Psychological therapies for chronic pelvic pain:systematic review of randomized controlled trials

Chronic pelvic pain (CPP), a common cause of disability in women, is a condition best viewed in the biopsychosocial framework. Psychological interventions are frequently considered alongside medical and surgical treatments. Our objective was to evaluate the effectiveness of psychological therapies for the treatment of CPP. Electronic literature searches were conducted in Medline, Embase, PsycInfo and DARE databases from database inception to April 2010. Reference lists of selected articles were searched for further articles. The studies selected were randomized controlled trials of psychological therapies in patients with CPP compared with no treatment, standard gynecological treatment or another form of psychological therapy. Two reviewers independently selected articles without language restrictions and extracted data covering study characteristics, study quality and results. Reduction in pain, measured using visual analog scales or other measurements, was the main outcome measure. Of the 107 citations identified, four studies satisfied the inclusion criteria. Compared with no psychological intervention, therapy produced a standardized mean pain score of -3.27 [95% confidence interval (CI) -4.52 to -2.02] and 1.11 (95% CI -0.05 to 2.27) at 3 months and -3.95 (95% CI -5.35 to -2.55) and 0.54 (95% CI -0.78 to 1.86) at 6 months and greater, based on a visual analog scale score of 0-10. The current evidence does not allow us to conclude whether psychological interventions have an effect on self-reported pain scores in women with CPP.

Chronic preoperative pain and psychological robustness predict acute postoperative pain outcomes after surgery for breast cancer

Background - Few epidemiological studies have prospectively investigated preoperative and surgical risk factors for acute postoperative pain after surgery for breast cancer. We investigated demographic, psychological, pain-related and surgical risk factors in women undergoing resectional surgery for breast cancer. Methods - Primary outcomes were pain severity, at rest (PAR) and movement-evoked pain (MEP), in the first postoperative week. Results - In 338 women undergoing surgery, those with chronic preoperative pain were three times more likely to report moderate to severe MEP after breast cancer surgery (OR 3.18, 95% CI 1.45–6.99). Increased psychological ‘robustness’, a composite variable representing positive affect and dispositional optimism, was associated with lower intensity acute postoperative PAR (OR 0.63, 95% CI 0.48–0.82) and MEP (OR 0.71, 95% CI 0.54–0.93). Sentinel lymph node biopsy (SLNB) and intraoperative nerve division were associated with reduced postoperative pain. No relationship was found between preoperative neuropathic pain and acute pain outcomes; altered sensations and numbness postoperatively were more common after axillary sample or clearance compared with SLNB. Conclusion - Chronic preoperative pain, axillary surgery and psychological robustness significantly predicted acute pain outcomes after surgery for breast cancer. Preoperative identification and targeted intervention of subgroups at risk could enhance the recovery trajectory in cancer survivors.

Brain activity modifications following spinal cord stimulation for chronic neuropathic pain:a systematic review

Background and objective: Spinal cord stimulation (SCS) is believed to exert supraspinal effects; however, these mechanisms are still far from fully elucidated. This systematic review aims to assess existing neurophysiological and functional neuroimaging literature to reveal current knowledge regarding the effects of SCS for chronic neuropathic pain on brain activity, to identify gaps in knowledge, and to suggest directions for future research. Databases and data treatment: Electronic databases and hand-search of reference lists were employed to identify publications investigating brain activity associated with SCS in patients with chronic neuropathic pain, using neurophysiological and functional neuroimaging techniques (fMRI, PET, MEG, EEG). Studies investigating patients with SCS for chronic neuropathic pain and studying brain activity related to SCS were included. Demographic data (age, gender), study factors (imaging modality, patient diagnoses, pain area, duration of SCS at recording, stimulus used) and brain areas activated were extracted from the included studies. Results: Twenty-four studies were included. Thirteen studies used neuroelectrical imaging techniques, eight studies used haemodynamic imaging techniques, two studies employed both neuroelectrical and haemodynamic techniques separately, and one study investigated cerebral neurobiology. Conclusions: The limited available evidence regarding supraspinal mechanisms of SCS does not allow us to develop any conclusive theories. However, the studies included appear to show an inhibitory effect of SCS on somatosensory evoked potentials, as well as identifying the thalamus and anterior cingulate cortex as potential mediators of the pain experience. The lack of substantial evidence in this area highlights the need for large-scale controlled studies of this kind.

Is alcohol consumption related to likelihood of reporting chronic widespread pain in people with stable consumption? : Results from UK Biobank

Acknowledgements This research has been conducted using the UK Biobank resource, and was funded by the University of Aberdeen. The authors have no conflicts of interest to declare.

Chronic pelvic pain in women of reproductive and post-reproductive age : a population-based study

Abimbola Ayorinde’s PhD funded by the Medical Research Council. This study was funded by the British Pain Society (Mildred Clulow Award) and preparatory work by National Health Service Grampian.

