Treatment of chronic non-cancer pain

Motivational nondirective resonance breathing versus transcutaneous vagus nerve stimulation in the treatment of fibromyalgia: study protocol for a randomized controlled trial

BACKGROUND

Chronic widespread pain (CWP), including fibromyalgia (FM), affects one in every ten adults and is one of the leading causes of sick leave and emotional distress. Due to an unclear etiology and a complex pathophysiology, FM is a condition with few, if any, effective and safe treatments. However, current research within the field of vagal nerve innervation suggests psychophysiological and electrical means by which FM may be treated. This study will investigate the efficacy of two different noninvasive vagal nerve stimulation techniques for the treatment of FM.

METHODS

The study will use a randomized, single-blind, sham-controlled design to investigate the treatment efficacy of motivational nondirective resonance breathing (MNRB™) and transcutaneous vagus nerve stimulation (Nemos® tVNS) on patients diagnosed with FM. Consenting FM patients (N = 112) who are referred to the Department of Pain Management and Research at Oslo University Hospital, in Oslo, Norway, will be randomized into one of four independent groups. Half of these participants (N = 56) will be randomized to either an experimental tVNS group or a sham tVNS group. The other half (N = 56) will be randomized to either an experimental MNRB group or a sham MNRB group. Both active and sham treatment interventions will be delivered twice per day at home, 15 min/morning and 15 min/evening, for a total duration of 2 weeks (14 days). Participants are invited to the clinic twice, once for pre- and once for post-intervention data collection. The primary outcome is changes in photoplethysmography-measured heart rate variability. Secondary outcomes include self-reported pain intensity on a numeric rating scale, changes in pain detection threshold, pain tolerance threshold, and pressure pain limit determined by computerized pressure cuff algometry, blood pressure, and health-related quality of life.

DISCUSSION

The described randomized controlled trial aims to compare the efficacy of two vagal nerve innervation interventions, MNRB and tVNS, on heart rate variability and pain intensity in patients suffering from FM. This project tests a new and potentially effective means of treating a major public and global health concern where prevalence is high, disability is severe, and treatment options are limited.

TRIAL REGISTRATION

ClinicalTrials.gov NCT03180554 . Registered on August 06, 2017.

Antihypernociceptive, Anxiolytic, and Antidepressant Properties of Aqueous and Ethanol Extracts of Dissotis thollonii Cogn. (Melastomataceae) in Mice

Diabetic neuropathy, which affects 7 to 9% of the world's population and that is usually accompanied by anxiety and depression, is chronic pain that results from impaired function of the central or peripheral nervous system. This study aimed at evaluating the antihypernociceptive, antiallodynic, anxiolytic, and antidepressant effects of Dissotis thollonii extracts. Diabetic neuropathy was induced by intraperitoneal injection of streptozotocin (200 mg/kg) in mice. The aqueous and ethanol extracts (250 and 500 mg/kg) were administered orally. Hyperalgesia (thermal and chemical), allodynia (mechanical and thermal), anxiety (high plus labyrinth, light-dark box, and social interaction), and depression (open field test, suspension test tail, and forced swimming test) were evaluated, and then the levels of some cytokines and growth factors were determined. The aqueous and ethanol extracts of Dissotis thollonii demonstrated significant antihypernociceptive (inhibition of hyperalgesia and allodynia), anxiolytic, and antidepressant activities in mice made diabetic by STZ. The extracts also significantly inhibited (p < 0.001) the levels of TNF-α, IL-1β, and IL-6 in the blood as well as the levels of TNF-α, IL-1β, IL-6, IGF, and NGF in the sciatic nerve. This study shows that the extracts of Dissotis thollonii have antihypernociceptive and neuroprotective effects which could be linked to the inhibition of proinflammatory cytokines and growth factors in the blood and the sciatic nerve.

Pain management in hidradenitis suppurativa and a proposed treatment algorithm

Pain contributes substantially to reduced quality of life in individuals living with hidradenitis suppurativa (HS). Although improved understanding of HS pathogenesis and treatment has resulted in improved evidence-based HS management guidelines, comprehensive pain management guidelines have yet to be developed. Few HS-specific data exist to guide pharmacologic analgesia; however, recognizing HS pain as either acute or chronic and predominantly nociceptive (aching and gnawing pain due to tissue damage) versus neuropathic (burning-type pain due to somatosensory nervous system dysfunction) provides a conceptual framework for applying outside pain management practices to HS management. This article incorporates the best available evidence from the HS and pain literature to propose an HS pain algorithm that integrates psychological, pharmacologic, and complementary and alternative treatment modalities.

Chronic non-cancer pain management by nurses in specialist pain clinics

BACKGROUND

Chronic non-cancer pain (CNCP) is one of the major causes of disability globally, and patients who suffer from it are a complex population, which makes it difficult to provide effective care. Specialist pain clinics and nursing professionals in them are the main care providers, but there is little research conducted in this field.

AIM

To explore the attitudes and knowledge of nurses working in specialist pain clinics regarding care of CNCP patients.

METHODS

Qualitative phenomenological approach. Sixteen semi-structured interviews were conducted in 2017 with nurses who worked in specialist pain clinics in six hospitals in southern Spain.

RESULTS

Data analysis led to the formation of two categories, 'being trained and improving knowledge in CNCP' and 'the challenge of caring for patients with CNCP', and five subcategories.

CONCLUSION

The need for care in CNCP is not covered by nurses in all the areas it requires. Lack of time, staffing issues, and specific training in this area makes it difficult to provide care. However, some areas for improvement are proposed, such as psychological interventions, group workshops, continuous training, and multidisciplinary teams.

Telemonitoring in Chronic Pain Management Using Smartphone Apps: A Randomized Controlled Trial Comparing Usual Assessment against App-Based Monitoring with and without Clinical Alarms

BACKGROUND

The usefulness of mHealth in helping to target face-to-face interventions for chronic pain more effectively remains unclear. In the present study, we aim to test whether the Pain Monitor mobile phone application (app) is well accepted by clinicians, and can help improve existent medical treatments for patients with chronic musculoskeletal pain. Regarding this last goal, we compared three treatment conditions, namely usual treatment, usual treatment with an app without alarms and usual treatment with an app with alarms. All treatments lasted one month. The three treatments were compared for all outcomes, i.e., pain severity and interference, fatigue, depressed mood, anxiety and anger.

METHODS

In this randomized controlled trial, the usual monitoring method (i.e., onsite; n = 44) was compared with daily ecological momentary assessment using the Pain Monitor app-both with (n = 43) and without alarms (n = 45). Alarms were sent to the clinicians in the presence of pre-established undesired clinical events and could be used to make treatment adjustments throughout the one-month study.

RESULTS

With the exception of anger, clinically significant changes (CSC; 30% improvement) were greater in the app + alarm condition across outcomes (e.g., 43.6% of patients experienced a CSC in depressed mood in the app + alarm condition, which occurred in less than 29% of patients in the other groups). The clinicians were willing to use the app, especially the version with alarms.

CONCLUSIONS

The use of apps may have some benefits in individual health care, especially when using alarms to tailor treatments.

Clinical and cost-effectiveness of a guided internet-based Acceptance and Commitment Therapy to improve chronic pain-related disability in green professions (PACT-A): study protocol of a pragmatic randomised controlled trial

INTRODUCTION

Chronic pain is highly prevalent, associated with substantial personal and economic burdens, and increased risk for mental disorders. Individuals in green professions (agriculturists, horticulturists, foresters) show increased prevalence of chronic pain and other risk factors for mental disorders. Available healthcare services in rural areas are limited. Acceptance towards face-to-face therapy is low. Internet and mobile-based interventions (IMIs) based on Acceptance and Commitment Therapy (ACT) might be a promising alternative for this population and may enable effective treatment of chronic pain. The present study aims to evaluate the clinical and cost-effectiveness of an ACT-based IMI for chronic pain in green professions in comparison with enhanced treatment as usual (TAU+).

