Structural MRI Analysis of Chronic Pain Patients Following Interdisciplinary Treatment Shows Changes in Brain Volume and Opiate-Dependent Reorganization of the Amygdala and Hippocampus.

OBJECTIVE: The present study examined pre- to post-treatment changes in volumes for brain structures known to be associated with pain processing (thalamus, caudate, putamen, pallidum, hippocampus, amygdala, and accumbens) following an interdisciplinary pain management program. DESIGN: Twenty-one patients participating in a four-week interdisciplinary pain management program completed the study. The program consisted of individual and group therapies with the following disciplines: physical therapy, occupational therapy, pain psychology, biofeedback/relaxation training, nursing lectures, and medical management. All patients underwent functional magnetic resonance imaging of the brain before the start and at completion of the program. They also completed standard outcome measures assessing pain, symptoms of central sensitization, disability, mood, coping, pain acceptance, and impressions of change. RESULTS: Our results showed a significant increase in total brain volume, as well as increased volumes in the thalamus, hippocampus, and amygdala. As expected, we also found significant improvements in our standard outcome measures. The majority of patients rated themselves as much or very much improved. The increase in volume in the hippocampus was significantly associated with patient perceptions of change. However, the correlations were in the unexpected direction, such that greater increases in hippocampal volume were associated with perceptions of less improvement. Further exploratory analyses comparing patients by their opioid use status (use vs no use) showed differential program effects on volume increases in the hippocampus and amygdala. CONCLUSIONS: These findings show that a four-week interdisciplinary pain management program resulted in changes in the brain, which adds objective findings further demonstrating program efficacy.

Impact of Symptom Reporting Agreement on Interdisciplinary Pain Program Participation.

OBJECTIVE: To investigate whether physician-patient agreement of potential patient problem areas impacts subsequent patient enrollment in an interdisciplinary pain management program. DESIGN: Retrospective chart review of 544 patients who underwent evaluation of their chronic pain. Physicians and their patients endorsed perceived patient problems during the evaluation. The potential problems included 7 clinical domains: pain, sleep, mood, physical functioning, ability to cope with pain, ability to manage pain flare-ups, and pain medication effectiveness. RESULTS: Results indicated statistically significant levels of agreement among the physicians and their patients (free-marginal kappa range, 0.19 to 0.94, P's < 0.001). The highest agreement occurred for pain and the lowest for pain medication effectiveness. Patients who enrolled in a recommended program did not differ from those who did not enroll based on either levels of agreement or average number of physician-patient agreements for the 7 clinical domains (P's > 0.05). Patients recommended for higher-intensity programs were perceived by their evaluating physician to have a significantly greater number of problematic clinical domains than those recommended for less intense pain programs. CONCLUSION: The level of physician-patient agreement regarding the patients' current difficulties did not appear to influence patients' decisions to participate in interdisciplinary pain management. Extraneous, nonclinical factors may have had a greater impact on participation in interdisciplinary pain management than physician-patient agreement. Future research should focus on identifying these factors and their impact. Also, studying the impact of physician-patient agreement beyond enrollment status (eg, on successful program completion) may be helpful in potentially enhancing patient outcomes.

Multidimensional Patient Impression of Change Following Interdisciplinary Pain Management.

OBJECTIVES: To assess patient impression of change following interdisciplinary pain management utilizing a newly developed Multidimensional Patient Impression of Change (MPIC) questionnaire. METHODS: A heterogeneous group of chronic pain patients (N = 601) participated in an interdisciplinary treatment program. Programs included individual and group therapies (pain psychology, physical therapy, occupational therapy, relaxation training/biofeedback, aerobic conditioning, patient education and medical management). Patients completed measures of pain, mood, coping, physical functioning and pain acceptance both prior to and at completion of their treatment programs. The newly developed MPIC is an expansion to the Patient Global Impression of Change (PGIC) including seven additional domains (Pain, Mood, Sleep, Physical Functioning, Cope with Pain, Manage Pain Flare-ups, and Medication Effectiveness). The MPIC was administered to the patients post-treatment. RESULTS: There were statistically significant pre- to post-treatment improvements found on all outcome measures. The majority of these improvements were significantly correlated with all domains of the MPIC. The original PGIC item was significantly associated with all of the new MPIC domains and the MPIC domains were significantly associated with each other; but there were variations in the distribution of responses highlighting variation of perceived improvements among the domains. The MPIC accounted for greater amounts of variance among the program outcomes than did the PGIC. CONCLUSION: Our results support the use of the MPIC as a quick and easy post-treatment assessment screening tool. Future research is needed to examine relevant correlates to Medication Effectiveness.

