Pain outcomes: a brief review of instruments and techniques

The effects of virtual reality neuroscience-based therapy on clinical and neuroimaging outcomes in patients with chronic back pain: a randomized clinical trial

ABSTRACT

Chronic pain remains poorly managed. The integration of immersive technologies (ie, virtual reality [VR]) with neuroscience-based principles may provide effective pain treatment by targeting cognitive and affective neural processes that maintain pain and therefore potentially changing neurobiological circuits associated with pain chronification and amplification. We tested the effectiveness of a novel VR neuroscience-based therapy (VRNT) to improve pain-related outcomes in n = 31 participants with chronic back pain, evaluated against usual care (waitlist control; n = 30) in a 2-arm randomized clinical trial ( NCT04468074) . We also conducted pre-treatment and post-treatment MRI to test whether VRNT affects brain networks previously linked to chronic pain and treatment effects. Compared with the control condition, VRNT led to significantly reduced pain intensity (g = 0.63) and pain interference (g = 0.84) at post-treatment vs pre-treatment, with effects persisting at 2-week follow-up. These improvements were partially mediated by reduced kinesiophobia and pain catastrophizing. Several secondary clinical outcomes were also improved by VRNT, including disability, quality of life, sleep, and fatigue. In addition, VRNT was associated with increases in dorsomedial prefrontal functional connectivity with the superior somatomotor, anterior prefrontal and visual cortices, and decreased white matter fractional anisotropy in the corpus callosum adjacent to the anterior cingulate, relative to the control condition. Thus, VRNT showed preliminary efficacy in significantly reducing pain and improving overall functioning, possibly through changes in somatosensory and prefrontal brain networks.

Electrical neuromodulation for the treatment of chronic pain: derivation of the intrinsic barriers, outcomes and considerations of the sustainability of implantable spinal cord stimulation therapies

INTRODUCTION

For over 60 years, spinal cord stimulation has endured as a therapy through innovation and novel developments. Current practice of neuromodulation requires proper patient selection, risk mitigation and use of innovation. However, there are tangible and intangible challenges in physiology, clinical science and within society.

AREAS COVERED

We provide a narrative discussion regarding novel topics in the field especially over the last decade. We highlight the challenges in the patient care setting including selection, as well as economic and socioeconomic challenges. Physician training challenges in neuromodulation is explored as well as other factors related to the use of neuromodulation such as novel indications and economics. We also discuss the concepts of technology and healthcare data.

EXPERT OPINION

Patient safety and durable outcomes are the mainstay goal for neuromodulation. Substantial work is needed to assimilate data for larger and more relevant studies reflecting a population. Big data and global interconnectivity efforts provide substantial opportunity to reinvent our scientific approach, data analysis and its management to maximize outcomes and minimize risk. As improvements in data analysis become the standard of innovation and physician training meets demand, we expect to see an expansion of novel indications and its use in broader cohorts.

Efficacy and safety of transcutaneous electrical acupoint stimulation for the management of primary dysmenorrhoea: protocol for a randomised controlled trial in China

INTRODUCTION

Primary dysmenorrhoea (PD) is a common menstrual concern with significant physical and psychosocial impacts. The effectiveness and safety of transcutaneous electrical acupoint stimulation (TEAS) in alleviating PD symptoms remain uncertain due to insufficient evidence. This single-centre, parallel, randomised controlled study intends to evaluate the efficacy and safety of TEAS for PD management.

METHODS AND ANALYSIS

60 participants aged 18-40 years diagnosed with moderate to severe PD will be recruited from Tai'an Hospital of Traditional Chinese Medicine (TCM) and randomly assigned to either a TEAS group or a TEAS-sham group (1:1). The TEAS group will undergo 12 sessions of TEAS treatment over two menstrual cycles, with 30 min per session, three sessions weekly. Participants in the TEAS-sham group will receive TEAS stimulation using identical devices and protocols but without current output. The primary outcome is the Visual Analogue Scale (VAS) for pain assessment. Secondary outcomes are Short-Form McGill Pain Questionnaire, total effective rate, uterine artery haemodynamics, prostaglandin and β-endorphin level, mental well-being and quality of life. Adverse events and their potential reasons and the use of analgesics will also be recorded.

ETHICS AND DISSEMINATION

This study was approved by the Medical Ethics Committee of Tai'an Hospital of TCM. Written informed consent will be obtained from each participant. The results will be submitted for publication in a peer-reviewed journal.

TRIAL REGISTRATION NUMBER

ChiCTR2300071686.

Does the Keele STarT MSK tool predict the risk of poor outcome in non-specific shoulder complaints in primary care in a Dutch population?

OBJECTIVES

The Keele STarT MSK tool is a questionnaire to identify the prognostic factors for musculoskeletal conditions, such as shoulder complaints, developed by Keele University, UK. This study assessed whether the Keele STarT MSK tool can predict the risk of poor outcome in non-specific shoulder complaints in a Dutch population.

DESIGN

Multicentre prospective cohort study.

SETTING

Fourteen primary care physiotherapy clinics in the Netherlands participated in this study.

PARTICIPANTS

In total, 180 patients with non-specific shoulder complaints with complete data from the Keele STarT MSK tool (baseline), Short-Form 12 Health Survey (SF-12), Shoulder Pain and Disability Index (SPADI), Numeric Pain Rating Score (NPRS) and Global Perceived Effect (GPE) scale at week 6, week 12 or endpoint were included. Data were collected from January 2019 to January 2020. Of these, 180 patients were eligible for the study. Of these, 139 completed the study and were included in the analysis.

MAIN OUTCOME MEASURES

Poor outcome was defined as: SF-12 score ≤33 (physical health), SPADI score ≥30% (disability in activity), NPRS score ≥3 (pain intensity) and GPE scale score ≥3 (patient-reported recovery).

RESULTS

The area under the receiver operating characteristic curves for prediction of outcome were excellent for the SF-12, acceptable for the SPADI and NPRS, and showed no discrimination for the GPE scale. The optimal cut-off value for the Keele STarT MSK score to discriminate between low and medium/high risk groups was ≥5.

CONCLUSIONS

The Keele STarT MSK tool is able to predict the risk of poor outcome in patients with non-specific shoulder complaints in primary care physiotherapy clinics. Further research is needed to establish whether stratified care (subgrouping and targeted treatment) is more efficient. CONTRIBUTION OF PAPER.

Use of CYP2D6 Inhibitors with CYP2D6 Opioids: Association with Emergency Department Visits for Pain

Hydrocodone, tramadol, codeine, and oxycodone are commonly prescribed opioids that rely on activation by cytochrome P450 2D6 (CYP2D6). CYP2D6 inhibitors can significantly decrease CYP2D6 activity, leading to reduced generation of active metabolites, and impairing pain control. To understand this impact, we assessed emergency department (ED) visits in patients initiating these CYP2D6-dependent opioids while on CYP2D6-inhibitor antidepressants vs. antidepressants that do not inhibit CYP2D6. This retrospective cohort study included adult patients prescribed CYP2D6-dependent opioids utilizing electronic health records data from the University of Florida Health (2015-2021). The association between ED visits and inhibitor exposure was tested using multivariable logistic regression. The primary analysis had 12,118 patients (72% female; mean (SD) age, 55 (13.4)) in the hydrocodone/tramadol/codeine cohort and 5,547 patients (64% female; mean (SD) age, 53.6 (14.2)) in the oxycodone cohort. Hydrocodone/tramadol/codeine-treated patients exposed to CYP2D6-inhibitor antidepressants (n = 7,043) had a higher crude rate of pain-related ED visits than those taking other antidepressants (n = 5,075) (3.28% vs. 1.87%), with an adjusted odds ratio (aOR) of 1.75 (95% CI: 1.36 to 2.24). Similarly, in the oxycodone cohort, CYP2D6-inhibitor antidepressant-exposed individuals (n = 3,206) had a higher crude rate of ED visits than individuals exposed to other antidepressants (n = 2,341) (5.02% vs. 3.37%), with aOR of 1.70 (95% CI: 1.27-2.27). Similar findings were observed in secondary and sensitivity analyses. Our findings suggest patients with concomitant use of hydrocodone/tramadol/codeine or oxycodone and CYP2D6 inhibitors have more frequent ED visits for pain, which may be due to inadequate pain control.

Application of Patient-Reported Outcome Measurements in Adult Tumor Clinical Trials in China: Cross-Sectional Study

BACKGROUND

International health policies and researchers have emphasized the value of evaluating patient-reported outcomes (PROs) in clinical studies. However, the characteristics of PROs in adult tumor clinical trials in China remain insufficiently elucidated.

OBJECTIVE

This study aims to assess the application and characteristics of PRO instruments as primary or secondary outcomes in adult randomized clinical trials related to tumors in China.

METHODS

This cross-sectional study identified tumor-focused randomized clinical trials conducted in China between January 1, 2010, and June 30, 2022. The ClinicalTrials.gov database and the Chinese Clinical Trial Registry were selected as the databases. Trials were classified into four groups based on the use of PRO instruments: (1) trials listing PRO instruments as primary outcomes, (2) trials listing PRO instruments as secondary outcomes, (3) trials listing PRO instruments as coprimary outcomes, and (4) trials without any mention of PRO instruments. Pertinent data, including study phase, settings, geographic regions, centers, participant demographics (age and sex), funding sources, intervention types, target diseases, and the names of PRO instruments, were extracted from these trials. The target diseases involved in the trials were grouped according to the American Joint Committee on Cancer Staging Manual, 8th Edition.