METHODS AND ANALYSIS

A two-armed pragmatic randomised controlled trial will be conducted. Two hundred eighty-six participants will be randomised and allocated to either an intervention or TAU+ group. Entrepreneurs in green professions, collaborating spouses, family members and pensioners with chronic pain are eligible for inclusion. The intervention group receives an internet-based intervention based on ACT (7 modules, over 7 weeks) guided by a trained e-coach to support adherence (eg, by positive reinforcement). Primary outcome is pain interference (Multidimensional Pain Interference scale; MPI) at 9 weeks post-randomisation. Secondary outcomes are depression severity (Quick Inventory Depressive Symptomology; QIDS-SR16), incidence of major depressive disorder, quality of life (Assessment of Quality of Life; AQoL-8D) and possible side effects associated with the treatment (Inventory for the Assessment of Negative Effects of Psychotherapy; INEP). Psychological flexibility (Chronic Pain Acceptance Questionnaire, Committed Action Questionnaire, Cognitive Fusion Questionnaire) will be evaluated as a potential mediator of the treatment effect. Furthermore, mediation, moderation and health-economic analyses from a societal perspective will be performed. Outcomes will be measured using online self-report questionnaires at baseline, 9-week, 6-month, 12-month, 24-month and 36-month follow-ups.

ETHICS AND DISSEMINATION

This study was approved by the Ethics Committee of the University of Ulm, Germany (file no. 453/17-FSt/Sta; 22 February 2018). Results will be submitted for publication in peer-reviewed journals and presented at conferences.

TRIAL REGISTRATION NUMBER

German Clinical Trial Registration: DRKS00014619. Registered on 16 April 2018.

Entraining Alpha Activity Using Visual Stimulation in Patients With Chronic Musculoskeletal Pain: A Feasibility Study

Entraining alpha activity with rhythmic visual, auditory, and electrical stimulation can reduce experimentally induced pain. However, evidence for alpha entrainment and pain reduction in patients with chronic pain is limited. This feasibility study investigated whether visual alpha stimulation can increase alpha power in patients with chronic musculoskeletal pain and, secondarily, if chronic pain was reduced following stimulation. In a within-subject design, 20 patients underwent 4-min periods of stimulation at 10 Hz (alpha), 7 Hz (high-theta, control), and 1 Hz (control) in a pseudo-randomized order. Patients underwent stimulation both sitting and standing and verbally rated their pain before and after each stimulation block on a 0-10 numerical rating scale. Global alpha power was significantly higher during 10 Hz compared to 1 Hz stimulation when patients were standing (t = -6.08, p < 0.001). On a more regional level, a significant increase of alpha power was found for 10 Hz stimulation in the right-middle and left-posterior region when patients were sitting. With respect to our secondary aim, no significant reduction of pain intensity and unpleasantness was found. However, only the alpha stimulation resulted in a minimal clinically important difference in at least 50% of participants for pain intensity (50%) and unpleasantness ratings (65%) in the sitting condition. This study provides initial evidence for the potential of visual stimulation as a means to enhance alpha activity in patients with chronic musculoskeletal pain. The brief period of stimulation was insufficient to reduce chronic pain significantly. This study is the first to provide evidence that a brief period of visual stimulation at alpha frequency can significantly increase alpha power in patients with chronic musculoskeletal pain. A further larger study is warranted to investigate optimal dose and individual stimulation parameters to achieve pain relief in these patients.

Psychological interventions for depression and anxiety: a systematic review and meta-analysis of Iranian chronic pain trials

Background: Chronic pain is commonly associated with anxiety and depression, making it more challenging to be managed. Psychological interventions are suggested for such complicated issues which are well evident in the United States and Europe. However, generalizing the evidence to Iranian population - as a Middle Eastern society - might be questionable. We aimed to synthesize our evidence on the effectiveness of these interventions among Iranian populations. Methods: This was a systematic review and meta-analysis. Persian and English literature were searched through Iran-doc, Elm-net, and PubMed until March 2019 using the following terms (or its Persian synonyms): chronic pain; persistent pain; chronic fatigue; fibromyalgia; neuropath*; LBP; irritable bowel; CFS; psycho*; cogniti*; acceptance; meaning; mindfulness; relaxation; biopsychosocial; rehabilitation; educat*. Eligible trials were randomized trials that evaluated the effectiveness of psychological interventions on Iranian adults with chronic pain. No setting restriction was considered. Risk of bias for each trial was assessed, and the random-effect model was used to pool summary effect across trials. Results: In all 30 eligible RCTs, the risk of bias for randomization was low except for one study. The pooled standardized mean difference (SMD) for depression and anxiety were 1.33 (95%CI: -1.42 to -0.68) and 1.25 (95% CI: -1.55 to -0.96), respectively. Conclusion: This study suggests that psychological interventions are highly effective in reducing depression and anxiety in Iranian patients with chronic pain, compared to what observed in the U.S. and European studies. However, there are still some methodological issues to be addressed. Future research should focus on high-quality trials with considerations on the methodological issues reported in the present study.

Gabapentin for presumed neuropathic ocular pain

Purpose

To report a case of chronic neuropathic ocular pain in a patient without visual complaints.

Observations

A 37-year-old male with a history of bilateral laser-assisted in situ keratomileusis (LASIK) presented with pain symptoms of 8 months duration in the left eye. The prior LASIK surgery was complicated by corneal ectasia in the left eye requiring penetrating keratoplasty and subsequent placement of a glaucoma drainage implant for uncontrolled, elevated intraocular pressure. The patient was evaluated with a complete clinical examination, including Goldmann applanation tonometry, dilated fundus examination, fluorescein angiography, optical coherence tomography, and magnetic resonance imaging. After 3 weeks of treatment with gabapentin 300 mg BID, the patient reported complete resolution of the ocular pain.

Conclusions and Importance

The pathophysiology of neuropathic ocular pain remains poorly understood. Clinical evaluation often reveals minimal ophthalmic exam findings, leading to an underdiagnosis of the condition by ophthalmologists. Gabapentin may be an underutilized medication in the treatment of chronic ocular pain.

Long-term opioid use after bariatric surgery

BACKGROUND

Opioid analgesics are often prescribed to manage pain after bariatric surgery, which may develop into chronic prescription opioid use (CPOU) in opioid-naïve patients. Bariatric surgery may affect opioid use in those with or without presurgical CPOU.

OBJECTIVE

To compare CPOU persistence and incidence in a large multisite cohort of veterans undergoing bariatric surgery (open Roux-en-Y gastric bypass, laparoscopic RYGB, or laparoscopic sleeve gastrectomy) and matched nonsurgical controls.

SETTING

Veterans Administration hospitals.

METHODS

In a retrospective cohort study, we matched 1117 surgical patients with baseline CPOU to 9531 nonsurgical controls, and 2822 surgical patients without CPOU at baseline to 26,392 nonsurgical controls using sequential stratification. CPOU persistence in veterans with baseline CPOU was estimated using generalized estimating equations by procedure type. CPOU incidence in veterans without baseline CPOU was estimated in Cox regression models by procedure type because postoperative pain, complications, and absorption may differ by procedure.

RESULTS

In veterans with baseline CPOU, postsurgical CPOU declined over time for each surgical procedure; these trends did not differ between surgical patients and nonsurgical controls. In veterans without baseline CPOU, compared with nonsurgical controls, bariatric patients had higher CPOU incidence within 5 years after open Roux-en-Y gastric bypass (hazard ratio = 1.19; 95% confidence interval: 1.06-1.34) or laparoscopic open Roux-en-Y gastric bypass (hazard ratio = 1.22, 95% confidence interval: 1.06-1.41). Veterans undergoing laparoscopic sleeve gastrectomy had higher CPOU incidence 1 to 5 years after surgery (hazard ratio = 1.28; 95% confidence interval: 1.05-1.56) than nonsurgical controls.

