APS and ACP Release Clinical Practice Guideline for Low Back Pain Published in Annals of Internal Medicine For low-back-pain patients and their doctors, a new evidence-based clinical practice guideline, published in the Annals of Internal Medicine, recommends less reliance on expensive diagnostic imaging and reports that there is strong evidence supporting the benefits of several therapies-with and without medication. According to Roger Chou, MD, director of the APS Clinical Practice Guideline Program and associate professor, Oregon Health and Science University, the guideline (sponsored by APS in collaboration with the American College of Physicians [ACP]) is based on a multidisciplinary panel's review and analysis of volumes of evidence related to diagnosis and treatment of low back pain in the primary care setting. "The evidence is much better than even 5 or 10 years ago and will help physicians be more confident when suggesting therapies for low back pain," said Chou. "There are a number of medications and nonpharmacologic therapies supported by high-quality studies. Physicians and patients should discuss the possibilities and choose the ones that make sense for their situation," he added. The APS guideline advises clinicians to minimize the routine use of X rays or other diagnostic tests to diagnose low back pain. "There is good evidence that physicians should not order X rays or other imaging tests for patients with nonspecific low back pain. They are not helpful and could result in excessive radiation exposure or lead to unnecessary procedures," said Chou. He added that the recommendations instruct physicians to perform diagnostic imaging tests for patients known or believed to have underlying neurological or spinal disorders. The guideline recommends that when determining treatment options, physicians should take into account whether potential medications are appropriate for the severity of baseline pain and functional impairment, and clinicians should carefully weigh the potential benefits and risks of any drug and explain them to the patient. "Several medications offer some benefits for low back pain, but they have risks," said Chou. "For example, acetaminophen is safe, but it is not that effective. NSAIDs provide more relief but they have gastrointestinal and cardiovascular side effects. And opioids can treat severe pain, but they pose risks for sedation and dependence over time." There are numerous nonpharmacological treatments for low back pain ranging from chiropractic care to massage therapy and the guideline panel recommended they be considered for patients who do not improve with self-care options and prefer not to take pain medications. "Above all," noted Chou, "the panel strongly recommends that low-back-pain patients stay active and talk honestly with their physicians about self-care and other interventions that may or may not involve drugs." A Landmark APS-ACP Collaboration The low-back-pain guideline is the first collaboration between APS and ACP. The ACP represents approximately 100,000 internists in the United States. The guideline is the fifth evidenced-based pain management clinical practice guideline published by APS; others have covered acute pain and pain from sickle-cell disease, arthritis, cancer, and fibromyalgia. For more information about APS guidelines, please visit http://www.ampainsoc.org/pub/cp_guidelines.htm. "This is a milestone collaboration in which organizations representing pain management and primary care have developed the first comprehensive evidence-based clinical practice guideline to assist clinicians in managing low back pain," said APS President Judith Paice, PhD RN FAAN. "We are grateful to the American College of Physicians for joining forces with APS in developing this long-awaited publication." The Annals of Internal Medicine article covers low-back-pain treatment in primary care settings only, and does not make recommendations regarding specialized invasive procedures to treat the condition. According to Chou, APS will release the complete guideline in 2008 and it will cover both primary care recommendations as well as invasive treatments for low back pain. Chou said the guideline panel, which comprises 25 members representing more than 15 different areas of expertise, unanimously approved all seven of the following recommendations published in the Annals of Internal Medicine article: Clinicians should conduct a focused history and physical examination to help place patients with low back pain into one of three broad categories: nonspecific low back pain, back pain potentially associated with radiculopathy (nerve disorders) or spinal stenosis (narrowing), or back pain associated with another specific cause. The history should include an assessment of psychosocial