News Category: Pain

The author suggests that the notion that pain is purely a sensory phenomenon is flawed. That in fact, patients with pain also differ in how they behave. Persons with pain report higher levels of physical and emotional distress, and suffering. The author proposes that persons in pain also act differently from persons without pain. Facial expressions, moans or sighs, guarding or rubbing the affected body part, altered gait pattern are typical behaviors. As behavioral programs are being increasingly recognized as part of pain treatment, the author feels that the conceptualization of pain should also include behavior as a defining feature.

Pain behavior is described as specific body movements enacted during the experience of pain. Two main behavior systems include a communicative behavior system and a protective behavior system. Behaviors that display distress relate information about the internal state of the individual, physical limitations, and needs for assistance. Facial grimacing and vocalizations such as groans and sighs are examples. Protective pain behaviors are those actions that are intended to reduce the likelihood of further injury, reduce the experience of pain, or are perceived to promote recovery from injury.

Research has shown that persons with underlying depression, or those who tend to catastrophize will display more intense facial responses to painful stimuli. The most common protective pain behavior is withdrawal. Protective behaviors can be reflexive or can be a more dramatic, larger display of behavior. Behaviors that function to protect, or promote recovery after injury include such things as holding or guarding the body part, guarding or minimized movements, altered gait. Protective pain behaviors such as avoidance of activities that are associated with pain can be a major contributor to disability.

The author feels that the dysfunction that is manifest in behavioral systems may be functionally separate from pain sensation. Therefore, treatments geared to reducing pain sensation may not be effective. He proposes that classifying the various dimensions of pain behavior into profiles would promote tailoring of interventions with the hope of reducing disability.

Nitric oxide (NO) is known to be both helpful and harmful in our bodies. Nitric oxide is produced from enzymes called nitric oxide synthases. There are several types of these enzymes. One of the isoenzymes is called constitutive nitric oxide synthase (cNOS). It is felt that cNOS is decreased in joints with osteoarthritis. Harmful nitric oxide is produced by an isoenzyme called inducible nitric oxide synthase (iNOS). As a response to trauma or wear and tear, iNOS may be increased.

The pain of osteoarthritis tends to lead to loss of movement, disability, decreased quality of life, and can be costly. Many pain-relieving medications have significant side effects or are not very effective for analgesia. Several non-pharmacological modalities have been shown to reduce pain in osteoarthritis. The authors propose that the use of monochromatic infrared photo energy (MIRE) can be a useful physical therapy treatment for osteoarthritis. Pain relief is a goal, as well as improvement or reversal of the osteoarthritis pathology. MIRE is believed to increase the production of NO in joints by the cNOS pathway.

The authors of the study propose that the use of MIRE produces energy at an 890 nm wavelength, applied at the skin surface can be absorbed in to blood vessels. Treatment involves the placement of pads containing 60 near-infrared diodes over the joint for 30 minutes. The authors propose that blood flow can be increased, inflammation can be decreased, and nerve excitability may be decreased by NO produced from cNOS after treatment with MIRE. They propose that chemical changes after treatment with MIRE can increase blood flow for as long as three hours.

Case studies have shown that treatment of knee osteoarthritis with MIRE can decrease pain, improve quality of life, and had no detrimental side effects. The authors also feel that MIRE may improve the underlying osteoarthritis pathology. Controlled clinical studies have not been conducted on the use of MIRE however.

More than 20 percent of people in the United States, age 35 years or older, have complained of chronic knee pain. Many complain of multiple sites, making musculoskeletal pain a common complaint. On the other hand, many who don’t have or complain of pain do have osteoarthritis but they don’t know it, while yet others have minor disability but experience and complain of severe pain.

Because of the perceived differences in pain, proper assessment is needed in order to provide adequate care for each individual. The authors of this article describe the development and validation of a multidimensional assessment tool called the Pain Standard Evaluation Questionnaire (SEQ Pain). the SEQ Pain was developed to aid in assessing pain location, pain intensity, pain during activity, pain triggers, onset and frequency.

