A review of chronic pain impact on patients, their social environment and the health care system

Mechanisms, Predictors, and Challenges in Assessing and Managing Painful Chemotherapy-Induced Peripheral Neuropathy

OBJECTIVE

To describe the known predictors and pathophysiological mechanisms of chronic painful chemotherapy-induced peripheral neuropathy (CIPN) in cancer survivors and the challenges in assessing and managing it.

DATA SOURCES

PubMed/Medline, CINAHL, Scopus, and PsycINFO.

CONCLUSION

The research on chronic painful CIPN is limited. Additional research is needed to identify the predictors and pathophysiological mechanisms of chronic painful CIPN to inform the development of assessment tools and management options for this painful and possibly debilitating condition.

IMPLICATIONS FOR NURSING PRACTICE

Recognition of the predictors of chronic painful CIPN and proactive CIPN assessment and palliative management are important steps in reducing its impact on physical function and quality of life.

Patient Experiences With Integrated Pain Care: A Qualitative Evaluation of One VA's Biopsychosocial Approach to Chronic Pain Treatment and Opioid Safety

Background

Mounting concern about the risks and limited effectiveness of opioid therapy for chronic pain has spurred the implementation of novel integrated biopsychosocial pain care models in health-care systems like the Department of Veterans Affairs (VA). However, little is known about patient experiences with these new care models.

Objective

We conducted a qualitative study to examine patient experiences with a pain care model currently being disseminated at the VA: interdisciplinary, integrated pain teams (IPTs) embedded in primary care.

Method

We interviewed 41 veterans who received care from VA’s first IPT to learn how working with the team impacted their pain care and quality of life. We asked about their overall experience with IPT, what worked and did not work for them, and what changes they would recommend to improve IPT care.

Results

The interviews revealed a wide spectrum of patient experiences and varying perspectives on the extent to which the new model improved their pain and quality of life. Thematic analysis shed light on factors impacting patients’ experiences, including pretreatment goals and expectations as well as attitudes toward opioids and nonpharmacological treatments.

Conclusion

We discuss the implications of our findings for national efforts to implement biopsychosocial pain care, and we offer recommendations to promote patient-centered implementation.

Dose-Dependent Effect of Hyperbaric Oxygen Treatment on Burn-Induced Neuropathic Pain in Rats

Hyperbaric oxygen treatment (HBOT) has been used to reduce neuropathic pain. Melatonin and opioid receptors are involved in neuropathic pain, but it is not known if HBOT works through these pathways to achieve its antinociceptive effect. We divided anesthetized rats into two treatment and three sham groups. The two treatment groups received third-degree burns on their right hind paws, one treated in a hyperbaric chamber for a week and the other for two weeks. We evaluated the mechanical paw-withdrawal threshold (MWT) and expression of melatonin receptor 1 (MT1), melatonin receptor 2 (MT2), μ (MOR) and κ (KOR) opioid receptor, brain-derived neurotrophic factor (BDNF), Substance P, and calcitonin gene-related peptide (CGRP) in cuneate nucleus, dorsal horn, and hind paw skin by immunohistochemical, immunofluorescence assays and real-time quantitative polymerase chain reaction (RT-PCR). The group receiving one-week HBOT had increased expressions of MT1, MT2, MOR and KOR and decreased expressions of BDNF, Substance P, and CGRP. Their mechanically measured pain levels returned to normal within a week and lasted three weeks. This anti-allodynia effect lasted twice as long in those treated for two weeks. Our findings suggest that increasing the duration of HBOT can reduce burn-induced mechanical allodynia for an extended period of time in rats. The upregulation of melatonin and opioid receptors observed after one week of HBOT suggests they may be partly involved in attenuation of the mechanical allodynia. Downregulation of BDNF, substance P and CGRP may have also contributed to the overall beneficial effect of HBOT.

Affective and cognitive behavior is not altered by chronic constriction injury in B7-H1 deficient and wildtype mice

Background

Chronic neuropathic pain is often associated with anxiety, depressive symptoms, and cognitive impairment with relevant impact on patients` health related quality of life. To investigate the influence of a pro-inflammatory phenotype on affective and cognitive behavior under neuropathic pain conditions, we assessed mice deficient of the B7 homolog 1 (B7-H1), a major inhibitor of inflammatory response.

Results

Adult B7-H1 ko mice and wildtype littermates (WT) received a chronic constriction injury (CCI) of the sciatic nerve, and we assessed mechanical and thermal sensitivity at selected time points. Both genotypes developed mechanical (p < 0.001) and heat hypersensitivity (p < 0.01) 7, 14, and 20 days after surgery. We performed three tests for anxiety-like behavior: the light–dark box, the elevated plus maze, and the open field. As supported by the results of these tests for anxiety-like behavior, no relevant differences were found between genotypes after CCI. Depression-like behavior was assessed using the forced swim test. Also, CCI had no effect on depression like behavior. For cognitive behavior, we applied the Morris water maze for spatial learning and memory and the novel object recognition test for object recognition, long-, and short-term memory. Learning and memory did not differ in B7-H1 ko and WT mice after CCI.

Conclusions

Our study reveals that the impact of B7-H1 on affective-, depression-like- and learning-behavior, and memory performance might play a subordinate role in mice after nerve lesion.

Comparing functioning in spinal cord injury and in chronic spinal pain with two ICF-based instruments: WHODAS 2.0 and the WHO minimal generic data set covering functioning and health

OBJECTIVE

To investigate whether the two briefest validated ICF-based (International Classification of Functioning, Disability and Health) tools can detect differences between different spinal conditions.

DESIGN

Cross-sectional study.

SETTING

University hospital rehabilitation clinic.

SUBJECTS

A total of 84 patients with spinal cord injury and 81 with chronic spinal pain.

MAIN MEASURES

Disability evaluated using self-reported and proxy 12-item WHODAS 2.0 ((World Health Organization Disability Assessment Schedule), and physician-rated WHO minimal generic data set covering functioning and health.

FINDINGS

The two measures used showed severe disability in both patient populations, those with spinal cord injury (mean age 47.5 years, SD 13.2) and those with chronic spinal pain (mean age 47.2 years, SD 9.5), WHODAS patient sum being 18.4 (SD 9.6) versus 22.0 (SD 9.0), P < 0.05, and the WHO generic data set 15.6 (SD 4.4) versus 14.2 (SD 3.7), P < 0.01, respectively. Correlations between patient and proxy ratings and between the two disability scales were mostly strong. Severe restrictions were found in the working ability of both the populations, in mobility of patients with spinal cord injury and in pain function of patients with chronic spinal pain. In this tertiary clinic patient population, patients with spinal pain perceived more problems in emotional and cognitive functions, and in participation than patients with spinal cord injury.

CONCLUSIONS

Both scales were able to find differences between two patient populations with severe disability.

