Assessment of Chronic Pain: Domains, Methods, and Mechanisms

A novel isoquinoline alkaloid HJ-69 isolated from Zanthoxylum bungeanum attenuates inflammatory pain by inhibiting voltage-gated sodium and potassium channels

ETHNOPHARMACOLOGY RELEVANCE

Zanthoxylum bungeanum Maxim. (Z. bungeanum), a member of the Rutaceae family, has a rich history of traditional use in Asia for treating arthritis and toothache conditions. As characteristic chemical components, numerous kinds of alkaloids have been extracted from plants and their diverse biological activities have been reported. However, research on the isoquinoline alkaloid, a specific type of alkaloids, in Z. bungeanum was scarce.

AIM OF THE STUDY

The study aimed to isolate a novel isoquinoline alkaloid from Z. bungeanum and explore its pharmacological activity in vitro and analgesic activity in vivo.

MATERIALS AND METHODS

Isoquinoline alkaloid isolation and identification from Z. bungeanum were conducted using chromatographic and spectroscopic methods. The whole-cell patch-clamp technique was applied to assess its impact on neuronal excitability, and endogenous voltage-gated potassium (Kv) and sodium (Nav) currents in acutely isolated mouse small-diameter dorsal root ganglion (DRG) neurons. Its inhibitory impacts on channels were further validated with HEK293 cells stably expressing Nav1.7 and Nav1.8, and Chinese hamster ovary (CHO) cells transiently expressing Kv2.1. The formalin inflammatory pain model was utilized to evaluate the potential analgesic activity in vivo.

RESULTS

A novel isoquinoline alkaloid named HJ-69 (N-13-(3-methoxyprop-1-yl)rutaecarpine) was isolated and identified from Z. bungeanum for the first time. HJ-69 significantly suppressed the firing frequency and amplitudes of action potentials in DRG neurons. Consistently, it state-dependently inhibited endogenous Nav currents of DRG neurons, with half maximal inhibitory concentration (IC50) values of 13.06 ± 2.06 μM and 30.19 ± 2.07 μM for the inactivated and resting states, respectively. HJ-69 significantly suppressed potassium currents in DRG neurons, which notably inhibited the delayed rectifier potassium (IK) currents (IC50 = 6.95 ± 1.29 μM) and slightly affected the transient outward potassium (IA) currents (IC50 = 523.50 ± 39.16 μM). Furtherly, HJ-69 exhibited similar potencies on heterologously expressed Nav1.7, Nav1.8, and Kv2.1 channels, which correspondingly represent the main components in neurons. Notably, intraperitoneal administration of 30 mg/kg and 100 mg/kg HJ-69 significantly alleviated pain behaviors in the mouse inflammatory pain model induced by formalin.

CONCLUSION

The study concluded that HJ-69 is a novel and active isoquinoline alkaloid, and the inhibition of Nav and Kv channels contributes to its analgesic activity. HJ-69 may be a promising prototype for future analgesic drug discovery based on the isoquinoline alkaloid.

Unpacking the relationship between Big Five personality traits and experimental pain: A systematic review and meta-analysis

Pain is essential for survival, but individual responses to painful stimuli vary, representing a complex interplay between sensory, cognitive, and affective factors. Individual differences in personality traits and in pain perception covary but it is unclear which traits play the most significant role in understanding the pain experience and whether this depends on pain modality. A systematic search identified 1534 records (CINAHL, MEDLINE, PsycInfo, PubMed and Web of Science), of which 22 were retained and included in a systematic review. Only studies from the pressure pain domain (n=6) could be compared in a formal meta-analysis to evaluate the relationship between Big Five traits and experimental pain. Pressure pain tolerance correlated positively with Extraversion and negatively with Neuroticism with a trivial effect size (<0.1). While these findings suggest personality might be only weakly related to pain in healthy individuals, we emphasize the need to consider standardization, biases, and adequate sample sizes in future research, as well as additional factors that might affect experimental pain sensitivity.

eHealth-Integrated Psychosocial and Physical Interventions for Chronic Pain in Older Adults: Scoping Review

BACKGROUND

Chronic noncancer pain (CNCP) is highly present among older adults, affecting their physical, psychological, and social functioning. A biopsychosocial multimodal approach to CNCP management is currently extensively suggested by international clinical practice guidelines. Recently, the growing development and application of eHealth within pain management has yielded encouraging results in terms of effectiveness and feasibility; however, its use among the older population remains underexamined.

OBJECTIVE

The overall aim of this scoping review was to systematically map existing literature about eHealth multimodal interventions (including both physical and psychosocial components) targeting older adults with CNCP.

METHODS

This review adhered to the JBI methodology, a protocol was a priori registered as a preprint on the medRxiv platform, and the results were reported according to the PRISMA-ScR (Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for Scoping Reviews) guidelines. Four electronic databases (PubMed, Cochrane Central Register of Controlled Trials, Web of Science, and PsycINFO) were systematically searched for relevant articles. Studies were included if they reported on multimodal interventions (including both physical and psychosocial components) delivered through any eHealth modality to an older population with any type of CNCP. Two reviewers selected the studies: first by screening titles and abstracts and second by screening full-text articles. The quality of the included studies was evaluated using the Quality Assessment Tool for Studies with Diverse Designs. The results of the studies were summarized narratively.

RESULTS

A total of 9 studies (n=6, 67% published between 2021 and 2023) with quality rated as medium to high were included, of which 7 (78%) were randomized controlled trials (n=5, 71% were pilot and feasibility studies). All the included studies evaluated self-management interventions, most of them (n=7, 78%) specifically designed for older adults. The participants were aged between 65 and 75 years on average (mean 68.5, SD 3.5 y) and had been diagnosed with different types of CNCP (eg, osteoarthritis and chronic low back pain). Most of the included studies (5/9, 56%) involved the use of multiple eHealth modalities, with a higher use of web-based programs and video consulting. Only 1 (11%) of the 9 studies involved a virtual reality-based intervention. The evaluated interventions showed signs of effectiveness in the targeted biopsychosocial outcomes, and the participants' engagement and ratings of satisfaction were generally positive. However, several research gaps were identified and discussed.

CONCLUSIONS

Overall, of late, there has been a growing interest in the potential that eHealth multimodal interventions offer in terms of improving pain, physical, and psychosocial outcomes in older adults with CNCP. However, existing literature on this topic still seems scarce and highly heterogeneous, with few proper randomized controlled trials, precluding robust conclusions. Several gaps emerged in terms of the older population considered and the lack of evaluation of comorbidities.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

RR2-10.1101/2023.07.27.23293235.

The Impact of Non-Pain Factors on Pain Interference Among U.S. Service Members and Veterans with Symptoms of Mild Traumatic Brain Injury

U.S. Service members and Veterans (SM/V) experience elevated rates of traumatic brain injury (TBI), chronic pain, and other non-pain symptoms. However, the role of non-pain factors on pain interference levels remains unclear among SM/Vs, particularly those with a history of TBI. The primary objective of this study was to identify factors that differentiate high/low pain interference, given equivalent pain intensity among U.S. SM/V participating in the ongoing Long-term Impact of Military-relevant Brain Injury Consortium-Chronic Effects of Neurotrauma Consortium (LIMBIC-CENC) national multi-center prospective longitudinal observational study. An explainable machine learning was used to identify key predictors of pain interference conditioned on equivalent pain intensity. The final sample consisted of n = 1,577 SM/Vs who were predominantly male (87%), and 83.6% had a history of mild TBI(s) (mTBI), while 16.4% were TBI negative controls. The sample was categorized according to pain interference level (Low: 19.9%, Moderate: 52.5%, and High: 27.6%). Both pain intensity scores and pain interference scores increased with the number of mTBIs (p < 0.001), and there was evidence of a dose response between the number of injuries and pain scores. Machine learning models identified fatigue and anxiety as the most important predictors of pain interference, whereas emotional control was protective. Partial dependence plots identified that marginal effects of fatigue and anxiety were associated with pain interference (p < 0.001), but the marginal effect of mTBI was not significant in models considering all variables (p > 0.05). Non-pain factors are associated with functional limitations and disability experience among SM/V with an mTBI history. The functional effects of pain may be mediated through multiple other factors. Pain is a multi-dimensional experience that may benefit most from holistic treatment approaches that target comorbidities and build supports that promote recovery.

Consensus on the preoperative management of patients with chronic moderate to severe shoulder pain to improve postoperative outcomes: Delphi results

BACKGROUND

Appropriate preoperative management of patients with chronic moderate to severe shoulder pain who are candidates for surgery owing to rotator cuff disease or glenohumeral osteoarthritis may improve surgery and patient outcomes, but published evidence in this regard is scarce. Therefore, the availability of recommendations on preoperative interventions based on expert consensus may serve as guidance.

METHODS

A Delphi study was conducted to develop a preoperative management algorithm based on a national expert consensus. A Delphi questionnaire was developed by a scientific committee following a systematic review of the relevant literature published during the past 10 years using PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-analyses) criteria. It consisted of 48 statements divided into 5 blocks (block I, assessment and diagnosis of preoperative pain; block II, preoperative function and psychosocial aspects; block III, therapeutic objectives; block IV, treatment; and block V, follow-up and referral), and 28 experienced shoulder surgeons from across the country were invited to answer.

RESULTS

All participants responded to the Delphi questionnaire in the first round, and 25 responded in the second round (89.3% of those invited). Overall, 46 of 49 final statements reached a consensus, on the basis of which a final preoperative management algorithm was defined by the scientific committee. First, surgeons should assess shoulder pain intensity and characteristics, shoulder functionality, and psychosocial aspects using specific validated questionnaires. Preoperative therapeutic objectives should include shoulder pain control, depression and/or nocturnal sleep improvement, opioid consumption adjustment, and substance abuse cessation. Postoperative objectives regarding the degree of shoulder pain reduction or improvement in functionality and/or quality of life should be established in agreement with the patient. Treatment of preoperative chronic moderate to severe shoulder pain should comprise nonpharmacologic as well as pharmacologic interventions. Follow-up of the shoulder pain levels, treatment adherence, and mental health status of these patients may be carried out by the surgical team (surgeon and anesthesiologist) together with the primary care team. Patients with very intense shoulder pain levels may be referred to a pain unit following specific protocols.