To formulate the questionnaire, researchers selected 10 questionnaires currently in use for assessing musculoskeletal pain. Using these questionnaires, an expert panel (one rheumatologist, two orthopedic surgeons, and one clinical epidemiologist) evaluated the questions, coming up with 18 items that they felt were necessary for the initial PSEQ.

These new questionnaires were sent out to patients with chronic musculoskeletal pain and a second was sent out to a certain number of patients, in order to test for reliability.

Because the questionnaire was meant for the general public, the questions were not specific as to a specific joint, for example. Instead, the questions focused on what types of activities caused the pain in what part or region of the body.

The questionnaire was added on until the final version was approved. Using three subscales, the respondents indicated which regions of the body were most affected: back and neck, upper extremities, or lower extremities.The researchers found that leaving 11 days between the first test and the second was too long because of the possible coming and going of acute pain episodes and changes in pain intensity. That being said, the authors did feel that the test reliability was high for the extremities (upper and lower) but not with the chest and stomach.

The researchers found that the final version of the SEQ Pain, with 28 items, was a reliable and valid method of assessing musculoskeletal pain.

The issue of empathy has intrigued scientists and researchers and they have been trying to determine the impact of empathy on pain.

In light of recent studies that have demonstrated a connection between pain and observing someone else in pain, the authors of this article predicted that “the empathetic states would induce sensitization of cortical areas” involved in the perception of pain.

Researchers recruited 48 subjects, aged between 18 and 31 years, to experience painful or non-painful stimuli while watching videos designed to make the subject feel neutral about an actor, compassionate or negative.

A fourth video was of the actor experiencing pain or not experiencing pain, alternating in two-minute segments. All subjects watched one of the first three and the fourth video. While watching the fourth video, the subjects experienced painful stimuli (heat) to one hand.

Using a 10-point Visual Analog scale (VAS), where 0 means no pain and 10 means the most severe possible, the subjects rated their own pain levels and estimated the actor’s pain level.

The subjects were asked to complete two trait empathy questionnaires, the Interpersonal Reactivity Index and the Balanced Emotional/Empathy Scale.

The results showed that the groups that watched the video designed to evoke compassion (Positive Affective Link, or AFF+) and those who watched the low empathy video (Negative Affective Line, or AFF-) did not have any differences in their pain ratings at baseline (before the “pain” video), however, after the “pain” video was viewed, subjects who had seen the AFF+ video reported a higher pain sensation than did those who watched the AFF- video. The more they empathized with the actor, the higher the pain level.

The authors concluded that their findings support pervious study finding and that empathy does play a role in intensity of pain, as well as in pain processing.

TENS, transcutaneous electrical nerve stimulation, is an increasingly popular non-medication pain treatment, but there has not yet been any definitive studies regarding its effect on chronic pain.

There are several causes of chronic pain, but the two mechanisms are muscle and joint tissue pain and nerve pain. The authors of this study examined the effects of TENS and if researchers could predict if high intensity TENS would be successful in patients with chronic pain.

Researchers recruited 163 subjects who had chronic noncancer pain. These subjects were divided into three groups, those with:

– osteoarthritis, osteoporosis, bursitis, or tendonitis
– peripheral neuropathic pain, nerve pain
– bone, soft tissue, and visceral (organs in the body) pain

The subjects were then randomized to receive either high intensity TENS or a sham treatment that looked identical to the TENS. They received 10 days of treatment and were assessed before and after the 10-day period.

The researchers evaluated whether the patients were satisfied with the TENS treatment and the pain intensity before and after. Pain levels were measured using a Visual Analog Scale (VAS), a scale from zero to 10, with zero being no pain and 10 being the most severe pain possible.

Disability from the pain was measured using the Pain Disability Index (PDI), also a scale from zero to 10, with zero being no disability and 10 being total disability. Pain coping was measured with the Pain Coping Inventory (PCI), while pain cognition was measured with the Pain Cognition List. Finally, depression was measured with the Beck Depression Inventory (BDI).