RESULTS

Among the 6445 trials examined, 2390 (37.08%) incorporated PRO instruments as part of their outcomes. Within this subset, 26.82% (641/2390) listed PRO instruments as primary outcomes, 52.72% (1260/2390) as secondary outcomes, and 20.46% (489/2390) as coprimary outcomes. Among the 2,155,306 participants included in these trials, PRO instruments were used to collect data from 613,648 (28.47%) patients as primary or secondary outcomes and from 74,287 (3.45%) patients as coprimary outcomes. The most common conditions explicitly using specified PRO instruments included thorax tumors (217/1280, 16.95%), breast tumors (176/1280, 13.75%), and lower gastrointestinal tract tumors (173/1280, 13.52%). Frequently used PRO instruments included the European Organisation for Research and Treatment of Cancer Quality of Life Core Questionnaire-30, the visual analog scale, the numeric rating scale, the Traditional Chinese Medicine Symptom Scale, and the Pittsburgh Sleep Quality Index.

CONCLUSIONS

Over recent years, the incorporation of PROs has demonstrated an upward trajectory in adult randomized clinical trials on tumors in China. Nonetheless, the infrequent measurement of the patient's voice remains noteworthy. Disease-specific PRO instruments should be more effectively incorporated into various tumor disease categories in clinical trials, and there is room for improvement in the inclusion of PRO instruments as clinical trial end points.

Focused Ultrasound Central Lateral Thalamotomy for the Treatment of Refractory Neuropathic Pain: Phase I Trial

BACKGROUND AND OBJECTIVES

Magnetic resonance-guided focused ultrasound (MRgFUS) central lateral thalamotomy (CLT) has not yet been validated for treating refractory neuropathic pain (NP). Our aim was to assess the safety and potential efficacy of MRgFUS CLT for refractory NP.

METHODS

In this prospective, nonrandomized, single-arm, investigator-initiated phase I trial, patients with NP for more than 6 months related to phantom limb pain, spinal cord injury, or radiculopathy/radicular injury and who had undergone at least one previous failed intervention were eligible. The main outcomes were safety profile and pain as assessed using the brief pain inventory, the pain disability index, and the numeric rating scale. Medication use and the functional connectivity of the default mode network (DMN) were also assessed.

RESULTS

Ten patients were enrolled, with nine achieving successful ablation. There were no serious adverse events and 12 mild/moderate severity events. The mean age was 50.9 years (SD: 12.7), and the mean symptom duration was 12.3 years (SD: 9.7). Among eight patients with a 1-year follow-up, the brief pain inventory decreased from 7.6 (SD: 1.1) to 3.8 (SD: 2.8), with a mean percent decrease of 46.3 (SD: 40.6) (paired t -test, P = .017). The mean pain disability index decreased from 43.0 (SD: 7.5) to 25.8 (SD: 16.8), with a mean percent decrease of 39.3 (SD: 41.6) ( P = .034). Numeric rating scale scores decreased from a mean of 7.2 (SD: 1.8) to 4.0 (SD: 2.8), with a mean percent decrease of 42.8 (SD: 37.8) ( P = .024). Patients with predominantly intermittent pain or with allodynia responded better than patients with continuous pain or without allodynia, respectively. Some patients decreased medication use. Resting-state functional connectivity changes were noted, from disruption of the DMN at baseline to reactivation of connectivity between DMN nodes at 3 months.

CONCLUSION

MRgFUS CLT is feasible and safe for refractory NP and has potential utility in reducing symptoms as measured by validated pain scales.

Clinical evidence for silver diamine fluoride to reduce dentine hypersensitivity: A systematic review

OBJECTIVE

To assess the clinical evidence for silver diamine fluoride (SDF) to reduce dentine hypersensitivity in adults.

METHODS

Two independent researchers searched the English literature in five databases (Scopus, PubMed, Web of Science, EMBASE and the Cochrane Library) up to 15th July 2023 for clinical trials investigating the desensitising effect of professionally applied SDF to manage dentine hypersensitivity in adults aged 18 or above at any follow-up period. The primary outcome was the change in dentine hypersensitivity between baseline and follow-up visits after SDF application regarding any validated pain outcome measures. The Cochrane guidelines were used for the risk of bias assessment.

RESULTS

Three hundred and thirty-one studies were identified, and four of them were finally included. Three of the included studies were rated as having a 'low risk' of bias. The SDF solution reduced dentine hypersensitivity in adults. The percentage reduction in dentine hypersensitivity ranged from 23 % to 56 % after a single application of SDF solution. Moreover, the SDF solution was more effective than potassium nitrate, potassium oxalate and glutaraldehyde plus hydroxyethyl methacrylate in reducing dentine hypersensitivity. Meta-analysis indicated a more significant reduction in visual analogue scales (1-10) by 1.35 (95 % CI:0.9-1.8; p<0.00001) after receiving the SDF application than controls.

CONCLUSION

The included clinical trials showed that SDF solution reduced dentine hypersensitivity in adults. However, clinical trials are few, and their protocol varied from one another. Further well-designed clinical trials should be conducted to provide more evidence on its use to manage dentine hypersensitivity.

CLINICAL SIGNIFICANCE

SDF is cleared as desensitizing agents by the US Food and Drug Administration to manage dentine hypersensitivity, which induces pain, limits food choice, and impacts the quality of life. Evidence from this systematic review informs clinicians and provides researchers insight for future research on SDF use for dentine hypersensitivity. THE INTERNATIONAL PROSPECTIVE REGISTER OF SYSTEMATIC REVIEWS (PROSPERO) REGISTRATION NUMBER: CRD42023462613.

The value-based healthcare approach to haemophilia: Development of outcome measures for the evaluation of care of people with haemophilia

INTRODUCTION

Considering the advances in haemophilia management and treatment observed in the last decades, a new set of value-based outcome indicators is needed to assess the quality of care and the impact of these medical innovations.

AIM

The Value-Based Healthcare in Haemophilia project aimed to define a set of clinical outcome indicators (COIs) and patient-reported outcome indicators (PROIs) to assess quality of care in haemophilia in high-income countries with a value-based approach to inform and guide the decision-making process.

METHODS

A Value-based healthcare approach based on the available literature, current guidelines and the involvement of a multidisciplinary group of experts was applied to generate a set of indicators to assess the quality of care of haemophilia.

RESULTS

A final list of three COIs and five PROIs was created and validated. The identified COIs focus on two domains: musculoskeletal health and function, and safety. The identified PROIs cover five domains: bleeding frequency, pain, mobility and physical activities, Health-Related Quality of Life and satisfaction. Finally, two composite outcomes, one based on COIs, and one based on PROIs, were proposed as synthetic outcome indicators of quality of care.

CONCLUSION

The presented standard set of health outcome indicators provides the basis for harmonised longitudinal and cross-sectional monitoring and comparison. The implementation of this value-based approach would enable a more robust assessment of quality of care in haemophilia, within a framework of continuous treatment improvements with potential added value for patients. Moreover, proposed COIs and PROIs should be reviewed and updated routinely.

Effect and safety profile of topical lidocaine on post-surgical neuropathic pain and quality of life: A systematic review and meta-analysis

STUDY OBJECTIVE

Post-surgical chronic pain with a neuropathic component is usually more severe and leads to worse quality of life. We conducted this systematic review to examine the evidence of topical lidocaine for post-surgical neuropathic pain.

DESIGN

Systematic review with meta-analysis.

SETTING

Published randomized controlled trials (RCTs) comparing topical lidocaine with placebo or no topical lidocaine for post-surgical neuropathic pain.

PATIENTS

Seven RCTs including 585 patients.

INTERVENTIONS

We systematically searched databases for randomized controlled trials (RCTs) investigating the effect and safety outcomes of topical lidocaine compared with placebo or no intervention.

MEASUREMENTS

We conducted meta-analyses to evaluate the effect of topical lidocaine on pain intensity, adverse events, and quality of life. Standardized mean difference (SMD) and relative risk (RR) with 95% CIs were effect measures for continuous and dichotomous outcomes, respectively. We assessed the risk of bias of included trials and the certainty of evidence for each outcome.

MAIN RESULTS

Our review included 7 studies with 585 participants. There is moderate certainty evidence that topical lidocaine may increase the likelihood of global pain relief, with a relative risk (RR) of 1.98 (95% confidence interval (CI): 1.04, 3.76; I2 = 70%, P = 0.04). Low certainty evidence suggested topical lidocaine may lead to more reduction in pain intensity (SMD: -0.70; 95% confidence interval: -1.46, 0.06; I2 = 93%, P = 0.07). High certainty evidence showed that topical lidocaine did not increase the adverse event risk (RR: 1.04; 95% CI: 0.93, 1.16; I2 = 0%, P = 0.51).

CONCLUSIONS

Topical lidocaine may lead to pain relief and is safe to use for patient with post-surgical pain, though its impact on quality of life is unclear. This review supports the use of topical lidocaine for patients with post-surgical pain, and reveals the evidence gap in topical lidocaine use. (Registration: PROSPERO CRD42021294100).

