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Table of Contents
doi : 10.1016/S1526-5900(21)00304-7
Volume 22, Issue 9, September 2021, Pages A3-A6
Non-Surgical Interventions for Lumbar Spinal Stenosis Leading To Neurogenic Claudication: A Clinical Practice Guideline
AndréBussières?†CarolinaCancelliere‡CarloAmmendolia§Christine M.Comer¶Fadi AlZoubi?Claude-EdouardChâtillon#GregChernish??James MCox††Jordan AGliedt‡‡DanielleHaskett§§Rikke KrügerJensen¶¶Andrée-AnneMarchand??ChristyTomkins-Lane##JulieO'Shaughnessy???StevenPassmore†††Michael J.Schneider‡‡‡§§§PeterShipka¶¶¶GregoryStewart???KentStuber###????AlbertYee††††JosephOrnelas‡‡‡‡§§§In collaboration with the Canadian Chiropractic Guideline Initiative in collaboration and Bone and Joint Canada
doi : 10.1016/j.jpain.2021.03.147
Volume 22, Issue 9, September 2021, Pages 1015-1039
Lumbar spinal stenosis (LSS) causing neurogenic claudication (NC) is increasingly common with an aging population and can be associated with significant symptoms and functional limitations. We developed this guideline to present the evidence and provide clinical recommendations on nonsurgical management of patients with LSS causing NC. Using the GRADE approach, a multidisciplinary guidelines panel based recommendations on evidence from a systematic review of randomized controlled trials and systematic reviews published through June 2019, or expert consensus. The literature monitored up to October 2020. Clinical outcomes evaluated included pain, disability, quality of life, and walking capacity. The target audience for this guideline includes all clinicians, and the target patient population includes adults with LSS (congenital and/or acquired, lateral recess or central canal, with or without low back pain, with or without spondylolisthesis) causing NC. The guidelines panel developed 6 recommendations based on randomized controlled trials and 5 others based on professional consensus, summarized in 3 overarching recommendations: (Grade: statements are all conditional/weak recommendations) Recommendation 1. For patients with LSS causing NC, clinicians and patients may initially select multimodal care nonpharmacological therapies with education, advice and lifestyle changes, behavioral change techniques in conjunction with home exercise, manual therapy, and/or rehabilitation (moderate-quality evidence), traditional acupuncture on a trial basis (very low-quality evidence), and postoperative rehabilitation (supervised program of exercises and/or educational materials encouraging activity) with cognitive-behavioral therapy 12 weeks postsurgery (low-quality evidence). Recommendation 2. In patients LSS causing NC, clinicians and patients may consider a trial of serotonin–norepinephrine reuptake inhibitors or tricyclic antidepressants. (very low-quality evidence). Recommendation 3. For patients LSS causing NC, we recommend against the use of the following pharmacological therapies: nonsteroidal anti-inflammatory drugs, methylcobalamin, calcitonin, paracetamol, opioids, muscle relaxants, pregabalin (consensus-based), gabapentin (very low-quality), and epidural steroidal injections (high-quality evidence).
Tetrahydrocannabinol (THC) Exacerbates Inflammatory Bowel Disease in Adolescent and Adult Female Rats
JeremyDunfordAndrea T.LeeMichael M.Morgan
doi : 10.1016/j.jpain.2021.02.014
Volume 22, Issue 9, September 2021, Pages 1040-1047
Inflammatory Bowel Disease (IBD) is a life-long disorder that often begins between the ages of 15 and 30. Anecdotal reports suggest cannabinoids may be an effective treatment. This study sought to determine whether home cage wheel running is an effective method to assess IBD, and whether Tetrahydrocannabinol (THC), the primary psychoactive compound in cannabis, can restore wheel running depressed by IBD. Adolescent and adult female Sprague-Dawley rats were individually housed in a cage with a running wheel. Rats were injected with trinitrobenzene sulphonic acid (TNBS) into the rectum to induce IBD-like symptoms. One day later, both vehicle and TNBS treated rats were injected with a low dose of THC (0.32 mg/kg, s.c.) or vehicle. Administration of TNBS depressed wheel running in adolescent and adult rats. No antinociceptive effect of THC was evident when administered 1 day after TNBS. In fact, administration of THC prolonged TNBS-induced depression of wheel running for over 5 days in adolescent and adult rats. These results show that home cage wheel running is depressed by TNBS-induced IBD, making it a useful tool to evaluate the behavioral consequences of IBD, and that administration of THC, instead of producing antinociception, exacerbates TNBS-induced IBD.
