The Aging Spine | Back Pain Prevention and More with Dr. Hugh Jenkins

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Contact Tina at TinaWiller ttwglobal. Download this book for free from November 10 thru 14, Just click on Amazon button. And a systematic review comparing oral NSAIDS with opioids for treatment of pain due to knee osteoarthritis over at least 8 weeks' duration found similar pain relief for both analgesics Smith et al. Antidepressants—including tricyclic antidepressants TCAs , combined serotonin-noradrenalin reuptake inhibitors SNRIs , and selective serotonin reuptake inhibitors SSRIs —are one of the oldest pharmacological treatments for chronic pain.

Studies have found specific antidepressants or classes of antidepressants to be effective for the treatment of various types of pain. For example, amitriptyline improves pain for postherpetic neuralgia Graff-Radford et al. TCAs and SNRIs are recommended as a first choice along with gabapentinoids for postherpetic neuralgia, painful neuropathies, and central pain Dworkin et al. SSRIs generally are better tolerated by patients relative to other antidepressants, but the evidence on their efficacy for treating chronic pain is inconclusive Patetsos and Horjales-Araujo, Although depression is common among patients with chronic pain Fishbain et al.

Pain relief occurs at lower doses than doses with an antidepression effect Hameroff et al. The mechanism of action of antidepressants on pain is not fully understood. Antidepressants act mainly by reducing noradrenalin and serotonin reuptake and enhancing the descending inhibition Gillman, While both norepinephrine and serotonin have an effect on mood and pain Sindrup and Jensen, , catecholamine blockade appears to be more important in pain reduction. Indirect mechanisms of action may include 1 enhancement of the effects of endogenous opioids by increasing either their production or expression of opioid receptors Hamon et al.

It is important to note that attenuation of chronic pain by antidepressants is not immediate; the clinical effect usually is noted only after days or weeks of treatment. Common side effects of antidepressants include dry mouth, blurred vision, constipation, difficulty in passing urine, weight gain, and drowsiness. The SSRIs are generally better tolerated than other antidepressants, but their side effects can include nausea, tremor, hyperarousal, and drowsiness Goodman et al.

Adverse effects may be less likely with gradual dose escalation. Combination therapy with gabapentinoids, opioids, and topical agents is sometimes considered in refractory cases Gilron et al. Anticonvulsant medications, principally gabapentin and, more recently, pregabalin , have come to serve as first-line therapies in the treatment of chronic neuropathic painful conditions with the exception of trigeminal neuralgia Wiffen et al.

Gabapentin, an anticonvulsant initially introduced for the treatment of partial complex seizures, is approved in the United States for postherpetic neuralgia PHN. With the expiration of the exclusivity patent on gabapentin, pregabalin was introduced and obtained FDA approval for the treatment of PHN, as well as diabetic polyneuropathy and fibromyalgia. Independently, gabapentin also has been found effective in the treatment of fibromyalgia, although further research is needed Cooper et al.

Expert opinion in the form of guideline recommendations has emerged as well, in many cases being updated by societies dedicated to the evidence-based management of neuropathic pain, such as the Neuropathic Pain Special Interest Group NeuPSIG Dworkin et al. Regrettably, these drugs have an emerging potential for misuse, particularly in individuals with OUD Evoy et al. Mechanistically, the goal of these agents is to suppress the sensation of peripheral neuropathic pain, described as arising from both unmyelinated C-type slowly conducting nerve fibers, associated with sensations of dull, aching, burning, and poorly localized pain, and thinly myelinated A-delta nerve fibers, which are more rapidly conducting and signal sensations of sharp, stabbing, and often well-localized pain.

Unlike opioids, gabapentinoids gabapentin, pregabalin act primarily to reduce hyperalgesic states under conditions of inflammation and nerve injury rather than changing pain thresholds under nonpathological conditions Werner et al. Therefore, gabapentinoids modulate the pain pathway under pathophysiologic conditions. Under hyperalgesic conditions, gabapentin and pregabalin act supraspinally to enhance the descending inhibitory noradrenergic system onto the dorsal horn of the spinal cord Hayashida et al.

As discussed earlier in the chapter, the use of gabapentin or pregabalin in the immediate preoperative setting has the potential to decrease the need for postsurgical opioids Tan et al. Analgesic response rates for peripheral neuropathic painful conditions tend to average approximately 30 percent and rarely if ever exceed 50 percent. Nevertheless, they may still offer a benefit to those patients who have failed other analgesic therapy.

