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(377) Pain-related anxiety and performance in an interdisciplinary pain management program
Abstracts
(377) Pain-related anxiety and performance in an interdisciplinary pain management program C Gagnon, J Jaros, and J Atchison; Rehabilitation Institute of Chicago, Chicago, IL
There are mixed findings regarding the relationships between painrelated anxiety and performance on the Functional Capacity Evaluation (FCE). No studies have evaluated the relationship between pain-related anxiety assessed via the Pain Anxiety Symptoms Scale (PASS-20) with FCE performance. This exploratory study investigated the relationships among pain-related anxiety and performance in an interdisciplinary pain program. Thirty-six chronic pain patients (mean age = 43 and mean pain duration = 33.17 months) with active worker’s compensation claims were included in the study. Outcome measures included the FCE and grip strength and patient’s perceptions of their disability (Pain Disability Index- PDI). Paired-samples t-tests were used to evaluate the impact of the pain program on pain-related anxiety, perceived disability, and grip strength. The results showed statistically significant reductions in PASS scores [all P’s < .05] and perceived disability [P < 0.001]. Although grip strength increased for both hands, these increases were not statistically significant [P’s = 0.169, 0.298]. The primary goal of the study was to investigate if initial pain-related anxiety would correlate with physical performance in the pain program. Pearson correlations assessed the relationships between initial PASS score and changes in grip strength and PDI totals, and the FCE strength level. The correlations were not statistically significant [all P’s > .05]. The final goal was to observe if reductions in pain-related anxiety would be associated with improvements in grip strength, perceived disability and performance on the FCE. Reductions in pain-related anxiety were not significantly associated with improvements in grip strength or FCE strength level [P > 0.05]; however, reductions in pain-related anxiety did correlate significantly with reductions in perceived disability [P’s < .05]. Thus, the initial level of pain-related anxiety was less predictive than was the patients’ reductions in their anxiety, via the effect of the pain program, on subsequent perceptions of disability.
Pharmacology (378) Trigeminal neuralgia: pharmacotherapy and surgical treatment patterns in the United States N Wu, J Lee, J Zakrzewska, B Werneburg, D Hoffman, and Y Liu; Biogen, Cambridge, MA Trigeminal neuralgia (TN) is a rare orofacial pain condition characterized by severe, unilateral, paroxysmal pain in the region of the trigeminal nerve. Clinical guidelines recommend carbamazepine (the only drug FDA-approved for TN) and oxcarbazepine as first-line therapies. Evidence for effectiveness of other pharmacotherapies, anesthetic/botulinum toxin injections, or neurosurgical procedures in TN is limited. We examined treatment patterns among a cohort of TN patients from the US TruvenHealth MarketScanâ database. Patients included were aged $18 years, newlydiagnosed with TN ($2 TN diagnoses $14 days apart, no diagnosis in prior year), and had $3 years’ follow-up after first TN diagnosis. Utilization of selected pharmacotherapies (carbamazepine, oxcarbazepine, pregabalin, gabapentin, baclofen, duloxetine, and topiramate) or procedures (includes anesthetic/botulinum toxin injections and neurosurgical procedures) for TN was assessed. A total of 3685 patients were included (2425 commercial, 1260 Medicare enrollees; 72% female, mean[SD] age 59[15] years). Overall, 76% received $1 treatment regimen (studied pharmacotherapy [monotherapy/combination] or procedure) in the 3 years after diagnosis, of whom 65% received $2 and 45% $3 unique regimens (defined by a change in pharmacotherapy or a procedure). 72% received $1 studied pharmacotherapy; most commonly carbamazepine (38% of patients), gabapentin (35%), pregabalin (17%), or oxcarbazepine (15%). 18% underwent procedures; of these patients, 70% received further medications after the first procedure. Our study indicates that a variety of treatments are used for TN in the US, despite carbamazepine being the only approved medication. Almost half of treated patients receive $3 unique regimens within 3 years after initial diagnosis, suggesting frequent switching of therapy potentially due to suboptimal efficacy/tolerability. A substantial proportion utilize invasive proced-
The Journal of Pain
S69
ures, with the majority of these patients requiring further treatments. Overall these data indicate a high burden-of-illness associated with TN and its treatment, and unmet needs with current therapies. This study was sponsored by Biogen.