risk factors, which predict risk for chronic disabling back pain. Clinicians should not routinely obtain imaging or other diagnostic tests in patients with nonspecific low back pain. Clinicians should perform diagnostic imaging and testing for patients with low back pain when severe or progressive neurologic deficits are present or when serious underlying conditions are suspected. Clinicians should evaluate patients with persistent low back pain and signs or symptoms of radiculopathy or spinal stenosis with magnetic resonance imaging (preferred) or computed tomography only if a patient is a potential candidate for surgery or epidural steroid injection (for suspected radiculopathy). Clinicians should provide patients with low-back-pain evidence-based information about their expected course, advise patients to remain active, and provide information about effective self-care options. For patients with low back pain, clinicians should consider the use of medications with proven benefits in conjunction with back care information and self-care. Clinicians should assess the severity of baseline pain and functional deficits, potential benefits, risks, and relative lack of long-term efficacy and safety data before initiating therapy. For patients who do not improve with self-care options, clinicians should consider the addition of nonpharmacologic therapy with proven benefits for low back pain. For acute low back pain, this includes spinal manipulation. For chronic or subacute low back pain, options include intensive interdisciplinary rehabilitation, exercise therapy, acupuncture, massage therapy, spinal manipulation, yoga, cognitive-behavioral therapy, or progressive relaxation. APS 2007 Future Leaders in Pain Small Grants Program The Future Leaders in Pain Small Research Grants Program has been established to fund research projects of doctorally prepared investigators who have not yet attained NIH RO1-level funding. The program's intent is to encourage pain research that will add to the body of knowledge and to allow investigators to develop pilot data that will help them secure additional major grant funding. The program began in 2005 and three $16,000 grants were awarded. With increased funding in 2006, APS was able to award five grants of $20,000 each. APS is pleased to announce this year's grant recipients: Laura A. Frey Law, PhD PT The University of Iowa Iowa City, IA "Individual Differences Contributing to Muscle Pain Heterogeneity" Anna C. Long, PhD Oregon Health & Science University Portland, OR "Web-Based Cognitive Behavioral Therapy for Adolescents with Chronic Pain: Measuring Functional Outcomes" Lisa C. Loram, PhD MSc University of Colorado at Boulder Boulder, CO "Long-Duration Reversal of Neuropathic Pain by a Single Intrathecal Administration of Adenosine 2a Receptor Agonists: A Novel Therapy for Neuropathic Pain" Magali Millecamps, PhD McGill University Montreal, Canada "Animal Models of Low Back Pain" Jamie L. Rhudy, PhD University of Tulsa Tulsa, OK "Menstrual Cycle Influences on Supraspinal Modulation of Pain and Nociception" APS gratefully acknowledges Cephalon and Endo Pharmaceuticals for their support of this program. Call for Nominations Do you possess leadership qualities such as vision, strategic thinking, and motivation? Are you dedicated to APS and its mission? Do you know someone who is? If you answered yes to any of these questions, send the APS Nominating Committee your nominations for the upcoming election. The Call for Nominations invitation will be sent to APS members this month. Members who have active e-mail addresses will be notified by e-mail; those without e-mail addresses will receive instructions by mail. Open positions include secretary, three directors-at-large, and seven positions on the nominating committee. Nominees must be APS Regular Members, and most importantly, want to achieve positive outcomes for the society, its members, and those who are served by its efforts. Elections for these positions will take place this winter and the new leaders will take office at the 2008 annual meeting. Position descriptions, a current list of board and nominating committee members, position vacancies, and the disciplinary composition and geographic representation of the board are available in the members-only section of the APS Web site. The online nomination and voting process is quick and easy. Please take advantage of this opportunity to be involved in the nomination process. Your participation is important to the future of APS. Final Reminder: APS Call for Paper and Poster Abstracts The call for paper and poster abstracts for the 27th Annual Scientific Meeting, May 7-10, 2008, in Tampa, FL, is now available online. Abstracts can be submitted until 11:59 pm Pacific Time on Tuesday, October 