Managing chronic widespread pain in primary care : a qualitative study of patient perspectives and implications for treatment delivery

Funding The MUSICIAN trial was supported by an award from Arthritis Research UK, Chesterfield, UK. Grant number: 17292. The funding body approved the design of the study. They played no role in the collection, analysis, and interpretation of data or the writing of the manuscript.

SYSTEMATIC REVIEW AND META-ANALYSIS: EFFECTS OF WALKING EXERCISE IN CHRONIC MUSCULOSKELETAL PAIN

SYSTEMATIC REVIEW AND META-ANALYSIS: EFFECTS OF WALKING EXERCISE IN CHRONIC MUSCULOSKELETAL PAIN O'Connor S.R.1, Tully M.A.2, Ryan B.3, Baxter D.G.3, Bradley J.M.1, McDonough S.M.11University of Ulster, Health & Rehabilitation Sciences Research Institute, Newtownabbey, United Kingdom, 2Queen's University, UKCRC Centre of Excellence for Public Health (NI), Belfast, United Kingdom, 3University of Otago, Centre for Physiotherapy Research, Dunedin, New ZealandPurpose: To examine the effects of walking exercise on pain and self-reported function in adults with chronic musculoskeletal pain.Relevance: Chronic musculoskeletal pain is a major cause of morbidity, exerting a substantial influence on long-term health status and overall quality of life. Current treatment recommendations advocate various aerobic exercise interventions for such conditions. Walking may represent an ideal form of exercise due to its relatively low impact. However, there is currently limited evidence for its effectiveness.Participants: Not applicable.Methods: A comprehensive search strategy was undertaken by two independent reviewers according to the preferred reporting items for systematic reviews and meta-analyses (PRISMA) and the recommendations of the Cochrane Musculoskeletal Review Group. Six electronic databases (Medline, CINAHL, PsychINFO, PEDro, Sport DISCUS and the Cochrane Central Register of Controlled Trials) were searched for relevant papers published up to January 2010 using MeSH terms. All randomised or non-randomised studies published in full were considered for inclusion. Studies were required to include adults aged 18 years or over with a diagnosis of chronic low back pain, osteoarthritis or fibromyalgia. Studies were excluded if they involved peri-operative or post-operative interventions or did not include a comparative, non exercise or non-walking exercise control group. The U.S. Preventative Services Task Force system was used to assess methodological quality. Data for pain and self-reported function were extracted and converted to a score out of 100.Analysis: Data were pooled and analyzed using RevMan (v.5.0.24). Statistical heterogeneity was assessed using the X2 and I2 test statistics. A random effects model was used to calculate the mean differences and 95% CIs. Data were analyzed by length of final follow-up which was categorized as short (≤8 weeks post randomisation), mid (2-12 months) or long-term (>12 months).Results: A total of 4324 articles were identified and twenty studies (1852 participants) meeting the inclusion criteria were included in the review. Overall, studies were judged to be of at least fair methodological quality. The most common sources of likely bias were identified as lack of concealed allocation and failure to adequately address incomplete data. Data from 12 studies were suitable for meta-analysis. Walking led to reductions in pain at short (<8 weeks post randomisation) (-8.44 [-14.54, -2.33]) and mid-term (>8 weeks - 12 month) follow-up (-9.28 [-16.34, -2.22]). No effect was observed for long-term (>12 month) data (-2.49 [-7.62, 2.65]). For function, between group differences were observed for short (-11.57 [-16.06, -7.08]) and mid-term data (-13.26 [-16.91, -9.62]). A smaller effect was also observed at long-term follow-up (-5.60 [-7.70, -3.50]).Conclusions: Walking interventions were associated with statistically significant improvements in pain and function at short and mid-term follow-up. Long-term data were limited but indicated that these effects do not appear to be maintained beyond twelve months.Implications: Walking may be an effective form of exercise for individuals with chronic musculoskeletal pain. However, further research is required which examines longer term follow-up and dose-response issues in this population.Key-words: 1. Walking exercise 2. Musculoskeletal pain 3. Systematic reviewFunding acknowledgements: Department of Employment and Learning, Northern Ireland.Ethics approval: Not applicable.

