The Use of L2 and L3 Lumbar Sympathetic Blockade for Cancer-Related Pain, an Experience and Recommendation in the Oncologic Population

Abstract Objective The sympathetic nervous system has a recognized role in transmission of pain, and the lumbar sympathetic blockade is intended to provide analgesia. We share our experiences of lumbar sympathetic blockade in the treatment of cancer-related pain. Methods We performed a retrospective analysis of patients with cancer-related pain in the back, abdomen, pelvis, or legs treated at Memorial Sloan Kettering Cancer Center between 2000 and 2018 undergoing lumbar sympathetic blockade at L2 or L3. Blocks were accomplished by injection of local anesthetic or local anesthetic with steroid under fluoroscopy. We measured numerical rating scale scores, percent relief, and relief time. The primary end point was defined as “effective” or “ineffective” pain relief. Effective pain relief was defined as ≥30% relief for at least one day. Results We identified 124 data points of lumbar sympathetic blockade at L2 or L3, of which 57 were with complete data and used for analysis. Peri-injection, 42 data points had active disease whereas 15 were in remission. Lumbar sympathetic blockade was 67% effective in the back pain cohort, 82% effective in the abdominopelvic pain cohort, and 75% effective in the leg pain cohort. Seventeen data points went on to neurolysis, two to neuromodulation, and eight to intrathecal pump implantation. Conclusions Lumbar sympathetic blockade is effective for back, abdominopelvic, and leg pain related to cancer and its treatments. Future research should be aimed at refining its role within multimodal pain management.

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CT-Guided Transforaminal Epidural Injections with Local Anesthetic, Steroid, and Tramadol for the Treatment of Persistent Lumbar Radicular Pain

January 2018 - Pain Physician ◽

10.36076/ppj.2012/15/153 ◽

2012 ◽

Vol 2;15 (2;3) ◽

pp. 153-159 ◽

Cited By ~ 2

Author(s):

Mathias Wewalka

Keyword(s):

Pain Relief ◽

Local Anesthetic ◽

Nerve Root ◽

Rating Scale ◽

Numerical Rating Scale ◽

Pain Reduction ◽

Radicular Pain ◽

Ct Guided ◽

Numerical Rating ◽

Serial Ct

Background: A substantial number of patients with persistent lumbar radicular pain are treated with a multimodal spectrum of conservative therapies without lasting effect. The duration of pain is certainly a risk factor for chronification. There is evidence that guided periradicular infiltrations are a valid option in the treatment of radiculopathies. Usually a combination of local anesthetic and/or corticosteroid is injected. Tramadol is being used for perioperative analgesia and has been shown to provide effective, long-lasting pain relief after epidural administration. Objective: The aim of this pilot study was to evaluate the efficacy of serial CT-guided transforaminal nerve root infiltrations with a supplement of tramadol for patients with persistent, radicular pain. Study Design: Interventional cohort study. Setting: Outpatient department for interdisciplinary pain medicine. Methods: 37 patients who had radicular leg pain for over 9 weeks received up to 3 CTguided transforaminal nerve root infiltrations at intervals of 2 weeks as long as their level of pain was over 3 on a numerical rating scale from 0 to 10. 50 mg of Tramadol were added to a combination of local anesthetic (Ropivacain, 2 mg) and corticosteroid (Triamcinolon, 40 mg). Evaluations were carried out 24 hours after the Infiltration as well as 2 weeks, 3 and 6 months after the treatment series. The intensity of their radicular pain was measured by a numerical rating scale (NRS). Pain reduction of at least 50% was defined as successful outcome. Results: In total, 65 infiltrations were carried out with pain relief in more than 90% of the patients within 24 hours and an average pain reduction of 64%. Six months post-injection 23 of 34 patients available for follow-up (67.6%) had a successful pain reduction of 84% on average. No adverse effects ascribable to the use of tramadol were noted. Limitations: Due to the lack of a control group we cannot make any statement if tramadol improves short-term pain reduction. Conclusion: Fast and lasting pain relief is the key to optimize rehabilitation for patients with radicular pain. There is a physiological rationale that the opioid receptors at the spinal level could be used to optimize the analgetic effect of guided periradicular injections. In our case series, serial CT-guided selective nerve root infiltrations with the supplement of tramadol were found to be highly effective in the treatment of persistant radiculopathies. Randomized controlled trials will be necessary to clarify the possible benefit of the supplement of an opioid. Key words: Serial, nerve root infiltration, tramadol, chronic pain, outcome.