CONCLUSION

A preoperative management algorithm for patients with chronic moderate to severe shoulder pain who are candidates for surgery owing to rotator cuff disease or glenohumeral osteoarthritis was defined based on a national expert consensus. Main points include comprehensive patient management starting with an objective assessment of shoulder pain and function, as well as quality of life; establishment of preoperative and postoperative therapeutic targets; prescription of individualized therapeutic interventions; and multidisciplinary patient follow-up. Implementation of these recommendations into clinical practice may result in better preoperative shoulder pain management and more successful surgical outcomes and patient satisfaction.

Assessment and management patterns for chronic musculoskeletal pain in the family practice setting

BACKGROUND

Chronic pain affects 11% of the US population. Most patients who experience pain, particularly chronic musculoskeletal pain, seek care in primary care settings. Assessment of the patient pain experience is the cornerstone to optimal pain management; however, pain assessment remains a challenge for medical professionals. It is unknown to what extent the assessment of pain intensity is considered in context of function and quality of life.

OBJECTIVE

To understand common practices related to assessment of pain and function in patients with chronic musculoskeletal disorders.

DESIGN

Cross-sectional survey.

METHODS

A 42-item electronic survey was developed with self-reported numeric ratings and responses related to knowledge, beliefs, and current practices. All physicians and non-physician clinicians affiliated with the AAFP NRN and 2000 AAFP physician members were invited to participate.

RESULTS/FINDINGS

Primary care clinicians report that chronic joint pain assessment should be comprehensive, citing assessment elements that align with the comprehensive pain assessment models. Pain intensity remains the primary focus of pain assessment in chronic joint pain and the most important factor in guiding treatment decisions, despite well-known limitations. Clinicians also report that patients with osteoarthritis should be treated by Family Medicine.

CONCLUSIONS

Pain assessment is primarily limited to pain intensity scales which may contribute to worse patient outcomes. Given that most respondents believe primary care/family medicine should be primary responsible for the care of patients with osteoarthritis, awareness of and comfort with existing guidelines, validated assessment instruments and the comprehensive pain assessment models could contribute to delivery of more comprehensive care.

Comparison of autologous platelet concentrates and topical steroids on oral lichen planus: a systematic review and meta-analysis

BACKGROUND

Oral lichen planus is a chronic and potentially malignant disorder of oral mucosa. Corticosteroids are used as first-line therapy for oral lichen planus patients; however, they have many side effects. Platelet concentrates (platelet-rich plasma and platelet-rich fibrin) are autologous bioactive materials. This systematic review investigated the effects of autologous platelet concentrates compared to topical steroids in treating symptomatic oral lichen planus patients.

MATERIALS AND METHODS

A systematic literature search was performed in PubMed, Web of Science, Scopus, Embase, and Cochrane for randomized controlled trials. Preferred Reporting Items for Systematic Reviews and meta-analysis guidelines were observed for article selection. For the pooling of studies, meta-analysis using Standardized Mean Differences by random effects model was carried out to estimate summary effect sizes for the treatment of oral lichen planus.

RESULTS

A total of six studies, incorporating 109 oral lichen planus patients, were involved. Both treatment modalities showed a statistically significant improvement in the outcome parameters (lesion size, pain score, Thongprasom score) from the baseline to the end of treatment and further to the follow-up visits. There was no significant difference in the pooled estimate SMD of pain decline in patients of the two groups (SMD = 0.17 (95% CI: -0.47 to 0.81); I2 = 63.6%). The SMD of Thongprasom score in patients receiving autologous platelet concentrates was lower than the corticosteroid groups, with no significant effect size (SMD= -2.88 (95% CI: -5.51 to -0.25); I2 = 91.7%). Therefore, there was no statistically significant difference between the autologous platelet concentrates and topical steroids regarding pain and clinical score.

CONCLUSION

Autologous platelet concentrates, and topical steroids decreased the size of lesions, Thongprasom scale, and pain in oral lichen planus patients, but the difference between the two treatments was not statistically significant. Thus, autologous platelet concentrates could be considered as an alternative treatment to topical steroids.

Effect of chronic pain on the occurrence of falls in older adults with disabilities: a prospective cohort study

BACKGROUND

The relationship between chronic pain and the occurrence of falls in healthy older adults has been clarified in previous studies, but its relationship in older adults with disabilities has not.

OBJECTIVE

This study aimed to determine whether chronic pain is related to the occurrence of falls in older adults with disabilities.

METHODS

The participants were 101 older adults above 65 years old who used long-term care insurance services in Japan. Of these, 30 were fallers and 71 were non-fallers. Chronic pain, defined as pain lasting more than three months, was assessed using questionnaires, and the falls' occurrence was followed up for six months using a fall calendar. Logistic regression analysis was used to analyze the data, with falls as the dependent variable, chronic pain as the independent variable, and age, sex, body mass index, number of drugs, sleep disorders, and depression as covariates.

RESULTS

After adjusting for covariates, chronic pain significantly influenced the occurrence of falls (odds ratio: 3.168, 95% confidence interval: 1.057-9.495, p = .04).

CONCLUSION

Chronic pain was related to the occurrence of falls in older adults with disabilities. There is a need to focus on chronic pain presence in falls' prevention among older adults with disabilities.

Psychometric properties and domains covered by patient-reported outcome measures used in trials assessing interventions for chronic pain

OBJECTIVES

To identify the patient-reported outcome measures (PROMs) used in clinical trials assessing interventions for chronic pain, describe their psychometric properties, and the clinical domains they cover.

STUDY DESIGN AND SETTING

We identified phase 3 or 4 interventional trials: on adult participants (aged >18 years), registered in clinicaltrials.gov between January 1, 2021 and December 31, 2022, and which provided "chronic pain" as a keyword condition. We excluded diagnostic studies and phase 1 or 2 trials. In each trial, one reviewer extracted all outcomes registered and identified those captured using PROMs. For each PROM used in more than 1% of identified trials, two reviewers assessed whether it covered the six important clinical domains from the Initiative on Methods, Measurement, and Pain Assessment in Clinical Trials (IMMPACT): pain, emotional functioning, physical functioning, participant ratings of global improvement and satisfaction with treatment, symptoms and adverse events, and participant disposition (eg, adherence to medication). Second, reviewers searched PubMed for both the initial publication and latest review reporting the psychometric properties of each PROM and assessed their content validity, structural validity, internal consistency, reliability, measurement error, hypotheses testing, criterion validity, and responsiveness using published criteria from the literature.

RESULTS

In total, 596 trials assessing 4843 outcomes were included in the study (median sample size 60, interquartile range 40-100). Trials evaluated behavioral (22%), device-based (21%), and drug-based (10%) interventions. Of 495 unique PROMs, 55 were used in more than 1% trials (16 were generic pain measures; 8 were pain measures for specific diseases; and 30 were measures of other symptoms or consequences of pain). About 50% PROMs had more than 50% of psychometric properties rated as sufficient. Scales often focused on a single clinical domain. Only 25% trials measured at least three clinical domains from IMMPACT.

CONCLUSION

Half of PROMs used in trials assessing interventions for chronic pain had sufficient psychometric properties for more than 50% of criteria assessed. Few PROMs assessed more than one important clinical domain. Only 25% of trials measured more than 3/6 clinical domains considered important by IMMPACT.

A randomized controlled study on acupuncture for peri-operative pain after open radical prostatectomy

OBJECTIVES

To evaluate the advantages of adding acupuncture to standard postoperative pain management for open radical prostatectomy (RP).

MATERIALS AND METHODS

A randomized controlled trial (1:1:1) comparing routine postoperative analgesic care (control [CON]) vs the addition of press tack needle acupuncture (ACU) or press tack placebo acupressure (SHAM) for pain management after open RP was performed. A total of 126 patients were enrolled between February 2020 and April 2021. After open RP, the CON group received standard postoperative analgesia, the ACU group received long-term acupuncture with press tacks at specific points (P-6, Shenmen and SP-6) along with standard analgesia, and the SHAM group received placebo press tacks at the same acupuncture points alongside standard analgesia. The primary endpoint was postoperative pain measured on a numeric rating scale, the NRS-11, calculated as the area under the curve. The cumulative use of routine postoperative analgesics, time to first defaecation, and quality of life were analysed using the Kruskal-Wallis rank sum test, Fisher's exact test, and Pearson's chi-squared test.

RESULTS

The ACU group reported significantly less postoperative pain compared to the SHAM (P = 0.007) and CON groups (P = 0.02). There were no significant difference in median (interquartile range) cumulative pain medication usage, time to first defaecation (CON: 37 [33, 44] h; SHAM: 37 [33, 42] h; ACU: 37 [33, 41] h; P > 0.9), or health status at discharge (EuroQol five-dimension, five-level general health assessment questionnaire: CON: 70 [65-83]; SHAM: 70 [60-80]; ACU: 70 [50-80]).

CONCLUSION

Incorporating acupuncture into postoperative pain management can improve patient postoperative outcomes.

Chronic pain in older adults with disabilities is associated with fall-related injuries: a prospective cohort study

PURPOSE

Previous studies have shown an association between chronic pain and the occurrence of falls in community-dwelling older adults; however, the association between chronic pain and fall-related injuries in older adults with disabilities is unclear. This study aimed to determine the association between chronic pain and fall-related injuries in older adults with disabilities.

