Chronic low back pain affects 50-80% of the population, while its consequences may impair the functioning of patients suffering from it, in many spheres of life. Hope is a factor which may influence coping with pain as well as cognitive reflection of pain experience. The aim of the study has been to check: 1) whether dependencies exist between hope-trait and hope-state and the perception of pain; 2) whether experiencing pain at the time of (...) filling questionnaires matters for the assessment of the level of hope; 3) whether there is interaction between hope, the pain experienced at the moment of investigation, and memory of the intensity of previously experienced pain. 150 patients participated in the study, they all reported aggravation of the chronic low back pain syndrome. The study was a cross-sectional study, based on questionnaires. On the third day of treatment the subjects were given the following questionnaires: Trait Hope Scale, State Hope Scale, and Numerical Rating Scale of Pain to fill. Poor correlation was demonstrated to exist between hope-state and hope-pathways on the one hand, and the intensity of minimum pain level experienced during the first three days of treatment. It has been noted that the presence of pain at the time of filling questionnaires results in reducing the hope-state, but only in those persons, who had experienced severe pain previously. On the other hand, in case of patients who had experienced slight pain previously, the pain present when filling in the questionnaires is conducive to enhanced hope-state. The results of the study confirm the complex character of relations between hope and pain. (shrink)

Objectives: To evaluate the effects of an 8-week DNS training program on pain, EMG activity, and quality of life in individuals with CLBP. Design: Semi-experimental study. Participants: Thirty male participants with non-specific CLBP, divided into DNS (n=15) and control (n=15) groups. Main Outcome Measures: Pain levels (Quebec Back Pain Disability Scale), lumbar muscle EMG activity (MegaWin EMG device), and quality of life (SF-36 questionnaire). Results: The DNS group showed significant pain reduction (P=0.00), increased EMG activity (...) in rectus abdominis (P=0.000), erector spinae (P=0.002), and gluteus maximus (P=0.002), and improved quality of life (P=0.02). Conclusions: DNS exercises significantly reduce pain, enhance muscle activity, and improve quality of life in CLBP patients. (shrink)

The comorbidity of chronic pain and opioid addiction is a serious problem that has been growing with the practice of prescribing opioids for chronic pain. Neuroimaging research has shown that chronic pain and opioid dependence both affect brain structure and function, but this is the first study to evaluate the neurophysiological alterations in patients with comorbid chronic pain and addiction. Eighteen participants with chronic low back pain and opioid addiction (...) were compared with eighteen age- and sex-matched healthy individuals in a pain-induction fMRI task. Unified structural equation modeling (SEM) with Lagrange multiplier (LM) testing yielded a network model of pain processing for patient and control groups based on 19 a priori defined regions. Tests of differences between groups on specific regression parameters were determined on a path-by-path basis using z-tests corrected for the number of comparisons. Patients with the chronic pain and addiction comorbidity had increased connection strengths; many of these connections were interhemispheric and spanned regions involved in sensory, affective, and cognitive processes. The affected regions included those that are commonly altered in chronic pain or addiction alone, indicating that this comorbidity manifests with neurological symptoms of both disorders. Understanding the neural mechanisms involved in the comorbidity is crucial to finding a comprehensive treatment, rather than treating the symptoms individually. (shrink)

In people with chronic low back pain, maladaptive structural and functional changes on a cortical level have been identified. On a functional level, somatosensory cortical excitability has been shown to be reduced in chronic pain conditions, resulting in cortical disinhibition. The occurrence of structural and/or functional maladaptive cortical changes in people with CLBP could play a role in maintaining the pain. There is currently no measurement protocol for cortical excitability that employs stimulation directly to (...) the lower back. We developed a protocol for the measurement of single pulse somatosensory evoked potential waveforms and paired-pulse behavior generated from sensory nerves of the lower back and quantified its test–retest reliability in a sample of 30 healthy individuals to gain insights into the normal variability of cortical responses, which could then be compared to results from people with CLBP. We investigated cortical excitability by measuring SEPs and PPB. PPB was defined as the ratio of the amplitude of the second cortical response divided by the first cortical response. A2s was determined by subtracting the response to single-pulse stimuli from the paired pulse stimuli response to account for linear superposition effects. The test–retest reliability of the protocol was very poor with no evidence of systematic bias but a high amount of random variability between sessions. There was no significant difference in the right side PPB for session 1 and session 2 ; mean session difference [ = −0.44 ; t = −1.17, p = 0.26]. The ICC3.1 for the outlier-removed right side PPB were 0.19 and 0.43 for left side PPB. This finding potentially has wider implications for PPB protocols. If these findings were replicated in other groups and other nerves, it would question the validity of this measure more generally. However, these findings are restricted to healthy people and sensory nerves of the lower back and may not be generalizable. (shrink)

Postural reflexes are essential for locomotion and postural stability, and may play an important role in the etiology of chronic back pain. It has recently been theoretically predicted, and with the help of unilateral perturbations of the trunk experimentally confirmed that the sensorimotor control must lower the reflex amplitude for increasing reflex delays to maintain spinal stability. The underlying neuromuscular mechanism for the compensation of postural perturbations, however, is not yet fully understood. In this study, we applied (...) unilateral and bilateral sudden external perturbations to the trunk of healthy subjects and measured the muscular activity and the movement onset of the trunk. We found that the onset of the trunk muscle activity is prior to, or coincident with, the onset of the trunk movement. Additionally, the results of our experiments imply that the muscular response mechanism integrates distant sensory information from both sides of the body. These findings rule out a simple monosynaptic stretch reflex in favor of a more complex polysynaptic postural reflex mechanism to compensate postural perturbations. Moreover, the previously predicted negative correlation between reflex delay and reflex gain was also confirmed for bilateral perturbations. (shrink)