30. Clinical Centers of Excellence in Pain Management Awards Program Applications due December 14 The Clinical Centers of Excellence (CCOE) in Pain Management awards program, which was launched in 2007, will annually award U.S-based healthcare teams who provide the most distinguished and comprehensive pain care. In 2007, six forward-thinking teams of healthcare professionals were recognized as CCOE in Pain Management award recipients. They were selected from an incredibly strong field of nearly 100 applicants from healthcare settings both large and small from around the country. Eligibility and Criteria The CCOE award is intended to honor programs or services that exemplify the provision of outstanding clinical care. Any U.S.-based, multidisciplinary clinical program that provides direct patient care and is primarily focused on the treatment of pain is eligible to apply. Selection of awardees will be based on judgment of the quality of services provided and not size of program. Attempts will be made to balance service excellence with available resources. The CCOE award honors programs that Provide care that is patient-centered, state-of-the-art, evidence-based, and safe. Provide appropriate access to multidisciplinary and multimodal care through the involvement of specialists from a variety of disciplines to ensure expert care. Act as local champions to improve pain management in systems of care that are related to the program, and/or are regional or national. Demonstrate innovation and serve as models of excellence in the structure, processes, and outcomes that are critical for excellence in pain management. Actively work with other health care organizations, health care providers, and the community to improve the quality of pain management across the continuum of care. Demonstrate a commitment to advancing and applying current scientific knowledge related to pain and disseminating relevant information to patients, colleagues, and the public. 2008 CCOE Committee The 2008 committee includes members who were recipients of the 2007 CCOE Awards. Michael E. Clark PhD, Chair James A. Haley Veterans Hospital Judith A. Paice, PhD RN FAAN, APS President Northwestern University Medical School Elsayed Abdel-Moty, PhD Rosomoff Comprehensive Pain Center Christopher Gharibo, MD New York University Medical Center Kenneth R. Goldschneider, MD Cincinnati Children's Hospital Robert N. Jamison, PhD Brigham & Women's Hospital Mark P. Jensen, PhD University of Washington Dennis C. Turk, PhD University of Washington Christine Dorothy Zampach, PT MEd DPT University of California, San Francisco Application Process The 2008 application process opened this month. The online submission system has been streamlined. Interested programs should visit http://aps.ccoe.confex.com/aps_ccoe/2007/cfp.cgi for application information. Applications are due December 14, 2007. The 2008 recipients will be honored at an awards gala, which will take place on Thursday, May 8, during the APS Annual Scientific Meeting. The Journal of Pain Highlights The following highlights summarize selected articles from the October 2007 issue (volume 8, number 10). Studies Show Emotions Influence Chronic Pediatric Pain Outcomes For physicians and families seeking relief for children with chronic pain, there are three new studies published in The Journal of Pain identifying several psychological and social influences that may contribute to the development of chronic pediatric pain and pain-related disability. In one study, a Spanish research team reviewed the literature and interviewed 30 clinicians and researchers with broad pediatric pain experience to identify consensus factors contributing to chronic pediatric pain and disability. The goal was to learn if factors predictive of chronic pain are different from those of functional disability. The authors reported that the factors exerting the greatest influence on pediatric pain for children who developed chronic pain were negative emotions and excessive fear or catastrophizing, excessive utilization of healthcare services and medications, and a tendency for children to show negative expectations and other psychological factors related to the pain experience. For children with a pain-related disability, their self-perception as being disabled and hesitancy to exercise for fear of injury were cited as the most influential predictive factors. The study concluded that the development of chronic pain and pain-related disability can result from interacting psychological, emotional, and social forces. The results of the study ultimately can be helpful for developing psychological intervention programs to help prevent long-term pain and disability in children. In another article, researchers at UCLA's David Geffen School of Medicine examined