Search

Context The OSTEOPATHIC Trial demonstrated substantial improvement in pain intensity, decreased need for rescue medication for pain, and greater likelihood of recovery in patients with chronic low back pain who received 6 osteopathic manipulative treatment (OMT) sessions over 3 months. Objective To assess osteopathic medical care and the effectiveness of OMT for chronic low back pain in a real-world setting without the constraints of a rigid research protocol. Methods An observational study of 445 adults with chronic low back pain who had an established osteopathic physician (ie, DO) or allopathic physician (ie, MD) was conducted within the PRECISION Pain Research Registry from April 2016 through February 2019. Primary outcome measures included a numerical rating scale for low back pain intensity, the Roland-Morris Disability Questionnaire for back-related functioning, and use of nonsteroidal anti-inflammatory drugs or opioids for low back pain. Results A total of 79, 48, and 318 patients, respectively, were treated by DOs who used OMT, DOs who did not use OMT, or MDs. Patients treated by DOs who used OMT reported significantly lesser low back pain intensity (mean numerical rating score, 5.6; 95% CI, 5.1-6.1 vs 6.1; 95% CI, 5.9-6.3; P=.04) and back-related disability (mean Roland-Morris Disability score, 12.4; 95% CI, 11.1-13.8 vs 14.4; 95% CI, 13.7-15.0; P=.009) than patients treated by MDs. Patients treated by DOs who used OMT also reported less frequent use of nonsteroidal anti-inflammatory drugs (multivariate odds ratio, 0.41; 95% CI, 0.24-0.70; P=.001) or opioids (multivariate odds ratio, 0.52; 95% CI, 0.28-0.98; P=.04). There were no significant differences in primary outcomes between DOs who did not use OMT and MDs. Conclusion This study of community-based patients in a pain research registry supports the effectiveness of OMT as an integral component of osteopathic medical care for chronic low back pain. Patients treated by DOs who did not use OMT did not experience better results than patients treated by MDs in any primary outcome measure. Further research is needed to more specifically compare the effects of OMT with other treatment effects that may be attributed to patient-DO interactions during medical encounters.

The goal of this research is to find an optimal adaptive treatment strategy to assist physicians in prescribing treatments for patients with chronic pain. This research proposes a two-stage stochastic programming (2SP) method to optimize a treatment procedure for interdisciplinary pain management. The 2SP model incorporates non-convex nonlinear mixed integer constraints, which are constructed based on data from a real pain management program. We derive a piecewise linear approximation method to approximate the non-convex nonlinear constraints in the 2SP model. Consequently, we formulate an equivalent mixed integer linear programming (MILP) model and then solve it using a commercial mixed-integer programming solver. A comparison of the policies generated by the MILP model with the policies generated by the original nonlinear 2SP model shows that, given limited CPU time, the policies generated by the MILP model outperform those of the original nonlinear 2SP model.

ObjectiveChronic musculoskeletal pain disorders (CMPDs) are among the leading causes of disabilities across populations, resulting in high social and financial burden. This persistent pain condition may include the central sensitization (CS) phenomenon, which implies a wide range of symptoms and that may be taken into account in CMPD treatment. CS symptoms can be measured by the Central Sensitization Inventory (CSI). The aims of the study were to describe CS symptoms in patients suffering from several CMPDs and to analyze differences due to gender, age, and body mass index (BMI).DesignThis cross-sectional study recruited a total of 395 Spanish participants suffering from several CMPDs.SettingCS symptoms were measured with the Spanish Version of the CSI. The total score (0–100) and a cutoff score of 40 were recorded.SubjectsA total of 395 participants were included.ResultsThe mean CSI total score for the whole sample was 24.6 ± 12.0 points. CSI total score had subclinical values in the whole sample, whereas participants with scores >40 were found across different CMPDs, such as low back pain (37.8%) and neck pain (32.4%); 14.6% of females and 1.7% of males presented CSI scores >40. Patients showed significant differences in CSI cutoff point by gender (P = 0.010) and CSI total score by age (P = 0.014).ConclusionsGiven the high prevalence of clinically relevant CSI scores (>40) in people with a CMPD, especially low back pain and neck pain, we recommend that clinicians supplement their assessment with the CSI for improved decision-making during treatment.

A highly effective modern method of curbing or better management of chronic pain is now better understood and utilized by the medical community: interdisciplinary pain management program (IPMP). As modern medical professionals continue to move away solely from prescribing opioids for the treatment of chronic pain, the efficacious and continuously improving methods of interdisciplinary pain rehabilitation will almost certainly continue to grow in popularity. An IPMP always incorporates a structured and unified team of various mental and physical health professionals who regularly meet and update one another on individual patients. Typically, these programs are structured in order to address the rehabilitation and continuous monitoring and progress of patients, often those who suffer from pain conditions. Therefore, IPMP teams will carefully track patient progress and outcomes, often for years after completing direct treatment. Within this Chapter, a more thorough overview of striving for better and new pain rehabilitation due to the opioid crisis will be addressed. An overview of the concept, background, professional roles, distinctions from multidisciplinary care, case studies, and implementations of interdisciplinary medicine focused on chronic pain management and suggestions for future improvements in the fields will also be explored.

