The IASP classification of chronic pain for ICD-11: applicability in primary care

Distinct functional cerebral hypersensitivity networks during incisional and inflammatory pain in rats

Although the pathophysiology of pain has been investigated tremendously, there are still many open questions with regard to specific pain entities and their pain-related symptoms. To increase the translational impact of (preclinical) animal neuroimaging pain studies, the use of disease-specific pain models, as well as relevant stimulus modalities, are critical. We developed a comprehensive framework for brain network analysis combining functional magnetic resonance imaging (MRI) with graph-theory (GT) and data classification by linear discriminant analysis. This enabled us to expand our knowledge of stimulus modalities processing under incisional (INC) and pathogen-induced inflammatory (CFA) pain entities compared to acute pain conditions. GT-analysis has uncovered specific features in pain modality processing that align well with those previously identified in humans. These include areas such as S1, M1, CPu, HC, piriform, and cingulate cortex. Additionally, we have identified unique Network Signatures of Pain Hypersensitivity (NSPH) for INC and CFA. This leads to a diminished ability to differentiate between stimulus modalities in both pain models compared to control conditions, while also enhancing aversion processing and descending pain modulation. Our findings further show that different pain entities modulate sensory input through distinct NSPHs. These neuroimaging signatures are an important step toward identifying novel cerebral pain biomarkers for certain diseases and relevant outcomes to evaluate target engagement of novel therapeutic and diagnostic options, which ultimately can be translated to the clinic.

How children and adolescents with chronic pain describe their pain experiences: A qualitative systematic review

PURPOSE

To explore how children and adolescents with chronic pain describe their pain experiences.

METHOD

A systematic search of OVID Medline, CINAHL Complete, OVID Embase and APA PsycINFO (database inception to 19th August 2024) was conducted for qualitative or mixed-method studies investigating children's chronic pain experiences. Studies were excluded if focused on post-surgical or acute pain. Two independent reviewers screened studies, and disagreements resolved by a third reviewer. Methodological quality was assessed with the CASP checklist. Data from included studies were extracted and analysed using qualitative analysis.

RESULTS

Forty studies were included, and 4 main themes were identified: 1. 'I'm missing out because of my pain'; in which children described frustration and isolation due to missing activities. 2. 'Things that help me to get by with my pain'; described a variety of children's coping mechanisms. 3. 'It hurts and no one else understands my pain'; where children felt frequently disbelieved about their pain severity, and 4. 'I keep trying to make sense of my pain'; in which children identified ways they seek to understand the cause and possible outcomes of their pain, including accessing health care services.

CONCLUSIONS

This review highlights how children describe their pain challenges in managing their day to day while emphasising the necessity of understanding and incorporating children's perspectives into research and practice.

PRACTICE IMPLICATIONS

This review found that children were primarily concerned by how their pain affects their day-to-day activities and highlights the need to equip children with multiple strategies and promote autonomy in managing their pain. Additionally, further research is warranted into the ways that children understand their pain experience and seek information about their pain.

Do Psychological Factors Explain the Persistence of Symptoms in Individuals With Rotator Cuff-related Shoulder Pain? A Prospective Cohort Study

OBJECTIVE

To determine whether psychosocial factors, such as resilience, perceived stress, catastrophizing, anxiety, depression, pain self-efficacy, and social support, explain the persistence of pain and disability in individuals with rotator cuff-related shoulder pain (RCRSP) following an education program.

METHODS

One hundred forty-three individuals with persistent RCRSP were included in this prospective cohort study. At baseline, participants completed self-reported questionnaires related to pain, disability, and psychosocial constructs, including resilience, stress, catastrophizing, anxiety and depressive symptoms, pain self-efficacy, and social support. Thereafter, participants took part in an educational program aimed at promoting self-management of RCRSP that included 2 meetings with a physiotherapist. After 12 and 24 weeks, participants filled out pain and disability questionnaires and, based on their scores, were classified as having persistent shoulder pain or as recovered.

RESULTS

A univariable modified Poisson regression showed that higher perceived stress (RR adjusted : 1.02; 95% CI: 1.01-1.04), catastrophizing (RR adjusted : 1.01; 95% CI: 1.01-1.02), symptoms of depression (RR adjusted : 1.03; 95% CI: 1.01-1.06) and anxiety (RR adjusted : 1.03; 95% CI: 1.01-1.06), along with lower resilience (RR adjusted : 0.90; 95% CI: 0.81-1.00), were associated with ongoing RCRSP at 12 weeks. In addition, reduced pain self-efficacy was associated with persistent pain at both 12 weeks (RR adjusted : 0.98; 95% CI: 0.97-0.99) and 24 weeks (RR adjusted : 0.99; 95% CI: 0.98-1.00). Multivariable regression indicated that only pain self-efficacy served as a protective factor against persistent RCRSP (RR adjusted : 0.98; 95% CI: 0.97-0.99).

DISCUSSION

This study sheds light on the impact of psychosocial factors on persistent RCRSP, underscoring the importance of positive beliefs in pain management. Importantly, pain self-efficacy emerges as a key factor in recovery.

The impact of opioid analgesics with concomitant antipsychotic use on pain modulation and management in internal medicine: a cross-sequential study protocol

Background

Acute and chronic pain represents an escalating public health concern, necessitating safer and more effective in-hospital management approaches, including mental health. New treatment combinations involving psycholeptics are rising, but real-world evidence is lacking.

Objectives

The study's primary objective is to evaluate the impact of combined opioid analgesics and antipsychotics in-hospital medication on pain modulation. The secondary objective is to evaluate pain management.

Methods

The cross-sequential study designed by this protocol will analyze retrospective data on 5,000 hospital admissions over four years (2019-2023) gathered from Electronic Health Records (EHR) of a multisite hospital in southern Switzerland. Eligible patients are aged 18 or older and hospitalized in an Internal Medicine ward. All patients with documented pain intensity assessment through a Visual Analogue Scale (VAS ≥ 1) will be included. Cross-sectional data on demographic and clinical variables and type of medication (opioid analgesics, antipsychotics, and selected other drugs according to the Anatomical Therapeutic Chemical classification system) will be screened at hospital admission (T1) and discharge (T2). Pain modulation will be assessed by gravity (VAS mean), intensity (VAS peak/extreme value), and pain treatment effectiveness (ΔT2-T1 VAS). Hospitalization paths (short- and long-term readmissions and total length of hospital stays) will be scrutinized as additional longitudinal indices for pain management and excluded from the cross-sectional analysis. A mixed model approach will assess VAS changes from T1 to T2. Logistic regression and regression models for count data will be used for short- and long-term readmission, respectively. Propensity score matching will be used to mitigate selection bias.

Discussion

This methodological approach combines cross-sectional and longitudinal EHR data gathering in a cross-sequential design. This integration allows for a comprehensive examination of pain modulation and management among internal medicine recipients of concomitant opioids and antipsychotic treatment, spanning both hospitalization and post-discharge periods. By leveraging EHR data, the study protocol ensures reliability and standardization while minimizing missing information. Additionally, the protocol addresses the potential limitations of observational designs.

Conclusions

This method offers a comprehensive and rigorous approach to investigating pain modulation and management in internal medicine patients receiving combined opioid analgesics and antipsychotics, with potential implications for enhancing clinical practice and healthcare resource utilization.

Pain revolution in the public health system: Active coping strategies for chronic pain unit

BACKGROUND

Chronic pain represents a global health challenge demanding a transition from traditional biomedical to patient-centered biopsychosocial models. This masterclass explores active coping strategies for effective chronic pain management within healthcare systems. It describes the Unit of Active Coping Strategies for Chronic Pain (UAAD - Unidad de Afrontamiento Activo para el Dolor) in Primary Care in Valladolid, Spain, as a successful example of implementing a biopsychosocial care model for treating chronic pain.