However, as noted above, misuse of gabapentinoids is of growing concern and the risk for misuse of these drugs may be higher in individuals with a history of opioid misuse Evoy et al. Persons suffering from chronic neuropathic pain often encounter difficulty with their pharmacotherapy and are unable to tolerate the side effects of such agents as anticonvulsants, antidepressants, and other centrally acting therapies.

Moreover, such therapies may be ineffective. Long before the advent of clinical trials, physicians successfully used native plant derivatives to provide pain relief. Among these, medicinal plant derivatives from hot chilies in South America were used as far back as BC. Capsaicin, the pungent principal ingredient in hot chili peppers, is now recognized as the primary therapeutic agent acting on the capsaicin receptor TRPV1 in many of these medicinal plants Schumacher, Acting predominantly on C-type primary afferent nociceptors, capsaicin has long been appreciated as inducing pain following its initial application, but paradoxically, having a topical analgesic effect with repeated application.

A series of overlapping capsaicin-induced effects that include desensitization, nociceptor dysfunction, neuropeptide depletion Cao et al. Topical creams or patches containing capsaicin can sometimes be effective for certain dermatomally restricted neuropathic conditions. However, several aspects of topical capsaicin treatment appear to limit its overall effectiveness and application in clinical practice: When such low-dose capsaicin preparations have been studied or compared with so-called first-line neuropathic pain treatments using a grading system requiring multiple RCTs, they typically have not provided robust neuropathic pain relief and showed poor to moderate efficacy in the treatment of either musculoskeletal or neuropathic symptoms Attal et al.

PHN is one of the most prevalent painful conditions associated with neuropathy that clinicians may encounter. It is driven in the United States by some , annual cases of primary herpes zoster infection Schmader, A Cochrane review examined six studies of topical capsaicin involving 2, patients conducted through December , which included RCTs and controlled trials of at least 6 weeks' duration.

In one study, high-dose 5 to 10 percent capsaicin, initially under regional anesthesia and later following topical local anesthetic pretreatment, was used in an attempt to circumvent the limitations of repeated low-dose capsaicin application and resulted in a wide range of posttreatment pain relief Robbins et al.

The strongest evidence exists for the use of high-dose capsaicin for the management of painful PHN. As with other therapeutic options for the treatment of painful neuropathic conditions, however, there appear to be responders and nonresponders to capsaicin among patients experiencing PHN and a range of other neuropathic conditions.

Overall, the quantified magnitude of the analgesic effect of capsaicin is typically modest 10 to 30 percent , although one study showed that among participants followed for 12 months, 10 percent experienced complete resolution of painful symptoms from PHN and other peripheral neuropathic conditions Mou et al. Beyond PHN, other painful neuropathic conditions sensitive to the analgesic effects of topical capsaicin with decreasing levels of evidence include HIV-associated painful neuropathy Derry et al.

The analgesic action is based on the ability to block voltage-gated sodium channel VGSC -mediated sodium influx into neuronal cells in response to local membrane depolarization. Since increased VGSC subtype expression on primary afferent neurons nociceptors is now linked to inflammatory and neuropathic pain, the blockade by local anesthetics represents a plausible mechanistic approach to treatment of chronic pain Waxman et al. However, widespread administration of local anesthetics is limited by toxicity to the CNS and the cardiac conduction system.

Selective, continuous infusion of low-dose local anesthetics adjacent to the nerve trunks, such as the brachial plexus or peripheral nerves, as well as through the epidural route, offers advantages over other modes of postoperative analgesia Guay, In many cases, these techniques have been extended to cancer and noncancer chronic pain treatments. Alternatively, continuous systemic infusion of the local anesthetic lidocaine has shown promise in the treatment of a wide range of chronic painful conditions that have not responded to more established analgesic approaches in both adults and pediatric patients Gibbons et al.

Although studies are still emerging, intravenous lidocaine infusion may help reduce intensity of pain and improve activity levels in a selected group of chronic pain patients. Lidocaine infusion also has been used safely and successfully in patients suffering from advanced cancer pain, both in the hospital setting without telemetric monitoring and in palliative care units, hospices, or even patients' homes, given suitable nursing supervision Peixoto and Hawley, The outcomes of lidocaine infusion in perioperative settings are mixed, with focused clinical applications, such as following complex spine surgery, showing promise Farag et al.

