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Common Meanings of Living with Diabetic Peripheral Neuropathic Pain from the Perspective of Patients
Abstract
Contemporary pain medicine is necessary to explain pain and to help in its treatment; yet, preference for biomedical explanation of pain in the field has meant that attention to the personal experience of pain and to the meanings of pain experience remain a blind spot in knowledge. Thus, the pain literature includes limited information about the common meanings of living with diabetic peripheral neuropathic pain (DPNP) from the perspective of patients. The purpose of this chapter is to describe some of the common meanings of pain in patients with DPNP, as currently reported in the literature, how these meanings interact with other common factors in pain experience, including specific negative emotions or moods (depression, anxiety, anger), or the psychosocial context surrounding pain, and to describe available evidence on the effectiveness of cognitive behavioral therapy (CBT) for patients with DPNP. Further quantitative, qualitative or mixed methods research is needed to more fully understand common experiences of pain in patients with DPNP, and the common meanings ascribed to these experiences. Clinical Implications: Pain in patients with DPNP involves a range of threatening pain sensations, including sensations with burning, shooting, tingling, or cramping qualities, and additional more cognitive meanings linked to persistent pain, including a sense that pain disrupts daily life in an intrusive way. Pain affects many aspects of daily experience that are meaningful to patients with DPNP; some describe ongoing physical difficulties, others describe work-related problems or challenges in sexual intimacy. Given the heavy personal burden that DPNP imposes on patients and the considerable challenge of managing the condition pharmacologically, clinical use of non-pharmacological therapies such as CBT for painful diabetic neuropathy might be warranted in individual patients.
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Introduction:
Diabetic peripheral neuropathy (DPN) affects almost 30% to 50% of patients with diabetes, 40% to 60% of whom suffer from diabetic peripheral neuropathic pain (DPNP). Few studies have focused on individual experiences of DPNP in patients with diabetes. The purpose of this qualitative study was to elucidate the effects of DPNP on daily life and individual feelings regarding living with DPNP from the perspective of Turkish patients.
Method:
A total of 14 patients were interviewed, and interpretative phenomenological analysis was used to identify themes.
Results:
Findings indicated four main themes, including (a) physical limitations, (b) difficulties with daily routines, (c) social limitations, and (d) psychological impacts such as emotional changes, and being a burden on family.
Conclusion:
This study revealed that the majority of patients carry significant concerns about becoming a burden on their family and are afraid of becoming dependent on others because of DPNP.
Implication for practice:
For the effective management of DPNP, health professionals need to consider using a holistic approach to address difficulties in daily living such as physical limitations and sexual problems.
There is a strong tradition of therapy development and evaluation in the field of psychological interventions for chronic pain. However, despite this research production, the effects of treatments remain uncertain, and treatment development has stalled. This review summarises the current evidence but focusses on promising areas for improvement. Advancing psychological therapies for chronic pain will come from a radical re-imagining of the content, delivery, place, and control of therapy. The next generation of therapeutic interventions will also need alternative methods of measurement and evaluation, and options are discussed.
This review summarizes the current meta-analysis literature on treatment outcomes of CBT for a wide range of psychiatric disorders. A search of the literature resulted in a total of 16 methodologically rigorous meta-analyses. Our review focuses on effect sizes that contrast outcomes for CBT with outcomes for various control groups for each disorder, which provides an overview of the effectiveness of cognitive therapy as quantified by meta-analysis. Large effect sizes were found for CBT for unipolar depression, generalized anxiety disorder, panic disorder with or without agoraphobia, social phobia, posttraumatic stress disorder, and childhood depressive and anxiety disorders. Effect sizes for CBT of marital distress, anger, childhood somatic disorders, and chronic pain were in the moderate range. CBT was somewhat superior to antidepressants in the treatment of adult depression. CBT was equally effective as behavior therapy in the treatment of adult depression and obsessive-compulsive disorder. Large uncontrolled effect sizes were found for bulimia nervosa and schizophrenia. The 16 meta-analyses we reviewed support the efficacy of CBT for many disorders. While limitations of the meta-analytic approach need to be considered in interpreting the results of this review, our findings are consistent with other review methodologies that also provide support for the efficacy CBT.
We explored the relationship between meaning in life and adjustment to chronic pain in a three-wave, 2 year, longitudinal study of 273 Belgian chronic pain patients. We examined the directionality of the relationships among the meaning in life dimensions (Presence of Meaning and Search for Meaning) and indicators of adjustment (depressive symptoms, life satisfaction, pain intensity, and pain medication use). We found that Presence of Meaning was an important predictor of well-being. Secondly, we used a typological methodology to distinguish meaning in life profiles, and the relationship of individual meaning in life profiles with indicators of adjustment. Five meaning in life profiles emerged: High Presence High Search, High Presence Low Search, Moderate Presence Moderate Search, Low Presence Low Search, and Low Presence High Search. Each meaning in life profile was associated with a unique adjustment outcome. Profiles that scored high on Presence of Meaning showed more optimal adjustment. The profiles showed little change over time and did not moderate the development of adjustment indicators, except for life satisfaction. Practical implications and suggestions for future research are discussed.
Purpose:
The aim of this qualitative study was to explore participants' perspectives on the effects of chronic pain on the psychophysical unity.
Methods:
Thirty-four chronic pain outpatients were interviewed, and the transcribed interviews were analysed with Giorgi's four-phase phenomenological method. The mean age of the participants was 48 years, and 19 of them were women. For 21 of the participants, the pain duration was more than 5 years, and most had degenerative spinal pain.
Results:
The results of this whole research project indicated that the phenomenon chronic pain consisted of four essential themes: Pain affects the whole person, invisibility, negativity, and dominance of pain. This study concentrates only on one theme "Chronic pain affects the whole person", in which were found eight subthemes in the interviews. The strongest argument made by the participants was not the physical pain itself but the psychosocial consequences, such as distress, loneliness, lost identity, and low quality of life which were their main problems.
Conclusions:
In multidisciplinary holistic rehabilitation, it is essential to take care of the patient's psychological distress. A potential source of psychosocial symptoms may be the subjective responses to experience of chronic pain due to the subjective meanings of pain. Implications for Rehabilitation About chronic pain Pain is an experience, not only an aversive sensation. Intensity of pain describes only the sensation, not the experience of pain. In chronic pain, the main complaint may be not the physical pain, but the distress. In rehabilitation, the patient needs to be taken as a whole person. Multidisciplinary rehabilitation, including patient counselling should be the fundamental part of treatment. In rehabilitation, the individual meaning of chronic pain needs to be disclosed.