Short-Term Functional, Emotional, and Pain Outcomes of Patients with Complex Regional Pain Syndrome Treated in a Comprehensive Interdisciplinary Pain Management Program.

BACKGROUND: Complex regional pain syndrome (CRPS) is difficult to effectively treat with unimodal approaches. OBJECTIVE: To investigate whether CRPS can be effectively treated in a comprehensive interdisciplinary pain management program. DESIGN: Observational cohort study of 49 patients aged 18-89 who fulfilled 'Budapest Criteria' for CRPS and completed an interdisciplinary pain management program. Preprogram to postprogram changes in physical functioning, perceived disability, emotional functioning, acceptance, coping, and pain were assessed. The measures used included: Pain Disability Index, Six minute walk test, 2-minute sit-to-stand, Numerical Rating Scale, Center for Epidemiologic Studies Depression Scale, Pain Anxiety Symptoms Scale, Chronic Pain Acceptance Questionnaire, Coping Strategies Questionnaire-Revised, RIC- Multidimensional Patient Global Impression of Change (RIC-MPGIC), and Medication Quantification Scale. For worker's compensation patients, the rate of successful release to work at the end of the program was calculated. RESULTS: Results indicated significant improvements in physical functioning and perceived disability (P's<0.001). Patients reported increased usage of an adaptive coping strategy, distraction (P = 0.010), and decreased usage of maladaptive and passive strategies (P's < 0.001). Patients showed greater chronic pain acceptance (P's ≤ 0.010) and reductions in emotional distress (P's < 0.001). Medication usage at 1-month follow-up was significantly reduced compared to program start (P < 0.001) and discharge (P = 0.004). Patients reported "much improvement" in overall functioning, physical functioning, mood, and their ability to cope with pain and flare-ups (RIC-MPGIC). Patient report of pain was not significantly reduced at discharge (P =0.078). Fourteen (88%) of 16 total worker's compensation patients were successfully released to work at the end of the program. CONCLUSIONS: This study demonstrates short-term improvements in physical and emotional functioning, pain coping, and medication usage. These findings are consistent with the rehabilitation philosophy of improving functioning and sense of well-being as of equal value and relevance to pain reduction.

Preliminary results of patient-defined success criteria for individuals with musculoskeletal pain in outpatient physical therapy settings.

OBJECTIVES: (1) To investigate patient-defined parameters of treatment success in an outpatient physical therapy setting with musculoskeletal pain, (2) to determine whether patient-defined treatment success was influenced by selected demographic and clinical factors, and (3) to examine whether patient subgroups existed for ratings of importance for each treatment outcome domain. DESIGN: Cross-sectional study. SETTING: Outpatient physical therapy clinic. PARTICIPANTS: Consecutive patients (N=110) with complaints of musculoskeletal pain. INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURE: We reported patient-defined treatment success targets for pain, fatigue, emotional distress, and interference with daily activities using the Patient-Centered Outcomes Questionnaire (PCOQ). We also investigated whether patient subgroups existed based on perceived importance of improvement for these same outcome domains. RESULTS: Patient-defined criteria for treatment success included mean reductions (from baseline scores) in pain of 3.0 points, in fatigue of 2.3 points, in emotional distress of 1.4 points, and in interference with daily activities of 3.4 points. There were no differences in patient-defined criteria for treatment success based on sex, age, postoperative rehabilitation, prior physical therapy, other prior health care interventions, duration of symptoms, and anatomical location of symptoms (P>.01). Cluster analysis of the PCOQ importance ratings indicated a 2-cluster solution. The multifocused subgroup demonstrated higher importance for improvement ratings in each treatment outcome domain when compared with the pain-focused subgroup (P>.05). CONCLUSIONS: These data indicate that patient-defined criteria for treatment success required greater reductions in the studied outcome domains to be considered successful. These data suggest the potential existence of patient subgroups that either rate improvement in all outcome domains as important or rate pain relief as the most important outcome.