On the other hand, broader application across the spectrum of perioperative pain care may yield less than expected outcomes as there is only low to moderate evidence that lidocaine infusion compared with placebo has a large impact on pain scores, especially in the early postoperative phase Kranke et al. Questions that need to be addressed before lidocaine can be used as a mainstream treatment include precise dosing regimen, infusion duration, and patient selection criteria Kandil et al.

Lidocaine topical patches 5 percent , represent yet another route of delivery of local anesthetics for the treatment of acute and chronic pain, having been shown to be efficacious for PHN and diabetic neuropathy Mick and Correa-Illanes, The efficacy of broader use of lidocaine patches in the treatment of other neuropathic pain ailments is undetermined Finnerup et al. Agonists such as clonidine can directly produce spinal analgesia, and intrathecal administration augments spinal levels of norepinephrine and acetylcholine, both of which may play a role in the consequent spinal analgesia Hassenbusch et al.

As there is no apparent cross-tolerance between clonidine and opioid analgesics at a spinal site of action, their ability to synergize with morphine under nerve injury and neuropathic conditions has emerged as a critical translational finding Ossipov et al. In addition, their systemic use in the perioperative period has been found to reduce opioid requirements and improve analgesia, although with common adverse effects such as bradycardia and arterial hypotension Blaudszun et al.

The use of systemic clonidine and dexmedetomidine for the treatment of chronic pain has been described, but well-controlled studies are lacking. More commonly, these agents have found a role in opioid-dependent patients and are FDA-approved for the treatment of opioid withdrawal symptoms in the detoxification of opioid dependence.

More recently, these agents have appeared in detoxification protocols in the setting of hyperalgesia Monterubbianesi et al. The analgesic action of ketamine is a consequence of its noncompetitive blockade of the NMDA receptor expressed both in the brain supraspinally and in the dorsal horn of the spinal cord. Following nociceptor activation, excitatory amino acids glutamate are released from the central terminals of primary afferent nociceptors onto spinal neurons expressing NMDA receptors. Under persistent nociceptive pain and activation of C-type nociceptors and in turn, activation of ionotropic NMDA receptors, changes occur in neuronal plasticity at the nociceptive processing center of the spinal cord—the dorsal horn Li et al.

Blockade of NMDA receptor function in the dorsal horn has been shown selectively to attenuate the pain, hyperalgesia, and allodynia associated with ongoing tissue injury. Importantly, the action of an NMDA antagonist such as ketamine at the dorsal horn can block sensitization but spare the normal signaling of acute pain detection Yaksh et al.

The notion that opioid-induced tolerance and hyperalgesia may share a common mechanism with central sensitization has been proposed. Escalating doses of opioids given in an attempt to manage the pain of progressive malignant and nonmalignant diseases in adults and children can drive further pain and hyperalgesia. Under these difficult clinical conditions, low-dose ketamine has been shown to offer improvement in both pain control and opioid dose reduction that are often greater than 50 percent Eilers et al. Use of low-dose ketamine is intended to reverse or prevent central sensitization, opioid tolerance, and hyperalgesia while improving pain control Aggarwal et al.

More recently, the role of low-dose ketamine was investigated in the treatment of complex chronic painful conditions in a study at an outpatient chronic pain clinic, with some promising outcomes Kosharskyy et al. Such positive findings are tempered by the variable and dose-dependent profile of ketamine-related adverse effects psychomimetic , which can limit its clinical application. Modest reductions in pain and short-term opioid requirements have been observed with the use of perioperative ketamine infusions Barreveld et al.

Limited additional evidence Loftus et al. Cannabis and its subcompounds, cannabinoids, have been used for medical and recreational purposes for hundreds of years. The use of cannabis as a recreational drug is illegal in most countries. Recently, however, some countries around the world and several U. Various studies have shown a positive effect of cannabinoids on chronic pain Whiting et al. More than cannabinoids have been identified in nature or chemically synthesized ElSohly and Gul, The best-known cannabinoid is tetrahydrocannabinol THC , known mainly for its psychosedative effects.

Two cannabinoid receptors CBs have been cloned. CB1 is present in the brain, the spinal cord, and the peripheral nervous system, as well as in a number of neuronal tissues, including the liver, skeletal muscle, and the gastrointestinal tract; most of its analgesic effect is mediated by the CB1 receptor. CB2 is found mainly in immune cells in the peripheral nervous system or microglia in the CNS and to a lesser extent in the peripheral nervous system, primarily after injury and inflammatory response Atwood and Mackie, ; Howlett, Several endocannabinoids have been identified, anandamide and 2-arachidonoylglycerol 2-AG probably being the best studied.