Central Sensitization (CS) involves the amplification of neural signaling within the central nervous system, which evokes pain hypersensitivity. The Central Sensitization Inventory (CSI) assesses 25 overlapping health-related symptom dimensions that have been found to be associated with CS-related disorders. Previous studies have found satisfactory test-retest reliability and internal consistency, but factor analyses have exhibited conflicting results in different language versions. The purpose of this cross-sectional study was to thoroughly examine the dimensionality and reliability of the CSI, with pooled data from 1,987 individuals, collected in several countries. The principal component analysis suggested that one general factor of CS best described the structure. A subsequent confirmatory factor analysis revealed that a bifactor model, which accounted for the covariance among CSI items, with regard to one general factor and four orthogonal factors, fit the CSI structure better than the unidimensional and the four-factor models. Additional analyses indicated substantial reliability for the general factor [i.e. Cronbach α= 0.92; Omega ω= 0.95; and omega hierarchical ω-h= 0.89]. Reliability results for the four specific factors were considered too low to be used for subscales. The results of this study clearly suggest that only total CSI scores should be used and reported.PERSPECTIVE: As far as we know, this is the first study that has examined the factor structure and reliability of the Central Sensitization Inventory (CSI) in a large multi-country sample. The CSI is currently considered the leading self-report measure of central sensitization-related symptoms worldwide.

Interdisciplinary pain management combines multiple disciplines of professionals to understand the biological and psychosocial factors causing a patient's pain and to determine the best tre...

Background Context The Central Sensitization Inventory (CSI) is a valid and reliable patient-reported instrument designed to identify patients whose presenting symptoms may be related to central sensitization (CS). Part A of the CSI measures a full array of 25 somatic and emotional symptoms associated with CS, and Part B asks if patients have previously been diagnosed with one or more specific central sensitivity syndromes (CSSs) and related disorders. The CSI has previously been validated in a group of patients with chronic pain who were screened by a trained psychiatrist for specific CSS diagnoses. It is currently unknown if the CSI can be a useful treatment-outcome assessment tool for patients with chronic spinal pain disorder (CSPD) who are not screened for comorbid CSSs. It is known, however, that previous studies have identified CS-related symptoms, and comorbid CSSs, in subsets of patients with CSPDs. Studies have also shown that CS-related symptoms can be influenced by cognitive and psychosocial factors, including abuse history in both childhood and adulthood, sleep disturbance, catastrophic and fear-avoidant cognitions, and symptoms of depression and anxiety. Purpose This study aimed to evaluate CSI scores, and their associations with other clinically relevant psychosocial variables, in a cohort of patients with CSPD who entered and completed a functional restoration program. Study Design/Setting A retrospective study of prospectively collected data from a cohort study of patients with CSPD, who completed the CSI at admission to, and discharge from, an interdisciplinary function restoration program (FRP) was carried out. Patient Sample A cohort of 763 patients with CSPD comprised the study sample. Outcome Measures Clinical interviews evaluated mood disorders and abuse history. A series of self-reported measures evaluated comorbid psychosocial symptoms, including pain intensity, pain-related anxiety, depressive symptoms, somatization symptoms, perceived disability, and sleep disturbance, at FRP admission and discharge. Methods Patients were grouped into five severity level groups, from mild to extreme, based on total CSI scores, at FRP admission, and then again at discharge. The FRP included a quantitatively directed and medically supervised exercise process, as well as a multimodal psychosocial disability management component. Results The CSI severity groups were strongly associated with Major Depressive Disorder and previous abuse history (p Conclusions In the present study, admission CSI scores were highly associated with previous CSS diagnoses, CS-related symptoms, and clinically relevant patient-reported psychosocial variables. All psychosocial variables, as well as scores on the CSI, were significantly improved at FRP discharge. The CSI may have important clinical utility, as a screener and as a treatment outcome measure, for patients with CSPD participating in an interdisciplinary FRP.

As chronic pain contributes to tremendous personal and societal costs, efforts at identifying and understanding pain-related disability via the biopsychosocial model have become increasingly important in addressing pain-related health outcomes. This study attempted to compare the predictive ability of the Pain Disability Questionnaire against other established measures in terms of health and pain-related outcomes. The sample consisted of 254 adult chronic pain patients seeking treatment through an interdisciplinary chronic pain management clinic. Participants were administered a battery of assessments including the Pain Disability Questionnaire and other established measures of health and pain-related outcomes (e.g., NIH PROMIS measures) at baseline and post-treatment time points. Results demonstrated convergent validity between the Pain Disability Questionnaire and the other study measures. Hierarchical regression analyses revealed significant associations between pain-related disability as measured by the Pain Disability Questionnaire and a range of biopsychosocial outcomes. Pain Disability Questionnaire scores, as placed in categorical severity levels, demonstrated good discriminative abilities in terms of predicting health-related factors. These findings support the clinical use of the Pain Disability Questionnaire as an empirically supported predictor of health-related outcomes as compared with other established measures of pain and health outcomes.

