A classification-based approach to low back pain in primary care - protocol for a benchmarking controlled trial.

BACKGROUND: Guidelines recommend a biopsychosocial framework for low back pain (LBP) management and the avoidance of inappropriate imaging. In clinical practice, care strategies are often inconsistent with evidence and guidelines, even though LBP is the most common disabling health condition worldwide. Unhelpful beliefs, attitudes and inappropriate imaging are common. LBP is understood to be a complex biopsychosocial phenomenon with many known multidimensional risk factors (symptom- and lifestyle-related, psychological and social) for persistent or prolonged disability, which should be identified and addressed by treatment. The STarT Back Tool (SBT) was developed for early identification of individual risk factors of LBP to enable targeted care. Stratified care according SBT has been shown to improve the effectiveness of care in a primary care setting. A biopsychosocially-oriented patient education booklet, which includes imaging guidelines and information, is one possible way to increase patients' understanding of LBP and to reduce inappropriate imaging. Premeditated pathways, education of professionals, written material, and electronic patient registry support in health care organizations could help implement evidence-based care. METHODS: We will use a Benchmarking Controlled Trial (BCT) design in our study. We will prospectively collect data from three health care regions before and after the implementation of a classification-based approach to LBP in primary care. The primary outcome will be change in PROMIS (Patient-Reported Outcomes Measurement Information System) (short form 20a) over 12-month follow-up. DISCUSSION: The implementation of a classification-based biopsychosocial approach can potentially improve the care of LBP patients, reduce inappropriate imaging without increasing health-care costs, and decrease indirect costs by reducing work disability. Using the BCT we will be able to evaluate the effectiveness of the improvement strategy for the entire care pathway. TRIAL REGISTRATION: ISRCTN,ISRCTN13273552, retrospectively registered 13/05/2019.

Changes in cases of nontraumatic chest pain treated in a chest pain unit over the 10-year period of 2008-2017. / Evolución de las características de las visitas por dolor torácico no traumático en una unidad de dolor torácico durante un periodo de 10 años (2008-2017).

OBJECTIVES: To analyze changes in the characteristics of consecutively treated patients attended in the chest pain unit of a hospital emergency department over a 10-year period. MATERIAL AND METHODS: All patients presenting with nontraumatic chest pain (NTCP) were included. We analyzed changes over time in epidemiologic characteristics, initial diagnostic classification (on clinical and electrocardiographic evaluation), final diagnosis (on discharge), and time until these diagnoses. RESULTS: A total of 34 552 consecutive patients with a mean (SD) age of 59 (13) years were included; 42% were women. The annual number of visits rose over time. Visits were fewer in summer and more numerous on workdays and between the hours of 8 AM and 4 PM (P<.001, both comparisons). The number of women increased over time (up 0.29% annually, P<.05) as did the number of patients under the age of 50 years (up 0.92% annually, P<.001). With time, patients had fewer cardiovascular risk factors and less often had a history of ischemic heart disease. Fewer cases of NTCP had signs suggestive of acute coronary syndrome (ACS). ACS was ruled out at the time of initial and final diagnoses in 52.2% and 80.4%, respectively, and these percentages which rose over the 10-year period by 1.86% (P<.001) and 0.56% (P=.04). Time to initial diagnosis did not change. However, time to final diagnosis did increase (P<.001), and the delay was longer in patients diagnosed with ACS (P<.001). CONCLUSION: The chest pain unit was more active at the end of the period, in keeping with the increase in patients with NTCP whose characteristics were not typical of coronary disease. The percentages of patients initially and finally diagnosed with ACS decreased with time.

OBJETIVO: Analizar la evolución de las características epidemiológicas de las visitas atendidas de forma consecutiva en una unidad de dolor torácico (UDT) de un servicio de urgencias hospitalario (SUH) durante un periodo de 10 años. METODO: Se incluyeron todas las visitas por dolor torácico no traumático (DTNT), analizándose la evolución temporal de las características epidemiológicas, de la clasificación diagnóstica inicial (evaluación clínica inicial y electrocardiograma) y final (al alta de la UDT), y los tiempos necesarios para alcanzar las mismas. RESULTADOS: Se incluyeron 34.552 pacientes consecutivos con una edad media 59 (DE 13) años, el 42% mujeres. Se observó un incrementó en el número anual de visitas a la UDT (p < 0,001), menor afluencia los meses de verano (p < 0,001), y mayor los días laborables (p < 0,001) y de 8-16 horas (p < 0,001). Se comprobó que progresivamente más pacientes eran mujeres (+0,29% anual, p < 0,05), menores de 50 años (+0,92%, p < 0,001), con más factores de riesgo cardiovascular, menos antecedentes de cardiopatía isquémica y con DTNT menos sugestivo de síndrome coronario agudo (SCA). La clasificación diagnóstica inicial y final descartó SCA en un 52,2% y un 80,4% de pacientes, respectivamente, hecho que aumentó progresivamente durante el periodo evaluado (+1,86%, p < 0,001; y +0,56%, p = 0,04; respectivamente). El tiempo de clasificación inicial no se modificó, pero se incrementó el necesario para la clasificación final (p < 0,001), que resultó superior en pacientes con diagnóstico final de SCA (p < 0,001). CONCLUSIONES: Se observa un mayor uso de la UDT tras su creación, causado por un incremento de pacientes con DTNT de características no típicamente coronarias, disminuyendo el porcentaje de clasificados inicial y finalmente como debidos a SCA.

