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Chiari Registry Project: Assessment of Surgical Outcome on Self-Focused Attention, Pain and Delayed Recall

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Background: Prior research has typically found a negative relationship between chronic pain and memory, and we examined whether cognitive control processes (e.g., reflection and rumination) moderated this relationship in individuals with Chiari malformation Type I (CM). CM is a neurological condition in which the cerebellar tonsils descend into the medullary and upper cervical spine regions potentially resulting in severe headaches and neck pain. Methods: CM patients who had (n=341) and had not (n=297) undergone decompression surgery completed the McGill Pain Questionnaire-Short Form-Revised (SF-MPQ-2), the Rey Auditory Verbal Learning Test (RAVLT), and the Rumination-Reflection Questionnaire (RRQ). Immediate recall scores were compared to those of 102 healthy controls, and delayed recall performance was compared across other variables within the CM group. Results: CM patients performed more poorly on immediate recall than did controls. Within CM patients, we observed main effects for reflection and age, and a Pain x Reflection x Surgical Status (surgery vs. no surgery) interaction in which non-decompressed individuals with low levels of pain and high levels of reflection showed superior delayed recall relative to non- decompressed individuals with higher pain and all decompressed individuals. Conclusions: CM patients show an immediate recall deficit relative to controls, regardless of surgical status. Also, high levels of reflection were associated with better delayed recall performance in non-decompressed CM patients with lower pain levels. High levels of chronic pain may overwhelm increased focused attention abilities, but higher levels of reflection partially overcome the distracting effects of pain and this may represent a type of resilience.
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... Also, Houston et al. (2022) showed the importance of considering pain effects when considering cognitive effects in CM-I. For example, distraction due to pain can result in cognitive dysfunction in CM-I (e.g., Allen et al., 2018), so it is important to consider whether there are cognitive effects in CM-I that are separate from the distracting effect of pain. The aim of this present study is to conduct a systematic review to update that of Rogers et al. (2018) and Houston et al. (2022), considering adult and pediatric populations, and to point out the significant developments and remaining challenges. ...
... Analyzing the sample design, 15 of a total of 21 articles included a control group (Allen et al., 2014;Allen et al., 2018;Besteiro & Torres, 2018;García et al., 2018aGarcía et al., , b, 2020aHouston et al., 2018;Houston et al., 2019;Houston et al., 2020;Houston et al., 2021;Kumar et al., 2011;Lacy et al., 2019;Lázaro et al., 2018;Yilmaz et al., 2022); however, only nine were age-, gender-, and education-matched (García et al., 2018a(García et al., , b, 2020aHouston et al., 2018;Houston et al., 2019;Houston et al., 2020;Lázaro et al., 2018;Yilmaz et al., 2022). That is another limitation of research examining cognitive functioning in the CM-I population. ...
... Analyzing neuroimaging evidence, five studies with adult samples accompanied their neuropsychological findings with brain structure and functional data (Houston et al., , 2020(Houston et al., , 2021Kumar et al., 2011;). Six studies in adult CM-I patients (Allen et al., 2014;Allen et al., 2018;Besteiro & Torres, 2018;Del Casale et al., 2012;Klein et al., 2014;Mahgoub et al., 2012) and four in pediatric patients (Gabrielli et al., 1998;Grosso et al., 2001;Haapanen, 2007;Novegno et al., 2008) reported information from MRI scans. However, they just indicated Chiari-related anatomical signs such as cerebellar ectopia below the foramen magnum and posterior fossa volumetric anomalies. ...