(379) Pain outcomes following intrathecal baclofen pump implant in individuals with cerebral palsy C Barney, A Merbler, J Stansbury, L Krach, M Partington, P Graupman, P Kim, D Song, and F Symons; Gillette Children’s Specialty Healthcare, St. Paul, MN
Cerebral Palsy (CP) is the most common congenital cause of disability in children. Spasticity is reported in approximately 70% of those with CP and, depending on severity, results in chronic pain and interferes with function. Intrathecal baclofen (ITB) is regarded as relatively effective in the reduction of spasticity associated with CP. Although almost all studies to date report changes in tone, the evidence for other outcomes including pain reduction is typically anecdotal/retrospective. We conducted a prospective study assessing pain intensity, duration, frequency and interference pre/post ITB pump implant. Participants were 32 individuals with CP (mean age= 12 years, 8 months). The majority of participants had a CP diagnosis of quadriplegia (72%) or diplegia (22%) and relied on wheeled mobility (91%; GMFCS level IV-V). For all participants, pain (Brief Pain Inventory [BPI]; Dalhousie Pain Interview [DPI]) and spasticity (Multiple Sclerosis Spasticity Scale [MSSS]) assessments were completed by parent report. A repeated measures ANOVA demonstrated a significant overall effect for pain duration F(2,10)= 4.467, p= .041 with a significant decrease in pain duration from pre (M= 60.04 hours, SD= 90.06 hours) to post surgery (M= 0.50 hours, SD= 1.20 hours; F(1, 11)= 7.946, p= .017). There was also a significant overall effect for spasticity F(1, 7) = 10.697, p = .007 with a significant decrease in spasticity from pre (M= 58.64, SD= 12.78) to post surgery (M= 44.87, SD= 12.12; F(1, 8) = 23.035, p = .001). The MSSS spasticity score correlated significantly with pain duration (r=.35, p=.005) and pain intensity (r=.36, p=.003). Although not statistically significant, pain intensity, frequency and pain interference all decreased following ITB pump implant. This initial analysis supports the anecdotal evidence that pain decreases along with decreases in spasticity related to ITB pump implant. The greatest impact appears to be on the duration of pain experience.
(380) Not all epidural patches are created equal: a case report of a large cerebral spinal leak and review of emerging techniques N Patel and S Pritzlaff; Stanford University Healthcare, Palo Alto, CA We present a case of 75-year-old female who presented with a large cerebral spinal fluid (CSF) leak after head trauma. The patient had a minor fall, striking her head. Within days of the incident, she developed a postural headaches and diplopia. Evaluation at an outside hospital revealed a 6th cranial nerve palsy and pachymeningeal enhancement with subdural collections on MRI. The diagnosis of CSF leak was suspected. Patient was treated with caffeine and two untargeted lumbar epidural blood patches with temporary relief. Several weeks later, she developed profound neurologic symptoms including severe headache and stupor. Upon transfer to our institution, a MRI myelogram found an extensive ventral and dorsal epidural collection throughout the cervical and thoracic spine confirming the diagnosis of CSF leak. A prominent anterior disc-osteophyte complex was seen at T10-11 causing deformation of the ventral thecal sac and was suspected to be the culprit. The patient subsequently underwent a targeted epidural blood patch with dramatic improvement in her symptoms and no recurrence of symptoms. Significant advances in the treatment of CSF leak have emerged in the past decade. Epidural patching can be achieved by differing techniques, patch material, and imaging used to perform the procedure.1 The more familiar material used for patching is autologous blood, but synthetic sealant material has shown promise especially in cases refractory to autologous blood. Options for synthetic sealant material include fibrin sealant patches, n-butyl cyanoacrylate, and polyethylene glycol hydrogel.2,3 Under all circumstances, a systematic stepwise approach should be utilized for treatment planning. (1. Correia I. et al. Case Rep Med 2016 2.