Emergency Physician Opioid Prescribing and Risk of Long-term Use in the Veterans Health Administration: an Observational Analysis.

BACKGROUND: Treatment by high-opioid prescribing physicians in the emergency department (ED) is associated with higher rates of long-term opioid use among Medicare beneficiaries. However, it is unclear if this result is true in other high-risk populations such as Veterans. OBJECTIVE: To estimate the effect of exposure to high-opioid prescribing physicians on long-term opioid use for opioid-naïve Veterans. DESIGN: Observational study using Veterans Health Administration (VA) encounter and prescription data. SETTING AND PARTICIPANTS: Veterans with an index ED visit at any VA facility in 2012 and without opioid prescriptions in the prior 6 months in the VA system ("opioid naïve"). MEASUREMENTS: We assigned patients to emergency physicians and categorized physicians into within-hospital quartiles based on their opioid prescribing rates. Our primary outcome was long-term opioid use, defined as 6 months of days supplied in the 12 months subsequent to the ED visit. We compared rates of long-term opioid use among patients treated by high versus low quartile prescribers, adjusting for patient demographic, clinical characteristics, and ED diagnoses. RESULTS: We identified 57,738 and 86,393 opioid-naïve Veterans managed by 362 and 440 low and high quartile prescribers, respectively. Patient characteristics were similar across groups. ED opioid prescribing rates varied more than threefold between the low and high quartile prescribers within hospitals (6.4% vs. 20.8%, p < 0.001). The frequency of long-term opioid use was higher among Veterans treated by high versus low quartile prescribers, though above the threshold for statistical significance (1.39% vs. 1.26%; adjusted OR 1.11, 95% CI 0.997-1.24, p = 0.056). In subgroup analyses, there were significant associations for patients with back pain (adjusted OR 1.25, 95% CI 1.01-1.55, p = 0.04) and for those with a history of depression (adjusted OR 1.28, 95% CI 1.08-1.51, p = 0.004). CONCLUSIONS: ED physician opioid prescribing varied by over 300% within facility, with a statistically non-significant increased rate of long-term use among opioid-naïve Veterans exposed to the highest intensity prescribers.

Avaliação da dor e fatores associados em pessoas que vivem com HIV/AIDS / Assessment of pain and associated factors in people living with HIV/AIDS / Evaluación del dolor y factores asociados en las personas que viven con el VIH/SIDA

Objetivo: avaliar a dor em pessoas que vivem com o vírus da imunodeficiência humana/síndrome da imunodeficiência adquirida e relacionar com fatores sociodemográficos, clínicos, sintomas depressivos e qualidade de vida relacionada à saúde. Método: estudo descritivo, analítico, observacional, de corte transversal e de caráter quantitativo. Participaram trezentas e duas (302) pessoas de um serviço de atendimento especializado. Foram utilizados instrumentos para avaliação de dados sociodemográficos, clínicos, sintomas depressivos e qualidade de vida relacionada à saúde. Empregou-se análise descritiva, bivariada e regressão logística múltipla. Resultados: foram encontrados 59,27% de presença de dor de intensidade leve, recorrente na cabeça, com interferência no humor, a maioria do sexo feminino e em indivíduos sem/baixa escolaridade. As mulheres apresentaram maior probabilidade de ter dores moderadas ou severas. Pessoas de 49 a 59 anos apresentaram maior intensidade de dor do que as de 18 a 29 anos. Sintomas depressivos e dor são variáveis diretamente proporcionais. Quanto maior o nível da qualidade de vida relacionada à saúde e escolaridade, menor a possibilidade da presença de dor. Conclusão: a presença de dor encontrada é preocupante e possui associação com o sexo feminino, sem/baixa escolaridade, pior nível da qualidade de vida relacionada à saúde e presença de sintomas depressivos.

Objective: to evaluate pain in people living with human immunodeficiency virus/acquired immunodeficiency syndrome and to relate it to sociodemographic and clinical factors, depressive symptoms and health-related quality of life. Method: descriptive, analytical, observational, cross-sectional and quantitative study. Three hundred and two (302) people assisted at a specialized care service participated in the study. Instruments were used to evaluate sociodemographic and clinical data, depressive symptoms, and health-related quality of life. Descriptive, bivariate analysis and multiple logistic regression were used. Results: the incidence of pain of mild intensity was 59.27%, recurrent in the head, with interference in mood, mostly affecting females and individuals with no schooling/low schooling. Women were more likely to have moderate or severe pain. People aged 49 to 59 years had greater pain intensity than people aged 18 to 29 years. The variables depressive symptoms and pain were directly proportional. The higher the health-related quality of life and schooling, the lower was the possibility of presence of pain. Conclusion: presence of pain is of concern and has association with female sex, lack of schooling/low schooling, worse level of health-related quality of life and presence of depressive symptoms.

