AAAPT Diagnostic Criteria for Acute Abdominal and Peritoneal Pain After Surgery.

Abdominal and peritoneal pain after surgery is common and burdensome, yet the lack of standardized diagnostic criteria for this type of acute pain impedes basic, translational, and clinical investigations. The collaborative effort among the Analgesic, Anesthetic, and Addiction Clinical Trial Translations, Innovations, Opportunities, and Networks, American Pain Society, and American Academy of Pain Medicine Pain Taxonomy (AAAPT) provides a systematic framework to classify acute painful conditions. Using this framework, a multidisciplinary working group reviewed the literature and developed core diagnostic criteria for acute abdominal and peritoneal pain after surgery. In this report, we apply the proposed AAAPT framework to 4 prototypical surgical procedures resulting in abdominal and peritoneal pain as examples: cesarean delivery, cholecystectomy, colorectal surgical procedures, and pancreas resection. These diagnostic criteria address the 3 most common surgical procedures performed in the United States, capture diverse surgical approaches, and may also be applied to other surgical procedures resulting in abdominal and peritoneal pain. Additional investigation regarding the validity and reliability of this framework will facilitate its adoption in research that advances our comprehension of mechanisms, deliver better treatments, and help prevent the transition of acute to chronic pain after surgery in the abdominal and peritoneal region. PERSPECTIVE: Using AAAPT, we present key diagnostic criteria for acute abdominal and peritoneal pain after surgery. We provide a systematic classification using 5 dimensions for abdominal and peritoneal pain that occurs after surgery, in addition to 4 specific surgical procedures: cesarean delivery, cholecystectomy, colorectal surgical procedures, and pancreas resection.

AAAPT Diagnostic Criteria for Acute Pain Following Breast Surgery.

Acute pain after breast surgery decreases the quality of life of cancer survivors. Previous studies using a variety of definitions and methods report prevalence rates between 10% and 80%, which suggests the need for a comprehensive framework that can be used to guide assessment of acute pain and pain-related outcomes after breast surgery. A multidisciplinary task force with clinical and research expertise performed a focused review and synthesis and applied the 5 dimensional framework of the AAAPT (Analgesic, Anesthetic, and Addiction Clinical Trial Translations, Innovations, Opportunities, and Networks [ACTTION], American Academy of Pain Medicine [AAPM], American Pain Society [APS] Pain Taxonomy) to acute pain after breast surgery. Application of the AAAPT taxonomy yielded the following: 1) Core Criteria: Location, timing, severity, and impact of breast surgery pain were defined; 2) Common Features: Character and expected trajectories were established in relevant surgical subgroups, and common pain assessment tools for acute breast surgery pain identified; 3) Modulating Factors: Biological, psychological, and social factors that modulate interindividual variability were delineated; 4) Impact/Functional Consequences: Domains of impact were outlined and defined; 5) Neurobiologic Mechanisms: Putative mechanisms were specified ranging from nerve injury, inflammation, peripheral and central sensitization, to affective and social processing of pain. PERSPECTIVE: The AAAPT provides a framework to define and guide improved assessment of acute pain after breast surgery, which will enhance generalizability of results across studies and facilitate meta-analyses and studies of interindividual variation, and underlying mechanism. It will allow researchers and clinicians to better compare between treatments, across institutions, and with other types of acute pain.

Preliminary appraisal of the reliability and validity of the Colorado State University Feline Acute Pain Scale.

