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Cephalalgia : An International Journal... Apr 2024Many risk factors have been associated with migraine progression, including insufficient and ineffective utilization of migraine medications; however, they have been... (Review)
Review
BACKGROUND
Many risk factors have been associated with migraine progression, including insufficient and ineffective utilization of migraine medications; however, they have been inadequately explored. This has resulted in suboptimal usage of medications without effective altering of prescribing recommendations for patients, posing a risk for migraine chronification.
METHODS
Our aim is to conduct a comprehensive review of the available evidence regarding the underuse of migraine medications, both acute and preventive. The term "underuse" includes, but is not limited to: (1) ineffective use of appropriate and inappropriate medication; (2) underutilization; (3) inappropriate timing of usage; and (4) patient dissatisfaction with medication.
RESULTS
The underuse of both acute and preventive medications has been shown to contribute to the progression of migraine. In terms of acute medication, chronification occurs as a result of insufficient drug use, including failure of the prescriber to select the appropriate type based on pain intensity and disability, patients taking medication too late (more than 60 minutes after the onset or after central sensitization has occurred as evidenced by allodynia), and discontinuation because of lack of effect or intolerable side effects. The underlying cause of inadequate effectiveness of acute medication lies in its inability to halt the propagation of peripheral activation to central sensitization in a timely manner. For oral and injectable preventive migraine medications, insufficient efficacy and intolerable side effects have led to poor adherence and discontinuation with subsequent progression of migraine. The underlying pathophysiology here is rooted in the repetitive stimulation of afferent sensory pain fibers, followed by ascending brainstem pain pathways plus dysfunction of the endogenous descending brainstem pain inhibitory pathway. Although anti-calcitonin gene-related peptide (CGRP) medications partially address pain caused by the above factors, including decreased efficacy and tolerability from conventional therapy, some patients do not respond well to this treatment. Research suggests that initiating preventive anti-CGRP treatment at an early stage (during low frequency episodic migraine attacks) is more beneficial than commencing it during high frequency episodic attacks or when chronic migraine has begun.
CONCLUSIONS
The term "medication underuse" is underrecognized, but it holds significant importance. Optimal usage of acute care and preventive migraine medications could potentially prevent migraine chronification and improve the treatment of migraine attacks.
Topics: Humans; Headache; Migraine Disorders; Pain; Risk Factors; Brain Stem; Calcitonin Gene-Related Peptide
PubMed: 38613233
DOI: 10.1177/03331024241245658 -
Journal of Pain and Symptom Management Sep 2023Pain is common among cancer patients. The evidence recommends using strong opioids in moderate to severe cancer pain. No conclusive evidence supports the effectiveness... (Randomized Controlled Trial)
Randomized Controlled Trial
CONTEXT
Pain is common among cancer patients. The evidence recommends using strong opioids in moderate to severe cancer pain. No conclusive evidence supports the effectiveness of adding acetaminophen to patients with cancer pain who are already using this regime.
OBJECTIVES
To assess the analgesic efficacy of acetaminophen in hospitalized cancer patients with moderate to severe pain receiving strong opioids.
METHODS
In this randomized blinded clinical trial, hospitalized cancer patients with moderate or severe acute pain managed with strong opioids were randomized to acetaminophen or placebo. The primary outcome was pain intensity difference between baseline and 48 hours using the Visual Numeric Rating Scales (VNRS). Secondary outcomes included change in morphine equivalent daily dose (MEDD), and patients' perception of improved pain control.
RESULTS
Among 112 randomized patients, 56 patients received placebo, 56 acetaminophen. Mean (standard deviation [SD]) decrease in pain intensity (VNRS) at 48 hours were 2.7 (2.5) and 2.3 (2.3), respectively (95% Confidence Interval (CI) [-0.49; 1.32]; P = 0.37). Mean (SD) change in MEDD was 13.9 (33.0) mg/day and 22.4 (57.7), respectively (95% CI [-9.24; 26.1]; P = 0.35). The proportion of patients perceiving pain control improvement after 48 hours was 82% in the placebo and 80% in the acetaminophen arms (P = 0.81).