Objetivos: evaluar el dolor en las personas que viven con el virus de la inmunodeficiencia humana/síndrome de inmunodeficiencia adquirida y relacionarse con factores sociodemográficos, clínicos, síntomas depresivos y calidad de vida relacionada con la salud. Método: estudio descriptivo, analítico, observacional, de corte transversal y de carácter cuantitativo. Participaron trescientos y dos (302) personas de un servicio de atención especializado. Se utilizaron instrumentos para la evaluación de datos sociodemográficos, clínicos, síntomas depresivos y calidad de vida relacionada con la salud. Se empleó el análisis descriptivo, bivariada y regresión logística múltiple. Resultados: se encontró un 59,27% de presencia de dolor de intensidad leve, recurrente en la cabeza, con interferencia en el humor, la mayoría del sexo femenino y en individuos sin/baja escolaridad. Las mujeres presentaron una mayor probabilidad de sufrir dolores moderados o severos. Las personas de 49 a 59 años presentaron mayor intensidad de dolor que las de 18 a 29 años. Los síntomas depresivos y dolor son variables directamente proporcionales. Cuanto mayor es el nivel de la calidad de vida relacionada con la salud y la escolaridad, menor es la posibilidad de la presencia de dolor. Conclusión: la presencia de dolor encontrado es preocupante y tiene asociación con el sexo femenino, sin/baja escolaridad, peor nivel de la calidad de vida relacionada a la salud y la presencia de síntomas depresivos.

Negative pain management index scores do not necessarily indicate inadequate pain management: a cross-sectional study.

BACKGROUND: The Pain Management Index (PMI) is widely used in the assessment of pain management, and negative scores are traditionally considered to indicate inadequate pain management. However, it is not known whether negative PMI scores are always problematic. METHODS: In this prospective observational study, we examined the data of 1156 patients with cancer and pain who were hospitalized in a cancer care hospital in Japan from July 2012 to January 2015 and compared the proportion of patients with PI across various PMI scores in this cohort. We further evaluated the predictive validity of PMI scores for PI using different cutoffs. This study aimed to examine the association between PMI scores and the proportion of patients whose pain interferes with their daily lives (i.e., pain interference [PI]). RESULTS: We found that lower PMI scores were generally associated with a higher percentage of patients with PI. A smaller proportion of patients with PMI scores of - 1 (567/1550, 36.6%) reported PI compared with those with PMI scores of 0 (788/1505, 52.4%). The sensitivities of PMI scores < - 1 and < 0 for predicting PI were 0.16 and 0.37 and the corresponding specificities were 0.95 and 0.71, respectively. CONCLUSIONS: These findings suggest that PMI scores are inversely associated with the proportion of patients with PI. However, PMI scores of - 1 do not always indicate inadequate pain management; pain management should therefore be evaluated from multiple perspectives.

An Assessment of Clinically Important Differences on the Worst Pain Severity Item of the Modified Brief Pain Inventory in Patients with Diabetic Peripheral Neuropathic Pain.

Objectives: Using patient global impression of change (PGIC) as an anchor, an approximately 30% reduction on an 11-point numeric pain intensity rating scale (PI-NRS) is considered a clinically important difference (CID) in pain. Our objective was to define the CID for another pain measure, the worst pain severity (WPS) item of the modified Brief Pain Inventory (m-BPI). Methods: In this post hoc analysis of a double-blind, placebo-controlled, phase 2 study, 452 randomized patients with diabetic peripheral neuropathic pain (DPNP) were followed over 5 weeks, with m-BPI data collected weekly and PGIC at treatment conclusion. Receiver operating characteristic (ROC) curves (via logistic regression) were used to determine the changes in the m-BPI-WPS score that best predicted ordinal clinical improvement thresholds (i.e., "minimally improved" or better) on the PGIC. Results: Similar to the PI-NRS, a change of -3 (raw) or -33.3% from the baseline on the m-BPI-WPS optimized prediction for the "much improved" or better PGIC threshold and represents a CID. There was a high correspondence between observed and predicted PGIC categories at each PGIC threshold (ROC AUCs were 0.78-0.82). Conclusions: Worst pain on the m-BPI may be used to assess clinically important improvements in DPNP studies. Findings require validation in larger studies.

Risk classification of patients referred to secondary care for low back pain.