The results showed the subject satisfaction varied significantly in the TENS group compared with the sham group, but no significant differences were seen in pain intensity between the two groups. Fifty-eight percent of the TENS group and 42 percent of the sham group were satisfied with the treatment result. Those who had injuries to the bone or soft tissues were the most satisfied.

The authors wrote that predicting the effect of the treatment depended on what the researchers were looking for. For example, they expected osteoarthritis to have better results than they actually did.

Scientists around the world are studying pain mechanisms of all kinds. In this article, the characteristics and causes of muscle pain are reviewed. Methods used to conduct experiments to better understand pain are explained.

For example, muscle pain can be evoked by internal versus external sources. Ischemia (decreased blood flow) and exercise are two ways to induce muscle pain. Electrical stimulation and mechanical and chemical causes of muscle pain are also discussed.

Exploring the causes and effects of muscle pain in an experimental fashion has shown researchers many new things. For example, muscle hyperactivity is not caused by muscle pain in the normal adult. But for someone with chronic musculoskeletal pain, increased electrical activity has been measured in the muscles. This occurs both at rest and after activity.

Recent studies have shown us that muscle pain can alter motor control. Muscle pain can cause changes in muscle coordination and changes in motor strategies. The exact effects depend on the specific motor task.

Maximal muscle contractions are less in people with muscle pain. But this is not as a result of changes in the muscle fibers. It appears to be a central effect. That means there has been a change in the motor control function (not in the muscle itself). Messages from the brain and/or spinal cord result in fewer motor units firing.

At the same time, muscle activity of other muscles that work together with the primary (painful) muscle are also inhibited. As a result, tenderness and referred pain in chronic musculoskeletal disorders are common.

The new information that motor control is affected by muscle pain has been a major breakthrough discovery. Experimental models of muscle pain will continue to help us understand how and why pain becomes chronic. Finding clues to stop pain messages is the desired effect. New treatment interventions for chronic pain may be the final outcome.

Scientists around the world are looking for the best way to treat chronic pain patients. But finding evidence that supports the best practice model isn’t always easy. In this article, researchers from the Netherlands ask the question, Are we measuring what we need to measure?

Many quality studies with high levels of evidence don’t provide guidance for real life situations. Patients may be given one type of treatment for the duration of the study. If the symptoms get worse or they aren’t helped, they must still finish out the study. In clinical practice, changes are made right away in treatment based on patient needs, wants, and individual characteristics.

Sometimes research results reported depend on how the study was conducted. How the data was collected, measured, and analyzed can make a difference. It’s not uncommon for different approaches to yield different results for the same group. How do we know which interpretation is correct?

Because of these problems and other research dilemmas, there’s no best evidence for the treatment of chronic pain at this time. It’s agreed that the goal is to find the right treatment for the right patient at the right time. Sometimes the best way to do that is to take a look back at results after the fact.

By looking at the patients who had the best results, it may be possible to identify common factors for success. These may be physical, behavioral, social, or a specific combination of these three variables. The presence of such characteristics may lead to the development of a clinical prediction rule (CPR).

A clinical prediction rule says that patients with the identified factor have the best chance of a good result with treatment. This is how subgroup classifications of patients are formed. Once the subgroups have been found, then researchers try to match treatment to the patients in those groups.

Experts working with chronic pain patients rely on various tools, surveys, and questionnaires. They use these to assess level of disability, presence of behavioral factors, or impaired movement. Any one of these items can interfere with physical activity and function. But there is not a screening instrument that can be used to help match patients to treatment yet.

Patient preferences must be taken into consideration. Their beliefs and attitudes can affect how they respond to treatment. Even the best practice approach recognizes that pain doesn’t always improve when evidence-based treatment is applied. Individuals experience and respond to pain in different ways based on cultural beliefs and values.

And finally, doctors use their clinical expertise and experience combined with best evidence to formulate their practice. But studies show that their treatment approach is often based on what they learned during their formal training. They may not be keeping up with the most recent best practice guidelines.

