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JAMA Network Open Feb 2021Acute low back pain (LBP) is highly prevalent, with a presumed favorable prognosis; however, once chronic, LBP becomes a disabling and expensive condition. Acute to...
IMPORTANCE
Acute low back pain (LBP) is highly prevalent, with a presumed favorable prognosis; however, once chronic, LBP becomes a disabling and expensive condition. Acute to chronic LBP transition rates vary widely owing to absence of standardized operational definitions, and it is unknown whether a standardized prognostic tool (ie, Subgroups for Targeted Treatment Back tool [SBT]) can estimate this transition or whether early non-guideline concordant treatment is associated with the transition to chronic LBP.
OBJECTIVE
To assess the associations between the transition from acute to chronic LBP with SBT risk strata; demographic, clinical, and practice characteristics; and guideline nonconcordant processes of care.
DESIGN, SETTING, AND PARTICIPANTS
This inception cohort study was conducted alongside a multisite, pragmatic cluster randomized trial. Adult patients with acute LBP stratified by SBT risk were enrolled in 77 primary care practices in 4 regions across the United States between May 2016 and June 2018 and followed up for 6 months, with final follow-up completed by March 2019. Data analysis was conducted from January to March 2020.
EXPOSURES
SBT risk strata and early LBP guideline nonconcordant processes of care (eg, receipt of opioids, imaging, and subspecialty referral).
MAIN OUTCOMES AND MEASURES
Transition from acute to chronic LBP at 6 months using the National Institutes of Health Task Force on Research Standards consensus definition of chronic LBP. Patient demographic characteristics, clinical factors, and LBP process of care were obtained via electronic medical records.
RESULTS
Overall, 5233 patients with acute LBP (3029 [58%] women; 4353 [83%] White individuals; mean [SD] age 50.6 [16.9] years; 1788 [34%] low risk; 2152 [41%] medium risk; and 1293 [25%] high risk) were included. Overall transition rate to chronic LBP at six months was 32% (1666 patients). In a multivariable model, SBT risk stratum was positively associated with transition to chronic LBP (eg, high-risk vs low-risk groups: adjusted odds ratio [aOR], 2.45; 95% CI, 2.00-2.98; P < .001). Patient and clinical characteristics associated with transition to chronic LBP included obesity (aOR, 1.52; 95% CI, 1.28-1.80; P < .001); smoking (aOR, 1.56; 95% CI, 1.29-1.89; P < .001); severe and very severe baseline disability (aOR, 1.82; 95% CI, 1.48-2.24; P < .001 and aOR, 2.08; 95% CI, 1.60-2.68; P < .001, respectively) and diagnosed depression/anxiety (aOR, 1.66; 95% CI, 1.28-2.15; P < .001). After controlling for all other variables, patients exposed to 1, 2, or 3 nonconcordant processes of care within the first 21 days were 1.39 (95% CI, 1.21-2.32), 1.88 (95% CI, 1.53-2.32), and 2.16 (95% CI, 1.10-4.25) times more likely to develop chronic LBP compared with those with no exposure (P < .001).
CONCLUSIONS AND RELEVANCE
In this cohort study, the transition rate to chronic LBP was substantial and increased correspondingly with SBT stratum and early exposure to guideline nonconcordant care.
Topics: Acute Pain; Adult; Aged; Analgesics, Opioid; Anxiety Disorders; Chronic Pain; Depressive Disorder; Diagnostic Imaging; Disease Progression; Female; Guideline Adherence; Humans; Low Back Pain; Male; Middle Aged; Obesity; Odds Ratio; Practice Guidelines as Topic; Primary Health Care; Prognosis; Referral and Consultation; Risk Factors; Smoking; United States
PubMed: 33591367
DOI: 10.1001/jamanetworkopen.2020.37371 -
JAMA Network Open Aug 2021The inclusion of digital therapeutics (eg, virtual reality [VR] systems) for the management of pain and anxiety associated with routine acutely painful medical... (Randomized Controlled Trial)
Randomized Controlled Trial
Effect of an Immersive Virtual Reality Intervention on Pain and Anxiety Associated With Peripheral Intravenous Catheter Placement in the Pediatric Setting: A Randomized Clinical Trial.
