Architectural Ultrasound Pennation Angle Measurement of Lumbar Multifidus Muscles: A Reliability Study.

The pennation angle has been shown to be a relevant parameter of muscle architecture. This parameter has not previously been measured in the lumbar multifidus musculature, and it is for this reason that it has been considered of great interest to establish an assessment protocol to generate new lines of research in the future. OBJECTIVE: The objective of this study was to establish a protocol for measuring the pennation angle of the multifidus muscles, with a study of intra-rater and interrater reliability values. DESIGN: This was a reliability study following the recommendations of the Guidelines for Reporting Reliability and Agreement Studies (GRRAS). SETTING: The study was carried out at University of Alcalá, Department of Physiotherapy. SUBJECTS: Twenty-seven subjects aged between 18 and 55 years were recruited for this study. METHODS: Different ultrasound images of the lumbar multifidus musculature were captured. Subsequently, with the help of ImageJ software, the pennation angle of this musculature was measured. Finally, a complex statistical analysis determined the intra- and interrater reliability. RESULTS: The intra-rater reliability of the pennation angle measurement protocol was excellent for observer 1 in the measurement of the left-sided superficial multifidus 0.851 (0.74, 0.923), and for observer 2 in the measurement of the right-sided superficial 0.711 (0.535, 0.843) and deep multifidus 0.886 (0.798, 0.942). Interrater reliability was moderate to poor, and correlation analysis results were high for thickness vs. pennation angle. CONCLUSIONS: The designed protocol for ultrasound measurement of the pennation angle of the lumbar multifidus musculature has excellent intra-rater reliability values, supporting the main conclusions and interpretations. Normative ranges of pennation angles are reported. High correlation between variables is described.

Perfiles de personalidad y resiliencia en dolor crónico: utilidad del CDRISC-10 para discriminar los tipos resiliente y vulnerable / Profiles of personality and resilience in chronic pain: utility of the CDRISC-10 to discriminate between resilient and vulnerable types

Introducción: Uno de los aspectos psicológicos asociados a la vivencia del dolor crónico han sido los perfiles de personalidad y, relacionado con ellos, la resiliencia. En el dolor crónico la resiliencia se refiere tanto a la capacidad de volver atrás tras el daño inicial como también a la de continuar con su funcionamiento habitual pese a la repetición de los problemas. En este campo, sin embargo, no hay referencias sobre si la resiliencia se relaciona con los perfiles de personalidad. En trabajos previos se ha abordado la cuestión de los perfiles de personalidad relacionados con el dolor crónico. El objetivo de este trabajo es replicar los perfiles encontrados previamente, determinar la capacidad diferencial de la resiliencia sobre dichos perfiles de personalidad evaluados a través del Modelo de los Big Five (FFM) y describir su relación con la adaptación a la enfermedad en enfermos con dolor crónico. Material y método: Sobre una muestra de 494 pacientes con diagnóstico de dolor crónico que asisten por primera vez a la Unidad Multidisciplinar para el Tratamiento del Dolor del Consorcio Hospital General Universitario de Valencia, se evalúan las dimensiones de personalidad (NEO-FFI), resiliencia (CDRISC-10), afrontamiento (CAD-R) y calidad de vida (SF-36). Resultados: Mediante análisis clúster se obtienen dos tipos de perfiles de personalidad: resilientes y sobrecontrolados o vulnerables. Posteriormente, mediante una curva ROC se ha determinado el punto de corte ≥ 25 de la medida de la resiliencia que permite separar óptimamente al grupo resiliente del vulnerable, observándose claras las diferencias en afrontamiento y calidad de vida a favor del grupo resiliente. Conclusión: A partir del punto de corte ≥ 25 del cuestionario CDRISC-10, se pueden diferenciar el uso de estrategias de afrontamiento y la repercusión en la calidad de vida del perfil de personalidad del grupo resiliente frente al vulnerable, lo cual supone un claro ahorro de tiempo y de sobrecarga de evaluación del paciente