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Chiari malformation has been classified as a group of posterior cranial fossa disorders characterized by hindbrain herniation. Chiari malformation type I (CM-I) is the most common subtype, ranging from asymptomatic patients to those with severe disorders. Research about clinical manifestations or medical treatments is still growing, but cognitive functioning has been less explored. The aim of this systematic review is to update the literature search about cognitive deficits in CM-I patients. A literature search was performed through the following electronic databases: MEDLINE, PsychINFO, Pubmed, Cochrane Library, Scopus, and Web of Science. The date last searched was February 1, 2023. The inclusion criteria were as follows: (a) include pediatric or adult participants with a CM-I diagnosis, (b) include cognitive or neuropsychological assessment with standardized tests, (c) be published in English or Spanish, and (d) be empirical studies. Articles that did not report empirical data, textbooks and conference abstracts were excluded. After the screening, twenty-eight articles were included in this systematic review. From those, twenty-one articles were focused on adult samples and seven included pediatric patients. There is a great heterogeneity in the recruited samples, followed methodology and administered neurocognitive protocols. Cognitive functioning appears to be affected in CM-I patients, at least some aspects of attention, executive functions, visuospatial abilities, episodic memory, or processing speed. However, these results require careful interpretation due to the methodological limitations of the studies. Although it is difficult to draw a clear profile of cognitive deficits related to CM-I, the literature suggests that cognitive dysfunction may be a symptom of CM-I. This suggest that clinicians should include cognitive assessment in their diagnostic procedures used for CM-I. In summary, further research is needed to determine a well-defined cognitive profile related to CM-I, favoring a multidisciplinary approach of this disorder.
... We collected data using a web-based survey containing the SF-MPQ-2 and other measures described below. We recruited a sample of 552 adult participants (i.e., � 18 years of age) from the Chiari 1000 database (i.e., a database established for the collection of behavioral and anatomical information from Chiari malformation patients; see Allen et al., 2018) [20] who had been diagnosed with Chiari malformation (CM). This malformation is often congenital in nature, impacting cranial and spinal column anatomy, and typically involving the base of the skull, upper vertebral column, and associated neural tissue [21]. ...
... We collected data using a web-based survey containing the SF-MPQ-2 and other measures described below. We recruited a sample of 552 adult participants (i.e., � 18 years of age) from the Chiari 1000 database (i.e., a database established for the collection of behavioral and anatomical information from Chiari malformation patients; see Allen et al., 2018) [20] who had been diagnosed with Chiari malformation (CM). This malformation is often congenital in nature, impacting cranial and spinal column anatomy, and typically involving the base of the skull, upper vertebral column, and associated neural tissue [21]. ...
... Our results of an optimal bifactor model with a general and a specific factor applied to Chiari patients have implications for both research and application of the assessment of pain using the SF-MPQ-2. Conceptually, the pattern of findings here might point to a general factor attributable to the acute experience of pain associated with tissue damage, encroachment, or inflammation (i.e., nociceptive), whereas the more specific pain factor (i.e., affective) may reflect more chronic centralized pain (e.g., Allen et al., 2018 [20]; 2022 [25]). Evidence supporting this dichotomy may be found in the pattern of less optimal post-surgical improvement observed among Chiari patients when there is greater than a two-year interval between initial diagnosis and surgery (Labuda et al., 2022 [48]). ...
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The Short-Form McGill Pain Questionnaire-2 (SF-MPQ-2; Dworkin et al., 2009) is intended to measure the multidimensional qualities of pain (i.e., continuous, intermittent, neuropathic, and affective) as well as total pain. Using structural equation modeling, we evaluated the fit of four competing measurement models of the SF-MPQ-2—an oblique 4-factor model, a 1-factor model, a higher-order model, and a bifactor model—in 552 adults diagnosed with Chiari malformation, a chronic health condition whose primary symptoms include head and neck pain. Results revealed the strongest support for the bifactor model, suggesting that SF-MPQ-2 item responses are due to both a general pain factor and a specific pain factor that is orthogonal to the general pain factor. Additional bifactor analyses of the SF-MPQ-2’s model-based reliability and dimensionality revealed that most of the SF-MPQ-2’s reliable variance is explained by a general pain factor, and that the instrument can be modeled unidimensionally and scored as a general pain measure. Results also indicated that the general and affective pain factors in the bifactor model uniquely predicted pain-related external criteria (e.g., depression, anxiety, and stress); however, the continuous, intermittent, and neuropathic factors did not.