IMPORTANCE
The inclusion of digital therapeutics (eg, virtual reality [VR] systems) for the management of pain and anxiety associated with routine acutely painful medical procedures may have a substantial impact on treatment adherence and improve long-term health outcomes among young patients.
OBJECTIVE
To determine whether a VR intervention decreases pain and anxiety among patients undergoing peripheral intravenous catheter (PIVC) placement compared with standard care in the pediatric setting.
DESIGN, SETTING, AND PARTICIPANTS
This randomized clinical trial was conducted from April 12, 2017, to July 24, 2019, among 107 patients aged 10 to 21 years who were undergoing PIVC placement in 2 clinical settings (a radiology department and an infusion center) at an urban pediatric academic medical center in the US. Patients, caregivers, and clinicians completed pre-PIVC and post-PIVC placement questionnaires measuring patient pain, anxiety, and anxiety sensitivity; only participants with complete data from before and after PIVC placment were included in the analyses.
INTERVENTIONS
Patients were randomized to receive standard care (simple distraction techniques [eg, music, coloring, singing, and talking] and the application of numbing cream) or a VR intervention using a balanced computer-generated randomization scheme stratified by sex. All patients who received the VR intervention were offered concurrent standard care; however, VR plus standard care was not specifically examined.
MAIN OUTCOMES AND MEASURES
Primary outcomes were patient pain (measured by the Faces Pain Scale-Revised) and anxiety (measured by a visual analogue scale) reported by the patient, caregiver, and clinician after PIVC placement. Outcomes were analyzed using generalized linear modeling with backward stepwise selection for final model building.
RESULTS
A total of 107 patients (median age, 14.7 years [interquartile range, 12.8-16.9 years]; 63 male participants [58.9%]) completed the clinical trial; 54 patients received standard care, and 53 patients also received the VR intervention. Patients who received the VR intervention compared with standard care had significantly lower mean post-PIVC anxiety scores when patient-reported (1.85 points [95% CI, 1.28-2.41 points] vs 3.14 points [95% CI, 2.59-3.68 points]; P < .001) and clinician-reported (2.04 points [95% CI, 1.37-2.71 points] vs 3.34 points [95% CI, 2.69-3.99 points]; P = .002). Patients in the VR group vs the standard care group also had significantly lower mean post-PIVC pain scores when patient-reported (1.34 points [95% CI, 0.63-2.05 points] vs 2.54 points [95% CI, 1.78-3.30 points]; P = .002), caregiver-reported (1.87 points [95% CI, 0.99-2.76 points] vs 3.01 points [95% CI. 1.98-4.03 points]; P = .04), and clinician-reported (2.05 points [95% CI, 1.47-2.63 points] vs 3.59 points [95% CI, 2.97-4.22 points]; P < .001). Aside from lower levels of baseline pain and anxiety, no demographic variables among patients in the VR group were associated with lower levels of post-PIVC pain and anxiety.
CONCLUSIONS AND RELEVANCE
In this randomized clinical trial, patients undergoing PIVC placement who received a VR intervention experienced significantly less anxiety and pain compared with those who received standard care. The use of patient, caregiver, and clinician data provided a variety of subjective information, as well as observable and objective data regarding perceived pain and anxiety beyond patient reporting alone.
TRIAL REGISTRATION
ClinicalTrials.gov Identifier: CHLA-15-00549.
