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Sexual abuse and lifetime diagnosis of somatic disorders: a systematic review and meta-analysis.
Paras ML, Murad MH, Chen LP, et al.
JAMA. 2009 Aug 5;302(5):550-61.
CONTEXT: Many patients presenting for general medical care have a history of sexual abuse. The literature suggests an association between a history of sexual abuse and somatic sequelae.
OBJECTIVE: To systematically assess the association between sexual abuse and a lifetime diagnosis of somatic disorders. Data Sources and Extraction A systematic literature search of electronic databases from January 1980 to December 2008. Pairs of reviewers extracted descriptive, quality, and outcome data from included studies. Odds ratios (ORs) and 95% confidence intervals (CIs) were pooled across studies by using the random-effects model. The I(2) statistic was used to assess heterogeneity.
STUDY SELECTION: Eligible studies were longitudinal (case-control and cohort) and reported somatic outcomes in persons with and without history of sexual abuse.
RESULTS: The search identified 23 eligible studies describing 4640 subjects. There was a significant association between a history of sexual abuse and lifetime diagnosis of functional gastrointestinal disorders (OR, 2.43; 95% CI, 1.36-4.31; I(2) = 82%; 5 studies), nonspecific chronic pain (OR, 2.20; 95% CI, 1.54-3.15; 1 study), psychogenic seizures (OR, 2.96; 95% CI, 1.12-4.69, I(2) = 0%; 3 studies), and chronic pelvic pain (OR, 2.73; 95% CI, 1.73-4.30, I(2) = 40%; 10 studies). There was no statistically significant association between sexual abuse and a lifetime diagnosis of fibromyalgia (OR, 1.61; 95% CI, 0.85-3.07, I(2) = 0%; 4 studies), obesity (OR, 1.47; 95% CI, 0.88-2.46; I(2) = 71%; 2 studies), or headache (OR, 1.49; 95% CI, 0.96-2.31; 1 study). We found no studies that assessed syncope. When analysis was restricted to studies in which sexual abuse was defined as rape, significant associations were observed between rape and a lifetime diagnosis of fibromyalgia (OR, 3.35; 95% CI, 1.51-7.46), chronic pelvic pain (OR, 3.27; 95% CI, 1.02-10.53), and functional gastrointestinal disorders (OR, 4.01; 95% CI, 1.88-8.57).
CONCLUSION: Evidence suggests a history of sexual abuse is associated with lifetime diagnosis of multiple somatic disorders.
Paras ML, Murad MH, Chen LP, et al.
JAMA. 2009 Aug 5;302(5):550-61.
CONTEXT: Many patients presenting for general medical care have a history of sexual abuse. The literature suggests an association between a history of sexual abuse and somatic sequelae.
OBJECTIVE: To systematically assess the association between sexual abuse and a lifetime diagnosis of somatic disorders. Data Sources and Extraction A systematic literature search of electronic databases from January 1980 to December 2008. Pairs of reviewers extracted descriptive, quality, and outcome data from included studies. Odds ratios (ORs) and 95% confidence intervals (CIs) were pooled across studies by using the random-effects model. The I(2) statistic was used to assess heterogeneity.
STUDY SELECTION: Eligible studies were longitudinal (case-control and cohort) and reported somatic outcomes in persons with and without history of sexual abuse. -
Reflection, analysis and change: the decade of pain control and research and its lessons for the future of pain management.
Boswell MV, Giordano J.
Pain Physician. 2009;12(6):923-8.