... While causality can't be definitively determined, it is logical to hypothesize that higher levels of disability due to pain and psychological distress interfere with cognitive processing, or more specifically in this case, recall and memory. This notion is supported in the literature, as Garcia et al. 29 and Houston et al. 30 both found that CMI patient performed more poorly on recall than controls, and Allen et al. 31 observed that increased efficiency in inhibiting pain via self-focused attention (reflection) resulted in higher levels of RAVLT recall in CMI relative to patients with lower levels of self-focused attention. In a diffusion tensor imaging study, CMI patients showed differences from healthy age and education matched controls in areas known to be associated with pain processing. ...
... However, in a post-hoc analysis we found that the surgical rate for the Low NDI group was 57% compared to 44% for the High NDI group (χ 2 =4.1, p=0.043). The reason that patients in the High NDI group are not decompressed is not available from this dataset, but in either case it could be that non-decompressed patients experience a type of reverse placebo effect, as proposed by Allen et al. 31 , from not receiving treatment, which leads to higher levels of disability. ...
Article
Objective: To quantify neck related disability in adult females with Chiari I and identify significantly related variables. Methods: Seventy variables were selected from the self-report history questionnaires (12 variables, N=474), standardized scales (15 variables, N=474), and morphometric data (43 variables, N=293-474) of adult women with Chiari malformation Type I (CMI). The variables were tested independently to identify those with a significant relationship to Neck Disability Index (NDI) score (p<0.00071) and ones that may be associated with NDI (p<0.05). A forward selection regression model was constructed to identify variables contributing unique variance to NDI. In addition, a mediation analysis was performed to determine if depression mediated the relationship between pain and disability. Results: Overall, 79.5% of the subjects scored at the Moderate level of disability or higher. Independent testing identified 16 significant variables, including duration of symptoms, tonsillar position, and measures of psychological distress. McGill pain (r=0.69, p<0.00001) and CES-D depression (r=0.56, p<0.00001) exhibited the highest correlations with NDI. The forward selection regression model produced an R2=0.6178. Pain and depression accounted for more than half of the NDI variance. Conclusion: High levels of disability are common among adult females with CMI, independent of surgical status. Pain and depression are primary factors related to this disability. Depression mediates the relationship between pain intensity and disability at a modest level (5%). Patients who experience symptoms for more than two years before diagnosis have on average 77% higher NDI scores, highlighting the importance of timely diagnosis.
... Above cognitive performance was determined by reaction times (RT) and accuracy for correct responses. Episodic memory was measured using the Rey Auditory Verbal Learning Test (RAVLT) (Allen, 2018), including short-term (RAVLT_S) and long-term memory scores (RAVLT_L). Executive function was assessed using the Trail Making Test (TMT) (Llinàs-Reglà, 2017), which includes two parts (TMT-A and TMT-B). ...
Article
Background Internal capsule strokes often result in multidomain cognitive impairments across memory, attention, and executive function, typically due to disruptions in brain network connectivity. Our study examines these impairments by analyzing interactions within the triple-network model, focusing on both static and dynamic aspects. Methods We collected resting-state fMRI data from 62 left (CI_L) and 56 right (CI_R) internal capsule stroke patients, along with 57 healthy controls (HC). Using independent component analysis to extract the default mode (DMN), executive control (ECN), and salience networks (SAN), we conducted static and dynamic functional network connectivity analyses (DFNC) to identify differences between stroke patients and controls. For DFNC, we used k-means clustering to focus on temporal properties and multilayer network analysis to examine integration and modularity Q, where integration represents dynamic interactions between networks, and modularity Q measures how well the network is divided into distinct modules. We then calculated the correlations between SFNC/DFNC properties with significant inter-group differences and cognitive scales. Results Compared to HC, both CI_L and CI_R patients showed increased static FCs between SAN and DMN and decreased dynamic interactions between ECN and other networks. CI_R patients also had heightened static FCs between SAN and ECN and maintained a state with strongly positive FNCs across all networks in the triple-network model. Additionally, CI_R patients displayed decreased modularity Q. Conclusion These findings highlight that stroke can result in the disruption of static and dynamic interactions in the triple network model, aiding our understanding of the neuropathological basis for multidomain cognitive deficits after internal capsule stroke.