Introduction: One of the psychological aspects associated with the experience of chronic pain have been personality profiles and, related to them, resilience. In chronic pain, resilience refers to both the ability to go back and the repetition of problems. In this field, however, there is no reference to whether resilience is related to personality profi les. Previous studies have addressed the issue of personality profiles related to chronic pain. The objective of this studie is to replicate previously found profi les, determine the differential capacity of the personality profiles evaluated through the Big Five Model (FFM) and describe their relationship with the adaptation to the disease in patients with chronic pain. Material and method: The personality dimensions (NEO-FFI) are evaluated on the sample of 494 patients diagnosed with chronic pain who attend the Multidisciplinary Unit for Pain Treatment of the Consortium of the General University Hospital of Valencia, for the first time, resilience (CDRISC-10), coping (CAD-R) and quality of life (SF-36). Results: Cluster analysis yields types of personality profi les: resilient and overcontrolled or vulnerable. Subsequently, using a ROC curve, the cutoff point = 25 of the resolution measure that allows separating the resilient group from the vulnerable group was determined, clearly observing the differences in coping and quality of life in favor of the resilient group. Conclusion: From the cut-off point of the CDRISC-10 questionnaire, the use of coping strategies and the impact on the quality of life of the personality profile of the resilient group can be differentiated from the vulnerable one, which implies a clear saving of time and patient evaluation overload

Prevalence of Burnout Among Pain Medicine Physicians and Its Potential Effect upon Clinical Outcomes in Patients with Oncologic Pain or Chronic Pain of Nononcologic Origin.

Objective: To evaluate the prevalence of burnout among physicians treating patients with chronic pain and to assess the potential relationships between the presence of burnout and patients' clinical outcomes such as pain relief, satisfaction with pain control, and quality of life. Design: An observational, prospective, and noncomparative study. Setting: Pain medicine clinics. Subjects: Physicians from medical departments involved in the management of chronic pain. Patients aged ≥18 years who exhibited moderate chronic pain lasting at least three months. Methods: Physicians were evaluated with the Maslach Burnout Inventory-Human Services Survey (MBI-HSS). Patients were evaluated with the Charlson Comorbidity Index, the Brief Pain Inventory-Short Form (BPI-SF), the EuroQol-5D (EQ-5D), and ad hoc instruments for evaluating satisfaction with pain control, the extent to which the treatment met patients' expectations, and subjective impressions of improvement. Results: Of the 301 physician participants, 22 (7.3%, 95% confidence interval [CI] = 4.9 to 10.8) met the criteria of burnout. Burnout was higher among physicians from pain units, while none of the 35 primary care physicians reported burnout. The presence of burnout was positively associated with patients' pain relief (odds ratio [OR] = 1.423, 95% CI = 1.090 to 1.858) but not with satisfaction with pain control or quality of life. Of the remaining independent variables, being treated by pain unit physicians was significantly associated with worse pain relief (OR = 0.592, 95% CI = 0.507 to 0.691), lower satisfaction (ß = -0.680, 95% CI = -0.834 to -0.525), and worse quality of life (ß = -4.047, 95% CI = -5.509 to -2.585) compared with being treated by physicians from other specialties (e.g., traumatologists, oncologists, etc.). Conclusions: Our study shows a lack of negative or clinically relevant (as shown by the negligible to small effect sizes) impact of burnout on patient-reported outcomes (namely, pain relief, satisfaction, and quality of life) in patients with chronic pain who are treated by pain medicine physicians.

Impact of Empathy in the Patient-Doctor Relationship on Chronic Pain Relief and Quality of Life: A Prospective Study in Spanish Pain Clinics.