SPECT-CT as a Predictor of Pain Generators in Patients Undergoing Intra-Articular Injections for Chronic Neck and Back Pain.

BACKGROUND: The ability to accurately predict pain generators for chronic neck and back pain remains elusive. OBJECTIVE: We evaluated whether injections targeted at foci with uptake on single-photon emission computerized tomography-computed tomography (SPECT-CT) were associated with improved outcomes in patients with chronic neck and back pain. METHODS: A retrospective review was completed on patients undergoing SPECT-CT for chronic neck and back pain between 2016 and 2020 at a tertiary academic center. Patients' records were reviewed for demographic, clinical, imaging, and outcomes data. Only those patients who had facet injections after SPECT-CT were included in this evaluation. Patients undergoing injections targeted at foci of abnormal radiotracer uptake were compared with patients without uptake concerning immediate positive response, visual analog scale, and the need for additional injection or surgery at the target level. RESULTS: A total of 2849 patients were evaluated with a SPECT-CT for chronic neck and back pain. Of those, 340 (11.9%) patients received facet joint injections after SPECT-CT. A propensity score regression analysis adjusted for age, gender, body mass index, hypertension, multiple target injections, and injection location showed uptake targeted injections not being associated with an improved immediate positive response (odds ratio: 0.64; 95% confidence interval: 0.34-1.21; P = 0.172). In patients with a failed facet injection preceding SPECT-CT, adding SPECT-CT to guide facet injections was associated with a decrease in visual analog scale pain scores 2 weeks after injection (P = 0.018), particularly when changes were made to the facets being targeted (P = 0.010). CONCLUSION: This study suggests that there is benefit with SPECT-CT specially to guide facet injections after failed prior facet injections.

Can AM-PAC "6-Clicks" Inpatient Functional Assessment Scores Strengthen Hospital 30-Day Readmission Prevention Strategies?

Background Prevention of unplanned hospital readmissions remains a priority in the US healthcare sector. Patient functional status has evolved as an important factor in identifying patients at risk for unplanned readmissions and poor predischarge functional performance has been shown to be predictive of increased readmission risk. Yet, patient functional status appears to be underutilized in readmission prediction models. Methods To examine the impact of inpatient functional status (mobility and activity performance) on unplanned 30-day hospital readmissions at two tertiary care hospitals, retrospective cohort analysis was performed on electronic health record data from adult inpatients (N = 26,298) having undergone completed functional assessments during their index hospitalization. Primary outcomes were functional assessment scores and unplanned all-cause patient readmission within 30 days following hospital discharge. Secondary analysis stratified the assessment by discharge destination. Functional assessment scores from the Activity Measure for Post-Acute Care (AM-PAC) "6-Clicks" Basic Mobility Short Form or Daily Activity Short Form were extracted along with patient demographics, admission diagnoses, comorbid conditions, and hospital readmission risk score.  Results Adjusting for age, sex, and comorbidity, lower AM-PAC "6-Clicks" Basic Mobility and Daily Activity scores resulted in higher readmission rates when each score was considered separately. When both scores were considered, only Daily Activity scores were significant.  Conclusion Patients with lower Basic Mobility and Daily Activity scores are at a higher risk for readmission. The relative importance of AM-PAC "6-Click" scores on short-term readmission depends on discharge destination. Timely identification of patient mobility and activity performance may lead to earlier intervention strategies to reduce readmissions.

Patient-centered perspective on treatment outcomes in chronic pain.

