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Effect of telecare management on pain and depression in patients with cancer: a randomized trial.
Kroenke K, Theobald D, Wu J et al.
JAMA. 2010 Jul 14;304(2):163-71.
CONTEXT: Pain and depression are 2 of the most prevalent and treatable cancer-related symptoms, yet they frequently go unrecognized, undertreated, or both.OBJECTIVE: To determine whether centralized telephone-based care management coupled with automated symptom monitoring can improve depression and pain in patients with cancer.
DESIGN, SETTING, AND PATIENTS: Randomized controlled trial conducted in 16 community-based urban and rural oncology practices involved in the Indiana Cancer Pain and Depression (INCPAD) trial. Recruitment occurred from March 2006 through August 2008 and follow-up concluded in August 2009. The participating patients had depression (Patient Health Questionnaire-9 score > or = 10), cancer-related pain (Brief Pain Inventory [BPI] worst pain score > or = 6), or both.
INTERVENTION: The 202 patients randomly assigned to receive the intervention and 203 to receive usual care were stratified by symptom type. Patients in the intervention group received centralized telecare management by a nurse-physician specialist team coupled with automated home-based symptom monitoring by interactive voice recording or Internet.
MAIN OUTCOME MEASURES: Blinded assessment at baseline and at months 1, 3, 6, and 12 for depression (20-item Hopkins Symptom Checklist [HSCL-20]) and pain (BPI) severity.
RESULTS: Of the 405 participants enrolled in the study, 131 had depression only, 96 had pain only, and 178 had both depression and pain. Of the 274 patients with pain, 137 patients in the intervention group had greater improvements in BPI pain severity over the 12 months of the trial whether measured as a continuous severity score or as a categorical pain responder (> or = 30% decrease in BPI) than the 137 patients in the usual-care group (P < .001 for both). Similarly, of the 309 patients with depression, the 154 patients in the intervention group had greater improvements in HSCL-20 depression severity over the 12 months of the trial whether measured as a continuous severity score or as a categorical depression responder (> or = 50% decrease in HSCL) than the 155 patients in the usual care group (P < .001 for both). The standardized effect size for between-group differences at 3 and 12 months was 0.67 (95% confidence interval [CI], 0.33-1.02) and 0.39 (95% CI, 0.01-0.77) for pain, and 0.42 (95% CI, 0.16-0.69) and 0.41 (95% CI, 0.08-0.72) for depression.
CONCLUSION: Centralized telecare management coupled with automated symptom monitoring resulted in improved pain and depression outcomes in cancer patients receiving care in geographically dispersed urban and rural oncology practices.
Kroenke K, Theobald D, Wu J et al.
JAMA. 2010 Jul 14;304(2):163-71.
CONTEXT: Pain and depression are 2 of the most prevalent and treatable cancer-related symptoms, yet they frequently go unrecognized, undertreated, or both.OBJECTIVE: To determine whether centralized telephone-based care management coupled with automated symptom monitoring can improve depression and pain in patients with cancer.
DESIGN, SETTING, AND PATIENTS: Randomized controlled trial conducted in 16 community-based urban and rural oncology practices involved in the Indiana Cancer Pain and Depression (INCPAD) trial. Recruitment occurred from March 2006 through August 2008 and follow-up concluded in August 2009. The participating patients had depression (Patient Health Questionnaire-9 score > or = 10), cancer-related pain (Brief Pain Inventory [BPI] worst pain score > or = 6), or both.
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EFNS/Peripheral Nerve Society Guideline on the use of skin biopsy in the diagnosis of small fiber neuropathy
Lauria G, Hsieh ST, Johansson O, et al.
Eur J Neurol. 2010 Jul;17(7):903-12.
BACKGROUND: Revision of the guidelines on the use of skin biopsy in the diagnosis of peripheral neuropathy, published in 2005, has become appropriate owing to publication of more relevant articles. Most of the new studies focused on small fiber neuropathy (SFN), a subtype of neuropathy for which the diagnosis was first developed through skin biopsy examination. This revision focuses on the use of this technique to diagnose SFN.METHODS: Task force members searched the Medline database from 2005, the year of the publication of the first EFNS guideline, to June 30th, 2009. All pertinent articles were rated according to the EFNS and PNS guidance. After a consensus meeting, the task force members created a manuscript that was subsequently revised by two experts (JML and JVS) in the field of peripheral neuropathy and clinical neurophysiology, who were not previously involved in the use of skin biopsy.
