Neonates as intrinsically worthy recipients of pain management in neonatal intensive care.

One barrier to optimal pain management in the neonatal intensive care unit (NICU) is how the healthcare community perceives, and therefore manages, neonatal pain. In this paper, we emphasise that healthcare professionals not only have a professional obligation to care for neonates in the NICU, but that these patients are intrinsically worthy of care. We discuss the conditions that make neonates worthy recipients of pain management by highlighting how neonates are (1) vulnerable to pain and harm, and (2) completely dependent on others for pain management. We argue for a relational account of ethical decision-making in the NICU by demonstrating how an increase in vulnerability and dependence may be experienced by the healthcare community and the neonate's family. Finally, an ethical framework for decisions around neonatal pain management is proposed, focussing on surrogate decision-making and the importance of compassionate action through both a reflective and an affective empathy. As empathy can be highly motivating against pain, we propose that, in addition to educational programs that raise awareness and knowledge of neonatal pain and pain management, healthcare professionals must cultivate empathy in a collective manner, where all members of the NICU team, including parents, are compassionate decision-makers.

Effects of Psychology and Extragastrointestinal Symptoms on Health Care Use by Subjects With and Without Irritable Bowel Syndrome.

BACKGROUND & AIMS: There is controversy about whether psychological factors (anxiety and depression) increase health care seeking by patients with irritable bowel syndrome (IBS). We investigated whether psychological factors increase health care seeking by patients with IBS and the effects of extragastrointestinal (extra-GI) symptoms. METHODS: We performed a population-based prospective study of health care use over a 12-year period in Sweden. From 2002 through 2006, 1244 subjects were selected randomly for an examination by a gastroenterologist and to complete questionnaires, including the Rome II modular questionnaire. Psychological factors were measured with the valid Hospital Anxiety and Depression scale and extra-GI symptoms were measured with a symptom checklist. Responses from 1159 subjects (57% female; mean age, 48.65 y) were matched with health records in 2016 (164 were classified as having IBS based on Rome II criteria). RESULTS: The overall association between depression or anxiety and health care use varied in subjects with and without IBS at baseline. The presence of extra-GI symptoms strengthened the relationship between anxiety and depression and prospective psychiatric visits for subjects with IBS and without IBS (incidence rate ratio, 1.14-1.26). Extra-GI symptoms did not alter the association of anxiety or depression with use of GI or extra-GI health care. CONCLUSIONS: In a population-based study in Sweden, we found that individuals with high baseline anxiety or depression were more likely to seek psychiatric health care, but not GI or extra-GI health care, in the presence of extra-GI symptoms at baseline. Patients with IBS might benefit from more thorough assessments that examine extra-GI and psychological symptoms, to reduce health care utilization.

Conditioned Pain Modulation (CPM) is Reduced in Irritable Bowel Syndrome: A Systematic Review and Meta-Analysis of CPM and the Role of Psychological Factors.

This systematic review summarises evidence assessing endogenous pain inhibition in people with irritable bowel syndrome (IBS) compared with healthy controls using conditioned pain modulation (CPM) and offset analgesia (OA). Evidence regarding the role of psychological variables is also examined. The review was conducted in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses statement. Four electronic databases were searched to retrieve studies assessing CPM or OA in adults diagnosed with IBS according to the ROME II/III criteria. Standardized mean differences were calculated for each study and a random effects model was used for meta-analysis. Eleven studies were included, 5 of which reported results on the relationship between CPM and psychological variables. None of the studies assessed OA. The risk of bias assessment found a lack of assessor blinding in all studies. The pooled effect estimate was 0.90 (95% CI, 0.40-1.40) indicating a significantly lower CPM effect in people with IBS compared with controls. This effect was reduced to 0.51 when 1 outlier was excluded from the analysis. In addition, reduced CPM responses were significantly correlated with higher anxiety (r=0.17 to 0.64), stress (r=0.63), and pain catastrophizing (r=0.38) in people with IBS; however, the evidence available was limited and the strength of these associations variable. Depression was not found to be associated with CPM in these IBS cohorts. The results of this review suggest that people with IBS, as a group, demonstrate reduced pain inhibition measured by CPM. The preliminary evidence about the association between psychological factors and CPM warrants further investigations.