Fear-avoidance (FA) beliefs are significantly associated with the experience of pain, especially when the pain becomes chronic in nature. The anticipated threat of intense pain will often result in the constant vigilance and monitoring of pain sensations, which, in turn, can cause even low-intensity sensations of pain to become unbearable for the person. Just the anticipation of increased pain or reinjury can further stimulate avoidance behaviors. A vicious cycle may develop, in which fears of increased pain or reinjury contribute to the avoidance of many activities, leading to inactivity and, ultimately, to greater disability. Anyone who assesses and treats pain-related disability should also be prepared to assess and treat pain-related FA.

Aims: To evaluate whether a biobehavioral intervention would be more effective than a self-care intervention or no intervention in reducing psychosocial distress, reducing pain, and improving functioning in patients with an acute myofascial temporomandibular disorder (m-TMD). Methods: Participants (n = 435) were from community dental clinics in the Dallas-Fort Worth Metroplex who were seeking treatment for their acute TMD symptoms and were recruited between 2008 and 2013. The participants were diagnosed using the Research Diagnostic Criteria for TMD (RDC/TMD) and assigned to a biobehavioral intervention, self-care intervention, or no intervention. Three outcomes were assessed: psychosocial distress, pain, and functioning; and treatment effectiveness was assessed according to TMD diagnosis. Outcome evaluations were conducted immediately postintervention as well as at 1 and 2 years postintervention. Analyses were conducted using two-level hierarchical multilevel linear models (MLMs). Results: Contrary to expectations, patients did not respond differently to the intervention based on their TMD diagnosis. Acute m-TMD patients, especially those with other comorbid TMD diagnoses, reported the highest levels of pain and pain-related symptoms and disability. They also exhibited poorer jaw functioning, especially if they were at high risk for chronic TMD. Conclusion: This study indicates that acute m-TMD tends to result in more severe symptom presentations, particularly if diagnosed in combination with other TMD comorbidities. Additionally, patients do not appear to respond better to biobehavioral or self-care intervention on the basis of their TMD diagnosis.

The objectives of this study: (1) to assess whether Multidimensional Pain Inventory (MPI) profiles predicted differential responses to a functional restoration program (FRP) in chronic disabling occupational musculoskeletal disorder (CDOMD) patients; (2) to examine whether coping style improves following FRP; and (3) to determine whether discharge MPI profiles predict discharge psychosocial and 1-year socioeconomic outcomes.Consecutive CDOMD patients (N=716) were classified into Adaptive Coper (AC, n=209), Interpersonally Distressed (ID, n=154), Dysfunctional (DYS, n=310), and Anomalous (n=43) using the MPI, and reclassified at discharge. Profiles were compared on psychosocial measures and 1-year socioeconomic outcomes. An intent-to-treat sample analyzed the effect of drop-outs on treatment responsiveness.The MPI classification significantly predicted program completion (P=0.001), although the intent-to-treat analyses found no significant effects of drop-out on treatment responsiveness. There was a significant increase in the number of patients who became AC or Anomalous at FRP discharge and a decrease in those who were ID or DYS. Patients who changed or remained as DYS at FRP discharge reported the highest levels of pain, disability, and depression. No significant interaction effect was found between MPI group and time for pain intensity or disability. All groups improved on psychosocial measures at discharge. DYS patients had decreased work retention and a greater health care utilization at 1 year.An FRP was clinically effective for CDOMD patients regardless of initial MPI profiles. The FRP modified profiles, with patients changing from negative to positive profiles. Discharge DYS were more likely to have poor 1-year outcomes. Those classified as Anomalous had a good prognosis for functional recovery similar to ACs.

Measuring treatments used by 202 patients with chronic low back pain in the PRECISION Pain Research Registry, this study determined the associations of opioid and nonsteroidal anti-inflammatory drug (NSAID) therapy with clinical status. More than one-fourth of patients did not use nonpharmacologic treatments for low back pain. Patients age 50-59 and 60-79 years old were more likely to use opioids than younger patients. Patients using opioids reported greater pain and back-related disability than did patients using NSAIDs. Patients concurrently using opioids and NSAIDs reported greater back-related disability and poorer quality of life than did patients using no or other pharmacologic therapy. No significant associations between pharmacologic therapy and clinical status remained after controlling for potential confounders. Neither opioids nor opioids combined with NSAIDs were more effective than just NSAIDs. Greater use of nonpharmacologic therapies and better second-line, nonopioid pharmacologic therapies appear necessary for more effective treatment of chronic low back pain.