CONCLUSION
Among patients with cancer pain on strong opioid regime, acetaminophen may not improve pain control, or decrease total opioid use. These results add to the current evidence available suggesting not to use acetaminophen as an adjuvant for advanced cancer patients with moderate to severe cancer pain who are on strong opioids.
Topics: Humans; Acetaminophen; Analgesics, Opioid; Analgesics, Non-Narcotic; Cancer Pain; Morphine; Acute Pain; Neoplasms; Double-Blind Method; Pain, Postoperative
PubMed: 37207788
DOI: 10.1016/j.jpainsymman.2023.05.002 -
The Cochrane Database of Systematic... Aug 2023Low back pain (LBP) is the leading cause of disability globally. It generates considerable direct costs (healthcare) and indirect costs (lost productivity). The many... (Review)
Review
BACKGROUND
Low back pain (LBP) is the leading cause of disability globally. It generates considerable direct costs (healthcare) and indirect costs (lost productivity). The many available treatments for LBP include exercise therapy, which is practised extensively worldwide.
OBJECTIVES
To evaluate the benefits and harms of exercise therapy for acute non-specific low back pain in adults compared to sham/placebo treatment or no treatment at short-term, intermediate-term, and long-term follow-up.
SEARCH METHODS
This is an update of a Cochrane Review first published in 2005. We conducted an updated search for randomised controlled trials (RCTs) in CENTRAL, MEDLINE, Embase, four other databases, and two trial registers. We screened the reference lists of all included studies and relevant systematic reviews published since 2004.
SELECTION CRITERIA
We included RCTs that examined the effects of exercise therapy on non-specific LBP lasting six weeks or less in adults. Major outcomes for this review were pain, functional status, and perceived recovery. Minor outcomes were return to work, health-related quality of life, and adverse events. Our main comparisons were exercise therapy versus sham/placebo treatment and exercise therapy versus no treatment.
DATA COLLECTION AND ANALYSIS
We used standard Cochrane methods. We evaluated outcomes at short-term follow-up (time point within three months and closest to six weeks after randomisation; main follow-up), intermediate-term follow-up (between nine months and closest to six months), and long-term follow-up (after nine months and closest to 12 months); and we used GRADE to assess the certainty of the evidence for each outcome.
MAIN RESULTS
We included 23 studies (13 from the previous review, 10 new studies) that involved 2674 participants and provided data for 2637 participants. Three small studies are awaiting classification, and four eligible studies are ongoing. Included studies were conducted in Europe (N = 9), the Asia-Pacific region (N = 9), and North America (N = 5); and most took place in a primary care setting (N = 12), secondary care setting (N = 6), or both (N = 1). In most studies, the population was middle-aged and included men and women. We judged 10 studies (43%) at low risk of bias with regard to sequence generation and allocation concealment. Blinding is not feasible in exercise therapy, introducing performance and detection bias. There is very low-certainty evidence that exercise therapy compared with sham/placebo treatment has no clinically relevant effect on pain scores in the short term (mean difference (MD) -0.80, 95% confidence interval (CI) -5.79 to 4.19; 1 study, 299 participants). The absolute difference was 1% less pain (95% CI 4% more to 6% less), and the relative difference was 4% less pain (95% CI 20% more to 28% less). The mean pain score was 20.1 (standard deviation (SD) 21) for the intervention group and 20.9 (SD 23) for the control group. There is very low-certainty evidence that exercise therapy compared with sham/placebo treatment has no clinically relevant effect on functional status scores in the short term (MD 2.00, 95% CI -2.20 to 6.20; 1 study, 299 participants). The absolute difference was 2% worse functional status (95% CI 2% better to 6% worse), and the relative difference was 15% worse (95% CI 17% better to 47% worse). The mean functional status score was 15.3 (SD 19) for the intervention group and 13.3 (SD 18) for the control group. We downgraded the certainty of the evidence for pain and functional status by one level for risk of bias and by two levels for imprecision (only one study with fewer than 400 participants). There is very low-certainty evidence that exercise therapy compared with no treatment has no clinically relevant effect on pain or functional status in the short term (2 studies, 157 participants). We downgraded the certainty of the evidence by two levels for imprecision and by one level for inconsistency. One study associated exercise with small benefits and the other found no differences. The first study was conducted in an occupational healthcare centre, where participants received one exercise therapy session. The other study was conducted in secondary and tertiary care settings, where participants received treatment three times per week for six weeks. We did not pool data from these studies owing to considerable clinical heterogeneity. In two studies, there were no reported adverse events. One study reported adverse events unrelated to exercise therapy. The remaining studies did not report whether any adverse events had occurred. Owing to insufficient reporting of adverse events, we were unable to reach any conclusions on the safety or harms related to exercise therapy.