As noted in this journal over the past year, pain medicine faces a crisis – literally a point of potential change (2-4) - brought to the fore, at least in part, by the efforts and outcomes of the Decade of Pain Control and Research (2000 – 2010). To be sure, this is more than a mere crisis in confidence, as a convergence of factors threatens the existence of pain management as a profession, and its authenticity as a practice. The complexity of pain- as symptom, disease and illness — may be one factor in the crisis. Despite our sophisticated research institutions, questions remain about the nature of pain, its effect upon – and the effects of — the brain, mind, consciousness and self of the pain patient, and what these contexts portend for the development and translation of diagnostic and therapeutic techniques, technologies and approaches (5). In short, we may need to re-examine “meanings” and “values” inherent to the experience and expression of pain, and equally examine such values in relation to the definition, and conduct of evidence-based pain medicine (6). Indeed, technology provides invaluable tools for diagnoses and treatments. But, technology alone does not provide the diagnosis, heal the patient, or sustain the profession and practice of pain medicine (7-9). This remains within the humanitarian domain of “care,” in the literal sense, here construed as concern, worry and regard. In this way, we argue that any regard for the pain patient — as the subject of the clinicians’ moral responsibility — must address the nature of pain as physical and phenomenal experience, its meanings, the needs and vulnerabilities it incurs in each individual, and from this determine what and how existing and new technologies and techniques may be employed to serve the patient’s best interests (10). In other words, the good of science in pain medicine is inextricably woven into its prudent use for the good of the pain patient.
Boswell MV, Giordano J.
Pain Physician. 2009;12(6):923-8.
As noted in this journal over the past year, pain medicine faces a crisis – literally a point of potential change (2-4) - brought to the fore, at least in part, by the efforts and outcomes of the Decade of Pain Control and Research (2000 – 2010). To be sure, this is more than a mere crisis in confidence, as a convergence of factors threatens the existence of pain management as a profession, and its authenticity as a practice. The complexity of pain- as symptom, disease and illness — may be one factor in the crisis. Despite our sophisticated research institutions, questions remain about the nature of pain, its effect upon – and the effects of — the brain, mind, consciousness and self of the pain patient, and what these contexts portend for the development and translation of diagnostic and therapeutic techniques, technologies and approaches (5). -
Diagnosis-Specific Management of Somatoform Disorders: Moving Beyond "Vague Complaints of Pain"
Dohrenwend A, Skillings JL.
J Pain. 2009;10(11):1128-37.
The DSM IV category, somatoform disorders, is composed of disorders that are characterized by symptom amplification-most typically, amplification of pain. Other than this commonality, there is considerable variability among the disorders in terms of etiology, course, comorbidities, and the presence or absence of insight. The heterogeneous nature of the somatoform group has led to calls to remove or radically alter the category in the next DSM revision. Despite these concerns, teaching articles addressing somatoform disorders tend to generalize across the category when making patient treatment recommendations. In this report, the authors encourage moving beyond catch phrases such as, "the somatic patient" and "vague complaints of pain," and toward accurate differential diagnosis between somatoform disorders. They argue that accurate diagnosis of somatoform disorders is both achievable and necessary to provide optimal care for this diverse population of patients. Diagnosis and patient-centered management is contrasted with more generalized treatment recommendations. PERSPECTIVE: This article highlights the appropriate diagnosis and treatment of somatoform disorders for patients with pain. In contrast to the majority of literature on the subject, the authors' emphasis the importance of differential diagnosis between somatoform disorders as well as patient-specific and diagnosis-specific treatment. The authors argue that there has been an incorrect tendency to overgeneralize across disorders, an error that is magnified by the exceptional weakness of the somatoform category.
Dohrenwend A, Skillings JL.
J Pain. 2009;10(11):1128-37.
The DSM IV category, somatoform disorders, is composed of disorders that are characterized by symptom amplification-most typically, amplification of pain. Other than this commonality, there is considerable variability among the disorders in terms of etiology, course, comorbidities, and the presence or absence of insight. The heterogeneous nature of the somatoform group has led to calls to remove or radically alter the category in the next DSM revision. Despite these concerns, teaching articles addressing somatoform disorders tend to generalize across the category when making patient treatment recommendations. In this report, the authors encourage moving beyond catch phrases such as, "the somatic patient" and "vague complaints of pain," and toward accurate differential diagnosis between somatoform disorders. -
Individual differences in pain sensitivity: measurement, causation, and consequences.
Nielsen CS, Staud R, Price DD
J Pain. 2009 Mar;10(3):231-7.
