Chronic pain as a symptom or a disease: the IASP Classification of Chronic Pain for the International Classification of Diseases (ICD-11)

Management of chronic musculoskeletal pain in veterans: a systematic review

BACKGROUND AND AIM OF THE WORK

Veterans are military with health problems due to military conditions. The improved body armor and operational conditions has reduced the number of deaths, but increased the number of veterans with severe injuries, affected by musculoskeletal pain and associated syndromes, such as post-traumatic stress disorder. Multimodal approaches are considered in USA the gold standard for the treatment of these problems, while in Europe and Italy the data are unknown. The aim of this review was to describe and summarize multimodal therapeutic approaches that apply to the veteran population for chronic musculoskeletal pain and relate syndromes management.

METHODS

A comprehensive systematic review of the literature on Cochrane Library, PubMed, CINAHL e PsycINFO databases was conducted, from 2001 to 2020.

RESULTS

228 papers have been found, 134 were selected after the first screening. 24 quantitative studies were included in the review, all from USA. Different multimodal interventions with different kind of treatment types emerged. The analyzed studies' sample size was 11 million (mean age = 57.67 years; SD=±11.94). The multimodal approaches showed a significant improvement in all outcomes (pain reduction and control, opioid therapy reduction, psychosocial outcomes) compared to traditional therapy.

CONCLUSIONS

Multimodal therapeutic approaches seem to guarantee a good management chronic musculoskeletal pain and related mental disorders, and the reduction and control to opioid use. Military nurses emerged as professionals who have a central role in this approach. European and Italian authorities should consider veterans, in order to assess their expected increase in the future.

Pre-Outpatient Group Education and Assessment in Chronic Pain: A Systematic Review

BACKGROUND

Pre-outpatient interventions in chronic pain have the potential to improve patient self-management earlier in primary or secondary care, which may minimize pain chronicity and negative health outcomes. The literature for this is sparse, and there are no existing systematic reviews on this topic.

METHODS

The purpose of this systematic review is to examine the evidence for pre-outpatient group interventions in chronic pain.

RESULTS

We identified four studies that looked at this: two randomized control trials, one prospective observational study, and one descriptive study. We identified high-quality evidence that a pre-outpatient group intervention reduces waiting times, moderate-quality evidence that it results in reduced costs per patient, very low-quality evidence that it reduces health care utilization, and very low-quality evidence that it improves service throughput. There were moderate-to-low levels of participant engagement with the initiative, which varied across the included studies. For patient outcome measures, we found no evidence that a pre-outpatient group intervention improves pain intensity, very low-quality evidence that it improves pain-related interference, low-quality evidence that it increases use of pain management strategies and produces high satisfaction levels, low-quality evidence that it improves pain self-efficacy, and no evidence that it improves psychological distress.

CONCLUSIONS

Group interventions before individual appointments have the potential to provide important improvements in service delivery, including improvements in waiting times and cost per patient. Benefits for patient outcome measures are less clear. Clinical heterogeneity and high levels of bias existed in the included studies. Further research is required so that meaningful conclusions can be made about these interventions.

Chronic Pain: What Does It Mean? A Review on the Use of the Term Chronic Pain in Clinical Practice

Chronic pain is nowadays used as an umbrella term referring to a wide range of clinical conditions, such as fibromyalgia, migraine, or long-standing pain states without actual known causes. However, labeling a patient’s clinical condition with the term “chronic pain”, when dealing with pain lasting longer than 3 months, might be misleading. This paper aims at analyzing the possible pitfalls related to the use of the term “chronic pain” in the clinical field. It appears, indeed, that the term “chronic pain” shows a semantic inaccuracy on the basis of emerging scientific evidences on the pathogenesis of different long-standing pain states. The major pitfalls in using this label emerge in clinical settings, especially with patients having a biomedical perspective on pain or from different cultures, or with healthcare providers of other medical specialties or different disciplines. A label solely emphasizing temporal features does not help to discern the multifaceted complexity of long-standing pain states, whose onset, maintenance and exacerbation are influenced by a complex and interdependent set of bio-psycho-social factors. Thus, finding a more meaningful name might be important. We call upon the necessity of bringing awareness and implementing educational activities for healthcare providers, as well as for the public, on the biopsychosocial approach to assess, prevent and care of chronic pain. Further research on the etiopathogenetic processes of chronic pain states is also required, together with examinative diagnostic methods, to individuate the most appropriate label(s) representing the complex long-standing pain states and to avoid adopting the term “chronic pain” inappropriately.

Pain medicine as a career

Pain is one of the most common causes of seeking medical care. In the day to day clinical practice, incidence of pain of some origin is next only to common cold. The average life span of an Indian has also increased and this population is vulnerable to chronic and cancer pain. Anaesthesiologists are well-versed with the art and science of treating pain and their role as pain physician is a natural extension of the professional work. ‘Pain Medicine’ is growing as a speciality. Last two decades have seen an explosive growth in the scientific study of pain and anaesthesiologists taking up pain medicine as a career. Postgraduate students can certainly adopt this super speciality. This article highlights the merits and depicts various aspects of ‘pain medicine’ as a career.

Health care providers' experiences of pain management and attitudes towards digitally supported self-management interventions for chronic pain: a qualitative study

BACKGROUND

Chronic pain constitutes a significant burden for the individuals affected, and is a frequent reason why patients seek health care services. While in-person psychosocial interventions can be of support to people living with chronic pain, such interventions are not always accessible. eHealth interventions may provide greater accessibility, but the evidence and use of digital self-management solutions for chronic pain are still limited and the lack of health care provider input in the development process of such solutions a concern. Therefore, the aim of the current study was to investigate health care providers' experiences of treating patients with chronic pain, their attitudes towards, and use of, digital solutions in pain management, and their suggestions for content and design elements for a potential digital pain self-management intervention.

METHODS

Twelve health care providers representing a variety of health care disciplines participated in semi-structured interviews. The interviews were analyzed using thematic analysis.

RESULTS

The material was analyzed into three main themes: [1] Patients with chronic pain and their current use of the health care services, [2] Health care providers' own motivation and impression of patient prerequisites for use of digital self-management interventions, and [3] Suggestions for content and design elements in a digital self-management intervention for people living with chronic pain. The challenges faced by patients living with chronic pain were described as numerous. Despite interest and positive attitudes, few of the health care providers had used or recommended eHealth solutions to their patients. A range of potential content and functionality elements were identified, including aspects of motivation and engagement and providers also emphasized the importance of easy access and positive, personal content to support existing treatment.

CONCLUSIONS

This study offers insights into health care providers' considerations for the potential of digital self-management interventions supporting patients living with chronic pain. Findings indicate the need for change and a more comprehensive treatment approach to pain management. eHealth solutions may contribute to such change, and providers pointed to a need for health care provider involvement, timely support and follow-up as important factors for integrating digital pain self-management interventions into clinical care.

TRIAL REGISTRATION

ClinicalTrials.gov : NCT03705104.

Chronic pain and cognitive impairment: a cross-sectional study in people living with HIV

Cognitive impairment and chronic pain are amongst the most prevalent neurological sequelae of HIV infection, yet little is understood about the potential bidirectional relationship between the two conditions. Cognitive dysfunction can occur in chronic pain populations whilst those with cognitive impairment can display modified responses to experimentally induced painful stimuli. To date, this has not been explored in HIV cohorts.This study aimed to identify any contribution of chronic pain to cognitive impairment in HIV and to determine differences in pain characteristics between those with and without cognitive dysfunction.This was an observational cohort study involving people living with HIV (n = 148) in the United Kingdom. Participants underwent validated questionnaire-based measurement of pain severity, interference and symptom quality as well as conditioned pain modulation and quantitative sensory testing. All participants completed a computer-based cognitive function assessment.Fifty-seven participants met the criteria for cognitive impairment and 73 for chronic pain. The cognitive impairment group had a higher prevalence of chronic pain (p = 0.004) and reported more neuropathic symptoms (p = 0.001). Those with chronic pain performed less well in emotional recognition and verbal learning domains. The interaction identified between chronic pain and cognitive dysfunction warrants further exploration to identify causal links or shared pathology.