John C Licciardone,1 Robert J Gatchel,2 Nicole Phillips,3 Subhash Aryal4 1Department of Family Medicine, University of North Texas Health Science Center, Fort Worth, TX, USA; 2Department of Psychology, College of Science, University of Texas at Arlington, Arlington, TX, USA; 3Department of Microbiology, Immunology and Genetics, University of North Texas Health Science Center, Fort Worth, TX, USA; 4Department of Biostatistics and Epidemiology, Institute for Patient Safety, University of North Texas Health Science Center, Fort Worth, TX, USA Background: Low back pain is the leading cause of disability worldwide. Nonsteroidal anti-inflammatory drugs (NSAIDs) are recommended as the first-line pharmacologic therapy for subacute or chronic low back pain, with opioids reserved for patients who fail on NSAIDs. CYP2D6, CYP2C9, and CYP2C19 genes have variants that place patients using analgesics at risk for adverse events. However, precision medicine based on pharmacogenetically informed prescribing is becoming more feasible as genotyping costs decline. This study aims to compare opioids vs NSAIDs in treating adults with subacute or chronic low back pain under the alternative models of usual care and precision medicine.Methods: An observational cohort study within the Pain Registry for Epidemiological, Clinical, and Interventional Studies and Innovation (PRECISION) will be used to simulate a randomized controlled trial. Patients using opioids and NSAIDs will be optimally matched at baseline using propensity scores. A saliva sample will also be collected to determine patient genotypes for drug metabolism based on CYP2D6 (single-gene model) and CYP2D6, CYP2C9, and CYP2C19 (multigene model). Prescribing that is concordant with pharmacogenetically informed care under these models will be considered “low risk”, whereas discordant prescribing will be considered “high risk”. Primary outcomes will be assessed over 6months using a Numerical Rating Scale for pain, the Roland-Morris Disability Questionnaire, and the Drug Adverse Events Index. Secondary outcomes will be assessed using quality-of-life measures. An estimated 600 patients will be enrolled to acquire at least 400 patients after attrition and allowing for unmatched patients. This will achieve a statistical power of at least 80% in detecting the effect sizes ranging from 0.35 (small–medium effect) to 0.69 (medium–large effect).Discussion: This PRECISION Pain Research Registry study builds on the concepts espoused in the Precision Medicine Initiative and addresses long-term goals established by the National Institutes of Health by assessing how precision medicine may prevent and treat chronic pain. Keywords: PRECISION Pain Research Registry, low back pain, physical functioning, quality of life, opioids, codeine, nonsteroidal anti-inflammatory drugs, pharmacogenetics, precision medicine, biopsychosocial model

Background The Pain Medication Questionnaire (PMQ) assesses the risk of opioid abuse in people with non-oncological chronic pain. Methods This is a methodological study conducted at a hemotherapy centre in Recife, Pernambuco state, Brazil. A Cross-cultural adaptation was carried out by a committee of nine specialists, and we applied the PMQ to a pre-final sample of 40 individuals with sickle cell anemia, in addition to a sociodemographic and clinical questionnaire. Results The mean agreement indexes for PMQ equivalences were the following: semantic (0.996), idiomatic (0.970), experiential (0.991), conceptual (0.953), language clarity (0.991), practical relevance (0.906), and theoretical relevance (0.945). Assessment of the PMQ showed that 50% of participants obtained a score equivalent to medium risk of opioid abuse. Cronbach’s alpha coefficient for the adapted PMQ instrument was 0.705, ranging from 0.641 to 0.736 among its items. Conclusion The cross-cultural adaptation of the Pain Medication Questionnaire was satisfactory and easy to apply in the Brazilian population. It is clinically relevant, contributing professional practice and enlightening patients with sickle cell anemia on their behavioral dynamics with respect to opioid consumption. It will also contribute to teaching and research, because it is a useful tool for investigating the risk of abusive behavior in people with chronic pain.

A good understanding of age-dependent changes and modifications in brain networks is crucial for fully exploring the effects of aging on the human brain. Few reports have been found in studies of functional brain networks using functional near-infrared spectroscopy (fNIRS). Moreover, little is known about the feasibility of using fNIRS to assess age-related changes in brain connectomes. This study applied whole brain fNIRS measurement, combined with graph theory analysis, to assess the age-dependent changes in resting-state brain networks. Five to eight minutes of resting-state brain hemodynamic signals were recorded from 48 participants (18 young adults and 30 older adults) with 133 optical channels covering the majority of the cortical regions. Both local and global graph metrics were computed to identify the age-related changes of topographical brain networks. Older adults showed an overall decline of both global and local efficiency compared to young adults, as well as the decline of small-worldness. In addition, young adults showed the abundance of hubs in the prefrontal cortex, whereas older adults revealed the hub shifts to the sensorimotor cortex. These obvious shifts of hubs may potentially indicate decreases of the decision-making, memory, and other high-order functions as people age. Our results showed consistent findings with published literature and also demonstrated the feasibility of whole-head fNIRS measurements to assess age-dependent changes in resting-state brain networks.

It is seen that as the general population is rapidly aging, there is a rise in chronic illnesses. This creates much strain on many organizations dealing with the management of human resources as the number of workers to select from is declining. In this chapter, we will analyze the most effective rehabilitation among the elderly as well as taking future actions into consideration in limiting the issues when it comes to the rise in chronic illnesses with aging.

Older adults are usually defined as 60 years of age or older. Currently, there are about 35 million older Americans, which is about 12.4% of the American population. Chronic persistent pain is caused by different biopsychosocial factors; some of these factors include increased risk of falling and potential comorbid psychological issues. In the best case, all these factors need to be included in the treatment planning to create the most effective treatment available to the patients. The field of pain management has come a long way, from a simplistic biomedical approach to a more comprehensive biopsychosocial approach which requires the close interdisciplinary collaboration of healthcare professionals and patients. As the most successful treatment, the multimodal, interdisciplinary approach is established. The article describes as a general introduction the necessities for a successful treatment of chronic pain patients including the elderly. This chapter also covers several interdisciplinary treatments and what has been added or adapted as they continued to develop. This continuing shift has resulted in the transformative care model, which connects the healthcare system to the patient in a way that patients are able to continue their treatment and adhere to the treatment program through use of the Internet.

