We assessed the impact of home-based care (HBC) for HIV+ patients, comparing outcomes between two groups of Zambians receiving antiretroviral therapy (ART) who lived in villages with and without HBC teams.We conducted a retrospective cohort study using medical charts from Macha Mission Hospital, a hospital providing HIV care in Zambia's rural Southern Province. Date of birth, date of ART initiation, place of residence, sex, body mass index (BMI), CD4+ cell count, and hemoglobin (Hgb) were abstracted. Logistic regression was used to test our hypothesis that HBC was associated with treatment outcomes.2). In bivariable analysis, lower BMI (P<0.001), low CD4+ cell count (P = 0.02), low Hgb concentration (P = 0.02), and older age at ART initiation (P = 0.047) were associated with unfavorable outcomes. In multivariable analysis, low BMI remained associated with unfavorable outcomes (P<0.001).Of 655 patients, 523 (80%) were eligible and included in the study. There were 428 patients (82%) with favorable outcomes  and 95 patients (18%) with unfavorable outcomes . A minority of the 523 eligible patients  lived in villages with HBC available. Living in a village with HBC was not significantly associated with treatment outcomes; 80% of patients in a village with HBC had favorable outcomes, compared to 82% of patients in a village without HBC (P = 0.6 by χWe did not find that living in a village with HBC available was associated with improved treatment outcomes. We speculate that the ART clinic's rigorous treatment preparation before ART initiation and continuous adherence counseling during ART create a motivated group of patients whose outcomes did not improve with additional HBC support. An alternative explanation is that the quality of the HBC program is suboptimal. Home-based care (HBC) is used as an adjunct to or replacement for traditional clinic-based HIV care programs, especially where public health services are strained th highest adult prevalence in the world. Zambia is one of the most poverty-stricken nations in the world, ranking 150/169 in the 2010 Human Development Index (HDI), a multidimensional measure of poverty that considers life expectancy at birth, mean years of schooling, expected years of schooling, and gross national income per capita when assessing a country's developmental status Zambia, a country of 12 million people in Southern Africa, had an adult HIV prevalence of 13.1–14.3% in 2009 With support largely from the United States of America in the form of the President's Emergency Plan for AIDS Relief (PEPFAR), Zambia's major HIV care scale-up has yielded positive results; prevalence and mother to child transmission rates are dropping while the proportion of patients with advanced HIV receiving ART has increased from 1.7% in 2005 to 68% currently The study was approved by the Vanderbilt University Institutional Review Board. Since data were collected from chart review and no specific identifiers were retained in the database, written informed consent was not obtained, with permission of the Vanderbilt Institutional Review Board. As a retrospective chart review, the study was considered a “program review” and thus exempt from Zambian Institutional Review Board oversight.Macha Mission Hospital (MMH) is a 208-bed inpatient hospital in Zambia's rural Southern Province that began an ART-based HIV care program in 2005. The provincial HIV prevalence for men and women age 15–49 in 2007 was estimated to be 15% The HBC program of the MMH is administrated by a clinical officer, who is responsible for resource allocation, volunteer training, and logistical support, and three paid field officers who train volunteers, monitor HBC activities, and provide site-level support for HBC groups. The care system is comprised of 206 volunteers distributed between 12 community-based HBC teams of 10–20 volunteer caregivers with variable levels of training obtained either through MMH, local nongovernmental organizations, or the Zambian government. The median distance between the HIV clinic and the HBC, as travelled by the shortest path accessible by motorcycle, is 14 km , their charts were missing, or their charts were incomplete for village of residence, date of birth, date of ART initiation, or outcome. Patients who were missing body mass index (BMI), CD4+ cell count, or hemoglobin concentration (Hgb) were included. Baseline CD4+ cell count and Hgb were considered “missing” if values were not available within 100 days before ART initiation.Date of birth, date of ART initiation, place of residence, sex, BMI at ART initiation, CD4+ cell count at ART initiation, and Hgb at ART initiation were abstracted from patient medical charts. Age at ART initiation was determined using date of birth and date of ART initiation. Patients were classified as living in an HBC-serviced area if their village of residence was within the catchment area of one of the twelve MMH home-based care groups. BMI was calculated from heights measured at a patient's initial clinic visit and weights measured at a patient's ART initiation visit. The most recent CD4+ cell count and Hgb measured before or on the day of ART initiation were recorded.Patient outcomes were assessed from medical chart reviews. Patients continuing to receive treatment at MMH until the time of the study were designated “alive and on ART.” Patients were classified as “dead” if they died after initiating ART. Patients were classified as “lost to follow-up” if they missed a clinic appointment without communicating a reason to the staff and were subsequently unable to be contacted over the ensuing 90 days. Patients were classified as “stopped treatment” if they voluntarily stopped taking ART. Patients were classified as “transferred in” if they initiated ART at another clinic and then began receiving ART at MMH. Patients were classified as “transferred out” if they stopped receiving treatment at the MMH HIV clinic but continued on ART at another clinic. Patients were classified as “PMTCT” if they only received ART perinatally. The outcome was defined as favorable  or unfavorable . Patients in other outcome categories  were excluded .2 test. The Wilcoxon rank sum test was used to assess associations between outcome and continuous variables. Multivariable logistic regression was used to determine the effects of variables on outcomes; all six independent variables  were included in the multivariable model.Data were managed using Excel™  and analyzed using R: A Language and Environment for Statistical Computing . Possible associations between outcomes and categorical variables were calculated using the Pearson χWe reviewed the charts of 655 patients; 132 patients were excluded (20.2%), and 523 patients were included (79.9%) as per our study design. Of the excluded patients, 39 patients transferred out of care, 33 patients transferred into care, 33 patients were <18 years of age, 3 patients enrolled solely for PMTCT, 12 had incomplete village information, 3 had no date of ART initiation, 4 had incomplete outcome data, 4 had missing charts, and 1 started before January 2006 .For BMI, CD4+ cell count, and/or Hgb data, 370 of 523 (70.7%) included patient charts were complete, 115 (22.0%) were missing one data point, 30 (5.7%) were missing two data points, and 8 (1.5%) were missing all three data points. Of the 523 included patient charts, 53 (10.1%) were missing BMI, 83 (15.9%) were missing CD4+ cell count, and 62 (11.9%) were missing Hgb. The demographics and patient characteristics of patients in areas serviced by an HBC group were well balanced when compared to patients in areas not serviced by an HBC group, with no statistically significant differences in any recorded variable between either group. 2 = 0.29, P = 0.6). Frequency of death, loss to follow-up, and stopping treatment rates were similar: 17%, 2%, and 1% respectively among patients living where HBC was available and 13%, 4%, and 1% among those living outside of HBC service areas.  had a favorable outcome and 95 patients (18%) had an unfavorable outcome. In the unfavorable outcome group, 69 died, 19 were lost to follow-up, and 7 stopped treatment. Of 84 patients living in villages with HBC available, 80% had a favorable outcome, compared to 82% of the 439 patients living without HBC services (χe areas. 2 (IQR (interquartile range): 16.8–20.6) in the favorable outcome group and a median BMI of 17.0 kg/m2 (IQR: 15.6–19.1) in the unfavorable outcome group. Age at ART initiation was greater in the favorable outcome group  with a median age of 38 years (IQR: 31.5–46.1) and a median age of 36 years in the unfavorable outcome group (IQR: 31.4–41.3). Hgb was higher in the favorable outcome group  with a median Hgb of 11 g/dL (IQR: 10–12) and a median Hgb of 10 g/dL in the unfavorable outcome group (IQR: 9–12). CD4+ cell count was also higher in the favorable outcome group  with a median CD4+ cell count of 151 cells/µL in the favorable outcome group (IQR: 87–203) and a median CD4+ cell count of 131 cells/µL in the unfavorable outcome group (IQR: 71–174). There were no statistically significant associations between outcome and patient gender.  with a median BMI of 18.7 kg/m gender. 2 to 16.5 kg/m2, the odds of an unfavorable outcome more than doubled (CI: 1.4–3.2).Multivariable analysis showed no significant association between living in a HBC area and treatment outcome (P = 0.6). Lower BMI at the time of ART initiation was the only factor found to have a statistically significant association with unfavorable patient outcome in the multivariable analysis (P<0.001); as BMI decreased from 20.5 kg/mWe did not find that availability of HBC services was associated with a favorable or unfavorable outcome in rural Zambia. Loss to follow-up was slightly less common in the HBC service communities, but the numbers were too small to derive inferences. Outcomes among all patients at the MMH HIV clinic were very good, possibly attributable to an intensive treatment preparation before ART initiation and to MHH's rigorous continuous adherence counseling program. This prepares all patients initiating ART for treatment success by offering ART only to those who have demonstrated adherence to followup appointments and non-ART medications and may diminish the measurable effects of HBC Nonetheless, since the Malawi study showed favorable outcome rates comparatively higher in persons receiving HBC, we believe that additional factors are likely mitigating the effects of HBC on patient outcomes Misclassification bias may have diluted the effect of HBC on patient outcomes. Patients were classified by HBC category based upon the village of residence listed in the medical chart. The spelling of many of these villages is variable – these villages have a single spoken name with several spellings. As our data were culled from written charts, variability in spelling may have led to misclassification of the exposure to HBC. This nondifferential misclassification of the exposure would bias results towards the null hypothesis, thus dampening any measured effect of HBC on outcomes Finally, the effect of HBC in this population may not be detectable using our simple therapeutic outcome measure and/or with this sample size. HBC has been shown to impact patient quality of life in many ways not measured in this study, including but not limited to adherence Our data were consistent with the literature in terms of the association of unfavorable outcome with lower BMI, age, CD4+ cell count, and Hgb The goal of improving sustainability of PEPFAR-supported programs is essential, as current U.S. government financial support may wane over time and is already diversifying to include a broader range of global health care and prevention priority areas