An update on the management of chronic pelvic pain in women

Chronic pelvic pain represents a major public health problem for women and impacts significantly on their quality of life. Yet it is under-researched and a challenge to manage. Women who suffer from chronic pelvic pain frequently describe their healthcare journey as long, via a variety of specialists and frustrating, with their pain often dismissed. Aetiological factors and associations are best conceptualised using the 'three P's' model of predisposing, precipitating and perpetuating factors. This integrates the numerous biological, psychological and social contributors to the complex, multifactorial nature of chronic pelvic pain. Overall management involves analgesia, hormonal therapies, physiotherapy, psychological approaches and lifestyle advice, which like other chronic pain conditions relies on a multidisciplinary team approach delivered by professionals experienced and trained in managing chronic pelvic pain.

Towards optimising experimental quantification of persistent pain in Parkinson's disease using psychophysical testing

People with Parkinson's disease (PD) may live for multiple decades after diagnosis. Ensuring that effective healthcare provision is received across the range of symptoms experienced is vital to the individual's wellbeing and quality of life. As well as the hallmark motor symptoms, PD patients may also suffer from non-motor symptoms including persistent pain. This type of pain (lasting more than 3 months) is inconsistently described and poorly understood, resulting in limited treatment options. Evidence-based pain remedies are coming to the fore but therapeutic strategies that offer an improved analgesic profile remain an unmet clinical need. Since the ability to establish a link between the neurodegenerative changes that underlie PD and those that underlie maladaptive pain processing leading to persistent pain could illuminate mechanisms or risk factors of disease initiation, progression and maintenance, we evaluated the latest research literature seeking to identify causal factors underlying persistent pain in PD through experimental quantification. The majority of previous studies aimed to identify neurobiological alterations that could provide a biomarker for pain/pain phenotype, in PD cohorts. However heterogeneity of patient cohorts, result outcomes and methodology between human psychophysics studies overwhelmingly leads to inconclusive and equivocal evidence. Here we discuss refinement of pain-PD paradigms in order that future studies may enhance confidence in the validity of observed effect sizes while also aiding comparability through standardisation. Encouragingly, as the field moves towards cross-study comparison of data in order to more reliably reveal mechanisms underlying dysfunctional pain processing, the potential for better-targeted treatment and management is high.

Pain Acceptance Creates an Emotional Context That Protects against the Misuse of Prescription Opioids: A Study in a Sample of Patients with Chronic Noncancer Pain

There is solid evidence of an association between several psychological flexibility processes, particularly pain acceptance, and adaptation to chronic pain. However, there are relatively few studies on the relationship between pain acceptance and opioid misuse in chronic pain patients. Thus, the aim of the present study was to test a hypothetical model in which pain acceptance would regulate pain sensations and pain-related thoughts and emotions, which would be related to opioid misuse. The sample comprised 140 chronic pain patients attending two hospitals. All patients were receiving pharmacological treatment, including opioid analgesics. Structural equation modelling analyses showed a significant association between higher pain acceptance and lower pain intensity and catastrophizing, and lower levels of anxiety and depression. Only higher anxiety and depression were significantly associated with increased opioid misuse. The results suggest that levels of anxiety, depression, and pain acceptance must be assessed before opioids are prescribed. Pain acceptance implies a relationship with internal events that protects against anxiety and depression and thus against opioid misuse. Acceptance and Commitment Therapy appears to be particularly appropriate for these patients.

The use of zebrafish as a non-traditional model organism in translational pain research: the knowns and the unknowns

The ability of the nervous system to detect a wide range of noxious stimuli is crucial to avoid life-threatening injury and to trigger protective behavioral and physiological responses. Pain represents a complex phenomenon, including nociception associated with cognitive and emotional processing. Animal experimental models have been developed to understand the mechanisms involved in pain response, as well as to discover novel pharmacological and non-pharmacological anti-pain therapies. Due to the genetic tractability, similar physiology, low cost, and rich behavioral repertoire, the zebrafish (Danio rerio) has been considered a powerful aquatic model for modeling pain responses. Here, we summarize the molecular machinery of zebrafish to recognize painful stimuli, as well as emphasize how zebrafish-based pain models have been successfully used to understand specific molecular, physiological, and behavioral changes following different algogens and/or noxious stimuli (e.g., acetic acid, formalin, histamine, Complete Freund's Adjuvant, cinnamaldehyde, allyl isothiocyanate, and fin clipping). We also discuss recent advances in zebrafish-based studies and outline the potential advantages and limitations of the existing models to examine the mechanisms underlying pain responses from an evolutionary and translational perspective. Finally, we outline how zebrafish models can represent emergent tools to explore pain behaviors and pain-related mood disorders, as well as to facilitate analgesic therapy screening in translational pain research.

Sensory neuron-associated macrophages as novel modulators of neuropathic pain

The peripheral nervous system comprises an infinity of neural networks that act in the communication between the central nervous system and the most diverse tissues of the body. Along with the extension of the primary sensory neurons (axons and cell bodies), a population of resident macrophages has been described. These newly called sensory neuron-associated macrophages (sNAMs) seem to play an essential role in physiological and pathophysiological processes, including infection, autoimmunity, nerve degeneration/regeneration, and chronic neuropathic pain. After different types of peripheral nerve injury, there is an increase in the number and activation of sNAMs in the sciatic nerve and sensory ganglia. The activation of sNAMs and their participation in neuropathic pain development depends on the stimulation of pattern recognition receptors such as Toll-like receptors and Nod-like receptors, chemokines/cytokines, and microRNAs. On activation, sNAMs trigger the production of critical inflammatory mediators such as proinflammatory cytokines (eg, TNF and IL-1β) and reactive oxygen species that can act in the amplification of primary sensory neurons sensitization. On the other hand, there is evidence that sNAMs can produce antinociceptive mediators (eg, IL-10) that counteract neuropathic pain development. This review will present the cellular and molecular mechanisms behind the participation of sNAMs in peripheral nerve injury-induced neuropathic pain development. Understanding how sNAMs are activated and responding to nerve injury can help set novel targets for the control of neuropathic pain.

Tinnitus and associations with chronic pain: The population-based Tromsø Study (2015-2016)

Tinnitus and pain have many similarities. Both are subjective sensations that may turn chronic, they are often accompanied by hypersensitivity in their respective sensory system, and overlapping brain changes have been observed. Since no population study has examined the empirical association between chronic pain and tinnitus, the present study aimed to explore the relationship in a general adult population. We used data from the seventh survey of the Tromsø Study (2015–2016). Participants (aged ≥40) responded to questions about pain and tinnitus. Using multiple logistic regression, we analysed the adjusted relationship between chronic pain and tinnitus in the full sample (n = 19,039), using several tinnitus definitions ranging from tinnitus >5 minutes within the past 12 months (broadest definition) to at least weekly and highly bothersome tinnitus (strictest definition). We also analysed relationships between number of body regions with pain, pain intensity and bothering, and tinnitus >5 minutes, among participants with chronic pain (n = 11,589). We found an association between chronic pain and tinnitus that was present irrespective of tinnitus definition, but was stronger with more bothersome tinnitus. With chronic pain, the odds of tinnitus >5 minutes was 64% higher, while odds of at least weekly, highly bothersome tinnitus was 144% higher than without chronic pain. Among participants with chronic pain, the number of pain regions was the pain variable most strongly associated with tinnitus >5 minutes (OR = 1.17 (95% CI: 1.14–1.20) for an increase of one region), whereas the other pain variables (intensity and bothering) showed weaker associations. All chronic pain variables had significant interactions with age, with the strongest associations for the youngest individuals (40–54 years). Our findings support the existence of an association between chronic pain and tinnitus and emphasises the importance of examining for comorbid pain in tinnitus patients to provide a more comprehensive treatment of tinnitus.