OBJECTIVE: To define patient-determined success criteria for fibromyalgia and back pain treatment across four outcome domains: pain, fatigue, emotional distress, interference with daily activities. DESIGN: Retrospective correlational clinical sample design. SETTING: Tertiary care clinics at health science center. PATIENTS: 248 fibromyalgia patients and 52 back pain patients. INTERVENTIONS: N/A. OUTCOME MEASURES: Patient Centered Outcomes Questionnaire, measures of usual pain intensity and pain unpleasantness. RESULTS: Overall, for treatment to be considered successful, fibromyalgia patients required pain levels of 3.30 (54% reduction), fatigue levels of 3.08 (60% reduction), distress levels of 2.49 (60% reduction), and interference levels of 2.67 (63% reduction). Comparatively, back pain patients required pain levels of 2.23 (58% reduction), fatigue levels of 2.29 (57% reduction), distress levels of 1.65 (67% reduction), and interference levels of 1.81 (68% reduction). Overall, both fibromyalgia and back pain patients did not expect to meet their criteria for success. CONCLUSIONS: Results highlight the importance of assessing the patient's view of successful outcome. Both fibromyalgia and back pain patients appear to have stringent criteria for success that existing treatments are often unlikely to meet. Comparison across groups indicated fibromyalgia patients have higher usual levels of pain, fatigue, distress, and interference. Interestingly, fibromyalgia patients also require greater changes across domains in order to consider treatment successful, despite rating higher levels of pain, fatigue, distress, and interference as successful. Recognizing patients' success criteria and treatment expectations encourages discussion and development of individualized treatment goals, and wider implementation of individualized treatment for chronic-pain populations is encouraged.

Defining patient-centered, multidimensional success criteria for treatment of chronic spine pain.

OBJECTIVE: This study aimed to define patient-determined success criteria for treatment of chronic spine pain across four domains: pain, fatigue, emotional distress, and interference with daily activities. PATIENTS: Seventy chronic spine pain patients were recruited from university-affiliated pain clinics. DESIGN: The study design was longitudinal, with pretreatment and post-treatment assessments. Post-treatment assessment occurred approximately 2 months after treatment initiation. OUTCOME MEASURES: Participants completed the Patient-Centered Outcomes Questionnaire and Follow-Up Patient-Centered Outcomes Questionnaire. RESULTS: At pretreatment, patient requirements for success were a 58% reduction in pain, 61% reduction in fatigue, 64% reduction in distress, and 66% reduction in interference. These criteria, derived using a direct-scaling approach, are more stringent than criteria developed using other methods. However, patients adjusted their success criteria over time by becoming less stringent, and they used these less stringent criteria to make global judgments of treatment success. Using a scale comparison approach, success criteria for pain were a raw change of 17.5 points (0-100 numerical rating scale) and percent change of 25%. Other criteria were 7.5 (11%) for fatigue, 5.0 (13%) for distress, and 9.5 (12%) for interference. CONCLUSIONS: Future research should validate these success criteria, particularly for the less studied domains of fatigue, distress, and interference, and investigate how these criteria evolve over the course of different treatments.

Evidence for sex differences in the relationships of pain, mood, and disability.

UNLABELLED: Disability demonstrates strong univariate associations with pain and negative mood. These relationships are more complex at the multivariate level and might be further complicated by sex differences. We investigated sex differences in the relationships of pain and negative mood to overall disability and to disability in specific functional domains. One hundred ninety-seven consecutive patients with low back, myofascial, neck, arthritis, and fibromyalgia pain were recruited from university pain clinics and completed measures of disability and negative mood. Overall disability and disability in voluntary activities were significantly associated with pain and negative mood (factor score) for both sexes. Significant sex differences emerged in the strength of the disability-mood relationship, with women evincing a stronger relationship. Disability in obligatory activities was also significantly related to pain and negative mood for both sexes; however, there were no sex differences in the strength of these relationships. Mediation analyses indicated that, in men, negative mood partially mediated the relationship between pain and both overall disability and disability in voluntary activities; mediation was not supported for disability in obligatory activities. In women, negative mood fully mediated the relationship between pain and all 3 types of disability. These data suggest that disability is more directly related to pain in men. In women, the effect of pain on disability appears to operate through negative mood. PERSPECTIVE: Results of this study demonstrate that sex differences exist in the relationships of pain, mood, and disability. Men and women might thus benefit from treatment interventions that differentially target these variables.

Sex differences in the associations among psychological factors and pain report: a novel psychophysical study of patients with chronic low back pain.