Gender Biases in Estimation of Others’ Pain
LanlanZhang*Elizabeth A. ReynoldsLosin†Yoni K.Ashar‡LeonieKoban§Tor D.Wager¶
doi : 10.1016/j.jpain.2021.03.001
Volume 22, Issue 9, September 2021, Pages 1048-1059
Caregiving and other interpersonal interactions often require accurate perception of others’ pain from nonverbal cues, but perceivers may be subject to systematic biases based on gender, race, and other contextual factors. Such biases could contribute to systematic under-recognition and undertreatment of pain. In 2 experiments, we studied the impact of perceived patient sex on lay perceivers’ pain estimates and treatment recommendations. In Experiment 1 (N?=?50), perceivers viewed facial video clips of female and male patients in chronic shoulder pain and estimated patients’ pain intensity. Multi-level linear modeling revealed that perceivers under-estimated female patients’ pain compared with male patients, after controlling for patients’ self-reported pain and pain facial expressiveness. Experiment 2 (N?=?200) replicated these findings, and additionally found that 1) perceivers’ pain-related gender stereotypes, specifically beliefs about typical women's vs. men's willingness to express pain, predicted pain estimation biases; and 2) perceivers judged female patients as relatively more likely to benefit from psychotherapy, whereas male patients were judged to benefit more from pain medicine. In both experiments, the gender bias effect size was on average 2.45 points on a 0–100 pain scale. Gender biases in pain estimation may be an obstacle to effective pain care, and experimental approaches to characterizing biases, such as the one we tested here, could inform the development of interventions to reduce such biases.
Patient Perceptions of Physician Burden in the Treatment of Chronic Pain
Raymond C.Tait*John T.Chibnall*DonnaKalauokalani†
doi : 10.1016/j.jpain.2021.03.140
Volume 22, Issue 9, September 2021, Pages 1060-1071
While patient perceptions of burden to caregivers is of recognized clinical significance among people with chronic pain, perceived burden to treating physicians has not been studied. This study examined how people with chronic pain perceived levels of medical evidence (low vs high) and pain severity (4,6,8/10) to influence physician burden and how burden then mediated expected clinical judgments. 476 people with chronic pain read vignettes describing a hypothetical patient with varying levels of medical evidence and pain severity from the perspective of a treating physician, rated the burden that patient care would pose, and made a range of clinical judgments. The effect of pain severity on clinical judgments was expected to interact with medical evidence and be conditionally mediated by burden. Although no associations with burden were found for the pain severity x medical evidence interaction or for pain severity alone, low levels of supporting medical evidence yielded higher burden ratings. Burden significantly mediated medical evidence effects on judgments of symptom credibility, clinical improvement, and psychosocial dysfunction. Results indicate that perceived physician burden negatively influenced judgments of patients with chronic pain, beyond the direct effects of medical evidence. Implications are discussed for clinical practice, as well as future research.
Are You Listening? Facilitation of the Auditory Blink Response in People with Fibromyalgia
CarolynBerryman*†Sarah BWallwork†Alberto MarcosHeredia-Rizo‡EmmaKnight*DannyCamfferman§LeslieRussek¶G. LorimerMoseley†
doi : 10.1016/j.jpain.2021.03.141
Volume 22, Issue 9, September 2021, Pages 1072-1083
The purpose of the current study was to determine whether auditory prepulse inhibition (PPI) and/or prepulse facilitation (PPF) were altered in people with fibromyalgia (FM) when compared with controls. Eyeblink responses were recorded from 29 females with FM and 27 controls, while they listened to 3 blocks of auditory stimuli that delivered pulses with either PPI or PPF. Using a linear mixed model, our main findings were that there was a GROUP*CONDITION interaction (F4, 1084?=?4.01, P= .0031) indicating that the difference in amplitude between FM group and control group changed depending on the condition (PPI or PPF). Post hoc tests revealed no differences between the groups in response to PPI. The FM group showed a greater reactivity of response to the PPF conditioned stimulus than the control group did (t(39.7)?=?2.03, P= .0494). Augmentation of PPF, as demonstrated by the FM group is thought to be linked to alterations in information processing mediated by an autonomically driven general orienting process. Activities that decrease autonomic drive or rebalance autonomic and parasympathetic tone such as vagal stimulation might be pursued as effective interventions for people with FM.