OBJECTIVE

To provide tools that allow the application of active coping strategies in the treatment of patients with chronic pain and how to implement the UAAD units in other healthcare systems.

METHODS

This masterclass describes the UAAD's innovative approach, starting with its comprehensive and personalized methodology. This includes a referral system, a thorough assessment encompassing biological, psychological, and social factors, and a functional categorization system. These elements guide personalized treatment plans delivered through group and individual programs grounded in therapeutic exercise and pain science education. Four key pillars are highlighted: clinical care, teaching, resource management, research and dissemination.

CONCLUSION

Embracing this model empowers healthcare providers to address the growing burden of chronic pain. It also enables patients to take an active role in their recovery and self-management.

The number of central nervous system-driven symptoms predicts subsequent chronic primary pain: evidence from UK Biobank

BACKGROUND

Chronic primary pain describes conditions where pain is the principal problem rather than a consequence of another disease. Primary pain is thought to be primarily owing to nociplastic pain (i.e. pain as a result of altered nociception despite the absence of tissue damage). Primary pain is often accompanied by other bothersome central nervous system (CNS)-driven symptoms, including disturbed sleep, mood, and cognition; however, it is unclear whether these symptoms precede onset of primary pain.

METHODS

In a prospective cohort study of the UK Biobank, we examined adults with no self-reported recent or chronic pain at baseline. Using linked primary care record data, we investigated the association between the number of CNS-driven symptoms and subsequent incidence of primary pain conditions. Multivariable regression analyses adjusted for sociodemographic and lifestyle factors.

RESULTS

Of 502 369 participants, 70 630 (14.0%) met the inclusion criteria, with a mean (range) age of 56.7 (40-70) yr, 51% being female. After 7.4 (range 0.5-11.02) yr, 12.2% developed a primary pain condition. We observed a positive relationship between the number of CNS-driven symptoms at baseline and risk of future primary pain (HR 1.43, 95% CI 1.34-1.52, P<0.001). Participants with more CNS-driven symptoms at baseline were also more likely to have chronic and more severe nociplastic pain, but not non-nociplastic pain at follow-up.

CONCLUSIONS

In adults with no current self-reported pain, those with a greater number of CNS-driven symptoms at baseline were more likely to develop a primary pain condition. This suggests a potential opportunity for early intervention in mitigating the burden of primary pain.

Do biopsychosocial factors predict the level of physical activity in individuals with persistent shoulder pain?

OBJECTIVE

The objective of this cross-sectional study was to compare the physical activity level between individuals with and without rotator cuff related shoulder pain (RCRSP), and, in individuals with RCRSP, investigate whether biopsychosocial factors are associated with the physical activity level.

METHODS

Seventy-four participants with and 84 participants without RCRSP wore a fitness tracking watch for seven consecutive days to assess physical activity (step count, moderate-to-vigorous physical activity (MVPA)-minutes). Additionally, participants with RCRSP completed questionnaires on their level of pain, disability, and physical activity (short version of the International Physical Activity Questionnaire [IPAQ]), as well as on biopsychosocial factors, including resilience, stress, catastrophizing, anxiety and depressive symptoms, self-efficacy, and social support. Statistical analysis included Mann-Whitney U tests and General Linear Models for group comparisons, as well as multiple regression analyses to explore predictors of physical activity.

RESULTS

No significant between-group difference was found concerning step count and MVPA-minutes. Age and depressive symptoms explained 14% of the variance in step count, while age and resilience explained 15% of MVPA-minutes variance. Additionally, resilience was associated with IPAQ (P < 0.05), indicating that higher resilience correlates with greater reported physical activity (odds ratio: 2.32 [1.27, 4.22]).

CONCLUSION

While individuals with RCRSP did not show lower physical activity levels compared to their healthy counterparts, greater physical activity was associated with younger age, lower depressive symptoms, and higher resilience in individuals with RCRSP. Future research should explore whether resilience and physical activity interventions can prevent the transition to persistent RCRSP.

Does Pain Explain Trends in Disability? An Analysis of Middle-Aged and Older U.S. Adults, 2002-2018

OBJECTIVES

This article investigates the role of pain in disability trends in the United States, within the context of recent unfavorable disability trends and the concurrent rise in pain.

METHODS

We conducted a 2-part analysis using National Health Interview Survey data from 2002 to 2018 for U.S. adults aged 45-84. First, we assessed how changes in the prevalence of 5 site-specific types of pain (headaches/migraines, joint, low back, neck, and facial/jaw pain) associated with disability trends. Second, we used self-reported causes of disability and examined whether there has been a change in the proportion of individuals who attribute their disability to 1 of 5 chronic or acute painful conditions.

RESULTS

The 5 site-specific types of pain, individually and collectively, were significantly associated with increases in disability. If site-specific chronic pain had not increased during the study period, the trend for functional limitations would have been 40% lower, and that for activity limitations would have shown a slight decline instead of an increase. Attributions of functional limitations to painful conditions increased by 23% during the 2002-2018 period, representing an additional 9.82 million Americans experiencing pain-attributable disability. Arthritis/rheumatism, back/neck problems, and other musculoskeletal/connective conditions were the primary sources of pain-related disability.

DISCUSSION

Our research provides the first systematic, national examination of how pain is contributing to disability trends in the United States. The findings have implications for disability reduction policies and shed light on the far-reaching consequences of pain for overall population health.

[Physical medicine for coincidence of cancer and inflammatory rheumatic disease : What speaks in favour and what to consider?]

The coincidence of an inflammatory rheumatic and a malignant disease causes a physical, cognitive and psychological reduction in performance. The prescription of physical therapy is therefore essential to address safety issues associated with both diseases, as well as side effects associated with antirheumatic and antineoplastic therapy that can impact the treatment. It is important to perform a risk assessment prior to physical therapy to identify potential safety issues and to determine baseline physical and functional status. In this review article descriptive information and the current literature on the safety of physical therapy interventions for people with rheumatic and malignant disease are highlighted, taking the disease process, treatment side effects and associated precautions and contraindications into account.

Perioperative Regional Anesthesia on Persistent Opioid Use and Chronic Pain after Noncardiac Surgery: A Systematic Review and Meta-Analysis of Randomized Controlled Trials

BACKGROUND

Whether regional anesthesia impacts the development of chronic postsurgical pain is currently debateable, and few studies have evaluated an effect on prolonged opioid use. We sought to systematically review the effect of regional anesthesia for adults undergoing noncardiac elective surgery on these outcomes.

METHODS

A systematic search was conducted in MEDLINE, EMBASE, CENTRAL, and CINHAL for randomized controlled trials (from inception to April 2022) of adult patients undergoing elective noncardiac surgeries that evaluated any regional technique and included one of our primary outcomes: (1) prolonged opioid use after surgery (continued opioid use ≥2 months postsurgery) and (2) chronic postsurgical pain (pain ≥3 months postsurgery). We conducted a random-effects meta-analysis on the specified outcomes and used the Grading of Recommendations, Assessment, Development, and Evaluations (GRADE) approach to rate the quality of evidence.