Living with Chronic Pain: A Qualitative Study of the Daily Life of Older People with Chronic Pain in Chile

One of the main causes of chronic pain in older people is spine deformity, an abnormal curvature of the spine. The purpose of this study is to improve understanding of the experience of chronic pain produced by spinal deformity in older people and understand how cultural factors may affect this experience. A qualitative study was performed with 10 older people. Participants were encouraged to describe a typical day in their life, including the factors that affect their pain and how their quality of life had been affected since experiencing chronic pain. The semistructured interviews were transcribed and analyzed using open coding. Pain caused by spine deformity produces disability, affecting how older people perform their daily activities, causing them to adapt their households and physical positions to perform these tasks, albeit slowly or incompletely. Chronic pain also affects emotional states and social relationships because older people become unable to undertake physical activities that they performed in the past. The close relationship with adult children and friends, typical in Latin cultures, is a source of comfort and support. At a community level, adaptation of public services (such as public transportation) must be improved.

Development of an education and self-management intervention for chronic headache - CHESS trial (Chronic Headache Education and Self-management Study)

BACKGROUND

Self-management interventions are well recognised and widely used in chronic conditions. Their application to chronic headaches has been limited and generally of low quality. We describe here our process for developing an evidence based, and theory driven, education and self-management intervention for those living with chronic headache.

METHODS

Our intervention was designed using several core information sources; the results of three systematic reviews, qualitative material from those living with chronic headaches, our knowledge from existing self-management interventions; and finally collaborative input from a multidisciplinary team of clinicians, academics, patients, and charity partners. We manualised the intervention and associated training as a package for use in a feasibility study. We made adaptations for its use in a randomised controlled trial.

RESULTS

We piloted the intervention in four groups with a total of 18 participants. Qualitative feedback from 12 participants and five facilitators allowed the intervention to be refined for the main randomised controlled trial. Some of the key changes included shortening of the overall intervention, changes to the originally planned facilitators and spreading the facilitator training over three days rather than two. We are now testing the final revised intervention in a randomised controlled trial of its clinical and cost effectiveness. The group component of the intervention is delivered over two days with the first day focused on living, understanding and dealing with chronic headaches and the second day exploring how to adapt and take control of one's life with chronic headaches.

CONCLUSION

Our pilot work indicates that our intervention is feasible to deliver, and with the relevant changes would be acceptable for use with this population. Our randomised control trial is ongoing. We anticipate publishing final results in 2021.

TRIAL REGISTRATION

ISRCTN79708100. Registered 16th December 2015, http://www.isrctn.com/ISRCTN79708100.

The association between frailty and quality of life among rural community-dwelling older adults in Kegalle district of Sri Lanka: a cross-sectional study

PURPOSE

The objective of this study was to estimate the cross-sectional association of frailty status with overall and domain-specific quality of life (QoL) in rural community-dwelling older adults in Kegalle district of Sri Lanka.

METHODS

A population-based cross-sectional study was conducted with 746 community-dwelling older adults aged ≥ 60 years living in the rural areas of Kegalle district of Sri Lanka in 2016. A three-stage probability sampling design was used to recruit participants. Frailty and QoL were assessed using the Fried phenotype and Older People's Quality of Life Questionnaire, respectively. Multivariable linear regression was used to estimate the association of frailty with QoL after accounting for the complex sampling design.

RESULTS

The median (IQR) age of the sample was 68 (64:75) years and comprised of 56.7% women. 15.2% (95% CI 12.4%, 18.7%) were frail and 48.5% (95% CI 43.9%, 53.2%) were pre-frail. The unadjusted means (SE) of the total QoL score for the robust, pre-frail and frail groups were 139.2 (0.64), 131.8 (1.04) and 119.2 (1.35), respectively. After adjusting for covariates in the final multivariable model, the estimated differences in mean QoL were lower for both frail and pre-frail groups versus robust. The estimated reduction in the total QoL score was 7.3% for those frail and 2.1% for those pre-frail. All QoL domains apart from 'social relationships and participation', 'home and neighbourhood' and 'financial circumstances' were associated with frailty.

CONCLUSIONS

Frailty was associated with a small but significant lower quality of life in this rural Sri Lankan population, which appears largely explained by 'health' and 'independence, control over life and freedom' QoL domains. Interventions aiming to improve quality of life in frail older adults should consider targeting these aspects.

Prevalence of low Back pain among adolescents in relation to the weight of school bags

BACKGROUND

The association between the weight of school bag and Low Back Pain (LBP) amongst students remains under intense debate worldwide. This study aimed to estimate the prevalence of LBP amongst public high school students (14 to 19 years) in Kuwait and to investigate the association between LBP and the weight of school bags.

METHODS

An analytical cross-sectional study using multistage cluster random sampling with probability proportional to size was conducted on a total of 950 public high school students from all governorates. Data on LBP were collected through face-to-face interviews using a structured questionnaire. A 0-10 Numeric Pain Rating Scale was used to rate the intensity of LBP. The students' height and weight in addition to the weight of their school bags were measured using appropriate weight and height scales. Logistic regression was used to investigate the association between the weight of school bags and LBP while adjusting for potential confounders.

RESULTS

The estimated lifetime, 6-month, and 1-month prevalence of LBP were 70.3% (95% CI: 67.30-73.21%), 49.1% (95% CI: 45.83-52.28%), and 30.8% (95% CI: 27.81-33.78%) respectively, with significantly higher prevalence amongst females compared to males (p < 0.001). The absolute weight of school bag was not significantly associated with LBP neither in univariable nor multivariable analysis. The relative weight of school bag (as a percentage of the body weight) was significantly associated with LBP in univariable analysis but not in multivariable analysis. The perceived heaviness of school bag, however, was found to be significantly associated with LBP throughout the analysis (p < 0.001).

CONCLUSION

In conclusion, LBP amongst high school students in Kuwait seems to be very common with a prevalence resembling that of high-income countries. Our data suggest that the perceived heaviness of school bag is far more important than the actual bag weight. Current recommendations about the weight of school bags, which are not supported by evidence, should be revised to take into account the students' perceived heaviness of school bag.

Cortical Network Response to Acupuncture and the Effect of the Hegu Point: An fNIRS Study

Acupuncture is a practice of treatment based on influencing specific points on the body by inserting needles. According to traditional Chinese medicine, the aim of acupuncture treatment for pain management is to use specific acupoints to relieve excess, activate qi (or vital energy), and improve blood circulation. In this context, the Hegu point is one of the most widely-used acupoints for this purpose, and it has been linked to having an analgesic effect. However, there exists considerable debate as to its scientific validity. In this pilot study, we aim to identify the functional connectivity related to the three main types of acupuncture manipulations and also identify an analgesic effect based on the hemodynamic response as measured by functional near-infrared spectroscopy (fNIRS). The cortical response of eleven healthy subjects was obtained using fNIRS during an acupuncture procedure. A multiscale analysis based on wavelet transform coherence was employed to assess the functional connectivity of corresponding channel pairs within the left and right somatosensory region. The wavelet analysis was focused on the very-low frequency oscillations (VLFO, 0.01–0.08 Hz) and the low frequency oscillations (LFO, 0.08–0.15 Hz). A mixed model analysis of variance was used to appraise statistical differences in the wavelet domain for the different acupuncture stimuli. The hemodynamic response after the acupuncture manipulations exhibited strong activations and distinctive cortical networks in each stimulus. The results of the statistical analysis showed significant differences (p<0.05) between the tasks in both frequency bands. These results suggest the existence of different stimuli-specific cortical networks in both frequency bands and the anaesthetic effect of the Hegu point as measured by fNIRS.