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Comparing the efficacy of nebulized morphine with intravenous morphine in traumatic musculoskeletal pain management

Journal of Research in Clinical Medicine ◽

10.34172/jrcm.2020.021 ◽

2020 ◽

Vol 8 (1) ◽

pp. 21-21

Author(s):

Mani Mofidi ◽

Ali Dashti ◽

Mahdi Rezai ◽

Niloufar Ghodrati ◽

Hoorolnesa Ameli ◽

...

Keyword(s):

Pain Management ◽

Pain Relief ◽

Musculoskeletal Pain ◽

Normal Saline ◽

Rating Scale ◽

Numerical Rating Scale ◽

Vital Signs ◽

Categorical Variables ◽

Intravenous Morphine ◽

Numerical Rating

Introduction: This study was designed to compare the effectiveness of intravenous morphine with nebulized morphine in pain relief of patients referring to the emergency setting with traumatic musculoskeletal pain. Methods: This randomized, placebo-controlled and double-blind clinical study evaluated 160 patients 18 to 65 years of age with acute traumatic pain, who attended the emergency department during 2019. Subjects were assessed with Numerical Rating Scale based on inclusion and exclusion criteria and randomly divided into two groups. In one group, 80 patients received IV morphine (0.1 mg/kg+5 mL normal saline) plus an equivalent volume of IV placebo. In the second group, 80 patients received nebulized morphine (0.2 mg/kg+5 mL normal saline) plus nebulized placebo. Pain score was monitored in all patients with Numerical Rating Scale before and after intervention at baseline, 15, 30, 45, and 60-minute intervals. Patients’ vital signs and possible adverse events were evaluated in each observation time points. Finally, all participants were assessed for their satisfaction with pain management. Data were analyzed using repeated measure analysis for continuous variables and Binomial test for categorical variables Results: There was no significant difference between the demographic characteristics of patients in study groups. Pain relief between the two groups was similar during the observation (0, 15, 30, 45, 60 min) (P>0.05). There were no changes in vital signs between two groups, although the nebulized group had lower systolic blood pressure at the time-point of 15 minutes after the treatment initiation (P=0.03). Conclusion: Although Nebulized morphine has similar efficacy in comparison with IV route, nebulization might be considered as the clinically efficacious route of morphine administration with minimal side effects, providing optimal pain relief in patients.

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Postendodontic Pain after Pulpotomy or Root Canal Treatment in Mature Teeth with Carious Pulp Exposure: A Multicenter Randomized Controlled Trial

Pain Research and Management ◽

10.1155/2020/5853412 ◽

2020 ◽

Vol 2020 ◽

pp. 1-14

Author(s):

Mohammad Jafar Eghbal ◽

Ali Haeri ◽

Arash Shahravan ◽

Ali Kazemi ◽

Fariborz Moazami ◽

...