RESULTS

Thirty-seven studies were included in the review. Pooled estimates indicated that regional anesthesia had a significant effect on reducing prolonged opioid use (relative risk [RR] 0.48, 95% CI, 0.24-0.96, P = .04, I 2 0%, 5 trials, n = 348 patients, GRADE low quality). Pooled estimates for chronic pain also indicated a significant effect favoring regional anesthesia at 3 (RR, 0.74, 95% CI, 0.59-0.93, P = .01, I 2 77%, 15 trials, n = 1489 patients, GRADE moderate quality) and 6 months (RR, 0.72, 95% CI, 0.61-0.85, P < .001, I 2 54%, 19 trials, n = 3457 patients, GRADE moderate quality) after surgery. No effect was found in the pooled analysis at 12 months postsurgery (RR, 0.44, 95% CI, 0.16-1.17, P = .10).

CONCLUSIONS

The results of this study suggest that regional anesthesia potentially reduces chronic postsurgical pain up to 6 months after surgery. Our findings also suggest a potential decrease in the development of persistent opioid use.

Clinicians diagnosing virtual patients with the classification algorithm for chronic pain in the ICD-11 (CAL-CP) achieve better diagnoses and prefer the algorithm to standard tools: An experimental validation study

BACKGROUND

The ICD-11 classification of chronic pain comprises seven categories, each further subdivided. In total, it contains over 100 diagnoses each based on 5-7 criteria. To increase diagnostic reliability, the Classification Algorithm for Chronic Pain in the ICD-11 (CAL-CP) was developed. The current study aimed to evaluate the CAL-CP regarding the correctness of assigned diagnoses, utility and ease of use.

METHODS

In an international online study, n = 195 clinicians each diagnosed 4 out of 8 fictitious patients. The clinicians interacted via chat with the virtual patients to collect information and view medical histories and examination findings. The patient cases differed in complexity: simple patients had one chronic pain diagnosis; complex cases had two. In a 2 × 2 repeated-measures design with the factors tool (algorithm/standard browser) and diagnostic complexity (simple/complex), clinicians used either the algorithm or the ICD-11 browser for their diagnoses. After each case, clinicians indicated the pain diagnoses and rated the diagnostic process. The correctness of the assigned diagnoses and the ratings of the algorithm's utility and ease of use were analysed.

RESULTS

The use of the algorithm resulted in more correct diagnoses. This was true for chronic primary and secondary pain diagnoses. The clinicians preferred the algorithm over the ICD-11 browser, rating it easier to work with and more useful. Especially novice users benefited from the algorithm.

CONCLUSIONS

The use of the algorithm increases the correctness of the diagnoses for chronic pain and is well accepted by clinicians. The CAL-CP's use should be considered in routine care and research contexts.

SIGNIFICANCE STATEMENT

The ICD-11 has come into effect in January 2022. Clinicians and researchers will soon begin using the new classification of chronic pain. To facilitate clinicians training and diagnostic accuracy, a classification algorithm was developed. The paper investigates whether clinicians using the algorithm-as opposed to the generic tools provided by the WHO-reach more correct diagnoses when they diagnose standardized patients and how they rate the comparative utility of the diagnostic instruments available.

Fibromyalgia pain management effectiveness from the patient perspective: a qualitative evidence synthesis

PURPOSE

This qualitative evidence synthesis aimed to identify and integrate findings where adults with fibromyalgia discussed how they managed their pain, and their perceptions of prescribed treatments from healthcare professionals.

MATERIALS AND METHODS

A comprehensive search strategy was implemented in PubMed, Scopus, ISI Web of Science, and Cinahl Plus databases. The GRADE-CERQual framework was used to evaluate the findings confidence. The findings were analyzed using an inductive thematic analysis approach.

RESULTS

A total of 35 studies (N = 728) were included. The confidence in the findings ranged from high to low confidence. Patients with fibromyalgia often do not benefit from seeking medical attention due to provider stigma, and have varying views on medication effectiveness commonly reporting feeling like "walking chemists." They find mixed effects from exercise, and consider psychological support essential, although the benefits of cognitive-behavioral therapy were controversial. Combining cognitive-behavioral therapy with physical exercise appears more effective, while natural and complementary therapies have short-term benefits and high costs.

CONCLUSIONS

Pain management is a source for frustration and an unmet need for patients with fibromyalgia. The current findings provide crucial insight for providers and researchers; and support the need for fibromyalgia phenotyping and precision medicine approaches to pain management.Implications for RehabilitationChronic widespread pain is the defining feature of fibromyalgia, yet pain reduction is often an unmet need for these individuals.The lack of effective treatments resulting in long-term relief proves frustrating for patients and healthcare providers.Rehabilitation professional should consider the unique insight into this complex, heterogeneous condition that this qualitative synthesis provides to better understand their patient's perspective on pain management.Given the differing perspectives on pain treatment approaches individuals with fibromyalgia report, providers should discuss with each patient their current strategies and take a patient-centered, individualized approach to form an effective treatment plan.

Epigenetic Landscapes of Pain: DNA Methylation Dynamics in Chronic Pain

Chronic pain is a prevalent condition with a multifaceted pathogenesis, where epigenetic modifications, particularly DNA methylation, might play an important role. This review delves into the intricate mechanisms by which DNA methylation and demethylation regulate genes associated with nociception and pain perception in nociceptive pathways. We explore the dynamic nature of these epigenetic processes, mediated by DNA methyltransferases (DNMTs) and ten-eleven translocation (TET) enzymes, which modulate the expression of pro- and anti-nociceptive genes. Aberrant DNA methylation profiles have been observed in patients with various chronic pain syndromes, correlating with hypersensitivity to painful stimuli, neuronal hyperexcitability, and inflammatory responses. Genome-wide analyses shed light on differentially methylated regions and genes that could serve as potential biomarkers for chronic pain in the epigenetic landscape. The transition from acute to chronic pain is marked by rapid DNA methylation reprogramming, suggesting its potential role in pain chronicity. This review highlights the importance of understanding the temporal dynamics of DNA methylation during this transition to develop targeted therapeutic interventions. Reversing pathological DNA methylation patterns through epigenetic therapies emerges as a promising strategy for pain management.

Comparative Analysis of Ventilatory Responses during Stress Tests in Patients with Chronic Pain: Implications for Therapeutic Interventions

Understanding the differences in ventilatory responses during exercise between patients with fibromyalgia and those with other chronic pain disorders is crucial for developing effective therapeutic interventions, especially in exercise to identify the better physical therapy prescription. Both populations face unique challenges that impact their ability to engage in physical activity; yet, the underlying physiological responses can vary significantly. In this context, the methodology of this study entailed conducting a comparative analysis of the ventilatory response during exercise in patients with fibromyalgia and those with other chronic pain disorders. The experimental protocol included a total of 31 participants (n = 13 diagnosed with fibromyalgia and n = 18 diagnosed with other chronic pain conditions). All participants completed a stress test, where the ventilatory parameters were measured in three stages (i.e., resting, incremental exercise, and recovery). The results revealed significant differences (p<0.05) in ventilatory responses between both groups. Patients with fibromyalgia exhibited reduced time for the aerobic threshold and a higher respiratory frequency in the anaerobic threshold compared to those with other chronic pain disorders. Furthermore, fibromyalgia patients demonstrated higher values in the ventilatory coefficient during the test and in the recovery stage. In conclusion, these differences underscore the need for tailored exercise programs that specifically address the unique ventilatory challenges faced by fibromyalgia patients to improve their physical function and overall quality of life.