OPENCRONIC Study. Knowledge and Experiences of Spanish Patients and Carers about Chronic Disease

Background: Chronic diseases are currently the main cause of morbidity and mortality and represent a major challenge to healthcare systems. The objective of this study is to know Spanish public opinion about chronic disease and how it affects their daily lives. Methods: Through a telephone or online survey of 24 questions, data was gathered on the characteristics of the respondents and their knowledge and experiences of chronic diseases. Results: Of the 2522 survey respondents, 325 had a chronic disease and were carers, 1088 had a chronic disease and were not carers, 140 did not have a chronic disease but were carers, and 969 did not have chronic disease and were not carers. The degree of knowledge on these diseases was good or very good for 69.4%, 56.0%, 62.2%, and 46.7%, respectively, for each group. All the groups agreed that chronic diseases mainly affect mood, quality of life and having to make sacrifices. Conclusions: Knowledge about chronic diseases is relatively good, although it can be improved among the Spanish population, especially among patients who report having a chronic disease and play the role of carers. However, it is important to continue maintaining the level of information and training concerning these diseases.

Chronic Musculoskeletal Pain, Self-Reported Health and Quality of Life among Older Populations in South Africa and Uganda

Chronic musculoskeletal pain (CMP) is a serious health concern especially among the elderly population and has significant bearing on health and quality of life. Not much is known about the relationship between chronic pain with self-reported health and quality of life among older populations in low-resource settings. Based on sub-national data from South Africa and Uganda, the present study aimed to explore whether the older population living with CMP report health and quality of life differently compared to those with no CMP complaints. This study was based on cross-sectional data on 1495 South African and Ugandan men and women collected from the SAGE Well-Being of Older People Study. Outcome variables were self-reported physical and mental health and quality of life (QoL). Mental health was assessed by self-reported depressive symptoms during the last 12 months. CMP was assessed by self-reported generalised pain as well as back pain. Multivariable logistic regression models were used to measure the association between health and QoL with CMP by adjusting for potential demographic and environmental confounders. The prevalence of poor self-rated health (61.2%, 95% CI = 51.7, 70.0), depression (37.2%, 95% CI = 34.8, 39.6) and QoL (80.5%, 95% CI = 70.8, 87.5) was considerably high in the study population. Mild/moderate and Severe/extreme generalised pain were reported respectively by 34.5% (95% CI = 28.9, 40.5) and 15.7% (95% CI = 12.2, 19.9) of the respondents, while back pain was reported by 53.3% (95% CI = 45.8, 60.4). The prevalence of both types was significantly higher among women than in men (p < 0.001). In the multivariate analysis, both generalised pain and back pain significantly predicted poor health, depression and QoL, however, it varied between the two different populations. Back pain was associated with higher odds of poor self-rated health [OR = 1.813, 95% CI = 1.308, 2.512], depression [1.640, 95% CI = 1.425, 3.964] and poor QoL [1.505, 95% CI = 1.028, 2.202] in South Africa, but not in Uganda. Compared to having no generalised pain, having Mild/Moderate [OR = 2.309, 95% CI = 1.219, 7.438] and Severe/Extreme [OR = 2.271, 95% CI = 1.447, 4.143] generalised pain was associated with significantly higher odds of poor self-rated health in South Africa. An overwhelmingly high proportion of the sample population reported poor health, quality of life and depression. Among older individuals, health interventions that address CMP may help promote subjective health and quality and life and improve psychological health.

Systematic review and meta-analysis on non-opioid analgesics in palliative medicine

Non-opioid analgesics are widely used for pain relief in palliative medicine. However, there is a lack of evidence-based recommendations addressing the efficacy, tolerability, and safety of non-opioids in this field. A comprehensive systematic review and meta-analysis on current evidence can provide a basis for sound recommendations in clinical practice. A database search for controlled trials on the use of non-opioids in adult palliative patients was performed in Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, PsycINFO, and EMBASE from inception to 18 February 2018. Endpoints were pain intensity, opioid-sparing effects, safety, and quality of life. Studies with similar patients, interventions, and outcomes were included in the meta-analyses. Our systematic search was able to only identify studies dealing with cancer pain. Of 5991 retrieved studies, 43 could be included (n = 2925 patients). There was no convincing evidence for satisfactory pain relief by acetaminophen alone or in combination with strong opioids. We found substantial evidence of moderate quality for a satisfactory pain relief in cancer by non-steroidal anti-inflammatory drugs (NSAIDs), flupirtine, and dipyrone compared with placebo or other analgesics. There was no evidence for a superiority of one specific non-opioid. There was moderate quality of evidence for a similar pain reduction by NSAIDs in the usual dosage range compared with up to 15 mg of morphine or opioids of equianalgesic potency. The combination of NSAID and step III opioids showed a beneficial effect, without a decreased tolerability. There is scarce evidence concerning the combination of NSAIDs with weak opioids. There are no randomized-controlled studies on the use of non-opioids in a wide range of end-stage diseases except for cancer. Non-steroidal anti-inflammatory drugs, flupirtine, and dipyrone can be recommended for the treatment of cancer pain either alone or in combination with strong opioids. The use of acetaminophen in the palliative setting cannot be recommended. Studies are not available for long-term use. There is a lack of evidence regarding pain treatment by non-opioids in specific cancer entities.

Assessment of pain-related fear in individuals with chronic painful conditions

Background

Heightened fear and anxiety related to pain may result in emotional and behavioral avoidance responses causing disability, distress, and depression. Fear and anxiety associated with pain can potentially change the course of the pain experience. It is plausible that fear and anxiety related to pain affect the duration and frequency of pain experienced by the patient.

Aim

The study aimed to examine the applicability of the Fear of Pain Questionnaire-III (FPQ-III) in identifying who are likely to report longer duration and greater frequency of pain experience.

Methods

To test this hypothesis, a cross-sectional study was conducted with 579 individuals from a community-based sample living with chronic pain. The factor structure and validity of FPQ-III in the community-based sample were also tested.

Results

The findings suggest higher fear of severe pain but lower fear of medical pain, associated with longer duration and more frequent pain experience. The analysis also confirmed the three-factor structure of FPQ-III, demonstrating good internal consistency for fear of severe pain (0.71) and fear of medical pain (0.73) and acceptable range for fear of minor pain (0.65).

Conclusion

These findings suggest that the FPQ-III can be potentially applied to identify individuals at risk for prolonged continuous pain and as a screening tool to measure fear and anxiety related to pain.