Having reviewed the many difficulties in today’s search for best practice and evidence-based practice, the authors remind us of the importance of the patient. We must seek evidence but use it to guide (not dictate) clinical practice. Each patient must be evaluated one at a time. But don’t expect one size (treatment) to fit all.

In this article, new ideas and research around the topic of pain are presented. A summary is provided of papers presented at the first Pain, Mind, and Movement conference. This conference was sponsored by the International Association for the Study of Pain (IASP). It was held in Cairns, Australia in 2005.

The overall theme of the conference was on the mechanisms, measurement, and management of chronic pain. The basic premise was that pain is a multidimensional problem. Chronic pain is both a symptom and a pathologic condition. It involves the mind, movement, and behavior.

Newer models of pain use a biologic-psychologic-motor control idea of movement related to pain. This is shortened to the biopsychomotor conceptual model. This model recognizes the complexity of pain and the human response to pain.

More recent experimental research has focused on the muscle’s response to painful stimuli. Scientists have found that painful muscles do not have increased electrical activity when at rest. This is contrary to previous beliefs. Painful muscles do, however, show a decrease in range of motion, force, and endurance. And pain doesn’t just occur in the muscles. Other tissues are also affected.

Virtual reality has a place in pain management. Perceived pain can be reduced with this technique. Research is just beginning to explore this novel area. The marriage of science and technology continues to drive research efforts to find better ways to treat pain.

Virtual reality is an analgesic intervention. It uses concepts of distraction, expectation, and belief systems to provide patients with an effective pain management tool. As discussed at the 11th World Congress of Pain conference, pain, mind, and movement are just a few of the important factors to consider when studying, understanding, measuring, and managing pain as a problem.

With the increase in use of intrathecal pain pumps for pain and spasticity, the author of a recent report highlights that there is a small but significant number of problems due to their use. One such complication is the formation of an inflammatory mass called a granuloma at the tip end of the catheter. The catheter tip is placed in the spinal canal so in some cases has caused neurological problems such as weakness and even paralysis. Catheter tip granulomas are thought to occur at a rate of three percent presently. This complication is expected to increase with the growing number of patients having the device implanted, and as patients receive infusions for longer periods of time.

Morphine for pain, and baclofen for spasticity, are the most common medications delivered by the intrathecal pump. Granuloma formation seems to be less common in those using baclofen. Ziconotide is a newer medication approved for use in chronic pain. It was felt that granulomas may be the result of compounding, or using a combination of medications as well as medications that were approved for use in the intrathecal pump. However, studies have shown that high doses and concentrations of morphine increase the risk for granuloma. This risk has also been shown to be cumulative over time.

Other complications include malfunction of the intrathecal pump; fracture, clogging, and dislodgement of the catheter, and human error to include accidental overdose.

New catheter materials, sensors to monitor amount of drug in the pump, and improved pump reliability are some of the new technologies that should improve patient safety.

The authors of this study suggest that enriched enrolment with randomised withdrawal (EERW), be used in drug studies, particularly analgesics for chronic pain patients. Individual response to a drug can be influenced by genetic differences, particularly in the metabolism of drugs. The authors feel that conventional clinical trials may not be adequate in assessing efficacy of a certain drug given some subjects may be non-responders to the drug. The risk is that false conclusions may be made due to lack of efficacy in traditional studies. Consequently, some drugs may not be approved that could be of benefit to those that are responders.

EERW designs are more sensitive than conventional designs that lower the proportion of responders. In typical randomised trials, the risk is that non-responders dilute the outcomes in terms of efficacy of a drug. The authors suggest that patients should be trialed on a drug first and those that have satisfactory response and at worst tolerable adverse effects are then randomised into the study. After randomisation, they are compared to a control group.

The authors feel that the EERW study design, using only those subjects that are known to be responders is more ideal. This may ensure that people will not be denied an effective treatment simply because results are diluted by non-responders in more traditional study designs.