Repetitive Transcranial Magnetic Stimulation in Fibromyalgia: Exploring the Necessity of Neuronavigation for Targeting New Brain Regions

Fibromyalgia and osteoarthritis are among the most prevalent rheumatic conditions worldwide. Nonpharmacological interventions have gained scientific endorsements as the preferred initial treatments before resorting to pharmacological modalities. Repetitive transcranial magnetic stimulation (rTMS) is among the most widely researched neuromodulation techniques, though it has not yet been officially recommended for fibromyalgia. This review aims to summarize the current evidence supporting rTMS for treating various fibromyalgia symptoms. Recent findings: High-frequency rTMS directed at the primary motor cortex (M1) has the strongest support in the literature for reducing pain intensity, with new research examining its long-term effectiveness. Nonetheless, some individuals may not respond to M1-targeted rTMS, and symptoms beyond pain can be prominent. Ongoing research aims to improve the efficacy of rTMS by exploring new brain targets, using innovative stimulation parameters, incorporating neuronavigation, and better identifying patients likely to benefit from this treatment. Summary: Noninvasive brain stimulation with rTMS over M1 is a well-tolerated treatment that can improve chronic pain and overall quality of life in fibromyalgia patients. However, the data are highly heterogeneous, with a limited level of evidence, posing a significant challenge to the inclusion of rTMS in official treatment guidelines. Research is ongoing to enhance its effectiveness, with future perspectives exploring its impact by targeting additional areas of the brain such as the medial prefrontal cortex, anterior cingulate cortex, and inferior parietal lobe, as well as selecting the right patients who could benefit from this treatment.

Efficacy and Safety of Computed Tomography-Guided Percutaneous Balloon Compression under Local Anesthesia for Recurrent Trigeminal Neuralgia: A Prospective Study

Purpose

There are several ways to treat trigeminal neuralgia (TN); however, TN may recur after treatment. This study investigated the efficacy and safety of computed tomography (CT)-guided percutaneous balloon compression (PBC) under local anesthesia for treatment of recurrent trigeminal neuralgia. Patients and Methods. This is a prospective and nonrandomized controlled clinical study. Forty-eight patients with classical TN were scheduled to undergo PBC surgery at the pain department of our institution between January 2021 and June 2021. The patients were prospectively divided into an initial onset group, A (21 cases), and a recurrence group, B (27 cases). All surgeries were performed with CT guidance and under local anesthesia. Postoperative complications were also observed. Pain was assessed using the visual analog scale (VAS) and Barrow Neurological Institute (BNI) scale. Efficacy indices were evaluated at 3, 6, 12, and 18 months after surgery.

Results

All participants reported complete pain relief at discharge. After 18 months of follow-up, the total effective rate of pain control was 89.5% (group A, 90.5%; group B, 88.8%). There was no significant difference in the BNI scores between the two groups before and after treatment. All patients had hypoesthesia on the affected side, and no severe complications such as diplopia, blindness, intracranial hemorrhage, or intracranial infection occurred.

Conclusions

CT-guided PBC under local anesthesia is safe and effective for the treatment of recurrent TN and thus acts as an effective alternative for geriatric patients and those with high-risk factors.

Pain as a disease in the new International Classification of Diseases (ICD-11): Latin American expert consensus

Aims: Pain diagnoses in the 10th version of the International Classification of Diseases (ICD-10) did not adequately support the current management of pain. Therefore, we aimed to review the new 11th revision (ICD-11) in order to analyze its usefulness for the management, coding, research and education of chronic pain from a Latin American perspective. Methods: The Latin American Federation of Associations for the Study of Pain convened a meeting of pain experts in Lima, Peru. Pain specialists from 14 Latin American countries attended the consensus meeting. Results: In ICD-11, chronic pain is defined as pain that persists or recurs longer than 3 months and is subdivided into seven categories: chronic primary pain and six types of chronic secondary pain. Chronic primary pain is now considered a disease in itself, and not a mere symptom of an underlying disease. Conclusion: The novel definition and classification of chronic pain in ICD-11 is helpful for better medical care, research and health statistics. ICD-11 will improve chronic pain management in Latin American countries, for both the pain specialist and the primary care physician.

Evidence-Based Opinions from Multidisciplinary Experts on Use of Naturopathic Herbal Remedies in Pain Management

Background

Pharmacological approaches to acute and chronic pain management, including non-steroidal anti-inflammatory drugs (NSAIDs) and opioids, are respectively associated with adverse reactions (such as gastrointestinal, cardiovascular, and renal effects) that might limit their use in patients with comorbidities and controversy related to inappropriate use. Naturopathic remedies might offer patients alternative and integrative treatments with minimal side effects.

Objective

To explore the regional variation in the acceptance and use of naturopathic remedies in pain management.

Methods

Two expert panel discussions were held by GlaxoSmithKline Consumer Healthcare (now Haleon Pte. Ltd.) over 9 and 12 hours in 2020 and 2021, respectively, and attended by multidisciplinary experts in naturopathy, Ayurvedic medicine, community pharmacy, physiotherapy, clinical pharmacy, Western medicine, academics, and naturopathic pain relief. Experts shared and discussed their experiences of naturopathic treatments and relevant clinical evidence related to different types of pain (including joint and muscle pain, migraine, sleeplessness due to pain, and general pain) and examined barriers to providing support to patients.

Results

Experts agreed on the potential for curcumin (2020, 71.4% [5/7]; 2021, 91.7% [11/12]) and fish oil (2020, 100% [7/7]) for management of osteoarthritic joint pain although these are not uniformly recommended in osteoarthritis treatment guidelines. In treatment of migraines, coenzyme Q10 and magnesium were favored by experts (2021, 90.9% [10/11] and 63.6% [7/11], respectively).

Conclusion

The need was emphasized for more and higher quality clinical studies to support naturopathic remedies, which might not be reflected in the latest treatment guidelines. The expert panel also highlighted missed opportunities for physicians and pharmacists to recommend effective naturopathic treatments.

Comparative safety and efficacy of percutaneous radiofrequency thermocoagulation and percutaneous balloon compression in CT-guided and local anesthesia for recurrent trigeminal neuralgia

Background

There are several ways to treat trigeminal neuralgia (TN); however, TN may recur after treatment. Although microvascular decompression (MVD) is considered an effective treatment for trigeminal neuralgia, patients with recurrence may not be willing to undergo craniotomy.

Objective

This study compared the safety and efficacy of percutaneous radiofrequency thermocoagulation and percutaneous balloon compression for treating recurrent trigeminal neuralgia.

Methods

This was a prospective non-randomized controlled study. A total of 52 with recurrent TN were scheduled to undergo surgery in our Hospital from January-June 2021. The patients were classified into percutaneous radiofrequency thermocoagulation (PRT) and percutaneous balloon compression (PBC) groups based on the treatment. All surgeries were performed under computed tomography guidance and local anesthesia. Post-operative complications were also observed. Pain was assessed using the visual analog scale (VAS) and Barrow Neurological Institute (BNI) scale. Efficacy indices were evaluated at 3, 6, 12, and 18 months after surgery.

Results

During follow-up, the efficacy rates of the two methods within 18 months were 76.0 and 88.9%, respectively. All patients had hypoesthesia on the affected side, and no severe complications. Notably, 5 patients (20%) in the PRT group with multiple-branch pain, including the first branch of the trigeminal nerve (V1) pain in the PRT group, received radiofrequency therapy for the supraorbital notch (foramen) after puncture of the foramen ovale. However, multiple pain episodes resolved with only one operation in the PBC group.

Conclusion

CT-guided percutaneous radiofrequency thermocoagulation and percutaneous balloon compression under local anesthesia may be good options for treating recurrent trigeminal neuralgia. Percutaneous balloon compression may be recommended when multiple branches are involved, particularly in cases of V1 neuralgia.

