- Email: [email protected]
Paper 324)
Abstracts (792) Pain medication use in older patients with diabetic peripheral neuropathy in the Veterans Health Administration S Able, X Ren, S Qian, L Kazia; Veterans Affairs Medical Center, Bedford, MA Pain-related medication use over time in patients 65 years or older with Diabetic Peripheral Neuropathy (DPN) were examined and compared to younger patients using Veteran’s Health Administration (VA) claims for fiscal 2002, 2003, and 2004. Patients with DPN (ICD-9-CM codes 357.2 and 250.6) and at least one claim for a pain-related medication were included in the study. While there were no FDA-approved pharmaceutical agents for managing pain associated with DPN during the study period, a variety of medications are commonly used for this purpose. Pain-related medication utilization included pharmaceutical agents from any of the following five categories - anticonvulsants, antidepressants, short-acting narcotics, long-acting narcotics, or non-narcotic analgesics. We excluded patients with a diagnosis of schizophrenia, bipolar or depressive disorder, or anxiety. An average of 33,180 older and 20,687 younger patients per year were available for study purposes. Most patients were men (older cohort: 98.3%; younger cohort 97.1%). While agents from the non-narcotic analgesic category were the most frequently used pain-related medications in both older (67.7%) and younger (78.0%) patients over the study period, utilization of Cox-II Inhibitors only declined significantly for older patients from 2002 (65.7%) to 2004 (45.5%). Utilization of gabapentin and tramadol increased substantially among both cohorts, but by a lesser percentage among older patients (gabapentin: 24.4% to 30.5%; tramadol: 2.4% to 7.5%) than younger (gabapentin: 29.4% to 41.8%; tramadol: 3.4% to 11.1%). Utilization of agents from more than one category of painrelated medication was common, but less so among older than younger patients (48.7% versus 60.0%; p⬍.01). Differing patterns of use between age cohorts may reflect different strategies for managing pain in older DPN patients as a result of greater concerns about drug tolerability, differences in the manifestations of pain associated with DPN as the condition progresses, and/or changes in patient perceptions of pain as they age.
S49 (794) Surgical trigger point excision for treatment of chronic neck pain and stiffness in whiplash N Nystrom, R Meuret, J Meza, W Stuberg; University of Nebraska Medical Center, Omaha, NC Whiplash Associated Disorders is a cause of considerable individual suffering and societal cost. In the absence of radiological or electrodiagnosic evidence of injury in spite of significant neck stiffness and pain, treatment options are generally limited to conservative modalities with limited scientific support. However, injections of local anesthetic solution to myofascial trigger points in the neck region may provide prompts temporary relief of symptoms. Based on this observation we assumed that similar results can be achieved with surgical excision of trigger points. In a prospective series of 108 patients with chronic neck pain after whiplash, cervical range-of-motion studies were performed before and 1-2 weeks after excision of trigger points in painful muscles of the neck. Preoperatively, all patients reported failure of conservative treatment for more than one year. Significant increase in neck mobility for each of six variables: flexion-extension, rotation right-left, abduction right-left, was documented at follow-up 1-2 weeks after surgery (p⬍0.0001), with 69% increase in total cervical range of motion. The statistical analysis of data also confirmed a significant positive correlation between improved neck mobility and reduction of pain at rest (p⬍0.0002) and after exercise. The early-outcome data from soft tissue surgery provide an explanatory model for the common failure of radiological and electrodiagnostic studies to identify pain generators in chronic whiplash syndrome with neck pain and stiffness.