Back injuries have a bad reputation. The workman looks upon them with apprehension, the insurance company with doubt, the medical examiner with suspicion, the lawyer with uncertainty. The medical examiner is faced with the difficulty of estimating the true value of the subjective symptoms in the comparative absence of physical signs. His suspicion is born of the frequent disparity between these two. This prophetic statement made almost 100 years ago highlights an ongoing problem - how people who are incapacitated (...) by painful conditions such as chronic low back pain can be evaluated consistently and equitably for purposes of disability compensation. We confronted this vexing problem when we participated in writing the chapter devoted to impairment associated with pain of the American Medical Association s Guides to the Evaluation of Permanent Impairment, 5th edition AMA Guides 5th Our purposes in this essay are to clarify several important conceptual issues associated with the assessment of pain among disability applicants, and to articulate reasons why pain should be considered in impairment and disability ratings. (shrink)

RATIONALE: The concept of evidence-based medicine is important in providing efficient health care. The process uses research findings as the basis for clinical decision making. Evidence-based practice helps optimize current health care and enables the practitioners to be suitably accountable for the interventions they provide. Little work has been undertaken to examine how allied health professionals change their clinical practice in light of the latest evidence. The use of opinion leaders to disseminate new evidence around the management of low (...) class='Hi'>back pain into practice has been proposed. AIMS: The aim of this study was to investigate if physiotherapists' clinical management of patients with low back pain would change following an evidence-based education package, which utilized local opinion leaders and delivered the best evidence. METHOD: Thirty musculoskeletal physiotherapists from a Community Trust in North Staffordshire were cluster randomized by location of work, to two groups. The intervention group received an evidence-based programme on the management of low back pain, including advice regarding increasing activity levels and return to normal activity and challenging patients' fears and beliefs about their pain. The control group received a standard in-service training package on the management of common knee pathologies. The physiotherapists' clinical management of patients with low back pain was measured prior to training and 6 months post training. Outcome measures were based on physiotherapists completing 'discharge summary' questionnaires, which included information relating to the use and importance of therapies for treating their low back pain patients. RESULTS: There were few significant differences in treatment options between the intervention and control groups post training. Whilst there was some indication that physiotherapists were already utilizing aspects of psychosocial management for patients with low back pain, there was little change in what physiotherapists perceived to be important to patient recovery and actual clinical practice following the intervention. CONCLUSIONS: Psychosocial factors have been identified as an important factor in the recovery of patients with low back pain. This project incorporated the latest evidence on the management of low back pain and utilized the theory of opinion leaders to disseminate this evidence into clinical practice. Whilst there were some limitations in the overall size of the study, the results help to give an insight into the challenges faced by the health care system and researchers alike to ensure quality evidence is actually utilized by practitioners for the benefits of patient care. (shrink)

In this study we investigated sensorimotor processing of painful pressure stimulation on the lower back of patients with chronic lower back pain (CLBP) by using functional near-infrared spectroscopy (fNIRS) to measure changes in cerebral hemodynamics and oxygenation. The main objectives were whether patients with CLBP show different relative changes in oxy- and deoxyhemoglobin ([O2Hb] and [HHb]) in the supplementary motor area (SMA) and primary somatosensory cortex (S1) compared to healthy controls (HC). Twelve patients with CLBP (32 (...) ± 6.1 years; range: 24 – 44 years; 9 women) and twenty HCs (33.5 ± 10.7 years; range 22-61 years; 8 women) participated in the study. Painful and non-painful pressure stimulation was exerted with a thumb grip perpendicularly to the spinous process of the lumbar spine. A force sensor was attached at the spinous process in order control for pressure forces. Tactile stimulation was realized by a one-finger brushing. Hemodynamic changes in the SMA and S1 were measured bilaterally using a multi-channel continuous wave fNIRS imaging system and a multi-distant probe array. Patients with CLBP showed significant stimulus-evoked hemodynamic responses in [O2Hb] only in the right S1, while the healthy controls exhibited significant [O2Hb] changes bilaterally in both, SMA and S1. However, the group comparisons revealed no significant different hemodynamic responses in [O2Hb] and [HHb] in the SMA and S1 after both pressure stimulations. This non-significant result might be driven by the high inter-subject variability of hemodynamic responses that has been observed within the patients group. In conclusion, we could not find different stimulus-evoked hemodynamic responses in patients with CLBP compared to HCs. This indicates that neither S1 nor the SMA show a specificity for CLBP during pressure stimulation on the lower back. However, the results point to a potential subgrouping regarding task-related cortical activity within the CLBP group; a finding worth further research. (shrink)

The purpose of this paper is to elaborate on the notion of clinical medicine as a hermeneutical enterprise and to bridge the gap between the general perspectives of hermeneutics and the particularities of medical practice. The case of a patient with low back pain is analyzed. The discussion centers around the metaphor of the patient as a text and a model of five social discourses about low back pain. The problems addressed are: (1) the nature of (...) a moral experience, (2) the variety of available texts, (3) the difference between the doctor's and patient's narratives, and (4) the patient's and doctor's responsibility regarding the existential, biographical meaning of an illness. Although many problems are left unsolved, it is argued that from a philosophical point of view the notion of medicine as a hermeneutical enterprise opens up the possibility of gaining insight in the foundations of the clinical encounter. (shrink)