Musculoskeletal pain is the most common single type of chronic pain. That is why this chapter specifically focuses on musculoskeletal pain and disability and what it consists of. Various common forms of musculoskeletal disorders, diagnosing strategies, and treatment strategies for specific musculoskeletal disorders (i.e., low back pain, arthritis, gout, tendon injury, and carpal tunnel syndrome) are discussed. Potential causation theories for musculoskeletal disorders are reviewed as to help discover why certain patients develop musculoskeletal disorders. Musculoskeletal disorders typically involve an integrated complex interaction of many biopsychosocial factors. These complications require the need to treat in a more integrated manner, using strengths from many disciplines to give the injured worker the best chance of recovery. Even with markedly varying economic, occupational, social, and worker compensation programs, the interdisciplinary approach to treating musculoskeletal disorders has been independently confirmed as being an effective treatment method. Therefore, it is essential for treatments to incorporate biopsychosocial approaches with an interdisciplinary treatment management style, making such a symptom management approach more accessible to the patients with musculoskeletal disorders.

This chapter discusses AARP (formerly known as the American Association of Retired Persons), the largest nonprofit organization dedicated to tackling common challenges of aging individuals. As the number of individuals over the age of 65 steadily increases, the demand for more resources and services compatible with aging adults increases as well. Issues including health, hunger, income, housing, and social isolation are all barriers older adults may face. Within the contents of this chapter lie the efforts of AARP, the AARP Foundation, and their affiliates used to knock down these barriers and improve the quality of life for aging adults. The AARP Foundation is one of the four nonprofit charitable affiliates of AARP, specifically focusing to provide the basic standards of living for those older adults in need. Additional services and initiatives provided by AARP are legal aid, employment resources, and Disrupt Aging, a book helping older adults understand the aging process. Many other nonprofit organizations and their specific focuses in helping aging individuals are discussed, including the Alzheimer’s Association, the American Geriatric Society, and more. While there are many organizations dedicated to improving the quality of life of aging individuals, there will continue to be new challenges that arise.

It is seen that chronic illnesses are prevalent among elderly individuals. Not only does aging increases the probability of developing chronic illnesses due to deterioration of the body, but it also increases the difficulty in maintaining a healthy lifestyle. As the United States is in the period in which the “baby boomers” are 60+ plus the other one-half billion people around the world, the diseases and injuries among the elderly will certainly grow. Those affected need to be educated on resources to pay back the debt of chronic diseases and learn about the preventive care for lifestyle changes. Many people are unaware how expensive the treatment for chronic illnesses is because there are overlooked factors such as medication, rehabilitation, and the need for variety of healthcare professionals. There are regional program, charities, and local health services that may be able to help families financially, but unfortunately, most bills are paid through health insurances or out of pocket. In this chapter, we will compare the prevalence and incidence of diseases among the population as a whole versus those who are 60 years of age and older. We will go in depth on the top common diseases seeing among the elderly including hypertension, upper respiratory conditions, and arthritis. Without treating this mass issue during the “graying revolution,” it will lead to many significant issues like higher financial cost, more deaths, and raising concerns within families. It is essential to know exactly how these diseases develop, the methods in hindering their progression, and how to potentially manage them better when they do occur.

This chapter emphasizes recent research on quality-of-life enhancement and longevity extension in the world’s growing population of older adults. Today, advances in society, science, and medicine have made contributions to the growing life expectancy seen in citizens in most regions across the world. At the same time, a rise in chronic diseases may be contributing to diminished well-being. Due to this, it is important to understand how applications to life extension may be utilized in such a way as they contribute to the enhancement of quality of life and optimal mental and physical health in this population. Various topics related to overall wellness and longevity modification are explored in the following passages. These include a focus on studies examining the relationship between older adult health, disease, and mortality rates as they associate with location, culture, gene-environment interactions, stress, diet, exercise, and interpersonal relationships. Additionally, recent epidemiological and clinical research studies on wellness and quality of life in the growing older adult population are investigated. Finally, suggestions for future exploration on healthy life extension and enhanced well-being and practical applications for this area of research will be suggested.

Effectively managing pain in older adults often requires an interdisciplinary approach that utilizes less traditional methods such as massage therapy, myofascial release therapy, yoga, electrical muscle stimulation, acupuncture, chiropractic adjustment, hypnosis, holistic approaches, surgical interventions, plasma injections, and prolotherapy. These methods are often used in complement to one another and may also coincide with traditional physical and pharmacological interventions. In addition to developing a customized management program, older adults face unique challenges that must be considered by healthcare providers exceeding the physical experience of pain and incorporating the social and psychological aspects of the pain experience. Older adults often face additional complications with traditional physical and pharmacological therapeutic approaches as stand-alone treatments due to comorbid conditions, the number of medications taken daily, lack of social support, and financial concerns. This chapter will focus on these therapeutic options for pain management in older adults as well as emphasizing the importance and effectiveness of customizable, interdisciplinary strategies.