CONCLUSIONS

Bariatric surgery was associated with greater risk of CPOU incidence in patients without baseline CPOU but was not associated with greater CPOU persistence.

An exploration of the use of visually appealing contexts in a pain management program

PURPOSE

Pleasant pictures can help to reduce stress, promote positive feelings, and even facilitate recovery from diseases. Visual stimulation is an approach of distraction that can effectively reduce pain thresholds and increase pain tolerances. The number of older adults who suffer from pain has increased due to age-related diseases. Technology is increasingly being applied to the management of acute pain. The pain situation among older people was explored in this study, and a visually appealing pain management program was designed with the participants' experiences in mind.

METHODS

This was a descriptive observational study. Participants were recruited from local nursing homes.

RESULTS

A total of 165 older adults joined the study. The mean age of the participants was 85.6. More female than male participants experienced pain and the intensity of their pain was significantly greater. The results showed no significant differences in pain interferences between males and females. The participants stated that photographs of family members, homes, and natural scenery made them feel relaxed and happy, and reminded them of past happy times. They preferred to view those visually appealing pictures using digital devices (iPad/iPhone) to seeing hard copy versions.

CONCLUSION

A digital-based pain management program using visually appealing contexts for older adults can be implemented. The patients' experiences were collected and will be considered when developing a future program.

Massage therapy treatment and outcomes in a patient with Charcot-Marie-Tooth disease: A case report

BACKGROUND

Charcot-Marie-Tooth (CMT) disease, a progressive hereditary peripheral neuropathy, leads to muscle weakness, wasting, and sensory and motor nerve deprivation. The two main types of CMT are CMT1 (demyelinating) and CMT2 (axonal). Initial findings include foot deformities and sensory changes with progression to altered gait, diminished reflexes, and muscle wasting and weakness. Treatment is aimed at reducing symptoms with physiotherapy, orthotics, splints, braces, fatigue and pain management and possible surgical intervention. Research is limited on the effects of massage or other complementary and alternative medicines (CAM) on CMT.

OBJECTIVE

To determine whether massage therapy would aid in reducing bilateral foot and lumbar pain and increasing lumbar range of motion (ROM) in a CMT patient.

METHOD

A 44-year-old male with CMT presented with lumbar and bilateral foot pain, and foot deformities. Treatment aims were to decrease lumbar and foot pain and increase lumbar ROM. A tape measure was used to measure lumbar flexion and extension pre- and post-treatment. The Numerical Rating Scale (NRS) was used to evaluate foot and lumbar pain intensity before and after each treatment. Rhythmical superficial touch, myofascial release, and petrissage techniques were applied to the back, legs, and neck. A massage therapy student provided treatments over seven weeks.

RESULTS

Bilateral foot and lumbar pain decreased and lumbar flexion and extension increased post-treatment, and overall. All other lumbar movements increased overall.

CONCLUSION

Massage therapy may positively affect pain intensity and ROM associated with CMT. Future studies linking massage therapy and CMT are needed.

The use of transcranial motor-evoked potentials, somatosensory-evoked potentials and free-run electromyography for proper placement of paddle leads in chronic pain

Introduction: As an alternative to those patients who cannot be performed an awake spinal cord stimulation (SCS) or had been percutaneously implanted with poor pain relief outcomes, neurophysiological monitoring through transcranial motor evoked potentials (MEPs), somatosensory-evoked potentials (SSEPs) and free-run electromyography (EMG) under general anesthesia allows the correct placement of surgical leads and provide objective responses.Methods: An initial series of 15 patients undergoing SCS implantation for chronic pain. Physiologic midline was determined with 32-channel NIM-Eclipse System equipment. During neurophysiological monitoring, MEPs, SSEPs, EMG and CMAPs were recorded.Results: MEPs, SSEPs, and EMG were able to target spinal cord physiological midline during SCS to all patients. Physiologic midline was deviated in 53% patients. No warning events in SSEPs, MEPs, or EMG were recorded in any patient.Conclusions: Bilateral CMAPs recording allows placement of paddle leads in physiological midline, obtaining an accurate coverage, pain relief and avoid unpleasant or ineffective stimulation postoperatively. While these neurophysiological techniques are generally used to provide information on the state of the nervous system and prevent neurological injury risks during SCS, our work has shown that can accurate direct lead placement.

Identification of herbal categories active in pain disorder subtypes by machine learning help reveal novel molecular mechanisms of algesia

Chronic pain is highly prevalent and poorly controlled, of which the accurate underlying mechanisms need be further elucidated. Herbal drugs have been widely used for controlling various pain disorders. The systematic integration of pain herbal data resources might be promising to help investigate the molecular mechanisms of pain phenotypes. Here, we integrated large-scale bibliographic literatures and well-established data sources to obtain high-quality pain relevant herbal data (i.e. 426 pain related herbs with their targets). We used machine learning method to identify three distinct herb categories with their specific indications of symptoms, targets and enriched pathways, which were characterized by the efficacy of treatment to the chronic cough related neuropathic pain, the reproduction and autoimmune related pain, and the cancer pain, respectively. We further detected the novel pathophysiological mechanisms of the pain subtypes by network medicine approach to evaluate the interactions between herb targets and the pain disease modules. This work increased the understanding of the underlying molecular mechanisms of pain subtypes that herbal drugs are participating and with the ultimate aim of developing novel personalized drugs for pain disorders.

Association of Cost and Medical Service Satisfaction with Korean and Conventional Medicine Use before and after Surgery in Postsurgical Patients: A Questionnaire Survey of Korean Patients with Postsurgical Pain Visiting Korean Medicine Hospitals

This study aimed to assess the costs, health status, and medical service satisfaction with Korean and conventional medicine use before and after surgery of patients visiting Korean medicine hospitals for postsurgical musculoskeletal pain. The study population comprised patients who visited KM hospitals for the first time between June and November 2017 for persistent or recurrent pain and discomfort after low back, neck, shoulder, or knee surgery. Various validated questionnaires were used to collect data. A total of 100 participants were enrolled, and the majority had undergone low back surgery (n = 82). The participants had received 1.3 ± 0.7 magnetic resonance imaging (MRI) examinations and 2.4 ± 2.8 X-rays before surgery. Conventional interventions used before surgery were physical therapy (43%), medications (34%), and injections (28%), in descending order, while 48% of patients reported having received acupuncture 51.3 ± 81.1 times. The mean satisfaction score for surgery was 5.5 ± 2.8 points based on a 9-point Likert scale, while that for KM-based interventions was 6.3 ± 1.7 points. With respect to health-related information, the mean scores were 6.0 ± 2.2 points on the Numeric Rating Scale (NRS), 0.6 ± 0.2 points on the 5-Level EuroQol-5 Dimension (EQ-5D-5L), and 15.3 ± 10.2 on Beck's Depression Index II (BDI-II). The mean score on the Oswestry Disability Index (ODI) in patients with low back pain was 40.1 ± 19.2 points. Work impairment, as measured using the Work Productivity and Activity Impairment Questionnaire: General Health (WPAI-GH), was 62.5 ± 47.8%, while activity impairment was 5.9 ± 2.6%. Participants tended to show low satisfaction regarding surgery and high preference for KM-based interventions. In particular, low back surgery patients reported high ODI scores, indicating high dysfunctional levels and poor prognosis after surgery. It can be inferred that it is therefore important to provide appropriate presurgical and postsurgical care for patients with musculoskeletal pain to improve pain, function, and quality of life.