Objective: To assess the impact of the empathy of physicians, perceived by patients with chronic pain, regarding pain relief and health-related quality of life (HR-QoL). Methods: A prospective noninterventional study was conducted in 2,898 patients with moderate to severe chronic pain who were referred to pain clinics. The same physician visited each patient at baseline and after one and three months. Study questionnaires included the Jefferson Scale of Patient Perceptions of Physician Empathy (JSPPPE), the Life Orientation Test-Revised (LOT-R), the Pain Coping Questionnaire (CAD-R), the Brief Pain Inventory Short Form (BPI-SF), and the EuroQol-5D (EQ-5D). Regression analyses were used to evaluate the independent contribution of the changes in perceived empathy over pain intensity and improvement of HR-QoL. Results: BPI-SF scores for pain intensity, rated as worst, least, average, and current pain, decreased significantly (P < 0.001) from baseline to month 3, with reductions of 33.7%, 42.5%, 40.0%, and 46.9%, respectively. Pain intensity decreased from 6.3 ± 1.5 at baseline to 4.7 ± 1.8 at one month and 3.8 ± 1.9 at three months (P < 0.050). Significant (P < 0.001) improvements in the EQ-5D tariff (+37.1%) and EQ-5D VAS (+26.7%) were also recorded. In the linear regression analysis, JSPPPE and LOT-R, but not CAD-R, were significantly associated with pain relief and HR-QoL. Conclusions: Physicians' empathy and patients' dispositional optimism have a role in determining positive outcomes in patients with chronic pain. Physicians' empathy may therefore be a suitable, yet relatively unexplored, target for intervention.

Identification of a microRNA signature for the diagnosis of fibromyalgia.

BACKGROUND: Diagnosis of fibromyalgia (FM), a chronic musculoskeletal pain syndrome characterized by generalized body pain, hyperalgesia and other functional and emotional comorbidities, is a challenging process hindered by symptom heterogeneity and clinical overlap with other disorders. No objective diagnostic method exists at present. The aim of this study was to identify changes in miRNA expression profiles (miRNome) of these patients for the development of a quantitative diagnostic method of FM. In addition, knowledge of FM patient miRNomes should lead to a deeper understanding of the etiology and/or symptom severity of this complex disease. METHODS: Genome-wide expression profiling of miRNAs was assessed in Peripheral Blood Mononuclear Cells (PBMCs) of FM patients (N=11) and population-age-matched controls (N=10) using human v16-miRbase 3D-Gene microarrays (Toray Industries, Japan). Selected miRNAs from the screen were further validated by RT-qPCR. Participating patients were long term sufferers (over 10 years) diagnosed by more than one specialist under 1990 American College of Rheumatology criteria. RESULTS: Microarray analysis of FM patient PBMCs evidenced a marked downregulation of hsa-miR223-3p, hsa-miR451a, hsa-miR338-3p, hsa-miR143-3p, hsa-miR145-5p and hsa-miR-21-5p (4-fold or more). All but the mildest inhibited miRNA, hsa-miR-21-5p, were validated by RT-qPCR. Globally, 20% of the miRNAs analyzed (233/1212) showed downregulation of at least 2-fold in patients. This might indicate a general de-regulation of the miRNA synthetic pathway in FM. No significant correlations between miRNA inhibition and FM cardinal symptoms could be identified. However, the patient with the lowest score for mental fatigue coincided with the mildest inhibition in four of the five miRNAs associated with the FM-group. CONCLUSIONS: We propose a signature of five strikingly downregulated miRNAs (hsa-miR223-3p, hsa-miR451a, hsa-miR338-3p, hsa-miR143-3p and hsa-miR145-5p) to be used as biomarkers of FM. Validation in larger study groups is required before the results can be transferred to the clinic.

Lack of evidence for retroviral infections formerly related to chronic fatigue in Spanish fibromyalgia patients.