METHODS

This 24-month prospective cohort study included older adults aged 65 years or older using Japanese long-term care insurance services. Chronic pain, defined as "pain that has persisted for more than three months to date," was assessed using a face-to-face questionnaire. Fall-related injuries, defined as "injuries requiring hospitalization or outpatient treatment due to a fall," were assessed using a fall calendar. Data were analyzed using a Cox proportional hazards model, with fall-related injury as the dependent variable, chronic pain as the independent variable, and confounders as covariates.

RESULTS

Among 133 included participants, 15 experienced fall-related injuries. After adjusting for age and sex as covariates, chronic pain was significantly associated with fall-related injuries (hazard ratio: 5.487, 95% confidence interval: 1.211-24.853, p = 0.027).

CONCLUSIONS

Chronic pain was associated with fall-related injuries in older adults with disabilities. In this population, a greater focus should be placed on treating chronic pain to reduce the occurrence of falls.

The Effect of Everyday-Life Social Contact on Pain

Pain is a biopsychosocial phenomenon, resulting from the interplay between physiological and psychological processes and social factors. Given that humans constantly interact with others, the effect of social factors is particularly relevant. Documenting the significance of the social modulation of pain, an increasing number of studies have investigated the effect of social contact on subjective pain intensity and pain-related physiological changes. While evidence suggests that social contact can alleviate pain, contradictory findings indicate an increase in pain intensity and a deterioration of pain coping strategies. This evidence primarily stems from studies examining the effect of social contact on pain within highly controlled laboratory conditions. Moreover, pain assessments often rely on one-time subjective reports of average pain intensity across a predefined period. Ecological momentary assessments (EMAs) can circumvent these problems, as they can capture diverse aspects of behavior and experiences multiple times a day, in real time, with high resolution, and within naturalistic and ecologically valid settings. These multiple measures allow for the examination of fluctuations of pain symptoms throughout the day in relation to affective, cognitive, behavioral, and social factors. In this opinion paper, we review the current state and future relevance of EMA-based social pain research in daily life. Specifically, we examine whether everyday-life social support reduces or enhances pain. The first part of the paper provides a comprehensive overview of the use of EMA in pain research and summarizes the main findings. The review of the relatively limited number of existing EMA studies shows that the association between pain and social contact in everyday life depends on numerous factors, including pain syndromes, temporal dynamics, the nature of social interactions, and characteristics of the interaction partners. In line with laboratory research, there is evidence that everyday-life social contact can alleviate, but also intensify pain, depending on the type of social support. Everyday-life emotional support seems to reduce pain, while extensive solicitous support was found to have opposite effects. Moreover, positive short-term effects of social support can be overshadowed by other symptoms such as fatigue. Overall, gathering and integrating experiences from a patient's social environment can offer valuable insights. These insights can help interpret dynamics in pain intensity and accompanying symptoms such as depression or fatigue. We conclude that factors determining the reducing versus enhancing effects of social contact on pain need to be investigated more thoroughly. We advocate EMA as the assessment method of the future and highlight open questions that should be addressed in future EMA studies on pain and the potential of ecological momentary interventions for pain treatment.

Physical therapy interventions for people experiencing homelessness to improve pain and self-perceived health status

BACKGROUND

Homeless shelters have emerged as components of the social services network, playing an important role in providing health care to the homeless population. The aim of this study was to evaluate an individualized physical therapy intervention for people experiencing homelessness and to determine the relationship between self-perceived variables.

METHODS

Pre and post study, setting at the "Santa y Real Hermandad de Nuestra Señora del Refugio y Piedad" homeless shelter in Zaragoza, Spain. Participants were people experiencing homelessness with musculoskeletal disorders who attended a physical therapy service at shelter facilities. A physical therapy program was implemented including health education, exercise and manual therapy, electrotherapy, thermotherapy and bandaging. Demographic variables (age and gender), nationality, employment situation, educational level, pain location, number of painful areas, feeling of loneliness (3-Item Loneliness Scale; values from 3 to 9), pain intensity (Numerical Pain Rating Scale [NPRS]; from 0 to 10) and self-perceived health (Clinical Global Impression [CGI]; from 1 to 7).

RESULTS

Sixty-four homeless people (age of 46.4 ± 10.9 years) participated in the study. Musculoskeletal pain was reported by 98.4% of subjects, with moderate pain intensities (6.1), and 48.4% presenting with pain at multiple sites. Perceptions of loneliness were low (3.7 ± 2.5) and self-perceived health status was moderately ill (3.5 ± 1.7). Positive significant correlations were identified between pain intensity and self-perceived health. The average number of sessions was 1.5 (± 0.8), with manual therapy (35.6%) followed by health education (23.5%) being the most frequently used techniques. Both pain and self-perceived health improved after treatment, even following a brief intervention.

CONCLUSIONS

This study demonstrates the potentially negative impact of untreated pain on the self-perceived health of homeless individuals with musculoskeletal disorders that should be targeted for consideration. The findings suggest that a paradigm shift in pain management, including a physical therapy service in shelters, is needed to address the rehabilitation demands of these individuals in a real-life context. This study was approved by the Aragon Ethics Committee (PI19/438) and performed according to the Transparent Reporting of Evaluations with Nonrandomized Designs (TREND) statement.

Validity and Reliability of the Greek Version of Pittsburgh Sleep Quality Index in Chronic Non-Specific Low Back Pain Patients

The purpose of this study was to investigate psychometric properties of the Greek translation of Pittsburgh Sleep Quality Index (GR-PSQI) in a Greek chronic non-specific low back pain (CNSLBP) sample, thus, providing insight on its clarity and acceptability as a widely used sleep assessment tool in clinical practice. Asymptomatic volunteers (n = 73) and CNSLBP volunteers (n = 47), participated in the study. For the assessment of construct validity, the known-groups method was used. Thus, all the participants (asymptomatic and CNSLBP) completed the GR-PSQI. For the assessment of concurrent validity, the CNSLBP participants additionally completed the following validated questionnaires for depression, insomnia and sleep quality: Beck Depression Inventory Questionnaire (BDI), Insomnia Severity Index (ISI), and Sleep Quality Numeric Rating Scale (SQNRS). For the assessment of test-retest reliability, the CNSLBP participants completed the GR-PSQI a second time, one week after the first time. The results showed excellent test-retest reliability (ICC = 0.969, SEM = 0.90, SDD = 2.49%) and internal consistency (Cronbach α = 0.985), moderate to good concurrent validity (from r = 0.556 to r = 0.860) among PSQI, BDI, SQNRS, and ISI, as well as excellent construct validity (p = 0.000) between the two groups. The Greek translation of PSQI could be a valuable tool for Greek healthcare professionals in both clinical and research environments.

The level of agreement between the numerical rating scale and visual analogue scale for assessing pain intensity in adults with chronic pain

The numerical rating scale and visual analogue scale are used to quantify pain intensity. However, it has not yet been explored whether these scores are interchangeable in adults with chronic pain. Data from the prospective multicentre cross-sectional INTERVAL study were used to evaluate the one-dimensionality and agreement between numerical rating scale scores and visual analogue scale scores in adults with chronic pain. Pain intensity scores using the numerical rating scale and visual analogue scale were provided by 366 patients with chronic pain for current, average, minimal and maximal pain. To evaluate whether pain intensity scales are completed in accordance with each other, the proportion of patients who satisfied the following condition was calculated: minimal pain intensity ≤ maximal pain intensity. A factor analysis confirmed the one-dimensionality of the pain measures. A significant difference was found between numerical rating scale and visual analogue scale scores for average, current, minimum and maximum pain. Intra-class correlation coefficient estimates ranged from 0.739 to 0.858 and all measures failed to show sufficient and acceptable agreement at the 95% level. The strength of agreement between pain severity categories was classified as 'moderate' for average and minimal pain and 'substantial' for current and maximal pain. The proportion of patients who scored minimal pain ≤ maximal pain was 97.5% for the numerical rating scale and 89.5% for the visual analogue scale. This study failed to show an acceptable agreement between the numerical rating scale and visual analogue scale when pain intensity was rated by adults with chronic pain, despite showing both scales measure the same information.

Development, refinement, and validation of an equine musculoskeletal pain scale

Musculoskeletal disease is a common cause of chronic pain that is often overlooked and inadequately treated, impacting the quality of life of humans and horses alike. Lameness due to musculoskeletal pain is prevalent in horses, but the perception of pain by owners is low compared with veterinary diagnosis. Therefore, this study aims to establish and validate a pain scale for chronic equine orthopaedic pain that is user-friendly for horse owners and veterinarians to facilitate the identification and monitoring of pain in horses. The newly developed musculoskeletal pain scale (MPS) was applied to 154 horses (mean age 20 ± 6.4 years SD) housed at an equine sanctuary, of which 128 (83%) suffered from chronic orthopaedic disease. To complete the MPS, the horses were observed and videotaped from a distance while at rest in their box or enclosure. In addition, they received a complete clinical and orthopaedic exam. The need for veterinary intervention to address pain (assessed and executed by the sanctuary independent from this study) was used as a longitudinal health outcome to determine the MPS's predictive validity. To determine the interrater agreement, the MPS was scored for a randomly selected subset of 30 horses by six additional blinded raters, three equine veterinary practitioners, and three experienced equestrians. An iterative process was used to refine the tool based on improvements in the MPS's correlation with lameness evaluated at the walk and trot, predictive validity for longitudinal health outcomes, and interrater agreement. The intraclass correlation improved from 0.77 of the original MPS to 0.88 of the refined version (95% confidence interval: 0.8-0.94). The refined MPS correlated significantly with lameness at the walk (r = 0.44, p = 0.001) and trot (r = 0.5, p < 0.0001). The refined MPS significantly differed between horses that needed veterinary intervention (mean MPS = 8.6) and those that did not (mean MPS = 5.0, p = 0.0007). In summary, the MPS showed good interrater repeatability between expert and lay scorers, significant correlation with lameness at the walk and trot, and good predictive validity for longitudinal health outcomes, confirming its ability to identify horses with orthopaedic health problems.