Exposure time as an influencing factor among rheumatoid arthritis patients subjected to traditional Siwan therapy

Rheumatoid arthritis (RA) is a long-term autoimmune disease characterized by intra- and extra-articular manifestations. Sand therapy is traditionally indicated for RA, chronic pain, skin diseases, and musculoskeletal disorders. Many places in the world use sand therapy, including Siwa, which is a famous place in Egypt. This study investigated the exposure time to Siwan traditional therapy as a factor influencing central sensitization, pain severity, pain threshold, and kinesiophobia in RA by measuring the central sensory inventory (CSI), visual analogue scale, pressure algometer, and TAMPA kinesiophobia scale, respectively. Twenty-four patients with RA were recruited from 6 traditional healing centers, 24 RA patients were recruited and randomly assigned to 2 equal groups (GI and GII). The first received Siwan traditional therapy for 3 days, while the second received the same program for 5 days. The results revealed a significant difference in CSI between pre- and posttreatment within the GII (P = .038). The Tampa Scale score improved significantly in both groups (P = .004 and P = .014, respectively). Pain severity and pain threshold at all sites showed significant posttreatment improvements in the GII. Significant posttreatment changes were only found for GI in terms of pain severity and the most painful joint (P = .010 and P = .035, respectively). Significant changes were observed in kinesiophobia, pain severity, and pain threshold in the most painful joint 3 and 5 days after Siwan traditional therapy. Despite the nonsignificant differences in all parameters between the 2 groups, all the measured parameters produced favorable results after 5 days of treatment, suggesting the need for a long-term effect investigation.

How Do Physiotherapists Explain Influencing Factors to Chronic Low Back Pain? A Qualitative Study Using a Fictive Case of Chronic Non-Specific Low Back Pain

BACKGROUND

While pain is influenced by multiple factors including psychosocial factors, previous research has shown that physiotherapists still favour a biomedical approach.

PURPOSE

To evaluate: (1) how physiotherapists explain the patient's chronic non-specific low back pain (LBP); (2) whether physiotherapists use one or multiple influencing factors, and (3) whether these factors are framed in a biopsychosocial or biomedical approach.

MATERIALS AND METHODS

This exploratory qualitative study uses a vignette depicting chronic non-specific LBP and employs a flexible framework analysis. Physiotherapists were asked to mention contributing factors to the pain based on this vignette. Five themes were predefined ("Beliefs", "Previous experiences", "Emotions", "Patients behaviour", "Contextual factors") and explored.

RESULTS

Physiotherapists use very brief explanations when reporting contributing factors to chronic pain (median 13 words). Out of 670 physiotherapists, only 40% mentioned more than two different themes and 2/3rds did not see any link between the patients' misbeliefs and pain. Only a quarter of the participants mentioned the patient's worries about pain and movement, which is considered to be an important influencing factor.

CONCLUSION

The lack of a multifactorial approach and the persistent biomedical beliefs suggest that it remains a challenge for physiotherapists to fully integrate the biopsychosocial framework into their management of chronic LBP.

Suffering out of sight but not out of mind - interpreting experiences of sick leave due to chronic pain in a community setting: a qualitative study

OBJECTIVE

Chronic pain is a complex health problem affecting about one-fifth of the European population. It is a leading cause of years lived with disability worldwide, with serious personal, relational and socioeconomic consequences. Chronic pain and sick leave adversely affect health and quality of life. Thus, understanding this phenomenon is essential for reducing suffering, understanding the need for support and promoting a rapid return to work and an active lifestyle. This study aimed to describe and interpret persons' experiences of being on sick leave due to chronic pain.

DESIGN

A qualitative study with semistructured interviews analysed using a phenomenological hermeneutic approach.

SETTING

Participants were recruited from a community setting in Sweden.

PARTICIPANTS

Fourteen participants (12 women) with experiences of part-time or full-time sick leave from work due to chronic pain were included in the study.

RESULTS

Suffering out of sight but not out of mind was the main theme of the qualitative analysis. This theme implies that the participants' constant suffering was invisible to others, causing them to feel they were not being justly treated in society. Feeling overlooked led to a continuous struggle for recognition. Moreover, the participants' identities and their trust in themselves and their bodies were challenged. However, our study also revealed a nuanced understanding of the experiences of sick leave as a consequence of chronic pain, where the participants learnt important lessons, including coping strategies and re-evaluated priorities.

CONCLUSIONS

Being on sick leave due to chronic pain threatens a person's integrity and leads to substantial suffering. An enhanced understanding of the meaning of sick leave due to chronic pain provides important considerations for their care and support. This study highlights the importance of feeling acknowledged and being met with justice in encounters with others.

The Efficacy of Acceptance and Commitment Therapy for Chronic Pain: A Systematic Review and Meta-analysis

OBJECTIVES

Previous meta-analyses of a small number of trials showed that acceptance and commitment therapy (ACT) might improve chronic pain. Many new trials have been published afterward, and the factors that may impact the efficacy of ACT are less understood. We, therefore, conducted an updated systematic review with meta-analysis to investigate the efficacy of ACT for people with chronic pain.

METHODS

Randomized controlled trials that investigated the efficacy of ACT in clinical or community setting for adult populations with chronic pain were included. The methodological quality of trials was assessed with the Cochrane Risk of Bias tool. Standardized mean differences between ACT and comparison groups in their effects on 6 outcomes (ie, pain acceptance, quality of life, pain-related functioning, pain intensity, anxiety, and depression) were pooled across studies.

RESULTS

Of the 3171 records identified, 21 trials with 1962 participants were included for analysis. The comparison groups included active treatment and waitlist control/usual care. The standardized mean difference was 0.67 (95% CI: 0.48, 0.87) for pain acceptance, 0.43 (95% CI: 0.29, 0.57) for quality of life, -0.88 (95% CI: -1.14, -0.63) for pain-related functioning, -0.45 (95% CI: -0.62, -0.27) for pain intensity, -0.35 (95% CI: -0.54, -0.15) for anxiety, and -0.74 (95% CI, -0.98, -0.50) for depression, all favoring ACT. Subgroup analyses showed that the effects were statistically significant across almost all subgroups and for some outcomes were greater in the trials conducted in people with a specific diagnosis (as compared with those conducted in people with general chronic pain), the trials with waitlist or usual care control, the trials with a greater number of sessions of ACT, and the trials with a longer ACT intervention.

DISCUSSION

ACT is effective and comparable to, if not better than, some other available active treatments for chronic pain.

Raising Awareness on the Clinical and Social Relevance of Adequate Chronic Pain Care

Appropriate pain care should be regarded as a right and effectively guaranteed to people with chronic pain (CP). Law 38, enacted in Italy in 2010, establishes the citizen's right not to suffer. Twelve years later, such right appears still disregarded in Italy and the current access to adequate pain care reveals significant shortcomings. In addition, a mismatch between CP-associated burden and the available healthcare resources in the framework of our national health system has been observed. This article gathers the perspectives of a Board of Italian anesthesiologists on the state of the art of CP management in Italy and aims at strengthening the scientific rationale and clinical relevance of pursuing the enforceability of the right not to suffer and at promoting widespread multidisciplinary care of patients with CP.

Chronic Pain in the ICD-11: New Diagnoses That Clinical Psychologists Should Know About

Background

In the 10th revision of the International Classification of Diseases and Related Health Problems (ICD-10), chronic pain was not represented adequately. Pain was left undefined and not recognized as a biopsychosocial phenomenon. Instead, a flawed dualism between psychological and somatic factors was implied. Individual diagnoses were ill-defined and scattered randomly through different chapters. Many patients received diagnoses in remainder categories devoid of meaningful clinical information.