BACKGROUND: The etiology of fibromyalgia and chronic fatigue syndrome (FM/CFS) is currently unknown. A recurrent viral infection is an attractive hypothesis repeatedly found in the literature since it would explain the persistent pain and tiredness these patients suffer from. The initial striking link of two distinct orphan retroviruses: the gamma retroviruses murine leukemia virus (MLV)-related virus and the delta retrovirus T-lymphotropic virus type 2 (HTLV-2) to chronic fatigue have not been confirmed to date. RESULTS: Genomic DNA (gDNA) from 75 fibromyalgia patients suffering from chronic fatigue and 79 age-matched local healthy controls were screened for the presence of MLV-related and HTLV-2 related proviral sequences. The XMRV env gene was amplified in 20% of samples tested (24% patients/15% healthy controls). Unexpectedly, no PCR amplifications from independent gDNA preparations of the same individuals were obtained. None of the positive samples showed presence of contaminating murine sequences previously reported by other investigators, neither contained additional regions of the virus making us conclude that the initial env amplification came from spurious air-driven amplicon contaminants. No specific HTLV-2 sequences were obtained at any time from any of the 154 quality-controlled gDNA preparations screened. CONCLUSIONS: Previous associations between MLV-related or HTLV-2 retrovirus infection with chronic fatigue must be discarded. Thus, studies showing positive amplification of HTLV-2 sequences from chronic fatigue participants should be revised for possible undetected technical problems.To avoid false positives of viral infection, not only extreme precautions should be taken when nested-PCR reactions are prepared and exhaustive foreign DNA contamination controls performed, but also consistent amplification of diverse regions of the virus in independent preparations from the same individual must be demanded.The fact that our cohort of patients did not present evidence of any of the two types of retroviral infection formerly associated to chronic fatigue does not rule out the possibility that other viruses are involved in inciting or maintaining fibromyalgia and/or chronic fatigue conditions.

The safety of magnetic resonance imaging in patients with programmable implanted intrathecal drug delivery systems: a 3-year prospective study.

BACKGROUND: It is common clinical practice to perform magnetic resonance imaging (MRI) in patients with indwelling programmable intrathecal drug delivery (IDD) systems, although the safety of the procedure has never been documented. We performed a single-center, 3-year, prospective evaluation in patients with a programmable implanted IDD to assess patient discomfort, IDD technical failures, and adverse effects during and after exposure to MRI. METHODS: Forty-three consecutive patients with an implanted programmable IDD system (SynchroMed® EL Implantable Infusion Pump, Model 8626L-18, and SynchroMed® II Model 8637-20, 8637-40; Medtronic, Inc., Minneapolis, MN) requiring a scheduled MRI evaluation were studied during a 3-year period. All MRI scans were performed with a 1.5-tesla clinical use magnet and a specific absorption rate of no more than 0.9 W/kg. Radiograph control was used to confirm postexposure pump rotor movement and detect system dislocations. IDD system failures, patient satisfaction, and discomfort were recorded. RESULTS: None of the patients experienced signs of drug overinfusion that could lead to hemodynamic, respiratory, or neurologic alterations. Radiologic evaluation after MRI revealed no spatial displacements of the intrathecal catheter tip or body pump, and programmer telemetry confirmed the infusion recovery. Patients' satisfaction after the procedure was high. CONCLUSION: Performing an MRI scan with the proposed protocol in patients with an implanted Medtronic programmable IDD system resulted in virtually no technical or medical complications.

Use of a spinal cord stimulator for treatment of Martorell hypertensive ulcer.