Keyword(s):

Postoperative Pain ◽

Pain Relief ◽

Root Canal ◽

Rating Scale ◽

Numerical Rating Scale ◽

Controlled Trial ◽

Mineral Trioxide Aggregate ◽

Preoperative Pain ◽

Multicenter Randomized Controlled Trial ◽

The Mean

This equivalence, randomized, clinical trial aimed to compare the postoperative pain of root canal therapy (RCT) with pulpotomy with mineral trioxide aggregate (PMTA) or calcium-enriched mixture (PCEM) in permanent mature teeth. In seven academic centers, 550 cariously exposed pulps were included and randomly allocated into PMTA (n = 188), PCEM (n = 194), or RCT (n = 168) arms. Preoperative “Pain Intensity” (PI) on Numerical Rating Scale and postoperative PIs until day 7 were recorded. Patients’ demographic and pre-/intra-/postoperative factors/conditions were recorded/analysed. The arms were homogeneous in terms of demographics. The mean preoperative PIs were similar (P=0.998), the mean sum PIs recorded during 10 postoperative intervals were comparable (P=0.939), and the trend/changes in pain relief were parallel (P=0.821) in all study arms. The incidences of preoperative moderate-severe pain in RCT, PMTA, and PCEM arms were 56.5%, 55.7%, and 56.7%, which after 24 hours considerably decreased to 13.1%, 10.6%, and 12.9%, respectively (P=0.578). The time span of endodontic procedures was statistically different; RCT = 69.73, PMTA = 35.37, and PCEM = 33.62 minutes (P<0.001). Patients with greater preoperative pain, symptomatic apical periodontitis, or presence of PDL widening suffered more pain (P=0.002, 0.035, and 0.023, resp.); however, other pre-/intra-/postoperative factors/conditions were comparable. Pulpotomy with MTA/CEM and RCT demonstrate comparable and effective postoperative pain relief.

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Evaluation of pain management in medical transfer of trauma patients by air

CJEM ◽

10.1017/cem.2019.394 ◽

2019 ◽

Vol 21 (6) ◽

pp. 776-783

Author(s):

Isabelle H. Miles ◽

Russell D. MacDonald ◽

Sean W. Moore ◽

James Ducharme ◽

Christian Vaillancourt

Keyword(s):

Pain Management ◽

Adverse Events ◽

Rating Scale ◽

Numerical Rating Scale ◽

Trauma Centre ◽

Air Transport ◽

Future Research ◽

Trauma Patients ◽

Numerical Rating ◽

Standard Deviation Range

ABSTRACTObjectivesWith regionalized trauma care, medical transport times can be prolonged, requiring paramedics to manage patient care and symptoms. Our objective was to evaluate pain management during air transport of trauma patients.MethodsWe conducted a 12-month review of electronic paramedic records from a provincial critical care transport agency. Patients were included if they were ≥18 years old and underwent air transport to a trauma centre, and excluded if they were Glasgow Coma Scale score <14, intubated, or accompanied by a physician or nurse. Demographics, injury description, and transportation parameters were recorded. Outcomes included pain assessment via 11-point numerical rating scale, patterns of analgesia administration, and analgesia-related adverse events. Results were reported as mean ± standard deviation, [range], (percentage).ResultsWe included 372 patients: 47.0 years old; 262 males; 361 blunt injuries. Transport duration was 82.4 ± 46.3 minutes. In 232 (62.4%) patients who received analgesia, baseline numerical rating scale was 5.9 ± 2.5. Fentanyl was most commonly administered at 44.3 [25–60] mcg. Numerical rating scale after first analgesia dose decreased by 1.1 [-2–7]. Thereafter, 171 (73.7%) patients received 2.4 [1-18] additional doses. While 44 (23.4%) patients had no change in numerical rating scale after first analgesia dose, subsequent doses resulted in no change in numerical rating scale in over 65% of patients. There were 43 adverse events recorded, with nausea the most commonly reported (39.5%).ConclusionsInitial and subsequent dose(s) of analgesic had minimal effect on pain as assessed via numerical rating scale, likely due in part to inadequate dosing. Future research is required to determine and address the barriers to proper analgesia.