... Taking into account the research to date, one of the main focus has been the study of the reported outcomes after undergoing surgical procedures (15,16,37,38). The most referred intervention is the PFD, which consists in a suboccipital craniectomy. ...
Article
Chiari Malformation type I (CM-I) is a neurological disorder characterized by cerebellar tonsillar herniation. Chronic pain, particularly headaches, is a prevalent symptom in CM-I patients, significantly impacting their quality of life. The objective of this study was to evaluate the perceived quality of life in adults with CM-I and examine the influence of chronic pain and comorbid symptoms on their well-being. 26 CM-I patients (8 with decompressive surgery) and 26 matched healthy controls were recruited. Participants completed the following questionnaires: WHOQOL-BREF, HDI, NDI, OLBPDQ and HADS. CM-I patients exhibited significantly lower scores across all domains of quality of life when compared to healthy controls. Chronic pain, including headache, neck pain, and low back pain, was more pronounced among CM-I patients and demonstrated a significant correlation with depressive symptoms. Notably, after controlling for chronic pain, the differences in quality of life between CM-I patients and controls diminished. The results suggest that chronic pain, especially headaches, and comorbid depressive symptoms exert a substantial impact on the quality of life of CM-I patients. Surgical intervention alone may not fully address these issues, highlighting the importance of considering psychological interventions as part of the comprehensive treatment. Further research with larger samples and pre-post-surgery assessments is needed to validate these findings and explore the potential benefits of psychological therapies in enhancing the quality of life for CM-I patients.
... We [15] have also provided evidence that individual differences in loneliness [20] and disability [21] in CMI have an impact on estrogen levels. There is also accumulating evidence that the cerebellum, in general, is related to social functioning [22,23] specifically in individuals with CMI [24,25]. In the past, we have not looked into how structural MRI-based morphometric measures combined with psychological measures and stressors (e.g., loneliness and disability) may be associated with biomarkers that are indices of allostatic load (especially estrogen) [17]. ...
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In the present study we report the relationship among MRI-based skull and cervical spine morphometric measures as well as symptom severity (disability—as measured by Oswestry Head and Neck Pain Scale and social isolation—as measured by the UCLA Loneliness scale) on biomarkers of allostatic load using estrogen, interleukin-6, C-reactive protein, and cortisol in a sample of 46 CMI patients. Correlational analyses showed that McRae line length was negatively associated with interleukin-6 and C-reactive protein levels, and Analysis of Variance (ANOVA) showed joint effects of morphometric measures (McRae line length, anterior CSF space) and symptom severity (disability and loneliness) on estrogen and intereukin-6 levels. These results are consistent with allostatic load. That is, when the combination of CSF crowding and self-report symptom (disability and loneliness) severity exceed the capacity of biological resilience factors, then biomarkers such as neuroprotective estrogen levels drop, rather than rise, with increasing symptom severity.
... Chronic pain can lead to disability, reduced functional status, psychological distress and negative impacts on the quality of life (Hadley, 2021 (Sim et al., 2017). In addition, chronic pain can lead to less attention to the surrounding environment and more 'self-focused' (DC) (Allen et al., 2018), which was observed in 1.4% of the sample. The presence of 'expresses fatigue' (DC) was detected in 3.2% of the study population, despite affecting more than half of the general population with chronic pain (Van & Becker, 2018). ...