the relationship between anxiety sensitivity and a poorer health-related quality of life in pediatric pain patients. Anxiety sensitivity is the fear of anxiety sensations. The concept of health-related quality of life describes perceived mental and physical health over time, which is valuable for assessing how chronic illness interferes with a patient's everyday quality of life. The study analyzed 87 children with chronic pain and found that higher anxiety sensitivity levels were associated with poorer perceived general and physical health, a greater level of impairment in family activities, lower self-esteem, increased behavior problems, and more social and academic limitations due to emotional problems. The authors concluded that their findings support using anxiety sensitivity as part of an extensive pain assessment process in children. In a third article covering pediatric pain, German researchers reported that negative psychological responses to pain, such as catastrophizing, correlate positively with depressive symptoms and with the frequency and intensity of pain episodes. They concluded that an abbreviated and internationalized pain questionnaire is valuable for assessing pain-related cognitions. Sources Predictive Factors of Chronic Pediatric Pain and Disability: A Delphi Poll Jordi Miró, Anna Huguet, and Rubén Nieto, Department of Psychology, Virgili University, Catalonia, Spain Anxiety Sensitivity and Health-Related Quality of Life in Children with Chronic Pain Jennie C. I. Tsao, Marcia Meldrum, Su C. Kim, and Lonnie K. Zeltzer, David Geffen School of Medicine at UCLA The Assessment of Pain Coping and Pain-Related Cognitions in Children and Adolescents: Current Methods and Further Development Christiane Hermann, Johanna Hohmeister, Katrin Zohsel, Friedrich Ebinger, and Herta Flor, University of Heidelberg and University of Leipzig, Germany Opioid Treatment Contracts Too Hard to Understand A study conducted at the University of Tennessee Graduate School of Medicine is the first to examine whether opioid contracts that provide instructions and guidance to patients regarding their treatment are understandable. A review of 162 such contracts showed that most were written in overly technical medical language. The authors recommended that the contracts be simplified by writing at a sixth-grade reading level to be more consistent with low health literacy. Only 12% of Americans have proficient health literacy skills. In a second article, these authors also developed a valid and readable low-literacy opioid contract that was written at a seventh-grade reading level and eliminated difficult medical terminology. The low-literacy contract was tested by a sample of patients; 19 of the 26 statements in the contract were understood by all. The authors concluded that the low-literacy opioid contract is suitable for use in clinical practice. Sources Literacy Demands and Formatting Characteristics of Opioid Contracts in Chronic Nonmalignant Pain Management Steven E. Roskos, Amy J. Keenum and Lindsay M. Newman, and Lorraine S. Wallace, University of Tennessee Graduate School of Medicine Development and Validation of a Low-Literacy Opioid Contract Lorraine S. Wallace, Amy J. Keenum, Steven E. Roskos, and Kelly S. McDaniel, University of Tennessee Graduate School of Medicine Highlights from the Clinical Journal of Pain The following highlights summarize selected articles from the October 2007 issue (volume 23, number 8). Impact of Continuous Low Level Heatwrap Therapy in Acute Low Back Pain Patients: Subjective and Objective Measurements Birgitt Kettenmann, PhD,*† Claudia Wille, MSc,* Elena Lurie-Luke, PhD,‡ Dave Walter, MSc,‡ and Gerd Kobal, MD PhD* *Department of Experimental and Clinical Pharmacology and Toxicology, University Erlangen-Nuremberg, Germany †Department of Radiology, Virginia Commonwealth University, Richmond, VA ‡P&G Health Sciences Institute, Procter & Gamble, Egham, UK Muscular pain is generally associated with increased muscle tension, which leads to a tension-pain cycle and increased alertness and stress. This study focused on combining objective parameters (i.e., spontaneous electroencephalogram [EEG] as a substitute for alertness and stress) with subjective parameters (i.e., self-assessed pain-affected variables) to determine how continuous low-level heat therapy affected low back pain (LBP) patients. In a randomized, active-controlled, parallel-designed study, 30 patients were randomly assigned to one of two groups: the control group (who received oral analgesics and were instructed to use them as needed) and the treatment group (who were given both oral analgesics-to use as rescue medication-and heatwrap therapy). The power of frequency bands in the spontaneous EEG was used to measure the objective parameters. A