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Tailoring of neurosurgical ablative procedures in the management of refractory cancer pain

Regional Anesthesia and Pain Medicine ◽

10.1136/rapm-2020-101566 ◽

2020 ◽

Vol 45 (9) ◽

pp. 696-701

Author(s):

Uri Hochberg ◽

Asaf Berger ◽

Miri Atias ◽

Rotem Tellem ◽

Ido Strauss

Keyword(s):

Pain Relief ◽

Cancer Pain ◽

Rating Scale ◽

Numerical Rating Scale ◽

Treatment Plan ◽

Metastatic Cancer ◽

Spinothalamic Tract ◽

Pain Syndromes ◽

Intractable Cancer Pain ◽

Ablative Procedures

IntroductionNeurosurgical ablative procedures can offer immediate and effective pain relief for patients suffering from refractory cancer pain. However, choosing the appropriate procedure for each patient may not be straightforward and warrants an interdisciplinary approach. The purpose of the current study was to evaluate the outcome of patients with cancer who were carefully selected for neurosurgical intervention by a dedicated interdisciplinary team composed of a palliative physician and nurse practitioner, a pain specialist and a neurosurgeon.MethodsA retrospective review was carried out on all patients who underwent neurosurgical ablative procedures in our institute between March 2015 and September 2019. All patients had advanced metastatic cancer with unfavorable prognosis and suffered from intractable oncological pain. Each treatment plan was devised to address the patients’ specific pain syndromes.ResultsA total of 204 patients were examined by our service during the study period. Sixty-four patients with localized pain and nineteen patients with diffuse pain syndromes were selected for neurosurgical interventions, either targeted disconnection of the spinothalamic tract or stereotactic cingulotomy. Substantial pain relief was reported by both groups immediately (cordotomy: Numerical Rating Scale (NRS) 9 ≥1, p=0.001, cingulotomy: NRS 9 ≥2, p=0.001) and maintained along the next 3-month follow-up visits.ConclusionsAn interdisciplinary collaboration designated to provide neurosurgical ablative procedures among carefully selected patients could culminate in substantial relief of intractable cancer pain.Trial registration numberIR0354-17.

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Nebulized morphine for analgesia in an emergency setting

Journal of Opioid Management ◽

10.5055/jom.2009.0003 ◽

2018 ◽

Vol 5 (1) ◽

pp. 23 ◽

Cited By ~ 4

Author(s):

Vincent Bounes, MD ◽

Jean Louis Ducassé, MD ◽

Annie Momo Bona, MD ◽

Florent Battefort, MD ◽

Charles-Henri Houze-Cerfon, MD ◽

...

Keyword(s):

Pain Relief ◽

Acute Pain ◽

Rating Scale ◽

Numerical Rating Scale ◽

Statistical Significance ◽

A Priori ◽

Primary Outcome Measure ◽

Point Estimate ◽

Emergency Setting ◽

Significant Difference

Objective: To evaluate the efficacy and safety of inhaled morphine delivered in patients experiencing severe acute pain in an emergency setting.Patients and Methods: Patients were eligible for inclusion if they were aged 18 years or older, with a severe acute pain defined by a numerical rating scale (NRS) score of 60/100 or higher. The intervention involved administering a single dose of 0.2 mg/kg morphine nebulized using a Misty-Neb nebulizer system. NRSs were recorded and were repeated at 1, 3, 5, and 10 minute after the end of inhalation (T10). The protocol-defined primary outcome measure was pain relief (defined by an NRS score of 30/100 or lower) at T10. Secondary outcomes included differences between pain scores at baseline and at T10 and incidence of adverse events.Results: A total of 28 patients were included in this study. No patient experienced pain relief 10 minutes after the end of inhalation, and no adverse effects were recorded. Respective initial and final median NRS scores were 80 (70-90) and 70 (60-80), p < 0.0001. Despite achieving statistical significance, the value of this point estimate is less than the 14 NRS difference that was defined a priori as representing a minimum clinically significant difference in pain severity.Conclusion: 0.2 mg/kg nebulized morphine is not effective in managing acute pain in an emergency setting. In spite of the potential advantages of the pulmonary route of administration, opioids should be intravenous prescribed at short fixed intervals to control severe acute pain in an emergency setting.

