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Faculdade de Medicina da Universidade do Porto
Risk factors which influence the evolution of acute pain into
chronic pain
Systematic Review Turma 6
Introduction
Definitions
Context
Objective
PainPain
Unpleasant sensory and emotional experience associated with actual or potential tissue damage [1].
Acute PainAcute Pain
Pain connected with real tissue lesions [1]; Shorter duration; Needs a treatment model
Chronic painChronic pain
Pain without biological value that has persisted beyond normal tissue healing time (3 months) [1].
“Current continuous or intermittent pain or discomfort which as persisted for more than three months, with recent or frequent seeking of treatment
or use of analgesic medication” [3].
Chronic painChronic pain
Opposite to acute pain, needs a rehabilitative rather than a treatment model [2].
Among the most disabling and costing afflictions in North America, Europe and Australia [4]..
Must be understood in a multi-dimensional way [2]. More women than man are affected Prevalence increases with age It is estimated that between 10 and 15 % of the population
suffers from it [2].
Chronic painChronic pain
Chronic no-malignant pain is commonest at limbs and joints, Chronic no-malignant pain is commonest at limbs and joints, at the back, as well as at neck and head [6][7].at the back, as well as at neck and head [6][7].
Has a deep impact on suffers, as it prorogues a sense of loss of Has a deep impact on suffers, as it prorogues a sense of loss of their lives, due to loss of confidence and self-esteem their lives, due to loss of confidence and self-esteem associated with psychological, social and economical associated with psychological, social and economical
implications [2].implications [2]. To manage it, to issues must be take in count [2]:To manage it, to issues must be take in count [2]:
- treatment - - treatment - drug therapy, invasive therapy, alternative drug therapy, invasive therapy, alternative therapiestherapies
- rehabilitation - - rehabilitation - physiotherapyphysiotherapy
ContextContext
Acute and chronic pain are intimately correlatedAcute and chronic pain are intimately correlated
Many factors are in the origin of such transitionMany factors are in the origin of such transition::- individual factors (obesity, severe radiating pain…)- individual factors (obesity, severe radiating pain…)
- psychological factors (anxiety, severe depression…)- psychological factors (anxiety, severe depression…)
- workplace factors (heavy jobs, monetary compensation - workplace factors (heavy jobs, monetary compensation during inability…)during inability…)
- …- …
ContextContext
Chronic pain may lead to loss of employment, loss of social Chronic pain may lead to loss of employment, loss of social and home roles, sleep disorders, having much psychological, and home roles, sleep disorders, having much psychological, social and economic implications [2]social and economic implications [2]
Importance and relevance of our work
ObjectiveObjective
To review systematically the literature regarding risk factors which influence the evolution of acute pain into chronic pain
Systematic ReviewSystematic Review
The key steps are [9]:The key steps are [9]: Formulation of a focused review questionFormulation of a focused review question A comprehensive, exhaustive search and inclusion of A comprehensive, exhaustive search and inclusion of
primary studiesprimary studies Quality assessment of included studies and data Quality assessment of included studies and data
extractionextraction Synthesis of study resultsSynthesis of study results Interpretation of the results and report-writingInterpretation of the results and report-writing
Formulation of the QuestionFormulation of the Question
It was verified that studies had already been made about the It was verified that studies had already been made about the subject in interestsubject in interest
Our target population is the published articles indexed on Our target population is the published articles indexed on MedlineMedline
Participants are articles that refer to the evolution of acute pain Participants are articles that refer to the evolution of acute pain into chronic paininto chronic pain
Cohort Studies were selected as the indicated Type of Study. No Cohort Studies were selected as the indicated Type of Study. No intervention will be appliedintervention will be applied
The pretend result is the achievement of a relation between the The pretend result is the achievement of a relation between the existence of certain factors (risk factors) and the development existence of certain factors (risk factors) and the development of chronic pain in individuals previously suffering of acute of chronic pain in individuals previously suffering of acute painpain