UNLABELLED: Previous studies have consistently suggested that there are sex differences in pain report, but there is no consensus regarding sex differences in the associations among psychological factors and pain report. This cross-sectional study used a novel, clinically relevant, psychophysical pain-induction technique to examine sex differences between sensory and affective pain report and sex differences in the association of depression, pain related anxiety, and catastrophizing with pain report. Patients with chronic low back pain (N = 53) were recruited from an outpatient spine clinic, and those consenting completed self-report measures of pain-related anxiety, depression, pain catastrophizing, and pain. A measure of induced low back pain was obtained by having study participants perform a protocol on the MedXtrade mark Low-Back Exercise Apparatus. Our results indicated that no sex differences were detected in psychological factors and self-reported or induced low back pain. However, the relationships between pain related anxiety and self-report of low back pain (z = 2.51, P < .05) and between pain-related anxiety and induced low back pain (z = 3.00, P < .05) were significantly stronger in men than women. These findings suggest that anxiety was linked to self-reported and induced low back pain for men, but not for women. PERSPECTIVE: Results of this study suggest that pain-related anxiety has a stronger association with psychophysical and clinical reports of low back pain for men.

Patient satisfaction with treatment for chronic pain: predictors and relationship to compliance.

OBJECTIVES: Patient satisfaction with treatment has been extensively researched in a variety of medical patients. However, satisfaction with treatment of chronic pain has received considerably less attention. The present study sought to identify the predictors of patient satisfaction with treatment of chronic pain. In addition, the relationship between patient satisfaction and compliance with treatment recommendations was explored. METHODS: One hundred eighty patients (84 men and 96 women) seeking treatment of chronic pain at University of Florida pain clinics were recruited for this telephone follow-up study. RESULTS: Satisfaction ratings were generally high, with ratings of satisfaction with care significantly higher (t179=9.58, P<0.001) than ratings of satisfaction with improvement. Aspects of the patient-provider interaction, pain relief, and anxiety at treatment onset predicted satisfaction with care. These same variables, with the exception of anxiety, also predicted satisfaction with improvement. Those patients who were more satisfied with their improvement were also more compliant with treatment recommendations, and this relationship was stronger for health care provider-rated compliance. DISCUSSION: Results suggest the importance of distinguishing between satisfaction with care and satisfaction with improvement in assessments. Satisfaction with treatment of chronic pain is not merely a matter of pain relief. To increase the probability of treatment success and satisfaction, attention to the interpersonal aspects of the health care provider-patient relationship appear critical. Explanations for satisfaction's stronger relationship to health care provider-rated compliance were discussed.

The challenge of teaching rehabilitative care in medical school.

Rehabilitative care has gained importance because the population is aging, and improved acute and chronic medical care saves and prolongs lives but leaves some patients with temporary or permanent physical impairments. However, despite its importance, the teaching and learning of rehabilitative care in medical school lag behind medical education relating to acute and chronic care. The authors analyze the broad scope of rehabilitative care and the need to include it in the medical school curriculum. They also discuss advantages for students and their patients of learning rehabilitative care in the undergraduate curriculum and suggest methods to improve teaching it.

Physicians' and patients' attitudes toward manual medicine: implications for continuing medical education.

INTRODUCTION: Manual medicine (MM) is a physical modality infrequently used in primary care clinics. This study examines primary care physicians' experience with and attitudes toward the use of MM in the primary care setting, as well as patients' experience with and attitudes toward MM. METHODS: Surveys were distributed to a convenience sample of physicians (54.3% response rate) attending a 1-week primary care continuing medical education (CME) conference in Kentucky. Similar surveys were also mailed to a random sample of primary care patients (35.3% response rate) living in a service region in which most conference attendees practiced. RESULTS: Similar responses were obtained from physicians and patients. A majority (81% and 76%, respectively) of physicians and patients felt that MM was safe, and over half (56% of physicians and 59% of patients) felt that MM should be available in the primary care setting. Although less than half (40%) of the physicians reported any educational exposure to MM and less than one-quarter (20%) have administered MM in their practice, most (71%) respondents endorsed desiring more instruction in MM. The majority of those seeking additional educational exposure (56%) were willing to pay for MM training that included CME credit. DISCUSSION: This survey suggests that primary care physicians feel that there is currently insufficient education in MM. The majority of physicians and patients feel that MM is beneficial, safe, and appropriate for use in a primary care setting. Thus, there may be a rising demand for quality instruction in MM from physical medicine doctors and other licensed therapists who currently practice MM.

The impact of patients' gender, race, and age on health care professionals' pain management decisions: an online survey using virtual human technology.