Socioeconomic status and occurrence of chronic pain: a meta-analysis

OBJECTIVE

To examine the association between socioeconomic status (SES) and the occurrence of chronic pain, defined as pain that persists or recurs for >3 months.

METHODS

We performed a structured search in Medline, Embase, WHO Global Index Medicus and Conference Proceedings Citation Index-Science databases to identify cohort and case-control studies on chronic pain and SES and its subgroups (SES combined index, educational level, income and occupational status). We extracted study characteristics, outcome measures and measures of association and their 95% CIs. Literature search, data extraction and risk of bias assessment were conducted by two independent researchers. We performed main and subgroup meta-analyses using random-effects model, and formally assessed heterogeneity and publication bias.

RESULTS

A total of 45 studies, covering a population of ∼175 000 individuals, were meta-analysed, yielding a pooled Odds Ratio (OR) of 1.32 (95% CI: 1.21, 1.44) and 1.16 (95% CI: 1.09, 1.23) for low and medium SES levels, respectively, compared with high level. We obtained similar results in all the subgroup analyses. Heterogeneity was generally moderate to high across strata, and some evidence of publication bias for low socioeconomic status was found.

CONCLUSION

Our results support a moderate increase in the risk of chronic pain for low and medium SES when compared with high SES, a feature that remained constant in all measures of exposure or outcome used. Further prospective research on populations from developing countries are needed to confirm our findings as the studies available for this meta-analysis were carried out exclusively in developed countries.

Quality of rheumatology care for patients with fibromyalgia and chronic pain syndromes

BACKGROUND

One-third of primary care providers (PCPs) refer patients with fibromyalgia or chronic pain (FM/CP) to specialist care, typically rheumatology. Yet, comprehensive data on the quality of rheumatology care for patients with FM/CP are currently lacking.

METHODS

Records of patients referred for rheumatology consultation for FM/CP and seen at a single academic centre between 2017 and 2018 were extracted by retrospective chart review. Variables were diagnostic accuracy (at referral vs consultation), resource utilisation (investigations, medications, medical and allied health referral), direct costs (physician billing, staff salary, investigation fees) and access (consult wait time). Patient experience and referring PCP experience surveys were administered.

RESULTS

79 charts were identified. Following consultation, 81% of patients (n=64) maintained the same diagnosis of FM/CP, 19% (n=15) were diagnosed with regional pain and 0% of patients (n=0) were diagnosed with an inflammatory arthritis or connective tissue disease. Investigations were ordered for 37% of patients (n=29), medication prescribed for 10% (n=8) and an allied health referral provided for 54% (n=43). Direct costs totalled $19 745 (average $250/consult; range $157-$968/consult). Consultation wait time averaged 184 days (range 62-228 days). Out of the seven (64%) responses to the patient experience survey, 86% of patients (n=6) were satisfied with provider communication but the consultation 'definitely' met the expectations of only 57% (n=4). The PCP survey returned an insufficient response rate.

CONCLUSIONS

This study found that no patient referred to rheumatology care for FM/CP was diagnosed with an inflammatory arthritis or connective tissue disease. Furthermore, patients with FM/CP experience lengthy wait times for rheumatology care which delay their management of chronic pain. Interdisciplinary and collaborative healthcare models can potentially provide higher quality care for patients with FM/CP.

Clinical Correlates of Opioid Prescription Among Pediatric Patients With Chronic Pain

INTRODUCTION

Up to 17%-20% of pediatric patients with chronic pain are prescribed opioid pharmacotherapy and face an increased risk of opioid misuse in adulthood. Little is known about the way clinical presentation may influence which children with chronic pain are prescribed opioids. This study examines the associations between child's and caregiver's report of child's pain, physical function, and socioemotional indices with opioid prescriptions in pediatric patients initiating treatment for chronic pain.

METHODS

Participants were 1,155 pediatric patients (71.26% female, n=823) aged 8-17 years and 1 of their caregivers (89% mothers) who presented for evaluation at a tertiary care pediatric pain clinic. Data were collected from 2015 to 2019 and analyzed in 2020.

RESULTS

Binary logistic regression analyses investigated the relative contribution of child's demographic, pain, and Patient-Reported Outcome Measurement Information System measures to opioid prescription status; separate models were conducted for child's and caregiver's report. Across child and caregiver models, findings were that child's age (older), pain duration (longer; child's report only), and increased physical limitations (mobility challenges and pain interference; caregiver's report only) were the most salient clinical correlates of positive opioid status. Contrary to the existing literature on adults with chronic pain, socioemotional indices (anxiety, depression, peer functioning) were nonsignificant.

CONCLUSIONS

A greater understanding of how clinical presentation may relate to prescribed opioid pharmacotherapy informs the field's conceptualization of the sequelae of opioid use and misuse in the context of pediatric chronic pain.

Pathophysiology of musculoskeletal pain: a narrative review

Musculoskeletal pain (excluding bone cancer pain) affects more than 30% of the global population and imposes an enormous burden on patients, families, and caregivers related to functional limitation, emotional distress, effects on mood, loss of independence, and reduced quality of life. The pathogenic mechanisms of musculoskeletal pain relate to the differential sensory innervation of bones, joints, and muscles as opposed to skin and involve a number of peripheral and central nervous system cells and mediators. The interplay of neurons and non-neural cells (e.g. glial, mesenchymal, and immune cells) amplifies and sensitizes pain signals in a manner that leads to cortical remodeling. Moreover, sex, age, mood, and social factors, together with beliefs, thoughts, and pain behaviors influence the way in which musculoskeletal pain manifests and is understood and assessed. The aim of this narrative review is to summarize the different pathogenic mechanisms underlying musculoskeletal pain and how these mechanisms interact to promote the transition from acute to chronic pain.

A Comprehensive Update of the Superior Hypogastric Block for the Management of Chronic Pelvic Pain

PURPOSE OF REVIEW

This is a comprehensive review of the superior hypogastric block for the management of chronic pelvic pain. It reviews the background, including etiology, epidemiology, and current treatment available for chronic pelvic pain. It then presents the superior hypogastric block and reviews the seminal and most recent evidence about its use in chronic pelvic pain.

RECENT FINDINGS

Several definitions exist for chronic pelvic pain (CPP), making the diagnosis more challenging for the clinician; however, they commonly describe continuous pain lasting 6 months in the pelvis, with an overwhelming majority of patients being reproductive-aged women. This pain is often one of mechanical, inflammatory, or neuropathic. It is generally underdiagnosed and affects anywhere between 5 and 26% of women. The diagnosis of chronic pelvic pain is clinical, consisting of mainly of a thorough history and physical and ruling out other causes. The pathophysiology is often endometriosis (70%) and also includes PID, adhesions, adenomyosis, uterine fibroids, chronic processes of the GI and urinary tracts, as well as pelvic-intrinsic musculoskeletal causes. Treatment includes physical therapy, cognitive behavioral therapy, and oral and parenteral opioids. Interventional techniques provide an added tier of treatment and may help to reduce the requirement for chronic opioid use. Superior hypogastric plexus block is one of the available interventional techniques; first described in 1990, it has been shown to provide long-lasting relief in 50-70% of patients who underwent the procedure. Two approaches described so far, both under fluoroscopy, have seen similar results. More recently, ultrasound and CT-guided procedures have also been described with similar success. The injectate includes local anesthetic, steroids, and neurolytic agents such as phenol or ethanol. CPP is a common debilitating condition. It is diagnosed clinically and is underdiagnosed globally. Current treatments can be helpful at times but may fall short of satisfactory pain relief. Interventional techniques provide an added layer of treatment as well as reduce the requirement for opioids. Superior hypogastric plexus block provides long-lasting relief in many patients, regardless of approach. Evidence level is limited, and further RCTs could help provide better tools for evaluation and patient selection.