Pain, Sleep, and Stress Questionnaire was administered to assess the subjective parameters. The heatwrap therapy group's EEG recordings showed decreased power in Beta-1 and Beta-2 frequency bands compared with the control group's, indicating a reduction in arousal. In addition, the heatwrap therapy group also reported significantly reduced LBP, less stress in everyday situations, a better night's sleep, and fewer daytime naps. The authors explain that "in addition to classical psychophysical assessment of pain-related parameters, sleep quality, and performance in daily life, we were able to obtain objectives measures (EEG) that suggest an acute therapeutic relaxation on the basis of the central nervous system effects accompanying the reported significant pain relief. We believe this was due to a reduced nociceptive information load in LBP patients after the use of the heatwrap therapy." Fear of Movement (Kinesiophobia), Pain, and Psychopathology in Patients With Sickle Cell Disease Jennifer Pell, PhD,* Christopher L. Edwards, PhD,*†‡ Camela S. McDonald, MA,* Mary Wood, MA,*† Crystal Barksdale, MA,* Jude Jonassaint, RN, ‡, Brittani Leach-Beale,§ Goldie Byrd, PhD,\\ Markece Mathis, BA,\\ Myleme O. Harrison, MD,* Miriam Feliu, PsyD MA,*† Lekisha Y. Edwards, MA,*† Keith E. Whitfield, PhD, and Lesco Rogers, MD, †# *Department of Psychiatry and Behavioral Sciences, Duke University Medical Center, Durham, NC #Department of Anesthesiology, Duke University Medical Center, Durham, NC ‡Department of Medicine, Division of Hematology, Duke University Medical Center, Durham, NC †Duke Pain and Palliative Care Center, Duke University Medical Center, Durham, NC Department of Psychology, Duke University, Durham, NC §Xavier University, Cincinnati, OH \\Department of Biology, North Carolina A&T State University, Durham, NC Kinesiophobia, or fear of movement, is a significant predictor of pain-related outcomes including disability and psychologic distress across various types of pain (e.g., back pain, headache, fibromyalgia, complex regional pain syndrome). However, research examining the prevalence of kinesiophobia in adults with sickle cell disease (SCD) does not exist. This study assessed the degree of kinesiophobia reported by African American men and women with SCD to determine whether it is related to pain and psychological distress in this population. Sixty-seven men and women with SCD were recruited from a comprehensive sickle cell treatment program in a large academic medical center and asked to complete questionnaires that assessed fear of movement, pain and pain interference, and psychological distress. The study showed that the reported levels of kinesiophobia were comparable to those obtained for patients with low back pain and fibromyalgia. Pain levels did not differ by sex, however, men reported greater kinesiophobia than women. Higher levels of kinesiophobia were also associated with greater psychological distress. According to the authors "both kinesiophobia and sex are relevant constructs for consideration in understanding pain-related outcomes in SCD," and "this study suggests that greater kinesiophobia is associated with greater pain and psychologic distress." NIH RFAs for Chronic Pelvic Pain The RFA Multidisciplinary Approach to the Study of Chronic Pelvic Pain (MAPP) Research Network (RFA-DK-07-003) is now available on the NIH Web site. The National Institute of Diabetes and Digestive and Kidney Diseases (NIDDK) funding commitment for this program is as much as $7.5 million per year for a 5-year funding period. This unique program promotes basic, translational, and clinical science interactions and multidisciplinary collaborative approaches among various experts in urology and investigators who are not traditionally involved in chronic urologic pain research to address unmet needs in our understanding of interstitial cystitis/painful bladder syndrome (IC/PBS) and chronic prostatitis/chronic pelvic pain syndrome (CP/CPPS). Investigators are encouraged to build strong multidisciplinary teams to address the goals of this effort and to submit applications for this new and important NIDDK solicitation. All inquiries should be directed via e-mail to either Dr. Chris Mullins at MullinsC@extra.niddk.nih.gov or Dr. Lee Nyberg at NybergL@mail.nih.gov. The NIDDK will host an in-person information session in Bethesda, MD, on November 5, 2007. The receipt date for applications is January 9, 2008. Pain Management Traineeship Offered to Pharmacists American Society of Health-System Pharmacists (ASHP) Foundation is offering a pain management traineeship for pharmacists in acute settings who are providing specialized services for patients in pain. The traineeship prepares participants (who have little experience in providing