RESULTS AND CONCLUSIONS: Distal leg skin biopsy with quantification of the linear density of intraepidermal nerve fibers (IENF), using generally agreed upon counting rules, is a reliable and efficient technique to assess the diagnosis of SFN (Recommendation Level A). Normative reference values are available for bright-field immunohistochemistry (Recommendation Level A) but not yet for confocal immunofluorescence or the blister technique. The morphometric analysis of IENF density, either performed with bright-field or immunofluorescence microscopy, should always refer to normative values matched for age (Recommendation Level A). Newly established laboratories should undergo adequate training in a well-established skin biopsy laboratory and provide their own stratified for age and gender normative values, intra- and interobserver reliability, and interlaboratory agreement. Quality control of the procedure at all levels is mandatory (Good Practice Point). Procedures to quantify subepidermal nerve fibers and autonomic innervated structures, including erector pili muscles, and skin vessels, are under development but need to be confirmed by further studies. Sweat gland innervation can be examined using an unbiased stereologic technique recently proposed (Recommendation Level B). A reduced IENF density is associated with the risk of developing neuropathic pain (Recommendation Level B), but it does not correlate with its intensity. Serial skin biopsies might be useful for detecting early changes of IENF density, which predict the progression of neuropathy, and to assess degeneration and regeneration of IENF (Recommendation Level C). However, further studies are warranted to confirm its potential usefulness as an outcome measure in clinical practice and research. Skin biopsy has not so far been useful for identifying the etiology of SFN. Finally, we emphasize that 3-mm skin biopsy at the ankle is a safe procedure based on the experience of 10 laboratories reporting absence of serious side effects in approximately 35,000 biopsies and a mere 0.19% incidence of non-serious side effects in about 15 years of practice (Good Practice Point).
Lauria G, Hsieh ST, Johansson O, et al.
Eur J Neurol. 2010 Jul;17(7):903-12.
BACKGROUND: Revision of the guidelines on the use of skin biopsy in the diagnosis of peripheral neuropathy, published in 2005, has become appropriate owing to publication of more relevant articles. Most of the new studies focused on small fiber neuropathy (SFN), a subtype of neuropathy for which the diagnosis was first developed through skin biopsy examination. This revision focuses on the use of this technique to diagnose SFN.METHODS: Task force members searched the Medline database from 2005, the year of the publication of the first EFNS guideline, to June 30th, 2009. All pertinent articles were rated according to the EFNS and PNS guidance.
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The role of chemical neurolysis in cancer pain.
Koyyalagunta D, Burton AW.
Curr Pain Headache Rep. 2010 Aug;14(4):261-7.
Pain continues to be a significant symptom burden in cancer patients, with prevalence in 53% of patients at all stages of cancer and as high as 58% to 69% in those with advanced cancer. Neurolytic blocks are a mainstay in the armamentarium of cancer pain management, more so in intractable pain from advanced cancer. There is no clear consensus on patient selection, technique, or timing of these blocks. Here we discuss the use of various neurolytic blocks for cancer pain and detail some of the recent literature and our experience.
Koyyalagunta D, Burton AW.
Curr Pain Headache Rep. 2010 Aug;14(4):261-7.
Pain continues to be a significant symptom burden in cancer patients, with prevalence in 53% of patients at all stages of cancer and as high as 58% to 69% in those with advanced cancer. Neurolytic blocks are a mainstay in the armamentarium of cancer pain management, more so in intractable pain from advanced cancer. There is no clear consensus on patient selection, technique, or timing of these blocks. Here we discuss the use of various neurolytic blocks for cancer pain and detail some of the recent literature and our experience. -
Pain management and the U.S. Department of Justice.
Garrison K, Mitty E.
Geriatr Nurs. 2010 May-Jun;31(3):214-9.
The Drug Enforcement Agency (DEA) may be restricting the ability of RNs and LPNs in assisted living communities (ALCs) in some states to provide pain relief for residents. The DEAs enforcement of the requirements of the Controlled Substances Act (CSA) to reduce diversion of controlled substances (particularly Schedule II meds) for criminal or nefarious reasons, has generated a variety of responses by pharmacies, ALCs, and practitioners. Residents are at risk for--and some residents have already experienced--inadequate pain management. The argument seems to turn on whether an ALC (or nursing home or home health nurse) is an "agent" of the physician. The term "agent" is poorly defined in section 1300 of the CSA. It neither confirms that an ALC/long-term care (LTC) nurse/medical aide may function as an agent of the provider nor does the definition preclude the ALC/LTC nurse/medical aide as the agent of the provider. This article is an alert to ALCs to examine their controlled drug procurement and pain management procedures and is also a call to advocacy by ALC nurses.