Insomnia severity and depressive symptoms in people living with HIV and chronic pain: associations with opioid use

Chronic pain commonly occurs in people living with HIV (PLWH). Many PLWH in the United States obtain opioids for chronic pain management. Whether insomnia severity and depressive symptoms are exacerbated by chronic pain and opioid use in PLWH remains to be determined. This study examined insomnia severity and depressive symptoms in 85 PLWH with chronic pain and 35 PLWH without chronic pain. Among PLWH with chronic pain, reported opioid use was examined in relation to insomnia severity and depressive symptoms. PLWH with chronic pain reported significantly greater insomnia severity (p = .033) and depressive symptoms (p = .025) than PLWH without chronic pain. Among PLWH with chronic pain who reported opioid use (n = 36), insomnia severity was greater compared to those who denied opioid use (n = 49), even after controlling for pain severity and number of comorbidities (p = .026). Greater pain severity was significantly associated with greater insomnia severity (p < .001) and depressive symptoms (p = .048) among PLWH with chronic pain who reported opioid use. These associations were not significant among those PLWH with chronic pain who denied opioid use. Findings suggest that PLWH with chronic pain are likely to experience poor sleep and depressed mood. Furthermore, poor sleep was associated with opioid use among PLWH with chronic pain.

Pharmacist-led intervention on chronic pain management: A systematic review and meta-analysis

AIMS

Pharmacists have been contributing to the management of chronic pain, ensuring the quality use of medicine. However, there is diversity in the interventions provided by pharmacists and their impact.

METHODS

Six electronic databases were searched from inception until June 2020 for articles published in English examining the intervention provided by the pharmacist in chronic pain management. Studies investigating the impact of pharmacist intervention individually or multidisciplinary teams including pharmacists for chronic pain management were included.

RESULTS

Fourteen studies (2365 participants) were included in the current review. Six studies were randomized controlled trials while the remainder were observational studies in which pharmacists provided intervention individually or in collaboration with other healthcare professionals. Medication review was the most common intervention provided by the pharmacist. The pooled analysis found that pharmacist-led interventions reduced the pain intensity (-0.22; 95% confidence interval [CI]: -0.35 to -0.09; moderate certainty) among participants with chronic pain. Opiate stewardship provided by pharmacists was effective; however, mixed results were noted on the impact of the intervention on physical functioning, anxiety, depression and quality of life. Pharmacist intervention was more expensive than treatment as usual.

CONCLUSIONS

Pharmacists contribute substantially to chronic pain management, ensuring the quality use of medicine, resulting in reduced pain intensity. Further studies with rigorous design are needed to measure the impact of pharmacist-provided intervention individually or in a multidisciplinary team on the economic benefit and other health outcomes.

Integrated cognitive behavioral therapy for chronic pain: An open-labeled prospective single-arm trial

BACKGROUND

We aimed to examine the feasibility of our newly-developed, integrated, and high-intensity individual cognitive behavioral therapy (CBT) protocol for treatment-resistant chronic pain.

METHODS

We conducted an open-labeled prospective single-arm trial for patients aged 18 years and above, suffering from chronic pain, and diagnosed with somatic symptom disorder with predominant pain. We provided 16 weekly sessions of CBT, each lasting for 50 minutes, which included 4 new strategies: attention shift, memory work, mental practice, and video feedback. For comparison, the study had a pre-test post-test design. The primary outcome was the change from baseline (week 1) to 16, as indicated by the Numerical Rating Scale and Pain Catastrophizing Scale. In addition, we evaluated depression, anxiety, disability, and quality of life as secondary outcomes.

RESULTS

Sixteen patients with chronic pain underwent our CBT program. Though there was no reduction in pain intensity, catastrophic cognition showed statistically significant improvement with a large effect size. Depression, anxiety, and disability demonstrated statistically significant improvements, with small to moderate effect sizes. No adverse events were reported.

CONCLUSION

Our newly integrated CBT program for chronic pain may improve catastrophic cognition, depression, anxiety, and disability. Large-scale randomized controlled studies are necessary to investigate the program's effectiveness in the future.

Management of Musculoskeletal Pain: An Update with Emphasis on Chronic Musculoskeletal Pain

Musculoskeletal pain is a challenging condition for both patients and physicians. Many adults have experienced one or more episodes of musculoskeletal pain at some time of their lives, regardless of age, gender, or economic status. It affects approximately 47% of the general population. Of those, about 39–45% have long-lasting problems that require medical consultation. Inadequately managed musculoskeletal pain can adversely affect quality of life and impose significant socioeconomic problems. This manuscript presents a comprehensive review of the management of chronic musculoskeletal pain. It briefly explores the background, classifications, patient assessments, and different tools for management according to the recently available evidence. Multimodal analgesia and multidisciplinary approaches are fundamental elements of effective management of musculoskeletal pain. Both pharmacological, non-pharmacological, as well as interventional pain therapy are important to enhance patient’s recovery, well-being, and improve quality of life. Accordingly, recent guidelines recommend the implementation of preventative strategies and physical tools first to minimize the use of medications. In patients who have had an inadequate response to pharmacotherapy, the proper use of interventional pain therapy and the other alternative techniques are vital for safe and effective management of chronic pain patients.

Investigating key predictors of persistent low back pain: A focus on psychological stress

AIM

To investigate the degree to which psychological stress, self-reported pain scores, and pain sensitivity during an acute state of low back pain (LBP) predict the development of persistent LBP trajectories.

BACKGROUND

Identifying which factors influence LBP trajectories is critical to understand why some individuals experience persistent LBP and to illuminate areas for nursing intervention.

METHODS

A secondary data analysis of a prospective study examining trajectories of LBP was conducted. The sample was comprised of 217 adults with acute-onset LBP recruited from the community and followed over 24 weeks. Variables of interest included demographic data, perceived stress scores, self-reported pain scores, and somatosensory characteristics collected within the first 4 weeks of LBP onset. The data were analyzed using non-parametric bivariate comparisons and a semi-parametric Cox proportional hazards model with interval-censoring.

RESULTS

Individuals with higher psychological stress scores were less likely to experience pain resolution (Hazard ratio [HR] = 0.555, 95% confidence interval [CI] = 0.36-0.85, p = 0.02). After adjustment for covariates in the final model, the analysis revealed household income (HR = 2.79, 95% CI [1.63-4.67], p < 0.001) to be the dominant predictor of LBP persistence in this sample.

CONCLUSION

Heightened psychological stress and pain severity as well as decreased pressure pain thresholds were indicated as influential factors of LBP trajectories. Household income was identified as the dominant predictor, demonstrating that individuals with a higher household income were more likely to resolve their pain. Strategies which integrate assessment of stress, self-reported pain scores, pain sensitivity, and social determinants for patients experiencing pain are needed to advance nursing care.

Specialized, pro-resolving mediators as potential therapeutic agents for alleviating fibromyalgia symptomatology

OBJECTIVE

To present a hypothesis on a novel strategy in the treatment of fibromyalgia (FM).

DESIGN

A narrative review.

SETTING

FM as a disease remains a challenging concept for numerous reasons, including undefined etiopathogenesis, unclear triggers and unsuccessful treatment modalities. We hypothesize that the inflammatome, the entire set of molecules involved in inflammation, acting as a common pathophysiological instrument of gut dysbiosis, sarcopenia, and neuroinflammation, is one of the major mechanisms underlying FM pathogenesis. In this setup, dysbiosis is proposed as the primary trigger of the inflammatome, sarcopenia as the peripheral nociceptive source, and neuroinflammation as the central mechanism of pain sensitization, transmission and symptomatology of FM. Whereas neuroinflammation is highly-considered as a critical deleterious element in FM pathogenesis, the presumed pathogenic roles of sarcopenia and systemic inflammation remain controversial. Nevertheless, sarcopenia-associated processes and dysbiosis have been recently detected in FM individuals. The prevalence of pro-inflammatory factors in the cerebrospinal fluid and blood has been repeatedly observed in FM individuals, supporting an idea on the role of inflammatome in FM pathogenesis. As such, failed inflammation resolution might be one of the underlying pathogenic mechanisms. In accordance, the application of specialized, inflammation pro-resolving mediators (SPMs) seems most suitable for this goal.