They are synthesized mainly by neurons but also by immune cells Bisogno et al. The endogenous action of cannabinoids is not limited to the cannabinoid receptors; it may be associated with calcitonin gene-related peptide CGRP , transient receptor potential vanilloid TRPV , and NMDA receptors as well Mitrirattanakul et al. In animal studies, the combination of opioids with cannabinoids has shown notable synergistic effects Cichewicz, For medical use, cannabinoids can be smoked; inhaled; mixed with food or drinks; or administered orally, sublingually, or even topically. They can be taken in herbal form, extracted naturally from the plant, or manufactured synthetically.

Recent systematic reviews and meta-analyses have found evidence to support the use of cannabinoids for the treatment of such chronic pain conditions as neuropathic pain, cancer-related pain, fibromyalgia, and HIV-associated neuropathy Lynch and Ware, ; Whiting et al. A recent National Academies of Sciences, Engineering, and Medicine report on the health effects of cannabis and cannabinoids cites substantial evidence that cannabis is an effective treatment for chronic pain in adults and effects improvements for some pain patients with chemotherapy-induced nausea and vomiting.

The report also notes a lack of evidence regarding the efficacy, dose, routes of administration, and side effects of cannabis products in the United States NASEM, While further research is needed, some studies also have shown that cannabinoids are associated with an increased risk of short-term adverse events such as cognitive and psychiatric effects, nervous systems disorders, dry mouth, and drowsiness Lynch and Ware, ; Whiting et al.

The precise magnitude and consequences of the risk associated with therapeutic cannabinoid use are presently unknown. However, psychoactivity, memory deficiencies, impaired coordination and performance, and long-term risk for mental illness are the major issues in the development of cannabinoid-based analgesics Karila et al.

Alternative approaches to overcome the undesired effects of cannabinoids can include the development of endocannabinoid degradation inhibitors Lomazzo et al. More research is necessary to determine the efficacy and safety of cannabinoid-related therapy for chronic pain patients and whether adjunctive therapies with existing analgesics may enhance its therapeutic effect while reducing unwanted side effects.

Some evidence, currently limited to a few case reports, indicates that greatly reduced doses of naltrexone one-tenth normal may have analgesic properties for limited chronic pain conditions, such as fibromyalgia and complex regional pain syndrome CRPS. Although the mechanism of action for analgesia associated with low-dose naltrexone is unclear, it is thought to involve an anti-inflammatory effect through the blocking of toll-like receptor 4 TLR4 on microglial cells, inhibiting microglial activation.

Activated microglia are thought to play a major role in the development of neuropathic pain Chopra and Cooper, ; Tsuda, ; Younger et al. Experimental animal models also demonstrate reversal of neuropathic pain by naltrexone via TLR4 antagonism Hutchinson et al. In a small randomized, double-blind, placebo-controlled, crossover design study, 31 women with fibromyalgia were given low-dose naltrexone or placebo. Chopra and Cooper report two cases of long-standing CRPS whose signs and symptoms were significantly improved with 4. More research, particularly replication of these limited reports, could help ascertain the potential role of low-dose naltrexone in the treatment of chronic pain.

A number of pharmacologic treatments can be used to manage pain. While each nonopioid alternative has its own indications and risks, some are likely to be as effective as opioids or more so for reducing pain associated with the conditions for which they are indicated and when used appropriately, carry lower risk of adverse outcomes. Nonopioids such as cannabinoids and ketamine, which have shown promise for relief of some forms of pain in some pain management settings, also have potential adverse side effects.

Interventional pain management involves the use of invasive techniques, such as joint injections, nerve blocks, spinal cord stimulation, and other procedures, to reduce pain. Such techniques are best performed in the context of a multimodal treatment regimen, including physical therapy to maximize functional restoration.

There has been a significant increase in the volume of certain interventional procedures over the past 10 years, much of it focused on low back and neck pain with or without radiation to the hip and other lower extremities Chou et al. Low back pain is the most common cause of chronic pain in adults in the United States, followed by severe headache or migraine and then neck pain Freburger et al. Epidural steroid injections are the most commonly performed interventional pain therapies Manchikanti et al. This increase, however, has not been matched by similar reductions in disability or improvements in health status among those with low back and leg pain, and may have contributed to the rise in health care costs Chou et al.