After the 2011 Institute of Medicine report on chronic pain, the Interagency Pain Research Coordinating Committee (IPRCC) was created to enhance research efforts among federal agencies. The IPRCC and Office of Pain Policy at the National Institutes of Health collaborated to identify gaps in knowledge and address them via a Federal Pain Research Strategy (FPRS). Interdisciplinary work groups (WGs) were established to make research recommendations in 5 areas: prevention of acute and chronic pain, acute pain and acute pain management, transition from acute to chronic pain, chronic pain and chronic pain management, and disparities in pain and pain care; cross-cutting issues were also considered. The objective was to provide guidance on current research and to make recommendations about addressing identified gaps. Findings from the Prevention of Acute and Chronic Pain WG are summarized in this article. The WG created subgroups to develop recommendations on specific aspects of prevention of acute and chronic pain, including: public education, primary prevention, secondary prevention, tertiary prevention, transition from acute to chronic pain, and cross-cutting mediators. No formal literature review was conducted; however, external advisors were available and consulted as needed. Seven key research priorities were identified. The one deemed “greatest near-term value” was to optimize public health strategies to educate patients on managing pain; that deemed “most impactful” was to determine an association between patient and intervention factors. Other recommendations were related to the epidemiology of acute pain from health care procedures, the epidemiology of acute pain from work-related injuries, safety and effectiveness of management of pain associated with health care procedures, optimizing approaches to acute postsurgical pain, and safety and effectiveness of early interventions for tertiary prevention. Stakeholders, including federally sponsored research programs, researchers, health care providers, policy makers, patients, and others should work together to implement recommendations and address important gaps. Perspective The FPRS Steering Committee created 5 WGs to identify research needs and make recommendations in key areas of research. This article reports the results of one—the Prevention of Acute and Chronic Pain group. Several research priorities emerged, and recommendations made to fill existing knowledge gaps.

Because of the great prevalence of chronic pain, it is not surprising that there have been a number of influential reports by the Institute of Medicine, National Institutes of Health, and the World Health Organization that have documented the medical, social and economic problems caused by it, and the need for better pain-management programs. The present article briefly reviews these reports, and then focuses on three important areas that need to be considered when addressing the continuing and growing epidemic of one of the most prevalent types of chronic pain [chronic low back pain (CLBP)]: the biopsychosocial model of chronic pain; the paradigm shift in medicine from a disease model to an illness model of CLBP; and a review of the treatment- and cost-effectiveness of interdisciplinary chronic pain management programs. This overview will serve as an important prelude to other topics related to low back pain included in this Special Issue of Healthcare. Topics covered will range from assessment and treatment approaches, to important psychosocial mediators/moderators such as coping and pain beliefs.

Purpose Chronic pain poses a significant problem for the US military. The benefits of self-management treatments for chronic pain are well-documented, but interpersonal responses also influence physical and psychological health and may not be addressed through self-management treatments alone. The current study examines whether perceived interpersonal responses to pain, as measured by the Multidimensional Pain Inventory (MPI), change as a result of participation in an intensive pain management program. It was hypothesized that interpersonal responses to pain would be significantly correlated to psychosocial and physical pain outcomes and that interpersonal responses to pain would change significantly for completers of a functional restoration (FR) program compared to those who were randomized to treatment-as-usual in the military medical system. Methods Forty-four participants were randomly assigned to one of two treatment groups. One treatment group received FR (n = 26) and the other group received treatment-as-usual (n = 18). Significant other responses to chronic pain were measured by the MPI (Pain 23(4):345-356, 1985). Participants also completed measures of impacted quality of life, reported disability, psychological distress, fear avoidance, pain interference, and physical activity. Results Perceived higher punishing responses from a significant other were significantly related to worse physical health-related quality of life (p = .037), work-related fear avoidance (p = .008), pain interference (p = .026), affective distress (p = .039), and pain while lifting (p = .017). Perceived higher solicitous responses from significant others were significantly associated with lower mental health-related quality of life (p = .011), household activity (p = 017), general activity (p = .042), self-reported disability (p = .030), lifting capacity (p = .005), and aerobic capacity (p = .009). Conclusions While findings are preliminary and of limited scope, it appears that the perception of significant others' responses may be impacted by psychosocial and physical pain outcomes and may change after treatment. More work in this area is needed to uncover the benefits one might achieve when a significant other is included within the FR treatment framework.

The aim of this study was to determine the ability of the central sensitization inventory (CSI), a new screening instrument, to assist clinicians in identifying patients with central sensitivity syndromes (CSSs).Patients from a psychiatric medical practice (N=161), which specialized in the assessment and treatment of complex pain and psychophysiological disorders, were assessed for the presence of a CSS. CSI scores, using a previously determined cutoff of "40" of "100," were compared between the CSS patient group (n=99) and the non-CSS patient group (n=62). Information on false positives, false negatives, true positives, and true negatives were analyzed, and sensitivity and specificity analyses were conducted. In addition, CSS-relevant variables such as depression, abuse, and substance abuse were examined.A large percentage of CSS patients had comorbid major depressive disorder (80%) and abuse history (43%), which was higher than rates for the patients without a CSS (55% and 24%, respectively). The CSI correctly identified 82.8% (n=82) of CSS patients as having a CSS (ie, sensitivity) and 54.8% (n=28) of non-CSS patients as not having a CSS (ie, specificity). False-positive patients (not diagnosed with a CSS, but scoring40 on the CSI) reported more severe pain, interference in daily functioning, and abuse history, compared with the non-CSS patients who scored below 40 (ie, true negatives).The CSI is a useful and valid instrument for screening patients for the possibility of a CSS, although the chances of false positives are relatively high when evaluating patients with complex pain and psychophysiological disorders.