Personal Network Analysis in the Study of Social Support: The Case of Chronic Pain

In the context of chronic illness, the individual's social and relational environment plays a critical role as it can provide the informal support and care over time, beyond healthcare and social welfare institutions. Social Network Analysis represents an appropriate theoretical and methodological approach to study and understand social support since it provides measures of personal network structure, composition and functional content. The aim of this mixed method study is to present the usefulness of Personal Network Analysis to explore social support in the context of chronic pain. Personal and support network data of 30 people with chronic pain (20 alters for each ego, 600 relationships in total) were collected, obtaining measures of personal network structure and composition as well as information about social support characteristics. Also, semi-structured interviews with participants were conducted to identify the context of their experience of pain, their limitations as regards leading an autonomous life, their social support needs and other aspects concerning the effect of pain on their social and relational lives. This approach shows the importance of non-kin social support providers and the significant role of non-providers in the personal networks of people suffering chronic pain.

Occupational Therapy's Unique Contribution to Chronic Pain Management: A Scoping Review

Occupational therapy (OT) makes a unique contribution to chronic pain (CP) management due to its overarching focus on occupation. The aim of this scoping review was to describe current knowledge about this contribution by documenting OT roles, models, assessments, and intervention methods used with adults living with CP. A systematic search exploring 10 databases and gray literature from 2006 to 2017 was conducted. Fifty-two sources were retained and analysed. Results bring forward the main role of OT being improving activities and participation (76.9 %), the Canadian Model of Occupational Performance (9.6 %), and the Canadian Occupational Performance Measure (21.2 %). Within the 30 reported interventions, 73.3% related directly to the person, 20% pertained to occupation (activities and participation), and 6.7% addressed environmental factors. The distinction and complementarity between the bottom-up and the top-down approaches to OT intervention were discussed. This review highlights OT specificity in adult CP management.

No association between G1359A CB1 polymorphisms and pain in young northeastern Mexicans

AIM

Recent studies show an association between the endocannabinoid system and pain. In this study, we analyzed the association between two CNR1 gene polymorphisms and pain perception in a northeast Mexican population.

METHODS

Genotypic and allelic frequencies were obtained for both polymorphisms. Pain threshold, tolerance and perception were measured using the cold pressor task.

RESULTS

No significant association between the polymorphisms and pain perception was found (p > 0.05).

CONCLUSION

Genotypic and allelic frequencies for both polymorphisms were reported for the first time in a Mexican population; however, our results suggest that there is not a significant association between these and pain.

Measuring the Quality of Mobile Apps for the Management of Pain: Systematic Search and Evaluation Using the Mobile App Rating Scale

Background

Chronic pain is a major health issue requiring an approach that not only considers medication, but also many other factors included in the biopsychosocial model of pain. New technologies, such as mobile apps, are tools to address these factors, although in many cases they lack proven quality or are not based on scientific evidence, so it is necessary to review and measure their quality.

Objective

The aim is to evaluate and measure the quality of mobile apps for the management of pain using the Mobile App Rating Scale (MARS).

Methods

This study included 18 pain-related mobile apps from the App Store and Play Store. The MARS was administered to measure their quality. We list the scores (of each section and the final score) of every app and we report the mean score (and standard deviation) for an overall vision of the quality of the pain-related apps. We compare the section scores between the groups defined according to the tertiles via analysis of variance (ANOVA) or Kruskal-Wallis test, depending on the normality of the distribution (Shapiro-Wilk test).

Results

The global quality ranged from 1.74 (worst app) to 4.35 (best app). Overall, the 18 apps obtained a mean score of 3.17 (SD 0.75). The best-rated sections were functionality (mean 3.92, SD 0.72), esthetics (mean 3.29, SD 1.05), and engagement (mean 2.87, SD 1.14), whereas the worst rated were app specific (mean 2.48, SD 1.00), information (mean 2.52, SD 0.82), and app subjective quality (mean 2.68, SD 1.22). The main differences between tertiles were found on app subjective quality, engagement, esthetics, and app specific.

Conclusions

Current pain-related apps are of a certain quality mainly regarding their technical aspects, although they fail to offer information and have an impact on the user. Most apps are not based on scientific evidence, have not been rigorously tested, and the confidentiality of the information collected is not guaranteed. Future apps would need to improve these aspects and exploit the capabilities of current devices.

Self-management of pain and depression in adults with spinal cord injury: A scoping review

Context: Pain and depression are two prevalent secondary complications associated with spinal cord injury (SCI) that negatively impact health and well-being. Self-management strategies are growing in popularity for helping people with SCI to cope with their pain and depression. However, there is still a lack of research on which approaches are best suited for this population.Objective: The aim of this scoping review was to determine what is known about the self-management of pain and depression through the use of pharmacological and non-pharmacological therapies in adults with SCI.Methods: Seven electronic databases were searched for articles published between January 1, 1990 and June 13, 2017. Grey literature was searched and additional articles were identified by manually searching the reference lists of included articles.Results: Overall, forty-two articles met the inclusion criteria; with the majority reporting on the self-management of pain, rather than on depression or on both complications. Non-pharmacological interventions were more likely to include self-management strategies than pharmacological interventions. A limited number of studies included all of the core self-management tasks and skills.Conclusions: There are significant knowledge gaps on effective self-management interventions for pain and depression post-SCI. There is a need to develop interventions that are multi-faceted, which include both pharmacological and non-pharmacological therapies to address multimorbidity.

Comorbid chronic pain and opioid use disorder: literature review and potential treatment innovations

Chronic pain (CP) and opioid use disorder (OUD) remain challenging complex public health concerns. This is an updated review on the relationship between CP and OUD and the use of stepped care models for assessment and management of this vulnerable population. A literature search was conducted from 2008 to the present in PubMed, Embase, and PsycInfo using the terms pain or chronic pain and opioid-related disorders, opiate, methadone, buprenorphine, naltrexone, opioid abuse, opioid misuse, opioid dependen*, heroin addict, heroin abuse, heroin misuse, heroin dependen*, or analgesic opioids, and stepped care, integrated services, multidisciplinary treatment, or reinforcement-based treatment. Evidenced-based data exists on the feasibility, implementation, and efficacy of stepped care models in primary care settings for the management of CP and opioid use. Although these studies did not enroll participants with OUD, they included a sub-set of patients at risk for the development of OUD. There remains a dearth of treatment options for those with comorbid CP and OUD. Future research is needed to explore the aetiology and impact of CP and OUD, and greater emphasis is needed to improve access to comprehensive pain and substance use programmes for high-risk individuals.

A Before and After Analysis of Health Care Utilization by Patients Enrolled in Opioid Controlled Substance Agreements for Chronic Noncancer Pain

OBJECTIVE

To evaluate the impact of opioid controlled substance agreements (CSAs) enrollment on health care utilization.

PATIENTS AND METHODS

We retrospectively evaluated health care utilization changes among 772 patients receiving long-term opioid therapy for chronic noncancer pain enrolled in a CSA between July 1, 2015, and December 31, 2015. We ascertained patient characteristics and utilization 12 months before and after CSA enrollment. Decreased utilization was defined as a decrease of 1 or more hospitalizations or emergency department visits and 3 or more outpatient primary and specialty care visits. Multivariate modeling assessed demographic characteristics associated with utilization changes.