(377) Pain-related anxiety and performance in an interdisciplinary pain management program C Gagnon, J Jaros, and J Atchison; Rehabilitation Institute of Chicago, Chicago, IL
There are mixed findings regarding the relationships between painrelated anxiety and performance on the Functional Capacity Evaluation (FCE). No studies have evaluated the relationship between pain-related anxiety assessed via the Pain Anxiety Symptoms Scale (PASS-20) with FCE performance. This exploratory study investigated the relationships among pain-related anxiety and performance in an interdisciplinary pain program. Thirty-six chronic pain patients (mean age = 43 and mean pain duration = 33.17 months) with active worker’s compensation claims were included in the study. Outcome measures included the FCE and grip strength and patient’s perceptions of their disability (Pain Disability Index- PDI). Paired-samples t-tests were used to evaluate the impact of the pain program on pain-related anxiety, perceived disability, and grip strength. The results showed statistically significant reductions in PASS scores [all P’s < .05] and perceived disability [P < 0.001]. Although grip strength increased for both hands, these increases were not statistically significant [P’s = 0.169, 0.298]. The primary goal of the study was to investigate if initial pain-related anxiety would correlate with physical performance in the pain program. Pearson correlations assessed the relationships between initial PASS score and changes in grip strength and PDI totals, and the FCE strength level. The correlations were not statistically significant [all P’s > .05]. The final goal was to observe if reductions in pain-related anxiety would be associated with improvements in grip strength, perceived disability and performance on the FCE. Reductions in pain-related anxiety were not significantly associated with improvements in grip strength or FCE strength level [P > 0.05]; however, reductions in pain-related anxiety did correlate significantly with reductions in perceived disability [P’s < .05]. Thus, the initial level of pain-related anxiety was less predictive than was the patients’ reductions in their anxiety, via the effect of the pain program, on subsequent perceptions of disability.
Pharmacology (378) Trigeminal neuralgia: pharmacotherapy and surgical treatment patterns in the United States N Wu, J Lee, J Zakrzewska, B Werneburg, D Hoffman, and Y Liu; Biogen, Cambridge, MA Trigeminal neuralgia (TN) is a rare orofacial pain condition characterized by severe, unilateral, paroxysmal pain in the region of the trigeminal nerve. Clinical guidelines recommend carbamazepine (the only drug FDA-approved for TN) and oxcarbazepine as first-line therapies. Evidence for effectiveness of other pharmacotherapies, anesthetic/botulinum toxin injections, or neurosurgical procedures in TN is limited. We examined treatment patterns among a cohort of TN patients from the US TruvenHealth MarketScanâ database. Patients included were aged $18 years, newlydiagnosed with TN ($2 TN diagnoses $14 days apart, no diagnosis in prior year), and had $3 years’ follow-up after first TN diagnosis. Utilization of selected pharmacotherapies (carbamazepine, oxcarbazepine, pregabalin, gabapentin, baclofen, duloxetine, and topiramate) or procedures (includes anesthetic/botulinum toxin injections and neurosurgical procedures) for TN was assessed. A total of 3685 patients were included (2425 commercial, 1260 Medicare enrollees; 72% female, mean[SD] age 59[15] years). Overall, 76% received $1 treatment regimen (studied pharmacotherapy [monotherapy/combination] or procedure) in the 3 years after diagnosis, of whom 65% received $2 and 45% $3 unique regimens (defined by a change in pharmacotherapy or a procedure). 72% received $1 studied pharmacotherapy; most commonly carbamazepine (38% of patients), gabapentin (35%), pregabalin (17%), or oxcarbazepine (15%). 18% underwent procedures; of these patients, 70% received further medications after the first procedure. Our study indicates that a variety of treatments are used for TN in the US, despite carbamazepine being the only approved medication. Almost half of treated patients receive $3 unique regimens within 3 years after initial diagnosis, suggesting frequent switching of therapy potentially due to suboptimal efficacy/tolerability. A substantial proportion utilize invasive proced-
The Journal of Pain
S69
ures, with the majority of these patients requiring further treatments. Overall these data indicate a high burden-of-illness associated with TN and its treatment, and unmet needs with current therapies. This study was sponsored by Biogen.