Garrison K, Mitty E.
Geriatr Nurs. 2010 May-Jun;31(3):214-9.
The Drug Enforcement Agency (DEA) may be restricting the ability of RNs and LPNs in assisted living communities (ALCs) in some states to provide pain relief for residents. The DEAs enforcement of the requirements of the Controlled Substances Act (CSA) to reduce diversion of controlled substances (particularly Schedule II meds) for criminal or nefarious reasons, has generated a variety of responses by pharmacies, ALCs, and practitioners. Residents are at risk for--and some residents have already experienced--inadequate pain management. The argument seems to turn on whether an ALC (or nursing home or home health nurse) is an "agent" of the physician. The term "agent" is poorly defined in section 1300 of the CSA. -
Intrinsic brain connectivity in fibromyalgia is associated with chronic pain intensity.
Napadow V, Lacount L, Park K, et al.
Arthritis Rheum. 2010 Apr 6.
OBJECTIVE:: Fibromyalgia (FM) is considered to be the prototypical central chronic pain syndrome and is associated with widespread pain that fluctuates spontaneously. Multiple studies have demonstrated altered brain activity in these patients. Our objective was to investigate the degree of connectivity between multiple brain networks in FM, as well as how activity in these networks correlates with spontaneous pain. METHODS:: Resting functional magnetic resonance imaging (fMRI) data in FM patients (n=18) and age-matched healthy controls (HC, n=18) were analyzed using dual regression independent component analysis (ICA) - a data driven approach used to identify independent brain networks. We evaluated intrinsic, or resting, connectivity in multiple brain networks: the default mode network (DMN), the executive attention network (EAN), and the medial visual network (MVN), with the MVN serving as a negative control. Spontaneous pain levels were also covaried with intrinsic connectivity. RESULTS:: We found that FM patients had greater connectivity within the DMN and right EAN (rEAN; p<0.05, corrected), and greater connectivity between the DMN and the insular cortex - a brain region known to process evoked pain. Furthermore, greater spontaneous pain at the time of the scan correlated with greater intrinsic connectivity between the insula and both the DMN and rEAN (p<0.05, corrected). CONCLUSION:: Our findings indicate that resting brain activity within multiple networks is associated with spontaneous clinical pain in FM. These findings may also have broader implications for how subjective experiences such as pain arise from a complex interplay amongst multiple brain networks.
Napadow V, Lacount L, Park K, et al.
Arthritis Rheum. 2010 Apr 6.
OBJECTIVE:: Fibromyalgia (FM) is considered to be the prototypical central chronic pain syndrome and is associated with widespread pain that fluctuates spontaneously. Multiple studies have demonstrated altered brain activity in these patients. Our objective was to investigate the degree of connectivity between multiple brain networks in FM, as well as how activity in these networks correlates with spontaneous pain. METHODS:: Resting functional magnetic resonance imaging (fMRI) data in FM patients (n=18) and age-matched healthy controls (HC, n=18) were analyzed using dual regression independent component analysis (ICA) - a data driven approach used to identify independent brain networks. -
Assessment of cancer-related neuropathy and neuropathic pain.
Cleeland CS, Farrar JT, Hausheer, FH.
Oncologist. 2010;15 Suppl 2:13-8.
Cancer-related neuropathic pain syndromes are common and serious complications of a patient's primary malignancy or its treatment, whether by surgery, radiation, or chemotherapy. They may compromise the patient's quality of life as well as their ability to receive effective treatment. In many patients, there may be more than one coexistent neuropathic pain syndrome, posing a diagnostic dilemma that, if unresolved, may result in the institution of therapies that are of limited scope or not targeted at the primary underlying pathophysiology. There is no single adequate diagnostic method that has been established to reliably diagnose or follow patients with cancer-related neuropathic pain syndromes. Clinical assessment of cancer-related neuropathic pain poses some important challenges diagnostically as well as in defining a clear and reliable endpoint assessment in controlled clinical trials. Many different approaches have been applied to the development of assessment or diagnostic tools. Careful review of these methods has been helpful in developing a clearer vision for the future design and refinement of more reliable tools, and more importantly, validation of the clinical utility as well as the reliability of such tools when employed as endpoints in clinical trials focused on prevention, mitigation, or treatment of cancer neuropathic pain.