Low‐back pain can be invalidating physically as well as mentally. Despite professional help to treat and prevent low‐back pain, the pain often persists, and so do the problems related to low‐back pain. An intervention that made it possible for a significant part of patients with low‐back pain to improve health and well‐being raised the question: Why was it possible to help some and not others? The aim of the present paper was (...) to achieve a deeper understanding of factors patients experienced as helpful in professional support related to low‐back pain. This was explored using a hermeneutic‐phenomenological approach while analysing 20 interviews with patients with low‐back pain purposively chosen interviews conducted in relation to the intervention. An analysis was made using Ricoeur's interpretation theory. Data on both positive and negative experiences were read and reflected upon. We found that healthcare professionals’ adoption of a narrative approach facilitating the patient's perspective was perceived as helpful. Patients experienced this as being taken seriously; an experience that could be explained at a deeper, more nuanced level using Heidegger's philosophy. Facilitating the patient's perspective was conditional not only on the professional obtaining access to the patient's perspective but also on understanding and acknowledging the patient's existence. The challenge for healthcare professionals in this respect is to bridge the gap between the consultation's fact‐focused concern with the medical implications of low‐back pain and the patient's concern with the implications low‐back pain has for his or her personal identity and life. Listening to the patient's perspective in itself supports the subjective recovery process, while also supporting the quality of patient‐centred support and strengthening the patient's trust in its helpfulness. (shrink)

Human decisions are increasingly supported by decision support systems (DSS). Humans are required to remain “on the loop,” by monitoring and approving/rejecting machine recommendations. However, use of DSS can lead to overreliance on machines, reducing human oversight. This paper proposes “reflection machines” (RM) to increase meaningful human control. An RM provides a medical expert not with suggestions for a decision, but with questions that stimulate reflection about decisions. It can refer to data points or suggest counterarguments that are less compatible (...) with the planned decision. RMs think against the proposed decision in order to increase human resistance against automation complacency. Building on preliminary research, this paper will (1) make a case for deriving a set of design requirements for RMs from EU regulations, (2) suggest a way how RMs could support decision-making, (3) describe the possibility of how a prototype of an RM could apply to the medical domain of chronic low back pain, and (4) highlight the importance of exploring an RM’s functionality and the experiences of users working with it. (shrink)

Next SectionEvidence based medicine is rightly at the core of current medicine. If patients and society put trust in medical professional competency, and on the basis of that competency delegate all kinds of responsibilities to the medical profession, medical professionals had better make sure their competency is state of the art medical science. What goes for the ethics of clinical trials goes for the ethics of medicine as a whole: anything that is scientifically doubtful is, other things being equal, ethically (...) unacceptable. This particularly applies to so called orphaned fields of medicine, those areas where medical research is weak and diverse, where financial incentives are lacking, and where the evidence regarding the aetiology and treatment of disease is much less clear than in laboratory and hospital based medicine. Examples of such orphaned fields are physiotherapy, psychotherapy, medical psychology, and occupational health, which investigate complex syndromes such as RSI, whiplash, chronic low back pain, and chronic fatigue syndrome. It appears that the primary ethical problem in this context is the lack of attention to the orphaned fields. Although we agree that this issue deserves more attention as a matter of potential injustice, we want to argue that, in order to do justice to the interplay of heterogeneous factors that is so typical of the orphaned fields, other ethical models than justice are required. We propose the coordination model as a window through which to view the important ethical issues which relate to the communication and interaction of scientists, health care workers, and patients. (shrink)

OBJECTIVE: How outside factors affect physician decision making remains an open question of vital importance. We sought to investigate the importance of various influences on physician decision making when clinical guidelines differ from patient preference. -/- METHODS: An online survey asking 469 primary care providers (PCPs) across four practice sites whether they would order magnetic resonance imaging for a patient with uncomplicated back pain. Participants were randomized to one of four scenarios: a patient's preference for imaging (control), a (...) patient's preference plus a colleague's opinion against imaging (colleague), a patient's preference plus a professional society's recommendation against imaging (profession), or a patient's preference plus an accountable care organization's quality metric that measures physician use of imaging (ACO). Demographic information and the reasoning behind participants' decisions also were obtained. -/- RESULTS: A total of 168 PCPs completed the survey, yielding a 36% completion rate. A majority chose not to pursue imaging: control 68%, colleague 85%, profession 87%, and ACO 78%. Multivariate logistic regression revealed that participants were more likely not to order advanced imaging only when reminded of a professional society recommendation (P = 0.017). Regression also suggested that practice site exerted an effect on the primary outcome. Evidence-based medicine and clinical judgment were the most cited reasons for the decision. -/- CONCLUSIONS: Our results reinforce the potential to leverage professional societies to advance evidence-based medicine and reduce unnecessary testing. At the same time, practice site appeared to exert influence, suggesting that these recommendations must be part of local institutional culture to be effective. (shrink)