Topics: Acute Pain; Adolescent; Adult; Anxiety Disorders; Catheterization, Peripheral; Child; Female; Humans; Los Angeles; Male; Pain Management; Patient Education as Topic; Virtual Reality Exposure Therapy; Young Adult
PubMed: 34432011
DOI: 10.1001/jamanetworkopen.2021.22569 -
The British Journal of Radiology Nov 2021Acute pelvic pain (APP) requires urgent medical evaluation and treatment. Differential diagnosis of APP is broad, including a variety of gynecologic and non-gynecologic/... (Review)
Review
Acute pelvic pain (APP) requires urgent medical evaluation and treatment. Differential diagnosis of APP is broad, including a variety of gynecologic and non-gynecologic/ urinary, gastrointestinal, vascular and other entities. Close anatomical and physiological relations of pelvic structures, together with similar clinical presentation of different disorders and overlapping of symptoms, especially in the emergency background, make the proper diagnosis of APP challenging. Imaging plays a crucial role in the fast and precise diagnosis of APP. Ultrasonography is the first-line imaging modality, often accompanied by CT, while MRI is utilized in specific cases, using short, tailored protocols. Recognizing the cause of APP in females is a challenging task, due to the wide spectrum of possible origin and overlap of their imaging features. Therefore, the radiologist has to be familiar with the possible causes of APP, and, relying on clinical presentation, together with laboratory findings, choose the best imaging strategy in order to establish a fast and accurate diagnosis.
Topics: Acute Pain; Diagnostic Imaging; Female; Gastrointestinal Diseases; Genital Diseases, Female; Humans; Male; Pelvic Pain; Urologic Diseases; Vascular Diseases
PubMed: 34491817
DOI: 10.1259/bjr.20210281 -
JAMA Network Open Nov 2021The use of intercostal nerve block (ICNB) analgesia with local anesthesia is common in thoracic surgery. However, the benefits and safety of ICNB among adult patients... (Meta-Analysis)
Meta-Analysis
IMPORTANCE
The use of intercostal nerve block (ICNB) analgesia with local anesthesia is common in thoracic surgery. However, the benefits and safety of ICNB among adult patients undergoing surgery is unknown.
OBJECTIVE
To evaluate the analgesic benefits and safety of ICNB among adults undergoing thoracic surgery.
DATA SOURCES
A systematic search was performed in Ovid MEDLINE, Ovid Embase, Scopus, and the Cochrane Library databases using terms for ICNB and thoracic surgery (including thoracic surgery, thoracoscopy, thoracotomy, nerve block, intercostal nerves). The search and results were not limited by date, with the last search conducted on July 24, 2020.
STUDY SELECTION
Selected studies were experimental or observational and included adult patients undergoing cardiothoracic surgery in which ICNB was administered with local anesthesia via single injection, continuous infusion, or a combination of both techniques in at least 1 group of patients. For comparison with ICNB, studies that examined systemic analgesia and different forms of regional analgesia (such as thoracic epidural analgesia [TEA], paravertebral block [PVB], and other techniques) were included. These criteria were applied independently by 2 authors, and discrepancies were resolved by consensus. A total of 694 records were selected for screening.
DATA EXTRACTION AND SYNTHESIS
This study followed the Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) reporting guideline. Data including patient characteristics, type of surgery, intervention analgesia, comparison analgesia, and primary and secondary outcomes were extracted independently by 3 authors. Synthesis was performed using a fixed-effects model.
MAIN OUTCOMES AND MEASURES
The coprimary outcomes were postoperative pain intensity (measured as the worst static or dynamic pain using a validated 10-point scale, with 0 indicating no pain and 10 indicating severe pain) and opioid consumption (measured in morphine milligram equivalents [MMEs]) at prespecified intervals (0-6 hours, 7-24 hours, 25-48 hours, 49-72 hours, and >72 hours). Clinically relevant analgesia was defined as a 1-point or greater difference in pain intensity score at any interval. Secondary outcomes included 30-day postoperative complications and pulmonary function.
