An Interventional Response Phenotyping Study in Chronic Low Back Pain: Protocol for a Mechanistic Randomized Controlled Trial.

Evidence-based treatments for chronic low back pain (cLBP) typically work well in only a fraction of patients, and at present there is little guidance regarding what treatment should be used in which patients. Our central hypothesis is that an interventional response phenotyping study can identify individuals with different underlying mechanisms for their pain who thus respond differentially to evidence-based treatments for cLBP. Thus, we will conduct a randomized controlled Sequential, Multiple Assessment, Randomized Trial (SMART) design study in cLBP with the following three aims. Aim 1: Perform an interventional response phenotyping study in a cohort of cLBP patients (n = 400), who will receive a sequence of interventions known to be effective in cLBP. For 4 weeks, all cLBP participants will receive a web-based pain self-management program as part of a run-in period, then individuals who report no or minimal improvement will be randomized to: a) mindfulness-based stress reduction, b) physical therapy and exercise, c) acupressure self-management, and d) duloxetine. After 8 weeks, individuals who remain symptomatic will be re-randomized to a different treatment for an additional 8 weeks. Using those data, we will identify the subsets of participants that respond to each treatment. In Aim 2, we will show that currently available, clinically derived measures, can predict differential responsiveness to the treatments. In Aim 3, a subset of participants will receive deeper phenotyping (n = 160), to identify new experimental measures that predict differential responsiveness to the treatments, as well as to infer mechanisms of action. Deep phenotyping will include functional neuroimaging, quantitative sensory testing, measures of inflammation, and measures of autonomic tone.

Intimate Partner Violence and Telemedicine Usage and Satisfaction Early in the COVID-19 Pandemic.

BACKGROUND: COVID-19 has transformed the landscape of telemedicine utilization, shifting from predominantly in-person services to increased virtual encounters. Although telemedicine offers increased accessibility for medical care, many advocates voice concern about utilization and satisfaction with these services among individuals who experience intimate partner violence (IPV) given the unique practical, mental, and physical health challenges many face. OBJECTIVE: The purpose of the present study was to evaluate differences in telemedicine utilization and satisfaction, as well as global health and perceived loneliness, among data-driven patterns of IPV during the early phases of the pandemic. METHODS: In this longitudinal survey study, participants first completed an online survey between May 2019 and February 2020 that assessed social, psychological, and physical functioning, as well as emotional and physical IPV. A follow-up survey sent in May 2020 assessed recent telemedicine use and satisfaction, as well as response to the COVID-19 pandemic. RESULTS: Latent class analysis favored 4 classes of IPV that differed based on severity and features of IPV experienced. Although all 4 classes reported high satisfaction with telemedicine, individuals reporting low IPV had the highest satisfaction with telemedicine and the lowest rates of telemedicine utilization. Individuals who experienced IPV, particularly multiple forms of emotional and physical IPV, reported high physical and social concerns and perceived stress. CONCLUSIONS: Clinicians using telemedicine should be aware of the multiple challenges faced by individuals experiencing IPV and take additional steps to ensure their needs are met in a safe way. These results have potentially important clinical and policy implications.

Perceived social support partially mediates the association between childhood abuse and pain-related characteristics.

Higher perceived social support has been shown to buffer the impact of negative stressful events like childhood abuse on health outcomes. Yet, the role of perceived social support as a mediator of the association between childhood abuse and pain-related characteristics is not well understood. The present study explored this premise. Patients (n = 1,542) presenting to a tertiary-care, outpatient pain clinic completed a cross-sectional survey consisting of regularly collected clinical data and validated measures. Path analysis suggested that the impact of childhood abuse on sensory and affective pain-related characteristics was partially explained by perceived emotional support. Survivors of childhood abuse display a more complex clinical pain phenotype and this extends to more negative perceptions of social support. Our findings may reflect processes whereby childhood abuse negatively impacts social relationships across the lifespan, and these negative social perceptions and relationships influence sensory and affective components of pain.

Centralized pain and pain catastrophizing mediate the association between lifetime abuse history and self-reported pain medication side effects.

BACKGROUND: Self-reported side effects of pain medication are important determinants of treatment course that can affect patient adherence, medication discontinuation and physician decisions. Yet, few studies have investigated patient-level predictors of self-reported pain medication side effects. The present study sought to fill this gap by exploring the impact of physical or sexual abuse history on self-reported pain medication side effects and considered a mediation model in which those effects are transmitted through a centralized pain phenotype and pain catastrophizing. METHODS: We conducted a cross-sectional analysis of 3118 patients presenting to a tertiary-care, outpatient pain clinic. RESULTS: Approximately 15% of the sample (n=479) reported a lifetime history of abuse. Patients with a lifetime history of abuse, particularly abuse that occurred in both childhood and adulthood, reported more pain medication side effects compared with patients reporting no abuse history. Furthermore, path analysis showed that a centralized pain phenotype and pain catastrophizing mediated the association between lifetime abuse history and the sum of pain medication side effects. CONCLUSIONS: This suggests that individuals who experience abuse may develop a heightened physiological sensitivity to stimuli, as well as a tendency to interpret stimuli negatively, exaggerate the impact of aversive stimuli and undermine their ability to cope with the stressor. This study highlights the need for physicians to understand patient-level predictors of medication tolerance and to consider a history of abuse and trauma in decisions regarding treatment and medication management.