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Remifentanil versus combined spinal-epidural technique for labour analgesia in multiparous women: a prospective non-randomized trial

10.21203/rs.2.21366/v2 ◽

2020 ◽

Author(s):

Tatjana Stopar Pintaric ◽

Tea Zagar ◽

Neli Semrl ◽

Nejc Umek ◽

Miha Lucovnik ◽

...

Keyword(s):

Pain Relief ◽

Randomized Trial ◽

Rating Scale ◽

Numerical Rating Scale ◽

Personal Control ◽

Labour Analgesia ◽

High Rate ◽

Combined Spinal Epidural ◽

Multiparous Women ◽

Spinal Epidural

Abstract Background : Remifentanil has a suitable pharmacological profile for labour analgesia. Fast set up, onset, and limited time efficacy may render it useful in multiparas with a faster labour progression. The objective of this prospective, non-randomized trial was to compare the pain relief for vaginal delivery between remifentanil patient-controlled analgesia (RPCA) with that of combined spinal-epidural analgesia (CSEA) in multiparas. Methods : After making an informed choice of either RPCA or CSEA, 162 multiparous women in the active phase of first-stage labour were enrolled in this study. The primary outcome was pain intensity measured during the whole period of labour using an 11-point numerical rating scale. The secondary outcomes were satisfaction with pain-relief, adverse effects, labour progress and outcomes. Results : CSEA provided lower pain scores and a higher satisfaction rate than RPCA [3.9 (0.36) vs 2.6 (1.1), P <0.001]. Also, more patients opted for the CSEA for their next labour [CSEA; 77 (95%) vs. RPCA; 65 (81%), P =0.003]. However, more than 80% of women in the RPCA group graded their satisfaction as good and very good with a high rate of recommendation and no crossovers observed. Remifentanil was associated with desaturation, bradypnea and apnoea in 27 (34%), 17 (21%) and 20 (25%) respective cases. All recovered spontaneously upon verbal or tactile stimulation. No clinically important differences were noted in sedation level, labour progress and outcomes. Conclusions : CSEA provided superior pain relief compared to RPCA in multiparas. Despite that, remifentanil was highly rated, with a high rate of recommendation and no crossovers to CSEA. That can be attributed to the fact that women with previewed shorter labour were more likely to choose a less invasive analgesic option which provided an element of personal control. Thus, given no difference in labour outcomes, remifentanil could be offered as a routine analgesic option provided rigorous adherence to the necessary protocols are ensured. The presence of a midwife is essential for timely management of respiratory depression or other severe outcomes.

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Addition of Fusion to Decompression for Grade I Degenerative Lumbar Spondylolisthesis is Associated With Greater Patient-Reported Outcome Improvements at Twenty-Four-Month Follow-Up: A Multicenter Study Using the Quality Outcomes Database

Neurosurgery ◽

10.1093/neuros/nyz310_112 ◽

2019 ◽

Vol 66 (Supplement_1) ◽

Author(s):

Jian Guan ◽

Erica F Bisson ◽

Mohamad Bydon ◽

Mohammed A Alvi ◽

Steven D Glassman ◽

...