AUTHORS' CONCLUSIONS
Exercise therapy compared to sham/placebo treatment may have no clinically relevant effect on pain or functional status in the short term in people with acute non-specific LBP, but the evidence is very uncertain. Exercise therapy compared to no treatment may have no clinically relevant effect on pain or functional status in the short term in people with acute non-specific LBP, but the evidence is very uncertain. We downgraded the certainty of the evidence to very low for inconsistency, risk of bias concerns, and imprecision (few participants).
Topics: Adult; Male; Middle Aged; Female; Humans; Low Back Pain; Exercise Therapy; Acute Pain; Exercise; Asia; Randomized Controlled Trials as Topic
PubMed: 37646368
DOI: 10.1002/14651858.CD009365.pub2 -
BMJ (Clinical Research Ed.) Jul 2023
Topics: Humans; Knee Joint; Knee; Acute Pain; Osteoarthritis, Knee
PubMed: 37414429
DOI: 10.1136/bmj-2023-075577 -
The Cochrane Database of Systematic... Dec 2023Postherpetic neuralgia (PHN) is a common, serious, painful complication of herpes zoster. Corticosteroids have anti-inflammatory properties, and might be beneficial.... (Review)
Review
BACKGROUND
Postherpetic neuralgia (PHN) is a common, serious, painful complication of herpes zoster. Corticosteroids have anti-inflammatory properties, and might be beneficial. This is an update of a review first published in 2008, and previously updated in 2013.
OBJECTIVES
To assess the effects (benefits and harms) of corticosteroids in preventing postherpetic neuralgia.
SEARCH METHODS
We updated the searches for randomised controlled trials (RCTs) of corticosteroids for preventing postherpetic neuralgia in the Cochrane Neuromuscular Specialised Register, CENTRAL, MEDLINE, Embase, two other databases, and two trials registers (June 2022). We also reviewed the bibliographies of identified trials, contacted authors, and approached pharmaceutical companies to identify additional published or unpublished data.
SELECTION CRITERIA
We included all RCTs involving corticosteroids given by oral, intramuscular, or intravenous routes for people of all ages, with herpes zoster of all degrees of severity within seven days after onset, compared with no treatment or placebo, but not with other treatments.
DATA COLLECTION AND ANALYSIS
Two review authors independently identified potential articles, extracted data, assessed the risk of bias of each trial, and the certainty of the evidence. Disagreement was resolved by discussion among the co-authors. We followed standard Cochrane methodology.
MAIN RESULTS
We identified five trials with a total of 787 participants that met our inclusion criteria. No new studies were identified for this update. All were randomised, double-blind, placebo-controlled parallel-group studies. The evidence is very uncertain about the effects of corticosteroids given orally during an acute herpes zoster infection in preventing postherpetic neuralgia six months after the onset of herpes (risk ratio (RR) 0.95, 95% confidence interval (CI) 0.45 to 1.99; 2 trials, 114 participants; very low-certainty evidence (downgraded for serious risk of bias and very serious imprecision)). The three other trials that fulfilled our inclusion criteria were not included in the meta-analysis because they did not provide separate information on the number of participants with PHN at six months. Adverse events during or within two weeks after stopping treatment were reported in all five included trials. There were no observed differences in serious (RR 1.65, 95% CI 0.51 to 5.29; 5 trials, 755 participants; very low-certainty evidence (downgraded for serious risk of bias and very serious imprecision)), or non-serious adverse events (RR 1.30, 95% CI 0.90 to 1.87; 5 trials, 755 participants; low-certainty evidence (downgraded for serious risk of bias and serious imprecision)) between the corticosteroid and placebo groups. One of these trials was at high risk of bias because of incomplete outcome data, two were at unclear risk of bias, and the other was at low risk of bias. The review was first published in 2008; no new RCTs were identified for inclusion in subsequent updates in 2010, 2013, and 2023.