Cleeland CS, Farrar JT, Hausheer, FH.
Oncologist. 2010;15 Suppl 2:13-8.
Cancer-related neuropathic pain syndromes are common and serious complications of a patient's primary malignancy or its treatment, whether by surgery, radiation, or chemotherapy. They may compromise the patient's quality of life as well as their ability to receive effective treatment. In many patients, there may be more than one coexistent neuropathic pain syndrome, posing a diagnostic dilemma that, if unresolved, may result in the institution of therapies that are of limited scope or not targeted at the primary underlying pathophysiology. There is no single adequate diagnostic method that has been established to reliably diagnose or follow patients with cancer-related neuropathic pain syndromes. -
Opioids, Chronic Pain, and Addiction in Primary Care.
Barry DT, Irwin KS, Jones ES, et al.
J Pain. 2010 Jun 1.
Research has largely ignored the systematic examination of physicians' attitudes towards providing care for patients with chronic noncancer pain. The objective of this study was to identify barriers and facilitators to opioid treatment of chronic noncancer pain patients by office-based medical providers. We used a qualitative study design using individual and group interviews. Participants were 23 office-based physicians in New England. Interviews were audiotaped, transcribed, and systematically coded by a multidisciplinary team using the constant comparative method. Physician barriers included absence of objective or physiological measures of pain; lack of expertise in the treatment of chronic pain and coexisting disorders, including addiction; lack of interest in pain management; patients' aberrant behaviors; and physicians' attitudes toward prescribing opioid analgesics. Physician facilitators included promoting continuity of patient care and the use of opioid agreements. Physicians' perceptions of patient-related barriers included lack of physician responsiveness to patients' pain reports, negative attitudes toward opioid analgesics, concerns about cost, and patients' low motivation for pain treatment. Perceived logistical barriers included lack of appropriate pain management and addiction referral options, limited information regarding diagnostic workup, limited insurance coverage for pain management services, limited ancillary support for physicians, and insufficient time. Addressing these barriers to pain treatment will be crucial to improving pain management service delivery. PERSPECTIVE: This article demonstrates that perceived barriers to treating patients with chronic noncancer pain are common among office-based physicians. Addressing these barriers in physician training and in existing office-based programs might benefit both noncancer chronic pain patients and their medical providers. Copyright © 2010 American Pain Society. Published by Elsevier Inc. All rights reserved.
Barry DT, Irwin KS, Jones ES, et al.
J Pain. 2010 Jun 1.
Research has largely ignored the systematic examination of physicians' attitudes towards providing care for patients with chronic noncancer pain. The objective of this study was to identify barriers and facilitators to opioid treatment of chronic noncancer pain patients by office-based medical providers. We used a qualitative study design using individual and group interviews. Participants were 23 office-based physicians in New England. Interviews were audiotaped, transcribed, and systematically coded by a multidisciplinary team using the constant comparative method. Physician barriers included absence of objective or physiological measures of pain; lack of expertise in the treatment of chronic pain and coexisting disorders, including addiction; lack of interest in pain management; patients' aberrant behaviors; and physicians' attitudes toward prescribing opioid analgesics. -
Cancer-related pain management: a report of evidence-based recommendations to guide practice.
Green E, Zwaal C, Beals C, et al.
Clin J Pain. 2010;26(6):449-62.
OBJECTIVES: Cancer may be associated with many symptoms, but pain is the one most feared by patients. Pain is experienced by one-third of patients receiving treatment for cancer and about two-thirds of those with advanced cancers. To aid in providing quality care and pain relief for cancer patients, Cancer Care Ontario's Cancer-related Pain Management Guideline Panel conducted a systematic review of guidelines to provide evidence-based and consensus recommendations for the management of cancer-related pain to guide the practice of healthcare providers. METHODS: Published and unpublished cancer-related pain management guidelines were sought by conducting an Internet search, which included health organizations and the National Guidelines Clearinghouse, the Guideline International Network, and the McMillan Group. Also, MEDLINE searches were conducted for guidelines published between the years 2000 and May 2006. RESULTS: Twenty-five guidelines were found and the quality of each guideline was evaluated using the Appraisal of Guideline Research and Evaluation Instrument and the utility of the guideline for recommendations was assessed. Using these 2 criteria, 8 relevant and high-quality pain guidelines were identified. From these guidelines, the Panel articulated core principles of the management of cancer pain and selected or adapted specific recommendations through consensus to become a part of the cancer-related pain guide for practice. DISCUSSION: The domains on which recommendations were drafted include: assessment of pain; assessors of pain; time and frequency of assessment; components of pain assessment; assessment of pain in special populations; plan of care; pharmacologic intervention; nonpharmacologic intervention; documentation; education; and outcome measures of cancer-pain management.