Systematic review and meta-analysis suggest that varying prevalence of non-acute pain in critically ill infants may be due to different definitions.

AIM: Our aim was to quantify the prevalence of non-acute pain in critically ill infants and to identify how non-acute pain was described, defined and assessed. METHODS: This systematic review and meta-analysis used multiple electronic databases to search for papers published in any language to March 2018: 2029 papers were identified, and 68 full texts were screened. Studies reporting the prevalence of non-acute pain in infants younger than 2 years and admitted to critical care units were included. The extracted data included the use of non-acute pain descriptions, definitions and pain assessment tools. RESULTS: We included 11 studies published between 2002 and 2018 that comprised 1204 infants from Europe, the USA, Canada and India. They were prospective observational (n = 7) and retrospective observational (n = 1) studies and randomised controlled trials (n = 3). The prevalence of non-acute pain was 0%-76% (median 11%). Various pain assessment tools were used, and only two could be pooled. This gave a pooled prevalence of 3.7%-39.8%. A number of different descriptors were used for non-acute pain, and all of these were poorly defined. CONCLUSION: The prevalence of non-acute pain in infants admitted to critical care units varied considerably. This could have been because all the studies used different definitions of non-acute pain.

Which Patients With Chronic Pain Are More Likely to Improve Pain Biology Knowledge Following Education?

BACKGROUND: Pain education is an important part of multidisciplinary management of chronic pain. The characteristics of people likely to have more improvement in pain biology knowledge following pain education are unknown. OBJECTIVE: To identify the baseline factors predicting changes in pain biology knowledge in adults with chronic pain following a 2-hour multidisciplinary pain education session. METHODS: Fifty-five adults with chronic pain attended a 2-hour pain education session prior to a multidisciplinary assessment at a pain clinic. Patients completed the 12-item revised Neurophysiology of Pain Questionnaire (rNPQ, score/12) before and after the pain education session. The primary outcome was change in pain biology knowledge, evaluated with the change in rNPQ score. Ten preselected predictors were investigated using univariate models followed by multivariable models with a manual forwards-building process. RESULTS: Education level and age were significantly associated with change in rNPQ score in the univariate models. Participants with higher levels of education had, on average, 1.96 (0.68 to 3.23) points more improvement in rNPQ score than those with lower levels of education. For every 10 years older a participant was, his or her rNPQ score changed on average by 0.5 (0.1 to 0.8) points less. In the multivariable model, only the education level remained significant, explaining 17% of the variance (R2  = 0.17). The clinical variables that were assessed (pain severity, pain interference, pain self-efficacy, depression, anxiety, and pain catastrophizing) did not predict any knowledge change. CONCLUSION: This study suggests that, of those patients with chronic pain who choose to attend pain education, more educated patients are more likely to improve their pain biology knowledge after a pain education session.

A patient-designed integrative oncology intervention for stage IV locally recurrent rectal cancer: A case report.

INTRODUCTION: Stage IV colorectal cancer is a highly challenging condition to treat, with 5-year survival rates of 13% in Australia, improving to 40% for those patients with locally recurrent rectal cancer who are suitable for total neoadjuvant therapy and pelvic exenterative surgery. This study reports a unique case of a patient with Stage IV locally recurrent rectal cancer (LRRC), who designed and implemented a holistic integrative oncology intervention. CASE PRESENTATION: The patient was 59-years-old when diagnosed with Stage IV locally recurrent rectal cancer, and referred to a highly specialised centre for colorectal cancer care at a tertiary teaching hospital in Sydney, Australia. Treatment included chemo/radiotherapy, liver resection and posterior pelvic exenteration surgery. The patient's background as a health researcher and clinician optimised her ability to design and implement an integrative oncology model of care, including yoga, mindfulness, Buddhist meditation and study, social connection, exercise, psychotherapeutic and nutritional support. This paper describes these mind-body practices and lifestyle modifications and outlines her experiences and outcomes at each stage of her extensive and radical treatment. CONCLUSION: This case provides a unique perspective into how the integration of mind-body practices and lifestyle modifications with conventional treatment can support those living with colorectal cancer.

