Value Demonstrated of Cognitive-Behavioral Therapy in Perioperative Pain Management
The authors hypothesized that cognitive-behavioral therapy (CBT) might reduce preoperative pain catastrophizing and improve postsurgical pain outcomes.
They conducted a randomized controlled trial of patients undergoing elective total knee arthroplasty between January 2013 and March 2020 in 2 phases.
In phase 1, the change in the Pain Catastrophizing Scale (PCS) scores among 4- or 8-week telehealth, 4-week in person, and no-CBT sessions was compared in 80 patients with a PCS score greater than 16. In phase 2, the proportion of patients who achieved a 3-month decrease in the Western Ontario and McMaster Osteoarthritis Index (WOMAC) pain subscale greater than 4 after 4-week telehealth with no-CBT controls were compared in 80 subjects.
They found that, in phase 1, 4-week telehealth CBT had the highest completion rate 17/20 (85%), demonstrated an adjusted median reduction in the PCS of -9 (95% confidence interval -1 to -14, P < 0.01) compared with no-CBT, and was noninferior to 8-week telehealth CBT. In phase 2, 29 of 35 (83%) in the 4-week telehealth CBT and 26 of 33 (79%) subjects in the no-CBT demonstrated a decrease in the WOMAC pain subscale greater than 4 at 3 months.
They concluded that the findings indicate that CBT interventions before surgery either in person or via telehealth can reduce PCS scores; however, this reduction did not lead to improved 3-month pain outcomes.
Trial registration: ClinicalTrials.gov (NCT01772329), registration date January 21, 2013. (See Buvanendran A, Sremac AC, Merriman PA, et al. Preoperative cognitive-behavioral therapy for reducing pain catastrophizing and improving pain outcomes after total knee replacement: a randomized clinical trial [published online ahead of print January 15, 2021]. Reg Anesth Pain Med. doi:10.1136/rapm-2020-102258.)
Mindfulness-Based Stress Reduction for Migraine, Compared With Headache Education
Mindfulness-based stress reduction (MBSR) improved disability and depression in patients with migraine, but did not reduce the frequency of migraine, when compared to headache education.
The authors conducted a randomized clinical trial in 89 patients of MBSR meditation versus headache education. All patients experienced 4 to 20 migraine days per month. Participants were blinded as to active versus comparator group assignments and principal/investigator/data analysts (to group assignment).
Participants underwent MBSR (standardized training in mindfulness and yoga) or headache education (migraine information) delivered in groups that met for 2 hours each week for 8 weeks.
Participants were mainly female (92%) with a mean age of 44 years with an average of 7 migraines per month and high disability. Follow-up was 32 to 36 weeks.
Participants in both groups had fewer migraine days at 12 weeks (MBSR: -1.6 migraine days per month; 95% confidence interval, -0.7 to -2.5; headache education: -2.0 migraine days per month; 95% confidence interval, -1.1 to -2.9). Those who participated in MBSR had improvements from baseline at all follow-up time points including measures of disability, quality of life, self-efficacy, pain catastrophizing, and depression scores and decreased experimentally induced pain intensity and unpleasantness.
The authors concluded that MBSR did not improve migraine frequency more than did the use of headache education, as both groups had similar decreases. However, MBSR showed significant improvement in other factors out to 36 weeks. Thus, although MBSR may help total migraine burden, larger studies are indicated.
Trial registration: ClinicalTrials.gov Identifier: NCT02695498. (See Wells RE, O'Connell N, Pierce CR, et al. Effectiveness of mindfulness meditation vs headache education for adults with migraine: a randomized clinical trial [published online ahead of print December 14, 2020]. JAMA Intern Med. doi:10.1001/jamainternmed.2020.7090.)
Chronic Pain Leads to Cognitive Dysfunction in the Elderly, Study Shows
Chronic pain (CP) has been associated with impaired cognitive performance in several cross-sectional studies conducted in older adults. However, other studies have questioned these findings and the link remains debated.
Using a present analysis, the authors reviewed the relationship between CP and the change in several tests assessing memory, attention, verbal fluency, and processing speed. The study population was selected from the PAQUID study, a cohort of community dwellers 65 years and older, including 693 subjects who received a pain assessment.