Method

The International Association for the Study of Pain launched a Task Force to improve the diagnoses for the 11th revision of the ICD and this international expert team worked from 2013-2019 in cooperation with the WHO to develop a consensus based on available evidence and to improve the diagnoses.

Results

A new chapter on chronic pain was created with a biopsychosocial definition of pain. Chronic pain was operationalized as pain that persists or recurs longer than three months and subdivided into seven categories: Chronic primary pain and six types of chronic secondary pain. All diagnoses were based on explicit operationalized criteria. Optional extension codes allow coding pain-related parameters and the presence of psychosocial aspects together with each pain diagnosis.

Conclusion

First empirical studies demonstrated the integrity of the categories, the reliability, clinical utility, international applicability and superiority over the ICD-10. To improve reliability and ease of diagnosis, a classification algorithm is available. Clinical psychologists and other clinicians working with people with chronic pain should watch the national implementation strategies and advocate for multimodal and interdisciplinary treatments and adequate reimbursement for all providers involved.

Defining and measuring multimorbidity in primary care in Singapore: Results of an online Delphi study

Multimorbidity, common in the primary care setting, has diverse implications for both the patient and the healthcare system. However, there is no consensus on the definition of multimorbidity globally. Thus, we aimed to conduct a Delphi study to gain consensus on the definition of multimorbidity, the list and number of chronic conditions used for defining multimorbidity in the Singapore primary care setting. Our Delphi study comprised three rounds of online voting from purposively sampled family physicians in public and private settings. Delphi round 1 included open-ended questions for idea generation. The subsequent two rounds used questions with pre-selected options. Consensus was achieved based on a pre-defined criteria following an iterative process. The response rates for the three rounds were 61.7% (37/60), 86.5% (32/37) and 93.8% (30/32), respectively. Among 40 panellists who responded, 46.0% were 31-40 years old, 64.9% were male and 73.0% were from the public primary healthcare setting. Based on the findings of rounds 1, 2 and 3, consensus on the definition of a chronic condition, multimorbidity and finalised list of chronic conditions were achieved. For a condition to be chronic, it should last for six months or more, be recurrent or persistent, impact patients across multiple domains and require long-term management. The consensus-derived definition of multimorbidity is the presence of three or more chronic conditions from a finalised list of 23 chronic conditions. We anticipate that our findings will inform multimorbidity conceptualisation at the national level, standardise multimorbidity measurement in primary care and facilitate resource allocation for patients with multimorbidity.

The association between short-term, chronic localized and chronic widespread pain and risk for cardiovascular disease in the UK Biobank

AIMS

The interplay between pain of different chronicity and cardiovascular disease (CVD) is incompletely understood. We aimed to investigate the association between different levels of chronic or nonchronic pain and risk of CVD.

METHODS AND RESULTS

Participants in the UK Biobank who reported pain at baseline were divided into three groups according to pain duration and widespreadness. Participants reporting no pain were controls. Multivariable Cox regression was used to investigate the association between pain and incidence of myocardial infarction, heart failure, stroke, cardiovascular mortality, and composite CVD (defined as any of the before-mentioned cardiovascular events). Of 475 171 participants, 189 289 reported no pain, 87 830 reported short-term pain, 191 716 chronic localized pain, and 6336 chronic widespread pain (CWP). During a median of 7.0 years' follow-up, participants with chronic localized pain and CWP had, after adjustment for age, sex, established cardiovascular risk factors, physical activity, anxiety, depression, cancer, chronic inflammatory/painful disease, pain/anti-inflammatory medication, socioeconomic status, a significantly increased risk for composite CVD [hazard ratio (HR) 1.14, confidence interval (CI) 1.08-1.21, P < 0.001; and HR 1.48, CI 1.28-1.73, P < 0.001, respectively] compared with controls, with similar results when using the different specific CVDs as outcomes. Population attributable risk proportion for chronic pain as a risk factor for composite CVD was comparable with that of diabetes (8.6 vs. 7.3%, respectively).

CONCLUSION

Chronic pain is associated with an increased risk for myocardial infarction, stroke, heart failure, and cardiovascular death independent of established cardiovascular risk factors, socioeconomic factors, comorbidities and medication. Our study, the largest to date, confirms and extends our understanding of chronic pain as an underestimated cardiovascular risk factor with important public health implications.

Fitbit Activity, Quota-Based Pacing, and Physical and Emotional Functioning Among Adults With Chronic Pain

Physical activity can improve function in patients with chronic pain, however, adherence is low, in part due to inconsistent activity patterns. Smart wearable activity trackers, such as Fitbits, may help promote activity. In our program for chronic pain, we examined: 1) Fitbit activity patterns (ie, step count, moderate-to-vigorous physical activity (MVPA), sedentary behavior), and 2) whether achievement of weekly, individualized Fitbit step goals was associated with functional outcomes. We conducted a secondary analysis of Fitbit data from our 10-week mind-body activity program for chronic pain (GetActive-Fitbit arm, N = 41). Participants self-reported emotional and physical function and completed performance-based and accelerometer-based assessments. From week 1 to week 10, 30% of participants increased >800 steps; 32.5% increased MVPA; and 30% decreased sedentary behavior. Only step count significantly changed across time with mean steps peaking at week 8 (M = +1897.60, SD = 467.67). Fitbit step goal achievement was associated with improvements in anxiety (ß = -.35, CI [-2.80, -.43]), self-reported physical function (ß = -.34, CI [-5.17, 8.05]), and performance-based physical function (ß = .29, CI [-71.93, 28.38]), but not accelerometer-based physical function or depression. Adhering to individualized Fitbit step goals in the context of a mind-body activity program may improve anxiety and self-reported and performance-based physical function. PERSPECTIVE: We examine Fitbit activity patterns and the association between quota-based pacing and functional outcomes within a mind-body activity program for adults with chronic pain. Complementing quota-based pacing and coping skills with Fitbits may be a useful approach to promote activity engagement and behavior change in chronic pain populations.

Pain severity ratings in the 11th revision of the International Classification of Diseases: a versatile tool for rapid assessment

ABSTRACT

An improved classification of chronic pain is included in the 11th revision of the International Classification of Diseases (ICD-11). For all diagnoses of chronic pain, an optional dimensional code for the chronic pain severity will supplement the categorical diagnoses. Pain severity combines pain intensity, pain-related interference, and pain-related distress. Each component is rated by the patient on a numerical rating scale (NRS) from 0 to 10, and subsequently translated into severity stages ('mild'/'moderate'/'severe'). The present study aimed to evaluate this severity code by comparing the ratings with established psychometric measures of pain-related interference and distress. An online survey was posted to self-help groups for chronic pain, and 595 participants (88.7% women, 59.5±13.5 years) rated each of the severity parameters (pain intensity, pain-related interference, pain-related distress) on an NRS from 0 to 10 and completed the Pain Disability Index (PDI) and the Pain Coping Questionnaire (FESV, 3 subscales). The participants reported a mean pain intensity of 6.4±1.9, mean pain-related interference of 6.7±2.1, and mean pain-related distress of 5.7±2.5. The respective NRS ratings showed substantial correlations with the PDI score (r=.65) and the FESV subscales (r=.65, r=.56, r=.37). The extension code for pain severity is a valid and efficient way of recording additional dimensional pain parameters, which can be used to monitor the course of chronic pain and its treatment. The specifier's efficiency makes it possible to use the code when a questionnaire would not be feasible due to time constraints, such as in primary care.