Preceding the joint meeting of the 19th annual Diabetic Neuropathy Study Group of the European Association for the Study of Diabetes (NEURODIAB) and the 8th International Symposium on Diabetic Neuropathy in Toronto, Canada, 13-18 October 2009, expert panels were convened to provide updates on classification, definitions, diagnostic criteria, and treat merits of diabetic peripheral neuropathies (DPNs), autonomic neuropathy, painful DPNs, and structural alterations in DPNs. Diabetes Care 33:2285-2293, 2010
Osteoarthritis pain affects more than half of all older adults, many of whom experience co-morbid sleep disturbance. Pain initiates and exacerbates sleep disturbance, whereas disturbed sleep maintains and exacerbates pain, which implies that improving the sleep of patients with osteoarthritis may also reduce their pain. We examined this possibility in a secondary analysis of a previously published randomized controlled trial of cognitive behavioral therapy for insomnia (CBT-I) in patients with osteoarthritis and co-morbid insomnia.
Twenty-three patients (mean age 69.2 years) were randomly assigned to CBT-I and 28 patients (mean age 66.5 years) to an attention control. Neither directly addressed pain management. Twelve subjects crossed over to CBT-I after control treatment. Sleep and pain were assessed by self-report at baseline, after treatment, and (for CBT-I only) at 1-year follow-up.
CBT-I subjects reported significantly improved sleep and significantly reduced pain after treatment. Control subjects reported no significant improvements. One-year follow-up found maintenance of improved sleep and reduced pain for both the CBT-I group alone and among subjects who crossed over from control to CBT-I.
CBT-I but not an attention control, without directly addressing pain control, improved both immediate and long-term self-reported sleep and pain in older patients with osteoarthritis and comorbid insomnia. These results are unique in suggesting the long-term durability of CBT-I effects for co-morbid insomnia. They also indicate that improving sleep, per se, in patients with osteoarthritis may result in decreased pain. Techniques to improve sleep may be useful additions to pain management programs in osteoarthritis, and possibly other chronic pain conditions as well.
Few direct head-to-head comparisons have been conducted between drugs for the treatment of diabetic peripheral neuropathic pain (DPNP). Approved or recommended drugs in this indication include duloxetine (DLX), pregabalin (PGB), gabapentin (GBP) and amitriptyline (AMT). We conducted an indirect meta-analysis to compare the efficacy and tolerability of DLX with PGB and GBP in DPNP, using placebo as a common comparator.
We searched PubMed, EMBASE, CENTRAL databases and regulatory websites for randomized, double-blind, placebo-controlled, parallel group or crossover clinical trials (RCTs) assessing DLX, PGB, GBP and AMT in DPNP. Study arms using approved dosages with assessments after 5-13 weeks were eligible. Efficacy criteria were: reduction in 24-hour pain severity (24 h PS) for all three drugs, and response rate (>or= 50% pain reduction) and Patient Global Impression of Improvement/Change (PGI-I/C) for DLX and PGB only. Tolerability criteria included: discontinuation, diarrhoea, dizziness, headache, nausea and somnolence. Direct comparisons versus placebo were conducted with pooled fixed - and random-effects analyses on endpoints reported in at least two studies of each drug. Indirect comparisons were performed between DLX and each of PGB and GBP using Bayesian simulation.
Three studies of DLX, six of PGB, two of GBP and none of AMT met the inclusion criteria. In random-effects and fixed-effects analyses of DLX, PGB and GBP, all were superior to placebo for all efficacy parameters, with some tolerability trade-offs. Indirect comparison of DLX with PGB found no differences in 24 h PS, but significant differences in PGI-I/C, favouring PGB, and in dizziness, favouring DLX were apparent. Comparing DLX and GBP, there were no statistically significant differences.
From the few available studies suitable for indirect comparison, DLX shows comparable efficacy and tolerability to GBP and PGB in DPNP. Duloxetine provides an important treatment option for this disabling condition.
Patients with diabetes mellitus frequently suffer from foot pain. This pain seems to be a neglected area in studies on the diabetic foot. The purpose of this study was to identify clinical variables associated with foot pain in diabetic patients. In addition, the relationships between foot pain and several functional impairments and disabilities were explored.
The research group consisted of 29 diabetic patients with any symptoms possibly associated with a diabetic foot, who were referred to podiatry. The relationships between several clinical measures and foot pain were analysed by means of Mann-Whitney U-tests. In addition, Spearman rank correlations coefficients were computed to assess the relationships between foot pain and measures of functional health.
Diabetic patients suffering from sensory neuropathy experience more severe foot pain. Furthermore, patients with more severe foot pain experience more fatigue, more disabilities in walking and a lower level of affective well-being.
Based on these findings this paper concludes that foot pain in diabetic patients is an important impairment which deserves further scientific attention.
A computer and a hand search of the literature recovered 33 papers from which 25 trials suitable for meta-analysis were identified. We compared the effectiveness of cognitive-behavioural treatments with the waiting list control and alternative treatment control conditions. There was a great diversity of measurements which we grouped into domains representing major facets of pain. Effect sizes, corrected for measurement unreliability, were estimated for each domain. When compared with the waiting list control conditions cognitive-behavioural treatments were associated with significant effect sizes on all domains of measurement (median effect size across domains = 0.5). Comparison with alternative active treatments revealed that cognitive-behavioural treatments produced significantly greater changes for the domains of pain experience, cognitive coping and appraisal (positive coping measures), and reduced behavioural expression of pain. Differences on the following domains were not significant; mood/affect (depression and other, non-depression, measures), cognitive coping and appraisal (negative, e.g. catastrophization), and social role functioning. We conclude that active psychological treatments based on the principle of cognitive behavioural therapy are effective. We discuss the results with reference to the complexity and quality of the trials.
Chronic tension-type headaches are characterized by near-daily headaches and often are difficult to manage in primary practice. Behavioral and pharmacological therapies each appear modestly effective, but data are lacking on their separate and combined effects.
To evaluate the clinical efficacy of behavioral and pharmacological therapies, singly and combined, for chronic tension-type headaches.
Randomized placebo-controlled trial conducted from August 1995 to January 1998 at 2 outpatient sites in Ohio.
Two hundred three adults (mean age, 37 years; 76% women) with diagnosis of chronic tension-type headaches (mean, 26 headache d/mo).
Participants were randomly assigned to receive tricyclic antidepressant (amitriptyline hydrochloride, up to 100 mg/d, or nortriptyline hydrochloride, up to 75 mg/d) medication (n = 53), placebo (n = 48), stress management (eg, relaxation, cognitive coping) therapy (3 sessions and 2 telephone contacts) plus placebo (n = 49), or stress management therapy plus antidepressant medication (n = 53).
Monthly headache index scores calculated as the mean of pain ratings (0-10 scale) recorded by participants in a daily diary 4 times per day; number of days per month with at least moderate pain (pain rating >/=5), analgesic medication use, and Headache Disability Inventory scores, compared by intervention group.