A strange foot not far from CRPS I

Introduction.- Since the work of the "International Association for the Study of Pain" (IASP), complex regional pain syndrome type 1 (CRPS I) or algodystrophy includes motor disorders (tremor, dystony, myoclony) as diagnosis criterion. This can lead to confusion with some neurologic disorders which can wrongly be considered as CRPS I. The following observation illustrates this problem.Observation.- A 31-year-old man was hospitalised in a rehabilitation clinic in April 2007 with suspected CRPS I with persistent pain in the left leg. In 2005, the patient underwent ligament reconstruction at the right ankle. In May 2006, a recurrence of his ankle sprain was treated conservatively. The course of this pathology was unfavourable with an extension of the pain areas (leg and foot) as well as an appearance of abnormal motion. Toe motion in abduction was observed (especially T5) followed by a flexion cramp; an hypoesthesia in the sural nerve area, a scar allodynia and discrete vasomotor disorders. The scintigraphy was compatible with a stage 2 algodystrophy. Lower limb electromyography was normal; measurement of pseudo periodic activity of the motor unit at the foot level (abductor of the 5th toe, 4th interosseous). A "Painful legs and moving toes syndrome" was diagnosed which was treated with gabapentin and carbamazepine with a partial improvement.Discussion.- The "Painful legs and moving toes syndrome" is a rare pathology rehabilitation specialists should recognize. The origin is often peripheral nerve damage. The medullar interneuron activation (between the dorsal and ventral horn) is considered as the source of the efferent motor nerves which are responsible for the abnormal movements. This observation illustrates the need for a demanding approach before establishing the diagnosis of CRPS I and the respect of the 4th criterion of the ASP (exclusion of this syndrome when another pathology may explain pain and dysfunction).

Pitkäaikainen kipu ja toimintaterapia : CRPS 1 -kipuoireyhtymää sairastavien kokemuksia

Opinnäytetyömme yhteistyökumppanina toimii Kuntoutus Ortonin toimintaterapiayksikkö. Opinnäytetyömme käsittelee pitkäaikaista kipua sekä toimintaterapian mahdollisuuksia pitkäaikaisesta kivusta kärsivien kuntoutuksessa. Aihe on laaja, joten työmme on kohdennettu selvittämään CRPS 1 - kipuoireyhtymää (Complex Regional Pain Syndrome) sairastavien kokemuksia. Opinnäytetyön tavoitteena oli selvittää miten toimintaterapia vaikuttaa CRPS 1-kipuoireyhtymää sairastavan toimintakykyyn sekä arjessa selviytymiseen. Kuntoutus Ortonin toimintaterapeuteilla on kokemusta CRPS -kipuoireyhtymää sairastavien kuntoutuksesta, mutta yleisesti oireyhtymää sairastavien kuntoutus on vielä melko tuntematonta. Työn tarkoituksena on tuoda esille toimintaterapian mahdollisuuksia ja keinoja oireyhtymää sairastavien kuntoutuksessa. Yhteistyökumppanimme voi hyödyntää työtämme oman työn kehittämisessä. Teoriaosuudessa esittelemme tarkemmin pitkäaikaisen kivun vaikutuksia sekä CRPS -kipuoireyhtymää ja toimintaterapian käytäntöjä. Opinnäytetyössä kootaan yhteen tuoreimpien pitkäaikaiseen kipuun ja toimintakykyyn liittyvien tutkimusten tuloksia. Olemme käyttäneet opinnäytetyössämme laadullista tutkimusmenetelmää. Aineistonkeruumenetelmänä käytimme teemahaastattelua, jonka avulla selvitimme neljän Kuntoutus Ortonin CRPS 1 - kipuoireyhtymää sairastavan kokemuksia toimintaterapiapalveluista toimintakyvyn ja arjessa selviytymisen näkökulmasta. Teemahaastattelun aihealueet pohjautuvat Kanadalaisen toiminnallisen suoriutumisen malliin. Analysoimme aineiston deduktiivisesti sisällönanalyysin avulla. Opinnäytetyön tuloksista ilmenee, että toimintaterapia vaikutti eniten kuntoutujien fyysiseen toimintakykyyn sekä itsestä huolehtimiseen. Kaikkien kuntoutujien kohdalla oli pyritty vaikuttamaan myös vapaa-aikaan, lepoon sekä affektiiviseen ja kognitiiviseen toimintakykyyn erilaisin tuloksin. Toimintaterapiassa ei oltu kiinnitetty erityisesti huomiota työhön, sillä kuntoutujat eivät ole olleet toimintaterapian toteutumisen aikana työkykyisiä. Tuloksissa kuvataan tarkemmin mistä toimintaterapiapalveluista ja -keinoista kuntoutujat kokevat erityisesti hyötyneen. Johtopäätöksenä voimme todeta, että toimintaterapia voi vaikuttaa CRPS 1 -kipuoireyhtymää sairastavan toimintakykyyn sekä arjessa selviytymiseen. Vaikutus koetaan hyvin yksilöllisesti sillä oireyhtymä esiintyy jokaisella hieman eri tavoin.