(793) Pediatric nurses’ cognitive representations of children’s pain
E. Treatment Approaches (Physical)
C Vincent; University of Illinois at Chicago, Chicago, IL In spite of advances over the past decade in pain assessment and pharmacological management, hospitalized children continue to report significant unrelieved pain. Untreated pain may delay recovery, prevent healing, prolong hospitalization, and even lead to death. Research has shown that pediatric nurses consistently administer less analgesia than available and recommended, and believe that children over-report their pain. Survey data of nurses’ knowledge and attitudes have failed to predict pain assessment and management behaviors. Pilot data suggest that measurement of nurses’ cognitive representations may be more sensitive than survey instruments to capture data that may explain and predict nurses’ behaviors. The purpose of this study is to examine pediatric nurses’ cognitive representations (CRs) of assessment and management of children’s pain to identify and better understand influences on their assessment and management behaviors. The specific aims for this study are to: (1) determine pediatric nurses’ CRs of assessment of children’s pain, (2) determine pediatric nurses’ CRs of management of children’s pain, and (3) examine the degree of congruence between their CRs and their decisions about pain assessment and analgesic administration. A descriptive exploratory design addresses the study aims. Data currently are being collected from 100 registered nurses employed at a children’s hospital. Nurses’ CRs are measured with the Conceptual Content Cognitive Map (3CM) open-ended technique. This mapping method permits identification of the assumptions, beliefs, facts, and misconceptions most likely to influence behavior. Nurses also are asked to provide their responses to case studies about assessment and analgesia administration. Data analysis includes descriptive and content analyses and exploratory regression analysis to address the study aims. Once nurses’ CRs are better understood, researchers will be able to develop interventions to improve nurses’ practice and children’s pain relief. Supported by the NIH NINR1 R03 NR009809-01.
E01 - Acupuncture (795/Paper 324) mu-Opioid Receptor (MOR) Binding Predicts Differential Responsiveness to Acupuncture and Sham Acupuncture Therapy in Fibromylagia (FM) R Harris, D Scott, M Guevara, R Gracely, J Zubieta, D Clauw; University of Michigan, Ann Arbor, MI Controlled clinical trials of acupuncture in FM demonstrate that both sham and real acupuncture are effective at reducing pain. Currently no biological factor has been shown to predict responsiveness to either treatment. Since MORs are implicated in both acupuncture and placebo effects, we investigated the relationship of baseline MOR binding to subsequent pain relief. 18 female FM patients were randomized to receive either one acupuncture or one sham acupuncture treatment. Immediately prior to needle insertion, all subjects underwent a single 40 minute 11C-carfentanil positron emission tomography (PET) scan. Clinical pain was assessed pre- and post-treatment with the Short Form of the McGill Pain Questionnaire (SF-MPQ). PET images were processed with Logan plot analysis resulting in maps of whole-brain MOR binding potential (BP). Since patient expectancies prior to treatment have been associated with placebo effects, we limited our analysis to three brain regions (L caudate, L insula, and L precentral gyrus) that showed significant correlations between MOR BP and expectations of pain relief in all participants. Correlations between changes in SF-MPQ and MOR BP were performed using SPSS v14.0. Both groups displayed clinically meaningful reductions in clinical pain (SF-MPQ total score), but this was not statistically different between groups (mean difference pre-post⫹SD: acu⫽4.2⫹8.9; sham⫽5.2⫹5.8; p⫽0.78). Within the left insula, individual changes in SF-MPQ total score were negatively correlated with MOR BP pre-treatment for the acupuncture group (r⫽-0.76; p⫽0.017) whereas in the sham group there was a statistically insignificant trend in the opposite direction (r⫽0.50; p⫽0.17). However within the left precentral gyrus, both groups showed similar relationships between MOR BP and changes in affective pain (SF-MPQ affective score; acu: r⫽-0.68, p⫽0.04; sham: r⫽-0.64, p⫽0.06). Baseline levels of MOR binding within the left insula are associated with differential responsiveness to acupuncture treatment. The mechanism of action of this effect remains to be elucidated.
S49 (794) Surgical trigger point excision for treatment of chronic neck pain and stiffness in whiplash N Nystrom, R Meuret, J Meza, W Stuberg; University of Nebraska Medical Center, Omaha, NC Whiplash Associated Disorders is a cause of considerable individual suffering and societal cost. In the absence of radiological or electrodiagnosic evidence of injury in spite of significant neck stiffness and pain, treatment options are generally limited to conservative modalities with limited scientific support. However, injections of local anesthetic solution to myofascial trigger points in the neck region may provide prompts temporary relief of symptoms. Based on this observation we assumed that similar results can be achieved with surgical excision of trigger points. In a prospective series of 108 patients with chronic neck pain after whiplash, cervical range-of-motion studies were performed before and 1-2 weeks after excision of trigger points in painful muscles of the neck. Preoperatively, all patients reported failure of conservative treatment for more than one year. Significant increase in neck mobility for each of six variables: flexion-extension, rotation right-left, abduction right-left, was documented at follow-up 1-2 weeks after surgery (p⬍0.0001), with 69% increase in total cervical range of motion. The statistical analysis of data also confirmed a significant positive correlation between improved neck mobility and reduction of pain at rest (p⬍0.0002) and after exercise. The early-outcome data from soft tissue surgery provide an explanatory model for the common failure of radiological and electrodiagnostic studies to identify pain generators in chronic whiplash syndrome with neck pain and stiffness.