CONCLUSIONS

The capability of various SPMs to prevent and attenuate pain has been repeatedly demonstrated in laboratory animal experiments. Since SPMs suppress inflammation in a manner that does not compromise host defense, they could be attractive and safe candidates for the alleviation of FM symptomatology, probably in combination with anti-dysbiotic medicine.

Efficacy and Safety of N-acetylcysteine for the Management of Chronic Pain in Adults: A Systematic Review & Meta-analysis

OBJECTIVE

To assess the efficacy and safety of N-acetylcysteine in the treatment of chronic pain.

METHODS

A systematic search was carried out until April 2020 for clinical studies of N-acetylcysteine in the management of any persistent or recurrent chronic pain condition for adults ≥ 18 years old. Risk of Bias was assessed using the validated risk of bias tools. When appropriate, a meta-analysis using a random-effects model was performed, with a fixed-effect model for sensitivity analysis.

RESULTS

Nine studies (n = 863) were included (5 randomized controlled trials [RCTs], 2 open-label non-comparative studies and 2 comparative studies), that evaluated patients with sickle cell disease (3), complex regional pain syndrome (1), pelvic pain/endometriosis (2), rheumatoid arthritis (1), diabetic neuropathy (1), and chronic neuropathic pain (1). In the pooled analysis of 3 RCTs, N-acetylcysteine did not reduce pain intensities (SMD -0.21, 95% CI -0.33 to 0.75, random-effects), improve functional outcomes (SMD 0.21, 95% CI -0.33 to 0.75) or quality of life (SMD 0.60, 95% CI -4.44 to 5.64); however, sensitivity analysis with a fixed effect model demonstrated an effect for pain intensities and function. Due to adverse events being inconsistently reported, no conclusion could be made regarding safety of N-acetylcysteine in chronic pain.

CONCLUSIONS

While there is some evidence to indicate N-acetylcysteine may provide analgesic efficacy for certain pain conditions, there is insufficient evidence to provide definitive evidence on NAC in chronic pain management. Larger-size RCTs spanning a variety of chronic pain conditions are needed to determine N-acetylcysteine's role, if any, in pain medicine.

Chronic noncancer pain is not associated with accelerated brain aging as assessed by structural magnetic resonance imaging in patients treated in specialized outpatient clinics

Chronic pain is often associated with changes in brain structure and function, and also cognitive deficits. It has been noted that these chronic pain-related alterations may resemble changes found in healthy aging, and thus may represent accelerated or premature aging of the brain. Here, we test the hypothesis that patients with chronic noncancer pain demonstrate accelerated brain aging compared with healthy control subjects. The predicted brain age of 59 patients with chronic pain (mean chronological age ± SD: 53.0 ± 9.0 years; 43 women) and 60 pain-free healthy controls (52.6 ± 9.0 years; 44 women) was determined using the software brainageR. This software segments the individual T1-weighted structural MR images into gray and white matter and compares gray and white matter images with a large (n = 2001) training set of structural images, using machine learning. Finally, brain age delta, which is the predicted brain age minus chronological age, was calculated and compared across groups. This study provided no evidence for the hypothesis that chronic pain is associated with accelerated brain aging (Welch t test, P = 0.74, Cohen's d = 0.061). A Bayesian independent-samples t test indicated moderate evidence in favor of the null hypothesis (BF01 = 4.875, ie, group means were equal). Our results provide indirect support for recent models of pain-related changes of brain structure, brain function, and cognitive functions. These models postulate network-specific maladaptive plasticity, rather than widespread or global neural degeneration.

Efficacy and safety of Shi-style cervical manipulation therapy for treating acute and subacute neck pain: study protocol for a randomized controlled trial

Background

Neck pain is a common clinical disease, which seriously affects people’s mental health and quality of life and results in loss of social productivity. Improving neck pain’s curative effect and reducing its recurrence rate are major medical problems. Shi’s manipulation therapy has unique advantages and technical features that aid in the diagnosis and treatment of neck pain. Compared with first-line non-steroidal anti-inflammatory drug (NSAID) treatment of neck pain, Shi’s cervical manipulation lacks the relevant research basis of therapeutic advantage, safety, and satisfaction for treating acute and subacute neck pain. Herein, we aim to confirm our hypothesis in a clinical trial that the safety and efficacy of Shi’s cervical manipulation will be more effective, safer, and more satisfactory than NSAIDs to treat acute and subacute neck pain.

Methods

In this multicenter, positive-controlled, randomized clinical trial, traditional analgesic drug (NSAID) is used to evaluate and show that Shi’s manipulation is more effective, safe, and satisfactory for treating acute and subacute neck pain. Overall, 240 subjects are randomly divided into the trial and control groups, with both groups treated by the corresponding main intervention method for up to 12 weeks. Clinical data will be collected before the intervention and immediately after the first treatment; at 3 days and 1, 2, 4, 8, and 12 weeks after the intervention; and at 26 and 52 weeks after treatment follow-up of clinical observation index data collection. The clinical observation indices are as follows: (1) cervical pain is the primary observation index, measured by Numerical Rating Scale. The secondary indices include the following: (2) cervical dysfunction index, measured by patient self-evaluation using cervical Neck Disability Index; (3) cervical activity measurement, measured by the cervical vertebra mobility measurement program of Android mobile phone system; (4) overall improvement, measured by patient self-evaluation with SF-36; and (5) satisfactory treatment, determined by patient self-evaluation.

Discussion

We will discuss whether Shi’s cervical manipulation has greater advantages in efficacy, safety, and satisfaction of acute and subacute neck pain than traditional NSAIDs, to provide a scientific basis for the dissemination and application of Shi’s cervical manipulation.

Trial registration

China Registered Clinical Trial Registration Center ChiCTR1900021371. Registered on 17 February 2019

A Review on Stem Cell Therapy for Neuropathic Pain

Neuropathic pain is a complex, chronic pain state that is heterogeneous in nature and caused by the consequence of a lesion or disease affecting the somatosensory system. Current medications give a long-lasting pain relief only in a limited percentage of patients also associated with numerous side effects. Stem cell transplantation is one of the attractive therapeutic platforms for the treatment of a variety of diseases, such as neuropathic pain. Here, the authors review the therapeutic effects of stem cell transplantation of different origin and species in different models of neuropathic pain disorders. Stem cell transplantation could alleviate the neuropathic pain; indeed, stem cells are the source of cells, which differentiate into a variety of cell types and lead trophic factors to migrate to the lesion site opposing the effects of damage. In conclusion, this review suggests that stem cell therapy can be a novel approach for the treatment of neuropathic pain.

Does pain neuroscience education improve pain knowledge, beliefs and attitudes in undergraduate physiotherapy students?

BACKGROUND

To evaluate the effect of a brief pain neuroscience education (PNE) session on physiotherapy students' knowledge of pain and their beliefs and attitudes about the treatment of patients with chronic low back pain.

METHODS

This study was a single-center, cross-sectional study including 205 physiotherapy undergraduate students. The participants completed the Neurophysiology of Pain Questionnaire (NPQ) and Pain Attitudes and Beliefs Scale for Physiotherapists (PABS-PT). They then received a 70-min neuroscience education session covering the mechanisms and biopsychosocial aspects of chronic low back pain. The questionnaires were readministered immediately after the educational session and at 6 months posteducation.

RESULTS

Our analysis included data from 156 participants (mean age: 20.9 ± 2.51, 69.8% women) who completed the questionnaires pre-, post-, and 6 months after the educational session. To assess the effect of the education on the scores of the questionnaires, a repeated-measures ANOVA was conducted. There was a significant interaction observed for NPQ over time (p = 0.00; η ²  = 0.654), for PABS-PT factor 1(p < 0.001; η2 = 0.50) and for PABS-PT factor 2 over time (p = 0.02; η ²  = 0.04) CONCLUSION: This study showed that a 70-min session of PNE improves the level of pain knowledge in undergraduate physiotherapy students and influences their beliefs and attitudes concerning chronic low back pain. These findings suggest that adding PNE to the curricula of physiotherapy and rehabilitation programs may be beneficial.