pharmaceutical care to patients in pain) to design patient-specific pharmacotherapy; solve drug therapy problems; and develop protocols, policies, and procedures for the treatment of such patients. The traineeship will also strengthen pharmacists' ability to help their institutions meet pain assessment and management standards issued by the Joint Commission. For more information, click here. Critical Vote for 2008 Health Research Funding: Contact Your Senators Now The Senate is expected to vote on the 2008 Labor, Health and Human Services and Education (LHHS) appropriations bill this week. Urge your Senators to support this bill with no new amendments. It contains vital increases in funding for the NIH, CDC, and AHRQ. Contact your Senators and encourage them or their health staff to support this bill. A simple way to contact your Senators is through the Senate Web site, www.senate.gov/general/contact_information/senators_cfm.cfm. President Bush has threatened to veto appropriations bills if together they exceed his proposed budget total. Funding in the Senate LHHS bill is $11 billion more than proposed in President's 2008 budget. An important step in convincing the President to sign the LHHS bill will be strong bipartisan support for the bill in the Senate. Let your Senators know that investing in the NIH, CDC, AHRQ, and other LHHS programs now will pay off in the future—Americans will be healthier and our nation will retain its competitive edge. IASP Announces Its "Real Women, Real Pain" Campaign On October 15, 2007, the International Association for the Study of Pain (IASP) launched its Global Year Against Pain "Real Women, Real Pain" campaign, which aims to underscore the significant impact chronic pain has on women and the need for more effective care. IASP has a number of international activities planned for the campaign, such as a special issue of PAIN dedicated to women. This exciting issue, which will be available in November, includes three reviews, thirteen original research manuscripts, and the Consensus Conference Report from the IASP Sex, Gender, and Pain Special Interest Group. Pain: Clinical Updates will also publish educational articles throughout the year that focus on various issues affecting women. Visit the IASP Web site, www.iasp-pain.org, for more information on the campaign as well as local chapter activities. The Web site has fact sheets on pain in women available in several languages. Update on Tamper-Proof Rx Pads Many healthcare providers have been concerned about having to upgrade to tamper-proof prescription pads, which was reported in last month's APS E-News. This measure came up unexpectedly this summer, and was scheduled to take effect October 1. Efforts to delay the requirement for 6 months have passed in both houses of Congress and the delay provision is now attached to a bill that President Bush is expected to sign. Volunteer Spotlight: Timothy Brennan, MD Timothy Brennan, MD, has been an anesthesiologist for 15 years and currently practices at the University of Iowa Medical Center, Iowa City, IA. Before he attended medical school (and before he chose the specialty of anesthesiology) he studied pharmacology and pain management. Brennan has been a member of APS for the past 10 years and currently serves as the Scientific Program Chair for the 2008 APS Annual Scientific Meeting. He joined APS because "it provides an excellent venue to present basic science, clinical research, and translational research." His own research interests focus on the mechanisms of surgical pain. "Postoperative pain research is interesting because it has so much influence on acute-pain research," says Brennan. "Surgical pain is very predictable because we know the origin, extent, and duration of the pain problem. So the goal should be to make surgery pain-free some day." Looking ahead to the APS Annual Scientific Meeting in Tampa, FL, Brennan says attendees can expect a strong program for both clinicians and basic scientists in addition to the fabulous Florida spring weather. "As both a clinician and basic researcher, I have a broad perspective on the needs and interests of our membership and have applied it in developing the scientific program for 2008." New in 2008, three workshops will be offered on Friday, May 9. These workshops, which will take place during the meeting rather than as preconference events, are available to all attendees at no additional cost. This will eliminate the need for early travel and associated expenses. Workshop topics include ion channels, pediatric pain, and the use of opioids in noncancer pain management. "The committee has done an excellent job developing the program content and recruiting faculty. APS members can look forward to another first-rate meeting next year," assures Brennan.