Formulation of the QuestionFormulation of the Question
Systematic Review of pre-existing literature Systematic Review of pre-existing literature indexed on Medline, that refers and is based indexed on Medline, that refers and is based on cohort studies, in order to analyse and on cohort studies, in order to analyse and evaluate the relation between the presence of evaluate the relation between the presence of certain risk factors and the evolution of an certain risk factors and the evolution of an acute pain into a chronic painacute pain into a chronic pain
Research and Study SelectionResearch and Study Selection
Bibliographic ResearchBibliographic Research
Study SelectionStudy Selection
Bibliographic ResearchBibliographic Research Bibliographic Database: MedlineBibliographic Database: Medline
Established Limits: HumansEstablished Limits: Humans
Separated sensitive research Queries:Separated sensitive research Queries:““Chronic”, “Pain”, “Chronicity”Chronic”, “Pain”, “Chronicity”
Application of Boolean operators:Application of Boolean operators: ““Chronicity AND Pain”, “Chronic AND Pain”, “Chronicity AND Chronicity AND Pain”, “Chronic AND Pain”, “Chronicity AND
Pain AND Factors”, “Chronicity AND Pain AND Factors AND Cohort Pain AND Factors”, “Chronicity AND Pain AND Factors AND Cohort Studies”, “(“Chronicity AND Pain”) OR (“Chronic AND Pain”)”Studies”, “(“Chronicity AND Pain”) OR (“Chronic AND Pain”)”
Bibliographic ResearchBibliographic Research
Selection of adequate Query:Selection of adequate Query:
““Chronicity AND Pain”Chronicity AND Pain”
Participants: 369 articlesParticipants: 369 articles
Study SelectionStudy Selection
Definition of Selection Criteria:Definition of Selection Criteria:
Exclusion CriteriaExclusion Criteria
Inclusion CriteriaInclusion Criteria
Study SelectionStudy Selection
Exclusion Criteria:Exclusion Criteria:
Studies that do not consider that acute pain Studies that do not consider that acute pain becomes chronic pain in a period of three becomes chronic pain in a period of three monthsmonths
Articles that do not include cohort studiesArticles that do not include cohort studies
Study SelectionStudy Selection
Inclusion Criteria:Inclusion Criteria:
Cohort Studies that refer to factors wich Cohort Studies that refer to factors wich influence the evolution of acute pain into influence the evolution of acute pain into chronic painchronic pain
Studies that include certain types of painStudies that include certain types of pain Studies that refer to certain types of factorsStudies that refer to certain types of factors
Study SelectionStudy Selection
Organization of reviewer groups:Organization of reviewer groups:
4 Reviewer Groups: three groups of 2 4 Reviewer Groups: three groups of 2 elements and one group of 3 elementselements and one group of 3 elements
4 Article Groups: three of 92 articles and one 4 Article Groups: three of 92 articles and one of 93 articlesof 93 articles
Study SelectionStudy Selection
Articles Revision by Titles and AbstractsArticles Revision by Titles and Abstracts Application of Exclusion CriteriaApplication of Exclusion Criteria
““Cohort Studies”: X articles excludedCohort Studies”: X articles excluded
““Chronic Pain Definition”: Y articles excludedChronic Pain Definition”: Y articles excluded Articles excluded by language different from Articles excluded by language different from
English: Z Articles excludedEnglish: Z Articles excluded
Study SelectionStudy Selection
Remaining Articles Revision by Full TextRemaining Articles Revision by Full Text Exclusion of articles which full text is not Exclusion of articles which full text is not
available: S articles excludedavailable: S articles excluded Application of exclusion criteria: Q articles Application of exclusion criteria: Q articles
excludedexcluded Application of inclusion criteriaApplication of inclusion criteria
Study SelectionStudy Selection
Reference Management software:Reference Management software: Register causes of exclusionRegister causes of exclusion List of articles included in the systematic List of articles included in the systematic
review: W articlesreview: W articles
Quality AssessmentQuality Assessment
Organization of reviewer groupsOrganization of reviewer groups
Quality criteriaQuality criteria
Quality AssessmentQuality Assessment
Quality criteria:Quality criteria: The sample of patients is representative and The sample of patients is representative and