Detecting insomnia in patients with low back pain: accuracy of four self-report sleep measures.

BACKGROUND: Although insomnia is common in patients with low back pain (LBP), it is unknown whether commonly used self-report sleep measures are sufficiently accurate to screen for insomnia in the LBP population. This study investigated the discriminatory properties of the Pittsburgh Sleep Quality Index (Pittsburgh questionnaire), Insomnia Severity Index (Insomnia index), Epworth Sleepiness Scale (Epworth scale) and the sleep item of the Roland and Morris Disability Questionnaire (Roland item) to detect insomnia in patients with LBP by comparing their accuracy to detect insomnia to a sleep diary. The study also aimed to determine the clinical optimal cut-off scores of the questionnaires to detect insomnia in the LBP population. METHODS: Seventy nine patients with LBP completed the four self-reported questionnaires and a sleep diary for 7 consecutive nights. The accuracy of the questionnaires was evaluated using Receiver Operator Characteristic (ROC) curves with the Area Under the Curve (AUC) used to examine each test's accuracy to discriminate participants with insomnia from those without insomnia. RESULTS: The Pittsburgh questionnaire and Insomnia index had moderate accuracy to detect insomnia (AUC = 0.79, 95% CI = 0.68 to 0.87 and AUC = 0.78, 95% CI = 0.67 to 0.86 respectively), whereas the Epworth scale and the Roland item were not found to be accurate discriminators (AUC = 0.53, 95% CI = 0. 41 to 0.64 and AUC = 0.64, 95% CI = 0.53 to 0.75 respectively). The cut-off score of > 6 for the Pittsburgh questionnaire and the cut-off point of > 14 for the Insomnia index provided optimal sensitivity and specificity for the detection of insomnia. CONCLUSIONS: The Pittsburgh questionnaire and Insomnia index had similar ability to screen for insomnia in patients with low back pain.

Intercultural comparison of patient satisfaction with physiotherapy care in Australia and Korea: an exploratory factor analysis.

OBJECTIVES: The aim of this study was to conduct a cross-cultural comparison of the factors that influence patient satisfaction with musculoskeletal physiotherapy care in Australia and Korea. METHODS: Prospective studies were conducted in Australia and Korea. Patient satisfaction data were collected using the MedRisk Instrument for Measuring Patient Satisfaction with Physical Therapy Care (MRPS) from a total of 1666 patients who were attending clinics for physiotherapy treatment of a musculoskeletal condition. Exploratory factor analysis was conducted to identify factors determining patient satisfaction in each cohort. RESULTS: A four-factor solution for the MRPS was found for the Australian and Korean data sets, explaining 61 and 55% of the variance respectively. Communication and respect, convenience and quality time and person-focused care were factors common to both countries. One factor unique to Korea was courtesy and propriety. For both cultures, global patient satisfaction was significantly but weakly correlated with the outcome of treatment. CONCLUSIONS: The interpersonal aspect of care, namely effective communication and respect from the therapist, appears to be the predominant and universal factor that influences patient satisfaction with physiotherapy care, although other culturally specific factors were identified. Physiotherapists can maximize patient satisfaction with care by addressing those features that uniquely contribute to patient satisfaction in the cultural context in which they are working.

Standardized measurement of recovery from nonspecific back pain.