RESULTS
Of 694 records screened, 608 were excluded based on prespecified exclusion criteria. The remaining 86 full-text articles were assessed for eligibility, and 20 of those articles were excluded. All of the 66 remaining studies (5184 patients; mean [SD] age, 53.9 [10.2] years; approximately 59% men and 41% women) were included in the qualitative analysis, and 59 studies (3325 patients) that provided data for at least 1 outcome were included in the quantitative meta-analysis. Experimental studies had a high risk of bias in multiple domains, including allocation concealment, blinding of participants and personnel, and blinding of outcome assessors. Marked differences (eg, crossover studies, timing of the intervention [intraoperative vs postoperative], blinding, and type of control group) were observed in the design and implementation of studies. The use of ICNB vs systemic analgesia was associated with lower static pain (0-6 hours after surgery: mean score difference, -1.40 points [95% CI, -1.46 to -1.33 points]; 7-24 hours after surgery: mean score difference, -1.27 points [95% CI, -1.40 to -1.13 points]) and lower dynamic pain (0-6 hours after surgery: mean score difference, -1.66 points [95% CI, -1.90 to -1.41 points]; 7-24 hours after surgery: mean score difference, -1.43 points [95% CI, -1.70 to -1.17 points]). Intercostal nerve block analgesia was noninferior to TEA (mean score difference in worst dynamic panic at 7-24 hours after surgery: 0.79 points; 95% CI, 0.28-1.29 points) and marginally inferior to PVB (mean score difference in worst dynamic pain at 7-24 hours after surgery: 1.29 points; 95% CI, 1.16 to 1.41 points). The largest opioid-sparing effect of ICNB vs systemic analgesia occurred at 48 hours after surgery (mean difference, -10.97 MMEs; 95% CI, -12.92 to -9.02 MMEs). The use of ICNB was associated with higher MME values compared with TEA (eg, 48 hours after surgery: mean difference, 48.31 MMEs; 95% CI, 36.11-60.52 MMEs) and PVB (eg, 48 hours after surgery: mean difference, 3.87 MMEs; 95% CI, 2.59-5.15 MMEs).
CONCLUSIONS AND RELEVANCE
In this study, single-injection ICNB was associated with a reduction in pain during the first 24 hours after thoracic surgery and was clinically noninferior to TEA or PVB. Intercostal nerve block analgesia had opioid-sparing effects; however, TEA and PVB were associated with larger decreases in postoperative MMEs, suggesting that ICNB may be most beneficial for cases in which TEA and PVB are not indicated.
Topics: Acute Pain; Analgesia, Epidural; Anesthesia, Epidural; Female; Humans; Intercostal Nerves; Male; Nerve Block; Pain, Postoperative; Thoracic Surgical Procedures
PubMed: 34779845
DOI: 10.1001/jamanetworkopen.2021.33394 -
Medicine Nov 2022Pain is the most common complaint in the dental field and may have a significant impact on the patients' quality of life. However, objective pain assessment is sometimes... (Review)
Review
Pain is the most common complaint in the dental field and may have a significant impact on the patients' quality of life. However, objective pain assessment is sometimes difficult, and medical and dental clinicians may encounter cases of pain in the head and neck region, making it difficult to establish differential diagnoses. This study aimed to review acute pain in clinical dentistry at each phase of dental procedures and discuss the current status and issues in the development of acute dental pain assessment methods in the future. Acute pain in clinical dentistry may differ in nature and modifying conditions of pain at each stage: before dental procedures, while visiting dentists, and during and after dental procedures. They are related to actual or potential tissue damage, and may be modified and aided by personal experiences, including psychological and social factors. With respect to the aging and multinational population and pandemic of infectious diseases, significant breakthroughs in the development of new pain scales without verbal descriptions are desirable. Furthermore, it is expected that a new pain scale that can be applied to acute pain in the head and neck regions, including the oral cavity, will be developed.
Topics: Humans; Acute Pain; Quality of Life; Pain Measurement
PubMed: 36397373
DOI: 10.1097/MD.0000000000031727 -
The Journal of Pain Jul 2019
Topics: Acute Pain; Humans; Pain Measurement
PubMed: 30639193
DOI: 10.1016/j.jpain.2018.12.002 -
Journal of Feline Medicine and Surgery Jan 2022
Topics: Acute Pain; Animals; Pain Management
PubMed: 34937454
DOI: 10.1177/1098612X211066266 -
Sports Health 2020With increased use of cannabis-based products by the public for both recreational and medical use, sports medicine clinicians should be informed of historical context,... (Review)
Review
CONTEXT
With increased use of cannabis-based products by the public for both recreational and medical use, sports medicine clinicians should be informed of historical context, current legal considerations, and existing evidence with regard to efficacy, safety, and risks in the athletic community.
EVIDENCE ACQUISITION
A review of ClinicalTrials.gov, MEDLINE, and CINAHL from 2015 to present was conducted with emphasis on the most recent literature using search terms, . Bibliographies based on original search were utilized to pursue further literature search.