SOMAScience: A Novel Platform for Multidimensional, Longitudinal Pain Assessment

Chronic pain is one of the most significant health issues in the United States, affecting more than 20% of the population. Despite its contribution to the increasing health crisis, reliable predictors of disease development, progression, or treatment outcomes are lacking. Self-report remains the most effective way to assess pain, but measures are often acquired in sparse settings over short time windows, limiting their predictive ability. In this paper, we present a new mobile health platform called SOMAScience. SOMAScience serves as an easy-to-use research tool for scientists and clinicians, enabling the collection of large-scale pain datasets in single- and multicenter studies by facilitating the acquisition, transfer, and analysis of longitudinal, multidimensional, self-report pain data. Data acquisition for SOMAScience is done through a user-friendly smartphone app, SOMA, that uses experience sampling methodology to capture momentary and daily assessments of pain intensity, unpleasantness, interference, location, mood, activities, and predictions about the next day that provide personal insights into daily pain dynamics. The visualization of data and its trends over time is meant to empower individual users' self-management of their pain. This paper outlines the scientific, clinical, technological, and user considerations involved in the development of SOMAScience and how it can be used in clinical studies or for pain self-management purposes. Our goal is for SOMAScience to provide a much-needed platform for individual users to gain insight into the multidimensional features of their pain while lowering the barrier for researchers and clinicians to obtain the type of pain data that will ultimately lead to improved prevention, diagnosis, and treatment of chronic pain.

Pain history and experimental pressure pain responses in adolescents: Results from a population-based birth cohort

BACKGROUND

Sensitized pain mechanisms are often reported in musculoskeletal pain conditions, but population-based paediatric studies are lacking. We assessed whether adolescents with musculoskeletal pain history had evidence of increased responsiveness to experimental pressure stimuli.

METHODS

Data were from 1496 adolescents of the Generation XXI birth cohort. Pain history was collected using the Luebeck Pain Questionnaire (self-reported at 13, parent-reported at 7 and 10 years). Two case definitions for musculoskeletal pain were considered: (1) cross-sectional-musculoskeletal pain lasting more than 3 months at age 13 and (2) longitudinal-musculoskeletal pain at age 13 with musculoskeletal pain reports at ages 7 and/or 10. Lower limb cuff pressure algometry was used to assess pain detection and tolerance thresholds, conditioned pain modulation effects (CPM, changes in thresholds in the presence on painful conditioning) and temporal summation of pain effects (TSP, changes in pain intensity to 10 phasic painful cuff stimulations).

RESULTS

Adolescents with musculoskeletal pain at age 13 plus a history of pain in previous evaluations (longitudinal definition) had lower pain tolerance thresholds compared to the remaining sample (40.2 v. 49.0 kPa, p = 0.02), but showed no differences in pain detection threshold, CPM effect and TSP effect. Pain sensitivity, CPM effects and TSP effects were not significantly different when the current pain only case definition (cross-sectional) was used.

CONCLUSIONS

Adolescents with current musculoskeletal pain who had a history of pain since childhood had lower tolerance to cuff stimulation. This may suggest long-standing musculoskeletal pain since childhood may contribute to sensitisation, rather than the presence of current pain only.

SIGNIFICANCE

Repeated musculoskeletal pain up to age 13 years may contribute to higher pain sensitivity (particularly lowered pressure pain tolerance) in the general adolescent population. This does not seem to be the case when reported pain experiences are recent or when the outcomes are temporal pain summation or CPM. In this community-based paediatric sample, the vast majority showed no sign of altered pain processing, but a small fraction may reveal some pain sensitization at 13 years of age.

Adverse Events of the Long-Term Use of Opioids for Chronic Non-cancer Pain: A Narrative Review

BACKGROUND

The long-term use of opioids for chronic non-cancer pain (CNCP) has drawn more attention and debate. Although opioids are frequently used to treat chronic pain, their effectiveness and safety over extended periods are still unknown.

OBJECTIVES

The purpose of this review is to provide an overview of what is currently known about the adverse events of long-term use of opioids in CNCP. It also delivers patient-centered strategies designed to mitigate these risks.

METHODS

We conducted a literature search in PubMed, MEDLINE, EMBASE, and Web of Science databases. Search terms included CNCP, pain pathophysiology, opioid pharmacodynamics, opioid prescribing trends, guidelines for opioid use, and opioid side effects.  Results: Our review highlights that while opioids may provide short-term relief from CNCP, their effectiveness diminishes over time due to the development of opioid tolerance. This tolerance often leads to increased dosages, which can subsequently result in opioid dependence. Additionally, long-term opioid therapy is associated with a spectrum of adverse effects, including constipation, drowsiness, respiratory depression, and potential for drug interactions. Furthermore, our review indicates that alternative pain management strategies play a crucial role in controlling CNCP. They offer significant benefits with fewer adverse events. These strategies include non-opioid medications, physical therapy, cognitive-behavioral therapy (CBT), various interventional procedures, injection therapy, and acupuncture.

CONCLUSION

Using opioids to manage CNCP presents several challenges. Given these challenges, alternative treatments are being considered as viable options. Moreover, it is crucial to customize treatment plans to align with the patients' specific health requirements, existing conditions, and potential risks to ensure the best possible outcomes.

PaiNEd app. Assessing central sensitization in survivors of breast cancer: A reliability study

Introduction

Pain is a common adverse event in survivors of breast cancer (sBCs). As there is no gold standard to assess pain experience predominantly related to central sensitization (CS) symptoms, we designed the PaiNEd app, which includes an algorithm to report whether patients are under predominant CS pain mechanisms.

Objective

We aimed to assess the reliability of the PaiNEd app to estimate whether sBC pain experience is predominantly related to CS symptoms.

Methods

An observational, descriptive reliability design was employed to assess the inter- and intrarater reliability of the PaiNEd app. This app includes an algorithm that considers the number of painful body parts and some questionnaires related to pain, such as the Numeric Pain-Rating Scale, the Brief Pain Inventory, the Tampa Scale for Kinesiophobia, the Pain Catastrophizing Scale, and the Central Sensitization Inventory (CSI).

Results

A total of 21 sBCs with persistent pain were recruited. We observe a general trend of close agreement between the paper-based and app-based formats (ICCs ranged between 0.802 and 0.972; Cronbach's alpha ranged between 0.797 and 0.971). Test-retest reliabilities were moderate to excellent (ICCs ranged between 0.510 and 0.941; Cronbach's alpha ranged between 0.499 and 0.938). The agreement between the categorization of the CS algorithm and the CSI (cut-off point ≥ 40 for CS symptoms) was 95.24%.

Conclusion

The PaiNEd app emerges as a robust tool for evaluating pain experience predominantly related to CS and pain-related symptoms in sBCs. Its demonstrated reliability not only bolsters its utility but also signifies its potential as a valuable asset for healthcare professionals engaged in pain education programs.

Clinical Diagnosis and Treatment of Chronic Pain

More than 600 million people globally are estimated to be living with chronic pain. It is one of the most common complaints seen in an outpatient setting, with over half of patients complaining of pain during a visit. Failure to properly diagnose and manage chronic pain is associated with substantial morbidity and mortality, especially when opioids are involved. Furthermore, it is a tremendous financial strain on the healthcare system, as over USD 100 billion is spent yearly in the United States on healthcare costs related to pain management and opioids. This exceeds the costs of diabetes, heart disease, and cancer-related care combined. Being able to properly diagnose, manage, and treat chronic pain conditions can substantially lower morbidity, mortality, and healthcare costs in the United States. This review will outline the current definitions, biopsychosocial model, subclassifications, somatosensory assessments, imaging, clinical prediction models, and treatment modalities associated with chronic pain.

Psychometric Properties and The Best Form of The Revised Short-Form Mc-Gill Pain Questionnaire in Iranian Burn Patients

Pain is the most important factor that forces patients to seek help from health care systems. Burn injuries are associated with severe pain and the assessment and interventions are a focus of nursing care. The aim of this study was to evaluate the psychometric properties of the revised short-form Mc-Gill Pain Questionnaire (MPQ) in burn patients. The present study is a methodological study in which 153 burn patients were included by convenience sampling. To evaluate the psychometric properties of the 22-item revised MPQ, face validity, construct validity (exploratory factor analysis), and reliability were determined by Cronbach's α coefficient and split-half method. Data analysis was performed using SPSS22.0 software. During the quantitative face validity test, four items were removed from the instrument due to the impact score of less than 1.5 by burn patients. The results of exploratory factor analysis showed five factors (emotional, neuropathic, continuous, stimulatory, and shooting), which explained 72.32% of the total variance. The overall Cronbach's instrument was 0.836 and the coefficient obtained by the split-half method was 0.81. According to the validity and reliability, the 18-item MPQ obtained in the present study can be used to assess pain in Persian-speaking adult burn patients.

Evidence-based guideline on chronic postsurgical pain management in adult patients in resource-restricted setting, 2023: systematic review and guideline

Background

Chronic postsurgical pain (CPSP) after tissue trauma is frequent and may have a long-lasting impact on the functioning and quality of life. The development of CPSP increases the burden on both the patient and the community. This review aims to systematically review articles and, lastly, pull an evidence-based guideline for CPSP management in adult patients in resource-limited areas.

Methodology

The review was reported based on preferred reporting items for the systemic review and meta-analysis (PRISMA) protocol. A literature search was conducted from the Cochrane, PubMed/Medline, and Google Scholar databases, and other gray literature from 2010 to 2022. The conclusion was made based on the level of evidence.

Results

A total of 3521 articles were identified through the database by searching strategies. Finally, by filtering duplicates unrelated to the topics, 22 articles (9 meta-analyses and systematic reviews, 12 systematic reviews, and one cohort study) were selected on the management of CPSP in adult patients. Filtering was made based on the intervention, outcome data of the population, and methodological quality.