Objectives The patient health questionnaire (PHQ) is designed for screening psychopathology in primary care settings. However, little is known about its clinical utility in other chronic pain populations, which usually have high psychiatric comorbidities. Design A consecutive cohort of 546 patients with chronic disabling occupational musculoskeletal disorder (CDOMD) was administered and compared upon psychosocial assessments, including the PHQ and a structured clinical interview for DSM-IV (SCID). Four PHQ modules were assessed: major depressive disorder (MDD), generalized anxiety disorder (GAD), panic disorder (PD), and alcohol use disorders (AUD) [including both alcohol abuse and dependence]. Based on the SCID diagnosis, sensitivity and specificity were determined. Results The specificity of the PHQ ranged from moderate to high for all 4 PHQ modules (MDD, 0.79; GAD, 0.67; PD, 0.89; AUD, 0.97). However, the sensitivity was relatively low: MDD (0.58); GAD (0.61); PD (0.49); and AUD (0.24). The PHQ was also associated with psychosocial variables. Patients whose PHQ showed MDD, GAD, or PD reported significantly more depressive symptoms and perceived disability than patients who did not (Ps

Anchor- and distribution-based methods were combined to evaluate and establish minimally important differences (MIDs) for two Patient-Reported Outcomes Measurement Information System (PROMIS) measures in an outpatient chronic pain population. These included the computer-adaptive test (CAT) versions of two PROMIS measures: Depressive Symptoms and Anxiety-Related Symptoms (PROMIS; Cella, Gershon, Lai & Choi). Participants (n = 170) undergoing a behavioral medicine evaluation in an interdisciplinary pain management clinic completed two PROMIS CATs and multiple clinical anchor measures/questions. Modeled after similar analyses (Yost, Eton, Garcia, & Cella), three a priori criteria were used to select usable cross-sectional anchor-based MID estimates; these included a minimum Spearman correlation of .3 between the PROMIS measure and anchor item/categories, a minimum comparison group sample size of 10 within each anchor, and an effect size between .2 and .8 for each anchor-based estimate. For each PROMIS measure, the mean standard error of measurement was calculated and incorporated into MID analyses. Using a large sample (n = 170), a number of the cross-sectional T-score anchor-based MID estimates (57%) were not included due to failure to meet a priori criteria. Based on the analyses, the following T-score MID ranges are recommended: Depression CAT (3.5–5.5) and Anxiety CAT (3.0–5.5). The average effect sizes for MID estimates ranged from .32 to .57. This study is among the first to address MIDs for PROMIS measures; it is the first study to establish usable MIDs for psychological symptoms on outpatients with chronic/persistent pain. The results may be used to gauge minimally important clinical difference and/or treatment response for individuals within this patient population. MIDs for PROs are particularly useful when treatment responses are significant to the patient but are difficult to evaluate during the clinical visit.

A recent literature review concluded that the comorbidity of chronic pain and depression in adults is approximately 50%-65%. Physical and cognitive declines, concurrent multiple health conditions, and complex medication regimens add to the unique and complex challenges of effectively treating pain in particularly geriatric populations. Interdisciplinary medical intervention and monitoring for psychiatric sequelae, such as depression, cognitive change, and synergistic physical side effects are necessary. Areas covered: This review covers an extensive multi-database wide search of the pharmacotherapy of pain and depression in older adults, including biopsychosocial approaches. One of these, on which this review focuses, is Functional Restoration, an interdisciplinary application of quantified physical rehabilitation, case management, and cognitive behavioral and educational therapies to achieve improved well- being and better physical functioning. The biopsychosocial model incorporates an overview of the overlapping and interactive dimensions of a patient's life and addresses them within a comprehensive plan of treatment. Expert commentary: A multifactorial, rather than a single factor approach to the treatment of complicated health care problems such as chronic pain in an elderly patient is emphasized as an important change in perspective for the health care provider.