OBJECTIVES: The objective of this study was to determine the inter-rater reliability and convergent validity of the Colorado State University Feline Acute Pain Scale (CSU-FAPS) in a preliminary appraisal of its performance in a clinical teaching setting. METHODS: Sixty-eight female cats were assessed for pain after ovariohysterectomy. A cohort of 21 cats was examined independently by four raters (two board-certified anesthesiologists and two anesthesia residents) with the CSU-FAPS, and intra-class correlation coefficient (ICC) was used to determine inter-rater reliability. Weighted Cohen's kappa was used to determine inter-rater reliability centered on the 'need to reassess analgesic plan' (dichotomous scale). A separate cohort of 47 cats was evaluated independently by two raters (one board-certified anesthesiologist and one veterinary small animal rotating intern) using the CSU-FAPS and the Glasgow Composite Measure Pain Scale (CMPS-Feline), and Spearman rank-order correlation was determined to assess convergent validity. Reliability was interpreted using Altman's classification as very good, good, moderate, fair and poor. Validity was considered adequate if correlation coefficients were between 0.4 and 0.8. RESULTS: The ICC was 0.61 for anesthesiologists and 0.67 for residents, indicating good reliability. Weighted Cohen's kappa was 0.79 for anesthesiologists and 0.44 for residents, indicating moderate to good reliability. The Spearman rank correlation indicated a statistically significant ( P = 0.0003) positive correlation (0.31; 95% confidence interval 0.14-0.46) between the CSU-FAPS and the CMPS-Feline. CONCLUSIONS AND RELEVANCE: The CSU-FAPS showed moderate-to-good inter-rater reliability when used by veterinarians to assess pain level or need to reassess analgesic plan after ovariohysterectomy in cats. The validity fell short of current guidelines for correlation coefficients and further refinement and testing are warranted to improve its performance.

Effectiveness of the McKenzie Method of Mechanical Diagnosis and Therapy for Treating Low Back Pain: Literature Review With Meta-analysis.

Study Design Literature review with meta-analysis. Background The McKenzie Method of Mechanical Diagnosis and Therapy (MDT), a classification-based system, was designed to classify patients into homogeneous subgroups to direct treatment. Objectives To examine the effectiveness of MDT for improving pain and disability in patients with either acute (less than 12 weeks in duration) or chronic (greater than 12 weeks in duration) low back pain (LBP). Methods Randomized controlled trials examining MDT in patients with LBP were identified from 6 databases. Independent investigators assessed the studies for exclusion, extracted data, and assessed risk of bias. The standardized mean difference (SMD) and 95% confidence interval were calculated to compare the effects of MDT to those of other interventions in patients with acute or chronic LBP. Results Of the 17 studies that met the inclusion criteria, 11 yielded valid data for analysis. In patients with acute LBP, there was no significant difference in pain resolution (P = .11) and disability (P = .61) between MDT and other interventions. In patients with chronic LBP, there was a significant difference in disability (SMD, -0.45), with results favoring MDT compared to exercise alone. There were no significant differences between MDT and manual therapy plus exercise (P>.05) for pain and disability outcomes. Conclusion There is moderate- to high-quality evidence that MDT is not superior to other rehabilitation interventions for reducing pain and disability in patients with acute LBP. In patients with chronic LBP, there is moderate- to high-quality evidence that MDT is superior to other rehabilitation interventions for reducing pain and disability; however, this depends on the type of intervention being compared to MDT. Level of Evidence Therapy, level 1a. J Orthop Sports Phys Ther 2018;48(6):476-490. Epub 30 Mar 2018. doi:10.2519/jospt.2018.7562.

From acute to chronic postsurgical pain: the significance of the acute pain response.

The thesis comprises an overview and four papers, all published or submitted for publication in international peer-reviewed scientific journals.
 