Conclusion

Given the complexity and multidimensional nature of chronic postsurgical pain, effective assessment, and management require a comprehensive, multiaxial approach. Adequate preoperative preparation and counseling, potential risk identification and optimization, and use of a multimodal approach, and noninvasive surgical techniques are crucial in reducing the development of chronic postsurgical pain.

Electronic Health Record Recording of Patient Pain: Challenges and Discrepancies

PURPOSE OF REVIEW

In the present review, various categories of pain, clinician-observed pain scales, and patient-reported pain scales are evaluated to better understand factors that impact patient pain perceptions. Additionally, the expansion of areas that require further research to determine the optimal way to evaluate pain scale data for treatment and management are discussed.

RECENT FINDINGS

Electronic health record (EHR) data provides a starting point for evaluating whether patient predictors influence postoperative pain. There are several ways to assess pain and choosing the most effective form of pain treatment. Identifying individuals at high risk for severe postoperative pain enables more effective pain treatment. However, there are discrepancies in patient pain reporting dependent on instruments used to measure pain and their storage in the EHR. Additionally, whether administered by a physician or another healthcare practitioner, differences in patient pain perception occur. While each scale has distinct advantages and limitations, pain scale data is a valuable therapeutic tool for assisting clinicians in providing patients with optimal pain control. Accurate assessment of patient pain perceptions by data extraction from electronic health records provides a potential for pain alleviation improvement. Predicting high-risk postoperative pain syndromes is a difficult clinical challenge. Numerous studies have been conducted on factors that impact pain prediction. Postoperative pain is significantly predicted by the kind of operation, the existence of prior discomfort, patient anxiety, and age.

The Relationship Between Knee Osteoarthritis-Related Pain Severity and Daily Activities Involving the Upper and Lower Limbs in Saudi Adults: A Cross-Sectional Study

Introduction Earlier research has shown an association between pain intensity and everyday activities in adults. However, it is vital to examine the relationship within the context of Saudi people who have knee osteoarthritis. Therefore, this study aimed to explore the connection between pain intensity and daily activities involving the lower and upper limbs among patients with knee osteoarthritis in Saudi Arabia. Methods This study enrolled 209 individuals aged 55 years and above who were diagnosed with radiographic knee osteoarthritis by physicians from five hospitals in Riyadh, Saudi Arabia, between March 2016 and March 2017. Participants were divided into two groups based on their pain intensity, measured using the visual analog scale. The first group included 141 individuals with mild or moderate pain, while the second group comprised 68 individuals with severe pain. The study assessed the physical functioning of these individuals by evaluating their ability to perform daily activities involving the lower and upper limbs, using the Physical Functioning Subscale of the 36-item Short Form Health Survey, which includes 10 items. Results Adjusted logistic regression analysis revealed that individuals experiencing severe pain related to knee osteoarthritis were more likely to encounter difficulties in climbing several flights of stairs (odds ratio [OR] = 1.19, 95% confidence interval [CI] = 1.09-1.29), and one flight of stairs (OR = 1.19, 95% CI = 1.06-1.34), with challenges in bending, kneeling, or stooping (OR = 1.14, 95% CI = 1.05-1.23), walking more than one mile (OR = 1.15, 95% CI = 1.06-1.25), walking several blocks (OR = 1.17, 95% CI = 1.08-1.27), and walking one block (OR = 1.19, 95% CI = 1.06-1.34) than those with mild or moderate pain. Conclusion Our study results highlight the significant impact of severe pain on activities like climbing stairs, bending, kneeling, stooping, and walking longer distances among people with knee osteoarthritis in Saudi Arabia.

The PATIENT Approach: A New Bundle for the Management of Chronic Pain

BACKGROUND

Chronic pain is one of the most challenging diseases for physicians as its etiology and manifestations can be extremely varied. Many guidelines have been published and many therapeutic options are nowadays available for the different types of pain. Given the enormous amount of information that healthcare providers must handle, it is not always simple to keep in mind all the phases and strategies to manage pain. We here present the acronym PATIENT (P: patient's perception; A: assessment; T: tailored approach; I: iterative evaluation; E: education; N: non-pharmacological approach; T: team), a bundle which can help to summarize all the steps to follow in the management of chronic pain.

METHODS

We performed a PubMed search with a list of terms specific for every issue of the bundle; only English articles were considered.

RESULTS

We analyzed the literature investigating these topics to provide an overview of the available data on each bundle's issue; their synthesis lead to an algorithm which may allow healthcare providers to undertake every step of a patient's evaluation and management.

DISCUSSION

Pain management is very complex; our PATIENT bundle could be a guide to clinicians to optimize a patient's evaluation and treatment.

Short-chain fatty acid, butyrate prevents morphine-and paclitaxel-induced nociceptive hypersensitivity

Nociceptive hypersensitivity is a significant side effect with the chronic administration of opioids as well as chemotherapeutics. Both opioid-induced hypersensitivity (OIH) and chemotherapy-induced hypersensitivity (CIH) are characterized by an increased sensitivity to painful stimuli which can significantly reduce the quality of life for individuals on either drug(s). Here we demonstrate the nociceptive hypersensitivity associated with repeated administration of morphine (opioid) and paclitaxel (chemotherapeutic) treatment can be reversed by oral supplementation with the short-chain fatty acid (SCFA) sodium butyrate (NaBut). In two separate mouse behavioral models for nociceptive hypersensitivity, we found that thermal hyperalgesia (for OIH) and cold allodynia (for CIH) were prevented by treatment with oral butyrate (p.o, b.i.d). Electrophysiological recordings of small diameter dorsal root ganglia (DRG) neurons from morphine and paclitaxel treated mice showed an increase in neuronal hyperexcitability in both drug models which was likewise prevented by oral butyrate treatment. Using colonic conditioned media obtained from excised colon segments we found that gut mediators of morphine treated mice can induce hyperexcitability in naïve DRG neurons, but such enhanced excitability is not present when animals are co-treated with NaBut suggesting gut derived mediators modulate neuronal hyperexcitability. In-vitro NaBut treatment did not prevent morphine-induced excitability, suggesting an indirect role of butyrate in modulating neuronal hypersensitivity. These data taken together suggest that gut derived mediators affect opioid and chemotherapeutic-induced neuronal hypersensitivity that is prevented by the SCFA butyrate.

Bidirectional Links of Daily Sleep Quality and Duration With Pain and Self-rated Health in Older Adults' Daily Lives

BACKGROUND

Sleep and health perceptions, such as self-ratings of pain and health are closely linked. However, the temporal ordering of such associations is not well understood, and it remains unclear whether sleep quality and sleep duration show similar or differential associations with health perceptions.

METHODS

We used ecological momentary assessment data from 123 young-old (66-69 years, 47% women) and 47 old-old adults (84-90 years, 60% women). Across 7 consecutive days, participants reported their sleep quality and sleep duration each morning and rated their momentary pain and health 6 times per day. We applied dynamic structural equation models to examine bidirectional links of morning reports of sleep quality and duration with daily levels of self-rated pain and health.

RESULTS

In line with the hypotheses, results showed that when participants reported better sleep quality than what is typical for them, they reported less pain and better self-rated health on the day that followed. Longer sleep duration was not linked with subsequent pain or self-rated health. On days when people rated their health as better than usual, they reported better sleep quality but not longer sleep duration the following night. These associations were not moderated by age, gender, or chronic pain.

CONCLUSION

Findings suggest that in old age, sleep quality is more relevant for health perceptions than sleep duration. Associations between sleep quality and self-rated health seem to be bidirectional; daily pain was linked to prior but not subsequent sleep quality.

Revisiting the factor structure of the Short-Form McGill Pain Questionnaire-2 (SF-MPQ-2): Evidence for a bifactor model in individuals with Chiari malformation

The Short-Form McGill Pain Questionnaire-2 (SF-MPQ-2; Dworkin et al., 2009) is intended to measure the multidimensional qualities of pain (i.e., continuous, intermittent, neuropathic, and affective) as well as total pain. Using structural equation modeling, we evaluated the fit of four competing measurement models of the SF-MPQ-2-an oblique 4-factor model, a 1-factor model, a higher-order model, and a bifactor model-in 552 adults diagnosed with Chiari malformation, a chronic health condition whose primary symptoms include head and neck pain. Results revealed the strongest support for the bifactor model, suggesting that SF-MPQ-2 item responses are due to both a general pain factor and a specific pain factor that is orthogonal to the general pain factor. Additional bifactor analyses of the SF-MPQ-2's model-based reliability and dimensionality revealed that most of the SF-MPQ-2's reliable variance is explained by a general pain factor, and that the instrument can be modeled unidimensionally and scored as a general pain measure. Results also indicated that the general and affective pain factors in the bifactor model uniquely predicted pain-related external criteria (e.g., depression, anxiety, and stress); however, the continuous, intermittent, and neuropathic factors did not.

Graded chronic pain scale revised: validation in a Veteran sample

OBJECTIVE

The Graded Chronic Pain Scale (GCPS) is frequently used in pain research and treatment to classify mild, bothersome, and high impact chronic pain. This study's objective was to validate the revised version of the GCPS (GCPS-R) in a US Veterans Affairs (VA) healthcare sample to support its use in this high-risk population.

METHODS

Data were collected from Veterans (n = 794) via self-report (GCPS-R and relevant health questionnaires) and electronic health record extraction (demographics and opioid prescriptions). Logistic regression, adjusting for age and gender, was used to test for differences in health indicators by pain grade. Adjusted odds ratio (AOR) with 95% confidence intervals (CIs) were reported with CIs not including an AOR of 1 indicating that the difference exceeded chance.

RESULTS

In this population, the prevalence of chronic pain (pain present most or every day, prior 3 months) was 49.3%: 7.1% with mild chronic pain (mild pain intensity and lower interference with activities); 23.3% bothersome chronic pain (moderate to severe pain intensity with lower interference); and 21.1% high impact chronic pain (higher interference). Results of this study mirrored findings in the non-VA validation study; differences between bothersome and high impact were consistent for activity limitations and present but not fully consistent for psychological variables. Those with bothersome chronic pain or high impact chronic pain were more likely to receive long-term opioid therapy compared to those with no/mild chronic pain.