CP was evaluated using a questionnaire administered at 3-year follow-up. Cognitive performances were assessed every 2 to 3 years between 3 and 15 years.
Assessments included general cognition (Mini-Mental State Examination), verbal and visual memory (word paired-associate test and Benton test), attention and speed processing (Wechsler Digit Symbol Substitution Test and Zazzo's Cancellation Task), and language skills and executive functions (Isaacs Set Test). Latent process mixed models controlled for age, sex, education, comorbidities, depression, and analgesic drugs were used to determine a link between CP and any changes in cognitive function. Any association between CP and each of the cognitive scores was then tested with the same procedure.
The researchers found a significant relationship between CP and poorer 15-year scores on global cognitive performance (P = 0.004). Specifically, the Digit Symbol Substitution Test (P = 0.002) was associated with a higher slope of decline (P = 0.02). Also, CP was found to be associated with a higher cognitive decline, particularly in processing speed.
These findings reinforce the importance of actively treating CP with pharmacological and nonpharmacological strategies to prevent adverse cognitive consequences. (See Rouch I, Edjolo A, Laurent B, et al. Association between chronic pain and long-term cognitive decline in a population-based cohort of elderly participants. Pain. 2021;162(2);552-560. doi:10.1097/j.pain.0000000000002047.)
Update on 2012 Review of Virtual Reality Pain Research
Virtual reality (VR) applications have emerged as nonpharmacological alternatives or adjuncts for acute and chronic pain management, with the potential to reduce the need for opioid medications.
VR pain research is being increasingly applied to a wide range of acute and chronic pain conditions. The rise in this research is spurred by rapid technological advancements and creative deployment of VR capabilities, with developments in the areas of embodiment and manipulation of virtual cues to address pain-related targets.
However, this relatively young field needs replication and standardization to form a theoretical framework to facilitate purposeful progress, not driven solely by technology. The heuristic model offered by the current review aims to facilitate a language and critical examination of the key elements that drive VR effects on pain experience.
In this update, the authors examined the previous review with a critical assessment of the current state of VR applications to pain. The article starts by defining VR and summarizing evidence for its utility in addressing acute and chronic pain.
The authors identify pressing scientific gaps and promising future directions, all to provide a broad overview and theoretical synthesis of the field today-rather than a systematic review or meta-analysis, albeit with 106 references.
The review begins at http://links.lww.com/PAIN/B180 and summarizes the identified literature based on searches of MEDLINE (through PubMed) and Google Scholar with primary search terms of "virtual reality AND pain" and "virtual reality AND pain AND therapy" and "virtual reality AND pain management."
The search included systematic reviews, narrative reviews, meta-analyses, and empirical articles. Where available, Table S1 also provided ratings of methodological rigor for individual studies based on previous systematic reviews (available as supplemental digital content at http://links.lww.com/PAIN/B180). (See Trost Z, France C, Anam M et al. Virtual reality approaches to pain: toward a state of the science. Pain. 2021;162(2); 325-331. doi:10.1097/j.pain.0000000000002060.)
Call for Contributors
Topics in Pain Management (TPM) is seeking original manuscripts that provide new research, clinical reviews, case studies, or professional development information relevant to multidisciplinary pain management health care practitioners.
Article types include:
* Clinical review (4000-7000 words): a review of clinical literature addressing a specific problem, providing information and supported recommendations that include relevant educational activity. Include 10 questions for a CME/CE quiz.
* Scientific report (3000-5000 words)
Examples include:
* Disseminating pain research methods and/or findings (including from pilot work, methods, and research protocols)
* Pilot studies emphasizing feasibility, not estimation of efficacy, and providing implications for next phase of research
* Methodological and research protocols focusing on the methods used for large-scale pain research studies
If appropriate, TPM will request 10 continuing education quiz questions from the author(s) of a scientific report.
* Case studies (1000-1500 words per case): a single case or multiple cases pertinent to pain management practice
For more information, go to http://www.TopicsInPainManagement.com or email Anne Haddad, Associate Editor, at mailto:[email protected].