The Analgesic Effects of Static Magnetic Fields

Pain is one of the most common reasons why people seek medical care, which is related to most disease states. Magnetic fields (MFs) can be applied locally to specific parts of human bodies with high penetration and temporal control, which have a long-debated history in folk therapy. The purpose of this review is to collect and analyze experimental data about the analgesic effects of static magnetic fields (SMFs) so that we can have a scientific understanding regarding this topic. We collected 28 studies (25 English and 3 Chinese papers) with proper sham controls that investigated the effects of SMFs on pain relief in humans or mice. We found that 64% of the human studies and all mice studies in the literature showed positive analgesic effects of SMFs, which are related to factors including SMF intensity, treatment time, and pain types. Higher intensity and/or longer treatment time, as well as some specific pain types, may have better pain relief effects. Initial mechanistic studies indicated that membrane receptors, such as capsaicin receptor VR1/TRPV1, opioid receptors, and P2X3 receptors, might be involved. By describing experimental evidence and analysis, we found that SMFs actually hold considerable promise for managing some specific types of pain if proper SMF parameters are used. More studies comprehensively evaluating the parameters of SMF and its corresponding analgesic effects on different pain types, as well as the underlying molecular mechanisms, will be necessary to further validate its therapeutic potential in pain management in the future. Bioelectromagnetics. 00:00-00, 2021. © 2021 Bioelectromagnetics Society.

Tinnitus and tinnitus disorder: Theoretical and operational definitions (an international multidisciplinary proposal)

As for hypertension, chronic pain, epilepsy and other disorders with particular symptoms, a commonly accepted and unambiguous definition provides a common ground for researchers and clinicians to study and treat the problem. The WHO's ICD11 definition only mentions tinnitus as a nonspecific symptom of a hearing disorder, but not as a clinical entity in its own right, and the American Psychiatric Association's DSM-V doesn't mention tinnitus at all. Here we propose that the tinnitus without and with associated suffering should be differentiated by distinct terms: "Tinnitus" for the former and "Tinnitus Disorder" for the latter. The proposed definition then becomes "Tinnitus is the conscious awareness of a tonal or composite noise for which there is no identifiable corresponding external acoustic source, which becomes Tinnitus Disorder "when associated with emotional distress, cognitive dysfunction, and/or autonomic arousal, leading to behavioural changes and functional disability.". In other words "Tinnitus" describes the auditory or sensory component, whereas "Tinnitus Disorder" reflects the auditory component and the associated suffering. Whereas acute tinnitus may be a symptom secondary to a trauma or disease, chronic tinnitus may be considered a primary disorder in its own right. If adopted, this will advance the recognition of tinnitus disorder as a primary health condition in its own right. The capacity to measure the incidence, prevalence, and impact will help in identification of human, financial, and educational needs required to address acute tinnitus as a symptom but chronic tinnitus as a disorder.

A Paradigm Shift for Movement-based Pain Assessment in Older Adults: Practice, Policy and Regulatory Drivers

BACKGROUND

The profession of nursing has been on the front line of pain assessment and management in older adults for several decades. Self-report has traditionally been the most reliable pain assessment method, and it remains a priority best practice in identifying the presence and intensity of pain. Although advances in technology, biomarkers, and facial cue recognition now complement self-report, it is still important to maximize self-report of pain and to gather understanding of the total pain experience directly from patients. Practices in pain assessment in older adults have evolved over the past 25 years, and current research and quality improvement studies seek not only to detect the presence of pain, but also to determine the best protocol for assessment and most important pain characteristics to assess. Increasing data are now supporting two emerging practices: (1) consistently assessing the impact of pain on function, and (2) measuring pain during movement-based activities rather than at rest.

OBJECTIVE

The purpose of this article is thus to discuss the shifting paradigm for movement-based pain assessment in older adults, as well as the practice, policy, and regulatory drivers that support this practice change.

Exploring the origin of pain subclassification, with emphasis on low back pain: a scoping review

OBJECTIVE

This scoping review aimed to explore the different working definitions for the duration of acute, subacute, and chronic pain, with emphasis on low back pain, and to establish where these definitions originated and the rationale provided for the time frames used.

INTRODUCTION

From a global perspective, low back pain is a major social and economic problem. One of the most commonly used methods to stratify and manage low back pain is the traditional duration-based classification (acute, subacute, and chronic). Where these time points lie to differentiate these transitions continues to be debated within the scientific community, which may engender a degree of heterogeneity in study findings. Therefore, applying these findings to clinical practice may be somewhat challenging. This review encapsulates the historical origins of the different duration categories to provide an understanding of how these variations were derived.

INCLUSION CRITERIA

Studies that included participants with low back pain were the focus of this review. Sources that included children or other specific pain pathologies, such as cancer pain, were excluded. The main concept of interest was that the publication proposed an original definition of the duration of acute, subacute, or chronic low back pain. All study designs were included provided they gave a rationale for the duration that they used.

METHODS

The following databases were searched: MEDLINE, Embase, CINAHL, and PsycINFO, from the inception of each database until September 18, 2019. This review was limited to studies published in English. Two independent reviewers screened the retrieved articles against the eligibility criteria. Additional studies were searched from the reference lists of studies to find the original source. Some original sources overlapped with general pain duration literature. This led to a deviation from the scoping review protocol, which originally intended to focus on definitions of low back pain duration only. Data extraction was undertaken using a charting table developed specifically for the review objectives. The findings were presented using narrative synthesis.

RESULTS

Nineteen records were included in this review, and comprised three book chapters, four review articles, four articles that arose following pain expert group discussions, seven primary research studies, and a spinal guideline. Data were extracted from the included studies and categorized into four themes based on the origin of the classification of the duration. The themes included i) work/employment setting, ii) empirical studies, iii) expert reasoning, and iv) pathophysiological explanation.

CONCLUSIONS

This scoping review compiled the existing literature on the working definitions of the duration of acute, subacute, and chronic low back pain and found a wide variation. These ranged from seven days, 14 days, and seven weeks for the acute and subacute transition points, and seven weeks to three years for chronic low back pain. The duration definitions specifically referring to the general pain literature focused on three and/or six months for the transition to chronic. Better integration of reasoning between the identified themes could facilitate the establishment of more ideal duration definitions in the future. Although inconclusive, the definition most commonly cited, with most consensus, was three months for the transition to chronic low back pain.

Utilization of Magnesium for the Treatment of Chronic Pain

CONTEXT

The International Association for the Study of Pain (IASP) defines chronic pain as pain that persists or recurs for longer than 3 months. Chronic pain has a significant global disease burden with profound effects on health, quality of life, and socioeconomic costs.

EVIDENCE ACQUISITION

Narrative review.

RESULTS

There are several treatment options, including pharmacological therapy, physical rehabilitation, psychological therapies, and surgical interventions, for chronic pain management. Magnesium has been FDA-approved for several indications including hypomagnesemia, arrhythmia, prevention of seizures in eclampsia/preeclampsia, and constipation. Magnesium has been used for numerous off-label uses, notably for acute and chronic pain management. The mechanism of magnesium in pain management is primarily through its action as a voltage-gated antagonist of NMDA receptors, which are involved in pain transduction.

CONCLUSIONS

This narrative review will focus on the current evidence and data surrounding the utilization of magnesium as a treatment option for chronic pain.

Masterclass: A pragmatic approach to pain sensitivity in people with musculoskeletal disorders and implications for clinical management for musculoskeletal clinicians

INTRODUCTION

Research on musculoskeletal disorders indicates that pain sensitivity can be an important consideration for musculoskeletal clinicians in the holistic view of a patient presentation. However, diversity in research findings in this field can make this a difficult concept for clinicians to navigate. Limited integration of the concept of pain sensitivity into clinical practice for musculoskeletal clinicians has been noted.