Spinal cord stimulation has been an option to treat persistent neuropathic pain following back surgery. However, the battery life is between two to five years. This means that the patient has to undergo the expense, discomfort, and possible complications when having the battery replaced.

A new spinal cord stimulation system with a rechargeable power source may last ten to 25 or more years. The authors of the study projected the lifetime costs of the two systems using Medicare rates in 2006. While the newer, rechargeable system is initially more costly, the authors felt that the cost was offset in four years. They felt that the lifetime cost savings with the rechargeable system was approximately 100,000 to 150,000 US Dollars. In addition to the cost savings, patients would need far fewer replacement procedures, have less discomfort as a result, and be exposed to fewer possible complications.

Chronic pain can mean many things to many different people. Often, pain is termed chronic when it has reached a certain duration of time, such as three or six months. A group in the United States has attempted to develop a newer way of defining chronic pain that includes risk assessment and prognosis. The authors of the study then sought to see if this approach could be used in the United Kingdom.

The prediction as to whether pain will become chronic is felt to include psychosocial risk factors, distress, and preoccupation with body symptoms. These are also known as yellow flags. This newer approach predicts the probability of pain becoming chronic and significant in terms of disability. This allows for the identification of patients that would benefit from psychological and behavioral interventions. Being pain free is not always the goal, but having less pain severity and disability are desired goals.

In the UK study, 426 adults, age 30 to 59 years old were given questionnaires that assessed severity of pain, impact in daily life, pain duration, the presence of pain elsewhere than the back, and depression. These same areas were assessed in the original US study.

Risk was categorized as low, intermediate, possible chronic pain, and probable chronic pain. There were some differences found in the risk score groups between the US sample and the UK sample. Six percent of subjects in the US study were classified as being in the probable chronic back pain category. In the UK study, twenty-two percent of the sample were in this category. While thirty one percent of the US sample population were in the low risk category, eleven percent of the UK sample were in this category. This difference was not felt to be due to methods used, or sampling techniques.

While results were different among the two studies, the authors felt that this assessment approach that allows for prognosis of chronic pain is useful, and is generalisable to other similar populations other than in the US. This approach is thought to be especially reliable for the classification of people at high risk of having clinically significant back pain.

Complex regional pain syndrome (CRPS), a disorder that is not yet understood by doctors, can cause severe pain to a limb following a trauma, including surgery. Some patients who undergo carpal tunnel release do develop CRPS I following the surgery. This brings about a concern if these patients require a second surgery for carpel tunnel, something that is not uncommon.

The authors of this study examined the relative risk of CRPS in patients who had developed CRPS once before following the surgery. They wanted to see if there were signs that may show them that this may happen.

Researchers recruited 34 patients who had experienced CRPS following carpal tunnel release and who had been successfully treated. To be eligible for the study, the patient had to have at least one of the following: hand numbness, weakness in the thumb, or any of the diagnostic signs for carpal tunnel syndrome. Each patient’s hand was examined with laser Doppler imaging a few days before surgery and then again between 19 to 22 days after surgery.

The patients were divided into two groups, depending in the test findings. During the doppler examination, the researchers watched for signs of sweating or temperature change in response to the patient taking a deep gasp of air and holding the breath to stimulate such a reaction. Patients who did not have a reaction were put into group 1 and those who did have a reaction, were put into group 2.

When looking at the findings after the second surgery, the researchers found that eight of 11 patients in group 1 had developed recurrent CRPS, while only three of the 23 patients in group 2 did. Each patient who did develop CRPS was successfully treated. The authors wrote, “We attribute this success to the timely diagnosis and treatment of this condition.” They conclude that CRPS can recur following hand surgery and that it may be able to identify those at highest risk of recurrence.

More and more older adults are seeking help for their chronic low back pain outside of traditional medical practices. Complementary and alternative approaches to medicine (CAM) are a source of hope to many. These mind-body techniques include Reiki therapy, acupuncture, BodyTalk, Shiatsu massage, meditation therapy, and many others.