Chronic pain after surgery is a common and debilitating complication after many types of surgery. The cause and pathology behind is still mainly uncovered, though several risk factors have been proposed. One of the strongest risk factors for persistent postsurgical pain is the intensity of the acute pain response though the mechanisms involved remain unsettled. The acute pain response consists of several different types of pain (i.e. somatic pain, visceral pain, referred pain, neuropathic pain). It's uncovered whether some components of the acute pain response are closer correlated to chronic pain than others and whether treatment of acute pain can change the risk of developing chronic pain.
 The aim of the thesis was to investigate which components of the acute pain response, was correlated to chronic postsurgical pain in patients for cholecystectomy and lobectomy.
 Furthermore, to study the type and time course of ipsilateral shoulder pain after lobectomy and whether an ultrasound-guided supraclavicular phrenic nerve block was effective in preventing acute and chronic shoulder pain after major thoracic surgery.
 Paper I is based on a prospective, observational, multicenter, cohort study, in which 100 patients for cholecystectomy was examined preoperatively, 1 week postoperatively and 3, 6, and 12 months postoperatively for pain, psychological factors and signs of hypersensitivity.
 Paper II and III are based on a prospective, observational, cohort study, in which 60 patients for lobectomy ware examined preoperatively, 4 days postoperatively and 12 months postoperatively for pain, psychological factors and signs of hypersensitivity. 
Paper IV is based on a prospective, randomized, double-blind and placebo-controlled trial, where 76 patients were randomized to receive ultrasound guided supraclavicular phrenic nerve block with a blinded study solution (ropivacaine or saline). The primary endpoint was pain within the first 6 hours after surgery. Secondary endpoints included pain the following days and after 3 months.
 
Paper I: Nine patients developed chronic unexplained pain 12 months postoperatively. In a multivariate analysis, cumulated visceral pain during the first week and number of preoperative biliary pain attacks were identified as independent risk factors for unexplained pain 12 months after surgery. There were no consistent signs of increased hypersensitivity in the referred pain area before or after the operation in patients with chronic pain. 
Paper II: Sixteen patients developed chronic pain 12 months postoperatively. In a multivariate analysis thoracic pain during activity was the only significant predictor of chronic pain 12 months after surgery. Shoulder pain, referred pain and overall pain was not significant predictors. There were no signs of general hypersensitivity 12 months after surgery. 
Paper III: Forty-seven (78%) of patients experienced postoperative shoulder pain, but only 25 patients (42%) experienced clinically relevant pain (NRS > 3). On postoperative day 4, 19 (32%) of patients suffered shoulder pain, but only 4 (7%) suffered clinically relevant pain. Only 4 patients (8%) suffered chronic shoulder pain. Ipsilateral shoulder pain of the

 
musculoskeletal type is more intense than referred ipsilateral shoulder pain, though referred shoulder pain is more common. Surgical approach was not related to incidence of shoulder pain or type of pain.
 Paper IV: Shoulder pain within 6 hours of the operation was reported in 9 patients (24%) in the treatment group versus 26 (68%) in the placebo group (p<0.0001). Absolute and relative risk reductions were 44% (95% CI 22-67%) and 65% (95% CI 41-80%), respectively. No major complications, including respiratory compromise, were observed. Subsequent treatment with a nerve catheter was effective during the first 36 hours after surgery, but because of loss of nerve catheter or early submission of patients, data concerning pain the following days and after 3 months were inconclusive.

The ACTTION-APS-AAPM Pain Taxonomy (AAAPT) Multidimensional Approach to Classifying Acute Pain Conditions.