Green E, Zwaal C, Beals C, et al.
Clin J Pain. 2010;26(6):449-62.
OBJECTIVES: Cancer may be associated with many symptoms, but pain is the one most feared by patients. Pain is experienced by one-third of patients receiving treatment for cancer and about two-thirds of those with advanced cancers. To aid in providing quality care and pain relief for cancer patients, Cancer Care Ontario's Cancer-related Pain Management Guideline Panel conducted a systematic review of guidelines to provide evidence-based and consensus recommendations for the management of cancer-related pain to guide the practice of healthcare providers. METHODS: Published and unpublished cancer-related pain management guidelines were sought by conducting an Internet search, which included health organizations and the National Guidelines Clearinghouse, the Guideline International Network, and the McMillan Group. -
Severity of Acute Pain After Breast Surgery Is Associated With the Likelihood of Subsequently Developing Persistent Pain.
Hickey OT, Burke SM, Hafeez P, et al.
Clin J Pain. 2010 Jul 15.
OBJECTIVES: Persistent postsurgical pain (PPSP) after surgery for breast cancer has a prevalence of 20% to 52%. Neuroplastic changes may play a role in the aetiology of this pain. The principal objective of this study was to examine the relationship between acute pain after surgery for breast cancer and the likelihood of subsequently developing PPSP. METHODS: Twenty-eight women undergoing surgery for breast cancer completed visual analogue scales for pain and anxiety, the McGill Pain Questionnaire (long form) and the Hospital Anxiety and Depression Scale. Analgesic requirements and adverse effects of analgesic therapy were noted. Quantitative sensory testing was carried out perioperatively using an electrical stimulus, and the sensation perception, pain perception, and pain tolerance thresholds were measured bilaterally at the T4 dermatomes and at the contralateral L5 dermatome. Patients with and without PPSP 3 months postoperatively were compared in terms of these parameters. RESULTS: Eight participants (28.6%) reported PPSP. Those who subsequently developed PPSP reported greater pain scores on the McGill Pain Questionnaire 5 days postoperatively than those that did not (pain rating index, P=0.014; present pain intensity, P=0.032). None had sought medical attention for their persistent pain. Patients with and without PPSP were similar in terms of mental status (anxiety and depression), analgesic consumption, adverse effects of analgesic therapy, and changes on QST. DISCUSSION: Patients who developed PPSP experienced pain of greater intensity on the fifth postoperative day than those that did not.
Hickey OT, Burke SM, Hafeez P, et al.
Clin J Pain. 2010 Jul 15.
OBJECTIVES: Persistent postsurgical pain (PPSP) after surgery for breast cancer has a prevalence of 20% to 52%. Neuroplastic changes may play a role in the aetiology of this pain. The principal objective of this study was to examine the relationship between acute pain after surgery for breast cancer and the likelihood of subsequently developing PPSP. METHODS: Twenty-eight women undergoing surgery for breast cancer completed visual analogue scales for pain and anxiety, the McGill Pain Questionnaire (long form) and the Hospital Anxiety and Depression Scale. Analgesic requirements and adverse effects of analgesic therapy were noted. Quantitative sensory testing was carried out perioperatively using an electrical stimulus, and the sensation perception, pain perception, and pain tolerance thresholds were measured bilaterally at the T4 dermatomes and at the contralateral L5 dermatome. -
Updated practice guidelines from the American Society of Anesthesiologists Task Force on Chronic Pain Management and the America
Benzon HT, Connis RT, De Leon-Casasola OA, et al.
Anesthesiology. 2010;112(4):810-33.
Benzon HT, Connis RT, De Leon-Casasola OA, et al.
Anesthesiology. 2010;112(4):810-33.