In this study, one of the methods called mindfulness meditation is used with a group of older adults (65 years old and older). All subjects had moderately intense low back pain every day or nearly every day for the last three months or more.

Everyone was in a weekly mindfulness meditation group for 90 minutes. The session was led by trained health professionals. A daily home program of guided meditation was also prescribed and followed. Three specific meditation practices were taught including a body scan, sitting practice, and walking meditation. Each of these techniques was described in this article.

A second group was used as the comparison (control) group. They met the same requirements for the study but were placed on a waiting list. No treatment or meditation techniques were given to this group until after the study was completed.

Since this was a pilot study, many different variables were tested and measured. These included pain intensity, acceptance of pain, and physical function. Sleep, concentration, and quality of life (QOL) were also reviewed. All measures were taken before, right after, and three months after treatment.

Sixty-eight per cent of the subjects completed the program from start to finish. This was a measure of adherence, which was of interest to the researchers. They wanted to know if older adults would complete such a program. The authors suggest that greater compliance would have been possible. But other health and family obligations got in the way for some participants.

Differences in pain, physical function, and QOL were not significant before and after treatment. But the results in these areas were better when compared with the control group who got worse over time. More than half in the treatment group reported being able to sleep and concentrate better after treatment. They were able to take less medication for their pain and sleep problems.

Many of the older adults continued the meditation practice. Tests showed the treatment group had a higher rate of acceptance of their pain compared with the control group. This means they were able to let go of the struggle, accept the pain, and avoid judging themselves.

The authors conclude that an eight-week meditation program is possible with community-based older adults. Sustained improvements in physical function and pain acceptance may be expected. Mind-body therapy such as meditation may be a way to help reduce dependence on pain medications. Learning to live with chronic pain may help seniors stay active longer.

In this study, researchers used a self-report survey tool called the Brief Pain Inventory (BPI) to compare two groups of pain patients. The first group included cancer patients (men and women). Some had primary cancer (e.g., breast, lung, prostate, bladder, GI). Others had metastatic cancer (spread from the primary area to other parts of the body).

The second group included men and women with noncancer chronic pain (NCCP). Areas affected included back, neck, and local musculoskeletal areas. Everyone in both groups filled out the BPI. Pain was rated in intensity and as interference with function. Function was broken down into seven sections. General activity, mood, walking ability, normal work, relations with other people, sleep, and quality of life were included in the sections.

The goal of the study was to see if and how pain interferes with function for these two groups of patients. The BPI was used because it measures pain intensity and pain’s interference with functions.

The authors report that cancer patients had higher levels of pain interference with physical functions. The NCCP patients had more interference with psychologic functions. NCCP patients have had to cope with pain for much longer than cancer patients. They may have learned how to adapt better.

Cancer patients report interference with function from the effects of the disease, not just from pain. This may be because cancer patients often have many more symptoms than just pain. Chronic pain patients usually only have the pain to deal with.

This study helped point out that the type of diagnosis can affect the level of health-related quality of life. Pain intensity associated with cancer had a much greater effect on pain interference with function. Pain intensity is not as valuable of an assessment measure for NCCP patients.

Researchers from Harvard Medical School got a surprise this year. They studied the use of acupuncture for the treatment of arm pain from repetitive strain injuries (RSI). The expected result was that the patients treated with acupuncture would have better outcomes than those treated with sham (placebo) acupuncture.

The actual results showed that the sham acupuncture treatment reduced arm pain in patients more effectively than for those patients in the actual acupuncture group. The patients in both groups had forearm and/or hand pain for three months or more from repetitive use.

Each group received eight treatments over a four-week period of time. The sham group had what looked like a real acupuncture needle. But in reality, it had a blunt (not sharp) tip. The tip of the needle touched the skin but wasn’t inserted into the skin. The true acupuncture group had skin penetration with real needles. The patients did not know if they were getting true acupuncture or sham acupuncture treatments.

