Characteristics of patients who dropped out after multidisciplinary pain management in Japan: A prospective cohort study

BACKGROUND: Because regular visits to distant hospitals may be a burden to patients, both in terms of time and cost, some patients with chronic musculoskeletal pain may discontinue multidisciplinary pain treatment, unable to maintain motivation to attend. OBJECTIVE: To evaluate and compare the pre-program characteristics of patients who dropped out and patients who continued treatment, thereby clarifying the characteristics of patients at risk of dropping out. METHODS: A multidisciplinary pain management treatment program was implemented for patients at the Pain Management Center, Hoshi General Hospital. From April 2015 to March 2018, 23 patients participated in the program. Twelve of the 23 patients lived outside the prefecture where the hospital is located. Of these 12 patients, five completed the program, while seven did not. We compared the dropout and continuation groups in terms of patient characteristics, pain severity, pain-related psychosocial factors, and quality of life. RESULTS: We found significant differences (p< 0.05) in median age, Japanese Orthopaedic Association Back Pain Evaluation Questionnaire walking ability dysfunction score, and Roland-Morris Disability Questionnaire score. CONCLUSIONS: The characteristics of patients who dropped out were older age, walking ability dysfunction, and low quality of life associated with low back pain.

Patients’ experiences of occupational therapy within a multidisciplinary pain management programme: A qualitative study

Background Occupational problems are common for adults experiencing chronic pain, but occupational therapists are not always accessed as part of the multidisciplinary team. Despite evidence of benefit for work-focused interventions, there is limited evidence for broader benefit from occupational therapy interventions within the context of multidisciplinary pain management. The aim of this study was to explore the experiences of programme attendees who received structured intervention from an occupational therapist as part of a multidisciplinary pain management programme, and gain an understanding as to how they felt it influenced changes they made to occupational participation. Method A qualitative approach was undertaken with 9 individual patients recruited from a group pain management programme for adults with chronic low back pain. Semi-structured interviews were carried out, recorded and transcribed. Thematic analysis was used to identify themes in the data. Results Three key themes were identified: 1) the helpfulness of activity pacing techniques 2) the value of participating in a therapeutic activity-based session and 3) an increased understanding of the importance of leisure and creative activities in the context of their lives. Conclusion Participants perceived the specific occupational therapy content of the programme to be helpful in a number of different ways. The findings suggest that occupational therapy can be important in facilitating patients to apply theoretical techniques in the real world, thereby increasing the likelihood of long term benefit.

Hyaluronic acid injections for treatment of pediatric sickle cell avascular necrosis of the humeral head

BackgroundAvascular necrosis (AVN) can impact up to 50% of patients with sickle cell disease (SCD) and can result in significant pain, decline in physical function and decreased quality of life. While hyaluronic acid (HA) has been used in the adult population for shoulder osteoarthritic pain, we present the first published pediatric case of HA injections in the glenohumeral joint, used to improve function and pain control.Case presentationThe patient is a 12-year-old woman with SCD, who suffered from chronic pain due to AVN of the humeral and femoral head. Despite engaging in a multidisciplinary pain management plan, she continued to have severe decline in physical functioning and became a wheelchair user. As a result, she was scheduled for a right total hip arthroplasty, which necessitated aggressive postoperative therapies using the glenohumeral joint. To improve this pain and to facilitate postoperative recovery, the patient underwent 4 weekly HA injections into the glenohumeral joint. Over a 2-month period, the patient was able to improve physical functioning, decrease opiate use and participate in all postoperative therapies.ConclusionConservative options to improve functioning and pain are especially important in pediatric patients where it may be desirable to delay surgical interventions until skeletal maturity. Our case report demonstrates the benefits of intra-articular HA as part of a multidisciplinary pain management plan to improve function and decrease pain related to AVN of the humeral head. Future studies should assess the long-term benefits of HA injections for AVN in the setting of SCD.