OBJECTIVE: To propose standardized, patient-centered measures of recovery from nonspecific low back pain (LBP) in research, underpinned by an empirically derived concept of recovery and informed by expert opinion. DESIGN: Synthesis of literature reviews and expert panel opinion. SETTING: Primary care centers for the management of nonspecific LBP. PARTICIPANTS: Persons with nonspecific LBP. INTERVENTIONS: Conservative treatments for nonspecific LBP. MAIN OUTCOME MEASURES: Three phases of research were conducted. First, qualitative research that explored patients' perspectives of recovery from nonspecific LBP was reviewed. Second, measures of recovery used in LBP clinical trials during the past decade were investigated in a systematic review. Third, opinion was sought from an expert panel of clinicians and researchers about how to measure recovery from nonspecific LBP, in a workshop at the 10th International Forum for Primary Care Research in Low Back Pain. RESULTS: An empirically derived and patient-centered concept of recovery from nonspecific LBP was developed from the qualitative research phase. The systematic review conducted in the second study phase revealed that researchers have used vastly heterogeneous measures of LBP recovery in clinical trials during the past decade. Finally, the key conclusions of the LBP Forum workshop were (1) that appropriate patient-centered instruments to measure recovery include global measures and patient-specific measures; and (2) that the benefits of implementing the same recovery measures for acute and chronic LBP outweigh the disadvantages of using different measures. CONCLUSIONS: The results were synthesized to inform our recommendation that researchers consider adopting 2 instruments as standardized measures of recovery from nonspecific LBP, as an adjunct to the existing core set of LBP outcome measures. These instruments are an 11-point Global Back Recovery Scale, for a simple measure of global recovery, and the Patient-Generated Index of Quality of Life-Back Pain, to evaluate specific relevant dimensions of recovery. This recommendation has majority endorsement by members of the Australian National Health and Medical Research Council Acute Low Back Pain Review Group.

Patient satisfaction with musculoskeletal physiotherapy care in Australia: an international comparison.

OBJECTIVES: (1) To attain a quantitative estimate of patient satisfaction with physiotherapy care for musculoskeletal conditions in Australia; (2) to compare the observed level of patient satisfaction with care in Australia with those from other countries; and (3) to compare factors contributing to patient satisfaction between Australia and the United States (US). METHODS: We conducted a prospective study of 274 patients presenting for physiotherapy treatment of a musculoskeletal disorder in Australian clinics. Patient satisfaction was measured using the 20-item MedRisk Instrument for Measuring Patient Satisfaction with Physical Therapy Care (MRPS) and satisfaction scores were compared with those from Northern Europe, North America, the United Kingdom, and Ireland. To investigate factors contributing to patient satisfaction between Australia and the US, we compared 20-item MRPS data from Australian and Spanish-speaking US cohorts. RESULTS: Mean Australian MRPS satisfaction score was 4.55 (95% confidence interval: 4.51-4.59) on a scale of 1 to 5, where 1 indicates high dissatisfaction and 5 indicates high satisfaction. This high level of patient satisfaction is consistent with international data. Australian respondents specifically valued interpersonal aspects of care, including advice and information about their condition and an explanation about self-management. The correlation between treatment outcomes and global patient satisfaction was low (r = -0.22). A comparison of data collected from Australia and the US showed that MRPS items regarding interpersonal aspects of care, such as the therapists' communication skills, correlated strongly with global satisfaction in both countries. However, there were other questionnaire items for which the correlation with global satisfaction was significantly different between Australia and the US. CONCLUSIONS: Patient satisfaction with musculoskeletal physiotherapy care in Australia is high and comparable with Northern Europe, North America, the United Kingdom and Ireland. Comparison of data between Australia and the US indicates that while some determinants of patient satisfaction are common, country-specific differences also exist.

Development of an individualised primary care program for acute low back pain using a hybrid co-design framework.

BACKGROUND: Low back pain is the leading worldwide cause of years lost to disability and the problem is worsening. This paper describes and demonstrates the scholarly development and contextual refinement of a primary care program for acute low back pain in Sydney, Australia. METHODS: Hybrid theoretical frameworks were applied, and co-design was used to contextualise the program to the local healthcare setting. RESULTS: The program was developed in four stages. In stage 1, the scientific evidence about management of acute low back pain in primary care was examined. In stage 2, stakeholders (patients and clinicians) were consulted in nationwide surveys. Data from stages 1 and 2 were used to design an initial version of the program, called My Back My Plan. Stage 3 involved the contextual refinement of the program to the local setting, MQ Health Primary Care. This was achieved by co-design with primary care clinicians and patients who had sought care for low back pain at MQ Health Primary Care clinics. In stage 4, a panel of Australian experts on clinical care for low back pain reviewed the contextualised version of My Back My Plan and final amendments were made. CONCLUSION: My Back My Plan has been developed using an innovative scholarly approach to intervention development.