The authors offer some thoughts on the results. First, they pointed out that the groups were no different in terms of symptoms, sex, or level of education at the start of the study.

Both groups got better with treatment. The sham group improved more in pain intensity and severity. Arm function and grip strength were not better with one treatment over the other. An equal number of patients in both groups reported pain as a side effect of treatment.

It’s not clear why the sham group had better results than the true acupuncture group. Discomfort from the needles in the true acupuncture group may have made a difference. And the sham needles may have delivered an acupressure effect.

Acupuncture experts suggested that the treatment wasn’t long enough. Other studies have shown that true acupuncture takes longer than four weeks to be most effective. And after one month, the two groups were equal in terms of pain, symptoms, and function. More study is needed to find out when to use acupuncture and for how long.

Many treatment methods have been devised to treat chronic pain. But the Therapeutic Interactive Voice Response (TIVR) may be the first to prevent relapse months later.

The TIVR is an automated, telephone-based tool used for patients with chronic musculoskeletal pain. It was developed at the University of Vermont along with Duke University Medical School.

Patients using the TIVR were treated first in an 11-week cognitive-behavioral therapy (CBT) program. CBT included education about pain and the effect of chronic pain on people. Coping strategies using new patterns of thought and feelings were part of each CBT session. CBT also included relaxation, pacing, and distraction techniques. The importance of social support was also discussed.

Once the CBT was completed, then the patients did four months of the TIVR program. A second (control) group was used to compare the results of TIVR. The control group received CBT but not TIVR.

CBT recognizes the need to practice coping skills on a regular (even daily) basis. The TIVR has four parts to give patients the kind of daily self-monitoring needed to be successful in pain management. The program is accomplished using a touch-tone telephone to call-in.

These four components include 1) a set of 21 questions to answer every day (self-monitoring), 2) reminder of eight coping skills learned during CBT, 3) a guided session of coping skills that can be practiced, and 4) personalized return messages from a CBT therapist. The last part (monthly encouragement and feedback from the therapist) is based on a review of the patient’s daily report.

Both groups improved after CBT. Pain, function, disability, and coping were used to measure the results. Medication use (pain relievers, antiinflammatories, antidepressants) was also monitored before and after treatment.

The control group then declined and got worse over the next four months. At the same time, the CBT plus TIVR group did not relapse (get worse). In fact, the TIVR group continued to get better for months after the TIVR ended.

The results of this study support the use of a self-monitoring follow-up program after CBT for patients with chronic pain. Mastering the skill and improved self-monitoring may be what made the difference. After learning new coping skills, the TIVR made it possible for patients to continue practicing those skills.

Further research may validate the use of the TIVR as a tool to prevent pain behavior relapse. Future studies will determine if all four components of the TIVR are needed for success. It may be that patients only need one or two of the steps provided.

Buprenoprine, a medication that has been successfully used in patients who are fighting opioid addictions may also be an effective analgesic when used in the sublingual form.

A semisynthetic opioid, buprenorphine has a wider safety profile compared with other full opioid agonists. There also appear to be fewer issues with withdrawal when treatment with buprenorphine is discontinued.

Although the medication has an effect that can last for more than 24 hours when being used as treatment for opioid addiction, for pain relief, studies show that buprenorphine works best at three or four times a day dosages, sublingually.

Physicians who wish to prescribe buprenorphine as a treatment for opioid dependence, in the United States, may prescribe it with or without naloxone, but the physician must be a certified or specially trained physician who has received a waiver fro the requirement to register as a narcotic treatment program from the Center for Substance Abuse Treatment of the Substance Abuse and Mental Health Services Administration. However, off-label use of buprenorphine (Suboxone/Subutex) does not have the same requirements of the prescribing physicians. In order to prevent confusion with the pharmacy, however, it is best if the physician writes Chronic pain patient, or off-label use, in order to clarify the prescription.

When treating a patient with opioid addiction and who has pain, the approach will change according to the type of pain. The groups of pain are: anticipated acute pain (such as impending surgery), unanticipated acute pain (trauma), acute pain superimposed on chronic pain, and chronic pain.