RESULTS

The 772 patients enrolled in an opioid CSA during the study period had a mean ± SD age of 63.5±14.9 years and were predominantly female, white, and married. The CSA enrollment was associated with decreased outpatient primary care visits (odds ratio [OR], 0.16; 95% CI, 0.14-0.19) and increased diagnostic radiology services (OR, 1.22; 95% CI, 1.02-1.47). After CSA enrollment, patients with greater comorbidity (Charlson Comorbidity Index score >3) were more likely to have reduced hospitalizations (adjusted OR, 2.8; 95% CI, 1.3-6.0; P=.008), reduced outpatient primary care visits (adjusted OR, 2.0; 95% CI, 1.2-3.2; P=.005), and reduced specialty care visits (adjusted OR, 2.0; 95% CI, 1.2-3.3; P=.006).

CONCLUSION

For patients receiving long-term opioid therapy for chronic noncancer pain, CSA enrollment is associated with reductions in primary care visits and increased radiologic service utilization. Patients with greater comorbidity were more likely to have reductions in hospitalizations, outpatient primary care visits, and outpatient specialty clinic visits after CSA enrollment. The observational nature of the study does not allow the conclusion that CSA implementation is the primary reason for these observed changes.

Deficits in history taking skills among final year medical students in a family medicine course: A study from KSA

OBJECTIVES

History taking is considered an important diagnostic tool in medicine. Medical students should be competent in focused history-taking skills to reach initial diagnosis. The aim of this study was to identify deficits in history-taking skills among final year medical students in family medicine courses in Qassim University, KSA.

METHODS

All objective structured clinical examination (OSCE) sheets were collected and analysed to evaluate the history-taking component of the final examination from 2016 until January 2018.

RESULTS

A total of 94 OSCE sheets were evaluated. Achievement in some history taking skills of the students was low (differential diagnosis 31.9%, alarming symptoms of disease 39.4%, clarification of major complaint-associated symptoms 47.9%, and stress, anxiety, and depression screening 59.6%). However, the students' performances were better with respect to communication skills in general and exploration of the patients' ideas, concerns, and expectations. Significantly more male than female students had a better performance in some skills such as facilitating technique, appropriately exploring major complaint-associated symptoms, enquiring about differential diagnoses, and to rule out alarm symptoms.

CONCLUSIONS

In this study, the students' performance was generally better with respect to communication skills and psychosocial history. However, the students showed poor knowledge in other aspects of history-taking skills as they failed to formulate more than one hypothesis and to ask about alarm symptoms. Teaching communication and clinical reasoning skills and connecting physical and psychosocial aspects of patient care promotes understanding of the patient as a whole and should be taught in all courses of the clinical phase, with emphasis on bedside training.

Action of ear acupuncture in people with chronic pain in the spinal column: a randomized clinical trial1

OBJECTIVES

to assess the action of ear acupuncture on disability and tissue temperature in people with chronic pain in the spinal column.

METHOD

a clinical trial with a sample of 110 people, randomized into three groups: Treatment, Placebo and Control. The assessment instruments were the Rolland Morris Disability Questionnaire (RMDQ) and a thermographic camera, administered before the first treatment session, one week after and 15 days after (follow-up) the fifth session of ear acupuncture. In the analysis of the data, the Kruskal Wallis, Student-Newman Keuls and Wilcoxon tests were applied.

RESULTS

there was a significant reduction in disability in the Treatment and Placebo groups between the initial and final assessments (p<0.05) and between the initial assessments and follow-up (p<0.05). In the final assessment, the Treatment group presented improvement of disability when compared with the Placebo and Control groups (p<0.05). There was an increase in mean tissue temperature of the dorsal region between the initial and follow-up assessments in Treatment and Control groups (p<0.05), and between the final assessments and follow-up in the Treatment and Placebo groups (p<0.05).

CONCLUSION

ear acupuncture was efficacious in reducing disability and increasing tissue temperature in people with chronic pain in the spinal column. Brazilian Register of Clinical Trials (RBR-5X69X2).

A qualitative study of professional stakeholders' perceptions about the implementation of a stepped care pain platform for people experiencing chronic widespread pain

Background

Chronic widespread pain (CWP) is a major public health problem. Many people experiencing CWP experience mental health problems such as anxiety or depression. Complete relief of skeletal and body pain symptoms is unlikely but with appropriate treatment the impact upon quality of life, functioning and mental health symptoms can be reduced. Cognitive behavioural therapy (CBT) is widely used for a range of health conditions and can have short and long-term improvements in patients with CWP. This research aimed to explore, from a professional stakeholder perspective, the implementation of a local Pain Platform offering a stepped care approach for interventions including telephone delivered CBT (T-CBT).

Methods

Fourteen professional stakeholders holding various roles across primary and secondary care services within the Pain Platform took part in semi-structured interviews. Their views and experiences of the implementation of the Pain Platform were explored. Interviews were recorded, transcribed verbatim and analysed according to Normalisation Process Theory (NPT).

Results

Professional stakeholders were positive about the Pain Platform and its potential to overcome previously identified existing access issues to psychological interventions for CWP patients. It was considered a valuable part of ensuring that patients’ preferences and needs are more readily addressed. In some circumstances, however, introducing psychological interventions to patients was considered challenging and the introduction of new referral processes was raised concerns. To ensure sustainability more work is required to reduce professional isolation and ensure efficient referral procedures between primary and secondary care services are established to reduce concerns over issues related to clinical governance and potential risk to patient.

Conclusions

The findings provide professional insight into the key challenges of introducing a Pain Platform incorporating psychological support across primary and secondary care services within a local service. These included development of sustainable procedures and closer working relationships. Areas requiring future development are identified.

The Effectiveness of Orofacial Pain Therapy in Indonesia: A Cross-Sectional Study

OBJECTIVES

As the most complained oral problems in Indonesia, the therapy of orofacial pain has to be constantly evaluated. The objective of the current study was to evaluate the effectiveness of orofacial pain therapy in Indonesia.

METHODS

This study recruited 5412 (3816 female; 1596 male) participants from 27 districts in West Java province. Half of the participants (2714) were recruited from those who were treated at community health centers whilst the rest were those who were treated at private dental clinics. A Likert-scale questionnaire that consists of nine questions that were divided to three subsections was used. The first subsection of the questionnaire evaluated the participants' post-therapy basic oral functions (three questions), and the second part evaluated the participants' post-therapy pain intensity and frequency (three questions), whilst the last part evaluated the participants' post-therapy activities (three questions). All data were then cross-tabulated and correlated by using Spearman correlation.

RESULT

The current study revealed that out of 5412 participants, 4023 (74.33%) participants claimed that the therapy has enabled them to perform their work activity as usual, whilst 2576 (59.2%) claimed that the therapy has decreased the intensity of the pain moderately. A significant (p < 0.01) correlation (r = 0.1) between the type of dental facility visited and the total score of the therapy effectiveness was revealed.