Chronic back pain (CBP) is a leading cause of disability and results in considerable socio-economic burdens worldwide. Although CBP patients are commonly diagnosed and treated with a focus on the ‘end organ dysfunction’ (i.e., peripheral nerve injuries or diseases), the evaluation of CBP remains flawed and problematic with great challenges. Given that the peripheral nerve injuries or diseases are insufficient to define the etiology of CBP in some cases, the evaluation of alterations in the central nervous system (...) becomes particularly necessary and important. With the development of advanced neuroimaging techniques, extensive studies have been carried out to identify the cortical abnormalities in CBP patients. Here, we provide a comprehensive overview on a series of novel findings from these neuroimaging studies to improve our understanding of the cortical abnormalities originated in the disease. First, CBP patients normally exhibit central sensitization to external painful stimuli, which is indexed by increased pain sensitivity and brain activations in pain-related brain regions. Second, long-term suffering from chronic pain leads to emotional disorders, cognitive impairments, and the abnormalities of the relevant brain networks among CBP patients. Third, CBP is associated with massive cortical reorganization, including structural, functional, and metabolic brain changes. Overall, a deep insight into the neural mechanisms underlying the development and outcome of CBP through more sophisticated neuroimaging investigations could not only improve our current understanding of the etiology of CBP but also facilitate the diagnosis and treatment of CBP based on precision medicine. (shrink)

Research documents that many chronic non-malignant pain patients experience existential, spiritual and religious needs; however, research knowledge is missing on if and how physicians approach these needs. We conducted a systematic review to explore the extent to which physicians address these needs in their communication with chronic non-malignant pain patients and to explore the facilitators and challenges of this communication. We followed the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines, searching Embase, Medline, Scopus and (...) PsycINFO. The quality of the included articles was assessed based on design-specific screening tools. We included four of 2337 screened articles and found the quality to be good. Physicians’ communication about existential, spiritual and religious needs was given low priority and depended on the patients’ own initiative, except when clinicians were interested in holistic care. Patient dissatisfaction with the physician’s attention to these needs was related to higher pain and depression. Physicians’ challenges for addressing these needs were their tendency to prioritize physiological aspects and close further elaboration of existential needs when addressed by the patients. The main facilitator was the individual physician’s willingness to listen with openness and empathy to the patients’ existential concerns. A tentative conclusion is that physicians rarely meet the existential, spiritual and religious needs of their chronic non-malignant pain patients. This might be due to higher priority of physical aspects, lack of time and a lack of knowledge about the importance of and training in the ability to address these needs. Further research is needed on physicians’ communication about existential, spiritual and religious needs and on their training in here. (shrink)

This full-color, user-friendly book features simple meridian exercises that combine breathing, movement, stretching, and focused attention to improve overall balance and flexibility. The book identifies specific meridian exercises to alleviate common ailments, including headaches, colds, and the flu, as well as more serious conditions, such as high blood pressure, diabetes, and thyroid disorders. Meridian exercise is a technique developed and perfected over the course of thousands of years in the Asian healing arts traditions. This book includes the following features: Low-impact, (...) time-efficient exercises that relieve stress, restore physical health, and rebalance the mind Step-by-step instructions with accompanying photos for dozens of exercises specifically designed for common symptoms Breathing and relaxation techniques to awaken innate healing power and. (shrink)

Resilience factors have been suggested as key mechanisms in the relation between symptoms and disability among individuals with chronic pain. However, there is a need to better operationalize resilience and to empirically evaluate its role and function. The present study examined psychological flexibility as a resilience factor in relation to symptoms and functioning among 252 adults with chronic pain applying for participation in a digital ACT-based self-help treatment. Participants completed measures of symptoms (pain intensity, anxiety), (...) functioning (pain interference, depression), as well as the hypothesized resilience factor psychological flexibility (measured as avoidance, value obstruction, and value progress). As expected, symptoms, functioning and resilience factors were significantly associated. Hierarchical linear regression analyses showed that psychological flexibility significantly contributed to the prediction of pain interference and depression when adjusting for age, pain and anxiety. Also, participants with low levels of psychological flexibility were more likely to be on sick leave. Furthermore, a series of multiple mediation analyses showed that psychological flexibility (avoidance, value obstruction, value progress) had a significant indirect effect on the relationship between symptoms and functioning. Avoidance was consistently shown to contribute to the indirect effect. Results support previous findings and suggest the importance of psychological flexibility as a resilience factor among individuals with chronic pain and anxiety. (shrink)

Considerable heterogeneity among pediatric chronic pain patients may at least partially explain the variability seen in the response to behavioral therapies. The current study tested whether autistic traits and attention-deficit/hyperactivity disorder symptoms in a clinical sample of children and adolescents with chronic pain are associated with socioemotional and functional impairments and response to acceptance and commitment therapy treatment, which has increased psychological flexibility as its core target for coping with pain and pain-related distress. Children (...) and adolescents aged 8–18 years were recruited. Patients and their parents completed questionnaires pre- and post-ACT of 17 sessions. Correlational analyses and mixed-effects models were used to assess the role of autistic traits and ADHD symptoms in pretreatment functioning and ACT-treatment response. Outcome variables were degree to which pain interfered with daily activities, socioemotional functioning, psychological inflexibility, and pain intensity. Autistic traits and ADHD symptoms, pain frequency, and pain duration were measured at pretreatment only. Higher autistic traits were associated with greater pain interference, higher depression, and greater psychological inflexibility. Higher ADHD symptomatology was associated with greater pretreatment pain interference, lower emotional functioning, greater depression, and longer duration of pain. Across patients, all outcome variables, except for sleep disturbances and school functioning, significantly improved from pre- to post-ACT. Higher autistic traits were associated with greater pre- to post-ACT improvements in emotional functioning and sleep disturbance and non-significant improvements in pain interference. ADHD symptomatology was not associated with treatment outcome. The current results showed that neuropsychiatric symptoms in pediatric chronic pain patients are associated with lower functioning, particularly pain interfering with daily life and lower socioemotional functioning. The results suggest that not only pediatric chronic pain patients low in neuropsychiatric symptoms may benefit from ACT, but also those high in autism traits and ADHD symptoms. With the present results in mind, pediatric chronic pain patients higher in autistic traits may actually derive extra benefit from ACT. Future research could assess whether increased psychological flexibility, the core focus of ACT, enabled those higher in autism traits to cope relatively better with pain-related distress and thus to gain more from the treatment, as compared to those lower in autism traits. Moreover, to address specific effects of ACT, inclusion of an appropriate control group is key. (shrink)