Prospective Association between Dysmenorrhea and Chronic Pain Development in Community-Dwelling Women
RuiLi*Donna A.Kreher†‡Todd A.Jusko*Benjamin P.Chapman†Adrienne D.Bonham‡Christopher L.Seplaki*§
doi : 10.1016/j.jpain.2021.03.139
Volume 22, Issue 9, September 2021, Pages 1084-1096
Despite emerging evidence of associations between dysmenorrhea, enhanced pain sensitivity, and functional neuroimaging patterns consistent with chronic pain, it is unknown whether dysmenorrhea is prospectively associated with chronic pain development. Gaining a better understanding of this relationship could inform efforts in prevention of chronic pain. Using data from the national Midlife in the United States cohort, we examined the prospective association between dysmenorrhea and chronic pain development during a 10-year follow-up (starting 10 years after dysmenorrhea was measured) among 874 community-dwelling women aged 25-74 at baseline (when dysmenorrhea was measured). We fit modified Poisson regression models adjusting for sociodemographic, lifestyle and psychosocial factors. Among women who were menstruating at baseline, self-reported dysmenorrhea was associated with a 41% greater (95% confidence interval [CI]?=?6%-88%) risk of developing chronic pain. Women with dysmenorrhea also developed chronic pain in more body regions (?3 regions vs 1-2 regions vs none, odds ratio [OR]?=?1.77, 95% CI?=?1.18-2.64) and experienced greater pain interference (high-interference vs low-interference vs none, OR?=?1.73, 95% CI?=?1.15-2.59). Among women who had stopped menstruation at baseline, we did not find evidence of an association between their history of dysmenorrhea and subsequent risk of chronic pain development. Results suggest dysmenorrhea may be a general risk factor for chronic pain development among menstruating women.
The Relationship Between Adverse Life Events and Endogenous Inhibition of Pain and Spinal Nociception: Findings From the Oklahoma Study of Native American Pain Risk (OK-SNAP)
Parker A.KellNatalieHellmanFelicitas A.HuberEdward W.LannonBethany L.KuhnCassandra A.SturyczTyler A.ToledoMara J.DemuthBurkhart J.HahnJoanna O.ShadlowJamie L.Rhudy
doi : 10.1016/j.jpain.2021.03.146
Volume 22, Issue 9, September 2021, Pages 1097-1110
Adverse life events (ALEs) are a risk factor for chronic pain; however, mechanisms underlying this association are not understood. This study examined whether cumulative ALE exposure impairs endogenous inhibition of pain (assessed from pain report) and spinal nociception (assessed from nociceptive flexion reflex; NFR) in healthy, pain-free Native Americans (n?=?124) and non-Hispanic Whites (n?=?129) during a conditioned pain modulation (CPM) task. Cumulative ALE exposure was assessed prior to testing by summing the number of potentially traumatic events experienced by each participant across their lifespan. Multilevel modeling found that ALEs were associated with NFR modulation during the CPM task even after controlling for general health, body mass index, sex, age, blood pressure, sleep quality, stimulation intensity, stimulus number, perceived stress, and psychological distress. Low exposure to ALEs was associated with NFR inhibition, whereas high exposure to ALEs was associated with NFR facilitation. By contrast, pain perception was inhibited during the CPM task regardless of the level of ALE exposure. Race/ethnicity did not moderate these results. Thus, ALEs may be pronociceptive for both Native Americans and non-Hispanic Whites by impairing descending inhibition of spinal nociception. This could contribute to a chronic pain risk phenotype involving latent spinal sensitization.
Patients Describe their Lived Experiences of Battling to Live with Complex Regional Pain Syndrome
ColleenJohnston-Devin*†FlorinOprescu*MarionGray*‡MarianneWallis§¶
doi : 10.1016/j.jpain.2021.03.151
Volume 22, Issue 9, September 2021, Pages 1111-1128
Complex regional pain syndrome (CRPS) has never comprehensively been examined from a lived experience perspective. Patients generally have a poorer quality of life than people with other chronic pain conditions. This study aimed to understand the essence of living with CRPS. Data were collected from 17 patients via in-depth interviews. Hermeneutic discussions with four health professionals generated deeper insights. Internet blogs and a book containing patient stories were included for theme verification and triangulation. CRPS is seen as a war-like experience and five themes were identified within the battle: "dealing with the unknown enemy", "building an armoury against a moving target", "battles within the war", "developing battle plans with allies" and "warrior or prisoner of war". Patients live with a chronic pain condition and experience problems unique to CRPS such as fear of pain extending to other parts of their body. Use of the model generated by this research may assist patient/clinician interactions and guide therapeutic discussions. Support for people living with CRPS does not always exist, and some healthcare professionals require additional education about the condition. Better health outcomes are experienced by patients when their personal situation and experiences are heard and understood by health care professionals.