There is continuing uncertainty in back pain research as to which treatment is best suited to patients with non-specific chronic low back pain (CLBP). In this study, Gestalt therapy and the shock trauma method Somatic Experiencing® (SE) were used as interventions in parallel with the usual cross-disciplinary approach. The aim was to investigate how these treatments influence a patient’s capacity to cope with CLBP when it is coupled with depression.In this qualitative explorative study, a phenomenological–hermeneutic framework was adopted. Patients were recruited on the basis of following criteria: A moderate depression score of 23–30 according to the Beck Depression Inventory Scale and a pain score of 7–10  and attendance at five- six psychotherapeutic sessions. Six patients participated in the study. The data was comprised of written field notes from each session, which were subsequently analysed and interpreted at three levels: naive reading, structural analysis and critical interpretation and discussion.Three areas of focus emerged: the significance of previous experiences, restrictions in everyday life and restoration of inner resources during the therapy period. The study revealed a diversity of psychological stressors that related to loss and sorrow, being let down, violations, traumatic events and reduced functioning, which led to displays of distress, powerlessness, reduced self-worth, anxiety and discomfort.Overall, the sum of the stressors together with pain and depression were shown to trigger stress symptoms. Stress was down-played in the psychotherapeutic treatment and inner resources were re-established, which manifested as increased relaxation, presence, self-worth, sense of responsibility and happiness. This, in turn, assisted the patients to better manage their CLBP.stress seems to become prominent. In this study, Gestalt therapy and the SE-method may have helped to lower the six patients’ level of stress and restore their own internal resources, thereby increasing their capacity to cope with their CLBP.CLBP is a stress factor in itself but when coupled with depression, they can be regarded as two symptom complexes that mutually affect each other in negative ways. When pain, stress and depression become overwhelming and there are few internal resources available,  This article reports on the way in which two psychotherapeutic treatments can influence a patient´s capacity to cope with non-specific chronic low back pain when it is complicated by depression. Interest in this area stems from the first author´s experience as a nurse, Gestalt therapist and Somatic Experiencing® Practitioner, working with patients who have low back pain.Over the decades, treatment for patients with back pain has become more and more intensive; nevertheless, approximately 20% continue not to benefit from evidence-based somatic treatment . With loA literature review found that epidemiological research  has showA study of Gestalt therapy and chronic pain  reportedIn a meta-analysis of psychological interventions  for CLBPAnother meta-analysis, which focussed on patients in need of psychotherapy  reportedSome people get chronic pain and depression. Chronic pain  is oftenThe rationale for studying psychotherapeutic treatment is that there continues to be a degree of uncertainty in back pain research as to which treatment best benefits patients with a chronic and complex pain problem. It is assumed that by studying psychotherapeutic treatment, one can gain insight into, and glean new knowledge about, which conditions are significant when helping patients with CLBP and depression manage their situation better.The aim of the study was to investigate how the selected psychotherapeutic treatments can influence a patient’s capacity to cope with CLBP when it is coupled with depression.Gestalt therapy  was chosThe Somatic Experiencing® method (SE-method) was also used in the intervention ,11 becauThis study is a qualitative exploration study, undertaken following psychotherapeutic intervention. The framework for the study is phenomenological-hermeneutic and inspired by the work of the French philosopher, Paul Ricoeur, about narrative and interpretation . The metThe participants were drawn from a randomised study of patients with non-specific LBP  who had . Out of the 46 patients, only 6 met all the inclusion criteria. The participants included four women and two men, aged between 20 and 33 years (average 29 years). All were on sick leave and had an unresolved work situation ; and a score for LBP of 7–10 The data collection is inspired by Spradley’s ethnographic method , which iThe processing of the data was based on the Ricoeur-inspired method that consisted of analysis and interpretation at three levels: naive reading, structural analysis and critical interpretation and discussion. The analysis and interpretation were performed by both the first and second authors.In the first analysis, the written narratives were read and re-read several times. The process of naive reading allows for an overall grasp of the text as a whole, which gives an initial and holistic understanding of what the text contains. This is a kind of understanding where, according to Ricoeur, one sees and listens out for what moves one in the text.Subsequently, a structural analysis was carried out, which had an explicit function. Here the text was analysed based on units of meaning, (what is said) and units of significance . Topics were drawn out that were reflected in the entire text material, in order to identify some common themes. The text was analysed on the basis of not only the text in the form of direct quotations, but also the meaning behind the content, as a first interpretation of what was being talked about, in order to let themes emerge. In Figure The themes were analysed, interpreted and discussed in relation to the theory and other research results.In this final part of the analysis, there is movement from the individual patient to the study cohort, or from the specific to the general.Individual screening-based biopsychosocial services for patients with non-specific low back pain, was approved by the Ethics Committee of the Region of Southern Denmark (nr. VF-20060062). All participants signed a written informed consent. In the current qualitative study, no names are given. To ensure confidentiality of the participants, the study was designed according to the Ethical Guidelines for Nursing Research in the Nordic Countries  [As a basic starting point, the randomised study, n, 2003) . A requeThe significance of previous experiences’. We also found patterns related to pain, distress, insomnia, anger and irritation at not being as able as before. These were listed under the theme ‘Restrictions in everyday life’. Further, we discovered a number of positive statements that indicated joy, liberation, desire, strength, resolution of inner tensions, increased self esteem and desire to take action. We grouped these under the theme ’Restoration of inner resources’. The three themes were then analysed, interpreted and discussed. The results are reported in the following section.An overview was obtained from the naive reading. After examining the field notes in general and the participants’ quotations in particular, we found words or expressions that related to such things as sadness, failure in childhood or adolescence, abuse, anxiety, and powerlessness in the context of past experiences. These were clustered under the theme: ‘The analysis showed how previous experiences influenced the patients’ present life and functioning, and hence, their CLBP. For example, the loss of a close relative had triggered anger and sorrow that could have led to self-destructive behaviour, as evidenced by the following statement:"“I am angry that my sister allowed herself to die and leave her daughter, who was a year old. I wished that I was dead instead. It is really sad to talk about it. I have been on the ropes since then.”"It is well known that bereaved people can have an unconscious urge to ‘be in the grave themselves’ and can lose a grip on their own lives.And another statement:"“I took so much Somadril, just the thought of it makes me nauseous. I was saturated in medicine. I don’t understand how it’s so easy to get prescribed medicine. It was the Somadril that put me completely down in the depths. I felt that I had no idea what I was doing, when I took so much medicine. And it was not to commit suicide that I took so much and was hospitalised.”"I have done something wrong and shame means I am wrong. Self-blame thus focuses on the action and can be healthy, if one really has done something inappropriate to another person, as this can sometimes be rectified. In contrast, however, shame is ranked with sin and inferiority [Throughout the quotation, a feeling of sorrow was expressed, which is thought to have caused self-destructive behaviour in the form of medicine overdose. Other themes that came up in the study were self-blame and shame. Self-blame means eriority . From thOther previous experiences turned out to relate to being let down during childhood. One patient, who as an eight year old had been forced to act as an adult at home for an alcoholic mother and an absent father, made the following statement:"“I grew up with a mother who was always drunk and from the age of eight I had to be ‘mother’ for my two younger siblings, and made sure that they did not realise that she came home drunk or saw that I cleaned up vomit in the stairway.”"victim, saviour and the violation triangle, also called the drama triangle[The quotation suggests a feeling of being let down. An unhealthy and reversed mother-child/father-child relationship, where the child takes responsibility for the parent, in this case the mother, is seldom something the person is conscious of, since they don’t know of any other way. From additional notes taken during the interview, it was seen how the patient, now as an adult, despite pain, depression, stress and a poor financial situation, still had to spend most of her free time being a mother for her own mother without herself receiving any support. Theoretically speaking, we can speak of the concepts of  triangle. In the The data also included a description of a sudden event that seemed to be the cause of fear of becoming paralysed. The patient fell down backwards three metres. The written quotation was as follows:"“I fell off a front loader truck, and fell three metres. I was hoisted up and apparently was told that I was about to be lowered, but I didn’t hear that and we didn’t have eye contact, as we normally do. I didn’t register the message and suddenly I lost my balance and fell backwards. Something happened in my back and I couldn’t get up and run away. That’s what I have done all the other times I’ve fallen off ladders and the like. I wanted to crawl away, but I couldn’t move my muscles, I could only lift one leg a bit.”"In the quotation, the patient describes how, after a sudden fall, he felt unable