Tricyclic antidepressant medication and stress management therapy each produced larger reductions in headache activity, analgesic medication use, and headache-related disability than placebo, but antidepressant medication yielded more rapid improvements in headache activity. Combined therapy was more likely to produce clinically significant (>/=50%) reductions in headache index scores (64% of participants) than antidepressant medication (38% of participants; P =.006), stress management therapy (35%; P =.003), or placebo (29%; P =.001). On other measures the combined therapy and its 2 component therapies produced similar outcomes.
Our results indicate that antidepressant medication and stress management therapy are each modestly effective in treating chronic tension-type headaches. Combined therapy may improve outcome relative to monotherapy.
Although cognitive-behavioural treatments of patients with chronic pain generally are reported to be effective, customization might increase their effectiveness. One possible way to customize treatment is to focus the intervention on the supposed mechanism underlying the transition from acute to chronic pain disability. Evidence is accumulating in support of the conjecture that pain-related fear and associated avoidance behaviours are crucial in the development and maintenance of chronic pain disability. It seems timely to apply this knowledge to the cognitive-behavioural management of chronic pain. Two studies are presented here. Study 1 concerns a secondary analysis of data gathered in a clinical trial that was aimed at the examination of the supplementary value of coping skills training when added to an operant-behavioural treatment in patients with chronic back pain. The results show that, compared with a waiting list control, an operant-behavioural treatment with or without pain-coping skills training produced very modest and clinically negligible decreases in pain-related fear. Study 2 presents the effects of more systematic exposure in vivo treatment with behavioural experiments in two single patients reporting substantial pain-related fear. Randomization tests for AB designs revealed dramatic changes in pain-related fear and pain catastrophizing. In both cases, pain intensity also decreased significantly, but at a slower pace. Differences before and after treatment revealed clinically significant improvements in pain vigilance and pain disability.
Aim:
To synthesize qualitative descriptions of the experience of chronic pain across conditions.
Background:
Chronic pain is a transdiagnostic symptom in that while somatic pathology plays a role in activating pain pathways, psychological and social factors contribute to the experience of pain over time. The treatment of the underlying condition may require both biomedical intervention and biopsychosocial approaches.
Design:
Qualitative meta-synthesis using Confidence in the Evidence from Reviews of Qualitative Research (CERQual) developed by Grading of Recommendations Assessment Development and Evaluation (GRADE) working group to evaluate the strength of the evidence.
Data sources:
PubMed and Ovid Medline from 2000-2015.
Review methods:
Following a systematic search strategy all papers were assessed in relation to inclusion criteria and quality. Themes were extracted from each study and a meta-synthesis conducted before completing an evaluation of confidence in the findings.
Results:
Forty-one papers exploring the experience of chronic pain were included in the review. Five meta-themes were identified across the studies: 1) the body as obstacle; 2) invisible but real; 3) disrupted sense of self; 4) unpredictability; and 5) keeping going. There was high confidence in the evidence for three themes: 'the body as obstacle'; 'disrupted sense of self' and 'keeping going'; and moderate confidence in the evidence for 'invisible but real' and 'unpredictability'.
Conclusions:
The findings in this review suggest there are similarities in the experience of chronic pain across a range of conditions that have implications for the development of transdiagnostic pain management strategies and interventions.
Pain is an unpleasant sensory and emotional experience urging the individual to take action to restore the integrity of the body. The transition from a common episode of acute pain to a state of intermittent or chronic pain has been a constant preoccupation of researchers and clinicians alike. In this review, we approach chronic pain from a modern learning perspective that incorporates cognitive, affective, behavioral and motivational aspects. We view pain as a biologically hard-wired signal of bodily harm that competes with other demands in the person’s environment. The basic tenet is that pain urges people to interrupt ongoing activity, elicits protective responses that paradoxically increase interference with daily activities, and compromises the sense of self. Here we briefly summarize existing evidence showing how pain captures attention, and how attention for pain can be controlled. We also consider pain as a strong motivator for learning, and review the recent evidence on the acquisition and generalization of pain-related fear and avoidance behavior, which are likely to interfere with daily life activities. We highlight the paradoxical effects of pain avoidance behavior, and review treatment effects of exposure in vivo. A generally neglected area of research is the detrimental consequences of repeated interference by pain with daily activities on one’s sense of “self”. We end this review with a plea for the implementation of single-case experimental designs as a means to help customize and develop novel cognitive-behavioral treatments for individuals for chronic pain aimed at reducing the suffering of this large group of individuals.
Objective: To determine whether microscopic vasculitis explains the clinical and pathologic features of diabetic lumbosacral radiculoplexus neuropathy (DLSRPN). Background: DLSRPN is usually attributed to metabolic derangement or ischemic injury, but microscopic vasculitis as the sole cause needs consideration. Methods: We prospectively studied the clinical, laboratory, and EMG features as well as the pathology of distal cutaneous nerve biopsy specimens of patients with DLSRPN. Results: Study of DLSRPN nerve biopsy specimens (n = 33) compared with those from healthy controls (n = 14) and those with diabetic polyneuropathy (n = 21) provided strong evidence for ischemic injury (axonal degeneration, multifocal fiber loss, focal perineurial necrosis and thickening, injury neuroma, neovascularization, and swollen fibers with accumulated organelles), which we attribute to microscopic vasculitis (epineurial vascular and perivascular inflammation, vessel wall necrosis, and evidence of previous bleeding). Segmental demyelination was significantly associated with multifocal fiber loss. Conclusions: 1) This severe, debilitating neuropathy begins with symptoms unilaterally and focally in the leg, thigh, or buttock and spreads to involve the other regions of the same and then opposite side and is due to multifocal involvement of lumbosacral roots, plexus, and peripheral nerve (i.e., diabetic lumbosacral radiculoplexus neuropathy). 2) Motor, sensory, and autonomic fibers are all involved. 3) Ischemic injury explains the clinical features and pathologic abnormalities of nerve. 4) The proximate cause of the ischemic injury appears to be microscopic vasculitis. 5) The segmental demyelination is probably secondary to ischemic axonal dystrophy, thus providing a unifying hypothesis for both axonal degeneration and segmental demyelination.
