Appropriate referral and selection of patients with chronic pain for spinal cord stimulation: European consensus recommendations and e-health tool

Background: Spinal cord stimulation (SCS) is an established treatment for chronic neuropathic, neuropathic-like and ischaemic pain. However, the heterogeneity of patients in daily clinical practice makes it often challenging to determine which patients are eligible for this treatment, resulting in undesirable practice variations. This study aimed to establish patient-specific recommendations for referral and selection of SCS in chronic pain. Methods: A multidisciplinary European panel used the RAND/UCLA Appropriateness Method (RUAM) to assess the appropriateness of (referral for) SCS for 386 clinical scenarios in four pain areas: chronic low back pain and/or leg pain, complex regional pain syndrome, neuropathic pain syndromes and ischaemic pain syndromes. In addition, the panel identified a set of psychosocial factors that are relevant to the decision for SCS treatment. Results: Appropriateness of SCS was strongly determined by the neuropathic or neuropathic-like pain component, location and spread of pain, anatomic abnormalities and previous response to therapies targeting pain processing (e.g. nerve block). Psychosocial factors considered relevant for SCS selection were as follows: lack of engagement, dysfunctional coping, unrealistic expectations, inadequate daily activity level, problematic social support, secondary gain, psychological distress and unwillingness to reduce high-dose opioids. An educational e-health tool was developed that combines clinical and psychosocial factors into an advice on referral/selection for SCS. Conclusions: The RUAM was useful to establish a consensus on patient-specific criteria for referral/selection for SCS in chronic pain. The e-health tool may help physicians learn to apply an integrated approach of clinical and psychosocial factors. Significance: Determining the eligibility of SCS in patients with chronic pain requires careful consideration of a variety of clinical and psychosocial factors. Using a systematic approach to combine evidence from clinical studies and expert opinion, a multidisciplinary European expert panel developed detailed recommendations to support appropriate referral and selection for SCS in chronic pain. These recommendations are available as an educational e-health tool (https://www.scstool.org/)

Accettazione generale e Accettazione del dolore: il contributo nel predire benessere e qualità di vita in pazienti con endometriosi

Introduzione. Numerosi studi hanno esplorato il ruolo delle strategie di coping e dell’accettazione del dolore nell’adattamento al dolore cronico. Recenti studi suggeriscono che l’accettazione psicologica generale (intesa come classe di risposta verso le esperienze private in generale e non nello specifico verso il dolore) sia un processo che spiega l’adattamento al dolore cronico in modo ancora più forte rispetto al coping e all’accettazione del dolore. Il presente studio esamina il contributo dell'accettazione psicologica generale, confrontandolo con il contributo delle strategie di coping e dell’accettazione del dolore, nello spiegare la qualità di vita e il benessere psicologico in donne con endometriosi. Metodo. Hanno partecipato allo studio 286 donne con endometriosi reclutate tramite l'Associazione Progetto Endometriosi Onlus, con età media di 35 anni (SD = 5.9, range = 18-56). Le partecipanti hanno compilato una batteria di questionari per misurare qualità di vita, benessere psicologico, strategie di coping, accettazione del dolore e accettazione psicologica generale. Risultati. I risultati mostrano che più alti livelli di accettazione generale si associano con maggior benessere e qualità di vita; le correlazioni sono moderate e statisticamente significative. Le analisi di regressione gerarchica effettuate indicano che il contributo dell’accettazione generale nello spiegare il benessere e la qualità di vita è statisticamente significativo, controllando l’effetto delle variabili socio-demografiche e cliniche, delle strategie di coping e dell’accettazione del dolore. Inoltre, i risultati mostrano che la percentuale di varianza spiegata dall’accettazione del dolore e dall’accettazione generale è superiore alla percentuale di varianza spiegata dalle strategie di coping. Conclusioni. I risultati indicano che l'accettazione generale giochi un ruolo unico e indipendente dall’accettazione del dolore nel predire benessere e qualità di vita in donne con endometriosi. I risultati suggeriscono anche che l’accettazione del dolore e l’accettazione generale hanno maggior utilità nel predire benessere e qualità di vita rispetto alle strategie di coping

La relazione tra autostima e depressione, è moderata dalla fusione cognitiva?

Introduzione. Lo studio in oggetto esplora se la flessibilità nell’uso della Fusione Cognitiva (FC) sia un moderatore della relazione tra autostima e depressione. In accordo con il modello ACT (Acceptance and Commitment Therapy), appartenente agli approcci cognitivo-comportamentali di terza generazione, si ipotizza che la relazione tra autostima e depressione sia più forte in soggetti con alta FC piuttosto che in quelli con bassa FC. Metodo. Hanno partecipato allo studio 100 soggetti (74% maschi) con una età media di 23 anni (SD = 8.2, range = 18-58), reclutati fra gli studenti dell’Area Medica dell’Università di Pisa e i loro familiari. I partecipanti hanno compilato un pacchetto di questionari contente, oltre a dati sociodemografici, alcune scale tra cui il Cognitive Fusion Questionnaire per indagare la FC, la Rosenberg Self- Esteem Scale per misurare i livelli di autostima e la Beck Depression Inventory per indagare la sintomatologia depressiva. Risultati. I risultati derivanti dalle Analisi di Regressione effettuate indicano che il contributo dell’interazione tra autostima e FC nello spiegare i livelli di depressione è statisticamente significativo, suggerendo quindi che l’effetto dell’autostima sulla depressione dipenda dai livelli di FC. Ulteriori Analisi di Regressione condotte separatamente tra i soggetti con alta FC e bassa FC mostrano in entrambi i gruppi una associazione negativa, statisticamente significativa, tra depressione ed autostima ma tale relazione risulta più forte fra i soggetti con alta FC. Conclusioni. I risultati supportano l’ipotesi che la FC sia un moderatore della relazione tra autostima e depressione, suggerendo, in altre parole, che un uso flessibile della FC attenua gli effetti negativi di una bassa autostima sullo stato dell’umore