Resveratrol suppresses bone cancer pain in rats by attenuating inflammatory responses through the AMPK/Drp1 signaling

Bone cancer pain (BCP) is induced by primary bone cancer and secondary bone metastasis. During BCP pathogenesis, activated spinal astrocytes release proinflammatory cytokines, which participate in pain information transmission. In this study, we found that BCP rats showed disruption of trabecular bone structure, mechanical allodynia, and spinal inflammation. Moreover, reduced adenosine monophosphate-activated protein kinase (AMPK) activity, increased mitochondrial fission-associated protein Drp1 GTPase activity accompanied by the dysfunction of mitochondrial function, and abnormal BAX and Bcl-2 expression were found in the spinal cord of BCP rats. Notably, these alterations are reversed by resveratrol (Res) administration. Cell experiment results demonstrated that Res promotes mitochondrial function by activating AMPK, decreasing Drp1 activity, and inhibiting tumor necrosis factor-α-induced mitochondrial membrane potential reduction. Taken together, these results indicate that Res suppresses BCP in rats by attenuation of the inflammatory responses through the AMPK/Drp1 signaling pathway.

Design, synthesis, and biological activity of new endomorphin analogs with multi-site modifications

Endomorphin (EM)-1 and EM-2 are the most effective endogenous analgesics with efficient separation of analgesia from the risk of adverse effects. Poor metabolic stability and ineffective analgesia after peripheral administration were detrimental for the use of EMs as novel clinical analgesics. Therefore, here, we aimed to establish new EM analogs via introducing different bifunctional d-amino acids at position 2 of [(2-furyl)Map⁴]EMs. The combination of [(2-furyl)Map⁴]EMs with D-Arg² or D-Cit² yielded analogs with enhanced binding affinity to the μ-opioid receptor (MOR) and increased stability against enzymatic degradation (t_1/2 > 300 min). However, the agonistic activities of these analogs toward MOR were slightly reduced. Similar to morphine, peripheral administration of the analog [D-Cit², (2-furyl)Map⁴]EM-1 (10) significantly inhibited the pain behavior of mice in multiple pain models. In addition, this EM-1 analog was associated with reduced tolerance, less effect on gastrointestinal mobility, and no significant motor impairment. Compared to natural EMs, the EM analogs synthesized herein had enhanced metabolic stability, bioavailability, and analgesic properties.

4-Aryl-1-oxa-4,9-diazaspiro[5.5]undecane Derivatives as Dual μ-Opioid Receptor Agonists and σ1 Receptor Antagonists for the Treatment of Pain

The synthesis and pharmacological activity of a new series of 1-oxa-4,9-diazaspiro[5.5]undecane derivatives as potent dual ligands for the sigma-1 receptor (σ1R) and the μ-opioid receptor (MOR) are reported. The different positions of the central scaffold, designed using a merging strategy of both target pharmacophores, were explored using a versatile synthetic approach. Phenethyl derivatives in position 9, substituted pyridyl moieties in position 4 and small alkyl groups in position 2 provided the best profiles. One of the best compounds, 15au, showed a balanced dual profile (i.e., MOR agonism and sigma antagonism) and a potent analgesic activity, comparable to the MOR agonist oxycodone in the paw pressure test in mice. Contrary to oxycodone, as expected from the addition of σ1R antagonism, 15au showed local, peripheral activity in this test, which was reversed by the σ1R agonist PRE-084. At equianalgesic doses, 15au showed less constipation than oxycodone, providing evidence that dual MOR agonism and σ1R antagonism may be a useful strategy for obtaining potent and safer analgesics.

Turning Pain into Gain: Evaluation of a Multidisciplinary Chronic Pain Management Program in Primary Care

Objective

To measure the impact of the multidisciplinary Turning Pain Into Gain program in people experiencing chronic pain of any etiology.

Methods

A mixed-methods observational study of 252 participants was used to explore the impact of Turning Pain Into Gain on medication use; quality of life and functioning, as measured by the Pain Self-Efficacy Questionnaire; and self-reported hospitalizations between 2015 and 2016.

Results

Responses from 178 participants showed an increased alignment with Australian pain medication guidelines (e.g., a 7.3% reduction in paracetamol duplication was reported with a concurrent 5.1% rise in the administration of sustained-release paracetamol formulations); improved Pain Self-Efficacy Questionnaire scores from 23.1 (out of a possible score of 60) preprogram to 35.3 postprogram; and a reduction in self-reported hospitalizations from 50 cases in the 12 months preprogram to 11 cases in the 12 months postprogram.

Conclusions

Positive medication, Pain Self-Efficacy Questionnaire, and hospitalization changes provide evidence for the broader implementation of similar patient-centered programs to promote more holistic management of diverse types of chronic pain in primary care. Reduced hospitalization reflects potential for this intervention to be cost-effective, which could be investigated further.

Cannabis and Cannabinoids in the Treatment of Rheumatic Diseases

Chronic pain is a common complaint among patients, and rheumatic diseases are a common cause for chronic pain. Current pharmacological interventions for chronic pain are not always useful or safe enough for long-term use. Cannabis and cannabinoids are currently being studied due to their potential as analgesics. In this review we will discuss current literature regarding cannabinoids and cannabis as treatment for rheumatic diseases. Fibromyalgia is a prevalent rheumatic disease that causes diffuse pain, fatigue, and sleep disturbances. Treatment of this syndrome is symptomatic, and it has been suggested that cannabis and cannabinoids could potentially alleviate some of the symptoms associated with fibromyalgia. In this review we cite some of the evidence that supports this claim. However, data on long-term efficacy and safety of cannabinoid and cannabis use are still lacking. Cannabinoids and cannabis are commonly investigated as analgesic agents, but in recent years more evidence has accumulated on their potential immune-modulatory effect, supported by results in animal models of certain rheumatic diseases. While results that demonstrate the same effect in humans are still lacking, cannabinoids and cannabis remain potential drugs to alleviate the pain associated with rheumatic diseases, as they were shown to be safe and to cause limited adverse effects.

Pain management for patients with chronic kidney disease in the primary care setting

Pain is routinely reported in patients with chronic kidney disease. Pain is often multifaceted, making the treatment of this complex patient population even more challenging. Understanding pain types as well as treatment options for this patient population is an important skillset for the primary care provider.

Are Processes in Acceptance & Commitment Therapy (ACT) Related to Chronic Pain Outcomes Within Individuals Over Time? An Exploratory Study Using n-of-1 Designs

Introduction

Acceptance & Commitment Therapy (ACT) explicitly postulates experiential avoidance (EA) and values-based living (VBL) as essential treatment processes. As outcomes from between-subject studies cannot readily be generalized to within-subject processes in individuals, we explored the unfolding of, and relationship between, EA and VBL and levels of pain interference in daily life and emotional well-being within individuals experiencing chronic pain.

Methods

Using n-of-1 designs, three participants following a multidisciplinary treatment program filled out a 12-item daily questionnaire (87-110 days). After multiple imputation of missing data, McKnight Time-series analysis procedures were performed for each participant separately. The interrelationships of EA, VBL and pain intensity, and the relationship of EA and VBL beyond pain intensity with both chronic pain outcomes were assessed both concurrently (same day) and prospectively (consecutive days).

Results

Both EA and VBL were associated with at least one of five outcome variables (four domains of pain interference and emotional well-being) beyond pain intensity in two participants, but not in the third participant. These associations primarily existed for concurrent, but not consecutive, days. In contrast to VBL, EA was not associated with emotional well-being for any of the three participants.

Conclusions

Although the finding that ACT-processes were associated with pain outcomes on concurrent days is consistent with ACT theory, the absence of such associations on consecutive days means that alternative explanations cannot be rule out. One possibility is that pain interference fluctuates within days at a higher variability rate than was currently assessed. Future research should consider using a higher measurement frequency to be able to grasp time-lagged effects.