The injections are commonly given to relieve radicular pain or sciatica associated with disc protrusions. Epidural steroid injections came under increased scrutiny after reports of serious neurologic events related to contaminated compounded glucocorticoids, in addition to other catastrophic injuries related to the injection itself. Injuries related to the performance of cervical epidurals have garnered significant attention.

Guidelines for preventing associated neurologic complications were published in Rathmell et al. Other interventional pain therapies for axial low back pain include such techniques as trigger-point injections for myofascial pain of the low back, injections involving either the lumbar facet or sacroiliac joints, and denervation of the nerves that supply those joints.

Lumbar facet or zygapophyseal joints are richly innervated and a source of axial low back pain. The medial branch of the dorsal rami of the spinal nerves innervates both the facet joints and the overlying multifidus muscle, the interspinous ligament, and surrounding muscle, as well as the periosteum Cohen and Raja, Evidence to support the use of intra-articular facet joint injections for long-term pain relief is limited Chou et al.

The medial branches are first anesthetized using local anesthetic as a diagnostic tool to confirm the location of the pain.

If pain is relieved, the medial branches may be lesioned using radiofrequency RF denervation to provide pain relief for an average of The RF may then be repeated for prolonged relief Schofferman and Kine, Another type of lesioning, cooled RF, has been used in treating sacroiliac joint pain. Spinal cord stimulation SCS has expanded in scope in recent years, from being utilized mainly for neuropathic pain related to painful postlaminectomy pain syndrome or failed back surgery syndrome to being applied for other neuropathic, sympathetic, vascular, and even visceral pain syndromes Deer et al.

The therapy involves placing an electrical lead in the epidural space that is connected to a programmable generator to relieve pain. A trial stimulator is first placed percutaneously under image guidance and left in place for up to 1 week, followed by implantation if the trial provides significant pain relief. Traditional SCS has been successful in treating extremity pain, but other areas and types of pain have been difficult to treat. Newer models of SCS utilize higher-frequency stimulation of 10, Hz compared with 40 to 60 Hz to improve relief of intractable axial low back pain.

A comparison study found that the higher-frequency SCS provided superior pain relief Kapural et al. SCS has the advantage of being reversible and adjustable, and of being capable of providing years of pain relief Deer et al. There is evidence for its cost-effectiveness in the relief of pain due to failed back surgery syndrome, CRPS, painful peripheral artery disease, and refractory angina Kumar and Rizvi, Interventional therapies also are offered for pain relief from migraine and other forms of severe headache.

Botulinum toxin, a protease exotoxin derived from Clostridium botulinum , may be used for chronic migraine when other therapies have failed Persaud et al. Other forms of headache, particularly occipital headache, cervicogenic headache, and headache originating from the upper cervical spine, may be amenable to targeted spinal intervention, such as occipital nerve blocks and cervical medial branch RF denervation.

Careful patient selection is critical to the success of interventional therapies. It is recommended that before such interventions are considered, a targeted history and assessment be performed to rule out the presence of potentially harmful conditions e. Complications of interventional pain management are multifactorial and are related to issues including performance of the procedure, patient anatomy, and comorbidities.

The use of S. Safety, Appropriateness, Fiscal neutrality, and Effectiveness principles has been proposed as a foundation for interventional pain treatment algorithms Krames et al. This approach has been used in advocating for early intervention for some pain syndromes e. Further research is needed to better understand the effectiveness of a variety of interventional techniques for painful conditions, as well as optimal patient selection to improve health outcomes. However, these treatments may provide effective pain relief for many patients with some forms of pain e.

The use of acupuncture for the treatment of pain has become widespread in recent decades. Acupuncture is a key component of traditional Chinese medicine that involves insertion of needles through the skin to acupuncture points. Pressure, heat, electrical current, laser light, and other means also may be used to stimulate these points. Investigations have demonstrated that the nervous system, neurotransmitters, and other endogenous substances respond to the needling stimulation to induce analgesia Foster and Sweeney, It has been shown that acupuncture analgesia is mediated by opioids produced in the periaqueductal gray and can be reversed by naloxone, an opioid antagonist Cheng and Pomeranz, Recent studies also suggest activation of cannabinoid receptors as a possible mechanism of action Gondim et al.

Systematic reviews evaluating the effect of acupuncture in treating pain have revealed mixed results. Some reviews have found minimal or no effect Lee et al. Recent reviews and meta-analyses examining the effect of acupuncture on musculoskeletal pain neck and back pain, osteoarthritis, chronic headache and shoulder pain, fibromyalgia have found that overall, acupuncture is superior to sham and no acupuncture, but with relatively modest differences between true and sham acupuncture Vickers et al.