to move. He was terrified and went into a state of shock with the fear of becoming paralysed, although he was not paralysed. It can be assumed that he had a survival response, where the body instinctively reacted with a freeze response , an effe"“I was hospitalised, but was told that there was nothing wrong with me. I was given morphine, so finally I could sit up and the following day I was expected to go and get my own food, if I wanted something to eat.""It wasn’t a pleasant experience, and I can’t stand hospitals - they smell of death. I have witnessed so many deaths: my friends who drove themselves to their deaths, my grandparents and a close friend who died at 19.""So I wanted to get home quickly from the hospital and did so, but was in a lot of pain at home. At home, I cry a lot. Before the accident I was a lively guy who went round helping everyone.”"The quotation expressed how the patient experienced a lack of calm, care and security. Furthermore, he felt that “the hospital smelled of death”, which gave him stress, anxiety and discomfort, which was why he chose to discharge himself. The fall caused a fractured vertebra and concomitant severe pain that prevented the patient from doing his usual activities; the experience of shock probably remained in the body and he subsequently developed depression and experienced powerlessness.From a psychological viewpoint, the SE treatment was directed to help the patient to acknowledge that he had survived and to bodily integrate the fact that the danger had passed. . FurtherThe study showed how restrictions in everyday life can affect self-worth and identity. In the notes, it is stated how patients who, despite a dysfunctional family and poor social conditions, had managed to pursue an education, get a permanent job and develop a good financial situation for herself and her children. However, a workplace accident completely changed her quality of life as demonstrated in the following quotation:"“I fell onto a wet floor at my workplace a year ago and got back pain. I get so much pain and am wiped out after doing very little. And I take strong medicine, but I can’t even sleep at night. I can’t cope with it any longer.”"The statement shows how this patient with severe pain had sleep disturbance and felt herself to be in a powerless situation. It seems that the patient had gone into a vicious pain cycle, where pain led to insomnia and even the most minor stressor gave increased stress/high arousal causing lack of clarity and inability to cope. The patient´s level of stress was reduced via SE.Another patient had difficulty accepting that he couldn’t do what he previously took for granted, and it seemed to affect his perception of his own identity. This is shown in the following quotation:"“I can no longer work 100% as a craftsman. My body, my arms, where all my strength is, are now restricted because of my back.”"With reduced functioning as expressed here in connection with back pain, a person can be affected in relation to his/her own identity, be it in relation to the family as well as to work. Self-worth can decline along with physical and psychological limitations.And another statement:"“I cannot feel any emotion, there is nothing that makes me sad, I used to be hot-tempered, but of course one doesn’t lose one’s temper. I don’t get it (the anger) out of my body as I used to, when I worked and played football.”"The statement can be interpreted as conveying a repressed feeling of anger. It seems that the anger had accumulated and become either forbidden or difficult to express. Anger often creates tension in the body and exacerbates the pain. The patient worked therapeutically and phenomenologically with the pain and anger and found that the tensions in the back disappeared in the process. Another theory could be that anger can arise after an unresolved fight response . The patIn the field notes, there were descriptions of how the patients with CLBP sometimes came with anxious, stressed and unfocused eyes but by the end of the psychotherapeutic session they were calm, and their eyes were seen to have become relaxed and clear. They became present, felt better about themselves and were more able to grasp the situation and take action.Pain and depression can lead to feelings of inadequacy, both physically and mentally. Lack of sleep, confusion in everyday life and an uncertain future were characteristic of the participants, who described themselves as having myriad thoughts and being on the brink of not being able to cope. It is known that stress-activating life events , here exIt can be assumed that when stressors and worries become overwhelming and all internal resources have been used up, stress emerges. Stress is defined in the Encyclopaedia as ‘the pThe study showed, particularly in descriptions drawn from the end of the course of therapy, how an ability to tap into inner resources began to re-emerge. One female patient, who had experienced loss and sorrow and who had been self-destructive, was quoted as saying:"“My goal is to get back to work in the town and stay living in the little community, so my children can continue to go to school there. I can feel that I’m about to wake up, instead of being the little pathetic one.”"The study showed how, in the course of the therapy, the patient had arrived at a place where she could take responsibility and wanted to get back to work and out of the victim role. From being in a self-destructive and depressive condition, it seemed that the patient’s inner resources had now come up to the surface again and could be used.In the field notes, another patient described how she was busy trying to satisfy everyone but herself, then at the end said:"”I want to open my heart to myself”"From this quotation, it can be interpreted that the patient was beginning to take care of herself. It appears that the patient had arrived at an insight where she felt that she was worth something and was ready to take herself seriously in order to move on and cope with her LBP. It was not enough that, as before, she was available to everyone else. She expressed that she experienced an inner happiness and freedom; probably a way out of her depression and pain.For the six patients included in this study, Gestalt therapy and SE appeared to be effective for depression and therefore presumably also for pain. As the study was qualitative, it is not generalisable to people suffering from similar conditions. However, the findings are of sufficient interest to be considered in the design of future research.This study shows how pain and negative experiences are repeated in different guises. It pointed to the fact that during previous experiences, the conditions that appeared to hinder the patients’ capacity to cope with life with back pain and moderate depression were loss and sorrow that caused self-destructive behaviour, including overdosing on medicine. In addition, different forms of being let down were seen, including violations and the re-experiencing of failure in a pain situation, which caused reduced self-worth, and feelings of self-blame and shame. This is supported by the literature  which deThe results showed that CLBP and other concomitant stressors could result in tense, stressed and unfocused eyes, and how by the end of the session the eyes had relaxed and become focused and the patient had become present. Findings of stressed eyes in connection with severe stressors, pain and depression are considered to be interesting in the light of the fact that many of the patients’ reactions must be taken to be stress symptoms, e.g. anger, fear, anxiety, discomfort and powerlessness. Powerlessness, particularly in high arousal/high stress, is linked to a feeling of not being able to cope any longer. Anxiety and depression are often seen in patients with chronic pain and together they constitute a complex clinical problem  Pain in The literature describes how depression is associated with higher pain intensity, a lower pain threshold and pain tolerance. There is some evidence that depression occurs after the development of chronic pain, and not vice versa . When paDescriptions were found in the literature ,3 of howThe connection between pain, depression and stress is well known and well described ,7,27. ItThis study has shown how Gestalt therapy and SE were useful in contributing to the patients’ capacity to cope with CLBP. This was manifest in the patients’ renewed interest in taking responsibility for themselves, in the experience of happiness, in the feeling of being worth something, in experiencing release from muscle tension, in the reduction of stress and in the experience of being in contact with oneself and the environment.It was not possible to find similar studies in the literature, where Gestalt therapy was used in connection with CLBP and depression. However, in the book ”Gestalt therapy på svenska”  the authThe chosen method in the current study with field notes and use of narrative language was seen to be useful for those patients with CLBP and depression in articulating issues. The Ricoeur-inspired method used to analyse the data helped to give an overview, to structure, analyse and interpret the many findings that the study revealed. The strength of the research process was having an external researcher who performed the analysis and interpretation in parallel.stress seems to become prominent. Stressful situations can lower a person’s ability to cope with back pain.During psychotherapeutic treatment of patients with chronic non-specific low back pain and moderate depression, diverse psychological stressors were identified, relating to both the past and the present. This study found that when pain, stress and depression become overwhelming and there are few resources available, Back pain is a stress factor in itself and, coupled with depression, these must be seen as two symptom complexes that mutually affect each other in negative ways. With the help of Gestalt therapy and the Somatic Experiencing® method, the six patients in the current study developed a greater sense of being at peace and in harmony with themselves and their environment. It seems that they achieved insight and again became capable of acknowledging and using their own internal resources. Stress responses were reduced and the patients’ capacity to take responsibility for themselves was increased.As a result of the above-mentioned findings from the current study, a wider perspective could be introduced in the screening of patients with back pain for stress symptoms. Stress can be related to pain and a high depression score, and furthermore to traumatic events.In the Spine Centre of Southern Denmark, analyzes have shown, via the screening questionnaire, Harvard Trauma Questionnaire (HTQ) Part 4, that out of 3,500 patients, 5% scored symptoms equivalent to Post Traumatic Stress Disorder (PTSD). Another 5% scored stress equivalent to sub-clinical PTSD, that is, lacking 1–2 symptoms on the full score on HTQ. This scoring was related to an event, e.g. a traffic accident, fall trauma, work injury or violence of various kinds.More sophisticated tools for screening for stress and depression symptoms may help to lead to sub-grouping of patients and subsequent individually adapted psychological interventions. Thus, the road can be paved to increase the future success rate of treatment for patients with CLBP, an initiative that may be significant for the individual patient, the health care system and the society as a whole.The authors declare that they have no competing interests.Study design: HE and BDP. Data collection: HE. Analyses and manuscript preparation: HE and BDP. Both authors have read and approved the final manuscript.The pre-publication history for this paper can be accessed here:http://www.biomedcentral.com/1471-2474/13/166/prepub