Keyword(s):

Rating Scale ◽

Numerical Rating Scale ◽

Primary Outcome Measure ◽

Patient Reported Outcome ◽

Leg Pain ◽

Quality Outcomes ◽

Degenerative Lumbar Spondylolisthesis ◽

Patient Reported ◽

Lumbar Spondylolisthesis

Abstract INTRODUCTION Extensive investigation has not ascertained the ideal surgical management of grade 1 lumbar spondylolisthesis. Using the large, multicenter, prospectively collected Quality Outcomes Database (QOD), we compared 24-mo outcomes for patients undergoing decompression alone vs decompression and fusion. METHODS Patients undergoing single-level surgery from 7/1/2014 to 6/30/2016 were identified. The primary outcome measure, 24-mo Oswestry Disability Index (ODI) change, was analyzed with univariate and multivariable linear regression. EQ-5D scores, numerical rating scale (NRS) back and leg pain scores, and North American Spine Society patient satisfaction scores were also analyzed. RESULTS Of the 608 patients (85.5% with at least 24-mo follow-up) who met the inclusion criteria, 140 (23.0%) underwent decompression alone and 468 (77.0%) underwent decompression and fusion. The 24-mo change in ODI was significantly greater in the fusion group than the decompression-only group (−25.8 ± 20.0 vs −15.2 ± 19.8, P < .001). Fusion remained independently associated with 24-mo ODI change in our multivariable model (B = −7.05, 95% CI 10.70-3.39, P = < .001). Patients in the fusion group were significantly more likely to reach minimal clinically important difference (MCID, 12.8 points) in ODI at 24 mo (73.3% vs 56.0%, P = < .001), and to experience significantly greater NRS back pain improvement at 24-mo follow-up (3.8 ± 3.1 vs −1.8 ± 3.9, P < .001). Fusion was also independently associated with achieving MCID for ODI at 24 mo in our logistic regression model (OR 1.767, 95% CI 1.058-2.944, P = .029). CONCLUSION The results of our study suggest that decompression plus fusion may offer superior outcomes to decompression alone in patients with grade 1 lumbar spondylolisthesis at 24 mo. Longer-term follow-up is warranted to assess whether this effect is sustained.

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Global coronal decompensation and adult spinal deformity surgery: comparison of upper-thoracic versus lower-thoracic proximal fixation for long fusions

Journal of Neurosurgery Spine ◽

10.3171/2021.2.spine201938 ◽

2021 ◽

pp. 1-13

Author(s):

Thomas J. Buell ◽

Christopher I. Shaffrey ◽

Han Jo Kim ◽

Eric O. Klineberg ◽

Virginie Lafage ◽

...

Keyword(s):