Although it has been suggested that acupuncture is an effective treatment for pain, additional factors, such as potent placebo and context effects, may play a role in its observed effect as well Linde et al. It also has been suggested that acupuncture may have value in the treatment of chronic and tension headaches Linde et al.

Disease Prevention and Health Promotion

Additional RCTs are needed to determine the effect of acupuncture on neuropathic and postsurgical pain. Manual therapies, including massage and chiropractic and osteopathic manipulation such as spinal manipulative therapy , are commonly recommended for the treatment of musculoskeletal pain. However, high-quality evidence about these therapies is sparse, and there is little evidence that these therapies are as effective or more so than standard treatments. Cochrane reviews have been conducted on the evidence for these therapies in low back pain.

Evidence on combined chiropractic interventions shows a slight improvement in pain in the short and medium terms, but there is no evidence showing that chiropractic interventions have a clinically meaningful advantage over other treatments Walker et al. Spinal manipulative therapy has not been shown to be different from other common interventions Rubinstein et al.

A systematic review of massage therapy for fibromyalgia pain found that massage therapy of at least 5 weeks' duration resulted in significant improvement in pain, anxiety, and depression. However, the authors note that larger-scale and longer-term RCTs are needed to confirm these findings Li et al.

Physical therapy and exercise often are included in the treatment plan offered to patients suffering from musculoskeletal pain conditions such as fibromyalgia, arthritis, and back and neck pain. In addition to its direct effect on pain, exercise may improve overall physical and mental health Iacovides and Siamouli, The exact mechanisms by which physical therapy and exercise affect pain are unknown. It is believed, however, that activation of the CNS pain modulation pathways Lannersten and Kosek, and the release of beta-endorphins play a major role in the palliative effect Bement and Sluka, ; Stagg et al.

Other suggested mechanisms include activation of such neurotransmitters as norepinephrine and serotonin Dietrich and McDaniel, , interactions with the cardiovascular system Lovick, , and involvement of the adenosinergic system Martins et al. Despite the lack of strict guidelines or protocols for physical activity that may help patients with chronic pain, it appears that various types of physical activity can alleviate pain, including aerobic exercise, strength and flexibility training, walking, and manual therapy.

Systematic reviews have shown that these practices may be effective Bai et al. Exercise has been shown to be effective for treatment of many types and locations of pain, including fibromyalgia Busch et al. However, there are a number of barriers to the successful use of exercise therapy for pain management.

These barriers include patient factors, such as lack of knowledge about exercise, fears of worsening existing pain, depression, excessive deconditioning, and a lack of self-efficacy. Patients also may lack access to a safe place to exercise, time to exercise, and support from family or the workplace. Finally, there are health care delivery barriers, including the system's overly rigid focus on the biomedical model for pain, a lack of attention to or education about the value of exercise, a lack of supervision to ensure patient safety and comfort Kroll, , and a lack of insurance coverage of the costs of exercise and physical therapy.

Although it appears that recommending physical activity and exercise is warranted for patients suffering from chronic pain, further research is needed to evaluate the optimal treatment and intensity to recommend, and to explore the benefit of combining physical activity with other nonpharmacologic therapies and pharmacologic treatment for pain reduction.

In particular, there is some evidence that multidisciplinary rehabilitation, which includes physical treatments such as exercise as well as psychosocial interventions, may improve pain and function Kamper et al. CBT has been shown to be effective in managing chronic pain, either on its own or together with other pain management tools, such as medication. Over the past half century, evidence has accrued that the experience of pain is not based solely on sensory or neurologic states but is influenced by cognitive and affective processes Ehde et al.

A person's thoughts and beliefs about pain can affect a number of pain-related issues, including the intensity of pain, anxiety and depression, physical disability, activity limitations, and catastrophizing Ehde et al. Altering these thoughts and beliefs through CBT can change a person's experience of and adaptation to pain, decreasing its intensity and improving day-to-day functioning and the ability to cope with the pain Knoerl et al. CBT usually is delivered through multiple sessions of individual or group therapy in which a variety of strategies are conveyed to participants, including practicing relaxation techniques, reframing negative thoughts, scheduling activity to maximize functionality, and improving sleep patterns Knoerl et al.