Not only are some clinical conditions experienced as more painful than others, but the variability in pain ratings of patients with the same disease or trauma is enormous. Available evidence indicates that to a large extent these differences reflect individual differences in pain sensitivity. Pain sensitivity can be estimated only through the use of well-controlled experimental pain stimuli. Such estimates show substantial heritability but equally important environmental effects. The genetic and environmental factors that influence pain sensitivity differ across pain modalities. For example, genetic factors that influence cold pressor pain have little impact on phasic heat pain and visa versa. Individual differences in pain sensitivity can complicate diagnosis, among other reasons because low sensitivity to pain may delay self-referral. Inclusion of patients with reduced pain sensitivity can attenuate treatment effects in clinical trials, unless controlled for. Measures of pain sensitivity are predictive of acute postoperative pain, and there is preliminary evidence that heightened pain sensitivity increases risk for future chronic pain conditions. At this time, however, it is unclear which experimental pain modalities should be used as predictors for future pain conditions. Careful assessment of each individual's pain sensitivity may become invaluable for the prevention, evaluation, and treatment of pain. PERSPECTIVE: Large individual differences in pain sensitivity can complicate diagnosis and pain treatment and can confound clinical trials. Pain sensitivity may also be of great importance for the development of clinical pain. Thus, assessment of pain sensitivity may be relevant for the prevention, evaluation, and treatment of acute and chronic pain.
Nielsen CS, Staud R, Price DD
J Pain. 2009 Mar;10(3):231-7.
Not only are some clinical conditions experienced as more painful than others, but the variability in pain ratings of patients with the same disease or trauma is enormous. Available evidence indicates that to a large extent these differences reflect individual differences in pain sensitivity. Pain sensitivity can be estimated only through the use of well-controlled experimental pain stimuli. Such estimates show substantial heritability but equally important environmental effects. The genetic and environmental factors that influence pain sensitivity differ across pain modalities. For example, genetic factors that influence cold pressor pain have little impact on phasic heat pain and visa versa. Individual differences in pain sensitivity can complicate diagnosis, among other reasons because low sensitivity to pain may delay self-referral. -
Sex, Gender, and Pain: A Review of Recent Clinical and Experimental Findings
Fillingim RB, King CD, Ribeiro-Dasilva MC, et al.
J Pain. 2009 May; 10(5): 447–485.
Sex-related influences on pain and analgesia have become a topic of tremendous scientific and clinical interest, especially in the last 10 to 15 years. Members of our research group published reviews of this literature more than a decade ago, and the intervening time period has witnessed robust growth in research regarding sex, gender, and pain. Therefore, it seems timely to revisit this literature. Abundant evidence from recent epidemiologic studies clearly demonstrates that women are at substantially greater risk for many clinical pain conditions, and there is some suggestion that postoperative and procedural pain may be more severe among women than men. Consistent with our previous reviews, current human findings regarding sex differences in experimental pain indicate greater pain sensitivity among females compared with males for most pain modalities, including more recently implemented clinically relevant pain models such as temporal summation of pain and intramuscular injection of algesic substances. The evidence regarding sex differences in laboratory measures of endogenous pain modulation is mixed, as are findings from studies using functional brain imaging to ascertain sex differences in pain-related cerebral activation. Also inconsistent are findings regarding sex differences in responses to pharmacologic and non-pharmacologic pain treatments. The article concludes with a discussion of potential biopsychosocial mechanisms that may underlie sex differences in pain, and considerations for future research are discussed.
Fillingim RB, King CD, Ribeiro-Dasilva MC, et al.
J Pain. 2009 May; 10(5): 447–485.
Sex-related influences on pain and analgesia have become a topic of tremendous scientific and clinical interest, especially in the last 10 to 15 years. Members of our research group published reviews of this literature more than a decade ago, and the intervening time period has witnessed robust growth in research regarding sex, gender, and pain. Therefore, it seems timely to revisit this literature. Abundant evidence from recent epidemiologic studies clearly demonstrates that women are at substantially greater risk for many clinical pain conditions, and there is some suggestion that postoperative and procedural pain may be more severe among women than men. -
Assessment of Celiac Plexus Block and Neurolysis Outcomes and Technique in the Management of Refractory Visceral Cancer Pain.
Erdek MA, Halpert DE, Fernández MG, Cohen SP.