'A lifebuoy' and 'a waste of time': patients' varying experiences of multidisciplinary pain centre treatment- a qualitative study

Background

The recognition of chronic pain as a biopsychosocial phenomenon has led to the establishment of multidisciplinary pain treatment facilities, such as pain centres. Previous studies have focussed on inpatient, group-based or time-limited multidisciplinary pain programmes. The aim was to investigate variation in patients’ experiences of attending individual outpatient multidisciplinary treatment at pain centres in Norway.

Methods

This was a qualitative study using semi-structured individual interviews with 19 informants. The informants were recruited among persons who after referral by their general practitioners 12 months prior had attended multidisciplinary pain treatment at a pain centre. The data were analysed thematically using systematic text condensation.

Results

The informants had received different treatments at the pain centres. Some had undergone only one multidisciplinary assessment in which a physician, a psychologist and a physiotherapist had been present, whereas others had initially been to a multidisciplinary assessment and then continued treatment by one or more of the professionals at the centre. Their experiences ranged from the pain centre as being described as a lifebuoy by some informants who had attended treatment over time, to being described as a waste of time by others who had only attended one or two multidisciplinary sessions. Prominent experiences included being met with understanding and a perception of receiving the best possible treatment, but also included disappointment over not being offered any treatment and perceiving the multidisciplinary approach as unnecessary.

Conclusions

There were large variations in the informants’ experiences in the pain centres. The findings indicate that the pain centres’ multidisciplinary approach can represent a new approach to living with chronic pain but may also not provide anything new. Efforts should be devoted to ensuring that the pain centres’ multidisciplinary treatment approach is aligned with their patients’ actual needs.

Effectiveness of integrative medicine group visits in chronic pain and depressive symptoms: A randomized controlled trial

BACKGROUND

Current treatment options for chronic pain and depression are largely medication-based, which may cause adverse side effects. Integrative Medical Group Visits (IMGV) combines mindfulness techniques, evidence based integrative medicine, and medical group visits, and is a promising adjunct to medications, especially for diverse underserved patients who have limited access to non-pharmacological therapies.

OBJECTIVE

Determine the effectiveness of IMGV compared to a Primary Care Provider (PCP) visit in patients with chronic pain and depression.

DESIGN

9-week single-blind randomized control trial with a 12-week maintenance phase (intervention-medical groups; control-primary care provider visit).

SETTING

Academic tertiary safety-net hospital and 2 affiliated federally-qualified community health centers.

PARTICIPANTS

159 predominantly low income racially diverse adults with nonspecific chronic pain and depressive symptoms.

INTERVENTIONS

IMGV intervention- 9 weekly 2.5 hour in person IMGV sessions, 12 weeks on-line platform access followed by a final IMGV at 21 weeks.

MEASUREMENTS

Data collected at baseline, 9, and 21 weeks included primary outcomes depressive symptoms (Patient Health Questionnaire 9), pain (Brief Pain Inventory). Secondary outcomes included pain medication use and utilization.

RESULTS

There were no differences in pain or depression at any time point. At 9 weeks, the IMGV group had fewer emergency department visits (RR 0.32, 95% CI: 0.12, 0.83) compared to controls. At 21 weeks, the IMGV group reported reduction in pain medication use (Odds Ratio: 0.42, CI: 0.18-0.98) compared to controls.

LIMITATIONS

Absence of treatment assignment concealment for patients and disproportionate group attendance in IMGV.

CONCLUSION

Results demonstrate that low-income racially diverse patients will attend medical group visits that focus on non-pharmacological techniques, however, in the attention to treat analysis there was no difference in average pain levels between the intervention and the control group.

TRIAL REGISTRATION

clinicaltrials.gov NCT02262377.

Psychological Subgrouping to Assess the Risk for the Development or Maintenance of Chronic Musculoskeletal Pain: Is This the Way Forward?

BACKGROUND

Because musculoskeletal pain problems are so prevalent, new methods of evaluating and treating patients are needed to increase effectiveness. Subgrouping is a method wherein patients are classified into defined groups on the basis of psychosocial factors with the expectation of more specific and tailored treatments can be prescribed for them. For those seeking care for a new episode, the risk of developing chronic pain-related disability is assessed, whereas, for those with existing pain, the risk for the maintenance of the chronic pain problem is evaluated.

AIM

The purpose of this narrative review is to examine how patients are classified into subgroups with regard to methods of evaluation and to ascertain whether subgrouping actually facilitates treatment.

RESULTS

For the development of disability, screening tools, for example, the Örebro Musculoskeletal Pain Screening Questionnaire, accurately stratify patients into groups (eg, high, medium, low risk) that predict future pain-related work disability. In addition, several studies show that treatments that directly key in on risk groups enjoy enhanced outcomes compared with treatment as usual. For the maintenance of chronic musculoskeletal pain problems, there are several instruments that classify patients into specific groups or profiles, for example, on the basis of the avoidance and endurance model or the International Classification of Functioning, Disability and Health (ICF) assessment. Although some evidence shows that these classifications are related to treatment outcome, we found no study that directly tested a system for providing treatment matched to the subgrouping for maintenance.

CONCLUSIONS

We conclude that it is possible to reliably subgroup patients with musculoskeletal problems. Likewise, treatments that address the risk factors in the screening procedure may enhance outcomes compared with treatment as usual. More work is needed, however, to better understand the mechanism, so that assessment methods can be improved, and treatment specific to subgroups can be developed and evaluated.

Understanding Physiotherapists' Intention to Counsel Clients with Chronic Pain on Exercise: A Focus on Psychosocial Factors

Purpose: Twenty percent of Canadians experience chronic pain. Exercise is an effective management strategy, yet participation levels are low. Physiotherapists can be key to counselling clients to engage in long-term unsupervised exercise. Yet, investigations that identify psychosocial factors related to physiotherapists' intention to counsel are lacking. The purpose of this study was to examine whether physiotherapists' knowledge of chronic pain, beliefs about pain, and self-efficacy to counsel on exercise predicted their intention to counsel clients with chronic pain on exercise. Method: Practicing physiotherapists (N = 64) completed an online survey that assessed their knowledge of chronic pain, beliefs about pain, self-efficacy, and intention to counsel. A two-step hierarchical multiple regression predicted intention. Step 1 controlled for years of practice, and Step 2 included study variables significantly correlated with intention. Results: Beliefs about pain (r = -0.35, p < 0.01) and self-efficacy (r = 0.69, p < 0.01) were significantly correlated with intention. The overall regression model was significant, F _3,60 = 18.73; p < 0.001. Self-efficacy was the sole significant predictor, t ₆₀ = 5.71, p < 0.0001, sr ² = 28%. Conclusions: Self-efficacy may facilitate physiotherapists' intention to counsel on exercise for chronic pain. If shown to be a causal factor, interventions that target a change in physiotherapists' self-efficacy should be pursued.

Creating Value by Prioritizing Mental and Social Health After Injury

Given the strong influence of mental and social health on symptom intensity and magnitude of limitations, attempts to increase value in orthopedic trauma must attend to emotional and social recovery. Low value and potentially harmful interventions after trauma such as excessive reliance on medication, low value surgeries for "delayed healing" or "symptomatic implants," repeated visits with a physical therapist, and other biomedical interventions often reflect misdiagnosis and mismanagement of social and mental health. A better approach is to anticipate emotional and social recovery; to get social and mental health specialists involved immediately after injury; and to develop strategies that set firm limits on biomedical tests and treatments that are unlikely to contribute to health and risk reinforcing stress, distress, and less effective coping strategies.