Article
Aim: The aim of this study is to generate empirical evidence, drawing from clinical records, with the goal of elevating the level of evidence supporting the nursing diagnosis (ND) of ‘chronic pain’. Background: Chronic pain is a prevalent condition that affects all age groups. Patients often feel disbelieved about their pain perception, leading to adverse psychological effects, difficulty accessing healthcare and poor rehabilitation outcomes. Design: Retrospective descriptive study. Standards for Reporting Diagnostic Accuracy Studies guidelines were followed in this study. Methods: Data were extracted from Electronic Health Records (EHR) of patients admitted to the University Hospital of Perugia, Italy, between March 2016 and December 2022. The study sample comprised individuals without a specific medical diagnosis or high-risk population. Out of 1,048,565 EHR, 43,341 clinical-nursing diaries with the keyword ‘pain’ were identified, from which 283 clinical-nursing notes were selected based on a keyword-based retrieval technique and diagnostic definition for further analysis. Results: Our study findings support the diagnostic descriptors of the ‘chronic pain’ ND in clinical-nursing diaries. We observed the presence of 9 out of 11 defining characteristics, 7 out of 10 related factors, 4 out of 8 at-risk populations and 11 out of 17 associated conditions. Conclusions: The study validated diagnostic criteria for chronic pain and proposed ‘haematological pathology’ as a new associated condition. The findings were presented to the Diagnosis Development Committee of NANDA-International for further review. However, limitations of the study prompted the need for further analysis using natural language processing and artificial neural network techniques. As a result, a new research direction using artificial intelligence (AI) tools was initiated. Relevance to clinical practice: The study validates diagnostic descriptors for chronic pain and proposes future directions in semantic analysis and AI tools, aiming to enhance clinical practice and decision-making in nursing care. Patient or public contribution: No patient or public contribution.
Article
OBJECTIVE Craniocervical junction morphology has been associated with Chiari malformation type I (CMI) symptom severity; however, little is known about its deterministic effect on surgical outcomes in patients across age and sex differences. The goal of the present study was to assess the effects of age and sex on surgical outcomes in CMI. METHODS In the present study, the authors examined MRI-based morphometric data from 115 individuals diagnosed with CMI (54 adults including 39 women and 15 men, and 61 children including 24 girls and 37 boys) and correlated them with Chicago Chiari Outcome Scale (CCOS) scores obtained 1 year after posterior fossa decompression. The authors assessed 7 craniocervical junction morphology–related measures that have been associated with CMI symptom severity: McRae line length, clivus length, Wackenheim angle, anterior and posterior CSF spaces, clivo-supraoccipital angle, and tonsillar position. RESULTS In the pediatric cohort, none of the morphometric measures correlated with CCOS score, but both anterior and posterior CSF spaces did in adults. To further study sex and age effects, the authors used age group (children vs adults) and sex (female vs male) as independent variables and ran 3 separate ANOVA tests using CCOS score, anterior CSF space, and posterior CSF space as dependent variables, respectively. Both CCOS and anterior CSF space analyses resulted in significant interactions. Specifically, women showed lower CCOS scores and smaller anterior CSF spaces than girls, boys, or men. CONCLUSIONS These results provide evidence that joint age and sex differences moderate the surgical outcome of CMI patients. In females, smaller anterior CSF space was associated with lower CCOS score.