CONCLUSIONS

Findings highlight categorical differences captured with the GCPS-R, and convergent validity supports use of the GCPS-R in US Veterans.

Listening to Remotely Monitored Home-based Preferred Music for Pain in Older Black Adults with Low Back Pain: A Pilot Study of Feasibility and Acceptability

BACKGROUND

Low back pain (LBP) is a complex condition that is widespread among older Black adults. Nonpharmacologic interventions are recommended as first-line therapy, but their use in practice is limited, possibly due to misunderstanding of their analgesic characteristics.

AIM

To determine the feasibility and acceptability of listening to preferred music at home to relieve pain in older Black adults aged 65 years or older with LBP.

METHOD

We recruited 20 community-dwelling older adults (≥65 years) with LBP to use noise-isolating headphones to listen to their preferred music for 20 minutes twice daily for four days via the MUSIC CARE® app. Feasibility was determined using enrollment, adherence, and attrition rates, and acceptability was determined using the Treatment Acceptance and Preference (TAP) scale. Average pain scores were self-reported using the Numeric Rating Scale (NRS) after the second intervention of the day. Pain scores were evaluated using paired sample t test and repeated-measures ANOVA.

RESULTS

Enrollment, adherence, and attrition rates were 95.25%, 100.00%, and 0.00%, respectively. Most participants rated the TAP scale at ≥3, indicating acceptance. Pain scores decreased significantly from baseline (M = 46.90, SD = 21.47) to post-intervention (M = 35.70, SD = 16.57), t (19) = 2.29, p = .03. Repeated measures ANOVA showed a significant decrease in mean pain scores over time [F (2.36, 44.88) = 5.61, p = .004, η2 = .23].

CONCLUSIONS

Listening to preferred music for 20 minutes twice a day is a feasible and acceptable intervention that can considerably reduce pain in older Black adults with LBP.

Advancing herbal medicine: enhancing product quality and safety through robust quality control practices

This manuscript provides an in-depth review of the significance of quality control in herbal medication products, focusing on its role in maintaining efficiency and safety. With a historical foundation in traditional medicine systems, herbal remedies have gained widespread popularity as natural alternatives to conventional treatments. However, the increasing demand for these products necessitates stringent quality control measures to ensure consistency and safety. This comprehensive review explores the importance of quality control methods in monitoring various aspects of herbal product development, manufacturing, and distribution. Emphasizing the need for standardized processes, the manuscript delves into the detection and prevention of contaminants, the authentication of herbal ingredients, and the adherence to regulatory standards. Additionally, it highlights the integration of traditional knowledge and modern scientific approaches in achieving optimal quality control outcomes. By emphasizing the role of quality control in herbal medicine, this manuscript contributes to promoting consumer trust, safeguarding public health, and fostering the responsible use of herbal medication products.

Causal association of polyunsaturated fatty acids with chronic pain: a two-sample Mendelian randomization study

Background

Observational studies have indicated an association between polyunsaturated fatty acids (PUFAs) and chronic pain, but the potential causal link remains controversial. Here, we aimed to investigate whether a causal relationship exists between the concentration of circulating PUFAs and chronic pain as well as the direction of this association.

Methods

We collected statistical data from relevant genome-wide association studies to explore the causal link between four PUFAs, along with the ratio of omega-6 fatty acids (FAs) to omega-3 FAs (omega-6:3 ratio), and chronic pain in eight specific body parts. We used the inverse-variance weighting (IVW) method for two-sample Mendelian randomization (MR) analysis and conducted supplementary analyses using four other methods (MR-Egger, weighted median, weighted mode, and simple mode). To verify the robustness of the MR study, we performed multiple sensitivity analyses.

Results

The results revealed a negative correlation between omega-3 FAs [IVW, OR 95% CI: 0.952 (0.914, 0.991), p = 0.017] and docosahexaenoic acid (DHA) [IVW, OR 95% CI: 0.935 (0.893, 0.978), p = 0.003] with abnormal and pelvic pain. Furthermore, a positive correlation was observed between the omega-6:3 ratio [IVW, OR 95% CI: 1.057 (1.014, 1.101), p = 0.009] with abdominal and pelvic pain. Additionally, we found a negative correlation between omega-3 FAs [IVW, OR 95% CI: 0.947 (0.902, 0.994), p = 0.028] and lower back pain or sciatica. However, no causal relationship was found between the concentration of circulating PUFAs and pain in other body parts, including the face, throat and chest, joints, limbs, lower back, and gynecological parts. The robustness of these MR results was verified through multi-validity and retention method analyses.

Conclusion

Our analysis suggests that higher circulating concentrations of omega-3 FAs and DHA and a lower omega-6:3 ratio are associated with a reduced risk of abdominal and pelvic pain. Additionally, a higher concentration of circulating omega-3 FAs is linked to a reduced risk of lower back pain and/or sciatica. These findings have major implications for the targeted prevention and treatment of chronic pain using PUFAs.

Psychophysical assessment of pain in adults with moderate and severe haemophilia: A cross-sectional study

BACKGROUND

Joint pain is the hallmark of haemophilia; therefore it seems clinically rather a musculoskeletal than a bleeding disorder. Although joint pain in people with haemophilia (PwH) is a complex and multidimensional problem, pain assessment remains primarily focused on the structural evaluation of their joints. Whereas, only few data are available on the potential implication of psychophysical and psychological factors.

OBJECTIVE

This study aimed to perform a psychophysical pain assessment including quantitative sensory testing (QST) and an evaluation of psychological factors in a large sample of PwH, to get insight into the individuals' pain system.

METHODS

Ninety-nine adults (36.9 ± 13.5 years) with moderate/severe haemophilia A/B and 46 healthy controls filled in self-reported pain and psychological questionnaires and underwent a QST evaluation including static and dynamic tests. Static tests focused on the determination of thermal detection and pain thresholds and mechanical pressure pain thresholds. Dynamic tests evaluated pain facilitation and the efficacy of endogenous pain inhibition. Besides comparing PwH and healthy controls, between-subgroup differences were studied in PwH based on their pain distribution.

RESULTS

The study revealed increased thermal and mechanical pain sensitivity and the presence of unhelpful psychological factors such as anxiety/depression in PwH. Among the subgroups, especially PwH with widespread pain showed altered somatosensory functioning. Enhanced pain facilitation and impaired efficacy of endogenous pain inhibition in PwH could not be observed.

CONCLUSION

Altered somatosensory functioning and unhelpful psychological factors, appear to play an important role in the pathophysiology of pain in PwH, especially in PwH with widespread pain.

COMT Val158Met Affects the Analgesic Response to Acupuncture Among Cancer Survivors With Chronic Pain

Catechol-O-methyltransferase (COMT) is the major enzyme involved in the catabolism of dopamine, a neurotransmitter in the brain's reward system. The common COMT polymorphism Val158Met (rs4680 G>A) modulates pain response to opioids through a reward-motivated mechanism; however, its role in nonpharmacological pain medicine has not been clinically characterized. We genotyped 325 participants from a randomized controlled trial of cancer survivors with chronic musculoskeletal pain. We found that carrying methionine at position 158 (158Met) of COMT, encoded by the A allele, significantly increased the analgesic response to electroacupuncture (74% vs 50%; odds ratio [OR]: 2.79; 95% confidence interval [CI]: 1.31, 6.05; P < .01), but not to auricular acupuncture (68% vs 60%; OR: 1.43; 95% CI: .65, 3.12; P = .37) or usual care (24% vs 18%; OR: 1.46; 95% CI: .38, 7.24; P = .61) compared to Val/Val. These findings raise the possibility that COMT Val158Met might be an important predictor of analgesic response to electroacupuncture, providing novel insights into precision nonpharmacologic pain management tailored to individual genetic backgrounds. PERSPECTIVE: This work suggests the modulating effects of the polymorphism in COMT Val158Met on the response to acupuncture. Further research needs to validate these findings, increase the mechanistic understanding of acupuncture, and guide further development of acupuncture as a precision pain management strategy.

Microglial inflammation modulates opioid analgesic tolerance

As we all know, opioids are the drugs of choice for treating severe pain. However, very often, opioid use leads to tolerance, dependence, and hyperalgesia. Therefore, understanding the mechanisms underlying opioid tolerance and designing strategies for increasing the efficacy of opioids in chronic pain are important areas of research. Microglia are brain macrophages that remove debris and dead cells from the brain and participate in immune defense of the central nervous system during an insult or injury. However, recent studies indicate that microglial activation and generation of proinflammatory molecules (e.g., cytokines, nitric oxide, eicosanoids, etc.) in the brain may contribute to opioid tolerance and other side effects of opioid use. In this review, we will summarize the evidence and possible mechanisms by which proinflammatory molecules produced by activated microglia may antagonize the analgesic effect induced by opioids, and thus, lead to opioid tolerance. We will also delineate specific examples of studies that suggest therapeutic targets to counteract the development of tolerance clinically using suppressors of microglial inflammation.

Global Prevalence of Chronic Pain in Women with HIV: A Systematic Review and Meta-analysis

Chronic pain is common among people with human immunodeficiency virus (HIV) and detrimental to quality of life and overall health. It is often underdiagnosed, undertreated, and frankly dismissed in women with HIV, despite growing evidence that it is highly prevalent in this population. Thus, we conducted a systematic review and meta-analysis to estimate the global prevalence of chronic pain in women with HIV. The full protocol can be found on PROSPERO (identifier CRD42022301145). Of the 2984 references identified in our search, 36 were included in the systematic review and 35 in the meta-analysis. The prevalence of chronic pain was 31.2% (95% confidence interval [CI], 24.6%-38.7%; I2 = 98% [95% CI, 97%-99%]; P < .0001). In this global assessment, we found a high prevalence of chronic pain among women with HIV, underscoring the importance of understanding the etiology of chronic pain, identifying effective treatments, and conducting regular assessments in clinical practice.