Thoracic Spine ◽

Spinal Deformity ◽

Rating Scale ◽

Numerical Rating Scale ◽

Adult Spinal Deformity ◽

Leg Pain ◽

Sagittal Vertical Axis ◽

Upper Thoracic ◽

The Impact

OBJECTIVE Deterioration of global coronal alignment (GCA) may be associated with worse outcomes after adult spinal deformity (ASD) surgery. The impact of fusion length and upper instrumented vertebra (UIV) selection on patients with this complication is unclear. The authors’ objective was to compare outcomes between long sacropelvic fusion with upper-thoracic (UT) UIV and those with lower-thoracic (LT) UIV in patients with worsening GCA ≥ 1 cm. METHODS This was a retrospective analysis of a prospective multicenter database of consecutive ASD patients. Index operations involved instrumented fusion from sacropelvis to thoracic spine. Global coronal deterioration was defined as worsening GCA ≥ 1 cm from preoperation to 2-year follow-up. RESULTS Of 875 potentially eligible patients, 560 (64%) had complete 2-year follow-up data, of which 144 (25.7%) demonstrated worse GCA at 2-year postoperative follow-up (35.4% of UT patients vs 64.6% of LT patients). At baseline, UT patients were younger (61.6 ± 9.9 vs 64.5 ± 8.6 years, p = 0.008), a greater percentage of UT patients had osteoporosis (35.3% vs 16.1%, p = 0.009), and UT patients had worse scoliosis (51.9° ± 22.5° vs 32.5° ± 16.3°, p < 0.001). Index operations were comparable, except UT patients had longer fusions (16.4 ± 0.9 vs 9.7 ± 1.2 levels, p < 0.001) and operative duration (8.6 ± 3.2 vs 7.6 ± 3.0 hours, p = 0.023). At 2-year follow-up, global coronal deterioration averaged 2.7 ± 1.4 cm (1.9 to 4.6 cm, p < 0.001), scoliosis improved (39.3° ± 20.8° to 18.0° ± 14.8°, p < 0.001), and sagittal spinopelvic alignment improved significantly in all patients. UT patients maintained smaller positive C7 sagittal vertical axis (2.7 ± 5.7 vs 4.7 ± 5.7 cm, p = 0.014). Postoperative 2-year health-related quality of life (HRQL) significantly improved from baseline for all patients. HRQL comparisons demonstrated that UT patients had worse Scoliosis Research Society–22r (SRS-22r) Activity (3.2 ± 1.0 vs 3.6 ± 0.8, p = 0.040) and SRS-22r Satisfaction (3.9 ± 1.1 vs 4.3 ± 0.8, p = 0.021) scores. Also, fewer UT patients improved by ≥ 1 minimal clinically important difference in numerical rating scale scores for leg pain (41.3% vs 62.7%, p = 0.020). Comparable percentages of UT and LT patients had complications (208 total, including 53 reoperations, 77 major complications, and 78 minor complications), but the percentage of reoperated patients was higher among UT patients (35.3% vs 18.3%, p = 0.023). UT patients had higher reoperation rates of rod fracture (13.7% vs 2.2%, p = 0.006) and pseudarthrosis (7.8% vs 1.1%, p = 0.006) but not proximal junctional kyphosis (9.8% vs 8.6%, p = 0.810). CONCLUSIONS In ASD patients with worse 2-year GCA after long sacropelvic fusion, UT UIV was associated with worse 2-year HRQL compared with LT UIV. This may suggest that residual global coronal malalignment is clinically less tolerated in ASD patients with longer fusion to the proximal thoracic spine. These results may inform operative planning and improve patient counseling.

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Longitudinal clusters of pain and stiffness in polymyalgia rheumatica: 2-year results from the PMR Cohort Study

Rheumatology ◽

10.1093/rheumatology/kez533 ◽

2019 ◽

Vol 59 (8) ◽

pp. 1906-1915

Author(s):

Sara Muller ◽

Rebecca Whittle ◽

Samantha L Hider ◽

John Belcher ◽

Toby Helliwell ◽

...

Keyword(s):

Latent Class ◽

Rating Scale ◽

Numerical Rating Scale ◽

Postal Questionnaire ◽

The Other ◽

Future Research ◽

Partial Recovery ◽

Numerical Rating ◽

Sustained Recovery ◽

Over Time

Abstract Objectives To investigate potential subgroups of primary care–diagnosed patients with PMR based on self-reported pain and stiffness severity over time. Methods A total of 652 people with an incident PMR diagnosis were recruited from English general practices and completed a baseline postal questionnaire. They were followed up with a further six questionnaires over a 2 year period. A total of 446 people completed the 2 year follow-up. Pain and stiffness were reported on a 0–10 numerical rating scale. Latent class growth analysis was used to estimate the joint trajectories of pain and stiffness over time. A combination of statistical and clinical considerations was used to choose the number of clusters. Characteristics of the classes were described. Results Five clusters were identified. One cluster represented the profile of ‘classical’ PMR symptoms and one represented sustained symptoms that may not be PMR. The other three clusters displayed a partial recovery, a recovery followed by worsening and a slow, but sustained recovery. Those displaying classical PMR symptoms were in better overall health at diagnosis than the other groups. Conclusion PMR is a heterogeneous condition, with a number of phenotypes. The spectrum of presentation, as well as varying responses to treatment, may be related to underlying health status at diagnosis. Future research should seek to stratify patients at diagnosis to identify those likely to have a poor recovery and in need of an alternative treatment pathway. Clinicians should be aware of the different experiences of patients and monitor symptoms closely, even where there is initial improvement.

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