Contents: M.E. Maruish, Preface. Part I:General Considerations. M.E. Maruish, Introduction. C.J. Peek, R. Heinrich, Integrating Behavioral Health and Primary Care. M. Evers-Szostak, Integration of Behavioral Health Care Services in Pediatric Primary Care Settings. L.R. Derogatis, L.L. Lynn, II, Screening and Monitoring Psychiatric Disorder in Primary Care Populations. C.L. Ofstead, D.S. Gorban, D.L. Lum, Integrating Behavioral Health Assessment With Primary Care Services. Part II:Assessment Instruments. S.R. Hahn, K. Kroenke, J.B.W. Williams, R.L. Spitzer, Evaluation of Mental Disorders With the PRIME-MD. G.R. Grissom, K.I. Howard, Directions and COMPASS-PC. J. Shedler, The Shedler QPD Panel (Quick PsychoDiagnostics Panel): A Psychiatric "Lab Test" for Primary Care. L.R. Derogatis, K.L. Savitz, The SCL-90-R and Brief Symptom Inventory (BSI) in Primary Care. M.E. Maruish, Applications of the Symptom Assessment-45 Questionnaire (SA-45) in Primary Care Settings. P.J. Brantley, S.K. Jeffries, Daily Stress Inventory (DSI) and Weekly Stress Inventory (WSI). P.J. Brantley. D.J. Mehan, Jr., J.L. Thomas, The Beck Depression Inventory (BDI) and the Center for Epidemiologic Studies Depression Scale (CES-D). K.A. Kobak, W.M. Reynolds, The Hamilton Depression Inventory. T.L. Kramer, G.R. Smith, Tools to Improve the Detection and Treatment of Depression in Primary Care. F. Scogin, N. Rohen, E. Bailey, Geriatric Depression Scale. R.J. Ferguson, Using the Beck Anxiety Inventory in Primary Care. L.J. Davis, Self-Administered Alcoholism Screening Test (SAAST). G.J. Demakis, M.G. Mercury, J.J. Sweet, Screening for Cognitive Impairments in Primary Care Settings. H.P. Wetzler, D.L. Lum, D.M. Bush, Using the SF-36 Health Survey in Primary Care. A. Murray, D.G. Safran, The Primary Care Assessment Survey: A Tool for Measuring, Monitoring, and Improving Primary Care. S.R. Hahn, The Difficult Doctor Patient Relationship Questionnaire. Part III:Primary and Behavioral Health Care Integration Projects. P. Robinson, K. Strosahl, Improving Care for a Primary Care Population: Depression as an Example. A. Beck, C. Nimmer, A Case Study: The Kaiser Permanente Integrated Care Project. L. Goldstein, B. Bershadsky, M.E. Maruish, The INOVA Primary Behavioral Health Care Pilot Project. Part IV:Future Directions. K.A. Kobak, J.C. Mundt, D.J. Katzelnick, Future Directions in Psychological Assessment and Treatment in Primary Care Settings.

Purpose Functional restoration programs (FRPs), for patients with chronic disabling occupational musculoskeletal disorders (CDOMDs), have consistently demonstrated positive socioeconomic treatment outcomes, including decreased psychosocial distress and increased work return. The pre-treatment length of disability (LOD), or time between injury and treatment admission, has been shown to influence FRP work outcomes. Some studies have found that shorter LOD is associated with better work outcomes. However, few studies have actually examined cohorts with LOD duration longer than 18 months. This present study evaluated the effects of extended LOD (beyond 18 months) on important treatment outcomes. Methods A total cohort of 1413 CDOMD patients entered an FRP. Of those, 312 did not complete the program, so they were eliminated from outcome analyses. The 1101 patients who completed the FRP were classified based on LOD: Late Rehabilitation (LR, 3-6 months, n = 190); Chronic Disability (CD, 7-17 months, n = 494); and Late Chronic Disability (LCD). The LCD, in turn, consisted of four separate subgroups: 18-23 months (LCD-18, n = 110); 24-35 months (LCD-24, n = 123); 36-71 months (LCD-36, n = 74); and 72+ months (LCD-72, n = 110). Patients were evaluated upon admission and were reassessed at discharge. Those patients who chose to pursue work goals post-treatment (n = 912) were assessed 1-year later. Results Longer LOD was associated with less likelihood of completing the FRP (p .001). Compared to the other LOD groups, a relatively large percentage of patients (47%) in the longest- disability group were receiving social security disability benefits. Associations were found between longer LOD and more severe patient-reported pain, disability, and depressive symptoms at treatment admission. At discharge, symptom severity decreased for these patient-reported variables in all LOD groups (p .001). Using binary logistic regressions, it was found that LOD significantly predicted work-return (Wald = 11.672, p = .04) and work-retention (Wald = 11.811, p = .04) after controlling for covariates. Based on the LOD groups, the percentage of patients returning to, and retaining work, ranged from 75.6 to 94.1%, and from 66.7 to 86.3%, respectively. The odds of LCD-24 and LCD-72 patients returning to work were 2.9, and 7.4, respectfully, less likely, compared to LR patients. Furthermore, the odds of LCD-24 and LCD-72 patients retaining work were 3.3 and 3.8 times, respectively, less likely, compared to LR patients. Conclusions Long LOD was a risk factor for FRP non-completion, and was associated with more severe patient-reported variables, including pain intensity and perceived disability. Furthermore, long LOD was a significant predictor for work outcomes at 1 year following FRP discharge. Nevertheless, a large percentage of longer LOD (24 months) patients had returned to work within the year after discharge (above 85%), and had retained at least part-time work 1-year later (above 66%). These results support the effectiveness of the FRP in mitigating the effects of extended LOD in a large percentage of long-term LOD patients.

Chronic low back pain is a debilitating condition affecting millions of Americans annually. Older-adult populations suffer a high prevalence of this continually painful state, and further face a unique set of challenges to manage short- and long-term biopsychosocial functioning. As the population ages, and the proportion of older adults grow, it is essential to explore and develop the most effective interdisciplinary strategies to care for older adults who are chronic pain sufferers. In this Commentary, we highlight some of the special challenges that the older-adult population encounters, and their influence on pain management strategies.