BACKGROUND: Nonspecific low back pain is characterized by a wide range of possible triggering and conserving factors, and initial screening needs to scope widely with multilevel addressment of possible factors contributing to the pain experience. Screening tools for classification of patients have been developed to support clinicians. The primary aim of this study was to assess the criterion validity of STarT Back Screening Tool (STarT Back) against the more comprehensive Örebro Musculoskeletal Pain Questionnaire (ÖMPSQ), in a Norwegian sample of patients referred to secondary care for low back pain. Secondary aims were to assess risk classification of the patients, as indicated by both instruments, and to compare pain and work characteristics between patients in the different STarT Back risk categories. METHODS: An observational, cross-sectional survey among patients with low back pain referred to outpatient secondary care assessment at Trondheim University Hospital, Norway. Cohen's Kappa coefficient, Pearson's r and a Bland-Altman plot were used to assess criterion validity of STarT Back against ÖMPSQ. Furthermore, linear regression was used to estimate mean differences with 95% CI in pain and work related variables between the risk groups defined by the STarT Back tool. RESULTS: A total of 182 persons participated in the study. The Pearsons correlation coefficient for correspondence between scores on ÖMPSQ and STarT Back was 0.76. The Kappa value for classification agreement between the instruments was 0.35. Risk group classification according to STarT Back allocated 34.1% of the patients in the low risk group, 42.3% in the medium risk, and 23.6% in the high risk group. According to ÖMPSQ, 24.7% of the participants were allocated in the low risk group, 28.6% in the medium risk, and 46.7% in the high risk group. Patients classified with high risk according to Start Back showed a higher score on pain and work related characteristics as measured by ÖMPSQ. CONCLUSION: The correlation between score on the screening tools was good, while the classification agreement between the screening instruments was low. Screening for work factors may be important in patients referred to multidisciplinary management in secondary care.

Occipital Neuralgia: a noninvasive therapeutic approach / Neuralgia Occipital: uma abordagem terapêutica não invasiva / Neuralgia Occipital: un abordaje terapéutico no invasivo

ABSTRACT Objective: to evaluate the application of a noninvasive intervention consisting of a postural modification using personalized models and osteopathy in people with occipital neuralgia. Method: retrospective study of the intervention performed in adult population with occipital neuralgia, consisting of postural modification using personalized plantar orthoses and osteopathy, in a study period of four years. The observed variables were: persistence of headache, alignment of the axes, plantar support, center of gravity and center of mass; medical interview data, visual analogue scale, Win-Track gait analysis system and Kinovea software for video analysis (clinical assessment instruments used). Results: a total of 34 records of people with occipital neuralgia were studied. A fraction of 58.8% of the patients reported improvement after the intervention. The visual analogue scale data were provided for 64.7% of the records and significant differences (p <0.001) between the means before (8.4 ± 1.7) and after the intervention (2.6 ± 2.7) were found. Conclusion: postural modification using personalized orthoses and osteopathy substantially improves the symptomatology of patients with occipital neuralgia.

RESUMO Objetivo: avaliar a aplicação de uma intervenção não invasiva que consiste em uma modificação postural usando modelos personalizados e osteopatia em pessoas com neuralgia occipital. Método: estudo retrospectivo da intervenção realizada em população adulta com neuralgia occipital que consiste de modificação postural empregando órteses plantares personalizadas e osteopatia, em um período de estudo de quatro anos. As variáveis observadas foram: persistência de cefaleia, alinhamento dos eixos, apoio plantar, centro de gravidade e centro de massa; dados da entrevista médica, escala visual analógica, sistema de análise de marcha Win-Track e o software Kinovea para análise de vídeo (instrumentos de avaliação clínica utilizados). Resultados: foram estudados no total 34 registros de pessoas com neuralgia occipital. Uma fração de 58,8% dos pacientes informou apresentar melhoria após a intervenção. Os dados da escala visual analógica foram fornecidos para 64,7% dos registros, encontrando diferenças significativas (p<0,001) entre as médias antes (8,4±1,7) e depois da intervenção (2,6±2,7). Conclusão: a modificação postural empregando órteses personalizadas e osteopatia melhora substancialmente a sintomatologia dos pacientes com neuralgia occipital.

RESUMEN Objetivo: evaluar la aplicación de una intervención no invasiva consistente en una modificación postural empleando plantillas personalizadas y osteopatía en personas con neuralgia occipital. Método: estudio retrospectivo de la intervención llevada a cabo en población adulta con neuralgia occipital, de modificación postural empleando órtesis plantares personalizadas y osteopatía, en un período de estudio de cuatro años. Las variables observadas fueron: persistencia de cefalea, alineación de los ejes, apoyo plantar, centro de gravedad y centro de masa; datos de la entrevista médica, la escala visual análoga, el sistema de análisis de la marcha Win-Track y el software Kinovea para análisis de vídeo (instrumentos de valoración clínica utilizados). Resultados: un total de 34 registros de personas con neuralgia occipital fueron estudiados. Un 58,8% refería presentar mejoría tras la intervención. Los datos de la escala visual análoga eran proporcionados un 64,7% de los registros, encontrándose diferencias significativas (p<0,001) entre las medias previas a la intervención (8,4±1,7) y aquellas posteriores (2,6±2,7). Conclusión: la modificación postural empleando órtesis personalizadas y osteopatía mejora sustancialmente la sintomatología de los pacientes con neuralgia occipital.