Study Design. A literature review was conducted. Objective. To examine the outcome of behavioral (BT) and cognitive–behavioral treatment (CBT), collectively referred to as BT-CBT, for chronic pain, to identify the predictors of treatment outcome, and to investigate the change processes associated with these treatments. Summary of Background Data. Numerous controlled clinical trials of BT-CBT for chronic pain, alone or more commonly in multidisciplinary treatment contexts, suggest that these treatments are effective. However, further study is needed to examine which outcome variables change, when, for whom, and how. Methods. Published literature was gathered from Medline, PsychLit, and searches of relevant journals. Results. Overall, BT-CBT for chronic pain reduces patients’ pain, distress, and pain behavior, and improves their daily functioning. Differences across studies in sample characteristics, treatment features, and assessment methods seem to produce varied treatment results. Also, some patients benefit more than others. Highly distressed patients who see their pain as an uncontrollable and highly negative life event derive less benefit than other patients. Decreased negative emotional responses to pain, decreased perceptions of disability, and increased orientation toward self-management during the course of treatment predict favorable treatment outcome. Conclusions. Current BT-CBT helps many patients with chronic pain. Continuing clinical research should improve the matching of treatments with patient characteristics and refine the focus of treatments on behavior changes most associated with positive outcome. Further study of fear, attention, readiness to adopt self-management strategies, acceptance of pain, and new combinations of interdisciplinary treatments may lead to improved interventions.
Introduction:
Diabetic peripheral neuropathy (DPN) is the result of nerve damage in the toes, feet, or hands, causing loss of feeling or pain for up to 50 % of patients. The purpose of this qualitative study was to assess the burden and impact of DPN pain (DPNP) symptoms on patient's functioning and well-being.
Methods:
Four focus groups and 47 telephone interviews were conducted to understand the experience and impacts of DPNP from the patient's perspective. All participants were over the age of 18 years, read/spoke English, had a documented diagnosis of DPNP with symptoms for 6 months and a minimum 12-month history of diabetes mellitus, and had a daily pain rating of at least 4 on an 11-point numerical rating scale. Interview transcripts were analyzed thematically based on modified grounded theory principles.
Results:
There were 70 respondents-48 (68.6 %) males and 22 (31.4 %) females. The mean age was 54.0 years (range 26-70), and nearly all respondents had type 2 diabetes (87 %). Analysis identified four major areas of impact; DPNP patients reported difficulties with: (1) physical function, i.e. walking, exercise, energy, standing, balance, bending, and mobility; (2) daily life, i.e. productivity, recreational activities, work, enjoyment, focus, and chores; (3) social/psychological, i.e. anxiety, friends/family, irritability, depression, and fear; and (4) sleep, i.e. sleep, falling asleep, waking in the night, returning to sleep, and not feeling rested upon awakening.
Conclusion:
DPNP is a significant complication of diabetes with multiple impacts for patient functioning and well-being, which increase the burden of disease.
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A model of the affective-motivational dimension of pain is proposed that is based on phenomenological and psychophysical observations indicating that it is comprised of two stages. The immediate unpleasantness is based on several contributing processes, the most salient of which is the painful sensation itself. It represents an integration of nociceptive and non-painful sensory inputs, such as sight and sound, and is based on the perception of immediate threat to the body and consciousness. The secondary stage of pain affect is based on more complex meanings related to the longer term implications of pain. These two stages are distinct and separately measurable since they have different relationships to nociception and the sensory-discriminative dimension of pain and because there exist pharmacological and psychological factors that can selectively influence each of these stages. The functional relationships of these two stages to specific neural structures may be a promising area of future investigation.
Unlabelled:
The purpose of the present pilot study was to assess the efficacy of cognitive-behavioral therapy (CBT) for painful diabetic peripheral neuropathy. This was a randomized, treatment as usual (TAU), controlled, nonblinded intervention pilot study with a 4-month follow-up conducted in a VA medical center. It was hypothesized that participants who received CBT, as compared to those who received TAU, would report significant decreases on self-report measures of pain severity, interference, and depressive symptoms from pretreatment to 4-month follow-up. Participants meeting inclusion criteria were randomly assigned to 1 of the study conditions. Of the 20 eligible participants, 12 were randomized to CBT and 8 were randomized to TAU. Participants randomized to CBT showed significant decreases on measures of pain severity (B = -.54) and pain interference (B = -.77) from pretreatment to 4-month follow-up. There were no significant changes in the TAU participants' scores on measures of pain severity (B = .00) or pain interference (B = -.09). Neither CBT nor TAU participants showed significant changes in their levels of depressive symptoms from pretreatment to 4-month follow-up. CBT may be an effective treatment approach for reducing pain severity and interference associated with painful diabetic peripheral neuropathy.
Perspective:
The results of this study suggest that engaging patients in CBT for painful diabetic peripheral neuropathy may provide them the skills to become more active and experience less pain.
Approximately 1-2 million Americans are estimated to be infected with the human immunodeficiency virus (HIV). Peripheral neuropathic pain in ambulatory patients with HIV is prevalent and associated with significant psychological distress, social-vocational impairment and diminished quality of life. Alternatives to analgesics are needed for a variety of reasons including the fact that analgesics alone are not always successful in treating pain and many patients have fears regarding side effects, addiction, and tolerance. Pain Management Training (PMT), a manualized treatment developed by the authors, is designed to target HIV-related peripheral neuropathic pain and its related distressing symptoms. PMT employs a cognitive-behavioral approach to pain and suffering, with the primary goal of increasing the patient's sense of control and self-efficacy over the pain experience. This purpose of this paper is to describe, in detail, the structure of PMT utilizing patient examples to illustrate the approach.
There is now little doubt that poor blood glucose control is an important risk factor for the development of diabetic peripheral neuropathy (DPN). Furthermore, traditional cardiovascular risk factors for macrovascular disease appear to be associated with an increased risk of DPN. The recently established International Expert Group on Diabetic Neuropathy has recommended new criteria for the diagnosis of DPN in the context of clinical and research settings. Studies in experimental diabetes examining the pathogenesis of DPN have identified a number of metabolic abnormalities including polyol pathway hyperactivity, increased advanced glycation end-point formation, alterations in the protein kinase C beta pathway through diacylglycerol and oxidative stress. There is now strong evidence implicating nerve ischemia as the cause of DPN. Studies in human and animal models have shown reduced nerve perfusion and endoneurial hypoxia. These endoneurial microvascular changes strongly correlate with clinical severity and the degree of nerve-fiber pathology. Unfortunately, many compounds that have been effective in animal models of neuropathy have not been successful in human diabetic neuropathy. The only compounds found to be efficacious in human diabetic neuropathy, and are in clinical use, are the anti-oxidant, α-lipoic acid and the aldose reductase inhibitor, epalrestat. Overall, the evidence emphasizes the importance of vascular dysfunction, driven by metabolic change, in the etiology of DPN, and highlights potential therapeutic approaches. Epidemiological data on diabetic painful neuropathic pain (DPNP) are limited. In one population-based study, the prevalence of DPNP, as assessed by a structured questionnaire and examination, was estimated at 16%. It was notable that, of these patients, 12.5% had never reported symptoms to their doctor and 39% had never received treatment for their pain. Thus, despite being common, DPNP continues to be underdiagnosed and undertreated. Pharmacological treatment of DPNP include tricyclic compounds, serotonin noradrenalin reuptake inhibitors, the anti-oxidant α-lipoic acid, anticonvulsants, opiates, membrane stabilizers, topical capsaicin and so on. Management of the patient with DPNP must be tailored to individual requirements and will depend on the presence of other comorbidities. (J Diabetes Invest, doi: 10.1111/j.2040-1124.2010.00083.x)
Pain and other symptoms such as dyspnea (shortness of breath) have a physical basis, but suffering is personal. The path,
stretching from the physiological response evoked by a physical stimulus to the disintegration of the person experienced as
suffering, is important to understand not only for itself but also as an exemplar of mind-body interactions. As is well known,
the domains of body and mind have been kept separate in the intellectual life of Western culture from its earliest history
to the present. This is despite the fact that, in stage after stage in the development of Western medicine from the Hippocratic
tradition to the present, there has always been an understanding that the mental life — called the moral life at some periods
—has an impact on the body and its afflictions (Entralgo, 1956). It is difficult to make a statement about the relationship of these two realms that does not sound dualistic. This essay,
to the contrary, is based on the belief that we are of a piece — anything that happens to one part affects the whole, what
affects the whole affects every part. All the parts are interdependent and not one functions completely separate from the
rest. For example, although the functions of the lung are unique to that organ, their results influence the whole organism:
respiration, in all its complexity, flows through the whole. Similarly, reason and the passions (classically considered functions
of the mind) both require and act through the body, they flow through the whole. If you think this a strange idea, ask yourself
how there could be complete separation of any part from the whole, so that what happened in the part had no effect on the
whole?
