JAMA Internal Medicine: Pain Topic Collection

Reconstructing Angina: Cardiac Symptoms Are the Same in Women and Men

Kreatsoulas C, Shannon HS, Giacomini M, et al. — Mon, 13 May 2013 00:00:00 GMT

Coronary artery disease (CAD) is the leading cause of mortality in the Western world. The prevalence of angina and proportion of deaths from CAD is higher among women than men. Despite this, the perception that CAD is a man's disease prevails. Historic faulty assumptions in the construct of angina, failure to systematically include women in clinical studies, and differences in age-specific incidence rates have perpetuated this perception. As a result, the term typical angina has evolved to describe symptoms in men, whereas atypical angina is applied to women. This lack of clarity has been a source of controversy in understanding CAD in women.

Tailoring Chronic Pain Care by Brief Assessment of Impact and Prognosis Comment on “Point-of-Care Prognosis for Common Musculoskeletal Pain in Older Adults” Chronic Pain Care

Von Korff M. — Mon, 13 May 2013 00:00:00 GMT

In 2011, an Institute of Medicine report, Relieving Pain in America, called for a cultural transformation of pain care. The report concluded that “healthcare providers should increasingly aim at tailoring pain care to each person's experience, and self-management of pain should be promoted.”^(p1) Medical treatments are often less than adequate for patients with chronic musculoskeletal pain. Ordering more diagnostic tests of uncertain value, prescribing more prescription analgesics with poorly understood risks and benefits, and providing more surgical procedures, nerve blocks, and epidural injections will not achieve the aims of improved patient outcomes, increased patient satisfaction, and more prudent use of finite health care resources. Rather, we need to help patients with chronic pain resume valued life activities by placing more emphasis on improving quality of life and less on interventions that afford only short-term pain relief with appreciable risks and costs.

Point-of-Care Prognosis for Common Musculoskeletal Pain in Older Adults Musculoskeletal Pain in Older Adults

Mallen CD, Thomas E, Belcher J, et al. — Mon, 13 May 2013 00:00:00 GMT

Importance

Many site-specific, multivariable risk models for predicting the outcome of musculoskeletal pain problems have been published. The overlapping content in these models suggests a common set of generic indicators suitable for use in primary care.

Objective

To investigate whether a brief set of generic prognostic indicators can predict the outcome of musculoskeletal pain in older patients presenting to general practitioners.

Design, Setting, and Participants

A prospective observational cohort study conducted from September 1, 2006, through March 31, 2007, of consecutive patients 50 years or older presenting with noninflammatory musculoskeletal pain to 1 of the 5 participating general practices in the United Kingdom.

Main Outcome Measures

During consultation, the treating physician assessed and recorded 5 brief generic items (duration of present pain episode, current pain intensity, pain interference with daily activities, presence of multiple-site pain, and ultrashort depression screen) and recorded their overall prognostic judgment. The primary outcome was patient-rated improvement, which was measured 6 months after consultation and cross-validated with repeated measures up to 3 years.

Results

A total of 194 (48.1%) of 403 participants were classified as having an unfavorable outcome at 6 months. Inclusion of 3 generic prognostic indicators (duration of present pain episode, pain interference with daily activities, and presence of multiple-site pain) in the prognostic model improved on reliance on physicians' prognostic judgment alone (C statistic = 0.72 vs 0.62; net reclassification index = 0.136; proportion correctly classified = 69%). The improvement in prognostic accuracy was attributable to correcting physicians' tendency toward overoptimistic expectations of outcome.

Conclusions and Relevance

Three easy-to-obtain pieces of information followed by systematic recording of the general practitioners' prognostic judgment provide a simple generic assessment of prognosis at point of care in older persons presenting with musculoskeletal problems to primary care practices in the United Kingdom. Such an assessment offers a common foundation for investigating the usefulness of prognostic stratification for guiding management in the consultation across a range of common painful conditions.