Latent class analysis derived subgroups of low back pain patients - do they have prognostic capacity?

BACKGROUND: Heterogeneity in patients with low back pain is well recognised and different approaches to subgrouping have been proposed. One statistical technique that is increasingly being used is Latent Class Analysis as it performs subgrouping based on pattern recognition with high accuracy. Previously, we developed two novel suggestions for subgrouping patients with low back pain based on Latent Class Analysis of patient baseline characteristics (patient history and physical examination), which resulted in 7 subgroups when using a single-stage analysis, and 9 subgroups when using a two-stage approach. However, their prognostic capacity was unexplored. This study (i) determined whether the subgrouping approaches were associated with the future outcomes of pain intensity, pain frequency and disability, (ii) assessed whether one of these two approaches was more strongly or more consistently associated with these outcomes, and (iii) assessed the performance of the novel subgroupings as compared to the following variables: two existing subgrouping tools (STarT Back Tool and Quebec Task Force classification), four baseline characteristics and a group of previously identified domain-specific patient categorisations (collectively, the 'comparator variables'). METHODS: This was a longitudinal cohort study of 928 patients consulting for low back pain in primary care. The associations between each subgroup approach and outcomes at 2 weeks, 3 and 12 months, and with weekly SMS responses were tested in linear regression models, and their prognostic capacity (variance explained) was compared to that of the comparator variables listed above. RESULTS: The two previously identified subgroupings were similarly associated with all outcomes. The prognostic capacity of both subgroupings was better than that of the comparator variables, except for participants' recovery beliefs and the domain-specific categorisations, but was still limited. The explained variance ranged from 4.3%-6.9% for pain intensity and from 6.8%-20.3% for disability, and highest at the 2 weeks follow-up. CONCLUSIONS: Latent Class-derived subgroups provided additional prognostic information when compared to a range of variables, but the improvements were not substantial enough to warrant further development into a new prognostic tool. Further research could investigate if these novel subgrouping approaches may help to improve existing tools that subgroup low back pain patients.

Clinical classification in low back pain: best-evidence diagnostic rules based on systematic reviews.

BACKGROUND: Clinical examination findings are used in primary care to give an initial diagnosis to patients with low back pain and related leg symptoms. The purpose of this study was to develop best evidence Clinical Diagnostic Rules (CDR] for the identification of the most common patho-anatomical disorders in the lumbar spine; i.e. intervertebral discs, sacroiliac joints, facet joints, bone, muscles, nerve roots, muscles, peripheral nerve tissue, and central nervous system sensitization. METHODS: A sensitive electronic search strategy using MEDLINE, EMBASE and CINAHL databases was combined with hand searching and citation tracking to identify eligible studies. Criteria for inclusion were: persons with low back pain with or without related leg symptoms, history or physical examination findings suitable for use in primary care, comparison with acceptable reference standards, and statistical reporting permitting calculation of diagnostic value. Quality assessments were made independently by two reviewers using the Quality Assessment of Diagnostic Accuracy Studies tool. Clinical examination findings that were investigated by at least two studies were included and results that met our predefined threshold of positive likelihood ratio ≥ 2 or negative likelihood ratio ≤ 0.5 were considered for the CDR. RESULTS: Sixty-four studies satisfied our eligible criteria. We were able to construct promising CDRs for symptomatic intervertebral disc, sacroiliac joint, spondylolisthesis, disc herniation with nerve root involvement, and spinal stenosis. Single clinical test appear not to be as useful as clusters of tests that are more closely in line with clinical decision making. CONCLUSIONS: This is the first comprehensive systematic review of diagnostic accuracy studies that evaluate clinical examination findings for their ability to identify the most common patho-anatomical disorders in the lumbar spine. In some diagnostic categories we have sufficient evidence to recommend a CDR. In others, we have only preliminary evidence that needs testing in future studies. Most findings were tested in secondary or tertiary care. Thus, the accuracy of the findings in a primary care setting has yet to be confirmed.

Development and validation of the daily fatigue cancer scale (DFCS): Single-item questions for clinical practice.

PURPOSE: Cancer-Related Fatigue (CRF), subjective symptom, is considered the most prevalent and disabling in cancer. To help caregivers better understand it, we developed and evaluated the psychometric properties of a visual analog scale to assess daily CRF. METHOD: In our qualitative study, we conducted interviews with caregivers, patients and scientists (N = 30) to generate items and select the scale's format. We then administered the final scale to a sample of 104 patients hospitalized for cancer surgery. In our quantitative study, we evaluated psychometric items with standardized questionnaires to compare and identify the construct validity of our fatigue scale. Because clinicians need a cutoff to diagnose fatigue in daily care, we also analyzed the scale's sensitivity. RESULTS: Correlations evidenced good construct validity for our scale, with r = 0.886 (p > 0.01), confirming that both physical fatigue and psychological fatigue (r = 0.768) were effectively measured. The Receiver Operating Curve (ROC) showed good sensitivity and specificity (>0.80), giving clinicians a threshold to identify tired patients, with only a 3% chance of misdiagnosis. CONCLUSION: The Daily Fatigue Cancer Scale is a good tool to detect patient fatigue and improve patient care.