(793) Pediatric nurses’ cognitive representations of children’s pain
E. Treatment Approaches (Physical)
C Vincent; University of Illinois at Chicago, Chicago, IL In spite of advances over the past decade in pain assessment and pharmacological management, hospitalized children continue to report significant unrelieved pain. Untreated pain may delay recovery, prevent healing, prolong hospitalization, and even lead to death. Research has shown that pediatric nurses consistently administer less analgesia than available and recommended, and believe that children over-report their pain. Survey data of nurses’ knowledge and attitudes have failed to predict pain assessment and management behaviors. Pilot data suggest that measurement of nurses’ cognitive representations may be more sensitive than survey instruments to capture data that may explain and predict nurses’ behaviors. The purpose of this study is to examine pediatric nurses’ cognitive representations (CRs) of assessment and management of children’s pain to identify and better understand influences on their assessment and management behaviors. The specific aims for this study are to: (1) determine pediatric nurses’ CRs of assessment of children’s pain, (2) determine pediatric nurses’ CRs of management of children’s pain, and (3) examine the degree of congruence between their CRs and their decisions about pain assessment and analgesic administration. A descriptive exploratory design addresses the study aims. Data currently are being collected from 100 registered nurses employed at a children’s hospital. Nurses’ CRs are measured with the Conceptual Content Cognitive Map (3CM) open-ended technique. This mapping method permits identification of the assumptions, beliefs, facts, and misconceptions most likely to influence behavior. Nurses also are asked to provide their responses to case studies about assessment and analgesia administration. Data analysis includes descriptive and content analyses and exploratory regression analysis to address the study aims. Once nurses’ CRs are better understood, researchers will be able to develop interventions to improve nurses’ practice and children’s pain relief. Supported by the NIH NINR1 R03 NR009809-01.
E01 - Acupuncture (795/Paper 324) mu-Opioid Receptor (MOR) Binding Predicts Differential Responsiveness to Acupuncture and Sham Acupuncture Therapy in Fibromylagia (FM) R Harris, D Scott, M Guevara, R Gracely, J Zubieta, D Clauw; University of Michigan, Ann Arbor, MI Controlled clinical trials of acupuncture in FM demonstrate that both sham and real acupuncture are effective at reducing pain. Currently no biological factor has been shown to predict responsiveness to either treatment. Since MORs are implicated in both acupuncture and placebo effects, we investigated the relationship of baseline MOR binding to subsequent pain relief. 18 female FM patients were randomized to receive either one acupuncture or one sham acupuncture treatment. Immediately prior to needle insertion, all subjects underwent a single 40 minute 11C-carfentanil positron emission tomography (PET) scan. Clinical pain was assessed pre- and post-treatment with the Short Form of the McGill Pain Questionnaire (SF-MPQ). PET images were processed with Logan plot analysis resulting in maps of whole-brain MOR binding potential (BP). Since patient expectancies prior to treatment have been associated with placebo effects, we limited our analysis to three brain regions (L caudate, L insula, and L precentral gyrus) that showed significant correlations between MOR BP and expectations of pain relief in all participants. Correlations between changes in SF-MPQ and MOR BP were performed using SPSS v14.0. Both groups displayed clinically meaningful reductions in clinical pain (SF-MPQ total score), but this was not statistically different between groups (mean difference pre-post⫹SD: acu⫽4.2⫹8.9; sham⫽5.2⫹5.8; p⫽0.78). Within the left insula, individual changes in SF-MPQ total score were negatively correlated with MOR BP pre-treatment for the acupuncture group (r⫽-0.76; p⫽0.017) whereas in the sham group there was a statistically insignificant trend in the opposite direction (r⫽0.50; p⫽0.17). However within the left precentral gyrus, both groups showed similar relationships between MOR BP and changes in affective pain (SF-MPQ affective score; acu: r⫽-0.68, p⫽0.04; sham: r⫽-0.64, p⫽0.06). Baseline levels of MOR binding within the left insula are associated with differential responsiveness to acupuncture treatment. The mechanism of action of this effect remains to be elucidated.