OBJECTIVE: With the increasing societal awareness of the prevalence and impact of acute pain, there is a need to develop an acute pain classification system that both reflects contemporary mechanistic insights and helps guide future research and treatment. Existing classifications of acute pain conditions are limiting, with a predominant focus on the sensory experience (eg, pain intensity) and pharmacologic consumption. Consequently, there is a need to more broadly characterize and classify the multidimensional experience of acute pain. SETTING: Consensus report following expert panel involving the Analgesic, Anesthetic, and Addiction Clinical Trial Translations, Innovations, Opportunities, and Networks (ACTTION), American Pain Society (APS), and American Academy of Pain Medicine (AAPM). METHODS: As a complement to a taxonomy recently developed for chronic pain, the ACTTION public-private partnership with the US Food and Drug Administration, the APS, and the AAPM convened a consensus meeting of experts to develop an acute pain taxonomy using prevailing evidence. Key issues pertaining to the distinct nature of acute pain are presented followed by the agreed-upon taxonomy. The ACTTION-APS-AAPM Acute Pain Taxonomy will include the following dimensions: 1) core criteria, 2) common features, 3) modulating factors, 4) impact/functional consequences, and 5) putative pathophysiologic pain mechanisms. Future efforts will consist of working groups utilizing this taxonomy to develop diagnostic criteria for a comprehensive set of acute pain conditions. PERSPECTIVE: The ACTTION-APS-AAPM Acute Pain Taxonomy (AAAPT) is a multidimensional acute pain classification system designed to classify acute pain along the following dimensions: 1) core criteria, 2) common features, 3) modulating factors, 4) impact/functional consequences, and 5) putative pathophysiologic pain mechanisms. CONCLUSIONS: Significant numbers of patients still suffer from significant acute pain, despite the advent of modern multimodal analgesic strategies. Mismanaged acute pain has a broad societal impact as significant numbers of patients may progress to suffer from chronic pain. An acute pain taxonomy provides a much-needed standardization of clinical diagnostic criteria, which benefits clinical care, research, education, and public policy. For the purposes of the present taxonomy, acute pain is considered to last up to seven days, with prolongation to 30 days being common. The current understanding of acute pain mechanisms poorly differentiates between acute and chronic pain and is often insufficient to distinguish among many types of acute pain conditions. Given the usefulness of the AAPT multidimensional framework, the AAAPT undertook a similar approach to organizing various acute pain conditions.

The ACTTION-APS-AAPM Pain Taxonomy (AAAPT) Multidimensional Approach to Classifying Acute Pain Conditions.

Objective: With the increasing societal awareness of the prevalence and impact of acute pain, there is a need to develop an acute pain classification system that both reflects contemporary mechanistic insights and helps guide future research and treatment. Existing classifications of acute pain conditions are limiting, with a predominant focus on the sensory experience (e.g., pain intensity) and pharmacologic consumption. Consequently, there is a need to more broadly characterize and classify the multidimensional experience of acute pain. Setting: Consensus report following expert panel involving the Analgesic, Anesthetic, and Addiction Clinical Trial Translations, Innovations, Opportunities, and Networks (ACTTION), American Pain Society (APS), and American Academy of Pain Medicine (AAPM). Methods: As a complement to a taxonomy recently developed for chronic pain, the ACTTION public-private partnership with the US Food and Drug Administration, the APS, and the AAPM convened a consensus meeting of experts to develop an acute pain taxonomy using prevailing evidence. Key issues pertaining to the distinct nature of acute pain are presented followed by the agreed-upon taxonomy. The ACTTION-APS-AAPM Acute Pain Taxonomy will include the following dimensions: 1) core criteria, 2) common features, 3) modulating factors, 4) impact/functional consequences, and 5) putative pathophysiologic pain mechanisms. Future efforts will consist of working groups utilizing this taxonomy to develop diagnostic criteria for a comprehensive set of acute pain conditions. Perspective: The ACTTION-APS-AAPM Acute Pain Taxonomy (AAAPT) is a multidimensional acute pain classification system designed to classify acute pain along the following dimensions: 1) core criteria, 2) common features, 3) modulating factors, 4) impact/functional consequences, and 5) putative pathophysiologic pain mechanisms. Conclusions: Significant numbers of patients still suffer from significant acute pain, despite the advent of modern multimodal analgesic strategies. Mismanaged acute pain has a broad societal impact as significant numbers of patients may progress to suffer from chronic pain. An acute pain taxonomy provides a much-needed standardization of clinical diagnostic criteria, which benefits clinical care, research, education, and public policy. For the purposes of the present taxonomy, acute pain is considered to last up to seven days, with prolongation to 30 days being common. The current understanding of acute pain mechanisms poorly differentiates between acute and chronic pain and is often insufficient to distinguish among many types of acute pain conditions. Given the usefulness of the AAPT multidimensional framework, the AAAPT undertook a similar approach to organizing various acute pain conditions.

Acute Pain Characteristics in Patients with and without Chronic Pain following Lower Extremity Injury.