Antinociceptive compounds and LC-DAD-ESIMSn profile from Dictyoloma vandellianum leaves

Limonoids, quinolone alkaloids and chromones have been reported as constituents of Dictyoloma vandellianum Adr. Juss. (Rutaceae). Although those compounds are known for their biological activities, only the anti-inflammatory activity of chromones isolated from the underground parts has been evaluated. There are no studies of the pharmacological properties of the aerial parts of D. vandellianum. The present study was carried out to determine the phytochemical profile and antinociceptive activity of the methanol extract, fractions and isolated compounds of leaves of D. vandellianum. The phytochemical profile was performed by HLPC-DAD-ESIMSⁿ and pure substances obtained were characterized by MS and NMR spectroscopy. The antinociceptive activity was assessed using the formalin assay in mice, and the motor function in the rotarod test. ME and all the fractions obtained from ME produced antinociceptive effects. Among them, the ethyl ether fraction was the most active. Data from HPLC-DAD-ESIMSⁿ showed that the ethyl ether fraction presented 42 compounds. The major compounds isolated from this fraction—gallic acid, methyl gallate and 1,2,6-tri-O-galloyl-β-d-glucopyranose–were tested and produced antinociceptive effects. Gallic acid, methyl gallate and 1,2,6-tri-O-galloyl-β-d-glucopyranose at antinociceptive doses did not affect the motor performance in mice in the rotarod test. This work is the first report of the occurrence of gallotanins in D. vandellianum. In addition, the pharmacological study showed that D. vandellianum leaves present antinociceptive activity, probably induced by gallic acid, methyl gallate and 1,2,6-tri-O-galloyl-β-d-glucopyranose.

Changes in inflammatory plasma proteins from patients with chronic pain associated with treatment in an interdisciplinary multimodal rehabilitation program – an explorative multivariate pilot study

It has been suggested that alterations in inflammation molecules maintain chronic pain although little is known about how these factors influence homeostatic and inflammatory events in common chronic pain conditions. Nonpharmacological interventions might be associated with alterations in inflammation markers in blood. This study of patients with chronic pain investigates whether an interdisciplinary multimodal rehabilitation program (IMMRP) was associated with significant alterations in the plasma pattern of 68 cytokines/chemokines 1 year after rehabilitation and whether such changes were associated with clinical changes. Blood samples and self-reports of pain, psychological distress, and physical activity of 25 complex chronic pain patients were collected pre-IMMRP and at 12-month follow-up. Analyses of inflammatory proteins (cytokines/chemokines/growth factors) were performed directly in plasma using the multiplex immunoassay technology Meso Scale Discovery. This explorative pilot study found that 12 substances, mainly pro-inflammatory, decreased after IMMRP. In two other relatively small IMMRP studies, four of these proinflammatory markers were also associated with decreases. The pattern of cytokines/chemokines pre-IMMRP was associated with changes in psychological distress but not with pain or physical activity. The present study cannot impute cause and effect. These results together with the results of the two previous IMMRP studies suggest that there is a need for larger and more strictly controlled studies of IMMRP with respect to inflammatory markers in blood. Such studies need to consider responders/non-responders, additional therapies, involved pain mechanisms and diagnoses. This and the two other studies open up for developing biologically measurable outcomes from plasma. Such biomarkers will be an important tool for further development of IMMRP and possibly other treatments for patients w ith chronic pain.

Spinal DN-9, a Peptidic Multifunctional Opioid/Neuropeptide FF Agonist Produced Potent Nontolerance Forming Analgesia With Limited Side Effects

The development of multitarget opioid drugs has emerged as an attractive therapeutic strategy to eliminate opioid-related side effects. Our previous study developed a series of opioid and neuropeptide FF pharmacophore-containing chimeric peptides, including DN-9 (Tyr-D.Ala-Gly-NMe.Phe-Gly-Pro-Gln-Arg-Phe-NH₂), which produced potent nontolerance forming analgesia at the supraspinal level. In the present study, the antinociceptive effects of DN-9 in a series of preclinical pain models and the potential side-effects were investigated at the spinal level in mice. In the tail-flick test, intrathecal injection of DN-9 produced potent analgesia with an ED₅₀ value at 1.33 pmol, and the spinal antinociception of DN-9 was mainly mediated by μ- and κ-opioid receptors. In addition, DN-9-induced spinal antinociception was augmented by the neuropeptide FF receptors antagonist. Furthermore, DN-9 could decrease both the frequency and amplitude of sEPSCs in lamina IIo neurons of the spinal cord, which were mediated by opioid receptors. In contrast to morphine, chronic intrathecal treatments with DN-9 did not induce analgesic tolerance, c-Fos expression or microglial activation. Intrathecal injection of DN-9 showed potent analgesia with antinociceptive ED₅₀ values between .66 and 55.04 pmol in different pain models, including the formalin test, acetic acid-induced writhing test, carrageenan-induced inflammatory pain and neuropathic pain. Moreover, DN-9 did not show side effects in locomotor function and coordination, gastrointestinal transit inhibition, the cardiovascular system, and body temperature regulation at antinociceptive doses. Taken together, the present study showed DN-9 produced effective, nontolerance forming analgesia with reduced side effects at the spinal level. DN-9 might be a promising compound for developing multifunctional opioid analgesics with limited adverse effects. PERSPECTIVE: This article presents the potent and nontolerance forming analgesia effects of DN-9 in a series of preclinical pain models with less opioid related adverse effects at the spinal level in mice. This study also demonstrates that DN-9 has translational potential into an intrathecal analgesic.

Key Push and Pull Factors Affecting Return to Work Identified by Patients With Long-Term Pain and General Practitioners in Sweden

Research shows that working is positive for people with long-term pain but that work-related support from health professionals is inadequate. One explanation for this inadequacy is that patients and providers differ in terms of perspectives on motivation to work. In this article, we compare factors that 31 patients and 15 general practitioners consider important to promote return to work for people with long-term pain. We analyzed the interviews with thematic analysis and a motivational push and pull framework to cover different motivational factors, societal and individual, that might push or pull patients from or toward work. Providers said that a difference between working and nonworking patients is their level of individual motivation, while the patients' stories showed that the main difference was the physical (non)ability to push themselves to work. We suggest that work-related support can be improved by addressing such differences in clinical practice.

Empathic Accuracy in Chronic Pain: Exploring Patient and Informal Caregiver Differences and Their Personality Correlates

Background and objectives: Social factors have demonstrated to affect pain intensity and quality of life of pain patients, such as social support or the attitudes and responses of the main informal caregiver. Similarly, pain has negative consequences on the patient’s social environment. However, it is still rare to include social factors in pain research and treatment. This study compares patient and caregivers’ accuracy, as well as explores personality and health correlates of empathic accuracy in patients and caregivers. Materials and Methods: The study comprised 292 chronic pain patients from the Pain Clinic of the Vall d’Hebron Hospital in Spain (main age = 59.4 years; 66.8% females) and their main informal caregivers (main age = 53.5 years; 51.0% females; 68.5% couples). Results: Patients were relatively inaccurate at estimating the interference of pain on their counterparts (t = 2.16; p = 0.032), while informal caregivers estimated well the patient’s status (all differences p > 0.05). Empathic accuracy on patient and caregiver status did not differ across types of relationship (i.e., couple or other; all differences p > 0.05). Sex differences in estimation only occurred for disagreement in pain severity, with female caregivers showing higher overestimation (t = 2.18; p = 0.030). Patients’ health status and caregivers’ personality were significant correlates of empathic accuracy. Overall, estimation was poorer when patients presented higher physical functioning. Similarly, caregiver had more difficulties in estimating the patient’s pain interference as patient general and mental health increased (r = 0.16, p = 0.008, and r = 0.15, p = 0.009, respectively). Caregiver openness was linked to a more accurate estimation of a patient’s status (r = 0.20, p < 0.001), while caregiver agreeableness was related to a patient’s greater accuracy of their caregivers’ pain interference (r = 0.15, p = 0.009). Conclusions: Patients poorly estimate the impact of their illness compared to caregivers, regardless of their relationship. Some personality characteristics in the caregiver and health outcomes in the patient are associated with empathic inaccuracy, which should guide clinicians when selecting who requires more active training on empathy in pain settings.