Numerous studies have demonstrated the efficacy of CBT e. A Cochrane review Williams et al. However, the studies of CBT that have been performed have varied in the method of its delivery, the specific strategies used, and which outcome variables were studied, making it difficult to evaluate whether and to what extent CBT is efficacious for achieving specific pain-related outcomes Knoerl et al.

Knoerl and colleagues sought to remedy this evidence gap with an integrative review of 35 studies on CBT and chronic pain. They found that CBT was effective at reducing pain intensity in 43 percent of these trials only 8 of 35 studies used pain intensity as a primary outcome, although it was measured in all studies ; for a wider group of pain-related variables, including physical functioning, anxiety, depression, and quality of life, CBT was effective in 86 percent of trials.

The authors note that CBT has been understudied in military veterans and patients with chronic pain related to cancer treatment. Barriers to the provision of CBT include limited access to providers, inadequate insurance coverage, lack of knowledge about CBT among health care providers, and patients' perception of stigma associated with CBT Ehde et al.

A study Bee et al. However, patients who received the CBT intervention reported high satisfaction, finding that it helped them shift toward proactive pain management Bee et al. In addition to CBT, there are other psychosocial interventions for chronic pain, such as acceptance and commitment therapy ACT , in which patients are encouraged to change their responses to pain rather than seek a reduction in the pain itself. Late onset asthma is often a more severe phenotype, with less symptom free days, and a higher requirement for oral corticosteroids [ 6 ].

Late onset asthma patients tend to be less atopic with lower levels of serum IgE and both serum and sputum eosinophils. That is, they are likely to be non-atopic or have "intrinsic" asthma with evidence of sputum neutrophilia [ 6 , 7 ]. Late onset atopic asthma is predicted by high levels of IgE and previous allergen sensitisation.

However, allergen sensitisation can occur at any age. The Normative Ageing Study demonstrated that previous cat sensitisation was associated with late onset asthma as confirmed by methacholine bronchoprovocation testing [ 8 ]. Ageing is associated with a restricted chest wall as thoracic skeletal components become stiffer and less compliant [ 9 ].

Age related deterioration and calcification in the rib articulations appear to explain these findings. There is additional evidence that the contractile properties of the diaphragm deteriorate with ageing [ 10 ]. In addition, normal aging is associated with a reduction in elastic recoil of the lung due to loss of elastic fibres. In expiration the loss of elastic recoil leads to small airways collapse with associated air trapping and in increase in the residual volume, a normal finding in ageing.

There is also a decrease in the vital capacity as a result of a stiffer chest wall and muscle weakness. As a result, the ageing lung is put at a mechanical disadvantage. The diagnosis of late onset asthma can be difficult and delayed. There are both patient and physician factors underlying the problem.

Further, Ekici et al. Elderly asthmatics reported less breathlessness on Borg dyspnoea score compared to the young asthmatics for a comparable level of bronchoconstriction. Furthermore, even when dyspnoea is recognised, older patients may regard their symptoms as a consequence of old age and therefore not report their dyspnoea to doctors [ 13 ]. Low socio-economic status may result in lack of access to health care, contributing to such under-reporting in an elderly population [ 1 , 13 ]. In a community sample, 3. Furthermore, Dow and co-workers [ 15 ], in a cross sectional survey of 6, residents of Bristol over the age of 65, not taking asthma treatments, reported an estimated population prevalence for untreated asthma of 1.

A history of wheeze and breathlessness or a past history of doctor diagnosed asthma were most likely to indicate untreated asthma [ 15 ]. The diagnostic challenge is exacerbated by the reduced reliability of normal predicted spirometry values in the elderly population which are frequently extrapolated from younger age-groups [ 16 ].

Introduction

Further, old age years was an independent predictor for unsuccessful spirometry as defined by American Thoracic Society testing criteria amongst a Norwegian randomly selected population [ 17 ]. The prevalence of current asthma in those over 65 years has been documented in Australia as between 7. One of the controversies in the diagnosis of asthma in older people is the overlap with chronic obstructive airways disease so that a diagnosis of asthma is often considered less certain in this age-group.

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Asthma in the elderly is responsible for a significant and increasing mortality in the elderly population. Asthma deaths are highly over-represented by the elderly population. In Australia between and sixty-nine percent of all asthma deaths were in those 65 years and above [ 1 ]. The pattern of mortality in older people with asthma also differs from younger age-groups with the peak time of death occurring over winter months, in contrast to the more even spread of mortality throughout the year in the 5 to 64 year old age groups, suggesting a potential infective cause of death [ 1 , 2 ].