Diabetic peripheral neuropathy (DPN) affects up to 50% of patients with diabetes and is a major cause of morbidity and increased mortality. Its clinical manifestations include painful neuropathic symptoms and insensitivity, which increases the risk for burns, injuries and foot ulceration.
Several recent studies have implicated poor glycaemic control, duration of diabetes, hyperlipidaemia (particularly hypertryglyceridaemia), elevated albumin excretion rates and obesity as risk factors for the development of DPN.
Although there is now strong evidence for the importance of nerve microvascular disease in the pathogenesis of DPN, the risk factors for painful DPN are not known. However, emerging evidence regarding the central correlates of painful DPN is now afforded by brain imaging.
The diagnosis of DPN begins with a careful history of sensory and motor symptoms. The quality and severity of neuropathic pain if present should be assessed using a suitable scale. Clinical examination should include inspection of the feet and evaluation of reflexes and sensory responses to vibration, light touch, pinprick and the 10-g monofilament.
Glycaemic control and addressing cardiovascular risk is now considered important in the overall management of the neuropathic patient. Pharmacological treatment of painful DPN includes tricyclic compounds, serotonin–norepinephrine reuptake inhibitors (e.g. duloxetine), anticonvulsants (e.g. pregabalin), opiates, membrane stabilizers, the antioxidant alpha lipoic acid and others. Over the past 7 years, new agents with perhaps less side effect profiles have immerged. Management of patients with painful neuropathy must be tailored to individual requirements and will depend on the presence of other co-morbidities. There is limited literature with regard to combination treatment. Copyright
Randomized, double-blind, placebo-controlled trials on neuropathic pain treatment are accumulating, so an updated review of the available evidence is needed. Studies were identified using MEDLINE and EMBASE searches. Numbers needed to treat (NNT) and numbers needed to harm (NNH) values were used to compare the efficacy and safety of different treatments for a number of neuropathic pain conditions. One hundred and seventy-four studies were included, representing a 66% increase in published randomized, placebo-controlled trials in the last 5 years. Painful poly-neuropathy (most often due to diabetes) was examined in 69 studies, postherpetic neuralgia in 23, while peripheral nerve injury, central pain, HIV neuropathy, and trigeminal neuralgia were less often studied. Tricyclic antidepressants, serotonin noradrenaline reuptake inhibitors, the anticonvulsants gabapentin and pregabalin, and opioids are the drug classes for which there is the best evidence for a clinical relevant effect. Despite a 66% increase in published trials only a limited improvement of neuropathic pain treatment has been obtained. A large proportion of neuropathic pain patients are left with insufficient pain relief. This fact calls for other treatment options to target chronic neuropathic pain. Large-scale drug trials that aim to identify possible subgroups of patients who are likely to respond to specific drugs are needed to test the hypothesis that a mechanism-based classification may help improve treatment of the individual patients.
Many pain patients appreciate biofeedback interventions because of the integration of psychological and physiological aspects. Therefore we wanted to investigate in a sample of chronic back pain patients whether biofeedback ingredients lead to improved outcome of psychological interventions.
One hundred and twenty-eight chronic back pain patients were randomly assigned to cognitive-behavioural therapy (CBT), cognitive-behavioural therapy including biofeedback tools (CBT-B) or waitlist control (WLC). The sample was recruited from a highly disabled group including many patients with low education status and former back surgeries. Measures on pain, physical functioning, emotional functioning, coping strategies and health care utilisation were taken at pretreatment, posttreatment and 6 months of follow-up.
The results indicated significant improvements on most outcome measures for CBT-B and CBT in comparison to WLC. CBT-B and CBT were equally effective (e.g. ITT effect sizes for pain intensity: CBT-B, 0.66 (95% CI 0.39-0.95); CBT, 0.60 (95% CI 0.33-0.87)).
In conclusion, biofeedback ingredients did not lead to improved outcome of a psychological intervention. Cognitive-behavioural treatment as a "package" of respondent, operant and cognitive interventions was effective for ameliorating pain-related symptoms for chronic back pain patients treated in an outpatient setting. The high treatment acceptability associated with biofeedback ingredients can also be achieved with pure psychological interventions.
A number of different treatments for neuropathic pain have been studied, but the literature is sizable, rapidly evolving, and lacks important information about practical aspects of patient management. Under the auspices of the International Association for the Study of Pain (IASP) Neuropathic Pain Special Interest Group (NeuPSIG), a consensus process was used to develop evidence-based guidelines for the pharmacologic management of neuropathic pain that take into account clinical efficacy, adverse effects, impact on health-related quality of life, convenience, and costs. On the basis of randomized clinical trials, medications recommended as first-line treatments for neuropathic pain included certain antidepressants (i.e., tricyclic antidepressants and dual reuptake inhibitors of both serotonin and norepinephrine), calcium channel alpha(2)-delta ligands (i.e., gabapentin and pregabalin), and topical lidocaine. Opioid analgesics and tramadol were recommended as second-line treatments that can be considered for first-line use in selected clinical circumstances. Other medications that generally would be used as third-line treatments include certain other antidepressant and antiepileptic medications, topical capsaicin, mexiletine, and N-methyl-d-aspartate receptor antagonists. Two other national and international associations recently published pharmacologic treatment guidelines for neuropathic pain, which are summarized and contrasted with the NeuPSIG recommendations. Recent guidelines for the use of neurostimulation for the treatment of neuropathic pain also are summarized. For all treatments for neuropathic pain, long-term studies, head-to-head comparisons, and studies of treatment combinations are a priority for future research.
