A systematic review of therapeutic interventions to reduce acute and chronic post-surgical pain after amputation, thoracotomy or mastectomy

BACKGROUND: Perioperative neuropathic pain is under-recognized and often undertreated. Chronic pain may develop after any routine surgery, but it can have a far greater incidence after amputation, thoracotomy or mastectomy. The peak noxious barrage due to the neural trauma associated with these operations may be reduced in the perioperative period with the potential to reduce the risk of chronic pain. DATABASES AND DATA TREATMENT: A systematic review of the evidence for perioperative interventions reducing acute and chronic pain associated with amputation, mastectomy or thoracotomy. RESULTS: Thirty-two randomized controlled trials met the inclusion criteria. Gabapentinoids reduced pain after mastectomy, but a single dose was ineffective for thoracotomy patients who had an epidural. Gabapentinoids were ineffective for vascular amputees with pre-existing chronic pain. Venlafaxine was associated with less chronic pain after mastectomy. Intravenous and topical lidocaine and perioperative EMLA (eutectic mixture of local anaesthetic) cream reduced the incidence of chronic pain after mastectomy, whereas local anaesthetic infiltration appeared ineffective. The majority of the trials investigating regional analgesia found it to be beneficial for chronic symptoms. Ketamine and intercostal cryoanalgesia offered no reduction in chronic pain. Total intravenous anaesthesia (TIVA) reduced the incidence of post-thoracotomy pain in one study, whereas high-dose remifentanil exacerbated chronic pain in another. CONCLUSIONS: Appropriate dose regimes of gabapentinoids, antidepressants, local anaesthetics and regional anaesthesia may potentially reduce the severity of both acute and chronic pain for patients. Ketamine was not effective at reducing chronic pain. Intercostal cryoanalgesia was not effective and has the potential to increase the risk of chronic pain. TIVA may be beneficial but the effects of opioids are unclear

Reduced pressure pain thresholds in response to exercise in chronic fatigue syndrome but not in chronic low back pain: an experimental study

Objective The aims of this study were to examine (i) base line pressure pain thresholds in patients with chronic fatigue syndrome and those with chronic low back pain compared with healthy subjects, (ii) the change in mean pain threshold in response to exercise, and (iii) associations with exercise induced increase in nitric oxide Participants Twenty six patients with chronic fatigue syndrome suffering of chronic pain, 21 patients with chronic low back pain and 31 healthy subjects Methods Participants underwent a submaximal aerobic exercise protocol on a bicycle ergometer, preceded and followed by venous blood sampling (nitric oxide) and algometry (hand arm calf low back) Results Patients with chronic fatigue syndrome presented overall lower pain thresholds compared with healthy sub jects and patients with chronic low back pain (p<0 05) No significant differences were found between healthy subjects and patients with chronic low back pain After submaximal aerobic exercise, mean pain thresholds decreased in patients with chronic fatigue syndrome and increased in the others (p<0 01) At baseline nitric oxide levels were significantly higher in the chronic low back pain group After controlling for body mass index no significant differences were seen be tween the groups at baseline or in response to exercise Nitric oxide was not related to pain thresholds in either group Conclusion The results suggest hyperalgesia and abnormal central pain processing during submaximal aerobic exercise in chronic fatigue syndrome, but not in chronic low back pain Nitric oxide appeared to be unrelated to pain processin

AAPT Diagnostic Criteria for Chronic Sickle Cell Disease Pain

Pain in sickle cell disease (SCD) is associated with increased morbidity, mortality, and high health care costs. Although episodic acute pain is the hallmark of this disorder, there is an increasing awareness that chronic pain is part of the pain experience of many older adolescents and adults. A common set of criteria for classifying chronic pain associated with SCD would enhance SCD pain research efforts in epidemiology, pain mechanisms, and clinical trials of pain management interventions, and ultimately improve clinical assessment and management. As part of the collaborative effort between the Analgesic, Anesthetic, and Addiction Clinical Trial Translations Innovations Opportunities and Networks public-private partnership with the U.S. Food and Drug Administration and the American Pain Society, the Analgesic, Anesthetic, and Addiction Clinical Trial Translations Innovations Opportunities and Networks-American Pain Society Pain Taxonomy initiative developed the outline of an optimal diagnostic system for chronic pain conditions. Subsequently, a working group of experts in SCD pain was convened to generate core diagnostic criteria for chronic pain associated with SCD. The working group synthesized available literature to provide evidence for the dimensions of this disease-specific pain taxonomy. A single pain condition labeled chronic SCD pain was derived with 3 modifiers reflecting different clinical features. Future systematic research is needed to evaluate the feasibility, validity, and reliability of these criteria. Perspective: An evidence-based classification system for chronic SCD pain was constructed for the Analgesic, Anesthetic, and Addiction Clinical Trial Translations Innovations Opportunities and Networks-American Pain Society Pain Taxonomy initiative. Applying this taxonomy may improve assessment and management of SCD pain and accelerate research on epidemiology, mechanisms, and treatments for chronic SCD pain

Prevalence of chronic pain in Libya before and after the uprising of 17 February 2011.