CONCLUSION

The therapy of orofacial pain in Indonesian sample was proven to be effective. Further study evaluating the reasons underlying the current results is of importance.

Chronic Pain After Breast Surgery: A Prospective, Observational Study

BACKGROUND

Chronic pain is an important complication of breast surgery, estimated to affect 20-30% of patients. We prospectively examined surgical, demographic, and psychosocial factors associated with chronic pain 6 months after breast surgery.

METHODS

Patients undergoing breast surgery for benign and malignant disease preoperatively completed validated questionnaires to assess baseline pain and psychosocial characteristics. Pain at 6 months was quantified as the Pain Burden Index (PBI), which encompasses pain locations, severity, and frequency. Surgical type was categorized as breast-conserving surgery (BCS), mastectomy, and mastectomy with reconstruction; axillary procedure was categorized as no axillary surgery, sentinel lymph node biopsy (SLNB), and axillary dissection. PBI was compared between groups using one-way analysis of variance (ANOVA) or Kruskal-Wallis ANOVA, and the relationship between baseline demographic and psychosocial factors and PBI was assessed using Spearman's Rank Correlation. p < 0.05 was considered significant.

RESULTS

PBI was variable amongst patients reporting this endpoint (n = 216) at 6 months, but no difference was found between primary breast surgical types (BCS, mastectomy, and mastectomy with reconstruction) or with surgical duration. However, axillary dissection was associated with higher PBI than SLNB and no axillary procedure (p < 0.001). Younger age (< 0.001) and higher BMI (p = 0.010), as well as higher preoperative anxiety (p = 0.017), depression (p < 0.001), and catastrophizing scores (p = 0.005) correlated with higher 6-month PBI.

CONCLUSIONS

Amongst surgical variables, only axillary dissection was associated with greater pain at 6 months after surgery. Patient characteristics that were associated with higher PBI included lower age and higher BMI, as well as higher baseline anxiety, depression, and catastrophizing.

Anti-inflammatory and antinociceptive effects of 2,2`-dipyridyl diselenide through reduction of inducible nitric oxide synthase, nuclear factor-kappa B and c-Jun N-terminal kinase phosphorylation levels in the mouse spinal cord

Appropriate treatment of pain requires analgesics and anti-inflammatory drugs generally associated with undesirable side effects and not fully effective in a significant proportion of patients. Organoselenium compounds elicit a plenty of pharmacological effects in different animal models. Among these compounds, the 2,2`-dipyridyl diselenide (DPD) has a potent antioxidant effect and low toxicity. In this way, the aim of this study was to investigate the possible DPD antinociceptive effect and its mechanism of action, as well as the safety of the compound. Female Swiss mice were treated with vehicle or DPD (0.01-50 mg/kg) intragastrically. Dose-response curve and time-course of the antinociceptive effect of DPD were performed on formalin and tail immersion tests. Morphine (2.5 mg/kg, subcutaneous, 15 min earlier) was used as a positive control in behavioral tests. The results showed that DPD presents a rapid antinociceptive effect in low doses, without changing the spontaneous locomotor activity and parameters of toxicity in mice. The DPD antinociceptive effect was also confirmed in male Swiss mice in both formalin and tail immersion tests. In addition, DPD reduced the paw edema induced by 2.5% formalin and ear edema induced by 2.5% croton oil. l-arginine (600 mg/kg, intraperitoneally) reduced the DPD antinociceptive effect in the first phase of the formalin test. Moreover, DPD attenuated the increase in iNOS, NF-κB and JNK phosphorylation in the spinal cord of mice injected with formalin. These results showed that DPD exerts peripheral and central nociceptive actions associated with anti-inflammatory effect and this organoselenium compound could be an interesting alternative therapy for pain treatment.

Enriched Environment and Effects on Neuropathic Pain: Experimental Findings and Mechanisms

Neuropathic pain inflicts tremendous biopsychosocial suffering for patients worldwide. However, safe and effective treatment of neuropathic pain is a prominent unmet clinical need. Environmental enrichment (EE) is an emerging cost-effective nonpharmacological approach to alleviate neuropathic pain and complement rehabilitation care. We present here a review of preclinical studies in ascertaining the efficacy of EE for neuropathic pain. Their proposed mechanisms, including the suppression of ascending nociceptive signaling to the brain, enhancement of the descending inhibitory system, and neuroprotection of the peripheral and central nervous systems, may collectively reduce pain perception and improve somatic and emotional functioning in neuropathic pain. The current evidence offers critical insights for future preclinical research and the translational application of EE in clinical pain management.

The role of pain in chronic pain patients’ perception of health-related quality of life: a cross-sectional SQRP study of 40,000 patients

Background and aims

Health-related quality of life (Hr-QoL) reflects the burden of a condition on an overarching level. Pain intensity, disability and other factors influence how patients with chronic pain perceive their condition, e.g. Hr-QoL. However, the relative importance of these factors is unclear and there is an ongoing debate as to what importance pain measures have in this group. We investigated the importance of current pain level and mood on aspects of Hr-QoL in patients with chronic pain and investigated whether such relationships are influenced by demographics.

Methods

Data was obtained from the Swedish Quality Registry for Pain Rehabilitation (SQRP), between 2008 and 2016 on patients ≥18 years old who suffered from chronic pain and were referred to participating specialist clinics. Dependent variables were general Hr-QoL [using two scales from European Quality of Life instrument: EQ5D Index and the European Quality of Life instrument health scale (EQ thermometer)] and specific Hr-QoL [from the Short Form Health Survey (SF36) the physical component summary (SF36-PCS) and the mental (psychological) component summary (SF36-MCS)]. Independent variables were sociodemographic variables, pain variables, psychological distress and pain attitudes. Principal component analysis (PCA) was used for multivariate correlation analyses of all investigated variables and Orthogonal Partial Least Square Regression (OPLS) for multivariate regressions on health aspects.

Results

There was 40,518 patients (72% women). Pain intensity and interference showed the strongest multivariate correlations with EQ5D Index, EQ thermometer and SF36-PCS. Psychological distress variables displayed the strongest multivariate correlations with SF36-MCS. Demographic properties did not significantly influence variations in the investigated Hr-QoL variables.

Conclusions

Pain, mood and pain attitudes were significantly correlated with Hr-QoL variables, but these variables cannot explain most of variations in Hr-QoL variables. The results pinpoint that broad assessments (including pain intensity aspects) are needed to capture the clinical presentation of patients with complex chronic pain conditions.

Exploring psychological mechanisms of clinical response to an internet-delivered psychological pain management program

BACKGROUND

The evidence for Internet-delivered pain management programs for chronic pain is growing, but there is little empirical understanding of how they effect change. Understanding mechanisms of clinical response to these programs could inform their effective development and delivery.

METHODS

A large sample (n = 396) from a previous randomized controlled trial of a validated internet-delivered psychological pain management program, the Pain Course, was used to examine the influence of three potential psychological mechanisms (pain acceptance, pain self-efficacy, fear of movement/re-injury) on treatment-related change in disability, depression, anxiety and average pain. Analyses involved generalized estimating equation models for clinical outcomes that adjusted for co-occurring change in psychological variables. This was paired with cross-lagged analysis to assess for evidence of causality. Analyses involved two time points, pre-treatment and post-treatment.