This chapter focuses on cognitive behavioral approaches and neuropathic pain. It discusses the reason for suffering of people with pain, with an emphasis on pain management programs. Education is an important element of cognitive behavioral pain management interventions. People often respond to chronic pain as they would to acute pain. Cognitive theory as applied to pain suggests that people's idiosyncratic beliefs and thoughts about their pain and situation influence their response to their pain and the level and type of distress. Cognitive interventions aim to help change unhelpful cognitive and behavioral responses to pain by encouraging people to address and re-evaluate their beliefs and the meanings they hold about the pain, their expectations of selfefficacy and their everyday cognitions about their pain and situation. However, it is required to ascertain whether established cognitive behavioral pain management interventions are effective in improving the quality of life for people with neuropathic pain, or whether they require adaptation to meet the differing needs of this population.
A survey of employment problems in a random sample of diabetic patients and a group of control subjects aged 17-65 years was carried out in eight centres in the UK. Data were linked to information collected from patients' diabetic clinic notes relating to the presence and treatment of any diabetic complications and quality of diabetic control. Difficulties in obtaining employment because of diabetes were reported by 13% of diabetic patients, and because of illness by 2% of control subjects (p less than 0.001). Nine percent of diabetic patients and 2% of control subjects reported having to change their job because of their illness (p less than 0.001), and 7% of people with diabetes and 2% of people without diabetes reported losing a job because of their illness (p less than 0.001). Diabetic shift workers were twice as likely as control subjects working shifts to experience problems with their job (18 vs 8%, p = 0.045). Reports of any sickness absence in the last 12 months were not significantly different for people with and without diabetes (49 vs 45%). Sickness absence in excess of 20 days in the last 12 months was more common among diabetic patients than control subjects (29 vs 16%, p less than 0.001). People with diabetes are more likely to experience problems in obtaining employment and staying employed than people without diabetes.
The aim of this paper is to study the quality of verbal description and its diagnostic value in neuropathic pain. The verbal description of pain as assessed by a French adjective list questionnaire (QDSA) is compared between a group of 100 patients with neuropathic pain and a mixed group of 97 chronic benign and cancer non-neuropathic pain patients. Seventeen descriptors of the 61 QDSA descriptors have a significant intergroup frequency difference. By principal component analysis and Varimax rotation of the intercorrelation matrix of descriptors in the neuropathic group. 7 factors accounting for 66.0% of the total variance are derived. Six factors reflect purely sensory or affective aspects of the pain experience. Seven descriptors from the discriminant analysis function correctly assign 77% of neuropathic pain patients and 81% of the non-neuropathic pain patients. In a second neuropathic pain group of 32 patients, the discriminant function coefficient permits correct diagnostic categorization in 66% of the cases. Implications for clinical practice and trials are discussed.
This paper reports the development of a self-report instrument designed to assess pain in cancer and other diseases. It is argued that issues of reliability and validity should be considered for every pain questionnaire. Most research on measures of pain examine reliability to the relative neglect of validity concerns. The Wisconsin Brief Pain Questionnaire (BPQ) is evaluated with regard to both reliability and validity. Data from patients with cancer at 4 primary sites and from patients with rheumatoid arthritis suggest that the BPQ is sufficiently reliable and valid for research purposes. Additional methodological and theoretical issues related to validity are discussed, and the need for continuing evaluation of the BPQ and other measures of clinical pain is stressed.
Conventional treatment for painful peripheral diabetic neuropathy is largely symptomatic and often ineffective, with unacceptable side-effects. We tested electrical spinal-cord stimulation for the management of chronic neuropathic pain.
Ten diabetic patients who did not respond to conventional treatment (mean age 51 [SD 9.3] years, six with type II diabetes, mean duration of diabetes 12 [6.3] years, mean duration of neuropathy 5 [2.1] years) were studied. The electrode was implanted in the thoracic/lumbar epidural space. Immediate neuropathic pain relief was assessed by visual analogue scale (VAS) after connecting the electrode, in a random order, to a percutaneous electrical stimulator or to a placebo stimulator. Exercise tolerance was assessed on a treadmill.
Eight subjects had statistically significant pain relief with the electrical stimulator (p < 0.02) and were therefore converted to a permanent system. Statistically significant relief of both background and peak neuropathic pain was achieved at 3 months (n = 7, p = 0.016), at 6 months (n = 7, p = 0.03), and at the end of the study (14 months, n = 7, background pain p = 0.06, peak pain p = 0.03). One patient died 2 months after the start of the study of unrelated cause while continuing to benefit from treatment and another patient ceased to benefit at 4 months. McGill pain questionnaire scores with the stimulator turned off did not change significantly from baseline scores, indicating that the severity of the underlying pain was unaltered. However, with the stimulator turned on, there was a statistically significant (p < 0.05) improvement in all four components of the score, by the end of the study. At the end of the study, six patients continued to gain significant pain relief and used the stimulator as the sole treatment for their neuropathic pain. For example, median background and peak pain scores at the end of study, were, respectively, 77 and 81 with the stimulator off and 23 and 20 with the stimulator on. Exercise tolerance significantly improved at 3 months (n = 7, median % increase 85 [IQR, 62-360], p = 0.015) and at 6 months (n = 6, 163 [61-425], p = 0.0007). Electrophysiological tests, vibration perception-threshold, and glycaemic control were unchanged.
Electrical spinal-cord stimulation offers a new and effective way of relieving chronic diabetic neuropathic pain and improves exercise tolerance. The technique should be considered in patients with neuropathic pain who do not respond to conventional treatment.
There is little information on the extent of persistent pain across cultures. Even though pain is a common reason for seeking health care, information on the frequency and impacts of persistent pain among primary care patients is inadequate.
To assess the prevalence and impact of persistent pain among primary care patients.
Survey data were collected from representative samples of primary care patients as part of the World Health Organization Collaborative Study of Psychological Problems in General Health Care, conducted in 15 centers in Asia, Africa, Europe, and the Americas.
Consecutive primary care attendees between the age of majority (typically 18 years) and 65 years were screened (n = 25 916) and stratified random samples interviewed (n = 5438).
Persistent pain, defined as pain present most of the time for a period of 6 months or more during the prior year, and psychological illness were assessed by the Composite International Diagnostic Interview. Disability was assessed by the Groningen Social Disability Schedule and by activity-limitation days in the prior month.