In lieu of an abstract, here is a brief excerpt of the content:Silent Screams; Lily's StoryEva V. Regel"Trauma is personal. It does not disappear if it is not validated. When it is ignored or invalidated, the silent screams continue internally heard only by the one held captive. When someone enters the pain and hears the scream, healing can begin."—Danielle Bernock, "Emerging Wings; A true story of Lies, Pain and the Love that Heals."Some patients stay with you long after (...) they leave. They appear in your mind when you walk by the hospital room they occupied or when someone mentions their name. There is [End Page 19] something about the narrative of their life and illness that makes you hold on to them. Lily is one such patient for me.Lily was a 45-year-old paraplegic woman who was well known to many providers in the hospital. She had a complex trauma history (childhood physical and sexual abuse, intimate partner violence, domestic violence), homelessness, and multiple psychiatric admissions. In addition, she had a complex medical history, including chronic pain issues and substance use disorder. Many providers considered her to be a "very difficult" or "challenging" patient because she would "dictate" her care, had low distress tolerance and would have explosive angry outbursts requiring frequent visits from Police and Security. To top it off, after months of a challenging stay on a unit, she would eventually leave against medical advice. Everyone involved in her care felt that discharge to a safe setting such as a skilled nursing facility would be her best option. Yet, she was a very "hard" sell to any facility because of her behavioral issues, relatively young age, extensive history of drug use, and medication non-compliance. Even though the unit I worked in was familiar with "difficult" patients like Lily, the floor staff was anxious and concerned about the effect Lily would have on patients, staff, and providers. The combined anticipatory anxiety worsened after we were told that Lily left against medical advice three days before her admission to our unit as a reaction to the staff's attempt to develop a behavioral plan.I remember the day I met Lily. I was working as the clinical social worker on the floor, helping patients with adjustment to coping with hospitalization, addressing mental health issues that usually exacerbate in the acute care setting, and providing support to the staff caring for a psychosocially complex patient population. It was the second day after Lily arrived on the floor, and Police and Security had already come up three times. As I walked out of another patient's room, a bedside nurse stopped me in the hallway. "Can you please talk to her? … Please, just talk to her, or sit with her. I just need a break. I have been in that room since I started my shift. I am exhausted." The nurse had an exasperated and pleading look, and even though I was rushing to a meeting, I decided to meet with Lily instead. When I walked into her room, I saw a thin, small-framed woman with brown hair pulled back into a tight bun. She had freckles peppered all over her round face, neck, and chest. Her features were delicate and small, and her almond-shaped green eyes were her most prominent feature. She was wearing a white tee and jeans. She was sitting in her wheelchair; her makeup bag was lying on the table next to her. I introduced myself and my role on the team, trying not to stumble under a very heavy glare. "Tell them to leave me alone. That nurse is always in my room. Spying. I might not be able to walk, but I can still use my hands. I can call if I need help."And so I did. And when I came back, Lily and I talked a little about her life. And the next day, we talked a little more. And then again. Lily was giving me small glimpses of who she was and the events in her life. Then, one day, in the middle of the conversation about her day and telling me how much she hated to be confined to her hospital room, she looked... (shrink)

In lieu of an abstract, here is a brief excerpt of the content:Sweating the Small StuffTim CunninghamAs an emergency nurse, I often do not notice the small stressors as compared to the loads of intense physical and emotional suffering I witness while working at a level–one–trauma center. The horrendous deaths and injuries caused by gun violence, motorized vehicles, people in emotional distress and those suffering from chronic diseases build up on the mind as a veritable ‘scrapbook of nightmares.’ Emergency (...) providers know, in taking on this profession, that this is ‘all in a day’s work.’ Consequently, we put our selves at risk for emotional burnout as we bear witness to profound suffering while trying to improve lives.I see the traumas, the end–of–life decision making thrust upon families amidst a medical crisis and the other aspects of emergent suffering as bails of hay, against which I tried to build coping mechanisms in order to experience them but also be able to let go. For the most part I am confident to report that I have been able to work through major traumatic situations without belaboring the emotional residue. What I have failed to notice though are not the bails of hay, but individual straws of which they are made.A straw that nearly broke my back came to my pediatric emergency room as a 9–year–old girl who was involved in a low speed motor vehicle collision. She was restrained in the passenger seat; and although she was walking at the scene and crying, she was backboarded by EMS and placed in a cervical spine brace. On arrival to our emergency department she presented with normal vital signs and mutation. Her only complaint was diffuse abdominal pain. We preformed a FAST (Focused Assessment with Sonography for Trauma) exam, which was negative for free abdominal blood. Despite our efforts to make the patient comfortable, we were unable to ease her pain. The patient reported that her pain decreased after we took her off the backboard, but she still did not feel herself.Our attending and resident physicians decided that this child should have an abdominal computed tomography scan (CT) to rule out organ damage with subsequent bleeding. According to hospital protocol, this decision was within our standards of care. I stood by the family when the physician team discussed the plan of care and noticed the parents’ collective body language, which was troubled. I left the room with the physicians but not long after, the family subtly requested that I speak with them.The family was concerned about the radiation to which their child would be exposed. At the same time, they too were concerned about her abdominal pain and understood that a CT could confirm serious abdominal injury. They knew the gravity of the worst–case scenario and wanted to do what was best for their child.The mother asked me if this girl were my child what would I do.My first thought was: No CT, go home, watch her and return if symptoms worsen. My second thought conflicted with the first as I realized this was instruction that fell out of protocol differing from the opinions of the physician team. I paused before responding and found myself sputtering some pointless information about CT scans and mechanisms of injuries sustained from car accidents—I [End Page E9] was filling space, avoiding their question as I pondered the best answer.The girl’s parents told me that one was leaning towards the CT and the other against, they wanted my advice to make a decision. They pressed me saying, “What would you do.” Although I felt an uneasiness and nausea in that moment, I told them my truth, which was that I would go home without the CT.The family appeared relieved and I felt the sensation of stress leaving my body as if I had just taken a deep breath. Contented, but a daughter still with abdominal pain, the family left that evening with specific instructions to watch for adverse symptoms.In that moment, I felt like I had done the right thing but by the end of my shift I left work questioning my choice. I lost sleep that night because of... (shrink)