Pain Med. [Epub ahead of print]
Objective. To assess demographic and clinical factors associated with celiac plexus neurolysis outcomes. Design. Retrospective clinical data analysis. Setting. A tertiary care, academic medical center. Patients. Forty-four patients with terminal visceral (mostly pancreatic) cancer who failed conservative measures. Interventions. Fifty celiac plexus alcohol neurolytic procedures done for pain control after a positive diagnostic block. Outcome Measures. A successful treatment was predefined as >50% pain relief sustained for >/=1 month. The following variables were analyzed for their association with treatment outcome: age, gender, duration of pain, origin of tumor, opioid dose, type of radiological guidance used, single- vs double-needle approach, type of block (e.g., antero- vs retrocrural), immediate vs delayed neurolysis, volume of local anesthetic employed for both diagnostic and neurolytic blocks, and use of sedation. Results. Those variables correlated with a positive outcome included lower opioid dose and the absence of sedation. Strong trends for a positive association with outcome were found for the use of computed tomography (vs fluoroscopy), and using <20 mL of local anesthetic for the diagnostic block. Conclusions. Celiac plexus neurolysis may provide intermediate pain relief to a significant percentage of cancer sufferers. Both careful selection of candidates based on clinical variables, and technical factors aimed at enhancing the specificity of blocks may lead to improved outcomes.
Erdek MA, Halpert DE, Fernández MG, Cohen SP.
Pain Med. [Epub ahead of print]
Objective. To assess demographic and clinical factors associated with celiac plexus neurolysis outcomes. Design. Retrospective clinical data analysis. Setting. A tertiary care, academic medical center. Patients. Forty-four patients with terminal visceral (mostly pancreatic) cancer who failed conservative measures. Interventions. Fifty celiac plexus alcohol neurolytic procedures done for pain control after a positive diagnostic block. Outcome Measures. A successful treatment was predefined as >50% pain relief sustained for >/=1 month. The following variables were analyzed for their association with treatment outcome: age, gender, duration of pain, origin of tumor, opioid dose, type of radiological guidance used, single- vs double-needle approach, type of block (e.g. -
Randomized controlled trial of an Internet-delivered family CBT intervention for children and adolescents with chronic pain
Palermo TM, Wilson AC, Peters M, et al.
Pain. 2009;146(1-2):205-13.
Cognitive-behavioral therapy (CBT) interventions show promise for decreasing chronic pain in youth. However, the availability of CBT is limited by many factors including distance to major treatment centers and expense. This study evaluates a more accessible treatment approach for chronic pediatric pain using an Internet-delivered family CBT intervention. Participants included 48 children, aged 11-17years, with chronic headache, abdominal, or musculoskeletal pain and associated functional disability, and their parents. Children were randomly assigned to a wait-list control group or an Internet treatment group. Primary treatment outcomes were pain intensity ratings (0-10 NRS) and activity limitations on the Child Activity Limitations Interview, both completed via an online daily diary. In addition to their medical care, the Internet treatment group completed 8weeks of online modules including relaxation training, cognitive strategies, parent operant techniques, communication strategies, and sleep and activity interventions. Youth randomized to the wait-list control group continued with the current medical care only. Findings demonstrated significantly greater reduction in activity limitations and pain intensity at post-treatment for the Internet treatment group and these effects were maintained at the three-month follow-up. Rate of clinically significant improvement in pain was also greater for the Internet treatment group than for the wait-list control group. There were no significant group differences in parental protectiveness or child depressive symptoms post-treatment. Internet treatment was rated as acceptable by all children and parents. Findings support the efficacy and acceptability of Internet delivery of family CBT for reducing pain and improving function among children and adolescents with chronic pain.
Palermo TM, Wilson AC, Peters M, et al.
Pain. 2009;146(1-2):205-13.
Cognitive-behavioral therapy (CBT) interventions show promise for decreasing chronic pain in youth. However, the availability of CBT is limited by many factors including distance to major treatment centers and expense. This study evaluates a more accessible treatment approach for chronic pediatric pain using an Internet-delivered family CBT intervention. Participants included 48 children, aged 11-17years, with chronic headache, abdominal, or musculoskeletal pain and associated functional disability, and their parents. Children were randomly assigned to a wait-list control group or an Internet treatment group. Primary treatment outcomes were pain intensity ratings (0-10 NRS) and activity limitations on the Child Activity Limitations Interview, both completed via an online daily diary. -
A Pilot Study Investigating the Effects of Fast Left Prefrontal rTMS on Chronic Neuropathic Pain
Borckardt JJ, Smith AR, Reeves ST, et al.