Efetividade da finasterida no tratamento da síndrome da dor pélvica crônica: revisão sistemática e metanálise

Coordenação de Aperfeiçoamento de Pessoal de Nível Superior (CAPES)

Sacral Neuromodulation for Refractory Lower Urinary Tract Dysfunction: Results of a Nationwide Registry in Switzerland

OBJECTIVE: To assess the efficacy and safety of sacral neuromodulation (SNM) in patients with refractory lower urinary tract dysfunction in Switzerland based on a nationwide registry. PATIENTS AND METHODS: A total of 209 patients (181 females, 28 males) underwent SNM testing between July 2000 and December 2005 in Switzerland. Subjective symptom improvement, bladder/pain diary variables, adverse events, and their management were prospectively registered. RESULTS: SNM testing was successful (defined as improvement of more than 50% in bladder/pain diary variables) in 102 of 209 patients (49%). An implantable pulse generator (IPG) was placed in 91 patients (89% of all successfully tested and 44% of all tested patients). Of the IPG-implanted patients, 71 had urge incontinence, 13 nonobstructive chronic urinary retention, and 7 chronic pelvic pain syndrome. After a median follow-up of 24 mo, SNM was successful in 64 of the 91 IPG-implanted patients (70%) but failed in 27 patients. SNM was continued in 15 of the 27 patients considered failures, because following troubleshooting SNM response improved subjectively and the patients were satisfied. However, improvement in bladder/pain diary variables remained less than 50%. In the other 12 patients both the leads and the IPG were explanted. During the test phase and during/following IPG implantation, 6% (12 of 209) and 11% (10 of 91) adverse event rates and 1% (3 of 209) and 7% (6 of 91) surgical revision rates were reported, respectively. CONCLUSIONS: SNM is an effective and safe treatment for refractory lower urinary tract dysfunction. Adverse events are usually transient and can be treated effectively.

Safety of prolonged sacral neuromodulation tined lead testing

OBJECTIVE: Prolonged sacral neuromodulation (SNM) testing is more reliable for accurate patient selection than the usual test period of 4-7 days. However, prolonged testing was suspected to result in a higher complication rate due to infection via the percutaneous passage of the extension wire. Therefore, we prospectively assessed the complications associated with prolonged tined lead testing. PATIENTS AND METHODS: A consecutive series of 44 patients who underwent prolonged tined lead testing for at least 14 days between May 2002 and April 2007 were evaluated. Complications during prolonged tined lead testing, during and after tined lead explantation and during follow-up after implantation of the implantable pulse generator (IPG) were registered prospectively. RESULTS: Four patients suffered from urgency-frequency syndrome, 13 from urge incontinence, 18 from non-obstructive chronic urinary retention and nine from chronic pelvic pain syndrome. The median test phase was 30 days (interquartile range [IQR] 21-36). Thirty-two of the 44 patients (73%) had successful prolonged tined lead testing and 31 of these (97%) underwent the implantation of the IPG. The median follow-up of the IPG implanted patients was 31 months (IQR 20-41). The complication rate was 5% (2/44) during prolonged tined lead testing and 16% (5/31) during follow-up of the IPG implanted patients, respectively. None of the complications could be attributed to prolonged testing. No infections were observed during the study period. CONCLUSIONS: This prospective, observational non-randomised study suggests prolonged SNM tined lead testing is a safe procedure. Based on the low complication rate and the increased reliability for accurate patient selection, this method is proposed as a possible standard test procedure, subject to confirmation by further randomised, controlled clinical studies.

Posterolateral approach to the displaced posterior malleolus: functional outcome and local morbidity

BACKGROUND: Stable anatomical reconstruction of the joint surface in ankle fractures is essential to successful recovery. However, the functional outcome of fractures involving the posterior tibial plafond is often poor. We describe the morbidity and functional outcome for plate fixation of the displaced posterior malleolus using a posterolateral approach. MATERIALS AND METHODS: The posterolateral approach was used for osteosynthesis of the posterior malleolus in 45 consecutive patients (median age 54 years) with AO/Muller-classification type 44-A3 (n = 1), 44-B3 (n = 35), 44-C1 (n = 7), and 44-C2 (n = 2) ankle fractures. Thirty-three of the patients suffered complete fracture dislocation. Functional outcome at followup was measured using the modified Weber protocol and the standardized AAOS foot and ankle questionnaire. Radiological evaluation employed standardized anterior-posterior and lateral views. RESULTS: The fragment comprised a median of 24% (range, 10% to 48%) of the articular surface. Postoperative soft tissue problems were encountered in five patients (11%), one of whom required revision surgery. Two patients (4%) developed Stage I complex regional pain syndrome. Clinical and radiological followup at 25 months disclosed no secondary displacement of the fixed fragment. The median foot and ankle score was 93 (range, 58 to 100), shoe comfort score was 77 (range, 0 to 100). A median score of 7 (range, 5 to 16) was documented using the modified Weber protocol. CONCLUSION: The posterolateral approach allowed good exposure and stable fixation of a displaced posterior malleolar fragment with few local complications. The anatomical repositioning and stable fixation led to good functional and subjective outcome.