Methods for evaluating gait associated dynamic balance and coordination in rodents

Balance is the dynamic and unconscious control of the body's centre of mass to maintain postural equilibrium. Regulated by the vestibular system, head movement and acceleration are processed by the brain to adjust joints. Several conditions result in a loss of balance, including Alzheimer's Disease, Parkinson's Disease, Menière's Disease and cervical spondylosis, all of which are caused by damage to certain parts of the vestibular pathways. Studies about the impairment of the vestibular system are challenging to carry out in human trials due to smaller study sizes limiting applications of the results and a lacking understanding of the human balance control mechanism. In contrast, more controlled research can be performed in animal studies which have fewer confounding factors than human models and allow specific conditions that affect balance to be replicated. Balance control can be studied using rodent balance-related behavioural tests after spinal or brain lesions, such as the Basso, Beattie and Bresnahan (BBB) Locomotor Scale, Foot Fault Scoring System, Ledged Beam Test, Beam Walking Test, and Ladder Beam Test, which are discussed in this review article along with their advantages and disadvantages. These tests can be performed in preclinical rodent models of femoral nerve injury, stroke, spinal cord injury and neurodegenerative diseases.

Surgical Interventions Targeting the Nucleus Caudalis for Craniofacial Pain: A Systematic and Historical Review

INTRODUCTION

Craniofacial pain is a prevalent group of conditions, and when refractory to conventional treatments, it poses a significant burden. The last decade has seen a renewed interest in the multimodal management of pain. Interventions targeting the nucleus caudalis (NC) of the trigeminocervical complex have been available as a treatment option since the 1930s, yet evidence for efficacy remains limited.

MATERIALS AND METHODS

We present a systematic review of the literature providing a historical perspective on interventions targeting the NC leading up to the present. We examine the various intervention techniques, clinical indications, and procedural efficacy. A novel outcome-reporting scheme was devised to enable comparison among studies owing to historically variable reporting methods.

RESULTS

A review of the literature revealed 33 retrospective studies published over the last 80 years, reporting on 827 patients. The most common technique was the open NC dorsal root entry zone nucleotomy/tractotomy; however, there has been an emergence of novel approaches such as endoscopic and spinal cord stimulation in the last ten years. Regardless of intervention technique or preoperative diagnosis, 87% of patients showed improvement with treatment.

CONCLUSIONS

The literature surrounding NC intervention techniques is reviewed. Recent advancements and the wide range of craniofacial pain syndromes for which these interventions show potential efficacy are discussed. New and less invasive techniques continue to emerge as putative therapeutic options. However, prospective studies are lacking. Furthermore, the evidence supporting even well-established techniques remains of poor quality. Future work should be prospective, use standard outcome reporting, and address efficacy comparisons between intervention type and preoperative diagnosis.

Treatment of pain in length-dependent peripheral neuropathy with the use of spinal cord stimulation: a systematic review

BACKGROUND

Chronic intractable pain from peripheral neuropathy is a debilitating condition that might not respond to conventional medical management and pharmacotherapy. The primary objective of this systematic review was to assess change (or reduction) in pain intensity in patients with length-dependent peripheral neuropathy after spinal cord stimulation (SCS) therapy.

METHODS

This systematic review followed the Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) guidelines. The primary outcome was change (or reduction) in pain intensity after 12 months of SCS therapy compared with baseline in participants with length-dependent peripheral neuropathy. Secondary outcomes included change in pain intensity after 6 months and change in opioid consumption after 12 months. The Grading of Recommendations Assessment, Development, and Evaluation (GRADE) guidelines were used to appraise the quality of evidence.

RESULTS

Nineteen studies consisting of 376 participants who underwent SCS implantation met the inclusion criteria. Qualitative synthesis revealed that all eligible studies reported a significant improvement in pain intensity after 12 months of SCS therapy as compared with baseline. Mean differences with 95% confidence intervals were calculated for 4 studies, all of which achieved the minimal clinically important difference for change in pain intensity at 12 months. The GRADE quality of evidence for this outcome was appraised as very low quality.

CONCLUSION

This systematic review highlights that SCS could lead to significant improvement in pain intensity for length-dependent peripheral neuropathy, although future well-powered randomized controlled trials are warranted to increase the certainty of evidence in this finding.

STUDY REGISTRATION

PROSPERO (https://www.crd.york.ac.uk/PROSPERO/) ID: CRD42022377572.

The Use of Questionnaires in Pain Assessment during Orthodontic Treatments: A Narrative Review

Pain is a complex multidimensional feeling combined with sensorial and emotional features. The majority of patients undergoing orthodontic treatment report various degrees of pain, which is perceived as widely variable between individuals, even when the stimulus is the same. Orthodontic pain is considered the main cause of poor-quality outcomes, patients' dissatisfaction, and lack of collaboration up to the interruption of therapy. A deep understanding of pain and how it influences a patient's daily life is fundamental to establishing proper therapeutic procedures and obtaining the correct collaboration. Because of its multifaced and subjective nature, pain is a difficult dimension to measure. The use of questionnaires and their relative rating scales is actually considered the gold standard for pain assessment. Choosing the most appropriate instrument for recording self-reported pain depends on a patient's age and cognitive abilities. Although several such scales have been proposed, and a lot of them are applied, it remains uncertain which of these tools represents the standard and performs the most precise, universal, and predictable task. This review aims to give an overview of the aspects which describe pain, specifically the pain experienced during orthodontic treatment, the main tool to assess self-perceived pain in a better and more efficient way, the different indications for each of them, and their correlated advantages or disadvantages.

Daily Pain Prediction Using Smartphone Speech Recordings of Patients With Spine Disease

BACKGROUND

Pain evaluation remains largely subjective in neurosurgical practice, but machine learning provides the potential for objective pain assessment tools.

OBJECTIVE

To predict daily pain levels using speech recordings from personal smartphones of a cohort of patients with diagnosed neurological spine disease.

METHODS

Patients with spine disease were enrolled through a general neurosurgical clinic with approval from the institutional ethics committee. At-home pain surveys and speech recordings were administered at regular intervals through the Beiwe smartphone application. Praat audio features were extracted from the speech recordings to be used as input to a K-nearest neighbors (KNN) machine learning model. The pain scores were transformed from a 0 to 10 scale to low and high pain for better discriminative capacity.

RESULTS

A total of 60 patients were enrolled, and 384 observations were used to train and test the prediction model. Using the KNN prediction model, an accuracy of 71% with a positive predictive value of 0.71 was achieved in classifying pain intensity into high and low. The model showed 0.71 precision for high pain and 0.70 precision for low pain. Recall of high pain was 0.74, and recall of low pain was 0.67. The overall F1 score was 0.73.

CONCLUSION

Our study uses a KNN to model the relationship between speech features and pain levels collected from personal smartphones of patients with spine disease. The proposed model is a stepping stone for the development of objective pain assessment in neurosurgery clinical practice.

Treating hypersensitivity in older adults with silver diamine fluoride: A randomised clinical trial

OBJECTIVE

This study aimed to evaluate the desensitizing effect of topically applied 38% silver diamine fluoride (SDF) solution on the exposed root surface of hypersensitive teeth in older adults.

METHOD

This double-blind randomised clinical trial recruited healthy older adults with dentine hypersensitivity. A trained examiner tested the most hypersensitive tooth root surface with a blast of compressed cold air from a three-in-one syringe. The participants gave a sensitivity score (SS) in visual analogue scale from 0 (no pain) to 10 (agonizing) at the baseline visit. Then, they received 38% SDF or 5% potassium nitrate solution (control) as intervention on the root surface. After the intervention, they received a compressed cold air test and reported the SS again. The compressed cold air test followed by intervention was repeated at 4- and 8-week follow ups. The primary outcome was the reduction in SS at 8-week follow-up with reference to the SS at baseline before intervention. Shapiro-Wilk and Mann-Whitney U tests were performed for data analysis following a normality test of SS.

RESULTS

This trial recruited 148 participants, and 139 (94%) participants completed the trial. The median percentage reductions in SS in the SDF and potassium nitrate groups were 60% and 50%, respectively (p < 0.001).

CONCLUSION

According to the results, 38% SDF solution reduced hypersensitivity on the exposed root surface of older adults. In addition, 38% SDF was more effective than 5% potassium nitrate solution to reduce hypersensitivity on the exposed root surface of older adults.

CLINICAL SIGNIFICANCE

Dentin hypersensitivity is common amongst older adults and negatively affects their quality of life. To date, there is no gold standard professionally applied desensitizing therapy in treating hypersensitivity. Evidence from this clinical trial could aid clinical practice and improve oral health in older adults.

TRIAL REGISTRATION

This study was registered at ClinicalTrials.gov (NCT05392868).