Many patients with injuries to lower extremities report chronic pain. High pain intensity at time of admission for injury is a risk factor for chronic pain, but it is not clear whether specific acute pain patterns following injury influence the development of chronic pain. To examine the relationship between the pain trajectory, the mean pain score, and the frequency of pain documentation during the immediate hospitalization following injury, with the report of chronic pain. This was a descriptive, retrospective cohort study of adults admitted with lower extremity fractures to an academic urban trauma center. Participants, 6-45 months postinjury, rated their current pain, worst pain, and average pain over the last 3 months. Pain scores from hospitalization associated with the injury were obtained through a retrospective chart review. The pain trajectory, mean pain score, and frequency of pain documentation was compared between patients with and without chronic pain. A total of 129 patients were enrolled in this study and 78% reported chronic pain at the site of injury. The mean pain score (5.1 vs. 4.2) and first pain score (5.6 vs. 3.4) were higher for patients with chronic pain compared to patients with no chronic pain. Consistent with other studies, high pain intensity at time of injury was associated with chronic pain. The findings contribute valuable information about acute pain characteristics associated with chronic pain and provide insight into the importance of early and adequate acute pain treatment.

Can a back pain screening tool help classify patients with acute pain into risk levels for chronic pain?

BACKGROUND: The 9-item STarT-Back screening tool was developed in primary care patients with low back pain (LBP) to identify those at greatest risk for chronic pain and requiring targeted treatment. We conducted a secondary data analysis study to examine the performance of comparable questionnaire items in a sample of primary care patients with well-defined acute LBP. METHODS: In a prospective cohort study, 605 primary care patients with LBP of less than 30 days answered a questionnaire with 6 items identical and 3 items analogous to the 9-item STarT-Back. Participants were followed up at 6 months and 2 years. STarT-Back rules were applied to classify participant's risk of chronic LBP, and the performance of the screening items in predicting outcomes was assessed using likelihood ratios. RESULTS: The proportion of patients with chronic pain at follow-up was considerably lower (6 months: 22%; 2 years: 25%) than in the STarT-Back validation cohort (40%) of patients with pain of any duration. The probability of developing chronic pain given a high-risk designation by items similar to the STarT-Back increased the pre-test probability to 31% and 35%. Likelihood ratios were close to 1. CONCLUSIONS: A risk classification schema using the recommended cut-off scores with items similar to the STarT-Back in a primary care population with strictly defined acute LBP had limited ability to identify persons who progressed to chronic pain. The results suggest caution when applying the STarT-Back in patients with acute LBP and a need to consider a modification of its cut-offs.

[Acute pain therapy in surgery]. / Akutschmerztherapie in der Chirurgie.

Pain is no fundamental illness nor should it be a concomitant handicap in any medical treatment. Nevertheless there still is a huge discrepancy between the fundamentally existing medical options of an adequate pain therapy and the actual everyday care of affected patients. An adequate pain therapy in the perioperative or posttraumatic setting represents a basic prerequisite for a rapid recovery and a reduction of any postinterventional risk of morbidity and mortality. An immediate improvement in quality of life secondary to an adequate acute pain therapy increases the chances of an early mobilization, reduces the duration of hospitalization, and thus supports the physical and social rehabilitation of patients. Above that an adequate acute pain therapy will reduce the risk of the development of any chronic pain syndrome as secondary or late effect following operative interventions. These complex interrelations finally also lead to a direct means of cost reduction in the health care system.

Ranking of dental and somatic pain sensations among paediatric dental patients.