Two questionnaires were translated into Arabic and culturally adapted to measure chronic pain and neuropathic pain in the general population in Derna, Libya (1, 2), and then in a country-wide survey. A point prevalence of chronic pain and neuropathic pain in Libya was determined. The findings of this series of studies suggested that the prevalence of chronic pain in Libya, which was 19.6%, is similar to the average European estimate (3) despite the cultural dissimilarities of the two regions (4) and the environmental differences surrounding the surveyed samples. The studies of chronic pain in Libya conducted by our pain research team, which involved a PhD student sponsored by the Libyan High Education Authority, indicated that Libyan women were found to have more chronic pain conditions than men. These sex and gender differences in chronic pain highlighted a general trend in epidemiological studies in many parts of the world (5). However, this programme of studies on prevalence of chronic pain was conducted just before the uprising of 17 February 2011 in Libya, and one should be cautious about the validity of some of the findings’ implications for immediate pain management priorities in the country. For example, the findings of the pre-conflict survey that being an old woman with children carries double the risk of having a chronic pain condition compared to a young person with no children may have changed as a result of the war which claimed the lives of around 30,000 Libyans and caused serious injuries to more than 20,000 young men. There is an urgent need for a new programme of studies using the PRIME approach on prevalence, impact, and economic cost of chronic pain (6) in post-conflict Libya. This should inform the health authorities in Libya and help plan management of chronic pain conditions resulting from the conflict. This will also serve as a model that can be applied to other countries from the developing world experiencing similar conflicts (7)

British pain clinic practitioners' recognition and use of the bio-psychosocial pain management model for patients when physical interventions are ineffective or inappropriate : results of a qualitative study

Background To explore how chronic musculoskeletal pain is managed in multidisciplinary pain clinics for patients for whom physical interventions are inappropriate or ineffective. Methods A qualitative study was undertaken using semi-structured interviews with twenty five members of the pain management team drawn from seven pain clinics and one pain management unit located across the UK. Results All clinics reported using a multidisciplinary bio-psychosocial model. However the chronic pain management strategy actually focussed on psychological approaches in preference to physical approaches. These approaches were utilised by all practitioners irrespective of their discipline. Consideration of social elements such as access to social support networks to support patients in managing their chronic pain was conspicuously absent from the approaches used. Conclusion Pain clinic practitioners readily embraced cognitive/behavioural based management strategies but relatively little consideration to the impact social factors played in managing chronic pain was reported. Consequently multidisciplinary pain clinics espousing a bio-psychosocial model of pain management may not be achieving their maximum potential

Cognitive-behavioral factors associated with sleep quality in chronic pain patients

People with chronic pain commonly complain of sleep disturbance. This study reports the characteristics of the pain and sleep of a large sample of patients with chronic pain (n = 160). This study compared subgroups of good sleepers with pain (n = 48) and poor sleepers with pain (n = 108). Poor sleepers with pain were younger and reported more pain, pain-related disability, depression, pain-related anxiety, and dysfunctional beliefs about sleep. Using simultaneous regression analysis, this study examined the roles of pain, dysfunctional beliefs about sleep, pain-related disability, depression, and pain-related anxiety in predicting concurrent sleep quality. The findings are relevant to the development of models of sleep disturbance comorbid with chronic pain

Prevalence and time course of post-stroke pain: A multicenter prospective hospital-based study

OBJECTIVE: Pain prevalence data for patients at various stages after stroke. DESIGN: Repeated cross-sectional, observational epidemiological study. SETTING: Hospital-based multicenter study. SUBJECTS: Four hundred forty-three prospectively enrolled stroke survivors. METHODS: All patients underwent bedside clinical examination. The different types of post-stroke pain (central post-stroke pain, musculoskeletal pains, shoulder pain, spasticity-related pain, and headache) were diagnosed with widely accepted criteria during the acute, subacute, and chronic stroke stages. Differences among the three stages were analyzed with χ(2)-tests. RESULTS: The mean overall prevalence of pain was 29.56% (14.06% in the acute, 42.73% in the subacute, and 31.90% in the chronic post-stroke stage). Time course differed significantly according to the various pain types (P < 0.001). The prevalence of musculoskeletal and shoulder pain was higher in the subacute and chronic than in the acute stages after stroke; the prevalence of spasticity-related pain peaked in the chronic stage. Conversely, headache manifested in the acute post-stroke stage. The prevalence of central post-stroke pain was higher in the subacute and chronic than in the acute post-stroke stage. Fewer than 25% of the patients with central post-stroke pain received drug treatment. CONCLUSIONS: Pain after stroke is more frequent in the subacute and chronic phase than in the acute phase, but it is still largely undertreated