Opioid-Free Versus Opioid-Based Anesthesia on Postoperative Pain After Thoracoscopic Surgery: The Use of Intravenous and Epidural Esketamine

BACKGROUND

The effectiveness and safety of opioid-free anesthesia (OFA) regimens in distinct types of surgeries remain controversial. In this study, we investigated whether OFA could reduce the occurrence of chronic postoperative pain in patients receiving video-assisted thoracoscopic surgery (VATS).

METHODS

We conducted a 2-center, randomized, controlled trial from September 2021 to January 2022. A total of 162 lung tumor patients scheduled to undergo VATS were randomly divided into an opioid-based anesthesia (OA) group and an OFA group. The OA group received general anesthesia combined with thoracic epidural block using morphine, while the OFA group received general anesthesia combined with thoracic epidural block using esketamine. Patient-controlled epidural analgesia (PCEA) was used after surgery (ropivacaine and morphine for the OA group versus ropivacaine and esketamine for the OFA group). The primary end point was chronic pain rates at 3 months after VATS, which were analyzed using a logistic regression model. The secondary end points were chronic pain rates at 6 months, acute pain rates at 24 hours and 48 hours postoperatively, postoperative side effects, and perioperative variables.

RESULTS

The final analysis included 159 patients. Acute postoperative pain at 24 hours occurred in 0 of the 79 (0%) patients in the OA group and 10 of the 80 (17.5%) patients in the OFA group (odds ratio, 52.14; 95% confidence interval [CI], 6.47-420.10; P < .001). Acute postoperative pain at 48 hours occurred in 3 of the 79 (3.8%) patients in the OA group and 2 of the 80 (2.5%) patients in the OFA group (odds ratio, 2.07; 95% CI, 0.99-4.32; P = .053). In this study, none of the patients had moderate or severe pain in either group at 3 and 6 months postsurgically. Mild chronic postoperative pain at 3 months occurred in 27 of the 79 (34.2%) patients in the OA group and 14 of the 80 (17.5%) patients in the OFA group (odds ratio, 3.52; 95% CI, 1.49-8.31; P = .004). At 6 months, mild chronic pain still occurred in 23 of the 79 (29.1%) patients in the OA group and 9 of the 80 (11.3%) patients in the OFA group (odds ratio, 5.55; 95% CI, 2.01-15.33; P = .001). In addition, the OFA group included fewer patients with side effects, including nausea, vomiting, and pruritus, within 48 hours after surgery.

CONCLUSIONS

Replacement of opioids by esketamine, intraoperatively as intravenous injection and epidural infusion and postoperatively as epidural infusion, reduces the incidence of mild chronic postoperative pain and side effects in patients after VATS.

Central Sensitization in Cancer Survivors and Its Clinical Implications: State of the Art

Although the prevalence of cancer pain is 47% after treatment, cancer pain is often underestimated, and many patients are undertreated. The complexity of cancer pain contributes to the lack of its management. Recently, as the mechanism of cancer pain, it has become clear that central sensitization (CS) influences chronic pain conditions and the transition from acute to chronic pain. In this state-of-the-art review, we summarized the association of CS or central sensitivity syndrome with pain and the treatment for pain targeting CS in cancer survivors. The management of patients with CS should not only focus on tissue damage in either the affected body regions or within the central nervous system; rather, it should aim to target the underlying factors that sustain the CS process. Pain neuroscience education (PNE) is gaining popularity for managing chronic musculoskeletal pain and could be effective for pain and CS in breast cancer survivors. However, there is a study that did not demonstrate significant improvements after PNE, so further research is needed. Precision medicine involves the classification of patients into subgroups based on a multifaceted evaluation of disease and the implementation of treatment tailored to the characteristics of each patient, which may play a central role in the treatment of CS.

The prevalence of osteoporosis in postmenopausal women in urban Tianjin, China and its related factors

OBJECTIVES

The aims of the study are to understand the prevalence of osteoporosis in postmenopausal women in urban Tianjin, China and its related factors through a questionnaire and to assess the correlation between individual characteristics, physical mobility, psychological and emotional well-being, and prevalence, as well as people's awareness of osteoporosis.

METHODS

We selected 240 postmenopausal women from 12 randomly selected streets in 6 administrative districts of Tianjin for bone mineral density measurement and a face-to-face questionnaire survey to obtain the relevant data. Female residents who had lived in the communities under the jurisdiction of the incorporated streets for more than 10 years and had been in menopause for 2 years were included. The women were made aware of the study, there were no communication barriers, and they were willing to undergo dual-energy absorptiometry and cooperate in completing the questionnaire. We used one-way analysis of variance, Fisher exact test, and Pearson correlation analysis for the statistical analysis.

RESULTS

The overall prevalence of osteoporosis in postmenopausal women in the six districts of Tianjin was found to be 52.08%, and the χ 2 test for trend showed a clear trend of increasing with age ( P = 0.035). Body mass index was found to be the most significant personal characteristic affecting the prevalence of osteoporosis; the mean values of the nonosteoporosis and osteoporosis group were (25.45 ± 3.09) and (23.85 ± 3.16), respectively ( P < 0.001); previous fractures were closely associated with the prevalence of osteoporosis. Awareness about osteoporosis had not disseminated among the population, and 9.17% of the participants had never heard of the disease. While 75.42% and 72.92% of the participants, respectively, believe that the harm of osteoporosis cannot be compared with heart disease and cerebral infarction, 56.67% had never had an examination for osteoporosis and paid little to no attention to this disease. People still had major misconceptions about the hazards of osteoporosis and common-sense precautions that needed to be followed.

CONCLUSIONS

Although osteoporosis is prevalent among postmenopausal women in urban Tianjin and is strongly linked to both history of fracture and body mass index, most women are only familiar with the disease's name and lack an understanding of the dangers it poses as well as the importance of early diagnosis and treatment. To ensure the prevention and control of osteoporosis, it is crucial to focus on increasing the examination and treatment rates and spreading awareness of the three-level diagnosis and treatment pattern among the public.

Artificial Intelligence for Automatic Pain Assessment: Research Methods and Perspectives

Although proper pain evaluation is mandatory for establishing the appropriate therapy, self-reported pain level assessment has several limitations. Data-driven artificial intelligence (AI) methods can be employed for research on automatic pain assessment (APA). The goal is the development of objective, standardized, and generalizable instruments useful for pain assessment in different clinical contexts. The purpose of this article is to discuss the state of the art of research and perspectives on APA applications in both research and clinical scenarios. Principles of AI functioning will be addressed. For narrative purposes, AI-based methods are grouped into behavioral-based approaches and neurophysiology-based pain detection methods. Since pain is generally accompanied by spontaneous facial behaviors, several approaches for APA are based on image classification and feature extraction. Language features through natural language strategies, body postures, and respiratory-derived elements are other investigated behavioral-based approaches. Neurophysiology-based pain detection is obtained through electroencephalography, electromyography, electrodermal activity, and other biosignals. Recent approaches involve multimode strategies by combining behaviors with neurophysiological findings. Concerning methods, early studies were conducted by machine learning algorithms such as support vector machine, decision tree, and random forest classifiers. More recently, artificial neural networks such as convolutional and recurrent neural network algorithms are implemented, even in combination. Collaboration programs involving clinicians and computer scientists must be aimed at structuring and processing robust datasets that can be used in various settings, from acute to different chronic pain conditions. Finally, it is crucial to apply the concepts of explainability and ethics when examining AI applications for pain research and management.

Localized Pain and Fatigue During Recovery From Submaximal Resistance Exercise in People With Fibromyalgia

OBJECTIVE

Exercise is recommended as a main treatment in fibromyalgia. However, many people have limited exercise tolerance and report exacerbated pain and fatigue during and following a bout of exercise. This study examined the local and systemic changes in perceived pain and fatigue during exercise and through the 3-day recovery following isometric and concentric exercises in people with and without fibromyalgia.

METHODS

Forty-seven participants with a physician diagnosis of fibromyalgia (44 women; mean age [SD] = 51.3 [12.3] years; mean body mass index [SD] = 30.2 [6.9]) and 47 controls (44 women; mean age [SD] = 52.5 [14.7] years; mean body mass index [SD] = 27.7 [5.6]) completed this prospective, observational cohort study. A bout of submaximal resistance exercise (isometric and concentric) was performed localized to the right elbow flexors on 2 separate days. Baseline attributes (pain, fatigue, physical function, physical activity, and body composition) were assessed prior to exercise. Primary outcomes were: change in perceived pain and fatigue (0 to 10 on the visual analog scale) in the exercising limb and whole body during recovery with movement (immediately, 1 day following exercise, and 3 days following exercise). Secondary outcomes were perceived pain and exertion during exercise performance and pain and fatigue at rest during recovery.

RESULTS

Following a single bout of isometric or concentric exercise, there was increased perceived pain (ηp2 = 0.315) and fatigue (ηp2 = 0.426) in the exercising limb, which was greater in people with fibromyalgia (pain: ηp2 = 0.198; fatigue: ηp2 = 0.211). Clinically, relevant increases in pain and fatigue during exercise and through the 3-day recovery occurred in individuals with fibromyalgia only. Concentric contractions led to greater perceived pain, exertion, and fatigue during exercise compared with isometric exercise for both groups.

CONCLUSIONS

People with fibromyalgia experienced significant pain and fatigue in the exercising muscle during recovery from low-intensity and short-duration resistance exercise, with greater pain during concentric contractions.

IMPACT

These findings highlight a critical need to assess and manage pain and fatigue in the exercising muscles of people with fibromyalgia up to 3 days following a single bout of submaximal resistance exercise.

LAY SUMMARY

If you have fibromyalgia, you might have significant pain and fatigue up to 3 days following an exercise bout, with the pain and fatigue localized to the exercising muscles and no changes in whole-body pain.