RESULTS

Changes in pain-acceptance were strongly associated with changes in three (depression, anxiety and average pain) of the four clinical outcomes. Changes in self-efficacy were also strongly associated with two (anxiety and average pain) clinical outcomes. These findings suggest that participants were unlikely to improve in these clinical outcomes without also experiencing increases in their pain self-efficacy and pain acceptance. However, there was no clear evidence from cross-lagged analyses to currently support these psychological variables as direct mechanisms of clinical improvements. There was only statistical evidence to suggest higher levels of self-efficacy moderated improvements in depression.

CONCLUSIONS

The findings suggest that, while clinical improvements are closely associated with improvements in pain acceptance and self-efficacy, these psychological variables may not drive the treatment effects observed.

SIGNIFICANCE

This study employed robust statistical techniques to assess the psychological mechanisms of an established internet-delivered pain management program. While clinical improvements (e.g. depression, anxiety, pain) were closely associated with improvements in psychological variables (e.g. pain self-efficacy and pain acceptance), these variables do not appear to be treatment mechanisms.

A systematic review of outcome measures utilised to assess self-management in clinical trials in patients with chronic pain

OBJECTIVES

The aim of this review was to identify, appraise and synthesise the outcome measures used to assess self-management in patients with chronic pain.

METHODS

Medline, Embase, CINAHL, PsycINFO, the Cochrane Library and Google Scholar were searched to identify quantitative measures used within randomised or non-randomised clinical trials to assess self-management in adults (≥18 years) with chronic pain.

RESULTS

25 RCTs published between 1998 and 2016 were included in this review. Studies included patients with chronic pain, hip/knee osteoarthritis, rheumatoid arthritis, chronic low back pain, fibromyalgia and chronic fatigue syndrome. Included studies utilised 14 different measures assessing a variety of constructs including self-efficacy (n = 19), coping (n = 4), empowerment (n = 2), pain attitude and management (n = 3), self-care (n = 1), role behaviour (n = 1) and multiple constructs of self-management (n = 1). The Chronic Pain Coping Inventory (CPCI) and Health Education Impact Questionnaire (heiQ) cover different self-management related constructs across the physical, mental and social health domains.

CONCLUSION

The review identified 14 measures used as proxy measure to assess self-management in patients with chronic pain. These measures have good content and construct validity, and internal consistency. However additional research is required to develop their reliability, responsiveness and interpretability.

PRACTICE IMPLICATIONS

Multi-constructs measures (CPCI, heiQ) are suitable for assessing self-management.

Chronic pain experience and pain management in persons with spinal cord injury in Nepal

BACKGROUND AND AIMS

Chronic pain is the frequent and significantly challenging complications in persons with spinal cord injury (SCI). Socio-cultural background may lead people perceive and manage pain differently. The study aims to describe the chronic pain experience and pain management of SCI persons in Nepal.

METHODS

A descriptive cross sectional study was conducted among purposively selected sample of 120 SCI persons with chronic pain living in the eight districts of Bagmati Zone of Nepal. The data were collected using the International Spinal Cord Injury Pain Basic Data Set Version 2 (ISCIPBDS-2) and Open-ended Pain Management Questionnaire. The data were analyzed using descriptive statistics and content analysis method.

RESULTS

The back (n=84), lower legs/feet (n=63) and buttocks/hips (n=51) was found as the common pain locations. In common, the onset of pain was found within the first 6 month of the injury. Overall pain intensity and pain interference were found to be at the moderate level. The SCI persons used pain medications and non-pharmacological pain management. Ibuprofen was the commonly used pain medication and commonly used non-pharmacological pain management methods included physical support (e.g. massage, exercise), relaxation (e.g. distraction, substance abuse), coping (e.g. acceptance, praying), and traditional herbs.

CONCLUSIONS

SCI persons had chronic pain experience which interfered with their daily living. They used pain medications and non-pharmacological pain management methods based on their beliefs, knowledge, and community resources in Nepal.

IMPLICATIONS

This study provides some evidence to help the team of rehabilitation professional to plan and help SCI persons with chronic pain. Based on these findings, chronic pain management intervention for SCI persons should be developed and supported continuously from hospital to home based community context of Nepal.

Translational profiling of dorsal root ganglia and spinal cord in a mouse model of neuropathic pain

•

Translational landscape in DRG and spinal cord in SNI assay of neuropathic pain was established.

•

ERK is a central hub of both transcriptionally and translationally controlled genes.

•

Changes in translation efficiency and mRNA levels occur in the opposite direction for multiple mRNAs.

Acute pain serves as a protective mechanism, guiding the organism away from actual or potential tissue injury. In contrast, chronic pain is a debilitating condition without any obvious physiological function. The transition to, and the maintenance of chronic pain require new gene expression to support biochemical and structural changes within the pain pathway. The regulation of gene expression at the level of mRNA translation has emerged as an important step in the control of protein expression in the cell. Recent studies show that signaling pathways upstream of mRNA translation, such as mTORC1 and ERK, are upregulated in chronic pain conditions, and their inhibition effectively alleviates pain in several animal models. Despite this progress, mRNAs whose translation is altered in chronic pain conditions remain largely unknown. Here, we performed genome-wide translational profiling of dorsal root ganglion (DRG) and spinal cord dorsal horn tissues in a mouse model of neuropathic pain, spared nerve injury (SNI), using the ribosome profiling technique. We identified distinct subsets of mRNAs that are differentially translated in response to nerve injury in both tissues. We discovered key converging upstream regulators and pathways linked to mRNA translational control and neuropathic pain. Our data are crucial for the understanding of mechanisms by which mRNA translation promotes persistent hypersensitivity after nerve injury.

Reliability and validity of the Athens Insomnia Scale in chronic pain patients

Purpose

To confirm the psychometric properties of the Athens Insomnia Scale (AIS) among Japanese chronic pain patients.

Patients and methods

In total, 144 outpatients were asked to complete questionnaires comprising the AIS and other study measures. According to the original article, the AIS has 2 versions: the AIS-8 (full version) and the AIS-5 (brief version). To validate the AIS-8 and AIS-5 among chronic pain patients, we confirmed: 1) factor structure by confirmatory factor analysis; 2) internal consistency by Cronbach's a; 3) test-retest reliability using with interclass correlation coefficients; 4) known-group validity; 5) concurrent validity; and 6) cut-off values by receiver operating characteristic analysis. In addition, semi-structured interviews were conducted to assess the participants' sleep disturbance. If the participants had any sleep complaints, including difficulty in initiating sleep, difficulty in maintaining sleep, and early morning awakening, they were defined as insomnia symptoms.