The Effects of Virtual Reality Neuroscience-based Therapy on Clinical and Neuroimaging Outcomes in Patients with Chronic Back Pain: A Randomized Clinical Trial

Chronic pain remains poorly managed. The integration of innovative immersive technologies (i.e., virtual reality (VR)) with recent neuroscience-based principles that position the brain as the key organ of chronic pain may provide a more effective pain treatment than traditional behavioral therapies. By targeting cognitive and affective processes that maintain pain and potentially directly changing neurobiological circuits associated with pain chronification and amplification, VR-based pain treatment has the potential for significant and long-lasting pain relief. We tested the effectiveness of a novel VR neuroscience-based therapy (VRNT) to improve pain-related outcomes in n = 31 participants with chronic back pain, evaluated against usual care (n = 30) in a 2-arm randomized clinical trial ( NCT04468074) . We also conducted pre- and post-treatment MRI to test whether VRNT affects brain networks previously linked to chronic pain and treatment effects. Compared to the control condition, VRNT led to significantly reduced pain intensity (g = 0.63) and pain interference (g = 0.84) at post-treatment vs. pre-treatment, with effects persisting at 2-week follow-up. The improvements were partially mediated by reduced kinesiophobia and pain catastrophizing. Several secondary clinical outcomes were also improved, including disability, quality of life, sleep, and fatigue. In addition, VRNT was associated with modest increases in functional connectivity of the somatomotor and default mode networks and decreased white matter fractional anisotropy in the corpus callosum adjacent to anterior cingula, relative to the control condition. This, VRNT showed preliminary efficacy in significantly reducing pain and improving overall functioning, possibly via changes in somatosensory and prefrontal brain networks.

Comparison of the effectiveness of eHealth self-management interventions for pain between oncological and musculoskeletal populations: a systematic review with narrative synthesis

OBJECTIVES

The aim of this systematic review is to compare the effectiveness of eHealth self-management interventions on pain intensity between oncological and musculoskeletal populations and to examine barriers and facilitators of the use of eHealth self-management tools.

CONTENT

In March 2021, a systematic search of the literature was conducted using the databases PubMed and Web of Science. Studies that investigated the effect of eHealth self-management interventions on pain intensity in an oncological and/or a musculoskeletal population were included.

SUMMARY

No study was found with a direct comparison of the two populations. Of the ten included studies, only one (musculoskeletal) found a significant interaction effect in favor of the eHealth program and three (musculoskeletal and breast cancer) showed a significant time-effect of the eHealth intervention. In both populations user-friendliness of the tool was considered as a facilitator, the length of the program and the lack of an in-person session as barrier. Due to the absence of a direct comparison, no conclusion can be made on how the effectiveness differs between both populations.

OUTLOOK

Further research should incorporate patient-experienced barriers and facilitators and there is a high need of studies making the direct comparison of the effect of an eHealth self-management intervention on pain intensity in an oncological vs. a MSK population.

Comparison of dental anesthetic efficacy between the periodontal intraligamentary anesthesia and other infiltration anesthesia: a systematic review and meta-analysis

Background

Uncertainty exists regarding the pain scores and the success rate of intraligamentary anesthesia compared to other infiltration anesthesia. Based on the conditions of clinical anesthesia techniques, we conducted a systematic review and meta-analysis to compare the efficacy of intraligamentary anesthesia with other infiltration anesthesia.

Methods

The search was carried out in PubMed Central, Cochrane Central Register of Controlled Trials, MEDLINE (via OVID), Embase (via OVID), and Scopus from the inception to March 26, 2023.

Results

Seven eligible randomized controlled trials were included in the meta-analysis. The results indicated no significant difference in the success rate (RR = 0.96; 95% CI [0.81-1.14]; p = 0.65; I²= 73%) and visual analog scale (VAS) during dental procedures (MD = 3.81; 95% CI [-0.54-8.16]; p = 0.09; I²= 97%) between intraligamentary anesthesia and other infiltration anesthesia. However, intraligamentary anesthesia exhibited a higher VAS score during injection than other infiltration anesthesia (MD = 8.83; 95% CI [4.86-12.79]; p < 0.0001; I²= 90%). A subgroup analysis according to infiltration techniques showed that supraperiosteal anesthesia had a lower VAS score during dental procedures than intraligamentary anesthesia.

Conclusions

Intraligamentary anesthesia and other infiltration anesthesias have the same success rate and pain during dental procedures. However, the pain during injection of intraligamentary anesthesia is heavier than that of other infiltration anesthesia.

Atlas-based finite element analyses with simpler constitutive models predict personalized progression of knee osteoarthritis: data from the osteoarthritis initiative

New technologies are required to support a radical shift towards preventive healthcare. Here we focus on evaluating the possibility of finite element (FE) analysis-aided prevention of knee osteoarthritis (OA), a disease that affects 100 million citizens in the US and EU and this number is estimated to increase drastically. Current clinical methods to diagnose or predict joint health status relies on symptoms and tissue failures obtained from clinical imaging. In a joint with no detectable injuries, the diagnosis of the future health of the knee can be assumed to be very subjective. Quantitative approaches are therefore needed to assess the personalized risk for the onset and development of knee OA. FE analysis utilizing an atlas-based modeling approach has shown a preliminary capability for simulating subject-specific cartilage mechanical responses. However, it has been verified with a very limited subject number. Thus, the aim of this study is to verify the real capability of the atlas-based approach to simulate cartilage degeneration utilizing different material descriptions for cartilage. A fibril reinforced poroviscoelastic (FRPVE) material formulation was considered as state-of-the-art material behavior, since it has been preliminary validated against real clinical follow-up data. Simulated mechanical tissue responses and predicted cartilage degenerations within knee joint with FRPVE material were compared against simpler constitutive models for cartilage. The capability of the atlas-based modeling to offer a feasible approach with quantitative evaluation for the risk for the OA development (healthy vs osteoarthritic knee, p < 0.01, AUC ~ 0.7) was verified with 214 knees. Furthermore, the results suggest that accuracy for simulation of cartilage degeneration with simpler material models is similar to models using FPRVE materials if the material parameters are chosen properly.

The Effect of Aromatherapy with Citrus aurantium Aroma on Pain after Orthopedic Surgery: A Randomized Clinical Trial

Introduction

Postoperative pain is one of the most common physiological and psychological stress in patients that disrupts body function and can endanger patients' health. This study aims to determine the effect of aromatherapy with Citrus aurantium essential on pain after orthopedic surgery.

Methods

This randomized clinical trial was performed on 60 candidates for orthopedic surgery. Patients were selected through convenience sampling and divided into intervention and control groups through randomized block allocation. If the visual analogue scale (VAS) score was above 3, patients in the intervention group received aromatherapy with C. aurantium essential and the patients in the control group received a placebo (almond oil). VAS was used to measure pain. Data analysis was performed using independent t test, paired t test, and analysis of variance with repeated measures using SPSS software version 13.

Results

Mean (SD) of pain intensity after intervention in experimental and control groups within 4, 8, and 12 hours after surgery was 7.30 (1.23) vs. 7.90 (0.99), 5.30 (0.98) versus 5.53 (0.68) and 2.53 (0.9) vs. 3.60 (0.77) respectively. The findings indicated that there was a significant difference in mean pain intensity between the experimental and control groups at 4 and 12 hours after surgery. Use of analysis of variance with repeated measures test with taking into account the interaction of time and group also showed a significant difference in mean pain intensity between the two experimental and control groups.

Conclusion

Aromatherapy with Citrus aurantium essential can be effective in reducing mild to moderate pain after orthopedic surgery. Further studies are recommended to confirm this finding.

A systematic review of neurophysiological sensing for the assessment of acute pain

Pain is a complex and personal experience that presents diverse measurement challenges. Different sensing technologies can be used as a surrogate measure of pain to overcome these challenges. The objective of this review is to summarise and synthesise the published literature to: (a) identify relevant non-invasive physiological sensing technologies that can be used for the assessment of human pain, (b) describe the analytical tools used in artificial intelligence (AI) to decode pain data collected from sensing technologies, and (c) describe the main implications in the application of these technologies. A literature search was conducted in July 2022 to query PubMed, Web of Sciences, and Scopus. Papers published between January 2013 and July 2022 are considered. Forty-eight studies are included in this literature review. Two main sensing technologies (neurological and physiological) are identified in the literature. The sensing technologies and their modality (unimodal or multimodal) are presented. The literature provided numerous examples of how different analytical tools in AI have been applied to decode pain. This review identifies different non-invasive sensing technologies, their analytical tools, and the implications for their use. There are significant opportunities to leverage multimodal sensing and deep learning to improve accuracy of pain monitoring systems. This review also identifies the need for analyses and datasets that explore the inclusion of neural and physiological information together. Finally, challenges and opportunities for designing better systems for pain assessment are also presented.

Kinesio Taping as an Adjunct Therapy in Postoperative Care after Extraction of Impacted Third Lower Molars—A Randomized Pilot Study

Non-steroidal anti-inflammatory drugs (NSAIDs) are commonly administered according to protocol for the management of complications such as pain, swelling, and trismus following the removal of the third impacted lower molar; however, treatment with NSAIDs may result in multiple adverse effects. The aim of this study was to compare the effectiveness of kinesio taping (KT) and the use of NSAIDs in the treatment of postoperative complications after extraction of an impacted third lower molar. Material and methods: The study comprised a group of 30 patients, randomly divided into the test group (with KT, n = 15) or the control group (without KT, n = 15). The surgery was performed according to standard procedures. In the test group, KT was applied immediately after surgery. Pain, swelling, and trismus were assessed. The VAS scale was used to assess pain. Swelling was measured based on six reference points on the face using a tailor’s meter, and a caliper was used to measure the distance between the upper and lower medial incisors of the upper and lower teeth to determine the extent of trismus. Measurements were performed three times: on the day of the surgery, on the second day following the surgery, and on the 7th day after the surgery. Results: Pain intensity (day of procedures), maximum mouth opening (on the seventh day after the surgery), and the use of NSAIDs (day of surgery) were significantly lower (p < 0.05) in the test group than in the control group. Conclusions: Kinesio taping in addition to NSAIDs was found to be more effective than NSAIDs alone in increasing the degree of jaw opening, decreasing pain intensity, and reducing the non-steroid anti-inflammatory dosage in patients after impacted mandibular wisdom teeth surgery.