AUTHORS' CONCLUSIONS
Based on the current available evidence, we are uncertain about the effects of corticosteroids given orally during an acute herpes zoster infection on preventing postherpetic neuralgia. Corticosteroids given orally or intramuscularly may result in little to no difference in the risk of adverse events in people with acute herpes zoster. Some researchers have recommended using corticosteroids to relieve the zoster-associated pain in the acute phase of the disease. If further research is designed to evaluate the efficacy of corticosteroids for herpes zoster, long-term follow-up should be included to observe their effect on the transition from acute pain to postherpetic neuralgia. Future trials should include measurements of function and quality of life, as well as updated measures of pain.
Topics: Humans; Infant, Newborn; Adrenal Cortex Hormones; Herpes Zoster; Neuralgia, Postherpetic; Randomized Controlled Trials as Topic
PubMed: 38050854
DOI: 10.1002/14651858.CD005582.pub5 -
American Family Physician Aug 2023Acute pelvic pain is defined as noncyclic, intense pain localized to the lower abdomen and/or pelvis, with a duration of less than three months. Signs and symptoms are...
Acute pelvic pain is defined as noncyclic, intense pain localized to the lower abdomen and/or pelvis, with a duration of less than three months. Signs and symptoms are often nonspecific. The differential diagnosis is broad, based on the patient's age and pregnancy status and gynecologic vs. nongynecologic etiology. Nongynecologic etiologies include gastrointestinal, urinary, and musculoskeletal conditions. Urgent gynecologic conditions include ectopic pregnancy, ruptured ovarian cyst, adnexal torsion, and pelvic inflammatory disease. Approximately 40% of ectopic pregnancies are misdiagnosed at the presenting visit. Urgent nongynecologic conditions include appendicitis and pyelonephritis. Less urgent etiologies include sexually transmitted infections, pelvic floor myofascial pain, dysmenorrhea, and muscle strain. Approximately 15% of untreated chlamydia infections lead to pelvic inflammatory disease. History and physical examination findings guide laboratory testing. Questions should focus on the type, onset, location, and radiation of pain; timing and duration of symptoms; aggravating and relieving factors; and associated symptoms. Performing a urine pregnancy test or beta human chorionic gonadotropin test is an important first step for sexually active, premenopausal patients. Imaging options should be considered, with transvaginal ultrasonography first, followed by computed tomography. Magnetic resonance imaging can be useful if ultrasonography and computed tomography are nondiagnostic.
Topics: Female; Humans; Pregnancy; Pelvic Inflammatory Disease; Pelvic Pain; Acute Pain; Chorionic Gonadotropin, beta Subunit, Human; Dysmenorrhea; Pregnancy, Ectopic
PubMed: 37590858
DOI: No ID Found -
International Journal of Sports... 2024In musculoskeletal and sports medicine, pain has traditionally been linked to tissue injury, often assuming a linear correlation between tissue damage and pain...
UNLABELLED
In musculoskeletal and sports medicine, pain has traditionally been linked to tissue injury, often assuming a linear correlation between tissue damage and pain intensity. However, modern pain science has illuminated the complexity of the human pain experience, incorporating psychosocial elements, nervous system sensitization, immune responses, and structural changes in the brain as factors. This contemporary understanding of pain has proven highly beneficial for both clinicians treating individuals in pain and those experiencing pain. Pain neuroscience education (PNE) provides individuals in pain with an understanding of the underlying neurobiology and neurophysiology of their pain experience, which has been shown to result in decreased self-reported pain, reduced disability, the alleviation of fear and fear-avoidance behaviors, diminished pain catastrophizing, and improved movement. Currently, research on PNE predominantly focuses on interventions with individuals with persistent or chronic pain conditions. However, those who experience acute, sub-acute, and perioperative pain also have the potential for elevated levels of fear, fear-avoidance, and pain catastrophizing, indicating potential benefits from PNE. This invited commentary seeks to inform readers about the latest advancements in pain science and propose a conceptual model for delivering PNE in acute pain experiences.
LEVEL OF EVIDENCE
5.
PubMed: 38835986
DOI: 10.26603/001c.118179