Pain Med. 2009;10(5):840-9.
ABSTRACT Objective. Stimulating the human cortex using transcranial magnetic stimulation (TMS) temporarily reduces clinical and experimental pain; however, it is unclear which cortical targets are the most effective. The motor cortex has been a popular target for managing neuropathic pain, while the prefrontal cortex has been investigated for an array of nociceptive pain conditions. It is unclear whether the motor cortex is the only effective cortical target for managing neuropathic pain, and no published studies to date have investigated the effects of prefrontal stimulation on neuropathic pain. Design. This preliminary pilot trial employed a sham-controlled, within-subject, crossover design to evaluate clinical pain as well as laboratory pain thresholds among four patients with chronic neuropathic pain. Each participant underwent three real and three sham 20-minute sessions of 10 Hz left prefrontal repetitive TMS. Daily pain diaries were collected for 3 weeks before and after each treatment phase along with a battery of self-report pain and mood questionnaires. Results. Time-series analysis at the individual patient level indicated that real TMS was associated with significant improvements in average daily pain in 3 of the 4 participants. These effects were independent of changes in mood in two of the participants. At the group level, a decrease of 19% in daily pain on average, pain at its worst, and pain at its least was observed while controlling for changes in mood, activity level and sleep. The effects of real TMS were significantly greater than sham. Real TMS was associated with increases in thermal and mechanical pain thresholds, whereas sham was not. No statistically significant effects were observed across the questionnaire data. Conclusions. The prefrontal cortex may be an important TMS cortical target for managing certain types of pain, including certain neuropathic pain syndromes.
Borckardt JJ, Smith AR, Reeves ST, et al.
Pain Med. 2009;10(5):840-9.
ABSTRACT Objective. Stimulating the human cortex using transcranial magnetic stimulation (TMS) temporarily reduces clinical and experimental pain; however, it is unclear which cortical targets are the most effective. The motor cortex has been a popular target for managing neuropathic pain, while the prefrontal cortex has been investigated for an array of nociceptive pain conditions. It is unclear whether the motor cortex is the only effective cortical target for managing neuropathic pain, and no published studies to date have investigated the effects of prefrontal stimulation on neuropathic pain. Design. This preliminary pilot trial employed a sham-controlled, within-subject, crossover design to evaluate clinical pain as well as laboratory pain thresholds among four patients with chronic neuropathic pain. -
A non-surgical approach to the management of lumbar spinal stenosis: Prospective observational cohort study with follow-up.
Murphy DR, Hurwitz EL, McGovern EE.
J Manipulative Physiol Ther. 2009;32(9):723-733.
OBJECTIVE: This study presents the outcomes of patients with lumbar radiculopathy secondary to disk herniation treated after a diagnosis-based clinical decision rule. METHODS: A prospective observational cohort study was conducted at a multidisciplinary, integrated clinic that includes chiropractic and physical therapy health care services. Data on 49 consecutive patients were collected at baseline, at the end of conservative, nonsurgical treatment and a mean of 14.5 months after cessation of treatment. Disability was measured using the Bournemouth Disability Questionnaire (BDQ) and pain using the Numerical Rating Scale for pain. Fear beliefs were measured with the Fear-Avoidance Beliefs Questionnaire (FABQ). Patients also self-rated improvement. RESULTS: Mean duration of complaint was 60.5 weeks. Mean self-rated improvement at the end of treatment was 77.5%. Improvement was described as "good" or "excellent" in nearly 90% of patients. Mean percentage improvement on the BDQ was 60.4%. Numerical Rating Scale improved 4.1 points and FABQ improved 4.8 points. Clinically meaningful improvements in pain and disability were seen in 79% and 70% of patients, respectively. Mean number of visits was 13.2. After an average long-term follow-up of 14.5 months, mean self-rated improvement was 81.1%. "Good" or "excellent" improvement was reported by 80% of patients. Mean percentage improvement in BDQ was 67.4%. Numerical Rating Scale improved 4.2 points and FABQ 4.5 points. Clinically meaningful improvements in pain and disability were seen in 79% and 73% of patients, respectively. CONCLUSIONS: Management based on the decision rule yielded favorable outcomes in this cohort study. Improvement appeared to be maintained over the long term.