PURPOSE

The purpose of this masterclass is to provide a framework for the consideration of pain sensitivity as a contributing factor in the presentation of people with musculoskeletal pain. It provides pragmatic synthesis of the literature related to pain sensitivity through a lens of how this information can inform clinical practice for musculoskeletal clinicians. Guidance is provided in a 'how to' format for integration of this knowledge into the clinical encounter to facilitate personalised care.

IMPLICATIONS

The relationship of pain sensitivity with pain and disability is not clear or linear. The real importance of pain sensitivity in a clinical presentation may be: (1) the potential for pain sensitivity to modify the effect of common treatments utilised by musculoskeletal clinicians, or (2) the effect of pain sensitivity on the prognosis/course of a disorder. Screening tools and subjective features have been highlighted to indicate when physical assessment of pain sensitivity should be prioritised in the physical examination. A pragmatic blueprint for specific assessment related to pain sensitivity has been outlined. A framework for integrating assessment findings into clinical reasoning to formulate management plans for the pain sensitive patient is provided.

Differences in personality, perceived stress and physical activity in women with burning mouth syndrome compared to controls

OBJECTIVES

Burning mouth syndrome (BMS) is a long-lasting pain condition which is commonly associated with anxiety symptoms and experience of adverse, stressful life events have been reported by those diagnosed with the syndrome. Stress-related biomarkers have been related to personality traits in BMS and a personality with high stress susceptibility and perceived stress may be of importance. Although biopsychosocial approaches are suggested to manage long-lasting orofacial pain, to date little is known about physical activity in women with BMS. The aim of this study was to investigate if personality, perceived stress and physical activity distinguish women with BMS from controls.

METHODS

Fifty-six women with BMS and 56 controls matched on age and gender completed Swedish universities Scales of Personality (SSP), Perceived Stress Questionnaire (PSQ) and a general questionnaire with an item on weekly physical activity frequency. In addition, health-related quality of life was explored by additional questionnaires and reported in a companion article (Jedel et al. Scand J Pain. 2020. PubMed PMID: 32853174).

RESULTS

SSP subscales Somatic Trait Anxiety, Psychic Trait Anxiety, Stress Susceptibility and Verbal Trait Aggression differed between women with BMS and controls and the personality factor scores for Neuroticism and Aggressiveness were higher. Perceived stress measured by PSQ index was higher for women with BMS compared to controls. Women with BMS reported lower physical activity frequency compared to controls and those reporting physical activity <4 days/week scored higher on PSQ compared to those with weekly physical activity ≥4 days/week.

CONCLUSIONS

Personality distinguished women with BMS from controls in this study. Perceived stress was higher and weekly physical activity was lower in women with BMS compared to controls. Our findings suggest physical activity should be more comprehensively measured in future BMS studies and, by extension, physical activity may be a treatment option for women with BMS. Pain management aiming to restore function and mobility with stress reduction should be considered in clinical decision making for women with BMS who have a personality with stress susceptibility, especially if reporting high perceived stress and insufficient physical activity.

Cogstate Brief Battery: Cognition and the feigning of cognitive impairment in chronic pain

Chronic pain (CP) is often associated with cognitive impairment. The Cogstate Brief Battery (CBB), a computerized assessment battery, has been studied in several neuropsychiatric disorders but not in CP. Since feigning of cognitive impairment is common in CP, the current study aimed to assess the CBB's utility in differentiating CP patients (n = 64) from healthy participants (n = 33), as well as to assess the effect of simulating cognitive impairment by CP patients on performance in the battery. CP outpatients were randomly assigned to one of two groups: (a) Patients performing the CBB to the best of their ability. (b) Patients simulating cognitive impairment. Independent-samples t-tests indicated that three of four CBB tasks successfully differentiated CP patients from matched healthy controls. Additionally, an analysis of covariance (ANCOVA) indicated that CP patients who simulated cognitive impairment performed more poorly in all four CBB tasks, with the detection task having the strongest discrimination capacity. This is the first study to point toward the usefulness and sensitivity of the CBB for assessment of cognition and detection of feigned cognitive impairment in CP. Further studies are required to validate these preliminary findings and assess the CBB's utility in daily clinical practice.

Moving With Pain: What Principles From Somatic Practices Can Offer to People Living With Chronic Pain

This article brings together research from the fields of chronic pain management and somatic practices to develop a novel framework of principles to support people living with persistent pain. These include movement-based approaches to awareness of the internal body (interoception), the external environment (exteroception) and movement in space (proprioception). These significantly work with the lived subjective experiences of people living with pain, to become aware of body signals and self-management of symptoms, explore fear and pleasure of movement, and understand how social environments impact on pain. This analysis has potential to create new ways of supporting, understanding and articulating pain experiences, as well as shaping the future of somatic practices for chronic pain.

Lack of correlation between central sensitization inventory and psychophysical measures of central sensitization in individuals with painful temporomandibular disorder

OBJECTIVE

To assess the correlation between the Central Sensitization Inventory (CSI) scores and the results of psychophysical tests and psychosocial questionnaires according to the presence of painful temporomandibular disorder (TMD).

DESIGN

It was a cross-sectional study involving 146 participants, aged 20-65 years. Painful TMD was classified using the Research Diagnostic Criteria for Temporomandibular Disorders. CSI was applied to assess "central sensitization-related symptoms", as has been suggested. Wind-up ratio, pressure pain threshold and conditioned pain modulation were used as psychophysical tests to evaluate signs and symptoms of central sensitization. Psychosocial factors were assessed by the presence of non-specific physical symptoms, depressive and anxiety symptoms. The sample was divided into two groups: Control (n = 31); Painful TMD (n = 115). Descriptive statistics characterized the sample. Correlation analysis were performed using Pearson's and Spearman's correlation coefficients (α = 5%).

RESULTS

Of the total sample, 78.8 % presented painful TMD, and the mean (standard deviation) age was 37.4 (±11.5) years. Anxiety symptoms (p = 0.028) and non-specific physical symptoms (p < 0.001) were more frequent in the painful TMD group than in controls. Painful TMD patients presented higher scores of the CSI (p < 0.001) and lower pressure pain thresholds (p ≤ 0.020) compared to controls. CSI scores were significantly correlated with psychosocial measures (p < 0.001) but not with psychophysical tests (p ≥ 0.089).

CONCLUSION

The CSI scores did not correlate with psychophysical measures of central sensitization but were positively correlated with the results of psychosocial questionnaires.

Pain Characteristics and Quality of Life in Older People at High Risk of Future Hospitalization

This study deals with how pain characteristics in conjunction with other factors affect quality of life (QoL) in a vulnerable primary care population. We recruited vulnerable older people (75+, n = 825) living in south-eastern Sweden. A postal questionnaire included pain aspects, QoL (EQ-5D-3L, RAND-36 physical functioning, attitudes toward own aging, and life satisfaction), functional status, social networks, and basic demographic information. Pain extent and localization was obtained by digitalization of pain drawings reported on standard body charts. Most respondents were experiencing pain longer than 3 months (88.8%). Pain frequency varied mostly between occasionally (33.8%) and every day (34.8%). A minority reported high pain intensity (13.6%). The lower back and lower legs were the most frequently reported pain locations (>25%). Multiple linear regression model revealed three characteristics of pain (intensity, frequency, and extent) remained inversely associated with the EQ-5D-3L index score (R² = 0.57). Individually, each of these pain characteristics showed a negative impact on the other three dimensions of QoL (R² = 0.23–0.59). Different features of pain had impact on different dimensions of QoL in this aging population. A global pain assessment is useful to facilitate individual treatment and rehabilitation strategies in primary care.