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The brain’s default network (DN) has been a topic of considerable empirical interest. In fMRI research, DN activity is associated with spontaneous and self-generated cognition, such as mind-wandering, episodic memory retrieval, future thinking, mental simulation, theory of mind reasoning, and creative cognition. Despite large literatures on developmental and disease-related influences on the DN, surprisingly little is known about the factors that impact normal variation in DN functioning. Using structural equation modeling and graph theoretical analysis of resting-state fMRI data, we provide evidence that Openness to Experience—a normally distributed personality trait reflecting a tendency to engage in imaginative, creative, and abstract cognitive processes—underlies efficiency of information processing within the DN. Across two studies, Openness predicted the global efficiency of a functional network comprised of DN nodes and corresponding edges. In Study 2, Openness remained a robust predictor—even after controlling for intelligence, age, gender, and other personality variables—explaining 18% of the variance in DN functioning. These findings point to a biological basis of Openness to Experience, and suggest that normally distributed personality traits affect the intrinsic architecture of large-scale brain systems.
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This study examines how self-consciousness is defined and assessed using self-report questionnaires (Self-Consciousness Scale (SCS), Self-Reflection and Insight Scale, Self-Absorption Scale, Rumination-Reflection Questionnaire, and Philadelphia Mindfulness Scale). Authors of self-report measures suggest that self-consciousness can be distinguished by its private/public aspects, its adaptive/maladaptive applied characteristics, and present/past experiences. We examined these claims in a study using 602 young adults to whom the aforementioned scales were administered. Data were analyzed as follows: (1) correlation analysis to find simple associations between the measures; (2) factorial analysis using Oblimin rotation of total scores provided from the scales; and (3) factorial analysis considering the 102 items of the scales all together. It aimed to clarify relational patterns found in the correlations between SCSs, and to identify possible latent constructs behind these scales. Results support the adaptive/maladaptive aspects of self-consciousness, as well as distinguish to some extent public aspects from private ones. However, some scales that claimed to be theoretically derived from the concept of Private Self-Consciousness correlated with some of its public self-aspects. Overall, our findings suggest that while self-reflection measures tend to tap into past experiences and judged concepts that were already processed by the participants’ inner speech and thoughts, the Awareness measure derived from Mindfulness Scale seems to be related to a construct associated with present experiences in which one is aware of without any further judgment or logical/rational symbolization. This sub-scale seems to emphasize the role that present experiences have in self-consciousness, and it is argued that such a concept refers to what has been studied by phenomenology and psychology over more than 100 years: the concept of pre-reflective self-conscious.
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A distinction between ruminative and reflective types of private self-attentiveness is introduced and evaluated with respect to L. R. Goldberg's (1982) list of 1,710 English trait adjectives (Study 1), the five-factor model of personality (FFM) and A. Fenigstein, M. F. Scheier, and A. Buss's(1975) Self-Consciousness Scales (Study 2), and previously reported correlates and effects of private self-consciousness (PrSC; Studies 3 and 4). Results suggest that the PrSC scale confounds two unrelated motivationally distinct disposition-rumination and reflection-and that this confounding may account for the "self-absorption paradox" implicit in PrSC research findings: Higher PrSC sources are associated with more accurate and extensive self-knowledge yet higher levels of psychological distress. The potential of the FFM to provide a comprehensive Framework for conceptualizing self-attentive dispositions, and to order and integrate research findings within this domain, is discussed.
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Background: 50% of patients with Chiari Malformation (CM) report a history of depression; however, rates of other psychological symptoms are unknown. Further, it is unclear whether surgical correction impacts pain, disability, and psychological symptoms. Objective: /Hypothesis: We examined rates of symptoms in a nationwide sample of CM patients who had (n = 639) and had not (n = 551) undergone surgical correction. We hypothesized lower symptom severity in the latter group. Methods: Participants completed assessments and submitted pre-surgical MRI scans online (n = 286). Informed by the Fear-Avoidance Model of pain, we controlled for psychological symptoms when assessing pain/disability, and pain/disability when assessing psychological symptoms. Results: Overall, high rates of depression (44% moderate-severe) and anxiety (60% moderate-severe) were reported. Groups (surgery vs. no-surgery) did not differ in the proportion of patients meeting cutoff scores for current disability; however, the no-surgery group was more likely to meet cutoffs for anxiety (χ2 = 11.26, p < .05), stress (χ2 = 14.63, p < .01) and health anxiety (χ2 = 4.63, p < .05). The surgery group reported lower levels of continuous affective pain F(1, 1065) = 10.28, p < .001), anxiety F(1,1026) = 4.96, p < .05) and stress F(1, 978) = 5.67, p < .05) although effect sizes were small (η2s ranging from 0.010 to 0.006, Cohen's D ranging from 0.17 to 0.25). Conclusion: CM patients experience high rates of psychological symptomatology regardless of surgical status, suggesting that all CM patients may benefit from evidence-based interventions to address anxiety and depression.