Chest pain is one of the most common causes of the admission to the emergency departments. It, however, can be due to numerous diseases some of which are life threatening.In the current study, we evaluated the prognostic value of TIMI  and Modified TIMI risk scores to stratify the risk for patients with atypical chest pain being discharged from the emergency department.In a prospective-analytic study, we collected data from 1020 patients with atypical chest pain enrolled to the study. All eligible patients were visited by the emergency medicine residents who were trained for this study. Based on the criteria in both systems, the emergency medicine attending decided on either discharging or hospitalizing patients. Patients were allocated into 2 equal groups randomly. In order to predict the opposing accidents in 30 days  TIMI risk scores and Modified TIMI risk scores were assessed based on TIMI risk score (0 or 1) and Modified TIMI risk score (0 or 1).No significant difference could be observed between both groups regarding demographic characteristics, ejection fraction, left ventricle hypertrophy, TRS criteria, risk factors and the history of coronary artery stenosis. None of the atypical chest pain patients discharged based on TIMI and modified TIMI risk scores experienced any adverse events.The results obtained from this study support the idea that the TIMI and modified TIMI risk scores might be valuable tools that could be used to stratify the risk of patients with atypical chest pain in the emergency department. Chest pain is one of the most common reasons of the patients’ referral to the emergency departments (EDs). It, however, can be due to numerous diseases some of which are life threatening. Cardiovascular diseases, aortic dissection, pulmonary emboli, pneumothorax, and pericarditis are some of the fatal diagnoses associated with chest pain. Acute coronary syndrome (ACS), as one of the most important causes of chest pain with a high associated mortality rate, is of great importance and should be diagnosed as early as possible . ApproacIn other words, atypical chest pain is a common clinical problem which the physicians working in the internal medicine, emergency medicine, and cardiology departments are faced with. Atypical chest pain is mostly seen in the young female patients which is a rarely of the coronary arteries origin. However, whenever of a cardiac origin, it is associated with an additional 7% mortality rate compared with male patients at the same age. Most of these patients undergo angiography to rule out the chance of the coronary artery disease . TherefoTIMI Risk Score (TRS) which is used to determine the risk for patients with ACS and is mostly used for patients having chest pain syndrome with unstable angina or myocardial infarction without ST segment elevation (NSTEMI). The scoring uses seven major criteria, each measured as one score, as following -11: Age older than 65 years Coronary artery stenosis of more than 50% More than two cardiac disease risk factors History of taking aspirin in the previous seven days  Incidence of more than one spells of chest pain within the previous 24 hours ECG changes rather than STEMI Elevated serum levels of cardiac biomarkers Score Interpretation for TIMI scoring system would be as featured as % risk at 14 days of all-cause mortality, new or recurrent MI, or severe recurrent ischemia requiring urgent revascularization:The criteria used in Modified TIMI Risk Score (MTRS) are comparable to that of TRS; while in Modified TIMI, the scoring stays between 0-10 and a score of 5, if positive , reflects cardiac biomarker changes or ECG .In the current study, we evaluated the risk of the patients with atypical chest pain using previously-introduced risk scores of TIMI and Modified TIMI.In a prospective-analytic study carried out in the ED of Shahid Madani hospital, Tabriz, IR Iran from 2011-2012, patients over 25 years old and with atypical chest pain were included. The Exclusion criteria were as following: age younger than 25 years old, diagnosed STEMI, pregnancy, hospitalization due to other reasons , and cases for which follow-up was not practical. This study was approved by the Ethics Committee of “Tabriz University of Medical Sciences” and registered under the Code Number of 8966. After obtaining written informed consents from all patients, ECGs were taken and cardiac Troponin-I enzyme (cTnI) were checked on admission and 12 hours post-symptoms onset. To evaluate cTnI, cTnI ELISA kit , and to evaluate EKGs ECG monitors  were used. All equipment was calibrated prior to administration. Later, patients were allocated into two equal subgroups of I and II randomly by block randomization. Patients in Groups I and II were assessed by TRS and modified TRS, respectively and those with low risk (0-1) were discharged.All eligible patients were visited by the emergency medicine residents who were trained for this study. Hospitalization or discharge of patients were decided on by the emergency medicine attending (a same attending) based on the two systems. Follow-up via telephone for any probable unwanted complications such as MI, revascularization or death consisted of a one-month period. The data were analyzed using descriptive and deductive-statistical approaches by SPSS ver. 15 software. Variation between qualitative variables and the relation between qualitative and quantitative variables were study using Chi-square and T-test approaches, respectively. The normality of variables was checked by Kolmogorov – Smirnov Z test. Man-Whitney test was used whenever required and P ≤ 0.05 was considered statistically significant. A flow diagram of our study is showed in . Within the one-year period of the study, 1020 patients with atypical chest pain were allocated to the study from which 20 people were excluded due to unavailability of follow-up for adverse events  and finally 1000 people (500 people for each group) including 595 (59.5 %) males and 405 (40.5 %) females were studied. The mean age of the studied patients was 47.72 ± 13.59 years . Demographic characteristics, ejection fraction, and left ventricle hypertrophy were of no significant difference in both groups . None of the atypical chest pain patients discharged based on TIMI and modified TIMI risk scores experienced any adverse events. No statistically significant difference was observed between both groups regarding TRS criteria, risk factors and the history of coronary artery stenosis; however, a significant difference was detected regarding the number of patients using aspirin  -4. From all patients with atypical chest pain referring to the ED, almost 7% have been reported to have ECGs with the signs of ischemia or MI and only do 6-10% of the patients have primary positive cardiac enzymes. Rest of the patients, despite not fulfilling the required diagnostic criteria, could also have ACS demanding further tests for confirming or ruling out ACS . TIMI RiAlthough TRS enables us to classify the unselected ED chest pain population and achieve solid decisions, it is prone to missing 2-5% of the patients with myocardial infarction . In anotOne of the limitations of the current study was its being single center studying only Iranian patients. In addition, we were not able to follow almost 20 patients. Another factor which may have posed selection bias leading to misclassification is the fact that our trained researchers were present in the emergency department for only 12 hours a day and seven days a week.In conclusion Both TRS and MTRS could be used for risk prediction in patients discharged with atypical chest pain from the EDs. However, further future multi-center studies with higher sample volumes are recommended to approve the result obtained from the current study.


Chronic low back pain (CLBP) was shown to be associated with pathophysiological changes at several levels of the sensorimotor system. Changes in sensory thresholds have been reported but complete profiles of Quantitative Sensory Testing (QST) were only rarely obtained in CLBP patients. The aim of the present study was to investigate comprehensive QST profiles in CLBP at the painful site (back) and at a site distinct from their painful region (hand) and to compare these data with similar data in healthy controls. We found increased detection thresholds in CLBP patients compared to healthy controls for all innocuous stimuli at the back and extraterritorial to the painful region at the hand. Additionally, CLBP patients showed decreased pain thresholds at both sites. Importantly, there was no interaction between the investigated site and group, i.e. thresholds were changed both at the affected body site and for the site distinct from the painful region (hand). Our results demonstrate severe, widespread changes in somatosensory sensitivity in CLBP patients. These widespread changes point to alterations at higher levels of the neuraxis or/and to a vulnerability to nociceptive plasticity in CLBP patients. Chronic low back pain (CLBP) is one of the major health problems, especially in industrialized countries. The costs of CLBP in the US alone are estimated to be at least $ 100 billions a year CLBP was shown to be associated with several pathophysiological changes at various level of the sensorimotor system, including the cortical level  as introduced by the German research network for neuropathic pain (DFNS) The aim of the present study was to investigate comprehensive sensory profiles of CLBP patients on the hand and on the painful site at the back and to compare these data with similar data in healthy controls (HC). So our primary hypothesis is that CLBP patients exhibit a generalized hypersensitivity to painful stimuli. We also hypothesize alterations for innocuous stimuli within the QST profile.Results are presented with respect to the hypotheses, i.e. different to the usual representation of QST data by the DFNS. Here we analyzed data for pain thresholds (primary hypothesis) before presenting data for innocuous stimuli. Original data can be found in supplementary materials , S2, S3.Analysing the pain thresholds and related pain parameters of the QST profile see  A, ANOVABeyond significant main effects, ANOVA with factors Group, Region, and Pain parameter revealed a significant interaction between Pain parameter and Group  = 3.23; P<0.05; ε = 0.84). Post-hoc contrasts revealed a significantly higher sensitivity for pinprick stimuli at threshold  and suprathreshold stimulus levels  for the CLBP patients compared to HC. Importantly, there were no significant interactions for Region x Group, Region x Pain parameter, or Group x Region x Pain parameter . For detailed raw data - see Pain to light stroking tactile stimuli, i.e. dynamic mechanical allodynia (DMA), was very rare and only observed in CLBP patients . It was Mixed-model ANOVA with the factors Group , Region , and Detection threshold  revealed a