Like most EM physicians presented with a wide assortment of patients I've never seen before, will probably never see again, and cannot schedule for a more convenient return visit when there are not three ambulances pulling up to the door, I sometimes get a bit cranky when I interview a patient who has registered for a less‐than‐valid “emergency.” As a resident in Mel Konner's Becoming a Doctor put it, “Low back pain? Low fucking back pain? You're (...) waking me up for low fucking back pain?” Although I ceased a long time ago to ask, “Why now?”—you almost never get an answer that is satisfying—I still think it. Often, I am sad to say. Perhaps it is a result of the obvious forces of callousness born of distance born of training and of stress. Again, Konner captures it well: “It is obvious … that the stress of clinical training alienates the doctor from the patient, that in a real sense the patient becomes the enemy. … At first I believed that this was an inadvertent and unfortunate concomitant of medical training, but I now think that it is intrinsic. Not only stress and sleeplessness but the sense of the patient as the cause of one's distress contributes to the doctor's detachment.” Such detachment can blinker our eyes from seeing why patients come to the emergency room and prevent our ears from hearing. (shrink)

In recent years, the opioid crisis in the United States has sparked significant discussion on doctor–patient interactions concerning chronic pain treatments, but little to no attention has been given to investigating the vocal aspects of patient talk. This exploratory sociolinguistic study intends to fill this knowledge gap by employing prosodic discourse analysis to examine context-specific linguistic features used by the interlocutors of two distinct medical interactions. We found that patients employed both low pitch and creak as linguistic resources (...) when describing chronic pain, narrating symptoms and requesting opioids. The situational use of both features informs us about the linguistic ways in which patients frame fraught issues like chronic pain in light of the current opioid crisis. This study expands the breadth of phonetic analysis within the domain of discourse analysis, serving to illuminate discussions surrounding the illocutionary role of the lower vocal tract in expressing emotions. (shrink)

Previous studies examining EEG and LORETA in patients with chronic pain discovered an overactivation of high theta and low beta power in central regions. MEG studies with healthy subjects correlating evoked nociception ratings and source localization described delta and gamma changes according to two music interventions. Using similar music conditions with chronic pain patients, we examined EEG in response to two different music interventions for pain. To study this process in-depth we conducted a mixed-methods case (...) study approach, based on three clinical cases. Effectiveness of personalized music therapy improvisations versus preferred music on chronic pain was examined with 16 participants. Three patients were randomly selected for follow-up EEG sessions three months post-intervention, where they listened to recordings of the music from the interventions provided during the research. To test the difference of EM versus preferred music, recordings were presented in a block design: silence, their own composed EM, preferred music, and a non-participant’s EM as a control. Participants rated their pain before and after the EEG on a 1–10 scale. We conducted a detailed single case analysis to compare all conditions, as well as a group comparison of entrainment-healing condition versus preferred music condition. Power spectrum and according LORETA distributions focused on expected changes in delta, theta, beta, and gamma frequencies, particularly in sensory-motor and central regions. Intentional moment-by-moment attention on the sounds/music rather than on pain and decreased awareness of pain was experienced from one participant. Corresponding EEG analysis showed accompanying power changes in sensory-motor regions and LORETA projection pointed to insula-related changes during entrainment-pain music. LORETA also indicated involvement of visual-spatial, motor, and language/music improvisation processing in response to his personalized EM which may reflect active recollection of creating the EM. Group-wide analysis showed common brain responses to personalized entrainment-healing music in theta and low beta range in right pre- and post-central gyrus. We observed somatosensory changes consistent with processing pain during entrainment-healing music that were not seen during preferred music. These results may depict top–down neural processes associated with active coping for pain. (shrink)