BACKGROUND: Children suffer from somatic and dental pain, which may interfere with their everyday life. Pain self-report tools are available for children. Research is needed to better understand the perception of dental pain in comparison with pain in other organs. AIM: To investigate relations between the perceptions of dental and somatic pain complaints among school-age children. DESIGN: One hundred and two children, aged 7-17 years (mean age, 11.5 ± 2.65 years), completed questioners regarding their somatic and dental: 1. Memory pain rank (MPR) and 2. Wong-Baker FACES Pain Rating Scale (FRS). RESULTS: Children reported increased dental pain after school in both scales (P = 0.015 in MPR). In both MPR and FRS, the pattern of pain ranking was similar: Abdominal pain was scored highest (2.75 ± 1.4 and 1.56 ± 1.63, respectively), followed by headache, ear, dental and TMJ (Temporomandibular joint). CONCLUSION: There was a strong correlation between pain perception and current pain scores in every organ. Somatic pain, namely head, abdomen and ears, was ranked significantly higher than dental and TMJ pain. School-aged children rank current pain and pain experience significantly lower while they are pre-occupied (school time) in comparison with times when they are less busy (after school time).

Profiling the clinical presentation of diagnostic characteristics of a sample of symptomatic TMD patients.

BACKGROUND: Temporomandibular disorder (TMD) patients might present a number of concurrent clinical diagnoses that may be clustered according to their similarity. Profiling patients' clinical presentations can be useful for better understanding the behavior of TMD and for providing appropriate treatment planning. The aim of this study was to simultaneously classify symptomatic patients diagnosed with a variety of subtypes of TMD into homogenous groups based on their clinical presentation and occurrence of comorbidities. METHODS: Clinical records of 357 consecutive TMD patients seeking treatment in a private specialized clinic were included in the study sample. Patients presenting multiple subtypes of TMD diagnosed simultaneously were categorized according to the AAOP criteria. Descriptive statistics and two-step cluster analysis were used to characterize the clinical presentation of these patients based on the primary and secondary clinical diagnoses. RESULTS: The most common diagnoses were localized masticatory muscle pain (n = 125) and disc displacement without reduction (n = 104). Comorbidity was identified in 288 patients. The automatic selection of an optimal number of clusters included 100% of cases, generating an initial 6-cluster solution and a final 4-cluster solution. The interpretation of within-group ranking of the importance of variables in the clustering solutions resulted in the following characterization of clusters: chronic facial pain (n = 36), acute muscle pain (n = 125), acute articular pain (n = 75) and chronic articular impairment (n = 121). CONCLUSION: Subgroups of acute and chronic TMD patients seeking treatment can be identified using clustering methods to provide a better understanding of the clinical presentation of TMD when multiple diagnosis are present. Classifying patients into identifiable symptomatic profiles would help clinicians to estimate how common a disorder is within a population of TMD patients and understand the probability of certain pattern of clinical complaints.

Morphine consumption is not modified in patients with severe pain and classified by the DN4 score as neuropathic.

Neuropathic pain has been poorly investigated in the emergency department, although it is known to be less sensitive to opioids than other forms of pain. We tested the hypothesis that morphine requirements are increased in patients having severe pain classified as neuropathic using the DN4 score. We included adult patients with acute severe pain (visual analog scale ≥ 70), assessed using the DN4 score, and treated with intravenous morphine titration (bolus of 2 or 3 mg [body weight >60 kg] with 5-minute intervals between each bolus). Pain relief was defined as a visual analog scale 30 or less. Patients were divided into 2 groups: control group (DN4 score <4) and neuropathic pain group (DN4 score ≥ 4). The main outcome was the total dose of morphine administered. Data are mean ± SD or median (interquartile range). Among the 239 patients included (mean age, 43+14 years), 35 patients (15%) had a DN4 score 4 or more. The main characteristics of the 2 groups were comparable. There were no significant differences between the 2 groups in morphine dose (0.16+0.09 vs 0.17+0.11 mg/kg, P=.32), number of boluses administered (3.5 [3-5] vs 3 [3-6], P=.97), proportion of patients with pain relief (75 vs 83%, P=.39), or morphine-related adverse effects (11% vs 3%, P=.14). In conclusion, morphine consumption was not significantly modified in patients having severe pain classified as neuropathic using the DN4 score as compared with a control group, suggesting that specific detection of neuropathic pain may not be useful in the emergency department.