BACKGROUND: Previous literature indicates that biases exist in pain ratings. Healthcare professionals have been found to use patient demographic cues such as sex, race, and age when making decisions about pain treatment. However, there has been little research comparing healthcare professionals' (i.e., physicians and nurses) pain decision policies based on patient demographic cues. METHODS: The current study used virtual human technology to examine the impact of patients' sex, race, and age on healthcare professionals' pain ratings. One hundred and ninety-three healthcare professionals (nurses and physicians) participated in this online study. RESULTS: Healthcare professionals assessed virtual human patients who were male and African American to be experiencing greater pain intensity and were more willing to administer opioid analgesics to them than to their demographic counterparts. Similarly, nurses were more willing to administer opioids make treatment decisions than physicians. There was also a significant virtual human-sex by healthcare professional interaction for pain assessment and treatment decisions. The sex difference (male>female) was greater for nurses than physicians. CONCLUSIONS: Results replicated findings of previous studies using virtual human patients to assess the effect of sex, race, and age in pain decision-making. In addition, healthcare professionals' pain ratings differed depending on healthcare profession. Nurses were more likely to rate pain higher and be more willing to administer opioid analgesics than were physicians. Healthcare professionals rated male and African American virtual human patients as having higher pain in most pain assessment and treatment domains compared to their demographic counterparts. Similarly the virtual human-sex difference ratings were more pronounced for nurses than physicians. Given the large number of patients seen throughout the healthcare professionals' careers, these pain practice biases have important public health implications. This study suggests attention to the influence of patient demographic cues in pain management education is needed.

NSAIDs for musculoskeletal pain management:current perspectives and novel strategies to improve safety.

BACKGROUND: Musculoskeletal disorders are a growing burden on the health care system in the United States. Nonsteroidal anti-inflammatory drugs (NSAIDs) are commonly used to assist in the management of mild-to moderate musculoskeletal pain. After the withdrawal of rofecoxib because of cardiovascular toxicity, the safety of these agents became a topic of controversy and confusion. Recent evidence is facilitating a better understanding of the risks and mechanisms by which NSAIDs cause injury. In an effort to raise awareness, this review addresses the current challenges, recent progress, and novel strategies for improving tolerability. With new data to help guide decision making and the anticipated increase in pharmacological options for managing musculoskeletal pain, the role of the managed care professional is particularly important in this evolving field. OBJECTIVES: To review recommendations for the appropriate use of NSAIDs, incorporate risk/benefit analysis into decision making, and evaluate the efficacy and safety of recently approved and emerging NSAID formulations. SUMMARY: Musculoskeletal-related conditions are a major public health burden. NSAIDs are among the most commonly used medications for musculoskeletal conditions. Since the introduction of selective cyclooxygenease-2 (COX-2) inhibitors (or coxibs), there has been ongoing discussion and debate about the safety of all NSAIDs. Current available evidence suggests both traditional NSAIDs and coxibs increase the risk of gastrointestinal and cardiovascular toxicity; however, with proper risk assessment, these dangers can be limited. Moreover, new and emerging NSAID formulations and delivery systems aim to enhance the effectiveness and reduce the toxicity associated with these anti-inflammatory agents.

Obesity and low back pain: relationships and treatment.

SUMMARY Low back pain (LBP) and obesity (defined as BMI ≥30 kg/m(2)) are common problems in the general population. The treatment of LBP is not clearly defined and has variable success in different populations and time-frames. When a person presents with LBP who also meets the criteria for obesity, many questions are raised as to the value of weight-loss treatments and the success and/or safety of usual treatments of LBP, especially exercise. Based on the current medical literature for the treatment of LBP in patients who are obese: there should be attempts at weight loss (nonsurgical or surgical), especially if the person is in the morbidly obese (BMI >40 kg/m(2)) range; all usual forms of exercise and physical therapy treatments are possible and can be beneficial without increased concerns for injury; and, if necessary, invasive treatments such as spinal injections or surgery are potentially beneficial and have similar complication rates to the nonobese population. These options should be offered when medically necessary and appropriate.

Effects of obesity on rehabilitation outcomes after orthopedic trauma.