What is the content of virtually delivered pain management programmes for people with persistent musculoskeletal pain? A systematic review

Introduction: Virtual consultations (VC) have been embraced by healthcare organisations during the COVID-19 pandemic. VC allows continuation of patient care while adhering to government advised restrictions and social distancing measures. Multidisciplinary pain management programmes (PMPs) are a core element of many pain services and utilising virtual methods to deliver PMPs has allowed them to continue to provide care. This systematic review aimed to explore the content of existing virtually delivered PMPs and discuss if and how these findings can be used to guide clinical delivery. Methods: Eligible studies included adults (aged ⩾18 years) with persistent musculoskeletal pain and any virtually delivered intervention that was described as a PMP or that had components of PMPs. Databases were searched from inception until July 2020. We performed a content analysis comparing existing interventions with established evidence-based clinical guidelines published by the British Pain Society (BPS). Intervention reporting quality was assessed using the Template for Intervention Description and Replication (TIDieR) checklist: an established checklist developed to improve the completeness of the reporting of interventions. Results: Eight studies were included. One intervention included six of the seven components recommended by the BPS; none included all seven. ‘Skills training and activity management’ was present in all eight interventions; ‘education’ and ‘cognitive therapy methods’ were present in six interventions; ‘graded activation’ and ‘methods to enhance acceptance, mindfulness and psychological flexibility’ were present in four interventions; ‘physical exercise’ was present in two interventions and ‘graded exposure’ was present in one intervention. None of the studies described all 12 items of the TIDieR checklist adequately enough for replication. Conclusion: Published virtual PMPs partially meet established clinical guidelines. Future virtual PMPs should be based on evidence-based clinical guidelines, and more research is needed to explore the effectiveness of virtually delivered PMPs and each recommended component.

Pain in sickle cell disease

Sickle cell disease (SCD) presents a potentially complex pain disorder to clinicians. Pain from vaso-occlusion of sickle erythrocytes can occur in multiple musculoskeletal locations, several internal viscera such as the spleen, and the penis. Such pain is typically intermittent in childhood, shares features of acute pain with other pain disorders, and often responds to nonsteroidal anti-inflammatory drugs and opioid analgesics. Adolescents with SCD often experience more frequent pain, and those with bone disease in spine, hips, or shoulders may experience chronic pain. Like other chronic pain disorders, this pain often responds poorly to opioids, but there is limited current clinical or research data to support alternative medications. Many cognitive behavior strategies are helpful as part of multidisciplinary pain management, particularly in adolescents, who may also benefit from psychological support to treat coexistent mood disorders, to increase coping skills, and to support appropriate school and family functioning. Future advances in pharmacological and psychological therapies are needed to ameliorate the substantial burden of pain in children and adolescents with SCD.

A single bout of coordination training does not lead to EIH in young healthy men – a RCT

ObjectivesPhysical activity can lead to hypoalgesic effects and is often recommended as part of multidisciplinary pain management. Based on the idea, that in future specific and more differentiated sports therapeutic interventions could be used for a multidisciplinary pain management, various type of sports and their effects on pain sensitivity should be analysed. Whereas endurance as well as strengthening exercises are associated with a decrease in pain sensitivity in healthy people as well as people with chronic pain states, the effects of a specific coordination training (CT) on pain sensitivity have not yet been sufficiently investigated. Therefore, aim of the present study was to examine if a single bout of CT leads to exercised-induced hypoalgesia in young healthy men.MethodsThirty five healthy men (mean age 27 ± 3 years) were examined in a randomised crossover design before and after a single bout of 45-min CT and a 45-min resting session as control condition by means of Quantitative Sensory Testing (QST). The QST is a validated instrument to assess the function of the somatosensory system, by applying thermal and mechanical stimuli. By doing so, various detection and pain thresholds were determined at the dorsum of one foot. Exercises of CT were chosen to generate high proprioceptive input for the ankle joints.ResultsAnalysis of the QST data in respect of the factors group (CT/control condition), time (pre/post) and stimuli (parameter of QST) revealed no statistically significant main effects of a single bout of CT on somatosensory system, neither for the factors group*time (p=0.51), nor the factors group*time*stimuli (p=0.32). All stimuli remained constant in the course of both conditions (e.g. mean ± sd of heat pain threshold pre/post in °C: coordination: 44.7 ± 3.1/44.8 ± 2.9; rest: 45.5 ± 3.0/44.9 ± 3.0).ConclusionsIn this setting, a single bout of CT had no effect on the somatosensory system in young healthy men. Therefore, this specific CT did not lead to an exercised-induced hypoalgesia in healthy people. Intensity of sensory input during training intervention might be too low to generate analgesic effects in a non-pathological altered somatosensory system of young healthy men. Further research is needed to clarify if a CT can induce exercised-induced hypoalgesia in people with pathological alterations of the somatosensory system. In addition, it has to examined if analgesic effects can be induced by changing the intensity of CT in healthy people. Detailed knowledge regarding the effects of different training interventions on pain modulation is needed to completely understand the mechanism of exercised-induced hypoalgesia.