Classification and Treatment of Chronic Neck Pain: A Longitudinal Cohort Study.

BACKGROUND AND OBJECTIVES: Neck pain exerts a steep personal and socioeconomic toll, ranking as the fourth leading cause of disability. The principal determinant in treatment decisions is whether pain is neuropathic or nonneuropathic, as this affects treatment at all levels. Yet, no study has sought to classify neck pain in this manner. METHODS: One hundred participants referred to an urban, academic military treatment facility with a primary diagnosis of neck pain were enrolled and followed up for 6 months. Pain was classified as neuropathic, possible neuropathic, or nonneuropathic using painDETECT and as neuropathic, mixed, or nociceptive by s-LANSS (self-completed Leeds Assessment of Neuropathic Symptoms and Signs pain scale) and physician designation. Based on previous studies, the intermediate possible neuropathic pain category was considered to be a mixed condition. The final classification was based on a metric combining all 3 systems, slightly weighted toward physician's judgment, which is considered the reference standard. RESULTS: Fifty percent of participants were classified as having possible neuropathic pain, 43% as having nonneuropathic pain, and 7% with primarily neuropathic pain. Concordance was high between the various classification schemes, ranging from a low of 62% between painDETECT and physician designation for possible neuropathic pain, to 83% concordance between s-LANSS and the 2 other systems for neuropathic pain. Individuals with neuropathic pain reported higher levels of baseline disability, were more likely to have a coexisting psychiatric illness, and underwent surgery more frequently than other pain categories, but were also more likely to report greater reductions in disability after 6 months. CONCLUSIONS: Although pure neuropathic pain comprised a small percentage of our cohort, 50% of our population consisted of mixed pain conditions containing a possible neuropathic component. There was significant overlap between the various classification schemes.

Classification characteristics of a chronic low back pain population using a combined McKenzie and patho-anatomical assessment.

BACKGROUND: Physiotherapists use musculo-skeletal classification systems for patient assessment. Since its early development, the McKenzie lumbar spine assessment (MK) has been incorporated into examination algorithms and combined with a series of patho-anatomical diagnostic tests. No previous studies have used a MK and a combined examination (MK-C) to provide a detailed profile of patients, report and compare the classification characteristics of a chronic low back pain (CLBP) population. OBJECTIVE: To report the classification characteristics of a CLBP population using MK and MK-C examinations, and conduct inter-classification comparison of the MK-C for demographics, the Oswestry Disability Index (ODI), Roland Morris Disability Index (RM), Modified Somatic Perceptions Questionnaire (MSPQ), symptom duration and intensity. METHOD: A prospective cross-sectional study conducted in a spinal clinic by a MK trained physiotherapist. RESULTS: Results were obtained in 150 patients. Using MK, 31% (n = 47) of participants were classified as inconclusive. Following MK-C only 6% of participants remained inconclusive (n = 9). The most frequent MK-C classification was facet joint syndrome (FJS) (49%). Participants with FJS were significantly older than those classified as discogenic (p < 0.001; CI 3.96 ̶ 19.74), or mixed (p < 0.001; CI 5.98 ̶ 36.41). Participants classified as discogenic had significantly higher RM (p = 0.022) and MSPQ (p = 0.005) scores than FJS. CONCLUSION: Results indicated that 94% of CLBP patients could be classified using a MK-C. The most common presentation in CLBP was facet joint syndrome. Age, RM and MSPQ appeared to be distinguishing characteristics of this population. Future studies should be conducted to establish the validity and reliability of the MK-C.

Intraperitoneal Local Anesthetic in Pediatric Surgery: A Systematic Review.

Introduction Systematic reviews report intraperitoneal local anesthetic (IPLA) effective in adults but until now no review has addressed IPLA in children. The objective of this review was to answer the question, does IPLA compared with control reduce pain after pediatric abdominal surgery. Materials and Methods Data sources: MEDLINE, EMBASE, Cochrane databases, trials registries, ProQuest, Web of Science, Google Scholar, and Open Gray. STUDY SELECTION: Independent duplicate searching for randomized controlled trials of IPLA versus no IPLA/placebo in children ≤ 18 years of age, reporting pain, or opioid use outcomes. DATA EXTRACTION: Independent duplicate data extraction and quality assessment using standardized fields. Results The selection process uncovered three eligible published trials and one unpublished study, all in laparoscopy surgery. Qualitative synthesis suggested that IPLA may reduce pain scores, opioid use, time to first opioid, and the need for rescue analgesia, with no effect on hospital stay. Risk of bias was significant. Conclusions IPLA appears promising in pediatric surgery. The high absorptive capacity of the peritoneum and high peritoneal surface area to volume ratio in children presents a dose limitation. In comparison to adult surgery, IPLA has been understudied in pediatric surgery.