Across all 15 centers, 22% of primary care patients reported persistent pain, but there was wide variation in prevalence rates across centers (range, 5.5%-33.0%). Relative to patients without persistent pain, pain sufferers were more likely to have an anxiety or depressive disorder (adjusted odds ratio [OR], 4.14; 95% confidence interval [CI], 3.52-4.86), to experience significant activity limitations (adjusted OR, 1.63; 95% CI, 1.41 -1.89), and to have unfavorable health perceptions (adjusted OR, 1.26; 95% CI, 1.07-1.49). The relationship between psychological disorder and persistent pain was observed in every center, while the relationship between disability and persistent pain was inconsistent across centers.
Persistent pain was a commonly reported health problem among primary care patients and was consistently associated with psychological illness across centers. Large variation in frequency and the inconsistent relationship between persistent pain and disability across centers suggests caution in drawing conclusions about the role of culture in shaping responses to persistent pain when comparisons are based on patient samples drawn from a limited number of health care settings in each culture.
The quality of life (QOL) of 79 people with type 1 and type 2 diabetes and 37 non-diabetic controls was assessed using the Nottingham Health Profile (NHP). The NHP consists of six domains assessing energy, sleep, pain, physical mobility, emotional reactions and social isolation. Symptomatic diabetic neuropathy was present in 41 of the patients. The neuropathy patients had significantly higher scores (impaired QOL) in 5/6 NHP domains than either the other diabetic patients (p < 0.01) or the non-diabetic (p < 0.001) controls. These were: emotional reaction, energy, pain, physical mobility and sleep. The diabetic patients without neuropathy also had significantly impaired QOL for 4/6 NHP domains compared with the non-diabetic control group (p < 0.05) (energy, pain, physical mobility and sleep). This quantification of the detrimental effect on QOL of diabetes, and in particular of chronic symptomatic peripheral diabetic neuropathy, emphasizes the need for further research into effective management of these patients.
There is growing evidence for the idea that in back pain patients, pain-related fear (fear of pain/physical activity/(re)injury) may be more disabling than pain itself. A number of questionnaires have been developed to quantify pain-related fears, including the Fear-Avoidance Beliefs Questionnaire (FABQ), the Tampa Scale for Kinesiophobia (TSK), and the Pain Anxiety Symptoms Scale (PASS). A total of 104 patients, presenting to a rehabilitation center or a comprehensive pain clinic with chronic low back pain were studied in three independent studies aimed at (1) replicating that pain-related fear is more disabling than pain itself (2) investigating the association between pain-related fear and poor behavioral performance and (3) investigating whether pain-related fear measures are better predictors of disability and behavioral performance than measures of general negative affect or general negative pain beliefs (e.g. pain catastrophizing). All three studies showed similar results. Highest correlations were found among the pain-related fear measures and measures of self-reported disability and behavioral performance. Even when controlling for sociodemographics, multiple regression analyses revealed that the subscales of the FABQ and the TSK were superior in predicting self-reported disability and poor behavioral performance. The PASS appeared more strongly associated with pain catastrophizing and negative affect, and was less predictive of pain disability and behavioral performance. Implications for chronic back pain assessment, prevention and treatment are discussed.
Chronic pain is recognised as an important problem in the community but our understanding of the epidemiology of chronic pain remains limited. We undertook a study designed to quantify and describe the prevalence and distribution of chronic pain in the community.
A random sample of 5036 patients, aged 25 and over, was drawn from 29 general practices in the Grampian region of the UK and surveyed by a postal self-completion questionnaire. The questionnaire included case-screening questions, a question on the cause of the pain, the chronic pain grade questionnaire, the level of expressed needs questionnaire, and sociodemographic questions.
3605 questionnaires were returned completed. 1817 (50.4%) of patients self reported chronic pain, equivalent to 46.5% of the general population. 576 reported back pain and 570 reported arthritis; these were the most common complaints and accounted for a third of all complaints. Backward stepwise logistic-regression modelling identified age, sex, housing tenure, and employment status as significant predictors of the presence of chronic pain in the community. 703 (48.7%) individuals with chronic pain had the least severe grade of pain, and 228 (15.8%) the most severe grade. Of those who reported chronic pain, 312 (17.2%) reported no expressed need, and 509 (28.0%) reported the highest expressed need.
Chronic pain is a major problem in the community and certain groups within the population are more likely to have chronic pain. A detailed understanding of the epidemiology of chronic pain is essential for efficient management of chronic pain in primary care.
To determine whether microscopic vasculitis explains the clinical and pathologic features of diabetic lumbosacral radiculoplexus neuropathy (DLSRPN).
DLSRPN is usually attributed to metabolic derangement or ischemic injury, but microscopic vasculitis as the sole cause needs consideration.
We prospectively studied the clinical, laboratory, and EMG features as well as the pathology of distal cutaneous nerve biopsy specimens of patients with DLSRPN.
Study of DLSRPN nerve biopsy specimens (n = 33) compared with those from healthy controls (n = 14) and those with diabetic polyneuropathy (n = 21) provided strong evidence for ischemic injury (axonal degeneration, multifocal fiber loss, focal perineurial necrosis and thickening, injury neuroma, neovascularization, and swollen fibers with accumulated organelles), which we attribute to microscopic vasculitis (epineurial vascular and perivascular inflammation, vessel wall necrosis, and evidence of previous bleeding). Segmental demyelination was significantly associated with multifocal fiber loss.
1) This severe, debilitating neuropathy begins with symptoms unilaterally and focally in the leg, thigh, or buttock and spreads to involve the other regions of the same and then opposite side and is due to multifocal involvement of lumbosacral roots, plexus, and peripheral nerve (i.e., diabetic lumbosacral radiculoplexus neuropathy). 2) Motor, sensory, and autonomic fibers are all involved. 3) Ischemic injury explains the clinical features and pathologic abnormalities of nerve. 4) The proximate cause of the ischemic injury appears to be microscopic vasculitis. 5) The segmental demyelination is probably secondary to ischemic axonal dystrophy, thus providing a unifying hypothesis for both axonal degeneration and segmental demyelination.
Studies on the psychosocial impact of neuropathic pain conditions, including postherpetic neuralgia, diabetic neuropathy, complex regional pain syndrome, post spinal cord injury, postamputation, and AIDS-related neuropathy, are reviewed. Although limited, data are consistent with the larger literature on chronic pain and indicate that neuropathic pain reduces quality of life, including mood and physical and social functioning. Depression and pain coping strategies such as catastrophizing and social support predict pain severity, and a single diary study demonstrates a prospective relation between depressed mood and increased pain. Clinical trials of psychological interventions have not been reported, although some case series of successful treatment of neuropathic pain are reported, primarily in the area of biofeedback. Given the evidence indicating the broad impact of neuropathic pain on many areas of function, it is surprising that so few studies have investigated the impact of psychological interventions in these populations.
