepam orally or alfentanil i.m. If, in spite of supplemental local anaesthetic the patient still felt pain from the sampling needle tip, i.m. alfentanil was administered.Results: There was a clear association between anxiety and pain during all stages of the procedure, except during biopsy. The NRS scores varied from 0 to 10 in all the various stages of BMAB. The first-timers did not differ from the more experienced patients with regard to pain experiences; only the pain felt during the local anaesthetic infiltration was milder (P=0.007) in first-timers than in the others. Procedural pain in those who were given analgesic or sedative premedication was similar (P>0.05) to that in the non-pre-medicated patients. The words characterizing the pain of the various stages belonged to a major extent (76–90%) to the sensory class of words.Conclusion: Pre-procedural anxiety had a major impact on the pain ratings. The first-timers and patients with previous experience of BMAB had a similar degree of pre-procedural anxiety, as well as of the intensity of procedural pain, except that infiltration of local anaesthetic was less painful in the first-timers.Implications: Identification of anxious (fearful) patients prior to BMAB, and premedicating them individually may improve satisfaction in both patient and caregiver.

What is required from studies evaluating multidisciplinary treatment in pain clinics?

Petter C. Borchgrevink — 2012-04-01

This issue of the Scandinavian Journal of Pain presents a study with the ambitious title “Long-term outcome of multidisciplinary intervention of chronic non-cancer pain patients in a private setting” by Meineche-Schmidt et al. . The title is ambitious because very few studies so far have actually proved scientifically that multidisciplinary pain treatment (MDPT) of chronic non-cancer pain patients is in fact effective long term. Although some studies have found a beneficial effect , others have not , and very few have presented follow up results. A less convincing effect is found in studies that have included heterogeneous groups of patients from pain clinics, e.g. in the mentioned study compared with those who have included only patients with selected diagnoses like low back pain and fibromyalgia . Most studies evaluating outcome of MDPT have done so for specific diagnoses, while only few studies have evaluated outcome of multidisciplinary intervention in clinics receiving the whole range of patients with chronic non-cancer pain .

Long-term outcome of multidisciplinary intervention of chronic non-cancer pain patients in a private setting

Villy Meineche-Schmidt, Niels-Henrik Jensen, Per Sjøgren — 2012-04-01

Highlights: ► In a private pain clinic in Denmark beneficial outcomes of multidisciplinary intervention in non-cancer chronic pain patients have been demonstrated. ► Long-term effects were demonstrated in biological, psychological and social aspects of chronic pain. ► Group therapy may possibly be advantageous compared with individualized treatment concerning long-term outcomes. ► However, in this pragmatic study, patients were not randomized and the group treated had less serious baseline pain conditions.Abstract: Background and aim: The present study reports on chronic non-cancer patients who were referred to a private pain clinic, according to a waiting time guarantee and treated within one month from referral. Based on evaluation by members of the multidisciplinary staff at our pain clinic a pain management program could be offered individually or as group therapy.Methods: Health related quality of life, psychometric tests, use of pain medication; socio-economic status and number of consultations in general practice were recorded at referral to the clinic and by postal questionnaires at follow-up 21 months later. The primary treatment outcome (treatment success) was defined as an improvement of at least 40 points in the physical component and/or the mental component of SF-36 from baseline to follow-up. Secondary outcome measures were changes in Beck's Anxiety Inventory and Beck's Depression Inventory, use of analgesics, work status and transfer income and number of consultations at the GP's office due to the chronic pain condition.Results: A total of 306 patients were included: 141 were treated individually and 165 were treated in groups. At follow-up, data were obtained from 189 patients (62%). Comparing baseline to follow-up data, 62% of group treated patients were treated successfully, compared with 41% of individually treated patients. Anxiety and depression were significantly improved in group treated patients but not in those treated individually. Significantly more patients had work income (and less patients transfer income) among group treated, compared with individually treated. At follow-up use of antidepressants and anticonvulsants was increased whereas use of tranquilizers and strong opioids was decreased in all patients. Number of consultations at their GPs due to chronic pain was significantly reduced in all patients.Conclusions: Multidisciplinary treatment in a private pain clinic seems to have a long-term effect in relation to biological, psychological and social aspects of the chronic pain condition. Treatments based on group therapy may offer better results than individual treatment courses.Implications: The effect of group therapy should be explored further.

Optimal thoracic epidural analgesia—Again

Harald Breivik, Geir Niemi — 2012-04-01

In this issue of the Scandinavian Journal of Pain, Gísli Vigfússon and Gísli H. Sigurðsson from the University Hospital of Reykjavik, Iceland publish an interesting, very well done study on thoracic epidural analgesia for pain after open postero-lateral thoracotomy in 253 elderly patients . They compared the effects of thoracic epidural infusion of a standardized low concentrations epidural mixture in two homogeneous groups of women and men 50–70 years of age. They documented that even after painful open postero-lateral thoracotomies it is possible to obtain excellent analgesia during rest as well as during deep inspiration and forceful coughing when the patients receive an optimally placed, triple component epidural infusion, starting before surgery and continuing during the postoperative days as long as needed . They were able to clearly document that female patients need less epidural infusion volumes and less rescue analgesics than male patients .

Epidural pain management after open lateral thoracotomy: Female patients have better pain relief and need smaller amounts of analgesics than males

Gísli Vigfússon, Gísli H. Sigurðsson — 2012-04-01

Highlights: ► Thoracic epidural analgesia after lateral thoracotomy gives optimal dynamic pain relief. ► Low-cons. of bupivacaine (1mg/ml), fentanyl (2μg/ml), and adrenaline (2μg/ml) suffice. ► Dynamic pain relief is better for female patients. ► Females need smaller volumes of epidural infusion and less rescue analgesics.Abstract: Background and aims: There is an ongoing dispute whether or not there is a gender difference in epidural drug requirements. The objective of this study was to compare the effects of a triple drug epidural mixture used for postoperative pain relief on male and female patients undergoing major surgery.Materials and methods: To avoid possible influence of different age and type of surgery only 50–70year old patients undergoing open lateral thoracotomy were included. 253 patients were enrolled: 116 males and 137 females. All patients received a mixture of bupivacaine 0.1mg/ml, fentanyl 2μg/ml, and adrenaline 2μg/ml (BFA) by continuous infusion into the thoracic epidural space for postoperative pain relief. Infusion rate of the BFA solution was recorded and pain score was evaluated by numeric rating scale (NRS, 1–10) for 48h post operatively.Results: Adequate postoperative pain relief (NRS≤3) at rest was accomplished in 91% of male patients on day one and 92% on day two and by 94% and 100% of female patients, respectively. Females had significantly lower median pain scores than males on day two both at rest (P<0.011) and by movement (P<0.012). In addition females required significantly smaller amounts of BFA mixture (P<0.01) and less frequently rescue opioids (P<0.025) than males.Conclusion: Female patients had significantly better pain relief both at rest and by movement, needed smaller amounts of the epidural bupivacaine, fentanyl, adrenaline mixture for postoperative pain relief and received less frequently rescue opioids than males.Implications: The dose of thoracic epidural infusion of low-concentration bupivacaine-, fentanyl-, and adrenaline-solution should routinely be set lower for postmenopausal women than for elderly male patients during and after thoracotomy.