A Seamless Navigation to ICD-10-CM for Interventional Pain Physicians: Is a Rude Awakening Avoidable?

Since October 1, 2015, the International Classification of Diseases, 10th Revision, Clinical Modification (ICD-10-CM) was integrated into U.S. medical practices. This monumental transition seemingly occurred rather unceremoniously, despite significant opposition and reservations having been expressed by the provider community. In prior publications, we have described various survival strategies for interventional pain physicians. The regulators and beneficiaries of system-CMS, consultants, and health information technology industry are congratulating themselves for a job well done. Nonetheless, this transition comes at an immeasurable financial and psychological drain on providers. However, a rude awakening may be making its way with expiration of initial concessions from government and private payers.This manuscript provides a template for interventional pain management professionals with multiple steps for seamless navigation, including descriptions of the most commonly used codes, navigation through ICD-10-CM manual, steps for correct coding, and finally, detailed coding descriptions for various interventional techniques.

Determination of Pain Phenotypes in Knee Osteoarthritis: A Latent Class Analysis Using Data From the Osteoarthritis Initiative.

OBJECTIVE: Knee osteoarthritis (OA) is a broadly applied diagnosis that may describe multiple subtypes of pain. The purpose of this study was to identify phenotypes of knee OA, using measures from the following pain-related domains: 1) knee OA pathology, 2) psychological distress, and 3) altered pain neurophysiology. METHODS: Data were selected from a total of 3,494 participants at visit 6 of the Osteoarthritis Initiative study. Latent class analysis was applied to the following variables: radiographic OA severity, quadriceps strength, body mass index, the Charlson Comorbidity Index (CCI), the Center for Epidemiologic Studies Depression Scale, the Coping Strategies Questionnaire-Catastrophizing subscale, number of bodily pain sites, and knee joint tenderness at 4 sites. The resulting classes were compared on the following demographic and clinical factors: age, sex, pain severity, disability, walking speed, and use of arthritis-related health care. RESULTS: A 4-class model was identified. Class 1 (4% of the study population) had higher CCI scores. Class 2 (24%) had higher knee joint sensitivity. Class 3 (10%) had greater psychological distress. Class 4 (62%) had lesser radiographic OA, little psychological involvement, greater strength, and less pain sensitivity. Additionally, class 1 was the oldest, on average. Class 4 was the youngest, had the lowest disability, and least pain. Class 3 had the worst disability and most pain. CONCLUSION: Four distinct pain phenotypes of knee OA were identified. Psychological factors, comorbidity status, and joint sensitivity appear to be important in defining phenotypes of knee OA-related pain.

[Pain in hospital: Assessing the pain situation in Austrian patients]. / Schmerz im Krankenhaus: Erfassung der Schmerzsituation österreichischer Patienten.

BACKGROUND: In a survey of all adult inpatients at the Wilhelminen Hospital in Vienna and the Klagenfurt Clinic on Lake Wörthersee, data on pain prevalence, the most frequent sites of pain, pain intensity, pain type, effect of pain on patients, pain evaluation on the various wards, pain precipitating factors, and patient satisfaction were collected. MATERIALS AND METHODS: All inpatients > 18 years were questioned using a questionnaire developed by the investigators at the Department for Anesthesia, Intensive Care, and Pain Medicine at the Wilhelminen Hospital. RESULTS: A pain prevalence of 45.7% was found at the Wilhelminen Hospital and of 40.8% at the Klagenfurt Clinic. Women reported pain significantly more often than men. No significant difference was found between surgical and conservative treatment wards in terms of pain prevalence. Patients on conservative treatment wards reported significantly higher current pain intensity than those in surgical departments. The most common areas of pain were joints and bones. A score >3 in the ID pain questionnaire was reached by 8.8% (Wilhelminen Hospital) and 4.0% (Klagenfurt Clinic) of participants. Pain influenced mood, mobility, and nighttime sleep, and was intensified by the daily clinical routine. CONCLUSION: Overall, it was demonstrated that the majority of patients at both hospitals were satisfied with the pain management. However, pain management in conservative treatment disciplines must not be neglected. More intense current pain, a worse quality of life, and a trend toward lower patient satisfaction indicate that analgesic treatment in nonsurgical disciplines should be optimized.

Low back pain: guidelines for the clinical classification of predominant neuropathic, nociceptive, or central sensitization pain.