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Type 1 Chiari malformations (CMs) are a group of congenital or acquired disorders which include the abnormal presence of the cerebellar tonsils in the upper spinal canal, rather than the posterior fossa. The resulting anatomic abnormality causes crowding of the structures at the craniocervical junction and can impair the normal flow of cerebral spinal fluid (CSF) in this region. This impairment in CSF flow dynamics can led to the development of syringomyelia or hydrocephalus. Type 1 CMs have been associated with a wide array of symptoms resulting from either cerebellar and brainstem compression and distortion or disturbances in CSF dynamics, and can affect both children and adults. The clinical diagnosis may be difficult. Age usually matters in the clinical presentation, and in symptomatic patients, surgical intervention is usually required. [Full article available at http://rimed.org/rimedicaljournal-2017-06.asp].
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Purpose. Type I Chiari malformation (CMI) is a radiologically-defined structural dysmorphism of the hindbrain and posterior cranial fossa (PCF). Traditional radiographic identification of CMI relies on the measurement of the cerebellar tonsils in relation to the foramen magnum with or without associated abnormalities of the neuraxis. The primary goal of this retrospective study was to comprehensively assess morphometric parameters above the McCrae line in a group of female CMI patients and normal controls. Material and Methods. 29 morphological measurements were taken on 302 mid-sagittal MR images of adult female CMI patients (N=162) and healthy controls (N=140). All MR images were voluntarily provided by CMI subjects through an online database and control participant images were obtained through the Human Connectome Project and a local hospital system. Results. Analyses were performed on the full dataset of adult female MR images and a restricted dataset of 229 participants that were equated for age, race, and body mass index. 18 group differences were identified in the PCF area that grouped into three clusters; PCF structures heights, clivus angulation, and odontoid process irregularity. 14 group differences persisted after equating CMI and control groups on demographic characteristics. Conclusion. PCF structures reliably differ in adult female CMI patients relative to healthy controls. These differences reflect structural abnormalities in the osseous and soft tissue structures of the clivus, odontoid process, and cerebellum. Clinical and pathophysiological implications are discussed.
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Unlabelled: Previous studies showed equivocal findings regarding the efficacy of focused attention and distraction to experimental pain. This study examined the relative efficacy of these strategies on perception of cold pressor pain in 41 chronic back pain patients and 41 healthy control participants. Participants were randomized to the 2 strategies and then completed a 7-minute cold pressor test. Pain intensity and discomfort ratings were obtained during the task. Participants who completed the first task were asked to complete a second cold pressor task without instructions. Pain and discomfort ratings differed by condition across time. In the distraction condition, pain levels started low but continued to rise throughout the cold pressor immersion, whereas in the focused attention condition, pain levels started higher, rose less quickly, and then decreased from the middle of the task. Focused attention was associated with higher pain and lower completion rates in chronic pain patients compared with healthy control subjects. Focused attention might therefore not be an effective intervention strategy for individuals with chronic back pain. Finally, in the second cold pressor test, patients' pain reports rose more rapidly than those of healthy control subjects. The results of this study can be explained in terms of differences in cognitive appraisal between pain patients and healthy control participants. Perspective: Marked differences were found between chronic back pain patients and control participants regarding focused attention as compared with distraction as a means of coping with cold pressor-induced pain. These differences underline the importance of taking into account previous experience with pain when recommending strategies to cope with painful procedures.