Virtual reality for management of pain in hospitalized patients: A randomized comparative effectiveness trial

Objectives

Therapeutic virtual reality (VR) has emerged as an effective, drug-free tool for pain management, but there is a lack of randomized, controlled data evaluating its effectiveness in hospitalized patients. We sought to measure the impact of on-demand VR versus “health and wellness” television programming for pain in hospitalized patients.

Methods

We performed a prospective, randomized, comparative effectiveness trial in hospitalized patients with an average pain score of ≥3 out of 10 points. Patients in the experimental group received a library of 21 VR experiences administered using the Samsung Gear Oculus headset; control patients viewed specialized television programming to promote health and wellness. Clinical staff followed usual care; study interventions were not protocolized. The primary outcome was patient-reported pain using a numeric rating scale, as recorded by nursing staff during usual care. Pre- and post-intervention pain scores were compared immediately after initial treatment and after 48- and 72-hours.

Results

There were 120 subjects (61 VR; 59 control). The mean within-subject difference in immediate pre- and post-intervention pain scores was larger in the VR group (-1.72 points; SD 3.56) than in the control group (-0.46 points; SD 3.01); this difference was significant in favor of VR (P < .04). When limited to the subgroup of patients with severe baseline pain (≥7 points), the effect of VR was more pronounced vs. control (-3.04, SD 3.75 vs. -0.93, SD 2.16 points; P = .02). In regression analyses adjusting for pre-intervention pain, time, age, gender, and type of pain, VR yielded a .59 (P = .03) and .56 (P = .04) point incremental reduction in pain versus control during the 48- and 72-hour post-intervention periods, respectively.

Conclusions

VR significantly reduces pain versus an active control condition in hospitalized patients. VR is most effective for severe pain. Future trials should evaluate standardized order sets that interpose VR as an early non-drug option for analgesia.

Short-Acting Opioids Are Associated with Comparable Analgesia to Long-Acting Opioids in Patients with Chronic Osteoarthritis with a Reduced Opioid Equivalence Dosing

Setting

There are no studies that exist within the primary care setting that address optimal opioid therapy in osteoarthritis patients. In light of the recently released US Centers for Disease Control and Prevention guidelines on opioid use in chronic noncancer pain, there is a pressing need to better characterize the effectiveness of long- and short-acting opioids.

Objective

To examine the effectiveness of short-acting opioids (SAO) vs long-acting opioids (LAO) and combination therapies (SAO and LAO) for treating chronic osteoarthritis pain in a retrospective trial.

Methods

Average and lowest pain scores approximately one to two weeks prior to patient appointments were collected and averaged for both SAO and LAO patients who were actively enrolled in a pain clinic at an academic medical center.

Results

There was no statistical difference between reported average and low pain scores for the SAO vs LAO groups (P = 0.201 and P = 0.296, respectively), although the SAO group on average had a significantly lower morphine equivalence (P < 0.001). Various covariates for both groups were tested in an adjusted model to look at trends in the use of nonopioid medications (i.e., acetaminophen, nonsteroidal anti-inflammatory drugs, antidepressants, and adjunct analgesic agents). No significant differences in pain scores existed when comparing covariates for the SAO vs LAO groups.

Conclusions

The study suggests that in addition to being effective, short-acting opioid medications may also provide a safer and cheaper alternative to long-acting opioid therapies in the treatment of chronic osteoarthritis.

Perspective

This article investigates the effectiveness of short-acting vs long-acting opioids for the treatment of chronic noncancer pain, specifically osteoarthritis. This information could potentially aid practitioners in primary care environments to design equally efficacious and less costly opioid regimens, while simultaneously enhancing patient safety.

Mind the Gaps: A Qualitative Study Combining Patients' and Nurses' Reflections on Pain Care

Chronic noncancer pain is a serious health problem, one that is often associated with physical debility and emotional suffering. Although chronic noncancer pain is one of the primary reasons that people seek medical care, a significant body of evidence indicates that chronic pain is underdiagnosed and undertreated. There is a consensus among professional stakeholders in pain care that there is a need to strengthen quality, capacity, and competence in pain management at all levels of health care. Thus, there is a need for more in-depth knowledge of both the recipients and the providers of pain care, and qualitative studies can contribute to this. The aim is to explore and combine the perspectives of patients receiving pain care and registered nurses providing care at pain clinics. A multimethod design was based on two qualitative studies consisting of semistructured interviews with patients receiving pain care (N = 10) and nurses providing pain care at pain clinics (N = 10). Qualitative content analysis was applied to interpret and abstract their experiences. The themes developed from triangulation revealed significant gaps between ideal pain care and actual practice: "Dissonance in reflections on personalized care," "A corresponding need for improved information flow in all levels," and "A corresponding need for improved structure in pain care." We suggest a stronger commitment to efficient information flow and person-centered communication to facilitate the patient involvement and self-management. In addition, more resources, education, and training are necessary to enable nurses and other professionals to act upon guidelines and ensure effective pain care.

A Randomized, Double-Blind, Placebo-Controlled, Prospective Clinical Trial Evaluating Water-Soluble Chicken Eggshell Membrane for Improvement in Joint Health in Adults with Knee Osteoarthritis

Osteoarthritis (OA) is a chronic condition that impacts quality of life and functionality for which consumers often seek dietary supplements to provide some relief. The purpose of this double-blind, placebo-controlled clinical trial was to assess the safety and efficacy of a water-soluble chicken eggshell membrane hydrosylate (WSEM) dietary supplement (BiovaFlex^®) 450 mg daily on knee function, mobility, and general health and well-being in 88 adults with OA randomized into intervention (n = 44) or placebo (n = 44) groups. Outcomes were assessed periodically over 12 weeks, including the Western Ontario McMaster Osteoarthritis Index (WOMAC), the six-minute walk test (6MWT), knee range of motion (ROM) testing, and safety. Normalized analysis (improvement over baseline) showed that the poorest initial performers benefited the greatest from the WSEM by day 5 in the 6MWT, with the rest of the population showing significant improvement over placebo by week 12. The normalized WOMAC Stiffness score was also significantly improved over placebo by day 5 (P < .05). Without normalization, no statistically significant improvements were seen in WOMAC, 6MWT, and ROM testing. The Product was also found to be safe in this study. In conclusion, daily consumption of WSEM significantly enhanced average individual physical capacity (walking distance and ability), reduced stiffness by the fifth day of supplementation with the greatest benefit seen by the most compromised individuals, and was maintained over 12 weeks. A WSEM dietary supplement may offer a safe option for relief from symptoms and increased mobility for those with OA.

Local anesthetics and regional anesthesia versus conventional analgesia for preventing persistent postoperative pain in adults and children: A Cochrane systematic review and meta-analysis update

BACKGROUND

Regional anesthesia may mitigate the risk of persistent postoperative pain (PPP). This Cochrane review, published originally in 2012, was updated in 2017.

METHODS

We updated our search of Cochrane CENTRAL, PubMed, EMBASE and CINAHL to December 2017. Only RCTs investigating local anesthetics (by any route) or regional anesthesia versus any combination of systemic (opioid or non-opioid) analgesia in adults or children, reporting any pain outcomes beyond three months were included. Data were extracted independently by at least two authors, who also appraised methodological quality with Cochrane 'Risk of bias' assessment and pooled data in surgical subgroups. We pooled studies across different follow-up intervals. As summary statistic, we reported the odds ratio (OR) with 95% confidence intervals and calculated the number needed to benefit (NNTB). We considered classical, Bayesian alternatives to our evidence synthesis. We explored heterogeneity and methodological bias.