STUDY DESIGN
Clinical review.
LEVEL OF EVIDENCE
Level 3.
RESULTS
At present, limited high-quality studies exist for use of cannabinoids for acute pain, chronic pain, or concussion. None of the trials involving cannabinoids included the athletic population. Thus, results from this clinical review are extrapolated to conditions of the sports medicine population. For acute pain, 2 small-randomized double-blinded crossover trials concluded no immediate effect of cannabinoid therapy. More robust evidence exists for treatment of chronic pain conditions through meta-analysis and systemic reviews. Cannabinoid therapy exhibits moderate efficacy as a treatment for some chronic pain conditions. Investigations included a broad spectrum of chronic pain conditions, including neuropathic, musculoskeletal, inflammatory, and central pain conditions, and reveal reduction in pain and improvement of quality of life with limited adverse effects. For concussion, evidence is based on preclinical in vitro and animal models revealing possible neuroprotective effects as well as 2 clinical studies involving the presence of cannabinoids for concussion (some sports-related), but there are no high-quality trials evaluating efficacy for treatment with cannabinoids at this time.
CONCLUSION
Although various biochemical explanations exist on the use of cannabinoid therapy through modulation of the endocannabinoid system for several medical issues affecting athletes, recommendations from clinicians must be extrapolated from a majority of research done in the nonathletic population. Lack of strong-quality clinical evidence, coupled with inconsistent federal and state law as well as purity issues with cannabis-based products, make it difficult for the sports medicine clinician to widely recommend cannabinoid therapeutics at present. Future larger, higher quality clinical research studies with standardized pure extracts will better guide appropriate medical use going forward. At present, evidence for a multitude of therapeutic applications is emerging for cannabinoid treatment approaches. With emphasis placed on patient-centered clinical decisions, cannabinoids hold promise of treatment for athletes with chronic pain conditions. Clinicians who treat the athletic community must consider legal and ethical issues when discussing and recommending the use of cannabinoids, with acknowledgment of inconsistencies in purity of various formulations and concerns of drug testing.
Topics: Acute Pain; Athletic Injuries; Brain Concussion; Cannabinoids; Chronic Pain; Evidence-Based Medicine; Humans; Marijuana Use; Medical Marijuana; Pain Management; United States
PubMed: 32936058
DOI: 10.1177/1941738120956604 -
Clinical Medicine (London, England) Jul 2022Older adults may experience a number of physiological changes that influence how acute pain is perceived, diagnosed and managed by healthcare professionals....
Older adults may experience a number of physiological changes that influence how acute pain is perceived, diagnosed and managed by healthcare professionals. Understanding these differences enables the identification, assessment and treatment of acute pain in older adults. Combining careful selection of pain medications with appropriate titration and monitoring allows the analgesic needs of this group to be met.
Topics: Acute Pain; Aged; Analgesics; Humans; Pain Management; Pain Measurement
PubMed: 35882483
DOI: 10.7861/clinmed.22.4.ac-p -
Current Pain and Headache Reports Sep 2023Optimal treatment requires a thorough understanding of all factors contributing to pain in the individual patient. In this review, we investigate the influence of... (Review)
Review
PURPOSE OF REVIEW
Optimal treatment requires a thorough understanding of all factors contributing to pain in the individual patient. In this review, we investigate the influence of cultural frameworks on pain experience and management.
RECENT FINDINGS
The loosely defined concept of culture in pain management integrates a predisposing set of diverse biological, psychological and social characteristics shared within a group. Cultural and ethnic background strongly influence the perception, manifestation, and management of pain. In addition, cultural, racial and ethnic differences continue to play a major role in the disparate treatment of acute pain. A holistic and culturally sensitive approach is likely to improve pain management outcomes, will better cover the needs of diverse patient populations and help reduce stigma and health disparities. Mainstays include awareness, self-awareness, appropriate communication, and training.
Topics: Humans; Acute Pain; Ethnicity; Pain Management; Social Stigma
PubMed: 37405553
DOI: 10.1007/s11916-023-01125-2