P2Y12 receptor involved in the development of chronic nociceptive pain as a sensory information mediator

Direct or indirect damage to the nervous system (such as inflammation or tumor invasion) can lead to dysfunction and pain. The generation of pain is mainly reflected in the activation of glial cells and the abnormal discharge of sensory neurons, which transmit stronger sensory information to the center. P2Y12 receptor plays important roles in physiological and pathophysiological processes including inflammation and pain. P2Y12 receptor involved in the occurrence of pain as a sensory information mediator, which enhances the activation of microglia and the synaptic plasticity of primary sensory neurons, and reaches the higher center through the ascending conduction pathway (mainly spinothalamic tract) to produce pain. While the application of P2Y12 receptor antagonists (PBS-0739, AR-C69931MX and MRS2359) have better antagonistic activity and produce analgesic pharmacological properties. Therefore, in this article, we discussed the role of the P2Y12 receptor in different chronic pains and its use as a pharmacological target for pain relief.

Short-chain fatty acid, Butyrate prevents Morphine and Paclitaxel induced peripheral hypersensitivity

Peripheral hypersensitivity is a significant side effect with the chronic administration of opioids as well as chemotherapeutics. Both opioid-induced hypersensitivity (OIH) and chemotherapy induced hypersensitivity (CIH) are characterized by an increased sensitivity to painful stimuli which can significantly reduce the quality of life for individuals on either drug(s). Here we demonstrate the peripheral hypersensitivity associated with chronic morphine (opioid) and paclitaxel (chemotherapeutic) treatment can be reversed by oral supplementation with the short-chain fatty acid (SCFA) sodium butyrate. In two separate mouse behavioral models for peripheral hypersensitivity, we found that thermal hyperalgesia (for OIH) and cold allodynia (for CIH) were prevented by co-treatment with oral butyrate. Electrophysiological recordings of small diameter dorsal root ganglia (DRG) neurons from morphine and paclitaxel treated mice showed an increase in neuronal hyperexcitability in both drug models which was likewise prevented by oral butyrate treatment. Using colonic conditioned media obtained from excised colon segments we found that gut mediators of morphine treated mice can induce hyperexcitability in naïve DRG neurons, but such enhanced excitability is not present when animals are co-treated with butyrate suggesting gut derived mediators modulate neuronal hyperexcitability. In-vitro butyrate treatment did not prevent morphine induced excitability, suggesting an indirect role of sodium butyrate in modulating neuronal hypersensitivity. These data taken together suggest that gut derived mediators affect opioid and chemotherapeutic induced neuronal hypersensitivity that is prevented by the SCFA butyrate.

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.

Reporting of scar outcomes in the hand and wrist; a state-of-the-art literature review

OBJECTIVES

The aim of this literature review was to synthesise and report current practice in evaluation and reporting of scar outcomes in hand and wrist clinical research.

METHODS

A systematic search from inception to 2022 was conducted using three electronic databases. English language randomized controlled trials and observational cohort studies reporting standardised scar outcome measures and/or scar symptoms, appearance, impairment, function, or mental health outcomes in patients with hand and wrist scars were included. Two independent reviewers determined study eligibility and performed data extraction of a priori identified scar outcome domains. Data analysis included descriptive statistics and identification of discordance in taxonomy.

RESULTS

Fifty-nine studies were included. Elective surgery cohorts were the most frequently included clinical population (n = 28; 47%) followed by burns (n = 16; 27%). Six different standardised scar outcome measures were reported by 25% of studies however only 7% of studies utilised a patient-reported measure. Scar symptoms were the most frequently reported outcome domain (81%); but taxonomy was incongruous, constructs lacked working definitions required for generalisability and outcome measurement was variable and unreported. Nineteen different measures of scar appearance and structure were reported by 30 (51%) of studies however only nine (23%) were patient-reported. Seven different hand function PROMs were reported by 25 (43%) studies. Person-centred domains including scar acceptability (12%), mental health impact (5%), and social participation (4%) were rarely reported.

CONCLUSIONS

This review highlights that evaluation and reporting of hand and wrist scar outcomes is not standardised, assessment methods and measures are under-reported and there is discordance in taxonomy. Evaluation is not person-centred, rather it is dependent on clinician assessment. Domains including scar acceptability, mental health, and social participation are rarely addressed. A stakeholder consensus derived hand and wrist scar core outcome measurement set will promote standardisation and underpin improvements in clinical research quality, transparency, and rigour.

Pain assessment 3 × 3: a clinical reasoning framework for healthcare professionals

OBJECTIVES

To give an overview of central aspects of pain medicine-specific clinical reasoning when assessing a pain patient. Clinical reasoning is the thinking and decision-making processes associated with clinical practice.

METHODS

Three core pain assessment areas that are crucial for clinical reasoning in the field of pain medicine are discussed, each of them consisting of three points.

RESULTS

First, it is important to distinguish acute, chronic non-cancer, and cancer-related pain conditions. This classical and very simple trichotomy still has important implications treatment-wise, e.g., concerning the use of opioids. Second, the pain mechanism needs to be assessed. Is the pain nociceptive, neuropathic, or nociplastic? Simply put, nociceptive pain has to do with injury of non-neural tissue, neuropathic pain is caused by a disease or lesion of the somatosensory nervous system, and nociplastic pain is believed to be related to a sensitized nervous system (c.f. the concept of "central sensitization"). This also has implications concerning treatment. Some chronic pain conditions are nowadays viewed more as diseases rather than the pain being merely a symptom. In the new ICD-11 pain classification, this is conceptualized by the characterization of some chronic pains as "primary". Third, in addition to a conventional biomedical evaluation, psychosocial and behavioral aspects must also be assessed, the pain patient being viewed as an active agent and not merely as the passive recipient of an intervention. Hence, the importance of a dynamic bio-psycho-social perspective. The dynamic interplay of biological, psychological, and social aspects must be taken into account, putative behavioral "vicious circles" thereby being identified. Some core psycho-social concepts in pain medicine are mentioned.

CONCLUSIONS

The clinical applicability and clinical reasoning power of the 3 × 3 framework is illustrated by three short (albeit fictional) case descriptions.

Widespread Pain Phenotypes Impact Treatment Efficacy Results in Randomized Clinical Trials for Interstitial Cystitis/Bladder Pain Syndrome: A MAPP Network Study

Clinical trials of pain are notoriously difficult and inefficient in demonstrating efficacy even for known efficacious treatments. Determining the appropriate pain phenotype to study can be problematic. Recent work has identified the extend of widespread pain as an important factor in the likelihood of response to therapy, but has not been tested in clinical trials. Using data from three previously published negative studies of the treatment of interstitial cystitis/ bladder pain with data on the extent of widespread pain, we examined the response of patients to different therapies base on the amount of pain beyond the pelvis. Participants with predominately local but not widespread pain responded to therapy targeting local symptoms. Participants with widespread and local pain responded to therapy targeting widespread pain. Differentiating patients with and without widespread pain phenotypes may be a key feature of designing future pain clinical trials to demonstrate treatments that are effective versus not.

Diagnosing and Treating Infertility via Transvaginal Natural Orifice Transluminal Endoscopic Surgery versus Laparoendoscopic Single-Site Surgery: A Retrospective Study

OBJECTIVE

To evaluate the efficacy and safety of transvaginal natural orifice transluminal endoscopic surgery (vNOTES) in the treatment of female infertility.

MATERIALS AND METHODS

This study includes 174 female patients with a history of long-standing female infertility. We retrospectively reviewed 41 patients who underwent hysterolaparoscopy (HL) via transvaginal natural orifice transluminal endoscopic surgery (vNOTES) and 133 patients who underwent laparoendoscopic single-site surgery (LESS). Demographic data, operation records, and pregnancy outcomes were collected and analyzed. The deadline for postoperative follow-up was June 2022. All the included patients were followed up for at least 18 months after surgery.

RESULTS

Compared with the LESS group, the vNOTES group had a shorter postoperative bowel movement time and less pain at 4 and 12 h (p = 0.004 vs. 0.008); no differences were found in other perioperative indicators. The clinical pregnancy rates of the vNOTES and LESS groups were 87.80% and 74.43% (p = 0.073), respectively.

CONCLUSIONS

vNOTES represents a new, less invasive approach for infertility diagnosis and treatment that is particularly suitable for women who have special esthetic requirements. vNOTES is safe and practical and may be an ideal choice for scarless infertility surgery.

Transient Receptor Potential Ankyrin 1 (TRPA1) Methylation and Chronic Pain: A Systematic Review

BACKGROUND AND OBJECTIVE

Chronic pain represents a major global health issue in terms of psycho-physiological, therapeutic, and economic burden, not limited to adults but also to the pediatric age. Despite its great impact, its molecular mechanisms have still not been completely unraveled. Focusing on the impact of epigenetics in the pain complex trait, we assessed the association between chronic pain and the methylation pattern of TRPA1, a key gene related to pain sensitivity.

METHODS

We conducted a systematic review retrieving articles from three different databases. After deduplication, 431 items were subjected to manual screening, and then 61 articles were selected and screened again. Of these, only six were maintained for meta-analysis and analyzed using specific R packages.

RESULTS

Six articles were divided into two groups (group 1: comparison of mean methylation levels between healthy subjects and patients with chronic pain; group 2: correlation between mean methylation levels and pain sensation). A non-significant mean difference was obtained from the analysis of group 1 with a value of 3.97 (95% C.I. -7.79; 15.73). Analysis of group 2 showed a high level of variability between studies (correlation = 0.35, 95% C.I. -0.12; 0.82) due to their heterogeneity (I2 = 97%, p < 0.01).

CONCLUSIONS

Despite the high variability observed in the different studies analyzed, our results suggest that hypermethylation and increased pain sensitivity could be connected, possibly due to the variation of TRPA1 expression.