Results

A 2-factor model of the AIS-8 and 1-factor model of the AIS-5 demonstrated good fit. The AIS had adequate internal consistency and test-retest reliability. Patients with insomnia had a higher AIS score than those without insomnia. The sleep disturbance measured by the AIS was positively associated with pain intensity, disability, depression, anxiety, and pain catastrophizing, and negatively associated with pain-related self-efficacy. The cut-off values for detecting insomnia were estimated at 8 points in the AIS-8 and 4 points in the AIS-5.

Conclusion

The AIS-8 and AIS-5 had adequate reliability and validity in chronic pain patients.

A Novel Role for Lymphotactin (XCL1) Signaling in the Nervous System: XCL1 Acts via its Receptor XCR1 to Increase Trigeminal Neuronal Excitability

•

We identified XCR1 in the peripheral and central nervous systems and demonstrated its upregulation following nerve injury.

•

In injured nerve, XCR1 is present in nerve fibers, CD45-positive leucocytes and Schwann cells.

•

In Vc, XCR1 labeling is consistent with expression in terminals of Aδ- and C-fiber afferents and excitatory interneurons.

•

XCL1 increases neuronal excitability and activates intracellular signaling in Vc, a pain-processing region of the CNS.

•

These data provide the first evidence that the XCL1-XCR1 axis may play a role in trigeminal pain pathways.

Chemokines are known to have a role in the nervous system, influencing a range of processes including the development of chronic pain. To date there are very few studies describing the functions of the chemokine lymphotactin (XCL1) or its receptor (XCR1) in the nervous system. We investigated the role of the XCL1-XCR1 axis in nociceptive processing, using a combination of immunohistochemical, pharmacological and electrophysiological techniques. Expression of XCR1 in the rat mental nerve was elevated 3 days following chronic constriction injury (CCI), compared with 11 days post-CCI and sham controls. XCR1 co-existed with neuronal marker PGP9.5, leukocyte common antigen CD45 and Schwann cell marker S-100. In the trigeminal root and white matter of the brainstem, XCR1-positive cells co-expressed the oligodendrocyte marker Olig2. In trigeminal subnucleus caudalis (Vc), XCR1 immunoreactivity was present in the outer laminae and was colocalized with vesicular glutamate transporter 2 (VGlut2), but not calcitonin gene-related peptide (CGRP) or isolectin B4 (IB4). Incubation of brainstem slices with XCL1 induced activation of c-Fos, ERK and p38 in the superficial layers of Vc, and enhanced levels of intrinsic excitability. These effects were blocked by the XCR1 antagonist viral CC chemokine macrophage inhibitory protein-II (vMIP-II). This study has identified for the first time a role for XCL1-XCR1 in nociceptive processing, demonstrating upregulation of XCR1 at nerve injury sites and identifying XCL1 as a modulator of central excitability and signaling via XCR1 in Vc, a key area for modulation of orofacial pain, thus indicating XCR1 as a potential target for novel analgesics.

Efficiency of the combination of physical therapy modalities with topical nonsteroidal anti-inflammatory drugs for treatment of pain in rheumatology

Pain is the most common syndrome in rheumatology. NSAIDs are often used in its treatment. But they have limitations associated with side effects. An advantage of topical drugs and physical factors (electrophoresis, phonophoresis) combination is the use of low doses of the drug and a decrease in time, to achieve a therapeutic effect, reduce the risk of adverse reactions, increase the concentration of the drug in the inflammation focus, prolonged action (creating a drug depot in tissues). Ketoprofen gel (“Artrocol gel”) is one of the representatives of this pharmacological group. Physicochemical properties help ketoprofen to penetrate easily through the skin and create a therapeutic concentration in the underlying tissues. Objective. To assess the effectiveness of ketoprofen gel (“Arthrocol gel”) electrophonophoresis in the treatment of pain in rheumatological patients. Materials and methods. The study was carried out on the basis of Physiotherapy Department of Vinnytsia Regional Clinical Hospital named after M. I. Pirogov. All patients treated according to the unified clinical protocols were divided into experimental group (EG) and control group (CG). Patients of EG (98 persons) underwent electrophonophoresis with ketoprofen gel once a day for a week. In CG (43 persons) ketoprofen gel was used without electrophonophoresis. The intensity of the pain syndrome is monitored using a visual analog scale (VAS) of Huskisson at rest and during movement. A week later, the patient and the doctor evaluated satisfaction with the results of treatment on the scale: not effective, insufficient, satisfactory, good, excellent. Results. There was a persistent decrease in the intensity of pain syndrome in patients of both groups. The VAS scores were lower in the EG starting from the 3rd day of treatment. The intensity of the acute pain syndrome after 1-week treatment at rest (t = 4.71, p < 0.001) and during the movement (t = 3.84,  p < 0.001) more decrease in EG. Satisfaction with the results of treatment was higher in EG.

Evidence-Based Nonpharmacologic Strategies for Comprehensive Pain Care: The Consortium Pain Task Force White Paper

Medical pain management is in crisis; from the pervasiveness of pain to inadequate pain treatment, from the escalation of prescription opioids to an epidemic in addiction, diversion and overdose deaths. The rising costs of pain care and managing adverse effects of that care have prompted action from state and federal agencies including the DOD, VHA, NIH, FDA and CDC. There is pressure for pain medicine to shift away from reliance on opioids, ineffective procedures and surgeries toward comprehensive pain management that includes evidence-based nonpharmacologic options. This White Paper details the historical context and magnitude of the current pain problem including individual, social and economic impacts as well as the challenges of pain management for patients and a healthcare workforce engaging prevalent strategies not entirely based in current evidence. Detailed here is the evidence-base for nonpharmacologic therapies effective in postsurgical pain with opioid sparing, acute non-surgical pain, cancer pain and chronic pain. Therapies reviewed include acupuncture therapy, massage therapy, osteopathic and chiropractic manipulation, meditative movement therapies Tai chi and yoga, mind body behavioral interventions, dietary components and self-care/self-efficacy strategies. Transforming the system of pain care to a responsive comprehensive model necessitates that options for treatment and collaborative care must be evidence-based and include effective nonpharmacologic strategies that have the advantage of reduced risks of adverse events and addiction liability. The evidence demands a call to action to increase awareness of effective nonpharmacologic treatments for pain, to train healthcare practitioners and administrators in the evidence base of effective nonpharmacologic practice, to advocate for policy initiatives that remedy system and reimbursement barriers to evidence-informed comprehensive pain care, and to promote ongoing research and dissemination of the role of effective nonpharmacologic treatments in pain, focused on the short- and long-term therapeutic and economic impact of comprehensive care practices.

Waiting for multidisciplinary chronic pain services: A prospective study over 2.5 years

Despite many patients waiting more than 2 years for treatment at publicly funded multidisciplinary chronic pain services, waitlist studies rarely examine beyond 6 months. We investigated psychological adjustment and health-care utilisation of individuals (N = 339) waiting ≤30 months for appointments at an Australian tertiary pain unit. Outcomes were relatively stable during the first 6 months, but long-term deteriorations in pain-related interference, distress and pain acceptance were evident, albeit with sex differences. Sexes also differed in uptake of new treatments. Medication use increased over time, but pain severity and medication relief did not. Results suggest that early intervention is important, especially for women.