highly significant main effect of the factor Group  = 7.94; P<0.01). In contrast to analysis on pain parameters, CLBP patients showed significant lower sensitivity to innocuous stimuli . The quality of data is underlined by the fact that z-score values for our CLBP patients normalized to our HC group, on the one hand, and normalized to the DFNS reference data 2 = 0.976, P<0.001). Third, we compared the QST parameters between the affected area, i.e. the back, and the hand to distinguish between localized and generalized QST changes. When comparing these parameters for HC subjects, 11 out of 13 parameters were different at the back compared to the hand. This is in accordance with We also compared our data with respect to the reference data from the German Research Network on Neuropathic Pain (DFNS). First, we compared the results of our HC group with the normative data. Results obtained at the palmar site of the hand in our HC group were in the range of the DFNS reference data (dorsum of the hand) as judged by the recommended quality self-control procedure with an average z-score of 0.11 for HC subjects was<95% confidence interval of DFNS reference data, recommended to be<0.25 The aim of the present study was to investigate the profile of somatosensory changes occurring in CLBP patients at the affected painful region (back) and at a site distinct from the painful region (hand). CLBP patients exhibited an enhanced sensitivity to painful stimuli. Importantly, significantly enhanced pain sensitivity was also identified at the remote hand site. In addition, we also found a reduction of sensitivity to innocuous stimuli, especially for thermal detection thresholds. This phenomenon was also observed both at the hand and at the back.Our data revealed significantly decreased pain thresholds in CLBP patients compared to HC subjects. Gain of function in the sense of decreased pain thresholds at the back has been report previously in CLPB patients for PPT Importantly, the pain thresholds observed at the hand in our patients showed very similar results to the back. We also found lower pain thresholds at the hand expect for PPT, i.e. a site clear distinct and somatotopically far away from the painful back. This finding is of principal importance. It demonstrates increased pain sensitivity far beyond the painful lumbar back. To our knowledge, data on extrasegmental spread are not published yet. This result differs considerably from those of Blumenstiel et al. Parallel to the facilitation of mechanical painful stimuli, we identified a generalized hyposensitivity to innocuous stimuli in CLBP patients (main effect of Detection threshold). A similar hyposensitivity can be induced dynamically in experimental models and parallel to the experimental induction of central sensitization in pain patients; it resolves upon recovery Unexpectedly, we found that innocuous cold stimuli at the back elicited a painful sensation, i.e. paradoxical heat sensation PHS,  B, in 3 Our sample size with 34 subjects is relatively small. So the study should be extended to larger sample sizes and different centers. However, the sensory changes in this small sample are robust exhibiting large effect sizes . Furthermore, we only investigated female subjects. Further research should clarify whether similar changes can be found in male CLBP patients.The data do not allow to distinguish between the two major hypothesis for this higher-order effect, i.e., sensitization after an aversive event vs. susceptibility. Longitudinal studies might help to solve this question.Our results of widespread somatosensory disturbances for noxious and innocuous stimuli might be important for the therapy of chronic low back pain. They call for a therapy that is not restricted to the painful area. Taking our results into account, they are in line with the results of clinical studies demonstrating positive effects of multidisciplinary pain management programs Widespread changes of somatosensory sensitivity were found in CLBP patients. Most important, significantly enhanced pain thresholds were found not only at the back, but also at a non-painful remote site (hand). In addition, we found a significant loss of sensitivity to innocuous stimuli, especially for thermal detection. This results points to changes in the somatosensory information processing in CLBP with higher order plasticity rather than spinal cord mechanisms.Eighteen chronic low back pain (CLBP) patients and sixteen pain-free healthy controls (HC) participated in this study. Healthy control subjects and CLBP patients were matched concerning age and gender . One CLBP patient reported to take a non-opioid analgesic (katadolon) on demand, but not during the last week before the investigation. All investigated CLBP patients were without any analgesic medication for at least 48 hours before the examination.Low back pain related disability was measured using the German version of the 24-items Roland Morris disability questionnaire (RDQ) Quantitative sensory testing (QST) was assessed according to the standardized protocol of the German Research Network on Neuropathic Pain (DFNS) QST protocol was performed on the painful body site  and on a non-painful body site  in both CLBP patients and healthy control subjects. Hand palmar was used since we were also interested in the somatosensory sensibility of this region: External perturbations applied over the hand palmar were associated with prolonged reflex response latencies in CLBP. We also assessed MPS at the hand dorsum to assess our data with respect to the normative data of DFNS.In order to exclude a potential influence of different skin temperatures of the thermal detection and thermal pain thresholds as well as all other QST parameters, skin temperature was assessed for all body sites  before and after the QST. There were no significant skin temperature changes for any of the body sites before vs. after the QST protocol or between patients and controls.2. Cold detection threshold (CDT), warm detection threshold (WDT), thermal sensory limen procedure , and the number of paradoxical heat sensations by using the, TSL were assessed using the standard protocol of DFNS  Thermal testing was performed using a thermal stimulator  with a thermode contact area of 9 cm2-Set Marstock Nervtest, Germany) which exerts forces between 0.25 and 512 mN (factor 2 progression). Using the ‘methods of limit’, the final threshold was assessed as the geometric mean of five series of ascending and descending stimulus intensities Mechanical detection threshold (MDT) for light touch was assessed by using a series of standardised von Frey filaments  on the hand dorsum was measured using a Rydel–Seiffer graded tuning fork  that was placed over the processus styloideus ulnae according to the protocol of DFNS 2).Cold and heat thermal pain thresholds  were assessed the according to the standard protocol of DFNS using the same thermal stimulator as for detection thresholds  with fixed stimulus intensities that exerted forces of 8, 16, 32, 64, 128, 256, and 512 mN . The Stimulators were applied in ascending order until the first percept of sharpness was detected. MPT was determined using the ‘methods of limits’. The final threshold was the geometric mean of five series of ascending and descending stimuli intensities.Pain induced to punctate mechanical stimuli was measured using the same standard pinprick stimulators as for MPT. To obtain MPS for pinprick-evoked pain, all seven pinprick stimuli were applied in balanced order, five times each stimuli in every test site . MPS was assessed as the geometric mean of the given stimuli as in the standard protocol. To avoid effects of sensitization or fatigue, the successive stimuli were not applied at the same spot of skin, but some mm apart from previous stimulation side. Following each stimulus, participants were asked to rate the experienced pain intensity for each stimulus on a verbal rating scale . Pain to light touch  was assessed by light stroking with a cotton wisp (3 mN), a Q-tip fixed to an elastic strip (100 mN), and a soft make-up brush (200–400 mN). The set of the three light tactile stimulators where intermingled with the pinprick stimuli in balanced order In case the stroking stimuli were perceived as painful, participants were asked to give a verbal rating for the perceived pain magnitude (0–100).The perceptual correlate of temporal pain summation to repetitive pinprick stimuli  was assessed by trains of ten punctate stimuli (256 mN tested over hand and back) 1 Hz repetition rates. The participants were asked to give a pain rating representing the pain at the end of the train using a numerical rating scale. The pain ratings to single pinprick stimulation were compared with those of ten repeated punctate stimuli. To determine the wind-up-ratio, the ratio of the mean pain rating of trains divided by the mean pain rating to a single stimulus was calculated.2 (probe diameter of 1.1 cm) that exerts pressure up to 200 N/cm2/∼2000 kPa. The pressure pain threshold was determined with three series of ascending stimulus intensities, each applied as an increasing ramp of 10 kp/s.PPT was performed over the muscle on the painful  and at the non-painful site  using a pressure gauge device  with a probe site of 1 cm10-transformed before statistical analysis {Rolke 2006a}. Furthermore, QST data were z-transformed using the following expression:Tests were performed depending on data distribution properties. Cold pain thresholds, heat pain thresholds and vibration detection thresholds were normally distributed as analysed by the Shapiro-Wilks test. All other parameters were normally distributed in log space, and thus they were logindividual CLBP patient – mean controls)/SD controlsZ-score  =   using the z-values with respect to the group of healthy controls. We used the between-subject factor Group  and the within-subject factors Region  and Pain threshold . We also performed a similar ANOVA for the detection thresholds using the factors Group, Region, and Detection threshold . Results were corrected for violations of sphericity using the Greenhouse-Geisser approach for ε-correction of degrees of freedom. Post-hoc analyses were performed using one-way ANOVAs and t-tests. All statistical calculations were performed using SPSS 19 Software. Data are presented as mean z-scores of QST parameters±standard error of the mean (SEM).http://www.quantitativeskills.com/sisa/) separately for healthy controls and CLBP patients to compare data with the DFNS reference data.MPS was assessed at the hand dorsum in order to compare these data with the reference data from the German Research Network on Neuropathic Pain (DFNS) Table S1Individual values from the Quantitative sensory testing at the painful site  in female chronic low back pain patients (CLBP) and female healthy controls (HC).(PDF)Click here for additional data file.Table S2Individual values from the Quantitative sensory testing for the site distinct from the painful region  in female chronic low back pain patients (CLBP) and female healthy controls (HC).(PDF)Click here for additional data file.Table S3Individual values from the Quantitative sensory testing for the site distinct from the painful region (hand dorsum) in female chronic low back pain patients (CLBP) and female healthy controls (HC).(PDF)Click here for additional data file.


