Most patients present to the ED with acute exacerbations of chronic low back pain. Risk factors for a serious condition are common, but rarely do they develop. Racial disparities and psychosocial factors had concerning relationships with clinical decision-making.
Objectives: Many patients’ chronic musculoskeletal pain is strongly influenced by central nervous system processes such as sensitization or amplification. Education about pain neuroscience can change patients’ beliefs but has less consistent effects on pain outcomes. Patients may have greater clinical benefits if the educational intervention is personalized, and they evaluate various psychosocial risk factors with respect to their pain. We developed and tested a brief, internet-based Pain Psychology and Neuroscience (PPN) self-evaluation intervention. Materials and Methods: From a patient registry, 104 adults reporting chronic musculoskeletal pain were randomized to the PPN intervention or a matched, active, education control condition. At baseline and 1-month (primary endpoint) and 10-month follow-ups, participants reported pain severity (primary outcome) and multiple secondary outcomes. Primary analyses compared the 2 experimental conditions using analyses of covariances; post hoc exploratory analyses compared the effects of PPN in subgroups of patients who met criteria for fibromyalgia (FM; n=50) or who did not (n=54; primarily spinal pain). Results: At 1-month follow-up, compared with the control condition, PPN led to significantly lower pain severity (ηp 2=0.05) and interference (ηp 2=0.04), greater brain (ηp 2=0.07) and psychological (ηp 2=0.07) attributions for pain, and greater readiness for pain self-management (ηp 2=0.08). Effects on distress, pain catastrophizing, kinesiophobia, and life satisfaction were not significant. Exploratory analyses showed that the PPN intervention was especially beneficial for patients without FM but was of less benefit for those with FM. Most of the effects (except attributions) were lost at 10 months. Discussion: A brief PPN self-evaluation intervention, presented on-line, can yield short-term improvements in musculoskeletal pain severity and interference, especially for people with spinal/localized pain rather than FM, perhaps because the psychology/neuroscience perspective is more novel for such patients.
Chronic low back pain (cLBP) is a complex with a heterogenous clinical presentation. A better understanding of the factors that contribute to cLBP is needed for accurate diagnosis, optimal treatment, and identification of mechanistic targets for new therapies. The Back Pain Consortium (BACPAC) Research Program provides a unique opportunity in this regard as it will generate large clinical datasets including a diverse set of harmonized measurements. The Theoretical Model Working Group (TMWG) was established to guide BACPAC research, and to organize new knowledge within a mechanistic framework. This article summarizes the initial works of the TMWG. It includes a three-stage integration of expert opinion and an umbrella literature review of factors that affect cLBP severity and chronicity. During Stage 1, experts from across BACPAC established a taxonomy for risk and prognostic factors (RPFs) and preliminary graphical depictions. During Stage 2, a separate team conducted a literature review according to PRISMA guidelines to establish working definitions, associated data elements (ADEs), and overall strength-of-evidence (SOE) for identified RPFs. These were subsequently integrated with expert opinion during Stage 3. The majority (∼80%) of RPFs had little SOE confidence, while 7 factors had substantial confidence for either a positive association (pain-related anxiety, serum c-reactive protein, diabetes, and anticipatory/compensatory postural adjustments) or no association (serum interleukin 1-beta/interleukin 6, transversus muscle morphology/activity, and quantitative sensory testing) with cLBP. This theoretical perspective will evolve over time as BACPAC investigators link empirical results to theory, challenge current ideas of the biopsychosocial model, and utilize a systems approach to develop tools and algorithms that disentangle the dynamic interactions between cLBP factors.
This paper extends the idea of decoupling shrinkage and sparsity for continuous priors to Bayesian Quantile Regression (BQR). The procedure follows two steps: In the first step, we shrink the quantile regression posterior through state of the art continuous priors and in the second step, we sparsify the posterior through an efficient variant of the adaptive lasso, the signal adaptive variable selection (SAVS) algorithm. We propose a new variant of the SAVS which automates the choice of penalisation through quantile specific lossfunctions that are valid in high dimensions. We show in large scale simulations that our selection procedure decreases bias irrespective of the true underlying degree of sparsity in the data, compared to the un-sparsified regression posterior. We apply our two-step approach to a high dimensional growth-at-risk (GaR) exercise. The prediction accuracy of the un-sparsified posterior is retained while yielding interpretable quantile specific variable selection results. Our procedure can be used to communicate to policymakers which variables drive downside risk to the macro economy
BACKGROUND: Myofascial pain is a common, but poorly understood multifactorial condition. OBJECTIVE: This study analyzed how the degree of central sensitization (nociplastic pain) can impact the response to physical therapy for patients with myofascial pain. METHODS: This prospective, observational cohort study compared pain phenotyping and functional measures in 30 participants with non-acute neck/shoulder girdle primary myofascial pain following 3-months of physical therapy. The Fibromyalgia Survey Questionnaire Score served as a surrogate of central sensitization. RESULTS: All participants demonstrated some benefit from physical therapy; however, those with moderate levels of nociceptive pain features were less likely to have clinically significant improvements on the Neck Disability Index, PEG score, or pain catastrophizing measures. Those with higher levels of nociplastic pain had a similar chance of showing improvement as those with lower levels, except regarding catastrophizing. Significant improvements were independent of the type or amount of therapy received. CONCLUSION: The degree of nociplastic pain in patients with myofascial pain appears to be inversely related to improvements from a peripherally based treatment. This is not to say that individuals with moderate to higher levels of nociplastic pain do not benefit from physical therapy, but they proportionally benefit less.
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