My Back My Plan is a feasible and acceptable individualised program for acute low back pain in primary care.

BACKGROUND: Low back pain is the largest cause of years lived with a disability in Australia, and there is an urgent need for innovations to address global gaps between evidence and practice. METHODS: This study was a phase 1, single-group, pre-post pilot trial of My Back My Plan, a primary care program for acute low back pain. The trial was conducted at MQ Health Primary Care at Macquarie University in Sydney, Australia. The primary outcomes were feasibility and acceptability. RESULTS: Fourteen participants were recruited to the study, with 79% and 93% followed up at 1 and 3months respectively. Ten general practitioners and four physiotherapists at MQ Health Primary Care delivered the intervention. Although the rate of patient recruitment to the trial was low, other aspects of feasibility (such as intervention adherence and safety) were high. Participating clinicians reported that the program was useful for patients, and the majority stated that the program facilitated person-centred care. Patients rated My Back My Plan as highly acceptable, indicating that they had a better understanding of their low back pain, they were given personalised care and were more confident in self-managing their low back pain. At the 3month follow-up, 85% of participants stated they were very likely to recommend the program to others. CONCLUSIONS: This study suggests that the co-designed, contextually refined MBMP program for MQ Health Primary Care is acceptable to people with acute onset low back pain and warrants further evaluation.

Limited evidence of moderation of the association between gastrointestinal symptoms and prospective healthcare utilisation by quality of life.

BACKGROUND: An individual's drive to seek medical help remains a complex behavioural process, incorporating psychological, social and symptom-specific factors. Within irritable bowel syndrome (IBS), gastrointestinal symptoms only predict a small portion of the high healthcare-seeking experienced. AIM: To examine the moderating role of quality of life (QoL) domains on this relationship to help explain the variance observed. METHODS: This is an analysis of a Swedish population-based prospective study of healthcare use over a 12-year period. At baseline, gastrointestinal symptoms were measured with the valid Gastrointestinal Symptom Rating Scale, and QoL via the SF-36. 1159 subjects (57% female; mean age 48.6 years) had their health records matched with the initial survey. 164 were classified as IBS by Rome II criteria. Negative binomial or logistic models were fit to evaluate the moderating effect of particular QoL domains on the relationship between gastrointestinal symptoms and prospective healthcare utilisation. RESULTS: Gastrointestinal symptoms were associated with prospective healthcare use, but moderation in this relationship by particular QoL domains was not supported; most models did not reach statistical significance. Furthermore, the impact of IBS status did not alter the moderation hypotheses. CONCLUSIONS: Particular QoL domains did not impact the relationship between gastrointestinal symptoms on prospective healthcare seeking. Future research should continue to examine other psychological, social and symptom variables to identify predictors of high healthcare consumers in IBS.

Development of a national pain management competency profile to guide entry-level physiotherapy education in Canada.

BACKGROUND: National strategies from North America call for substantive improvements in entry-level pain management education to help reduce the burden of chronic pain. Past work has generated a valuable set of interprofessional pain management competencies to guide the education of future health professionals. However, there has been very limited work that has explored the development of such competencies for individual professions in different regions. Developing profession-specific competencies tailored to the local context is a necessary first step to integrate them within local regulatory systems. Our group is working toward this goal within the context of entry-level physiotherapy (PT) programs across Canada. AIMS: This study aimed to create a consensus-based competency profile for pain management, specific to the Canadian PT context. METHODS: A modified Delphi design was used to achieve consensus across Canadian university-based and clinical pain educators. RESULTS: Representatives from 14 entry-level PT programs (93% of Canadian programs) and six clinical educators were recruited. After two rounds, a total of 15 competencies reached the predetermined endorsement threshold (75%). Most participants (85%) reported being "very satisfied" with the process. CONCLUSIONS: This process achieved consensus on a novel pain management competency profile specific to the Canadian PT context. The resulting profile delineates the necessary abilities required by physiotherapists to manage pain upon entry to practice. Participants were very satisfied with the process. This study also contributes to the emerging literature on integrated research in pain management by profiling research methodology that can be used to inform related work in other health professions and regions.