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Background: Children with Chiari malformation type 1 (CM1) have increasingly presented to neurosurgery clinics. Limited research relating to the cognitive dysfunction experienced by this population has been completed. In adults, inhibition problems and executive dysfunction have been documented. Methods: Seventy-seven parental reports of children with CM1 were included in the study. Parents completed questions on a scale rating daily executive functioning as well as reporting on common neurological symptoms. Results: The sample consisted of 41 males and 36 females with a mean age of 133.57 ± 42.18 months. Thirty-eight subjects had had decompression surgery. The most common neurological symptoms included: headache (69%), a history of pain (31%) and gait disturbance (20%). One third of the sample demonstrated overall executive functioning impairment, with working memory elevations being most prevalent (44%). Depression, gender, age and decompression surgery were not related to executive dysfunction. Conclusions: The parental report of executive dysfunction in children with CM1 was higher than the standardized healthy sample. Metacognitive problems, especially working memory and initiation problems were most prevalent. A quick parental rating scale identifying children with executive dysfunction may be beneficial for neurosurgeons and assist with referrals for a more comprehensive neuropsychological assessment.
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Objective: To investigate underlying mechanisms of cognitive dysfunction in whiplash syndrome, focusing on psychologic factors and coping mechanisms. Background: Patients with whiplash often experience cognitive-functioning impairments. although neurologic and neuropsychologic test results do not always support this. Psychologic factors are also hypothesized to influence the existence of whiplash-related cognitive impairments. This has led to a controversy about the etiology of these experiences. Methods: In this retrospective study, 31 patients with whiplash were compared with 30 neurologic patients and a non-neurologic control group (i.e., with "nonorganic" psychologic symptoms) on memory attention, and cognitive flexibility. In addition, psychologic questionnaires (Minnesota Multiphasic personality Inventory, Symptom Checklist, and Utrecht Coping List) were used to investigate psychologic functioning and coping in these patient groups. Results: Patients with whiplash performed similarly to neurologic patients on the cognitive tasks and performed worse on memory and attention tasks compared with the control group. Furthermore, patients with whiplash had high scores on subscales measuring somatization and displayed a predominantly active and palliative coping style. Conclusions: Somatization in combination with inadequate coping. might play a role in the development, persistence, or aggravation of whiplash-related symptoms, such as pain or cognitive dysfunction.
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The number of acceptance- and mindfulness-based interventions for chronic pain, such as acceptance and commitment therapy (ACT), mindfulness-based stress reduction (MBSR), and mindfulness-based cognitive therapy (MBCT), increased in recent years. Therefore an update is warranted of our former systematic review and meta-analysis of studies that reported effects on the mental and physical health of chronic pain patients. Pubmed, EMBASE, PsycInfo and Cochrane were searched for eligible studies. Current meta-analysis only included randomized controlled trials (RCTs). Studies were rated for quality. Mean quality did not improve in recent years. Pooled standardized mean differences using the random-effect model were calculated to represent the average intervention effect and, to perform subgroup analyses. Outcome measures were pain intensity, depression, anxiety, pain interference, disability and quality of life. Included were twenty-five RCTs totaling 1285 patients with chronic pain, in which we compared acceptance- and mindfulness-based interventions to the waitlist, (medical) treatment-as-usual, and education or support control groups. Effect sizes ranged from small (on all outcome measures except anxiety and pain interference) to moderate (on anxiety and pain interference) at post-treatment and from small (on pain intensity and disability) to large (on pain interference) at follow-up. ACT showed significantly higher effects on depression and anxiety than MBSR and MBCT. Studies' quality, attrition rate, type of pain and control group, did not moderate the effects of acceptance- and mindfulness-based interventions. Current acceptance- and mindfulness-based interventions, while not superior to traditional cognitive behavioral treatments, can be good alternatives.