Pain intensity and attribution mediate the impact of patient weight and gender on activity recommendations for chronic pain

Background and purpose: Despite the notable benefits of physical activity for chronic pain, a large proportion of patients with chronic pain report that they do not receive activity-related recommendations from their providers. Research suggests that patient factors such as weight and gender influence activity-related recommendations for chronic pain. Research also suggests that appraisals of the intensity and cause of pain may explain these weight and gender effects. We investigated the influence of patient weight and gender on observers' likelihood of recommending activity-related treatments for pain. We also explored the mediating effects of observers' ratings of pain severity and the extent to which pain was due to medical and lifestyle factors (pain attribution). Patients and methods: Healthy young adults (N=616; 76% female) viewed videos (Ghent Pain Videos of Daily Activities) and vignettes of 4 patients with chronic back pain performing a standardized functional task. Patients varied by gender (female, male) and weight (normal, obese), but were otherwise equivalent on demographic characteristics and pain behaviors. Participants rated how much pain they perceived the patients to be experiencing, the extent to which they attributed the pain to medical and lifestyle factors, and their likelihood of recommending exercise, physical therapy (PT), and rest. Results: Patient weight and gender significantly interacted to influence exercise, PT, and rest recommendations. Both pain intensity and pain attribution mediated the relationships between patient weight and activity recommendations; however, these mediation effects differed across gender and recommendation type. Conclusion: Patient weight and gender influenced laypeople's activity recommendations for chronic pain. Moreover, the results suggest that observers' perceptions of pain intensity and pain attributions are mechanisms underlying these effects. If these findings are replicated in providers, interventions may need to be developed to reduce provider biases and increase their recognition of the benefits of physical activity for chronic pain

Towards a science and practice of resilience in the face of pain

The primary objective of this paper is to discuss how a resilience approach to (chronic) pain may advance our current understanding of (mal)adaptation to pain. Different resilience perspectives are described, and future challenges for research, prevention and treatment of (chronic) pain are discussed. Literature searches were performed in Web of Science and PubMed to identify relevant literature on risk and resilience in the context of pain. Resilience can be best defined as the ability to restore and sustain living a fulfilling life in the presence of pain. The Psychological Flexibility Model, the Broaden-and-Build Theory, and Self-Determination Theory are described as theories that may provide insight into resilience within the context of (chronic) pain. We describe how a resilience paradigm shifts the outcomes to pursue in pain research and intervention and argue the need for including positive outcomes in addition to negative outcomes. Psychological flexibility, positive affect and basic psychological needs satisfaction are described as potentially important resilience mechanisms with the potential to target both sustainability and recovery from pain. A resilience approach to chronic pain may have important implications for the prevention and treatment of chronic pain problems, as it may give specific indications on how to empower patients to continue living a fulfilling life (in the presence of pain)

To Live Means to Suffer: Exploring the Identity of Chronic Pain Conditions

This paper examines the necessary identity reconstruction for chronic pain patients through the use of illness narratives. The biographical interruption of a chronic illness, partnered with the patients’ inability to discuss embodiment and pain wholly (because language failures to capture the essence of pain and suffering) creates a devastating chasm between the world of the healthy and the world of the sick. Psychosomatic pain, and illnesses without diagnosis, are all the more divisive conditions, because these factors rob the patient further, disallowing them from constructing even an illness identity. Utilizing published patient interviews, sociological and anthropological texts, as well as illness narratives from authors such as Joan Didion, the first half of this paper explores the discourse surrounding chronic pain, reconciling it with the author’s own experience as a chronic pain patient. The second half of the paper includes interviews conducted by the author, and a discussion of the relationship between these illness narratives and the sociological expectations of the chronically ill. Through these interviews, texts, and narratives, the author explores the implications of chronic pain, which are unquantifiable. Chronic pain is a condition unto itself because it expands beyond the body, problematizing the lives of its victims, and requiring a revision of their identities. From these interviews, it is evident that illness narratives are powerful not because of the specifics of a patient’s pain, but due to the life trajectory interrupted by said pain. Ask chronic pain patients to tell you about their pain and they instead tell you about their lives—ruined vacations, lost friendships—“pain environed in a concrete world,” (Kleinman, 1988)