Contexte: Contexte: Les stratégies nationales nord-américaines préconisent des améliorations sensibles à la formation de base en matiére de prise en charge de la douleur afin de contribuer à la réduction du fardeau de la douleur chronique. Des travaux antérieurs ont généré un ensemble de compétences interprofessionnelles utile en matiére de prise en charge de la douleur afin de guider la formation des futurs professionnels de la santé. Cependant, trés peu de travaux ont porté sur l'acquisition de telles compétences pour des professions individuelles dans différentes régions. L'uisition de compétences spécifiques à une profession adaptées au contexte local est une première étape nécessaire pour leur intégration dans les systèmes réglementaires locaux. Notre groupe travaille à cet objectif dans le cadre de programmes de formation de base en physiothèrapie partout au Canada.Objectifs: Cette étude visait à créer un profil de compétences consensuel pour la prise en charge de la douleur, propre au contexte canadien de la physiothérapie.Méthodes: Un devis Delphi modifié a étè utilisé pour parvenir à un consensus parmi des formateurs en milieu universitaire et clinique en matière de douleur en milieu universitaire et clinique.Résultats: Des représentants de 14 programmes de formation de base en physiothérapie (93 % des programmes canadiens) et de six formateurs en milieu clinique ont été recrutés. Après deux tours, 15 compétences ont atteint le seuil d'approbation prédéterminé (75 %). La plupart des participants (85 %) ont déclaré être « très satisfaits ¼du processus.Conclusions: Ce processus a permis de dégager un consensus sur un nouveau profil de compétences en matiére de prise en charge de la douleur propre au contexte canadien de la physiothérapie. Ce profil délimite les habiletés requises des physiothérapeutes pour prendre en charge la douleur en début de pratique. Les participants ont été très satisfaits du processus. Cette étude contribue également à la littérature émergente sur la recherche intégrée en matière de prise en charge de la douleur en définissant une méthodologie de recherche qui peut être utilisée pour éclairer des travaux similaires dans d'autres professions de la santé et dans d'autres régions.

Prognosis of acute idiopathic neck pain is poor: a systematic review and meta-analysis.

OBJECTIVE: To conduct a systematic review and meta-analysis on the prognosis of acute idiopathic neck pain and disability. DATA SOURCES: EMBASE, CINAHL, Medline, AMED, PEDro, and CENTRAL were searched from inception to July 2009, limited to human studies. Reference lists of relevant systematic reviews were searched by hand. Search terms included: neck pain, prognosis, inception, cohort, longitudinal, observational, or prospective study and randomized controlled trial. STUDY SELECTION: Eligible studies were longitudinal cohort studies and randomized controlled trials with a no treatment or minimal treatment arm that recruited an inception cohort of acute idiopathic neck pain and reported pain or disability outcomes. Eligibility was determined by 2 authors independently. Seven of 20,085 references were included. DATA EXTRACTION: Pain and disability data were extracted independently by 2 authors. Risk of bias was assessed independently by 2 authors. DATA SYNTHESIS: Statistical pooling showed a weighted mean pain score (0-100) of 64 (95% confidence interval [CI], 61-67) at onset and 35 (95% CI, 32-38) at 6.5 weeks. At 12 months, neck pain severity remained high at 42 (95% CI, 39-45). Disability reduced from a pooled weighted mean score (0-100) at onset of 30 (95% CI, 28-32) to 17 (95% CI, 15-19) by 6.5 weeks, without further improvement at 12 months. Studies varied in length of follow-up, design, and sample size. CONCLUSIONS: This review provides Level I evidence that the prognosis of acute idiopathic neck pain is worse than currently recognized. This evidence can guide primary care clinicians when providing prognostic information to patients. Further research to identify prognostic factors and long-term outcomes from inception cohorts would be valuable.