Efficacy of high frequency spinal cord stimulation for the treatment of Buerger’s disease: a case report - Efficacia della stimolazione midollare ad alta frequenza per il trattamento del morbo di Buerger: caso clinico

SCS are used extensively in refractory peripheral artherosclerotic disease. The patient was a 50 year-old woman smoker affected by advanced Buerger’s disease with pain localized mostly in the distal extremities of lower limbs. Following the failure of different treatments we suggested performing SCS to obtain better pain control and better microcirculation. In 2009 the patient underwent SCS implantation and in May 2012, was found to have a decubitus ulcer in the area of the subcutaneous pocket. In October 2012 we implanted a high frequency SCS. We used a 10 cm VAS and ESAS Edmonton Symptoms Assessment Scale) to evaluate difference in quality of life, sleep, disability, pain relief and Patient Global Impression Scale (PGIS) to compare the patient’s satisfaction between treatments. The patient reported a significant improvement in pain reduction with both types of stimulators (tonic and high frequency). The quality of life improved more with the high frequency stimulation and the patient considers high frequency stimulation more effective than tonic stimulation. Our case report suggests that high frequency SCS can be a useful therapy for ischemic pain control

Neurophysiological Comparison Among Tonic, High Frequency, and Burst Spinal Cord Stimulation: Novel Insights Into Spinal and Brain Mechanisms of Action

Spinal cord stimulation (SCS) is an effective option for neuropathic pain treatment. New technological developments, as high-frequency (HF) and theta burst stimulation (TBS), have shown promising results, although putative mechanisms of action still remain debated

Common-sense model of self-regulation to cluster fibromyalgia patients. results from a cross-sectional study in italy

Objective Fibromyalgia is a severe and disabling chronic pain syndrome affecting millions of people worldwide. Various patients' subgroups were identified using different atheoretical measures, hardly effective to tailor treatments. Previous literature findings showed the relevance of fibromyalgia patients' illness perceptions in adjusting to the disease. The present study aims to identify clusters of fibromyalgia patients based on their illness perceptions and investigate whether they can differ across pain, mood, physical functioning, catastrophising, and pain acceptance measures.MethodsFifty-three newly referred fibromyalgia patients completed clinical and psychological questionnaires. Patients' subgroups were created by applying hierarchical cluster analysis to their answers to Illness Perception Questionnaire-Revised subscales. Potential differences across subgroups in outcome variables were tested.ResultsCluster analysis identified two patient groups. Group A (32 patients) had a higher representation of fibromyalgia as a chronic disease with severe consequences, lower beliefs in personal and treatment control, and a higher fibromyalgiarelated emotional distress than group B (21 patients). Clusters did not differ on pain intensity and duration. Group A, compared to group B, showed worse physical functioning and overall impairment due to fibromyalgia, a poorer psychological condition, a higher tendency to catastrophise, and less pain acceptance.ConclusionStudy findings reveal two fibromyalgia subgroups differing in emotional suffering and impairment despite similar pain intensity and duration. Patients' illness perceptions and attitudes towards pain, like catastrophising and acceptance, might be critical in adjusting to the disease. A detailed assessment of such risk and protective factors is critical to differentiate patients' subgroups with different needs and thus offer tailored treatments

Patient selection for spinal cord stimulation: The importance of an integrated assessment of clinical and psychosocial factors

Background : A previously developed educational e-health tool considers both clinical and psychosocial factors when selecting patients with chronic pain for spinal cord stimulation (SCS). The validity of the composite recommendations was evaluated in a retrospective study, demonstrating a strong relationship with patient outcomes after SCS. Methods : An additional retrospective analysis was performed to determine the added value of a psychosocial evaluation as part of the decision-making process on SCS. Data concerned 482 patients who were considered for SCS in 2018–2019. The analysis focused on the relationship between the different layers of the tool recommendations (clinical, psychosocial, composite) with trial results and patient outcomes at 6 months after SCS. Of the initial study population, 381 patients underwent SCS and had follow-up data on at least one of three pain-related outcome measures. Results : Pain improvement was observed in 76% of the patients for whom SCS was strongly recommended based on merely the clinical aspects. This percentage varied by the level of psychosocial problems and ranged from 86% in patients without any compromising psychosocial factors to 60% in those with severe problems. Similarly, the severity of psychosocial problems affected trial results in patients for whom SCS was either recommended or strongly recommended. Conclusions : The strong relationship between psychosocial factors embedded in the SCS e-health tool and patient outcomes supports an integrated and multidisciplinary approach in the selection of patients for SCS. The educational e-health tool, combining both clinical and psychosocial aspects, is believed to be helpful for further education and implementation of this approach. Significance statement: This study confirms the relevance of the psychosocial factors embedded in the educational SCS e-health tool (https://scstool.org/). The strong relationship between the severity of psychosocial factors with patient outcomes supports conducting a comprehensive psychological and behavioural assessment when determining the eligibility of patients for SCS