RESULTS

40 new and seven ongoing studies, identified in this update, brought the total included RCTs to 63. We were only able to synthesize data from 39 studies enrolling 3027 participants in a balanced design. Evidence synthesis favored regional anesthesia for thoracotomy (OR 0.52 [0.32 to 0.84], moderate-quality evidence), breast cancer surgery (OR 0.43 [0.28 to 0.68], low-quality evidence), and cesarean section (OR 0.46, [0.28 to 0.78], moderate-quality evidence). Evidence synthesis favored continuous infusion of local anesthetic after breast cancer surgery (OR 0.24 [0.08 to 0.69], moderate-quality evidence), but was inconclusive after iliac crest bone graft harvesting (OR 0.20, [0.04 to 1.09], low-quality evidence).

CONCLUSIONS

Regional anesthesia reduces the risk of PPP. Small study size, performance, null, and attrition bias considerably weakened our conclusions. We cannot extrapolate to other interventions or to children.

Prolonged Perioperative Use of Pregabalin and Ketamine to Prevent Persistent Pain after Cardiac Surgery

Editor’s Perspective

What We Already Know about This Topic

What This Article Tells Us That Is New

Background

Persistent postsurgical pain is common and affects quality of life. The hypothesis was that use of pregabalin and ketamine would prevent persistent pain after cardiac surgery.

Methods

This randomized, double-blind, placebo-controlled trial was undertaken at two cardiac surgery centers in the United Kingdom. Adults without chronic pain and undergoing any elective cardiac surgery patients via sternotomy were randomly assigned to receive either usual care, pregabalin (150 mg preoperatively and twice daily for 14 postoperative days) alone, or pregabalin in combination with a 48-h postoperative infusion of intravenous ketamine at 0.1 mg · kg−1 · h−1. The primary endpoints were prevalence of clinically significant pain at 3 and 6 months after surgery, defined as a pain score on the numeric rating scale of 4 or higher (out of 10) after a functional assessment of three maximal coughs. The secondary outcomes included acute pain, opioid use, and safety measures, as well as long-term neuropathic pain, analgesic requirement, and quality of life.

Results

In total, 150 patients were randomized, with 17 withdrawals from treatment and 2 losses to follow-up but with data analyzed for all participants on an intention-to-treat basis. The prevalence of pain was lower at 3 postoperative months for pregabalin alone (6% [3 of 50]) and in combination with ketamine (2% [1 of 50]) compared to the control group (34% [17 of 50]; odds ratio = 0.126 [0.022 to 0.5], P = 0.0008; and 0.041 [0.0009 to 0.28], P &lt; 0.0001, respectively) and at 6 months for pregabalin alone (6% [3 of 50]) and in combination with ketamine 0% (0 of 5) compared to the control group (28% [14 of 50]; odds ratio = 0.167 [0.029 to 0.7], P = 0.006; and 0.000 [0 to 0.24], P &lt; 0.0001). Diplopia was more common in both active arms.

Conclusions

Preoperative administration of 150 mg of pregabalin and postoperative continuation twice daily for 14 days significantly lowered the prevalence of persistent pain after cardiac surgery.

Effect of antidepressant treatment on plasma levels of neuroinflammation-associated molecules in patients with somatic symptom disorder with predominant pain around the orofacial region

OBJECTIVE

Burning mouth syndrome (BMS) and atypical odontalgia (AO) are examples of somatic symptom disorders with predominant pain around the orofacial region. Neuroinflammation is thought to play a role in the mechanisms, but few studies have been conducted. We aimed to better understand the role of neuroinflammation in the pathophysiology and treatment of BMS/AO.

METHODS

Plasma levels of 28 neuroinflammation-related molecules were determined in 44 controls and 48 BMS/AO patients both pretreatment and 12-week post-treatment with duloxetine.

RESULTS

Baseline plasma levels of interleukin (IL)-1β (p < .0001), IL-1 receptor antagonist (p < .001), IL-6 (p < .0001), macrophage inflammatory protein-1β (p < .0001), and platelet-derived growth factor-bb (.04) were significantly higher in patients than in controls. Plasma levels of granulocyte macrophage colony stimulating factor were significantly higher in patients than in controls (p < .001) and decreased with treatment (.009). Plasma levels of eotaxin, monocyte chemoattractant protein-1, and vascular endothelial growth factor decreased significantly with treatment (p < .001, .022, and .029, respectively).

CONCLUSIONS

Inflammatory mechanisms may be involved in the pathophysiology and/or treatment response of somatic symptom disorders with predominant pain around the orofacial region.

Nerve injury drives a heightened state of vigilance and neuropathic sensitization in Drosophila

Injury can lead to devastating and often untreatable chronic pain. While acute pain perception (nociception) evolved more than 500 million years ago, virtually nothing is known about the molecular origin of chronic pain. Here we provide the first evidence that nerve injury leads to chronic neuropathic sensitization in insects. Mechanistically, peripheral nerve injury triggers a loss of central inhibition that drives escape circuit plasticity and neuropathic allodynia. At the molecular level, excitotoxic signaling within GABAergic (γ-aminobutyric acid) neurons required the acetylcholine receptor nAChRα1 and led to caspase-dependent death of GABAergic neurons. Conversely, disruption of GABA signaling was sufficient to trigger allodynia without injury. Last, we identified the conserved transcription factor twist as a critical downstream regulator driving GABAergic cell death and neuropathic allodynia. Together, we define how injury leads to allodynia in insects, and describe a primordial precursor to neuropathic pain may have been advantageous, protecting animals after serious injury.

Acceptance and commitment therapy for chronic pain: protocol of a systematic review and individual participant data meta-analysis

BACKGROUND

Acceptance and commitment therapy (ACT) can be effective in treating chronic pain. Despite evidence supporting the effectiveness of ACT, uncertainties remain regarding which subgroups in the chronic pain population are likely to benefit most and least. This protocol describes the application for two meta-analytic approaches, one at the level of individual participant data and the other at the level of aggregated data, from randomized controlled trials of ACT for chronic pain (ACT-CP-MA).

METHODS

We will systematically conduct literature searches in CENTRAL, MEDLINE, EMBASE, PsycINFO, and trial registers. Two reviewers will independently select studies for inclusion and data extraction. ACT-CP-MA will include randomized controlled trials with ACT for chronic pain compared to control conditions for adults (≥ 18 years) with chronic pain (> 3 months). We will invite the authors of all eligible trials to share individual participant data. Outcomes will include standardized measures of pain interference, pain intensity, depression, anxiety, health-related quality of life, participants' rating of overall improvement, and ACT-related process variables. Using the Cochrane Collaboration's tool and GRADE, reviewers will independently check for risk of bias, quality of evidence, and strength of recommendations. In the individual participant data meta-analysis, we will use a one-step approach where participants are clustered with studies and data from all studies are modeled simultaneously. For analyses, we will use mixed-effects models. Additionally, we will employ a meta-analysis with aggregate data and compare the results of both meta-analyses.

DISCUSSION

This collaborative meta-analysis of individual participant data from randomized controlled trials of ACT for chronic pain versus control conditions will demonstrate how the known benefits of ACT for chronic pain vary across different subtypes of the chronic pain population. The results of the meta-analyses will be based on a comprehensive search of multiple databases and will help to inform future clinical trials and decision-making on the use of ACT in chronic pain and improve the quality, design, and reporting of future trials in this field.

SYSTEMATIC REVIEW REGISTRATION

PROSPERO CRD42019120901.

Motivational Non-directive Resonance Breathing as a Treatment for Chronic Widespread Pain

Chronic widespread pain (CWP) is one of the most difficult pain conditions to treat due to an unknown etiology and a lack of innovative treatment design and effectiveness. Based upon preliminary findings within the fields of motivational psychology, integrative neuroscience, diaphragmatic breathing, and vagal nerve stimulation, we propose a new treatment intervention, motivational non-directive (ND) resonance breathing, as a means of reducing pain and suffering in patients with CWP. Motivational ND resonance breathing provides patients with a noninvasive means of potentially modulating five psychophysiological mechanisms imperative for endogenously treating pain and increasing overall quality of life.