BACKGROUND: Low back pain (LBP) is a heterogeneous disorder including patients with dominant nociceptive (e.g., myofascial low back pain), neuropathic (e.g., lumbar radiculopathy), and central sensitization pain. In order to select an effective and preferably also efficient treatment in daily clinical practice, LBP patients should be classified clinically as either predominantly nociceptive, neuropathic, or central sensitization pain. OBJECTIVE: To explain how clinicians can differentiate between nociceptive, neuropathic, and central sensitization pain in patients with LBP. STUDY DESIGN: Narrative review and expert opinion SETTING: Universities, university hospitals and private practices METHODS: Recently, a clinical method for the classification of central sensitization pain versus neuropathic and nociceptive pain was developed. It is based on a body of evidence of original research papers and expert opinion of 18 pain experts from 7 different countries. Here we apply this classification algorithm to the LBP population. RESULTS: The first step implies examining the presence of neuropathic low back pain. Next, the differential diagnosis between predominant nociceptive and central sensitization pain is done using a clinical algorithm. LIMITATIONS: The classification criteria are substantiated by several original research findings including a Delphi survey, a study of a large group of LBP patients, and validation studies of the Central Sensitization Inventory. Nevertheless, these criteria require validation in clinical settings. CONCLUSION: The pain classification system for LBP should be an addition to available classification systems and diagnostic procedures for LBP, as it is focussed on pain mechanisms solely.

[Patients with pain in outpatient care. A nationwide cross-sectional survey with path model]. / Schmerz bei Patienten in der ambulanten Pflege. Eine bundesweite Querschnittsstudie mit Pfadmodell.

BACKGROUND: There is limited knowledge on the degree of pain and pain-related impairments in home care clients. This study was carried out to provide data on the prevalence of pain and pain-related impairments in home care patients and to investigate the impact on activities of daily living and on classification into the three levels of care as defined by the statutory German long-term care insurance. MATERIAL AND METHODS: In 2012 a representative cross-sectional multicenter study was conducted among clients of 100 German home care services. The stepwise sampling procedure included a random selection of 9 home care services in each of the 16 federal states and a randomized sampling among the clients of the participating home care services. The total sample consisted of 878 home care clients (inclusion criteria ≥ 18 years). The subjective pain intensity was measured using an 11-step Likert scale ranging from 0 (no pain) to 10 (most severe pain). Pain-related impairments were rated on a 6-step Likert scale (0 = no impairments to 5 = complete impairment) assessing the level of independence in household chores, mobility, personal hygiene, dressing and social participation. Furthermore, multimorbidity (number of diagnoses) and level of care according to the current classification in the German long-term care insurance were registered. The predictive significance of latent variables was determined by structural equation modelling. RESULTS: Of the subjects surveyed 68.5 % (n = 672) reported suffering from pain. The average intensity of pain was 2.9 (standard deviation SD 2.8) and pain-related impairments had the greatest effect on mobility (78.2 %). Path analysis revealed that a higher degree of pain-related impairments (ß = + 0.31) and a higher number of diagnoses (ß = + 0.19) were associated with classification to higher levels of care as defined in the German long-term care insurance. However, stronger pain and higher age were related to a classification to a lower level of care (ß = - 0.21). No relevant gender differences were identified except for the finding that old age in women had no significant effect on the classification to the level of care, whereas in men both old age and pain intensity did have an impact. CONCLUSION: Even though the majority of home care clients in this representative study suffered from pain, the degree of pain intensity only becomes an issue in home care if it concurs with impairments in daily living and a corresponding classification to higher levels of care dependency. These findings suggest that pain and pain management should receive more attention in home care, irrespective of observable impairments in daily living. In practice, nurses in home care services should regularly assess the level of pain intensity among home care clients and the results of these regular pain assessments should be taken into account for the identification of individual care needs.

Comparison of machine classification algorithms for fibromyalgia: neuroimages versus self-report.

UNLABELLED: Recent studies have posited that machine learning (ML) techniques accurately classify individuals with and without pain solely based on neuroimaging data. These studies claim that self-report is unreliable, making "objective" neuroimaging classification methods imperative. However, the relative performance of ML on neuroimaging and self-report data have not been compared. This study used commonly reported ML algorithms to measure differences between "objective" neuroimaging data and "subjective" self-report (ie, mood and pain intensity) in their ability to discriminate between individuals with and without chronic pain. Structural magnetic resonance imaging data from 26 individuals (14 individuals with fibromyalgia and 12 healthy controls) were processed to derive volumes from 56 brain regions per person. Self-report data included visual analog scale ratings for pain intensity and mood (ie, anger, anxiety, depression, frustration, and fear). Separate models representing brain volumes, mood ratings, and pain intensity ratings were estimated across several ML algorithms. Classification accuracy of brain volumes ranged from 53 to 76%, whereas mood and pain intensity ratings ranged from 79 to 96% and 83 to 96%, respectively. Overall, models derived from self-report data outperformed neuroimaging models by an average of 22%. Although neuroimaging clearly provides useful insights for understanding neural mechanisms underlying pain processing, self-report is reliable and accurate and continues to be clinically vital. PERSPECTIVE: The present study compares neuroimaging, self-reported mood, and self-reported pain intensity data in their ability to classify individuals with and without fibromyalgia using ML algorithms. Overall, models derived from self-reported mood and pain intensity data outperformed structural neuroimaging models.