Prevalence of painful diabetic peripheral neuropathy in type 2 diabetes mellitus and diabetic peripheral neuropathy: A nationwide cross-sectional study in mainland China

AIM

The study aimed to assess the prevalence and risk factors of painful diabetic peripheral neuropathy (PDPN) in patients with type 2 diabetes mellitus (T2DM) and diabetic peripheral neuropathy (DPN) in mainland China.

METHODS

This nationwide cross-sectional study enrolled T2DM patients with DPN from 25 provinces in China between July 2017 and December 2017. The prevalence, characteristics, and risk factors of PDPN were analyzed.

RESULTS

Among 25,710 patients with T2DM and DPN, 14,699 (57.2%) had PDPN. The median age was 63 years old. Age over 40 years old, education level, hypertension, myocardial infarction, duration of diabetes of over five years, diabetic retinopathy and nephropathy, moderate total cholesterol, moderate and higher low-density lipoprotein (LDL) increased uric acid (UA) and decreased estimated glomerular filtration rate (eGFR) were independently associated with PDPN (all P < 0.05). Compared with low levels of C-peptide, moderate levels were independently associated with a higher risk of PDPN, while high levels were associated with a lower risk (all P < 0.001).

CONCLUSIONS

In mainland China, more than half of the patients with DPN have neuropathic pain. Patients with older age, lower education level, longer duration of diabetes, lower LDL, increased UA, decreased eGFR, and comorbidities had an increased risk of PDPN.

Evaluating Pain Behaviours: Widely Used Mechanical and Thermal Methods in Rodents

Globally, over 300 million surgical procedures are performed annually, with pain being one of the most common post-operative side effects. During the onset of injury, acute pain plays a protective role in alerting the individual to remove noxious stimuli, while long-lasting chronic pain without any physiological reason is detrimental to the recovery process. Hence, it created an urgent need to better understand the pain mechanism and explore therapeutic targets. Despite the hardship in performing human pain studies due to ethical considerations, clinically relevant rodent pain models provide an excellent opportunity to perform pain studies. Several neurobehavioural tests are used to assess the drug efficacy in rodents to determine avoidance behaviour latency and threshold. This review article provides a methodological overview of mechanical (i.e. von Frey, Mechanical Conflict System) and thermal (i.e. Hargreaves Assay, Hot and Cold Plate, Temperature Place Preference) tests to assess pain in clinically relevant pain rodent models. We further discussed the current modifications of those tests along with their use in literature, the impact of confounding variables, advantages and disadvantages.

Influence of body mass index on early post-operative functional outcomes after total knee arthroplasty: A prospective, clinical and observational study

Background/Purpose: The evidence on the influence of body mass index (BMI) on functional outcomes following total knee arthroplasty (TKA) is conflicting. This study assessed and compared the effect of BMI on early mobility and function after TKA. Methods: Adult patients with osteoarthritis (OA) or rheumatoid arthritis (RA) who received unilateral TKA were recruited and then divided into normal, overweight and obese groups. The pain and functional outcomes of pre/post-TKA were examined using visual analogue scale (VAS) and Lysholm Knee Scale (LKS), respectively. Results: At 3 and 6 weeks post-TKA, LKS score was significantly higher in normal BMI group compared to overweight and obese. Lower BMI gained early improvement in functional outcome than higher BMI groups. However, patients showed considerable functional improvement at 6 months post-TKA, regardless of BMI category. Conclusion: Although BMI levels influence postoperative early functional improvement in TKA patients, the functional benefits after TKA at 6 months were similar regardless of BMI class.

Effects of a Myofascial Technique on the Stiffness and Thickness of the Thoracolumbar Fascia and Lumbar Erector Spinae Muscles in Adults with Chronic Low Back Pain: A Randomized before-and-after Experimental Study

The thoracolumbar fascia (TLF) may be a pain generator, given its rich innervation. Structural and biomechanical changes have also been documented in adults with chronic non-specific low back pain (LBP). Myofascial techniques (MFTs) are commonly used in manual therapy and are hypothesized to reduce tissue stiffness and pain. However, evidence for these effects is limited. The objective of this study was to evaluate the immediate effects of a standardized MFT compared to a simulated MFT on: (1) the stiffness of the TLF and erector spinae muscles (shear-wave sonoelastography), (2) the thickness of the TLF (B-mode ultrasound), and (3) pain intensity (numerical rating scale). Forty-nine participants with chronic non-specific LBP were included in a randomized before-and-after experimental study. Outcome measures were collected before (T0) and immediately after the intervention (T1). Pain intensity was also assessed on day two (T2) and seven (T7). The MFT group showed a significant decrease in left erector spinae muscle stiffness and left TLF thickness compared to the simulated group. In addition, there was a significant reduction in pain intensity in the MFT group compared to the simulated group at T1 and T2. The results of this study suggest that MFT results in immediate tissue changes and transient pain reduction in patients with LBP.

Scoping review of early pain-related outcome domains and measurement instruments after degenerative lumbar spine surgery

BACKGROUND

Optimization of perioperative pain interventions in lumbar spine surgery could reduce the incidence of acute and persistent postoperative pain and opioid consumption. Standardization in early outcome measurement provides a solid foundation for future clinical and research practices and should be integrated in core outcome sets for long-term treatment outcome evaluations. This scoping review provides an overview of outcomes used when evaluating early perioperative pain interventions after lumbar spine surgery.

OBJECTIVES

To create an overview of outcome domains and measurement instruments previously used in research on perioperative pain management for degenerative lumbar spine surgery.

EVIDENCE REVIEW

A scoping review was performed to identify articles comprising outcome evaluations in adult patients who undergo degenerative lumbar spine surgery, mentioning perioperative pain interventions. 75 articles were included for review. Data on study characteristics, outcome domains and measurement instruments were extracted and structured using the three-tiered hierarchy of Porter.

FINDINGS

12 outcome domains were identified: pain intensity (93.3%), adverse events (76%), analgesic consumption (70.7%), length of stay (52%), patient satisfaction (24%), daily functioning (22.7%), (early) mobilization (22.7%), quality of life (12%), mortality (9.3%), quality of recovery (6.7%), physical function (4%), and quality of sleep (2.7%). 63 corresponding measurement instruments were found.

CONCLUSIONS

This review portrays an extensive overview of outcome measurements used in perioperative pain management in lumbar spine surgery. A lack of consensus on the set of indicators exists. This scoping review is a call for action to create consensus on how to evaluate perioperative pain interventions in degenerative lumbar spine surgery.

WWOM VII: Effectiveness of systemic pharmacotherapeutic interventions in the management of BMS: A systematic review and meta-analysis

OBJECTIVES

To determine the effectiveness of systemic pharmacotherapeutic interventions compared to placebo in burning mouth syndrome (BMS) randomized controlled trials (RCTs) based on the core outcome domains recommended by the Initiative on Methods, Measurement, and Pain Assessment in Clinical Trials (IMMPACT).

METHODS

A systematic literature review of RCTs, concerning systemic pharmacotherapeutic interventions for BMS, published from January 1994 through October 2019, and meta-analysis was performed.

RESULTS

Fourteen RCTs (n = 734 participants) were included. Of those, nine were eligible for the quantitative assessment due to the availability/homogeneity of data for at least one of the IMMPACT domains. Pain intensity was the only domain reported in all RCTs. Weighted mean changes in pain intensity, based on visual analogue scale (ΔVAS), were reported in three RCTs at 6 ± 2 weeks and only one RCT at 10+ weeks follow-ups. Quantitative assessment, based on ΔVAS, yielded very low evidence for the effectiveness of alpha-lipoic acid and clonazepam, low evidence for effectiveness of trazodone and melatonin, and moderate evidence for herbal compounds.

CONCLUSIONS

Based on the RCTs studied, variable levels of evidence exist that suggest that select pharmacological interventions are associated with improved symptoms. However, the underreporting of IMMPACT domains in BMS RCTs restricts the multidimensional assessment of systemic interventions outcomes. Standardized outcome measures need to be applied to future RCTs to improve understanding of intervention outcomes.

Exploring the Cross-cultural Acceptability of Digital Tools for Pain Self-reporting: Qualitative Study

BACKGROUND

Culture and ethnicity influence how people communicate about their pain. This makes it challenging to develop pain self-report tools that are acceptable across ethnic groups.

OBJECTIVE

We aimed to inform the development of cross-culturally acceptable digital pain self-report tools by better understanding the similarities and differences between ethnic groups in pain experiences and self-reporting needs.

METHODS

Three web-based workshops consisting of a focus group and a user requirement exercise with people who self-identified as being of Black African (n=6), South Asian (n=10), or White British (n=7) ethnicity were conducted.