Cognitive-behavioral therapy has become a common nonpharmacologic treatment option for individuals experiencing chronic nonmalignant pain. This article begins with an overview of the cognitive-behavioral perspective on pain and pain management. The second section discusses relevant developmental issues and suggests refinements to cognitive-behavioral therapy for the elderly, followed by a case example describing the implementation of cognitive-behavioral therapy for an elderly gentleman in an ambulatory care setting. The details of assessment, treatment conceptualization and planning, intervention, and follow-up are explored in this context. This article concludes with suggestions for future refinements in the application of this approach in the management of chronic pain in the elderly.
The aim of the study was to determine the frequency of undiagnosed abnormal glucose metabolism in patients with idiopathic sensory neuropathy. Patients were separated into two groups depending on presence or absence of painful symptoms, and an oral glucose tolerance test was performed. Of the 48 patients studied, those with painful symptoms had a higher frequency of abnormal glucose metabolism than literature-based controls, whereas patients without painful symptoms showed no difference. Comparison of patients with and without painful symptoms had a P-value of 0.02. The results indicate the need to consider undiagnosed abnormal glucose metabolism in patients with idiopathic sensory neuropathy.
Neuropathic pains refer to a heterogeneous group of pain conditions characterised by lesion or dysfunction of the normal sensory pathways. Clinical characteristics include: delayed onset of pain after nervous system lesion, pain in area of sensory loss, spontaneous and different evoked types of pains. It has so far only been possible to classify these pains on basis of underlying cause or on anatomical location. The mechanisms underlying neuropathic pain are not yet clear, but neuronal hyperexcitability in those neurons that have lost their normal patterned input seems to be a common denominator for many, if not all types, of neuropathic pains. Along these lines, a mechanism-based classification has recently been proposed, which is an attractive approach because it provides a frame for a rationally based therapy of neuropathic pains. The clinical manifestations of neuronal hyperexcitability due to nervous system lesions is described.
The aim of this study was to evaluate and compare the psychometric properties of two generic health-related quality of life (HRQoL) instruments, the Short Form Health Survey (SF-36) and the Nottingham Health Profile (NHP) in a group of patients with chronic peripheral neuropathic pain (PNP). The sample consisted of 126 adults (56 men and 70 women) with PNP following a lesion of a peripheral nerve, spinal nerve or nerve root or patients with post-herpetic neuralgia. The battery of tests included visual analogue scales (VASs) for pain assessment and global rating of health and verbal rating scales of pain and other symptoms, as well as patient descriptors. The SF-36 had higher internal consistency reliability coefficients (alpha=0.79, range 0.70-0.90) than the NHP (alpha=0.68, range 0.49-0.79). Correlations between comparable dimensions of the two instruments were significant (range from -0.79 for the physical and mental dimensions to -0.29 for the social dimension) indicating a moderate degree of convergent validity. The study population had significantly worse scores on all dimensions of the two instruments when compared with the general population. Subjects with high VAS scores for pain on movement and those with low global health ratings had poorer scores on the both instruments. Overall, the SF-36 performed somewhat better on psychometric testing than did the NHP. However, the NHP contains dimensions such as sleep and more pain items which might be of particular importance in the PNP population. Since the instruments are short, both could be retained for continued testing in outcome studies of this population.
The present study was undertaken to assess the health-related quality of life (HRQoL) and burden of illness due to pain and its treatment for patients with peripheral neuropathic pain (PNP). It is the first step in finding reliable instruments/targets to evaluate treatment outcome in this patient population. Study population consisted of 126 patients suffering from neuropathic pain due to a peripheral nerve or root lesion, recruited from two multidisciplinary pain clinics. HRQoL was examined using Short Form 36 (SF-36) Health Survey and Nottingham Health Profile (NHP). Pain intensity in four categories (at rest and evoked by movement, touch and cold) was rated on a visual analogue scale (VAS). Degree of discomfort from pain and 25 symptoms related to pain and side-effects was also assessed. Reduction in workload due to pain was recorded, as was the pain relief from previous and current treatments and the reasons for discontinuing previous treatments. All dimensions in SF-36 and NHP were significantly impaired. SF-36 was a valid instrument for describing the impact of pain on the HRQoL of patients with PNP. NHP had a lower reliability but has other advantages that might be of importance. Many patients experienced poor pain relief from ongoing pain treatments. Most previous treatments were discontinued owing to lack of efficacy and/or severe side-effects. Many patients experienced a high intensity of at least one type of pain; median VAS for the highest pain intensity score of each patient (any type of pain) was 74/100. Besides pain, patients were most bothered by difficulty in sleeping, lack of energy, drowsiness, difficulty in concentrating and dry mouth. Employment status was reduced owing to pain in 52% of the patients. The intense pain, other troublesome symptoms, limited efficacy and tolerability of available treatments, together with the impaired health and reduced work status, amount to a substantial burden for patients with PNP.
This article reviews the prevalence, risk factors, natural history, and impact on quality of life of painful diabetic neuropathy (PDN) and postherpetic neuralgia (PHN).
Diabetes mellitus afflicts more than 14 million persons in the U.S. An estimated 20% to 24% of these persons experience PDN. Data on risk factors for PDN are limited, but duration of diabetes mellitus and poor glycemic control are probably important factors. Painful diabetic neuropathy may interfere with general activity, mood, mobility, work, social relations, sleep, leisure activities, and enjoyment of life. Herpes zoster strikes an estimated 800,000 persons each year in the U.S., most of whom are elderly or immunosuppressed. Using pain at 3 months after rash onset as a definition of PHN, between 25% and 50% of adults older than 50 years develop PHN, depending on early antiviral therapy for herpes zoster. Increasing age, greater pain and rash severity, greater degree of sensory impairment, and psychological distress are risk factors for PHN. Postherpetic neuralgia may cause fatigue, insomnia, depression, anxiety, interference with social roles and leisure activity, and impaired basic and instrumental activities of daily living.
Both conditions are common complications of their underlying disorders and can profoundly diminish the quality of life of affected persons.
The feasibility and acceptability of cognitive behavior therapy for HIV-related peripheral neuropathic pain was examined and the potential efficacy of the intervention was compared with that of supportive psychotherapy in reducing pain, pain-related interference with functioning, and distress. Sixty-one patients were randomly assigned to receive six weekly sessions of cognitive behavior therapy or supportive psychotherapy. Thirty-three subjects completed the protocol. Both groups showed significant reductions in pain. The cognitive behavior group improved in most domains of pain-related functional interference and distress; the supportive psychotherapy group showed fewer gains. The high dropout rate suggests that psychotherapeutic treatments for HIV-related pain may have limited feasibility and acceptability.