How is recovery from low back pain measured? A systematic review of the literature.

Recovery is commonly used as an outcome measure in low back pain (LBP) research. There is, however, no accepted definition of what recovery involves or guidance as to how it should be measured. The objective of the study was designed to appraise the LBP literature from the last 10 years to review the methods used to measure recovery. The research design includes electronic searches of Medline, EMBASE, CINAHL, Cochrane database of clinical trials and PEDro from the beginning of 1999 to December 2008. All prospective studies of subjects with non-specific LBP that measured recovery as an outcome were included. The way in which recovery was measured was extracted and categorised according to the domain used to assess recovery. Eighty-two included studies used 66 different measures of recovery. Fifty-nine of the measures did not appear in more than one study. Seventeen measures used pain as a proxy for recovery, seven used disability or function and seventeen were based on a combination of two or more constructs. There were nine single-item recovery rating scales. Eleven studies used a global change scale that included an anchor of 'completely recovered'. Three measures used return to work as the recovery criterion, two used time to insurance claim closure and six used physical performance. In conclusion, almost every study that measured recovery from LBP in the last 10 years did so differently. This lack of consistency makes interpretation and comparison of the LBP literature problematic. It is likely that the failure to use a standardised measure of recovery is due to the absence of an established definition, and highlights the need for such a definition in back pain research.

Prevalence of sleep disturbance in patients with low back pain.

Low back pain (LBP) is a common health condition that is often associated with disability, psychological distress and work loss. Worldwide, billions of dollars are expended each year trying to manage LBP, often with limited success. Recently, some researchers have reported that LBP patients also report sleep disturbance as a result of their LBP. However, as most of this evidence was obtained from highly selected groups of patients or from studies with small samples, high quality data on prevalence of sleep disturbance for patients with LBP are lacking. It is also unclear whether sleep disturbance is more likely to be reported by patients with recent-onset LBP than by patients with persistent LBP. Finally, it is not known whether high pain intensity, the most relevant condition-specific variable, is associated with higher rates of reported sleep disturbance. The present study aimed to determine the prevalence of reported sleep disturbance in patients with LBP. In addition, we aimed to determine whether sleep disturbance was associated with the duration of back pain symptoms and whether pain intensity was associated with reported sleep disturbance. Data from 1,941 patients obtained from 13 studies conducted by the authors or their colleagues between 2001 and 2009 were used to determine the prevalence of sleep disturbance. Logistic regression analyses explored associations between sleep disturbance, the duration of low back symptoms and pain intensity. The estimated prevalence of sleep disturbance was 58.7% (95% CI 56.4-60.7%). Sleep disturbance was found to be dependent on pain intensity, where each increase by one point on a ten-point visual analogue scale (VAS) was associated with a 10% increase in the likelihood of reporting sleep disturbance. Our findings indicate that sleep disturbance is common in patients with LBP. In addition, we found that the intensity of back pain was only weakly associated with sleep disturbance, suggesting that other factors contribute to sleep problems for LBP patients.

Exploration and Validation of Behavioral Pain Measures and Physiological Pain Measures Factor Structure Extracted From the Pain Assessment Tool Item Scores for Infants Admitted to Neonatal Intensive Care.