OBJECTIVE: This study examined whether differences existed in inpatient rehabilitation outcomes and therapy participation in nonobese and obese patients with orthopedic trauma. DESIGN: This was a retrospective study of 294 consecutive patients admitted to an inpatient rehabilitation hospital. Main outcomes included participation in therapy sessions, Functional Independence Measure (FIM) ratings, walking distance and stair climb, length of stay, FIM efficiency (FIM score gain/length of stay), and discharge to home. Data were stratified by patient body mass index values (nonobese, <30 kg/m; or obese, ≥30 kg/m). RESULTS: There were no differences in therapy participation or length of stay between groups. Both total and motor FIM ratings at discharge were lower in obese patients compared with nonobese patients (P < 0.05). FIM efficiency was significantly lower in the obese than in the nonobese group (2.6 ± 1.5 vs. 3.1 ± 1.5 points gained per day; P = 0.05). Walking distance and stair climb ability were similar between groups by discharge. Even morbidly obese patients attained some improvement with independence in walking. CONCLUSIONS: Obese patients make significant functional improvement during rehabilitation, but at a lesser magnitude and rate as their nonobese counterparts. Even with morbid obesity, small but important functional gains can occur during rehabilitation for orthopedic trauma.

Investigating patient expectations and treatment outcome in a chronic low back pain population.

OBJECTIVE: This study aimed to measure the outcomes that patients consider clinically meaningful across four treatment domains - (1) pain, (2) fatigue, (3) emotional distress, and (4) level of interference - and determine if patients met their own success criteria. Additionally, the role of expectations in treatment outcome was examined. This study also aimed to determine how change in levels of pain, fatigue, disability, and level of interference varied according to the type of treatment delivered to participants. PATIENTS: Forty-seven chronic low back pain patients were recruited from university-affiliated pain clinics. DESIGN: The study design was longitudinal, consisting of two randomly assigned treatment conditions. The first treatment condition used opioid medication only and the second used both opioid medication and brief cognitive behavioral therapy. Pre- and post-treatment assessments were conducted, which occurred approximately 3 months after the initiation of treatment. OUTCOME MEASURES: A patient-centered outcomes questionnaire was completed by participants at both pre- and post-treatment assessment. RESULTS: Results suggest that patients did not meet their own success criteria in treatment across any of the four domains. There was a significant main effect of time for level of pain indicating that both treatment groups had a decrease in their level of pain at post-treatment, F(1, 45) = 11.98, P < 0.001. There was a significant main effect of time for level of interference domain indicating that both groups experienced a reduction in the level of pain-related interference with daily activities, F(1, 45) = 5.46, P < 0.05. There were no significant effects of time for emotional distress or fatigue or any significant group by time interactions. Contrary to our hypothesis, no significant correlations were found between pretreatment expectations and usual level ratings at post-treatment across the four domains. CONCLUSION: Patients sought larger reductions in pain, fatigue, level of distress, and level of interference than they attained at post-treatment. Enhancing opioid treatment with brief cognitive behavioral therapy did not yield additional improvements for the four domains assessed in patients with chronic low back pain.

Intraindividual variability in daily sleep and pain ratings among chronic pain patients: bidirectional association and the role of negative mood.

OBJECTIVES: Sleep disturbance is a common problem among chronic pain patients. Cross-sectional data from clinical populations and experimental studies have shown an association between sleep disturbance and pain. However, there has been little prospective research into the relationship between daily variability between sleep and pain among chronic pain patients. METHODS: Twenty-two women with chronic pain (back pain, facial pain, fibromyalgia) completed a sleep diary and wore an actigraph for a 2-week period. Self-report measures of pain, mood, and sleep were also completed at baseline. Hierarchical linear modeling (HLM) was used to examine intraindividual variability in sleep and pain ratings among these women. The impact of mood and baseline pain ratings was also examined as potential moderators. RESULTS: Hierarchical linear modeling analyses supported a bidirectional relationship between sleep and pain, such that a night of poor sleep was followed by increased pain ratings the following day and a day of increased pain was followed by a night of poor sleep. Depression scores further influenced these relationships. DISCUSSION: Prospective examination supported a bidirectional relationship between sleep and pain among a group of women with chronic pain. Depressive symptoms had a moderating impact on these relationships. These findings suggest that addressing sleep is important in the treatment of individuals with chronic pain.