Inhibition of the Soluble Epoxide Hydrolase as an Analgesic Strategy: A Review of Preclinical Evidence

Chronic pain is a complicated condition which causes substantial physical, emotional, and financial impacts on individuals and society. However, due to high cost, lack of efficacy and safety problems, current treatments are insufficient. There is a clear unmet medical need for safe, nonaddictive and effective therapies in the management of pain. Epoxy-fatty acids (EpFAs), which are natural signaling molecules, play key roles in mediation of both inflammatory and neuropathic pain sensation. However, their molecular mechanisms of action remain largely unknown. Soluble epoxide hydrolase (sEH) rapidly converts EpFAs into less bioactive fatty acid diols in vivo; therefore, inhibition of sEH is an emerging therapeutic target to enhance the beneficial effect of natural EpFAs. In this review, we will discuss sEH inhibition as an analgesic strategy for pain management and the underlying molecular mechanisms.

Psychometric properties of Short Form-36 Health Survey, EuroQol 5-dimensions, and Hospital Anxiety and Depression Scale in patients with chronic pain

Supplemental Digital Content is Available in the Text.

This large-sample item response theory-based evaluation assessed the measurement properties of SF-36, EQ-5D, and hospital anxiety and depression scale for chronic pain patients in clinical settings.

Recent research has highlighted a need for the psychometric evaluation of instruments targeting core domains of the pain experience in chronic pain populations. In this study, the measurement properties of Short Form-36 Health Survey (SF-36),EuroQol 5-dimensions (EQ-5D) and Hospital Anxiety and Depression Scale (HADS) were analyzed within the item response-theory framework based on data from 35,908 patients. To assess the structural validity of these instruments, the empirical representations of several conceptually substantiated latent structures were compared in a cross-validation procedure. The most structurally sound representations were selected from each questionnaire and their internal consistency reliability computed as a summary of their precision. Finally, questionnaire scores were correlated with each other to evaluate their convergent and discriminant validity. Our results supported that SF-36 is an acceptable measure of 2 independent constructs of physical and mental health. By contrast, although the approach to summarize the health-related quality of life construct of EQ-5D as a unidimensional score was valid, its low reliability rendered practical model implementation of doubtful utility. Finally, rather than being separated into 2 subscales of anxiety and depression, HADS was a valid and reliable measure of overall emotional distress. In support of convergent and discriminant validity, correlations between questionnaires showed that theoretically similar traits were highly associated, whereas unrelated traits were not. Our models can be applied to score SF-36 and HADS in chronic pain patients, but we recommend against using the EQ-5D model due to its low reliability. These results are useful for researchers and clinicians involved in chronic pain populations because questionnaires' properties determine their discriminating ability in patient status assessment.

[Rheumatic pain and chronic pain in children, adolescents and young adults]

BACKGROUND

Rheumatic diseases, such as juvenile idiopathic arthritis (JIA), are typically associated with acute pain mainly caused by inflammation. Chronic pain is described as pain lasting at least 3 months. In JIA patients chronic pain may occur despite successful treatment. Chronic pain and pain disorders frequently occur during the course of the disease despite successful control of inflammation.

OBJECTIVE

Possible interrelations between JIA and pain disorders are presented.

METHOD

Besides a review of the available literature, a retrospective cohort study was conducted, including 906 patients with a chronic pain disorder with somatic and psychological factors (CPD) and/or a complex regional pain syndrome type I (CRPS I). The frequency of pre-existing rheumatic illnesses was analyzed.

RESULTS

The JIA is a risk factor for the development of a CPD. Especially polyarticular, extended oligoarticular, enthesitis-associated JIA and psoriatic arthropathy were found to be significantly associated with an increased risk for developing CPD. In contrast, an increased risk for development of CRPS I was not observed.

CONCLUSION

Our study demonstrates JIA to be a risk factor for the development of chronic pain not only as a result from malpositioning or arthrosis but also as a chronic pain disorder (CPD). Further studies are necessary to clarify the relevance of disease activity and duration and also of psychological factors for the pathogenesis.

Paravertebral block for the prevention of chronic postsurgical pain after breast cancer surgery

Patients frequently report chronic postsurgical pain (CPSP) after breast cancer surgery (BCS). The paravertebral block (PVB) is an effective technique to reduce acute postoperative pain after BCS, but its efficacy in preventing CPSP is unclear. This meta-analysis evaluates the efficacy of PVB in preventing CPSP after BCS. We searched Medline, Embase, CENTRAL, Database of Abstracts of Reviews of Effects, ClinicalTrials.gov, and WHO International Clinical Trials Registry Platform for studies comparing PVB with control for CPSP prevention after BCS, from inception to April 2020. The primary outcome was CPSP at 6 months, and the secondary outcomes were CPSP at 3 and 12 months, chronic postsurgical neuropathic pain (CPSNP) at 6 months, and PVB-related complications. Data were pooled and analyzed with a random-effects model, and the Grading of Recommendations, Assessment, Development and Evaluations (GRADE) system was used to evaluate the certainty of evidence. A total of 12 studies were included in the study; data for the 6-month time point from 7 studies (2161 patients) were analyzed, and no difference was found between PVB and control in terms of efficacy in preventing CPSP after BCS (risk ratio (RR) 0.82 (95% CI 0.62 to 1.08)), with a moderate quality of evidence according to the GRADE system. Similar results were obtained at 3 and 12 months (RR 0.78 (95% CI 0.57 to 1.06), RR 0.45 (95% CI 0.14 to 1.41), respectively). Data for the 12-month time point from seven studies (2087 patients) were analyzed and showed that PVB protected against CPSNP, with low quality of evidence (RR 0.51 (95% CI 0.31 to 0.85)). In conclusion, CPSP was not found significantly prevented by PVB after BCS despite the limits in the included studies; nevertheless, PVB could prevent CPSNP by impacting the transition from acute to chronic pain.

Brain Responses to Noxious Stimuli in Patients With Chronic Pain: A Systematic Review and Meta-analysis

IMPORTANCE

Functional neuroimaging is a valuable tool for understanding how patients with chronic pain respond to painful stimuli. However, past studies have reported heterogenous results, highlighting opportunities for a quantitative meta-analysis to integrate existing data and delineate consistent associations across studies.

OBJECTIVE

To identify differential brain responses to noxious stimuli in patients with chronic pain using functional magnetic resonance imaging (fMRI) while adhering to current best practices for neuroimaging meta-analyses.

DATA SOURCES

All fMRI experiments published from January 1, 1990, to May 28, 2019, were identified in a literature search of PubMed/MEDLINE, EMBASE, Web of Science, Cochrane Library, PsycINFO, and SCOPUS.

STUDY SELECTION

Experiments comparing brain responses to noxious stimuli in fMRI between patients and controls were selected if they reported whole-brain results, included at least 10 patients and 10 healthy control participants, and used adequate statistical thresholding (voxel-height P < .001 or cluster-corrected P < .05). Two independent reviewers evaluated titles and abstracts returned by the search. In total, 3682 abstracts were screened, and 1129 full-text articles were evaluated.

DATA EXTRACTION AND SYNTHESIS

Thirty-seven experiments from 29 articles met inclusion criteria for meta-analysis. Coordinates reporting significant activation differences between patients with chronic pain and healthy controls were extracted. These data were meta-analyzed using activation likelihood estimation. Data were analyzed from December 2019 to February 2020.

MAIN OUTCOMES AND MEASURES

A whole-brain meta-analysis evaluated whether reported differences in brain activation in response to noxious stimuli between patients and healthy controls were spatially convergent. Follow-up analyses examined the directionality of any differences. Finally, an exploratory (nonpreregistered) region-of-interest analysis examined differences within the pain network.

RESULTS

The 37 experiments from 29 unique articles included a total of 511 patients and 433 controls (944 participants). Whole-brain meta-analyses did not reveal significant differences between patients and controls in brain responses to noxious stimuli at the preregistered statistical threshold. However, exploratory analyses restricted to the pain network revealed aberrant activity in patients.

CONCLUSIONS AND RELEVANCE

In this systematic review and meta-analysis, preregistered, whole-brain analyses did not reveal aberrant fMRI activity in patients with chronic pain. Exploratory analyses suggested that subtle, spatially diffuse differences may exist within the pain network. Future work on chronic pain biomarkers may benefit from focus on this core set of pain-responsive areas.