BackgroundMental stress and imbalance of its two neural stress systems, the autonomic nervous system and the hypothalamic–pituitary–adrenal axis, are associated with chronic prostatitis/chronic pelvic pain syndrome and erectile dysfunction. However, the comprehensive analyses of psychological stress and stress systems are under-investigated, particularly in CP/CPPS patients complicated by lower urinary tract symptoms and ED.Materials and methodsParticipants were 95 patients in CP/CPPS+ED group, 290 patients in CP/CPPS group, 124 patients in ED group and 52 healthy men in control group. (...) The National Institutes of Health Chronic Prostatitis Symptom Index, the International Index of Erectile Function-5 and the International Prostate Symptom Score were used for assessing the disease severity of CP/CPPS, LUTS and ED. Psychometric self-report questionnaires including the Beck Anxiety Inventory, Perceived Stress Scale, Type A Personality Test and Symptom Checklist 90 were completed for distress from physical symptoms. Twenty-five subjects per group were randomly selected for further investigating the changes of the HPA axis and ANS. Saliva samples were taken on 3 consecutive days at 8 specific times with strict reference to time of morning awakening for evaluation of free cortisol. Heart rate variability as marker of the ANS was measured using 24 h electrocardiography, and time-and frequency-domain variables were analyzed.ResultsThe BAI and SCL-90 scores were significantly higher in the CP/CPPS+ED, CP/CPPS and ED groups compared with the control group. The PSS scores of both groups with ED were significantly higher than the control group. Compared with the CP/CPPS group, the differences of PSS, SCL-90 and TAPT scores were statistically significant in CP/CPPS+ED patients. The IPSS scores were shown to have significantly positive correlations with BAI, PSS and SCL-90 in the CP/CPPS patients. However, in all subjects, the IIEF-5 scores were shown to have significantly negative correlations with BAI, PSS, SCL-90 and quality of life score in NIH-CPSI. Cortisol awakening response parameters and diurnal cortisol levels did not significantly vary between the four groups. Time-dependent parameters of HRV also did not differ significantly across groups. In the frequency domain analysis, low frequency was significantly lower in ED patients when compared with CP/CPPS+ED patients and healthy controls, high frequency power was significantly higher in healthy controls compared to patients with ED, CP/CPPS and CP/CPPS+ED, and the CP/CPPS+ED group had significantly higher LF/HF ratio than the control group.ConclusionCP/CPPS and ED patients score exceedingly high on most psychosocial variables. The symptom scores of LUTS and ED positively correlate with the severity of psychological stress. Our findings also suggest that the ANS sympathovagal imbalance is associated with ED and LUTS in CP/CPPS, whereas HPA axis activity is not. (shrink)

The prevalence of obesity skyrocketed over the past decades to become a significant public health problem. Obesity is recognized as a low-grade inflammatory disease and is linked with several comorbidities such as diabetes, circulatory disease, common neurodegenerative diseases, as well as chronic pain. Adipocytes are a major neuroendocrine organ that continually, and systemically, releases pro-inflammatory factors. While the exact mechanisms driving obesity-induced pain remain poorly defined, nociceptors hypersensitivity may result from the systemic state of inflammation characteristic of (...) obesity as well as weight surplus-induced mechanical stress. Obesity and pain also share various genetic mutations, lifestyle risk factors, and metabolic pathways. For instance, fat pads are often found hyper-innervated and rich in immune cell types of multiple origins. These immunocytes release cytokines, amplifying nociceptor function, which, in turn, via locally-released neuropeptides sustain immunocytes’ function. Here, we posit that along with mechanical stressed stemming from extra weight, the local neuro-immune interplay occurring within the fat pads maintains the state of chronic low-grade inflammation and heightens sensory hypersensitivity. Overall, stopping the harmful neuro-immune crosstalk may constitute a novel pathway to prevent obesity-associated comorbidities, including neuronal hypersensitivity. (shrink)

In lieu of an abstract, here is a brief excerpt of the content:Pains And Gains Of Rural Health Practice:Lessons Books Never TaughtSridevi Seetharam, Bindu Balasubramaniam, G. S. Kumar, and M. R. SeetharamHow The Journey BeganIn the early 1980s, as fresh graduates from Mysore Medical College in southern India, we were brimming with a zeal to "cure the sick" and "change the world." We had an ideal of evidence-based, rational, ethical and equitable health care and set out to serve rural and (...) under-served communities which included displaced forest-based tribes. In the initial years, with the naivety of the inexperienced, we believed that by correcting the dehydration of the doe-eyed six-year-old Mare and giving her a free course of antibiotics, we had made health care accessible to her. Much to our dismay, within a month, Mare was back in the outpatient clinic, with diarrhea all over again and looking thinner than ever. We realized that it was a losing battle to keep her healthy as long as she continued to drink water from the same contaminated stream, live in unhygienic surroundings, and eat only the paltry meals that her family could barely afford. We gradually began to connect these living examples to what our preventive medicine text books had stressed all along—there are many social determinants of health which, if left unaddressed, do not permit realization of the vision of health for all.Such instances continually pulled us out of the hospital building and into the villages and tribal hamlets. We discovered that our textbook of Preventive and Social Medicine (Park, 1986) (P&SM as we used to call it), was our most valuable possession. [End Page 106] We devoured the descriptions of national health programs, sanitation procedures, water treatment protocols, and maintenance of cold chain for vaccines with a completely new perspective. We discovered the Manual of Basic Techniques for a Health Laboratory, (World Health Organization, 1980) detailing how to set up a laboratory with low cost, reliable and simple methods. We learned to drive a jeep to haul supplies and patients. To step up the level of clinical care, some of us pursued post-graduate programs and equipped ourselves to provide more specialized care too. It has been over two decades since we embarked on this journey. We have encountered a variety of perplexing dilemmas with no clear solutions. We have sometimes been compelled to adopt health practices that were not really evidence-based, seemingly irrational, inequitable and even downright unethical. This narration describes only a few of our thousands of cases, and hopefully conveys our periods of self-doubt, despair and hope, as well as, the challenges we face to reconcile with the difficult choices we are forced to make every day.Unforeseen Challenges in Saving Mothers and ChildrenHigh maternal and child mortality rates have been one of the most disturbing aspects of the health care scenario in rural India. To ensure immunization of all children, health workers with vaccine carriers go from village to village and hamlet to hamlet to reach those infants that would have missed visits to the immunization clinics. Our grass-root workers facilitate these visits by identifying households with such children. Occasionally, they encounter families who spirit away the infant into the adjoining woods as soon as the health worker is seen approaching, and blandly proclaim that the child is not at home. Despite reassurance and counseling about the safety and necessity of the vaccine, their apprehensions and misconceptions are insurmountable. What is the extent of the responsibility of the health worker? Is it ethical to hunt down the child and force the administration of the vaccine in view of the public health gains, besides the child's welfare?A few months ago, a pre-term neonate was admitted to our hospital, but worsened and needed referral to a higher centre in the city. The family refused to go despite repeated persuasion and detailed explanation about the technical limitations of care at our centre. From the family's perspective, the variety of social, cultural, and monetary challenges they would face in the city were themselves limitations for care. We were compelled to retain the baby and continue giving the best care we could.Two... (shrink)