RESULTS

Across ethnic groups, participants shared similar lived experiences and challenges in communicating their pain to health care professionals. However, there were differences in beliefs about the causes of pain, attitudes toward pain medication, and experiences of how stigma and gender norms influenced pain-reporting behavior. Despite these differences, they agreed on important aspects for pain self-report, but participants from non-White backgrounds had additional language requirements such as culturally appropriate pain terminologies to reduce self-reporting barriers.

CONCLUSIONS

To improve the cross-cultural acceptability and equity of digital pain self-report tools, future developments should address the differences among ethnic groups on pain perceptions and beliefs, factors influencing pain reporting behavior, and language requirements.

Eccentric exercise is more effective than other exercises in the treatment of mid-portion Achilles tendinopathy: systematic review and meta-analysis

Achilles tendinopathy (AT) is one of the most frequent overuse injuries in the ankle. The evidence base for its conservative management AT continues to evolve, but there is still a gap in the evidence for the efficacy of any modality of treatment in high-quality studies. This systematic review and meta-analysis investigated the efficacy of EE in improving pain and function in adult patients with mid-portion Achilles tendinopathy compared to other forms of exercise. A search was performed in PubMed, BIREME, SportDiscus, Cinahl, Web of Science and PEDro, in November 2022. The methodological quality was evaluated using the Risk of Bias 2 tool (RoB2) of the Cochrane collaboration, and the meta-analysis was performed using the Review Manager 5.1 program. 2024 articles were identified and eight fulfilled the inclusion criteria. RoB2 presented a final score with 62.5% of the studies presented "some concerns", and 37.5% (five and three articles, respectively) presenting "high risk" of bias. EE was effective for the managment of AT. The only variable for which a meta-analysis was possible was pain (five articles), analysed with the visual analogue scale/numerical visual scale. The mean difference (MD) in treatment effect using EE was - 1.21 (- 2.72 to - 0.30) with a 95% of confidence interval (CI), thus identifying a significant positive effect for the improvement of pain in patients with AT in whom EE was used. EE is effective in the management of AT. The meta-analysis shows the need for appropriately powered randomized controlled trials with better design, the use of standard outcome measures and well-planned protocols for conservative management of AT.Level of evidence: Level 1.Registration: CRD42018118016.

Heart rate variability is not suitable as surrogate marker for pain intensity in patients with chronic pain

ABSTRACT

The search towards more objective outcome measurements and consequently surrogate markers for pain started decades ago; however, no generally accepted biomarker for pain has qualified yet. The goal is to explore the value of heart rate variability (HRV) as surrogate marker for pain intensity chronic pain setting. Pain intensity scores and HRV were collected in 366 patients with chronic pain, through a cross-sectional multicenter study. Pain intensity was measured with both the Visual Analogue Scale and Numeric Rating Scale, while 16 statistical HRV parameters were derived. Canonical correlation analysis was performed to evaluate the correlation between the dependent pain variables and the HRV parameters. Surrogacy was determined for each HRV parameter with point estimates between 0 and 1 whereby values close to 1 indicate a strong association between the surrogate and the true endpoint at the patient level. Weak correlations were revealed between HRV parameters and pain intensity scores. The highest surrogacy point estimate was found for mean heart rate as marker for average pain intensity on the Numeric Rating Scale with point estimates of 0.0961 (95% CI from 0.0384 to 0.1537) and 0.0209 (95% CI from 0 to 0.05) for patients without medication use, and medication use respectively. This study indicated that HRV parameters as separate entities are no suitable surrogacy candidates for pain intensity, in a population of chronic pain patients. Further potential surrogate candidates and clinical robust true endpoints should be explored, in order to find a surrogate measure for the highly individual pain experience.

Lidocaine transdermal patches reduced pain intensity in neuropathic cancer patients already receiving opioid treatment

BACKGROUND

Limited efficacy has been observed when using opioids to treat neuropathic pain. Lidocaine patches reduce neuropathic pain in postherpetic neuralgia, but their benefits for cancer-related neuropathic pain remain unclear. This study aimed to investigate a treatment for cancer-related neuropathic pain.

METHODS

We conducted a prospective, open-label, single-arm study to assess the efficacy and safety of lidocaine transdermal patches in patients experiencing localized, superficial, neuropathic cancer pain. Terminal cancer patients already receiving opioid treatment participated in the 3-day study. The primary endpoint was pain intensity evaluated by the numerical rating scale (NRS). The secondary endpoints were the pain relief score and the quality of analgesic treatment.

RESULTS

The results showed a significant difference in the median NRS over 3 days (Kruskal-Wallis test, p < 0.0001). The median NRS pain intensity from Day 1 to Day 3 was 4.0 with 95% C.I. (3.3, 5.0), 3.0 (2.5, 3.5), and 2.6 (2.0, 3.0), respectively. The difference between the median NRS pain intensities of any 2 days was significant (Wilcoxon signed-rank test, p < 0.0001). The generalized estimating equation (GEE) estimation model showed significant differences between the NRS pain intensities on any 2 days. There was no significant difference in the pain relief score or the quality of analgesic treatment.

CONCLUSIONS

In this study, the 5% lidocaine transdermal patch reduced the NRS pain intensity in neuropathic cancer patients already receiving opioid treatment. Treatment of localized and superficial neuropathic pain caused by cancer was well tolerated and effective.

Comparison of adjuvant therapy with midazolam, paracetamol, tramadol, or magnesium sulfate during intravenous regional anesthesia with ropivacaine: A randomized clinical trial

Background

Intravenous (IV) regional anesthesia is an easy, safe, reliable, and efficient option for inducing anesthesia during surgeries but with tourniquet-related pain. This study aimed to evaluate midazolam, paracetamol, tramadol, and magnesium sulfate administration as adjuvants with ropivacaine on pain relief and hemodynamic changes in IV regional anesthesia.

Methods

A randomized, double-blind, placebo-controlled trial was conducted in subjects undergoing forearm surgery with IV regional anesthesia. The block randomization method was used to assign eligible participants to each of five study groups. Hemodynamic parameters were assessed before applying the tourniquet, at prespecified time points (5, 10, 15, and 20 min), then and every subsequent 10 min until surgery completion. A Visual Analog Scale was used to assess pain severity at baseline followed by every 15 min until completion of the surgery, and after tourniquet deflation every 30 min to 2 h, and at 6, 12, and 24 h postoperative. Data were analyzed using Chi-square and analysis of variance with repeated data testing.

Results

The shortest onset and the longest duration of sensory block were observed in the tramadol group and the shortest onset of motor block in the midazolam group (P < 0.001). Pain score was estimated to be significantly lower in the tramadol group at the time of tourniquet application and release, and 15 min to 12 h after tourniquet release (P < 0.05). In addition, the lowest dose of pethidine consumption was observed in the tramadol group (P < 0.001).

Conclusion

Tramadol appeared to be able to effectively relieve pain, shorten the onset of sensory block, prolong the duration of sensory block, and achieve the lowest consumption of pethidine.

Feasibility and Acceptability of the Pain Profile, a Clinical Questionnaire Aimed at Improving Pain Care

Purpose

Despite being one of the most common medical complaints, chronic pain is difficult to manage due to ineffective communication between providers and patients and time restraints during appointments. Patient-centered questionnaires have the potential to optimize communication by assessing a patient's pain history, prior treatments, and associated comorbidities to develop an effective treatment plan. This study aimed to analyze the feasibility and acceptability of a pre-visit clinical questionnaire aimed at improving communication and pain care.

Patients and Methods

The "Pain Profile" questionnaire was piloted across two specialty pain clinics in a large academic medical center. Patient and provider surveys were conducted with patients who completed the Pain Profile questionnaire and providers who use it in practice. Surveys consisted of multiple-choice and open-ended questions regarding the helpfulness, usability, and implementation of the questionnaire. Descriptive analyses of patient and provider surveys were conducted. Qualitative data were analyzed using matrix framework-based coding.

Results

A total of 171 patients and 32 clinical providers completed the feasibility and acceptability surveys. 77% of patients (N= 131) found the Pain Profile helpful in communicating their pain experiences and 69% of providers (N= 22) found it helpful in guiding clinical decisions. The section that assessed the impact of pain was rated most helpful by patients (4/5) while the open-ended section asking patients to describe their pain history was rated least helpful by patients and providers (3.7/5 and 4.1/5, respectively). Both patients and providers provided suggestions to future iterations of the Pain Profile, including the addition of opioid risk and mental health screening tools.

Conclusion

The Pain Profile questionnaire was feasible and acceptable in a pilot study at a large academic site. Future testing in a large-scale, fully powered trial is needed to assess the effectiveness of the Pain Profile in optimizing communication and pain management.

Percutaneous CT-Guided Cryoneurolysis of the Intercostobrachial Nerve for Management of Postmastectomy Pain Syndrome

PURPOSE

To evaluate the feasibility, safety, and efficacy of intercostobrachial nerve (ICBN) cryoneurolysis for pain control in patients with postmastectomy pain syndrome (PMPS).