When treating the pain, one issue is if the patient is NPO, fasting, as buprenorphine may not be a viable option, and other medications, such as oral transmucosal fentanyl lozenge, may be considered. For chronic pain, both with superimposition of acute pain or chronic pain alone, the divided doses of buprenorphine should be titrated to effect and in cases of acute pain, assisted with an immediate release/rapid-onset opioid.

The authors of this article point out that buprenorphine can be used effectively to treat patients how have pain as well as the disease of opioid addiction. By understanding the pharmacokinetics of buprenorphine, it is possible to prescribe the appropriate medications in the appropriate doses for this group of patients.

When chronic pain cannot be resolved with medications and treatment, self-management may help decrease the intensity of the pain and increase the ability to cope with it. Earlier studies have shown that use of a program called Therapeutic Interactive Voice Response (TIVR) was beneficial for patients for a short period. The authors of this study wanted to see if a TIVR-based intervention could have good effects over a longer period, increasing treatment compliance and adherence, allowing for better outcomes to treatment.

The researchers enrolled 50 patients who had history of chronic pain. After the patients participated in a cognitive behavioral therapy (CBT) program to work on decreasing maladaptive behavior associated with pain and helping patients use attention diversions and activity patterns, they were randomized into two equal groups, one that would participate in the TIVR program and the other would not.

The TIVR system consisted of four parts: daily self-monitoring through a questionnaire, an instructional review of coping skills and techniques, pre-recorded behavioral rehearsals of coping skills, and monthly feedback from a CBT who based the review on the daily reports received for each patient.

Patient assessments were done through the McGill Pain Questionnaire (MPQ) and the Enhanced SF-36 Total Pain Symptoms (TOPS). After the patients were randomized, the treatment group continued on with the TIVR program. The daily questionnaire consisted of 21 questions to be completed by phone. Questions cover topics such as pain medications used during that day, stress, and daily coping. The instructional review was available to the patients that helped reinforce the eight pain management techniques they learned during the CBT sessions. The third part of the program, the guided behavior rehearsal allowed patients to access rehearsals of the eight coping techniques through the phone. Finally, every month, the therapist would review the responses and use of reviews and rehearsals, and record pertinent messages individual to each patient.

The researchers found that, overall, the treatment group had a statistically significant improvement in maintaining all outcomes than did the control group. They continued to maintain improvements in the four months after the treatment period ended – a total of eight months since the start of the study. Although the non-treatment group did show improvement during the CBT sessions before the randomization, this was not maintained in the four months of the study.

The patients were assessed before the study, before the randomization, after the study, and again at eight months after the study began.

The authors acknowledged that there may have been some improvement in some patients because of medication use and the do point out some weaknesses in the study: the group was small and the study follow-up was short. However, the authors conclude that using TIVR as a coping skill could help in managing skills to cope with chronic pain and to help in controlling relapses.

This study examined maladaptive pain-related fear-avoidance and endurance coping in patients with chronic back pain. Endurance coping was defined as the tendency to endure severe pain to finish current activities irrespective of pain increases. 120 subjects referred for treatment of chronic pain where classified as dysfunctional, interpersonally distressed, or adaptive copers using the Multidimensional Pain Inventory.

The authors intended to evaluate whether the above subgroups differed with respect to maladaptive pain-related fear-avoidance coping and endurance coping. They also sought to investigate thought suppression and endurance behavior among the subgroups.

88 percent of the subjects were classified into one of the three subgroups. 16 percent were in the dysfunctional group, 24 percent in the interpersonally distressed group, and 62 percent in the adapative coper group.

New treatment and assessment approaches emphasize the positive association between positive mood, acceptance, and adjustment. Cognitive behavioral interventions may prove helpful particularly in dysfunctional subgroup of patients. Pain coping strategies differ among the subgroups, some utilizing fear avoidance coping and others endurance coping. Endurance coping may also be a risk factor for the development of chronic pain.