Chronic pain is a common reason for consultation in general practice. Current research distinguishes between chronic localized pain (CLP) and chronic widespread pain (CWP). The aim of this study was to identify differences between CWP and chronic low back pain (CLBP), a common type of CLP, in primary care settings.Fifty-eight German general practitioners (GPs) consecutively recruited all eligible patients who consulted for chronic low back pain during a 5-month period. All patients received a questionnaire on sociodemographic data, pain characteristics, comorbidities, psychosomatic symptoms, and previous therapies.GPs recruited 647 eligible patients where of a quarter  met the CWP criteria according to the American College of Rheumatology. CWP patients had significantly more comorbidities and psychosomatic symptoms, showed longer pain duration, and suffered predominantly from permanent pain instead of distinguishable pain attacks. CWP patients were more often females, are less working and reported a current pension application or a state-approved grade of disability more frequently. We found no other differences in demographic parameters such as age, nationality, marital status, number of persons in household, education, health insurance status, or in health care utilization data.This project is the largest study performed to date which analyzes differences between CLBP and CWP in primary care settings. Our results showed that CWP is a frequent and particularly severe pain syndrome.DRKS00003123.German Clinical Trial Register,  Chronic pain is a common reason for consultation in general practice. Current research distinguishes between chronic localized pain (CLP) and chronic widespread pain (CWP). CLP is defined as chronic pain restricted to one or few body regions . In contrast, CWP means chronic pain in several body regions. The American College of Rheumatology (ACR) defines CWP as pain in the left and right side of the body, as well as above and below the waist plus pain in the axial skeleton . It is sPopulation based studies reported a CWP point-prevalence of 4.7%-15% depending on the country -8. NordeSeveral studies have investigated differences in physical and psychological factors between CWP patients and healthy adults: CWP patients are more frequently female, older, less educated , have a In addition to differences in the pain distribution, it is also important to know if CWP patients are more negatively affected in other wellbeing areas when compared to CLP patients.To date, few studies have examined differences between CWP and CLP. Two studies present population based data on neck-shoulder pain  and myofOnly one study investigated differences of CLBP and CWP in primary care patients: Nordeman et al.  found anThe aim of this study is to identify differences between CWP and chronic low back pain (CLBP), a common type of CLP, in primary care settings. This would enable us to suggest priorities for health care interventions in CWP.The present study refers to the cross sectional baseline analysis of a 12-month cohort study which evaluates risk factors and protective factors of pain generalization in primary care CLBP patients. A detailed study protocol has been published elsewhere .This project is part of the research consortium LOGIN “Localized and Generalized Musculoskeletal Pain: Psychobiological Mechanisms and Implications for Treatment” funded by the German Federal Ministry of Education and Research. The study was approved by the local ethics commission of Philipps University in Marburg, Germany  and is in accordance with the Declaration of Helsinki.We invited all general practitioners (GPs) in the northern part of Germany’s state of Hessen to participate in our study. We asked participating GPs to consecutively recruit all eligible patients consulting for CLBP as a primary or secondary consulting reason (inclusion criteria), during a 5-month period. The symptom “chronic low back pain” was defined as pain in the back area under the costal arch, but over the bottom fold (with or without pain radiation), during most days in the last three months. Patients under 18 years, pregnant women, and patients with insufficient understanding of the German language or severe cognitive impairments  were excluded from the study.Doctors asked patients for study participation directly after consultation. All participating patients received a pen and paper questionnaire. Patients who refrained from participation were asked to give reasons for their decline. During the recruitment period, trained clinical monitors conducted two random quality control checks of the GPs’ performance.To explore distinctive features with regards to pain characteristics and sociodemographic data between CLBP and CWP patients, we evaluated the following physical and psychological parameters .For definition of CLBP and CWP, we assessed pain localization with the body pain drawing model from Pfau et al. . The CWPIn addition, we used the 3-item social support subscale of the West Haven-Yale Multidimensional Pain Inventory (MPI) to explore the partner’s reaction in response to patient’s pain  ,27. We rUsing the Self-Administered Comorbidity Questionnaire, we asked the patients about 14 common medical conditions  ,30. PatiThe Symptom Checklist-90-R (SCL-90-R) assess typical physical symptoms which accompany functional dysfunctions, but could also arise in somatic disorders.The SCL-90-R is a commonly used psychological status symptom inventory for psychopathology  .Potential red flags, which are frequently used risk factors for identifying serious disorders causing low back pain, were documented by the GPs for each patient .We calculated summary statistics  for each of the two study groups, i.e., CWP and CLBP.Testing for differences in outcome variables between CWP and CLBP patients was done using chi-square tests , Fisher’s exact tests , t-tests accounting for unequal variances (Welsh tests), and Mann–Whitney U tests .Fifty-eight of the 284-invited GPs (20.4%) participated in the study. The majority of them were male (58.6%), averaged 53 years old, and worked in practices with differing sizes from both urban and rural locations and having varying organizational structures (solo/group practices).During the recruitment period, 746 eligible patients were asked to participate. Seventy-six patients declined participation at once, and fifteen patients withdrew consent when seeing the questionnaire. Therefore, 655 participants completed the questionnaire. We excluded eight additional subjects from analyses because they did not report lower back pain on the pain drawing. A total of, 647 patients were analysed.A quarter of all participating CLBP patients  met CWP criteria in the pain drawing. The majority (52.1%) of all CLBP patients reported having back pain for more than ten years. On average, the participating patients were 56.5 years old. The majority was female (61.6%), married (65.1%), and lived in a two-person household (48.6%). Half of the participants are working (50.5%). Of the non-working participants, 75.2% were retired.A higher fraction of females was observed among CWP patients compared to CLBP patients (CWP 71.8% vs. CLBP 57.6%). CWP patients were less working (CWP 52.8% vs. CLBP 43.6%). Reasons for not working were comparable between groups. CWP patients more frequently reported a current pension application (CWP 14.1% vs. CLBP 5.2%) and having a degree of disability (CWP 54.2% vs. CLBP 38.5%). Other sociodemographic parameters such as age, marital status, education and reasons for not working, showed no differences between the two groups. For a detailed description of the sociodemographic data see Table The majority of CWP patients (61.3%) and 49.0% in the CLBP group reported long-lasting pain for more than ten years. While CLBP patients tended to have more pain attacks with pain-free time periods, CWP subjects suffered more frequently from permanent pain. With regards to the severity of chronic pain, we did not find significant differences between the groups. Similarly, no differences were found for the social support scale of the MPI or for the frequency of red flags between CWP and CLBP patients. More details about the pain characteristics are shown in Table CWP patients [mean (SD) 7.3 (4.1)] received a significantly higher number of different therapeutic strategies compared to CLBP patients [mean (SD) 5.7 (3.6)]. However, we found no differences in the number of GP consultations, the number of different doctors consulted, and stays in hospital during a six-month period prior to recruitment.In general, the CWP group showed a higher number of comorbidities referring to a higher frequency of ulcer/stomach disease, kidney disease, osteoarthritis/degenerative arthritis, rheumatoid arthritis, and depression. In comparison to CLBP patients, CWP patients suffered more often from psychosomatic symptoms. All data are shown in Table To our knowledge, this project is the largest study to date which analyzes differences between chronic localized low back pain and chronic widespread pain in primary care settings.A quarter of all included CLBP patients satisfy the ACR criteria for CWP. Altogether, CWP patients are predominantly female and showed more psychosomatic symptoms and comorbidities than CLBP patients.The observed high prevalence of CWP (25.2%) is in accordance with the findings of Nordeman et al., who reported a CWP prevalence of 28% in females in primary care settings . The sliApart from the apparently higher proportion of females in the CWP group, which confirms similar findings of other investigators ,11, we fIn contrast, a population-based study from Bergman et al. found a lower educational and social status among CWP patients . There iThe role of somatization processes in CWP is still unclear. In the literature, two hypotheses are discussed: First, somatization could be a consequence of CWP. Second, CWP could be a manifestation of the process of somatization . We onlyIn comparison to individuals without back pain , our totThe increased rates of ulcer/stomach and kidney diseases in our CWP sample might be related to a higher consumption of non-steroidal anti-inflammatory drugs (NSAID). Furthermore, ulcer and stomach diseases are typical symptoms of somatization processes as discussed above . Apart fThe definition of chronic widespread pain comprises duration and local extension of the pain . It is aIn discussing group differences, we must emphasize that our study population is comprised of patients with a severe disease pattern (52%: pain > 10 years). Therefore, we assume that our subgroups do not greatly differ due to the already extreme nature of our subjects. This might also be a reason for the similarity of CLBP and CWP patients regarding pain severity according to von Korff . Both grWith respect to methodological limitations, we have to think of selection bias in our study. In our study, some participations denied participation due to the long, demanding questionnaire. Selective recruitment might have occurred because general practitioners might forget to recruit patients due to a high workload. Furthermore, it might be possible that GPs are more likely to recruit special cases . This might reduce the external validity of our results.Although a GP recruitment rate of about 20% is normal in our research field, we should consider selection bias. We do not know if non-participating GPs have CLBP patients with characteristics different than the participating GPs. However, regarding