MATERIALS AND METHODS

Fourteen patients with PMPS were prospectively enrolled into this clinical trial after a positive response to a diagnostic computed tomography (CT)-guided percutaneous block of the ICBN. Participants subsequently underwent CT-guided percutaneous cryoneurolysis of the same nerve and were observed on postprocedural Days 10, 90, and 180. Pain scores, quality-of-life measurements, and global impression of change values were recorded before the procedure and at each follow-up point using established validated outcome instruments.

RESULTS

Cryoneurolysis of the ICBN was technically successful in all 14 patients. The mean pain decreased significantly by 2.1 points at 10 days (P = .0451), by 2.4 points at 90 days (P = .0084), and by 2.9 points at 180 days (P = .0028) after cryoneurolysis. Pain interference with daily activities decreased significantly by 14.4 points after 10 days (P = .0161), by 16.2 points after 90 days (P = .0071), and by 20.7 points after 180 days (P = .0007). There were no procedure-related complications or adverse events.

CONCLUSIONS

Cryoneurolysis of the ICBN in patients with PMPS was technically feasible and safe and resulted in a significant decrease in postmastectomy pain for up to 6 months in this small cohort.

Hyaluronic Acid and Radiofrequency in Patients with Urogenital Atrophy and Vaginal Laxity

Vaginal laxity (VL) and genitourinary syndrome of menopause (GSM), as well as aesthetic changes in the vulvar skin, often occur together and cause physical, psychological, and functional problems for women and their partners. The current study evaluated the efficacy of a nonsurgical radiofrequency device (RF) procedure combined with hyaluronic acid (HA) injection into the skin of the labia majora on clinical, histological, and aesthetic levels. Twenty women with GSM and VL, aged between 36 and 72 (mean age 53.4), were treated with bipolar RF SECTUM, vaginal and vulvar application, as well as with a hyaluronic acid (HA) injection into the skin of the labia majora. The Vaginal Laxity Questionnaire (VLQ), Vaginal Health Index (VHI), and Female Sexual Function Index (FSFI) were used to examine the clinical effects of the operations. The Global Aesthetic Improvement Scale was utilized to measure patient satisfaction. On a histochemical level, the concentrations of elastin and collagen in the vaginal wall and vulvar skin were examined. Results: There was significantly higher patient satisfaction and a considerable clinical improvement across all areas of analysis. On the histochemical level, elastin and collagen fiber concentration increased after the treatment protocol both in the vulvar skin and in the vaginal wall: elastin in the vaginal wall, 11.4%, and in the vulvar skin, 61%; collagen in the vaginal wall, 26%, and in the vulvar skin, 27%. The current study demonstrated the efficacy and safety of this nonsurgical RF procedure combined with a hyaluronic acid (HA) injection into the skin of the labia majora on clinical, histochemical, and aesthetic levels.

What is measured by the composite, single-item pain/discomfort dimension of the EQ-5D-5L? An exploratory analysis

PURPOSE

This study examines the EQ-5D-5L pain/discomfort dimension by drawing comparisons with five other pain and discomfort items (pain severity, discomfort severity, pain frequency, discomfort frequency and pain interference) collected in the Australian psychometric study for the EQ Health and Wellbeing instrument.

METHODS

Participants, recruited via a market research company, completed an online survey. Methods of analyses included the assessment of descriptive statistics, variation in reporting patterns using chi-square tests and cross-tabulations, correlation analyses, ordered univariate logistic regression, and discriminatory power analyses (Shannon index (H') and Shannon Evenness index (J')).

RESULTS

Survey data from 514 participants were used. Compared with EQ-5D-5L pain/discomfort, there was a higher proportion of respondents reporting some level of impairment on at least one of the pain severity and discomfort severity items (74% versus 81%). Correlation with EQ-5D-5L pain/discomfort was strongest for pain severity (r = 0.83) and weakest for discomfort frequency (r = 0.41); the same inferences were drawn for predictive ability. Adding any additional pain or discomfort items to the EQ-5D-5L increased the absolute informativity (H') but not the relative informativity (J'). When replacing EQ-5D-5L pain/discomfort with separate pain and/or discomfort items - i.e., adding items to a modified 'EQ-4D-5L'-absolute informativity increased, while relative informativity increased only when pain interference and frequency-related items (independently or in combination) were added.

CONCLUSION

The EQ-5D-5L pain/discomfort dimension captures aspects of pain more than aspects of discomfort. Potential reasons include the absence of descriptors or because pain is mentioned first in the composite item.

Protocol for double-blind RCT of acupuncture for vulvodynia

Background

Vulvodynia, vulvar pain of unknown origin lasting at least 3 months, affects 7% of American women. Dyspareunia, its frequent companion, renders sexual intercourse virtually impossible. Although few therapies are efficacious and rapid pain relief is rarely possible, there have been no sham/placebo-controlled studies of acupuncture for vulvodynia. Aims are to: 1) determine efficacy of acupuncture for vulvodynia, 2) explore duration of the acupuncture effect.

Methods

In a pretest/posttest randomized controlled, double-blind (practitioner-patient) efficacy trial of a standardized acupuncture protocol, we will randomize 80 participants 1:1 to either penetrating needle or skin-touch placebo needle groups. Both types of needles are designed to blind both the acupuncturist and participant. Participants with vulvodynia will insert and remove a tampon as a standardized stimulus and complete primary measures of vulvar pain (pain intensity) and secondary measures of dyspareunia (Female Sexual Function Index, FSFI dyspareunia subscale score) and sexual function (FSFI total score) pretreatment, after the 10th acupuncture session, and pain measures weekly until return to pretest levels. Upon study completion control group participants will be offered 10 free real acupuncture sessions.

Discussion

This is the first multi-needle multi-session RCT using double-blind acupuncture needles as a reliable sham. We hypothesize that controlling for baseline, at posttest there will be statistically significant less vulvar pain and dyspareunia and more sexual function over five weeks in the penetrating needle group compared to the skin touch placebo group.

Conclusion

This study is responsive to the need for efficacious pain management for women with vulvodynia.ClinicalTrials.gov Identifier: NCT03364127.

Minced Autologous Chondral Fragments with Fibrin Glue as a Simple Promising One-Step Cartilage Repair Procedure: A Clinical and MRI Study at 12-Month Follow-Up

OBJECTIVE

The aim of this study was to investigate early radiological and clinical outcome of autologous minced cartilage treatment as a single-step treatment option in patients with a chondral or osteochondral lesion (OCL) in the knee.

DESIGN

Eighteen patients with an OCL in the knee were included. Cartilage from healthy-appearing loose bodies and/or the periphery of the defect were minced into small chips and sealed in the defect using fibrin glue. Preoperatively, and at 3 (n = 14) and 12 (n = 18) months follow-up, magnetic resonance imaging (MRI) was performed. The Magnetic Resonance Observation of Cartilage Repair Tissue (MOCART) 2.0 score was used to assess the cartilage repair tissue on MRI at 12 months. The International Knee Documentation Score, Knee Injury and Osteoarthritis Outcome Score, EuroQoL-5D, and Visual Analogue Scale pain were collected preoperatively and 12 months after surgery.

RESULTS

Three months postoperative, MRI showed complete defect filling in 11 out of 14 patients. Mean MOCART 2.0 score at 12 months was 65.0 ± 18.9 with higher scores for lateral femoral chondral lesions compared to medial femoral chondral lesions (75.8 ± 14.3, 52.5 ± 15.8 respectively, P = 0.02). Clinical and statistical significant improvements were observed in the patient-reported outcome measures at 12 months postoperatively compared to preoperatively.

CONCLUSION

Treatment of OCLs using the autologous minced cartilage procedure resulted in good cartilage repair measured by MOCART 2.0. Clinically relevant improvements were observed in the clinical scores. This study suggests autologous minced cartilage as a promising, single-step treatment for OCLs.

Analysis of Physiological Responses during Pain Induction

Pain is a complex phenomenon that arises from the interaction of multiple neuroanatomic and neurochemical systems with several cognitive and affective processes. Nowadays, the assessment of pain intensity still relies on the use of self-reports. However, recent research has shown a connection between the perception of pain and exacerbated stress response in the Autonomic Nervous System. As a result, there has been an increasing analysis of the use of autonomic reactivity with the objective to assess pain. In the present study, the methods include pre-processing, feature extraction, and feature analysis. For the purpose of understanding and characterizing physiological responses of pain, different physiological signals were, simultaneously, recorded while a pain-inducing protocol was performed. The obtained results, for the electrocardiogram (ECG), showed a statistically significant increase in the heart rate, during the painful period compared to non-painful periods. Additionally, heart rate variability features demonstrated a decrease in the Parasympathetic Nervous System influence. The features from the electromyogram (EMG) showed an increase in power and contraction force of the muscle during the pain induction task. Lastly, the electrodermal activity (EDA) showed an adjustment of the sudomotor activity, implying an increase in the Sympathetic Nervous System activity during the experience of pain.