Classification of chronic pain for the International Classification of Diseases (ICD-11): results of the 2017 international World Health Organization field testing

ABSTRACT

Because chronic pain has been poorly represented in the International Statistical Classification of Diseases and Related Health Problems (ICD) despite its significant contribution to the burden of disease worldwide, the International Association for the Study of Pain (IASP) developed a classification of chronic pain that was included in the ICD-11 version as "MG30" and approved by the World Health Assembly in 2019. The objective of this field test was to determine how well the classification of chronic pain works in the context of the ICD-11. A web-based survey using the WHO-FiT platform recruited 177 healthcare professionals from all WHO regions. After a training on coding chronic pain hosted by the IASP Web site, participants evaluated 18 diagnostic codes (lines) of the 2017 frozen version of the ICD-11 and 12 vignettes (cases) describing chronic pain conditions. Correctness, ambiguity, and perceived difficulty of the coding were compared between the ICD-11 and the ICD-10 and the applicability of the morbidity rules for the ICD-11 verified. In the line coding, 43.0% of correct chronic pain diagnoses assigned with the ICD-10 contrasted with 63.2% with the ICD-11. Especially in cases in which the chronic pain is regarded as the symptom of an underlying disease, the ICD-11 (63.5%) commanded more correct diagnoses than the ICD-10 (26.8%). The case coding was on average 83.9% accurate, only in 1.6% of cases any difficulty was perceived. The morbidity rules were applied correctly in 74.1% of cases. From a coding perspective, the ICD-11 is superior to the ICD-10 in every respect, offering better accuracy, difficulty, and ambiguity in coding chronic pain conditions.

Chronic pain in the 11th revision of the International Classification of Diseases: users' questions answered

ABSTRACT

The upcoming 11th revision of the International Classification of Diseases (ICD-11) will include a comprehensive classification of chronic pain for the first time, which is based on the biopsychosocial definition of chronic pain. This presents a great opportunity for pain research and clinical practice. The new classification consists of seven main diagnostic categories of chronic pain, which are further divided into increasingly specific levels of diagnoses. Each diagnosis is characterized by clearly defined operationalized criteria. Future users will need to familiarize themselves with the new system and its application. The aim of the present publication is to provide users of the ICD-11 chronic pain classification with answers to frequently asked questions regarding the ICD-11 as a whole, the ICD-11 chronic pain classification, and its application to common pain syndromes. The questions compiled here reached the International Association for the Study of Pain Task Force via different routes (e.g., at conferences, by letter, or during field testing). Furthermore, the authors collected questions posted to the ICD-11 browser and contacted early users of the classification to enquire about their most frequent difficulties when applying the new diagnoses. The authors of the present publication prepared answers to these frequently asked questions. This publication intends to act as a guide for the future users of the new ICD-11 chronic pain classification, hence facilitating its implementation.

Population-Focused Approaches for Proactive Chronic Pain Management in Older Adults

Chronic pain, and the ethical management thereof, is the single most imperative health issue of this decade. Although a growing majority of individuals with chronic pain are middle-aged, the largest proportion of sufferers are older adults. Shifting tides in practice and research have led to population-focused approaches to pain management; however, the practice of many healthcare providers remains reactive and individualistic, limiting the discovery and implementation of long-term solutions for pain management in older adults. Yet, nurses and other health professionals have an opportune position to provide expert pain care by proactively providing evidence-based care for patients systematically. The purpose of this article is to stimulate discussion on three paradigms important to population-focused pain management: (1) prevention; (2) restoration and rehabilitation; and (3) palliation, which are in line with current national policy initiatives for improving patients' care experience, improving overall health and quality of life, and reducing associated health care costs.

Bedside clinical tests to assess sensitization in office workers with chronic neck pain

OBJECTIVE

This study aimed to assess pain sensitization in individual office workers with chronic neck pain through simple bedside quantitative sensory tests (QST) and to associate the findings with pain intensity and pain catastrophizing.

METHODS

One hundred-and-four office workers with chronic neck pain were assessed using pressure pain threshold (PPT) considering pain sensitive if PPTs were lower than 155 kPa in the upper trapezius and 245 kPa in the tibialis anterior. Pain sensitive to temporal summation of pain (TSP) was considered if there was a difference of two points in the visual analogue scale (VAS) comparing the first and last stimulus. Pain sensitive was considered to conditioned pain modulation (CPM) if the CPM-effect was less than -7.5%. Pain intensity and catastrophizing were measured using VAS and with the Pain Catastrophizing Scale.

RESULTS

There was at least one pain sensitive QST finding in 66 office workers (63.5%). TSP findings were the most common (48.1%), followed by PPT's (31.7%) and CPM (20.2%). Based on the QST findings, office workers were divided based on the number of individual QST findings, and higher pain intensity and pain catastrophizing scores were found in office workers with one (N = 38, P < 0.05) or two (N = 28, P < 0.05) compared with office workers with no QST findings (N = 38).

CONCLUSION

This study demonstrated that most office workers with chronic neck pain exhibit either widespread pressure hyperalgesia, facilitated TSP or impaired CPM, indicating pain sensitization within the central nervous system. This was associated with increased clinical pain and pain catastrophizing rumination scores.

Does TENS Reduce the Intensity of Acute and Chronic Pain? A Comprehensive Appraisal of the Characteristics and Outcomes of 169 Reviews and 49 Meta-Analyses

Background and Objectives: Uncertainty about the clinical efficacy of transcutaneous electric nerve stimulation (TENS) to alleviate pain spans half a century. There has been no attempt to synthesise the entire body of systematic review evidence. The aim of this comprehensive review was to critically appraise the characteristics and outcomes of systematic reviews evaluating the clinical efficacy of TENS for any type of acute and chronic pain in adults. Materials and Methods: We searched electronic databases for full reports of systematic reviews of studies, overviews of systematic reviews, and hybrid reviews that evaluated the efficacy of TENS for any type of clinical pain in adults. We screened reports against eligibility criteria and extracted data related to the characteristics and outcomes of the review, including effect size estimates. We conducted a descriptive analysis of extracted data. Results: We included 169 reviews consisting of eight overviews, seven hybrid reviews and 154 systematic reviews with 49 meta-analyses. A tally of authors' conclusions found a tendency toward benefits from TENS in 69/169 reviews, no benefits in 13/169 reviews, and inconclusive evidence in 87/169 reviews. Only three meta-analyses pooled sufficient data to have confidence in the effect size estimate (i.e., pooled analysis of >500 events). Lower pain intensity was found during TENS compared with control for chronic musculoskeletal pain and labour pain, and lower analgesic consumption was found post-surgery during TENS. The appraisal revealed repeated shortcomings in RCTs that have hindered confident judgements about efficacy, resulting in stagnation of evidence. Conclusions: Our appraisal reveals examples of meta-analyses with 'sufficient data' demonstrating benefit. There were no examples of meta-analyses with 'sufficient data' demonstrating no benefit. Therefore, we recommend that TENS should be considered as a treatment option. The considerable quantity of reviews with 'insufficient data' and meaningless findings have clouded the issue of efficacy. We offer solutions to these issues going forward.