sociodemographic data and practice characteristics, the GP sample seems to be representative for the region of northern Hessen.Our primary finding is the high CWP prevalence among CLBP patients in primary care settings. Therefore, CWP is a frequent and particularly severe pain syndrome. Although it is impossible to identify CWP patients with the help of typical sociodemographic profiles, we showed that CWP patients are more likely to suffer from psychosomatic symptoms and comorbidities than CLBP patients. These comorbidities must be considered when a GP makes treatment decisions based on the fact that a patient has CWP. Further research is needed to clarify the role of somatization in conjunction with chronic widespread pain to infer the direction of causality.ACR: American College of Rheumatology; CLBP: Chronic low back pain; CLP: Chronic localized pain; CWP: Chronic widespread pain; GP: General practitioner; MPI: West Haven-Yale Multidimensional Pain Inventory; SCL-90-R: Symptom Checklist-90-R.Annika Viniol, Nikita Jegan, Markus Brugger, Konstantin Strauch, Jürgen Barth, Erika Baum and Corinna Leonhardt do not state any financial or non-financial conflicts of interests.Annette Becker was a consultant for Grünenthal GmbH, from whom she has also received a speaker’s fee.AV collected and analyzed data and wrote the manuscript. NJ collected and analyzed data. MB and KS gave statistical support and planned the study. JB and EB planned and revised the study design. CL and AB planned the study, discussed the results, and revised the manuscript critically. All authors edited the drafted version of the manuscript. All authors read and approved the final manuscript.The pre-publication history for this paper can be accessed here:http://www.biomedcentral.com/1471-2474/14/351/prepub


A major problem in pain medicine is the lack of knowledge about which treatment suits a specific patient. We tested the ability of quantitative sensory testing to predict the analgesic effect of pregabalin and placebo in patients with chronic pancreatitis.Sixty-four patients with painful chronic pancreatitis received pregabalin (150–300 mg BID) or matching placebo for three consecutive weeks. Analgesic effect was documented in a pain diary based on a visual analogue scale. Responders were defined as patients with a reduction in clinical pain score of 30% or more after three weeks of study treatment compared to baseline recordings. Prior to study medication, pain thresholds to electric skin and pressure stimulation were measured in dermatomes T10 (pancreatic area) and C5 (control area). To eliminate inter-subject differences in absolute pain thresholds an index of sensitivity between stimulation areas was determined . Pain modulation was recorded by a conditioned pain modulation paradigm. A support vector machine was used to screen sensory parameters for their predictive power of pregabalin efficacy.P = 0.001). The electrical pain detection ratio was predictive for pregabalin effect with a classification accuracy of 83.9% (P = 0.007). The corresponding sensitivity was 87.5% and specificity was 80.0%. No other parameters were predictive of pregabalin or placebo efficacy.The pregabalin responders group was hypersensitive to electric tetanic stimulation of the pancreatic area (ePDT ratio 1.2 (0.9–1.3)) compared to non-responders group (ePDT ratio: 1.6 (1.5–2.0)) (The present study provides first evidence that quantitative sensory testing predicts the analgesic effect of pregabalin in patients with painful chronic pancreatitis. The method can be used to tailor pain medication based on patient’s individual sensory profile and thus comprises a significant step towards personalized pain medicine. A major problem for pain treatment is the lack of knowledge about which treatment best suits a specific patient. This is particularly important in patients with chronic pancreatitis (CP) due to complex and multifactorial pain aetiology, involving many factors including structural abnormalities of the pancreatic gland as well as abnormalities of peripheral and central pain processing static QST of skin dermatomes in the upper abdominal area can indirectly be used to obtain information about CNS neuroplasticity following increased barrage from pancreatic sensory afferents dynamic function of the sensory system, including descending inhibitory and facilitatory influences from the brain stem and higher cortical levels, e.g. by using conditioned pain modulation (CPM) paradigms The complex pain aetiology and wide variability in group treatment outcome makes it important to identify biomarkers linked to outcomes of pain treatment in individual patients. Quantitative sensory testing (QST) has in some studies been able to predict treatment outcome of analgesic therapy in chronic pain disorders A recent randomised, placebo controlled, clinical trial of pregabalin in patients with painful CP provided the opportunity to test a putative link between pre-treatment QST measurements and effectiveness of pregabalin and placebo in treating the pain of CP We hypothesized pregabalin to be more efficacious in CP patients characterized by central sensitization, as expressed by increased responsiveness to static QST in the upper abdominal region. In turn, we expected that descending pain modulation (i.e. dynamic QST) would not be associated with pregabalin efficacy, as pregabalin do not exert its primary effect through descending pain modulation Patients were recruited from an investigator initiated double-blinded, placebo-controlled, parallel-group study of pregabalin for painful CP conducted in Denmark  and the Netherlands  Key inclusion criteria were a diagnosis of CP based on The Mayo Clinic Diagnostic Criteria and chronic abdominal pain typical for pancreatitis, meeting the criteria for chronic pain (pain ≥3 days per week in at least 3 months) and by the patient considered severe enough for medical treatment The responsible Ethical Committees in both countries approved the study and all patients provided written informed consent prior to investigation.The study consisted of a 3-week period of pregabalin or placebo treatment titrated to analgesic effect and tolerability. In each patient, a QST session was performed before starting study medication. The session consisted of static (pain thresholds to pressure and electric tetanic stimulation) and dynamic QST . A detailed patient history was obtained to determine pain localization, intensity of ongoing pain ), and use of analgesics. Patients were then instructed and trained in VAS ratings to determine pain thresholds and the CPM paradigm. A 30 minute pause allowed the pain system to re-establish baseline conditions and was followed by the QST test session.After QST testing patients received escalating doses of pregabalin (300 to 600 mg/day) or matching placebo capsules for three weeks. Daily dosages were split into two equivalent doses, one administered in the morning and one in the evening. If unacceptable side effects were experienced by the patient, a single downward dose titration was allowed, after which the patient remained on the final dosage during the remainder of the study period. A minimum end dose of 300 mg/day was required; otherwise the subject was withdrawn from the study.average pain intensity after three weeks of treatment compared to baseline. The average daily pain scores (i.e. the average pain score for the last 24 hours) were collected by a pain diary based on a visual analogue scale (VAS), where 0 = no pain and 10 = worst pain imaginable. The baseline pain score was calculated as the average daily pain score during the week prior to randomization (i.e. no study medication). The response to study medication was calculated as the average daily pain score during the last week of treatment. Responders to treatment  were defined as patients with a reduction in clinical pain score of 30% or more after three weeks of treatment compared to baseline recordings.The clinical endpoint was the percentage change in daily Pressure pain thresholds were obtained for muscles overlying bone by pressing a handheld electronic pressure algometer . The probe had a surface area of 1 cm2 and the pressure was increased at a rate of 30 kPa/sec. The lower neck (C5 dermatome) and the upper abdominal area  on the dominant body side were stimulated. The upper abdominal area was chosen because dorsal horn neurons receiving painful stimuli from this skin area also receive nociceptive stimuli from the pancreas (i.e. pancreatic area). In contrast, the lower neck area was chosen because the nociceptive pathways from this area are separated from those coming from the pancreas at both peripheral and spinal levels (i.e. control area). For each stimulation site, pain detection thresholds were measured .Threshold testing took place using a standard temporal test sequence, which has been described in detail previously electric constant current skin stimulation (ePDT)  were measured on the same sites as for pressure stimulation.Pain thresholds to To obtain an index of sensitivity between stimulation areas (i.e. pancreatic area vs. control area) the relation between thresholds was determined as pPDT ratio (pPDT pancreas/pPDT control) and ePDT ratio (ePDT pancreas/ePDT control). This eliminated inter-subject differences in absolute pain thresholds and thereby provided a measure of “pancreatic sensitivity”.The CPM paradigm was performed to test the ability of the patient to generate descending inhibitory modulation. CPM is a clinically measurable form of descending pain modulation, which can be induced experimentally by a conditioning stimulus (e.g. the cold pressor test) and quantified by applying a test-stimulation before and after its induction Conditioning stimulus - the cold pressor task: The right hand was immersed in cooled water . The patients were told to remove the hand from the water after 3 minutes of immersion - or earlier if the pain was considered to be intolerable. The duration of cold pressor stimulation was measured for each patient (cold pressor).Test stimulus - somatic pressure stimulation: Pain tolerance thresholds  was determined on the quadriceps muscle 5 cm proximal to the patella (corresponding to the L4 dermatome) before the cold pressor task and immediately after its completion. The same pressure algometer as for the static QST paradigm was used. The CPM effect was defined as the relative change (%) in pPTT.a priori assumptions of the discriminative features The prediction algorithm was utilized by a support vector machine (SVM) based on machine learning The SVM was applied to discriminate responders and non-responders. As prediction studies should be based on analysis of individual patients rather than statistical analysis of differences between study groups, the various QST measurements should be tested independently. Hence, the SVM was first applied to screen the following parameters for discriminative capacity by a leave-one-out approach : 1) pPDTAfter screening the parameters, the QST measurements leading to the maximum discrimination of the responders and non-responders were considered the optimal prediction model. The model was then assessed with respect to statistical significance to predict if a patient would respond to pregabalin or placebo treatment based on baseline QST assessment. Finally, the SVM was applied to calculate the optimal separation between patients.U test and Fisher’s exact test as appropriate. The significance of the SVM