OBJECTIVE: The objective of the study was to explore and then validate the factor structure of the Pain Assessment Tool (PAT). MATERIALS AND METHODS: A retrospective medical record review was performed of all infants who were admitted to a neonatal intensive care unit between 2008 and 2018 and had 1 PAT assessment (n=2111). Scores on items of the PAT were collected. Infants were randomized to either the principal component analysis (n=1100) to explore the factor structure or confirmatory factor analysis (n=1011). RESULTS: Infants in the 2 samples were demographically comparable. A 2-factor model, consisting of factors Behavioral and Physiological Pain Measures, was extracted, explaining 39.8% of the total variance. There was a low interfactor correlation (r=0.12), and both Behavioral (r=0.59) and Physiological Pain (r=0.37) Measures factor scores were correlated with nurses' perception of pain scores. When the frequencies in the gestational age at birth categories were compared between upper and lower quartile score infants, there was more with pain at preterm than at term (χ2(3)=44.9, P<0.001) for the Physiological Pain Measures factor, whereas Behavioral Pain Measures frequency was higher at term than at preterm (χ2(3)=8.1, P<0.043). A similar pattern was observed for postmenstrual age at assessment categories: Behavioral Pain Measures (χ2(3)=41.8, P<0.001) Physiological Pain Measures (χ2(3)=46.1, P<0.001). The 2-factor correlated model performed better at explaining the observed variances: (χ2(13)=41.6, P<0.001) compared with rival models. DISCUSSION: The PAT assesses both Behavioral Pain and Physiological Pain Measures, and these dimensions need to be considered separately when assessing pain in infants in the neonatal intensive care unit. Behavioral item scores may be insufficient for detecting pain in premature infants if used alone.

The Concept of Pain Inventory for Adults (COPI-Adult): Assessing Knowledge and Beliefs Regarding Pain Science Education.

OBJECTIVES: Assessing knowledge and beliefs regarding pain science can identify gaps and misconceptions. The Concept of Pain Inventory (COPI) was recently developed in children with the intent to guide targeted pain science education. We utilized the original COPI item pool to (1) develop a tool to assess an adult's concept of pain in a cohort who had not received pain science education, (2) evaluate its psychometric properties, (3) examine distribution of scores in a cohort of adults who had received pain science education, and (4) examine associations between scores and clinical variables. MATERIALS AND METHODS: A total cohort of 627 adults were recruited through social media for an online survey. Initial development was conducted on those who had not received prior pain science education (n=125), then the COPI-Adult tool was tested in those who had received prior pain science education (n=502). RESULTS: The resulting unidimensional 13-item COPI-Adult had acceptable internal consistency (α=0.78) and good test-retest reliability at 1 week (Intraclass Correlation Coefficient3,1=0.84 (95% confidence interval: 0.71-0.91). Higher COPI-Adult scores reflect greater alignment with contemporary pain science. COPI-Adult scores were correlated with revised Neurophysiology of Pain Questionnaire (rNPQ) scores and inversely correlated with average and current pain intensity, and pain interference. Adults who reported having received pain science education had significantly higher mean COPI-Adult scores than those who had not, and this difference exceeded the smallest detectable change. DISCUSSION: The COPI-Adult is a brief questionnaire with promising psychometric properties to identify conceptual gaps or misconceptions to inform individualized pain science education.

Do numerical rating scales and the Roland-Morris Disability Questionnaire capture changes that are meaningful to patients with persistent back pain?

OBJECTIVES: To investigate patients' views about two common outcome measures used for back pain: Numerical Rating Scales for pain and the Roland-Morris Disability Questionnaire. SUBJECTS: Thirty-six working adults who had previously sought primary care for back pain and who could speak and read English. METHOD: Eight focus groups were conducted to explore participants' views about the 11-point Numerical Rating Scales and the 24-item Roland-Morris Disability Questionnaire. Each group was led by a facilitator and an interview topic guide was used. Audio recordings of focus groups were transcribed verbatim. Framework analysis was used to chart participants' views and an interpretive analysis performed to explain the findings. RESULTS: Participants reported that neither the Roland-Morris nor the Numerical Rating Scales captured the complex personal experience of pain or relevant changes in their condition. The time-frame of assessment was identified as particularly problematic and the Roland-Morris did not capture relevant functional domains. CONCLUSION: This study provides empirical data that working adults with persistent back pain consider these clinical outcome measures largely inadequate. These measures currently used for back pain may contribute to misleading conclusions about treatment efficacy and patient recovery.