Comparing the ICD-11 chronic pain classification with ICD-10: how can the new coding system make chronic pain visible? A study in a tertiary care pain clinic setting

ABSTRACT

Pain is a frequent reason for patients to ask for medical services. However, systematic information about the extent and impact of pain, especially in developing countries, has not been available up to now. We evaluated whether the 11th edition of the International Statistical Classification of Diseases and Related Health Problems (ICD) can fill this gap by coding all electronic out-patient medical records of the pain clinic at Siriraj Hospital in Thailand in 2019 (8714 visits), using the ICD-10 and ICD-11 browsers referenced on the WHO websites. The 3 most frequent pain-related codes in ICD-10 were R52.2 "other chronic pain" (29%), M54.5 "low back pain" (18%), and M79.6 "pain in limb" (13%). In ICD-11, the 3 most frequent codes were MG30.31 "chronic secondary musculoskeletal pain associated with structural changes" (28%), MG30.51 "chronic peripheral neuropathic pain" (26%), and MG30.10 "chronic cancer pain" (23%). Thus, using the currently valid ICD-10 system, roughly one-third of patient encounters were coded as "other chronic pain," and the next 2 were specifying the pain region rather than any underlying cause. By contrast, ICD-11 coding of the same patients identified underlying causes (bones and joints, somatosensory nervous system, cancer, or surgery), which provide guidance towards differential patient management. In our pain clinic, most patients suffered from chronic cancer pain, chronic neuropathic pain, and chronic secondary musculoskeletal pain, which were poorly defined or nonexistent in the current ICD-10 coding system. Compared with the ICD-10, the ICD-11 provides more detailed diagnostic categories and is more informative for clinical use, research, and resource allocation for pain-related conditions.

Pressure pain thresholds in office workers with chronic neck pain: A systematic review and meta-analysis

OBJECTIVES

The purpose of this study was to (a) compare pressure pain threshold (PPT) values between office workers with chronic neck pain and asymptomatic controls; (b) establish reference PPT values in chronic neck pain; and (c) evaluate associations between PPTs and pain intensity, and disability.

METHODS

Seven English/Portuguese databases were searched for relevant literature. Studies investigating adult office workers (age >18 years) with chronic neck pain were included if PPTs were an outcome. The risk of bias was assessed using the Downs and Black checklist. Meta-analysis was conducted if a cluster contained at least two studies reporting the same PPTs.

RESULTS

Ten high quality, two low quality, and one poor quality studies were included. The meta-analysis revealed decreased PPT values in the upper trapezius, extensor carpi ulnaris, and tibialis anterior in office workers with chronic neck pain when compared with healthy workers, without a statistical difference (p > 0.05). The PPT reference value in the upper trapezius was 263 kPa (95% confidence interval [CI] = 236.35 to 289.70), and 365 kPa (95% CI = 316.66 to 415.12) for the tibialis anterior in office workers with chronic neck pain. No correlations were found between the upper trapezius PPT and pain intensity and disability.

CONCLUSION

This meta-analysis found that all the PPT measurements were not significantly reduced in office workers with chronic neck pain compared with healthy workers. These assumptions were based on a small sample of existing studies, and therefore further studies are necessary to quantify the differences in PPTs. Hypersensitivity PPT reference values are proposed for localized and extrasegmental sites in office workers with chronic neck pain.

Pain Trends Among American Adults, 2002-2018: Patterns, Disparities, and Correlates

Determining long-term trends in chronic pain prevalence is critical for evaluating and shaping U.S. health policies, but little research has examined such trends. This study (1) provides estimates of pain trends among U.S. adults across major population groups; (2) tests whether sociodemographic disparities in pain have widened or narrowed over time; and (3) examines socioeconomic, behavioral, psychological, and medical correlates of pain trends. Regression and decomposition analyses of joint, low back, neck, facial/jaw pain, and headache/migraine using the 2002-2018 National Health Interview Survey for adults aged 25-84 (N  =  441,707) assess the trends and their correlates. We find extensive escalation of pain prevalence in all population subgroups: overall, reports of pain in at least one site increased by 10%, representing an additional 10.5 million adults experiencing pain. Socioeconomic disparities in pain are widening over time, and psychological distress and health behaviors are among the salient correlates of the trends. This study thus comprehensively documents rising pain prevalence among Americans across the adult life span and highlights socioeconomic, behavioral, and psychological factors as important correlates of the trends. Chronic pain is an important dimension of population health, and demographic research should include it when studying health and health disparities.

Utilisation of pain counselling in osteopathic practice: secondary analysis of a nationally representative sample of Australian osteopaths

OBJECTIVES

Advice, reassurance and education are recommended as first line treatments for musculoskeletal pain conditions such as low back pain. Osteopaths are registered primary contact allied health professionals in the Australian healthcare system who primarily manage acute and chronic musculoskeletal pain conditions. This study aimed to investigate the proportion of Australian osteopaths who do and do not utilise advice, reassurance and education (pain counselling) in their clinical practice, and determine the characteristics associated with the frequency of using pain counselling in clinical practice.

METHODS

A secondary analysis of practice characteristics from a nationally representative sample of Australian osteopaths was undertaken. Participants completed a 27-item practice characteristics questionnaire between July-December 2016. Bivariate analyses were used to identify significant variables for inclusion in a backward multiple logistic regression model. Adjusted odds ratios (OR) were calculated for significant variables.

RESULTS

Responses were received from 991 Australian osteopaths, representing 49% of the profession. Of these 264 (26.64%) indicated often utilising pain counselling, and 727 (73.36%) reported not often utilising pain counselling. Those who utilised pain counselling were more than twice as likely to report research evidence had a high impact on their clinical practice (OR 2.11), and nearly twice as likely to discuss physical activity with their patients (OR 1.84).

CONCLUSIONS

Pain counselling is under-utilised by nearly three quarters of the Australian osteopathic profession as a management strategy. Future studies are required to explore the reasons why most in the profession comprised in this sample are infrequently utilising this guideline recommendation. Given the frequency of chronic musculoskeletal pain conditions presenting to Australian osteopaths, strategies appear to be needed to advance the profession via professional development in accessing and using evidence-based care for pain conditions.

Pain and Neuropathic Pain in Rheumatic Diseases

Pain is a challenge to rheumatologists. Not only patients with active arthritis but also patients with a good therapeutic response and even in remission complain of persistent joint pain. It has been proposed that a chronic pain stimulus may have a greater impact in a chronic inflammatory state, and the process towards a pain condition may be influenced by individual predisposition for development of chronic pain. In addition, features of peripheral pain processing may be exacerbated by inflammation, and disturbed pain processing may be a feature contributing to widespread pain. Furthermore, a neuropathic component may be part of the total pain experience of our patients. There are many different strategies of pain therapy in patients with rheumatic diseases, such as pharmacological and non- pharmacological modalities.

Efficacy of Tuina in patients with chronic low back pain: study protocol for a randomized controlled trial

BACKGROUND

Low back pain is a common reason for medical care and carries a heavy social burden. The efficacy of Tuina or health care education for low back pain has been evaluated in previous systematic reviews. However, there is no evidence to support the superiority of one form of treatment over another. The aim of this study is to compare the efficacy of Tuina with health care education in the management of low back pain.

METHODS/DESIGN

This study is a randomized controlled trial with parallel-group design including two groups: a Tuina group and a health care education group. A total of 160 eligible participants will be randomly assigned to the groups in a 1:1 ratio. The interventions of both groups will last for 20 min and be carried out twice each week for a period of 12 weeks. The primary outcome is the Oswestry Disability Index. The secondary outcomes include a visual analogue scale and the 36-item Short Form Health Survey. They will be assessed at baseline, at the end of the intervention every month, and during 6 months and 9 months of follow-up by repeated measures analysis of variance. The significance level is 5%. The safety of Tuina and health care education will be evaluated after each treatment session. This study will focus on the value of Tuina and health care education for low back pain and will highlight any differences in the efficacy of the treatments.

DISCUSSION

This study will evaluate the efficacy and safety of Tuina intervention for low back pain, which could provide reliable evidence for clinical decision making for patients with low back pain.

TRIAL REGISTRATION

Chinese Clinical Trial Registry, ChiCTR1900022656. Registered on 23 April 2019.