Asthma in older age-groups has been observed to impact on survival. Forty-two percent of these patients had at least one hospital admission. In this study, the observed survival was not significantly different from the expected survival [ 23 ], an observation confirmed by Australian data [ 1 ]. Hospital statistics also testify to the relatively high rate of hospital admission for asthma in older age-groups with the 65 and older group having slightly higher admission rates for asthma than the 15 to year-old age-group [ 1 , 2 ]. Once in hospital the older group had a significantly longer length of stay [ 1 ].

Asthma was associated with a reduced quality of life. Asthmatics also reported increased impairment in activities of daily living and were twice as likely to have symptoms of depression. Asthmatics were more likely to rate their general health as fair or poor. Quality of life was significantly impaired in the asthmatic population. Asthmatics reported significantly impaired quality of life in the physical, social and general health domains of the SF and in all domains of the SGRQ.

Elderly asthmatics also reported more depressive symptoms than the controls [ 24 ]. Again, asthma in the elderly was associated with reduced quality of life across all domains of the SGRQ. Asthma derived direct costs in the elderly were double than the adult population. Most of this excess expense was explained by hospitalisation costs [ 25 ]. Fifteen young asthmatics, aged under 65 were also included in this analysis.

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Elderly patients with longstanding asthma had the most severe airway obstruction and importantly, also complained of fewer asthma symptoms. Asthma is a chronic inflammatory condition that has been shown to be correlated with a slow but progressive loss of lung function over time. These results stress the importance of good asthma control and the impact in the elderly asthmatic population where a prolonged duration of disease is evident. Pharmacological treatment of asthma in the elderly needs to be administered with care as this population are more likely to experience medication side effects and are also more likely to suffer from drug-drug interactions [ 28 , 29 ].

Beta-agonist therapy can cause tremor, a dose dependent reduction in serum potassium and tachycardia. To minimise systemic absorption though oropharyngeal deposition a spacer device is recommended [ 28 ]. Theophylline is recommended in patients with uncontrolled asthma despite combination inhaler therapy - Global Initiative for Asthma GINA - Step 3 [ 31 ]. Theophylline must be used carefully in the elderly population and is associated with a number of adverse effects particularly when drug levels are above the therapeutic range. Drug toxicity is most likely in those with established cardiac or liver disease and there are a number of described drug interactions eg.

Careful monitoring of drug levels is required to reduce the risk of very serious adverse events such as cardiac arrhythmias and seizures. However, side effects including nausea, insomnia and gasto-oesophageal reflux disease are not uncommon. Inhaled steroids at moderate doses are generally not associated with systemic side effects in the elderly population. However, local side effects are not uncommon and include oral candidiasis and hoarseness of the voice.

Asthma in the elderly

These effects are dose-dependent and can usually be managed with the addition of a spacer device. The fear of corticosteroid side effects are substantial in this age-group and are emphasised by the increasing frequency of cataracts and osteoporosis which are associated with "steroid" therapy in this age-group [ 13 , 30 ]. Systemic corticosteroids can cause or exacerbate significant systemic adverse effects in the elderly population including diabetes, cataracts, hypertension, osteoporosis and vertebral fractures.

Systemic maintenance corticosteroids are however indicated for severe, uncontrolled asthma indicated at the higher steps of the GINA treatment recommendations [ 31 ]. Fifty-one prevent reported adverse outcomes from their reliever medication, particularly tremor. Such concerns constitute a significant barrier to regular asthma medication use [ 13 , 30 ]. Beta-2 agonists are recommended as first line reliever therapy in asthma guidelines [ 31 , 32 ].

Cholinergic receptors appear to function independently of ageing. Indeed, some elderly patients respond better to anti-cholinergics than to beta agonists [ 33 ]. These findings have not translated into specific treatment guidelines. Elderly patients with severe allergic asthma should also be considered for omalizumab therapy. A subgroup analysis demonstrated that elderly patients also gain benefit from this medication [ 34 ]. Elderly patients are often prescribed a number of medical treatments for medical comorbidities. There is a list of medication that can trigger or exacerbate asthma.

There are case reports of timolol, a non-selective beta blocker, used for glaucoma triggering severe and fatal bronchospasm [ 35 ]. Non-steroidal anti-inflammatory medications used for osteoarthritic pain, highly prevalent in the elderly population, can also exacerbate asthma. Lack of access to medical care is a problem in the elderly population.