Martorell ulcer is a specific disease entity characterized by multiple small homogeneous, symmetrical lesions, although single lesions are observed as well, most commonly located on the anterolateral aspect of the lower leg. The pain associated to these lesions is disproportionate to their size.Martorell ulcer designates a specific disease entity that occurs predominantly in middle-aged women with poorly controlled hypertension in the form of skin ulcers on the anterolateral aspect of the lower legs. The lesions initially appear as small, painful blisters which may or may not be associated with trauma. The pathophysiology of Martorell ulcer is assumed to be related to hypertension-induced arteriole changes in the dermis. The pain is often disproportionate, and the symptoms are not relieved by rest or elevation.Spinal cord stimulation (SCS) is an accepted evidence-based therapy for the treatment of chronic ischemic pain. Spinal cord stimulation is used as a therapeutic tool in the management of this disease not only for symptomatic pain control but also for accelerating the healing process through its effects on causal mechanisms. The beneficial effects of SCS when used to treat ischemic pain include pain relief, decreased infarction or ulcer size, decreased oxygen requirements, and increased claudication distance. Clinical and basic studies indicate that these beneficial effects are mainly associated with an increase or redistribution of blood flow to the ischemic area and/or normalization of the activity in the nervous system.We present the case of a 71-year-old woman diagnosed with Martorell ulcer in the acute phase of the disease. The patient was treated with SCS to achieve both pain relief and healing of the cutaneous ulcer.

Peripheral neurostimulation in supraorbital neuralgia refractory to conventional therapy.

Supraorbital neuralgia has been identified as an infrequent cause of headache that may prove very difficult to control pharmacologically. Peripheral nerve stimulation using electrodes to stimulate the nerve segmentally responsible for the zone of pain may constitute a management alternative in such cases. We present the case of a patient with headache because of posttraumatic supraorbital neuralgia, refractory to medical treatment, with good analgesic control after peripheral nerve stimulation. Peripheral nerve stimulation may be considered a safe, reversible treatment for patients with headache secondary to supraorbital neuralgia who respond poorly to pharmacological treatment, thus avoiding irreversible alternatives such as surgery.

Oral ketamine for the treatment of type I complex regional pain syndrome.

Ketamine has been shown to be effective in the treatment of neuropathic pain. We present a case of severe complex regional pain syndrome type 1 that was treated with oral ketamine. The response and tolerability of this preparation suggest that further study is warranted.

Intervención psicológica en dolor oncológico: un estudio de revisión / Psychological intervention in oncological pain: a review

Objetivo: realizacion de una revision de la literatura sobre aspectos psicologicos relacionados con el dolor en pacientes oncologicos, asi como de los diferentes modelos de intervencion psicologica que han mostrado su efectividad en el tratamiento del dolor. Metodo: La revision bibliografica se realizo a traves de las bases de datos Medline y PsycINFO. Resultados y conclusiones: Las variables psicologicas relacionadas con el dolor en pacientes oncologicos se encuentran asociadas tanto a factores de personalidad neuroticismo, introversion-extraversion, locus de control, como psicosociales distress psicologico, ansiedad, depresion, apoyo social, estrategias de afrontamiento siendo la intervencion que mas apoyo cientifico ha conseguido por su eficacia respecto al alivio del dolor, la que parte desde una perspectiva cognitivo conductual, aunque tambien puede resultar de utilidad la empleada desde modelos psicoeducativos y la psicoterapia de apoyo. En cualquier caso, la intervencion psicologica debe estar encuadrada en el contexto de un tratamiento multidisciplinar, y debe entenderse como una terapia complementaria que facilita y complementa el efecto positivo de otras terapias mas centradas en los aspectos fisicos de la enfermedad

Objective: To realize a review of the existent literature about the psychological aspects related with cancer pain patients as well as the different psychological intervention models that have showed its efficacy in pain treatment. Methods: Medline and PsycINFO data bases were reviewed. Results and conclusions: The psychological variables related with cancer pain are associated with personality factors neuroticism, introversion, extraversion as well as psychosocial factors psychological distress, anxiety, depression, social support, coping strategies, and the cognitive conductual intervention is the perspective that has obtained the most scientific support due to its efficacy in the pain control, although psychoeducation models and support psychotherapy can be useful too. In any case, the psychological intervention must be framed in the context of a multidisciplinary treatment and must be understood as a complementary therapy that facility and complement the positive effect of other therapies more centred in physical aspects of the illness