Murphy DR, Hurwitz EL, McGovern EE.
J Manipulative Physiol Ther. 2009;32(9):723-733.
OBJECTIVE: This study presents the outcomes of patients with lumbar radiculopathy secondary to disk herniation treated after a diagnosis-based clinical decision rule. METHODS: A prospective observational cohort study was conducted at a multidisciplinary, integrated clinic that includes chiropractic and physical therapy health care services. Data on 49 consecutive patients were collected at baseline, at the end of conservative, nonsurgical treatment and a mean of 14.5 months after cessation of treatment. Disability was measured using the Bournemouth Disability Questionnaire (BDQ) and pain using the Numerical Rating Scale for pain. Fear beliefs were measured with the Fear-Avoidance Beliefs Questionnaire (FABQ). Patients also self-rated improvement. RESULTS: Mean duration of complaint was 60.5 weeks. -
Evaluation of the Effectiveness and Efficacy of Iyengar Yoga Therapy on Chronic Low Back Pain.
Williams K, Abildso C, Steinberg L, et al.
Spine (Phila Pa 1976). 2009 Aug 21.
STUDY DESIGN.: The effectiveness and efficacy of Iyengar yoga for chronic low back pain (CLBP) were assessed with intention-to-treat and per-protocol analysis. Ninety subjects were randomized to a yoga (n = 43) or control group (n = 47) receiving standard medical care. Participants were followed 6 months after completion of the intervention.
OBJECTIVE.: This study aimed to evaluate Iyengar yoga therapy on chronic low back pain. Yoga subjects were hypothesized to report greater reductions in functional disability, pain intensity, depression, and pain medication usage than controls.
SUMMARY OF BACKGROUND DATA.: CLBP is a musculoskeletal disorder with public health and economic impact. Pilot studies of yoga and back pain have reported significant changes in clinically important outcomes. METHODS.: Subjects were recruited through self-referral and health professional referrals according to explicit inclusion/exclusion criteria. Yoga subjects participated in 24 weeks of biweekly yoga classes designed for CLBP. Outcomes were assessed at 12 (midway), 24 (immediately after), and 48 weeks (6-month follow-up) after the start of the intervention using the Oswestry Disability Questionnaire, a Visual Analog Scale, the Beck Depression Inventory, and a pain medication-usage questionnaire.
RESULTS.: Using intention-to-treat analysis with repeated measures ANOVA (group x time), significantly greater reductions in functional disability and pain intensity were observed in the yoga group when compared to the control group at 24 weeks. A significantly greater proportion of yoga subjects also reported clinical improvements at both 12 and 24 weeks. In addition, depression was significantly lower in yoga subjects. Furthermore, while a reduction in pain medication occurred, this was comparable in both groups. When results were analyzed using per-protocol analysis, improvements were observed for all outcomes in the yoga group, including a greater trend for reduced pain medication usage. Although slightly less than at 24 weeks, the yoga group had statistically significant reductions in functional disability, pain intensity, and depression compared to standard medical care 6-months postintervention.
CONCLUSION.: Yoga improves functional disability, pain intensity, and depression in adults with CLBP. There was also a clinically important trend for the yoga group to reduce their pain medication usage compared to the control group.
Williams K, Abildso C, Steinberg L, et al.
Spine (Phila Pa 1976). 2009 Aug 21.
STUDY DESIGN.: The effectiveness and efficacy of Iyengar yoga for chronic low back pain (CLBP) were assessed with intention-to-treat and per-protocol analysis. Ninety subjects were randomized to a yoga (n = 43) or control group (n = 47) receiving standard medical care. Participants were followed 6 months after completion of the intervention.
OBJECTIVE.: This study aimed to evaluate Iyengar yoga therapy on chronic low back pain. Yoga subjects were hypothesized to report greater reductions in functional disability, pain intensity, depression, and pain medication usage than controls.
SUMMARY OF BACKGROUND DATA.: CLBP is a musculoskeletal disorder with public health and economic impact. Pilot studies of yoga and back pain have reported significant changes in clinically important outcomes. METHODS.