Primary headaches are highly prevalent and represent a major cause of disability in young adults. Neurofeedback is increasingly used in the treatment of chronic pain; however, there are few studies investigating its efficacy in patients with headaches. We report the results of a cross-over sham-controlled study on the efficacy of neurofeedback in the prophylactic treatment of tension-type headache. Participants received ten sessions of infra-low frequency electroencephalographic neurofeedback and ten sessions of sham-neurofeedback, with the order of treatments being randomized. (...) The study also included a basic psychotherapeutic intervention — a psychoeducational session performed before the main study phases and emotional support provided throughout the study period. The headache probability was modeled as a function of the neurofeedback and sham-neurofeedback sessions performed to date. As a result, we revealed a strong beneficial effect of neurofeedback and no influence of the sham sessions. The study supports the prophylactic use of infra-low frequency neurofeedback in patients with TTH. From a methodological point of view, we advocate for the explicit inclusion of psychotherapeutic components in neurofeedback study protocols. (shrink)

Music reduces pain in fibromyalgia (FM), a chronic pain disease, but the functional neural correlates of music-induced analgesia (MIA) are still largely unknown. We recruited FM patients ( n = 22) who listened to their preferred relaxing music and an auditory control (pink noise) for 5 min without external noise from fMRI image acquisition. Resting state fMRI was then acquired before and after the music and control conditions. A significant increase in the amplitude of low frequency fluctuations (...) of the BOLD signal was evident in the left angular gyrus (lAnG) after listening to music, which in turn, correlated to the analgesia reports. The post-hoc seed-based functional connectivity analysis of the lAnG showed found higher connectivity after listening to music with right dorsolateral prefrontal cortex (rdlPFC), the left caudate (lCau), and decreased connectivity with right anterior cingulate cortex (rACC), right supplementary motor area (rSMA), precuneus and right precentral gyrus (rPreG). Pain intensity (PI) analgesia was correlated ( r = 0.61) to the connectivity of the lAnG with the rPreG. Our results show that MIA in FM is related to top-down regulation of the pain modulatory network by the default mode network (DMN). (shrink)

Receiving a diagnosis of cancer can be devastating. Cancer continues to be one of the most feared diagnoses, and experiencing pain is a major fear for people diagnosed with cancer. Cancer pain is complex in aetiology and can be acute or chronic and can be caused by various compression, ischaemic, neuropathic or inflammatory processes. Many people with cancer will experience excruciating pain, which is often underreported and undertreated. The reasons for this are complex and include various (...) factors including fears and beliefs held by patients. Cognitive factors are important modulators of pain and the appraisals, meanings and beliefs that people have in relation to illness, cancer, and pain, have implications in regard to help-seeking behaviours and the coping strategies people adopt. Cancer pain can impact a range of psycho-social factors across its course. Cancer pain relates to higher rates of psychological distress, anxiety and low mood, and the perception of pain intensity is, in turn, influenced by psychological factors. Cancer pain can negatively affect psychological health, and psycho-social factors can affect the pain experience. It has been suggested that people with a life-limiting illness experience ‘total pain’, and this can encompass psychological, social, practical, spiritual domains. Research demonstrates that cancer is predominantly an illness affecting older people, yet there is a higher risk of under-treated pain in this age group and there is a paucity of research into the subjective experiences of older people managing their cancer pain. Many older people are required to self-manage cancer pain at home as outpatients, due to drivers to keep people out of inpatient care, such as the high healthcare costs of inpatient treatment, and patients wanting to manage their illness, and die, at home. Our own research into this area found that the self-management of cancer pain involves a sequential and temporal process, which centres on perceptions of control. We describe how the older people in our study experienced a perceived loss of control, followed by a sense of gaining control over pain through various experience of certain internal and external factors. The assessment and treatment of physical pain should be done in combination with assessment and treatment of psycho-social and spiritual pain, and interventions for cancer pain need to focus on increasing positive affect and reducing helplessness. No person should suffer with poorly controlled pain and we argue for the need for further research in this area to ensure adequate treatment for all.Clinical Implications: Assessment and treatment of physical pain in people with cancer needs to be conducted in combination with assessment and treatment of psycho-social issues and spiritual pain. Psychological and behavioural approaches have strong evidence supporting their efficacy for reducing cancer pain. Interventions should target helplessness and focus on increasing positive affect through positive psychological states including fighting spirit and resilience. Person-centred interventions that focus on helping people with the search for meaning may help those with cancer pain derive positive benefits. (shrink)