What Should Be Considered When Assessing Hyperacusis? A Qualitative Analysis of Problems Reported by Hyperacusis Patients

Hyperacusis (decreased sound tolerance) is a prevalent complaint. Yet, to date, no research has qualitatively evaluated the types of problems experienced by adults with hyperacusis. Our service evaluation aims to determine the hyperacusis-related problem domains reported by patients and the degree to which these domains were reported together. Retrospective analysis was conducted on an anonymised clinical dataset from 306 patients who attended a UK tinnitus and hyperacusis treatment centre between 1994 and 2017. Conventional content analysis was used to categorise responses to the question 'Why is hyperacusis a problem?' into domains which were then subjected to a cluster analysis. Twenty-five problem domains were identified, of which 12 were further classified into three overarching categories. 'Fear', 'Reduced quality of life' and 'Physical reaction to sound' were most frequently reported problems. Cluster analysis revealed that 'Sleep difficulties' and 'Despondency', were commonly reported together. Adults with hyperacusis face many challenges in their everyday lives. The nature of these problems indicates the need to develop complex interventions and assessments to aid management of hyperacusis. Current hyperacusis questionnaires may be useful in identifying some problem domains, but further assessment thorough patient interviews is required to fully explore all potential problems and make informed decisions about treatment.

A comparative study between transcutaneous electrical nerve stimulation and pulsed electromagnetic field therapy in the management of post-herpetic neuralgia of the sciatic nerve

OBJECTIVES

To compare the efficacy of pulsed electromagnetic field therapy (PEMFT) versus transcutaneous electrical nerve stimulation (TENS) in the treatment of post-herpetic neuralgia of the sciatic nerve.

METHODS

A double-blinded randomized clinical study has included 56 patients (18 males and 38 females). Participants were randomly and equally assigned into 2 groups. Both groups received conventional physical therapy treatment. Moreover, group (A) has an additional TENS, and group (B) had PEMFT. Both modalities were applied once daily, 3 times a week for 20 minutes for 8 successive weeks. Visual analog scale (VAS) and carbamazepine intake (CMI) dose have been assessed before and after interventions.

RESULTS

There was a significant decrease in VAS and CMI post-treatment in group A and B compared with that pretreatment (P > .001). The percent decrease in VAS and CMI in group A were 72.44% and 69.47% respectively and that for group B was 68.95% and 67.94% respectively. The findings revealed a non-significant difference in VAS and CMI (P > .05) between groups. The Means of VAS and CMI were (2.4 ± 0.78, 204.5 ± 16.76 and 2.67 ± 0.9, 210.57 ± 16.5) in group A and group B respectively. The mean difference for VAS and CMI was (-0.27 and -6.07) between groups post-treatment respectively.

CONCLUSION

Both TENS and PEMFT were effective and nearly equivalent in improving the post-herpetic neuralgia of the sciatic nerve as measured by in VAS and CMI. Clinical recommendations should be highlighted to instigate the using of TENS and PEMFT in the management of post-herpetic neuralgia of the sciatic nerve.

Clinical outcomes and complications of peripheral nerve field stimulation in the management of refractory trigeminal pain: a systematic review and meta-analysis

OBJECTIVE

Peripheral nerve field stimulation (PNFS) is a tool in the armamentarium of treatment options for trigeminal pain. The efficacy of this modality in mitigating trigeminal pain remains unclear. The aim of this study was to examine the existing literature on PNFS and elucidate pain score outcomes associated with its use in patients with trigeminal pain.

METHODS

A systematic review and meta-analysis was performed in accordance with the PRISMA framework. The PubMed, Web of Science, and Scopus databases were queried on June 10, 2020. Studies reporting pain outcomes in more than 5 adult patients treated with PNFS for facial pain were included. The primary outcome of the study was the mean difference in the visual analog scale (VAS) score from the last follow-up to baseline, and it was analyzed by an inverse-variance, random-effect model. The risk of bias was assessed using the Newcastle-Ottawa Scale and a funnel plot.

RESULTS

Of the 4597 studies screened for inclusion, 46 relevant full-text articles were assessed for eligibility. Eleven observational cohort studies from the 46 articles were found to be eligible, and reported on a total of 109 patients. In 86% (94/109) of cases, trial stimulation was successful and followed by a permanent system implantation. VAS scores improved by 75% (mean difference 6.32/10 points, 95% CI 5.38-7.27 points) compared to baseline. Seventy-six percent (42/55) of patients became medication free or required lower doses of medications. The complication rate necessitating surgical revision was estimated at 32% per procedure.

CONCLUSIONS

These findings support the belief that PNFS provides effective, long-term pain control for trigeminal pain. Statistical heterogeneity was considerable across all studies. Future work should be aimed at conducting double-blind randomized controlled trials to determine the utility of PNFS for treating various forms of trigeminal pain for which limited therapeutic options exist.

Evaluation of Functional and Symptomatic Outcomes After Vitamin D3 Administration in Carpal Tunnel Syndrome With Hypovitaminosis D

BACKGROUND

Vitamin D deficiency is now recognized as an independent risk factor and is involved in the pathogenesis of carpal tunnel syndrome (CTS). The purpose of this study was to evaluate the effects of vitamin D3 supplementation on functional and symptomatic outcomes in CTS patients with vitamin D deficiency.

METHODS

This was a prospective, single-arm study with a pretreatment or posttreatment quasi-experimental design. Carpal tunnel syndrome patients with vitamin D deficiency were treated with vitamin D3 (60 000 IU/week) plus standard treatment for a period of 3 months. Carpal tunnel syndrome-related pain and functional and symptomatic outcomes were assessed at baseline and at 3 months posttreatment using the Visual Analogue Scale (VAS) and the Boston Carpal Tunnel Questionnaire, respectively, along with serum vitamin D.

RESULTS

A total of 42 patients were analyzed. At 3 months posttreatment, there was a significant reduction in the severity of pain (VAS score) from baseline (Z = -5.71, P < .001). Similarly, the functional and symptomatic outcomes (Boston symptoms severity scale [SSS] and Boston functional status scale [FSS] score) at 3 months posttreatment significantly improved in comparison with baseline (Boston SSS: Z = -5.66, P < .001; Boston FSS: Z = -5.68, P < .001).

CONCLUSIONS

Vitamin D3 supplementation was associated with improvement in functional and symptomatic outcomes and CTS-related pain in CTS with vitamin deficiency. However, further robust randomized controlled trials are warranted to validate the results.

Grimace scale, burrowing, and nest building for the assessment of post-surgical pain in mice and rats-A systematic review

Several studies suggested an informative value of behavioral and grimace scale parameters for the detection of pain. However, the robustness and reliability of the parameters as well as the current extent of implementation are still largely unknown. In this study, we aimed to systematically analyze the current evidence-base of grimace scale, burrowing, and nest building for the assessment of post-surgical pain in mice and rats. The following platforms were searched for relevant articles: PubMed, Embase via Ovid, and Web of Science. Only full peer-reviewed studies that describe the grimace scale, burrowing, and/or nest building as pain parameters in the post-surgical phase in mice and/or rats were included. Information about the study design, animal characteristics, intervention characteristics, and outcome measures was extracted from identified publications. In total, 74 papers were included in this review. The majority of studies have been conducted in young adult C57BL/6J mice and Sprague Dawley and Wistar rats. While there is an apparent lack of information about young animals, some studies that analyzed the grimace scale in aged rats were identified. The majority of studies focused on laparotomy-associated pain. Only limited information is available about other types of surgical interventions. While an impact of surgery and an influence of analgesia were rather consistently reported in studies focusing on grimace scales, the number of studies that assessed respective effects was rather low for nest building and burrowing. Moreover, controversial findings were evident for the impact of analgesics on post-surgical nest building activity. Regarding analgesia, a monotherapeutic approach was identified in the vast majority of studies with non-steroidal anti-inflammatory (NSAID) drugs and opioids being most commonly used. In conclusion, most evidence exists for grimace scales, which were more frequently used to assess post-surgical pain in rodents than the other behavioral parameters. However, our findings also point to relevant knowledge gaps concerning the post-surgical application in different strains, age levels, and following different surgical procedures. Future efforts are also necessary to directly compare the sensitivity and robustness of different readout parameters applied for the assessment of nest building and burrowing activities.

Impact of audible pops associated with spinal manipulation on perceived pain: a systematic review

OBJECTIVES

An audible pop is the sound that can derive from an adjustment in spinal manipulative therapy and is often seen as an indicator of a successful treatment. A review conducted in 1998 concluded that there was little scientific evidence to support any therapeutic benefit derived from the audible pop. Since then, research methods have evolved considerably creating opportunities for new evidence to emerge. It was therefore timely to review the evidence.

METHODS

The following electronic databases were searched for relevant studies pertaining to the impact of audible pops in spinal manipulative therapy: PubMed, Index to Chiropractic Literature (ICL), Cumulative Index to Nursing & Allied Health Literature (CINAHL) and Web-of-Science. The main outcome was pain. Two reviewers independently selected studies, extracted data, and assessed risk of bias and quality of the evidence using the Downs and Black checklist. Results of the included literature were synthesized into a systematic review.

RESULTS

Five original research articles were included in the review, of which four were prospective cohort studies and one a randomized controlled trial. All studies reported similar results: regardless of the area of the spine manipulated or follow-up time, there was no evidence of improved pain outcomes associated with an audible pop. One study even reported a hypoalgesic effect to external pain stimuli after spinal manipulation, regardless of an audible pop.

CONCLUSIONS

Whilst there is still no consensus among chiropractors on the association of an audible pop and pain outcomes in spinal manipulative therapy, knowledge about the audible pop has advanced. This review suggests that the presence or absence of an audible pop may not be important regarding pain outcomes with spinal manipulation.