(379) Pain outcomes following intrathecal baclofen pump implant in individuals with cerebral palsy C Barney, A Merbler, J Stansbury, L Krach, M Partington, P Graupman, P Kim, D Song, and F Symons; Gillette Children’s Specialty Healthcare, St. Paul, MN
Cerebral Palsy (CP) is the most common congenital cause of disability in children. Spasticity is reported in approximately 70% of those with CP and, depending on severity, results in chronic pain and interferes with function. Intrathecal baclofen (ITB) is regarded as relatively effective in the reduction of spasticity associated with CP. Although almost all studies to date report changes in tone, the evidence for other outcomes including pain reduction is typically anecdotal/retrospective. We conducted a prospective study assessing pain intensity, duration, frequency and interference pre/post ITB pump implant. Participants were 32 individuals with CP (mean age= 12 years, 8 months). The majority of participants had a CP diagnosis of quadriplegia (72%) or diplegia (22%) and relied on wheeled mobility (91%; GMFCS level IV-V). For all participants, pain (Brief Pain Inventory [BPI]; Dalhousie Pain Interview [DPI]) and spasticity (Multiple Sclerosis Spasticity Scale [MSSS]) assessments were completed by parent report. A repeated measures ANOVA demonstrated a significant overall effect for pain duration F(2,10)= 4.467, p= .041 with a significant decrease in pain duration from pre (M= 60.04 hours, SD= 90.06 hours) to post surgery (M= 0.50 hours, SD= 1.20 hours; F(1, 11)= 7.946, p= .017). There was also a significant overall effect for spasticity F(1, 7) = 10.697, p = .007 with a significant decrease in spasticity from pre (M= 58.64, SD= 12.78) to post surgery (M= 44.87, SD= 12.12; F(1, 8) = 23.035, p = .001). The MSSS spasticity score correlated significantly with pain duration (r=.35, p=.005) and pain intensity (r=.36, p=.003). Although not statistically significant, pain intensity, frequency and pain interference all decreased following ITB pump implant. This initial analysis supports the anecdotal evidence that pain decreases along with decreases in spasticity related to ITB pump implant. The greatest impact appears to be on the duration of pain experience.
(380) Not all epidural patches are created equal: a case report of a large cerebral spinal leak and review of emerging techniques N Patel and S Pritzlaff; Stanford University Healthcare, Palo Alto, CA We present a case of 75-year-old female who presented with a large cerebral spinal fluid (CSF) leak after head trauma. The patient had a minor fall, striking her head. Within days of the incident, she developed a postural headaches and diplopia. Evaluation at an outside hospital revealed a 6th cranial nerve palsy and pachymeningeal enhancement with subdural collections on MRI. The diagnosis of CSF leak was suspected. Patient was treated with caffeine and two untargeted lumbar epidural blood patches with temporary relief. Several weeks later, she developed profound neurologic symptoms including severe headache and stupor. Upon transfer to our institution, a MRI myelogram found an extensive ventral and dorsal epidural collection throughout the cervical and thoracic spine confirming the diagnosis of CSF leak. A prominent anterior disc-osteophyte complex was seen at T10-11 causing deformation of the ventral thecal sac and was suspected to be the culprit. The patient subsequently underwent a targeted epidural blood patch with dramatic improvement in her symptoms and no recurrence of symptoms. Significant advances in the treatment of CSF leak have emerged in the past decade. Epidural patching can be achieved by differing techniques, patch material, and imaging used to perform the procedure.1 The more familiar material used for patching is autologous blood, but synthetic sealant material has shown promise especially in cases refractory to autologous blood. Options for synthetic sealant material include fibrin sealant patches, n-butyl cyanoacrylate, and polyethylene glycol hydrogel.2,3 Under all circumstances, a systematic stepwise approach should be utilized for treatment planning. (1. Correia I. et al. Case Rep Med 2016 2.