homogeneoushomogeneous Patients are homogeneous with respect to prognostic Patients are homogeneous with respect to prognostic
risk, exposure to factorsrisk, exposure to factors The follow up is sufficiently completeThe follow up is sufficiently complete Measurements of the outcomes are made in the same Measurements of the outcomes are made in the same
way on both groups (exposed and unexposed)way on both groups (exposed and unexposed)
Quality AssessmentQuality Assessment
Exclusion of articles that lack quality, not being Exclusion of articles that lack quality, not being compatible with the quality criteria establishedcompatible with the quality criteria established
Stratification of studies by qualityStratification of studies by quality
Data ExtractionData Extraction
Organization of reviewer groups for extraction Organization of reviewer groups for extraction of dataof data
Data extractionData extraction
Processing the data on appropriate softwareProcessing the data on appropriate software
Data ExtractionData Extraction
Data extraction on:Data extraction on: Information about existing influential factors:Information about existing influential factors:
Which factors;Which factors;How many factors was each individual exposed to;How many factors was each individual exposed to;How long was each individual exposed to these factors How long was each individual exposed to these factors
before developing acute pain and after developing acute painbefore developing acute pain and after developing acute pain Information on measurements taken after the development of Information on measurements taken after the development of
acute painacute pain Information on type of painInformation on type of pain Information on period of pain existenceInformation on period of pain existence
Study ResultsStudy Results
Analysis of DataAnalysis of Data
Synthesis and Summary of study Results:Synthesis and Summary of study Results: Tabulation of study characteristicsTabulation of study characteristics
ResultsResults PublishingPublishing
Results published in a Scientific Article:Results published in a Scientific Article:IntroductionIntroductionObjectiveObjectivePopulation studied and MethodsPopulation studied and MethodsResultsResultsDiscussion/ConclusionDiscussion/Conclusion
ReferencesReferences[1] [1] http://http://www.iasp-pain.orgwww.iasp-pain.org; IASP – International Association for the Study of Pain; IASP – International Association for the Study of Pain[2] Smith BH; Hopton JL and Chambers WA; [2] Smith BH; Hopton JL and Chambers WA; Chronic pain in primary care; Family PracticeChronic pain in primary care; Family Practice ; ;
1999; 16; 475-482 1999; 16; 475-482 [3] Purves AM, Penny K, Munro C [3] Purves AM, Penny K, Munro C et al.et al. Defining chronic pain for epidemiological research – Defining chronic pain for epidemiological research –
acessing a subjective definition. acessing a subjective definition. The Pain Clinic The Pain Clinic 1998; 10; 139-147.1998; 10; 139-147.[4] IASP – Pain Clinical Updates; volume XI, No. 2; June 2003[4] IASP – Pain Clinical Updates; volume XI, No. 2; June 2003[5] Von Korff M, Dworkin SF, Le Resche L. Graded chronic pain status: na epidemiologic [5] Von Korff M, Dworkin SF, Le Resche L. Graded chronic pain status: na epidemiologic
evaluation. evaluation. PainPain 1990; 40: 279-291 1990; 40: 279-291[6] Bowsher D, Rigge M, Sopp L. Prevalence of chronic pain in the British population: a [6] Bowsher D, Rigge M, Sopp L. Prevalence of chronic pain in the British population: a
telephone survey of 1037 households. telephone survey of 1037 households. The Pain Clinic The Pain Clinic 1991; 4: 223-2301991; 4: 223-230[7] Brattberg G, Thorslund M, Wilkman A. The prevalence of pain in the general population. The [7] Brattberg G, Thorslund M, Wilkman A. The prevalence of pain in the general population. The
results of a postal survey in a county in Sweden. results of a postal survey in a county in Sweden. PainPain 1989; 37: 215-222 1989; 37: 215-222[8] Fransen M, Woodward M, Norton R [8] Fransen M, Woodward M, Norton R et alet al, Risk Factors Associated with the Tansition From , Risk Factors Associated with the Tansition From
Acute to Chronic Occupational Back Pain, Acute to Chronic Occupational Back Pain, Spine, Spine, volume 27, number 1, pp 92-98, 2002volume 27, number 1, pp 92-98, 2002 [9] Pai M, McCulloch M, Gorman JD [9] Pai M, McCulloch M, Gorman JD et alet al, Systematic reviews, Systematic reviews
and meta-analyses: An illustrated, step-by-step guide. and meta-analyses: An illustrated, step-by-step guide. The nationalThe nationalmedical journal of India,medical journal of India, volume 17, No2, 2004 volume 17, No2, 2004