discrimination between responders and non-responders was analyzed by a Fisher’s exact test. A P-value <0.05 was considered as an indication of statistical significance. In case of multiple comparisons the P-value was adjusted to <0.01 All data are presented as medians with interquartile ranges unless otherwise indicated. Demographics, clinical data, and baseline QST measurements for responders and non-responders were compared by Wilcoxon signed rank test, Mann-Whitney P>0.10).Sixty-four patients with painful CP were enrolled for the study  were classified as responders compared to 12 of 29 patients (42%) in the placebo group (P = 0.45). A detailed analysis of the clinical endpoints was reported previously P = 0.001). All other baseline QST measurements were comparable between responders and non-responders (Baseline QST measurements are reported in sponders .P = 0.02). None of the other baseline QST measurements reached classification accuracy above chance level . For this threshold 14 of 16 patients were correctly classified in the responders group and 12 of 15 patients were correctly classified in the non-responders group . In addition, none of the other baseline QST measurements in the placebo group reached classification accuracy above chance level  reflecting the relation between stimulation areas (i.e. pancreatic vs. control area) was derived to eliminate individual differences in pain thresholds. The ratio reflects the excitability of the neuronal pool with convergent projections from pancreatic visceral afferents, thereby providing an indirect measure of spinal neuronal excitability due to pancreatic nociceptive input In order to obtain a clinical analogue to tonic pain and evoke maximal conditioning effect, a temperature of 2.0°C was used for the cold pressor paradigm The method for CPM assessment was chosen based on a previous review of the methodology of experimentally induced pain modulation, where the most sensitive models reported an average inhibitory effect of 40% in vitro studies indicate that pregabalin binds selectively to the alpha-2-delta subunit of voltage dependent calcium channels, thereby blocking the influx of calcium into presynaptic nerve terminals The rationale for the present study was based on the hypothesis that analgesic agents used for CP should be prescribed by relating their mode of action to the specific patient’s pattern of pain processing. Thus, an agent targeting neuronal excitability, such as pregabalin, should be more efficacious in patients with evidence of neuronal sensitization. In agreement with this, we found that patients with segmental hyperalgesia of the pancreatic viscerotome, sharing spinal segmental innervation with the pancreas, had a superior clinical response to pregabalin treatment compared to patients with less pronounced hyperalgesia. This finding reflects the known mechanisms of action underlying pregabalin analgesia. Accordingly, Only electric stimulation was predictive of pregabalin efficacy, while pressure stimulation was not associated with clinical outcome. This finding is in line with a recent study from our group were pregabalin treatment resulted in a greater increase of electric pain thresholds than of pressure pain thresholds Dynamic pain modulation (CPM) was not associated with pregabalin efficacy, which is an expected finding since pregabalin is not believed to target descending inhibitory pain modulation. Furthermore, as discussed above, CPM is not stable over time in CP patients, which may limit its usefulness for prediction of analgesic potency in CP patients The experimental protocol presented in the current study provides a non-invasive technique to identify patients with a specific pattern of abnormalities in central pain processing. This approach can be used to support clinicians when establishing treatment indications in patients with pancreatic pain (or other chronic pain disorders). Most analgesics are only effective in a subset of patients and many have adverse effects The present study provides first evidence that QST predicts the analgesic efficacy of pregabalin in patients with painful CP. The method thus carries the potential for shortening a long and painful trial and error process of finding an appropriate therapy for the individual patient and thus comprises a significant step towards personalized pain medicine.


Background and Purpose. Dry socket syndrome is one of the most irritating complications after tooth extraction. This study aims to investigate the efficacy of pastille GECB compared to ZOE. Materials and Methods. 30 patients with dry socket syndrome were selected and divided into two groups. GECB pastille was produced with 3% Guaiacol, 3% Eugenol 1.6% Chlorobutanol, sized 3 × 7 × 10 mm. GECB was applied in one group, and ZOE was used for the other group. Duration of pain after treatment and painkiller intake values were recorded within 20 days. The data were analyzed with independent samples t-test, Mann-Whitney, and Chi-Square tests. Results. Pain persisted for 45.53 ± 33.34 minutes in patients treated with ZOE and 19.87 ± 21.80 minutes in those treated with GECB (P = 0.19). Patients in the ZOE group reported more painkiller intake within 20 days (P = 0.031). Conclusion. GECB showed more significant efficacy in reducing complications after tooth extraction. Pain, bleeding, infection, paresthesia, temporomandibular disorders, abscess formation, and dry socket have been known as common complications following extraction of impacted wisdom teeth , 2. Dry Until now, different preventive and therapeutic methods have been proposed based on multifactorial and complex etiology of dry socket syndrome. Some studies focused on antibiotics and antibacterial agents as an effective way in the management of dry socket syndrome. In Swanson  and AkotFrom different suggested methods, Guaiacol, Eugenol, Chlorobutanol, and Balsam peru mixture (G.E.C.B) is a new material, introduced by Sultan company in the name of Dentalone. This mixture is a paste, consists of 3% guaiacol, 3% Eugenol, and 1.6% Chlorbutanol as an effective agent and Balsam peru as a base. According to therapeutic and alleviative effects of its ingredients, this paste was released by Sultan chemists in the name of Dry socket paste.Dry socket syndrome is one of the most painful complications following impacted third molar extraction, and it can affect both patients and clinicians emotionally and financially. As there are no definite explanations for the occurrence of this syndrome and prevention of this syndrome is an important duty for clinicians, the aim of this study is to investigate the efficacy of the new form of GECB drug as pastille in management of dry socket syndrome-related complications.In this randomized clinical trial, 30 patients aged from 18 to 40 who referred to maxillofacial surgery department of Isfahan University of medical sciences and diagnosed with dry socket syndrome after impacted lower third molar extraction were selected. These patients consisted of 7.5% of the whole patients. Patients with allergy to either of the dressing materials used in the study, infection in the site of tooth extraction and those who refused to participate in the study, were excluded. Patients who met the inclusion criteria  were randomly divided into two groups. Fifteen patients  undergone treatment with ZOE, and fifteen patients  were treated with pastille GECB. An informed consent was signed by patients, and the study has been ethically approved by Isfahan dental school (no. 390053).GECB pastille was prepared according to official formula which has been released by Sultan Company and approved by FDA. 3% eugenol (Merck), 3% Guaiacol (Merck), and 1.6% chlorobutanol are the effective ingredients in the pastille. All mentioned ingredients were inserted in the gelatin pastille formulation containing gelatin, glycerin, and sugar. After mixing all together, the mixture was poured in 3 × 7 × 10 mm mold. Molds were allowed to get cool, and then flexible pastilles were ready to use.t-test using SPSS software versus 15 (α = 0.05).First, patients' pain was assessed by visual analog scale (VAS). In the case group, GECB pastille and in control group ZOE dressing was used. After pastille and ZOE placement, the elapsed time for the patient's pain to significantly relieve was recorded. After the treatment, ibuprofen pills were prescribed as needed (PRN). Patients were followed for 20 days, and the pain severity was assessed by VAS, and the number of consumed pills was recorded after this period. Data were analyzed by Mann-withney and independent sample P = 0.339).In the present study, 30 patients with mean age of 29.87 ± 6.00 were assessed. The mean age of patients was 28.80 ± 5.52 and 30.93 ± 6.64 in ZOE and GECB group, respectively. The mean age of patients showed no significant difference between two groups (P = 0.136) as illustrated in 73% and 47% of the patients were male in ZOE and GECB groups, respectively. Also there was no significant difference between two groups regarding their gender (P = 0.839).In the present study, the severity of pain before any treatment was also assessed by VAS scale in each patient. The mean score was 8.33 ± 1.05 and 8.27 ± 0.7 in ZOE and GECB groups which showed no significant difference . In the ZOE and GECB groups, the pain reduced after 45.53 ± 33.34 and 19.87 ± 21.80 minutes, respectively.Independent sample Patients, who received ZOE and GECB treatments, averagely used 0.53 ± 0.74 and 0.07 ± 0.26 400 mg ibuprofen pills during the follow-up period. Mann-Whitney test showed that there was a significant difference in the number of consumed pills between the two groups .Despite the importance of the dry socket syndrome, many clinicians are not willing to discuss about a definite treatment approach toward this syndrome, as the etiology, and the treatment of this syndrome is highly controversial . Until tIn the present study, the mean age of patients showed no significant difference between the two groups. It is an important factor to consider, as some studies indicate that the incidence of dry socket syndrome increases with age . So to nMoreover, the primary pain before treatment was not significantly different between the two groups which cannot have any confounding effect on the results of the study.The pain rate in the GECB group was significantly lower, regarding its duration and the number of required pain killers. But it should be added that ZOE dressing is an acceptable treatment .Guaiacol is an eugenol-like phenolic combination . This maOne of the major advantages of GECB over traditional ZEO dressing is its convenience. As the treatment of dry socket syndrome by ZOE needs dressing replacement each 3 days for 1 week, some researchers consider it as an impediment in the treatment procedure . In the The comparison of the present study with other studies is challenging as the pastille form of this drug was used for the first time in the treatment of dry socket syndrome. Despite the conclusive results of the present study, further studies with bigger sample sizes and different concentrations of the medicament should be conducted.It can be concluded that there is a significant difference in the capacity of two different methods in pain alleviation. It seems that this effect is mainly due to use of Guaiacol. Also because of GECB pastille convenience and its one session use with less chair time, compared to ZOE, it can be an effective and reliable alternative for traditional ZOE method.