Acupuncture for chronic pain: individual patient data meta-analysis.

Acupuncture for Chronic Pain: Individual Patient Data Meta-analysis

Background Although acupuncture is widely used for chronic pain, there remains considerable controversy as to its value. We aimed to determine the effect size of acupuncture for 4 chronic pain conditions: back and neck pain, osteoarthritis, chronic headache, and shoulder pain. Methods We conducted a systematic review to identify randomized controlled trials (RCTs) of acupuncture for chronic pain in which allocation concealment was determined unambiguously to be adequate. Individual patient data meta-analyses were conducted using data from 29 of 31 eligible RCTs, with a total of 17 922 patients analyzed. Results In the primary analysis, including all eligible RCTs, acupuncture was superior to both sham and no-acupuncture control for each pain condition (P Conclusions Acupuncture is effective for the treatment of chronic pain and is therefore a reasonable referral option. Significant differences between true and sham acupuncture indicate that acupuncture is more than a placebo. However, these differences are relatively modest, suggesting that factors in addition to the specific effects of needling are important contributors to the therapeutic effects of acupuncture.

Acupuncture for Chronic Pain: Update of an Individual Patient Data Meta-Analysis

OBJECTIVE: We sought to examine the independent and interactive effects of common mental health disorders and chronic pain conditions on employment and work outcomes among individuals younger than 65 years of age. METHODS: We analyzed cross-sectional data from the second wave of Healthcare for Communities (HCC2), a household telephone survey of U.S. civilian adults conducted in 2000 to 2001 (N=5328). Common mental disorders were assessed using the short-form versions of the World Health Organization’s Composite International Diagnostic Interview (CIDI-SF). Chronic pain conditions and labor market outcomes were identified by self report. Logistic and linear regression analysis was used to provide estimates for work impairment based on the presence of a mental health disorder and/or a chronic pain condition. RESULTS: The interaction between presence of a mental health disorder and presence of a chronic pain condition was significantly associated with no work for pay in the past 12 months (OR 2.3 [1.2–4.2]) and number of days of work missed in the past month due to health (regression coefficient 1.5 [0.6]). In stratified analyses, this effect persisted in women but not men. The presence of a mental health disorder or chronic pain condition were each independently associated with limitations in work and any work missed in the past 30 days due to health, although the interaction was not significant. CONCLUSION: Mental health disorders and chronic pain are each associated with work disability. Mental health disorders are more highly associated with some work disability outcomes when accompanied by chronic pain, especially in women.

Practice guidelines for chronic pain management: an updated report by the American Society of Anesthesiologists Task Force on Chronic Pain Management and the American Society of Regional Anesthesia and Pain Medicine.

Several recently published books and a number of recent meetings, one of which is the subject of the Meeting Review in this issue, have highlighted the complexity of chronic orofacial pain and headache conditions and the challenges they present to clinicians for diagnosis and treatment of these conditions; this complexity and the clinical challenges are also evident from articles in this issue of the journal.1,2 The factors that bear on the success (or not) of the management approaches used for the conditions can also be gleaned from the material presented in these books and meetings. In view of their importance to clinical practice, I have summarized several of these factors below. One important influence on the diagnosis and treatment of chronic orofacial pain and headache conditions is the uncertainty that exists about the etiology and pathogenesis, and the management, of the vast majority of these conditions. We do know, in terms of pathogenesis, that neuroplastic changes occur in the central nervous system (CNS) in pain conditions and are associated with nociceptive neuronal hyperexcitability (central sensitization) as well as changes in the CNS circuits underlying the psychosocial functioning of the patient. These changes may gradually become maintained over time unless the pain condition is managed effectively in its early stages. If not, an entrenched condition may result that becomes even more difficult to manage. But effective management may not be straightforward for some patients because many of the numerous diagnostic and treatment approaches advocated for chronic orofacial pain and headache conditions lack a solid scientific underpinning and have muddied further our understanding of their management.3–5 Diagnosis and treatment are also complicated by the complex nature of pain itself and its multidimensional character, encompassing sensory-discriminative, cognitive-evaluative, and affective-motivational dimensions. These factors especially come into play in chronic pain states, where they can impact the emotional and psychosocial well-being and quality of life of the patient. In addition, there are differences between individuals in these dimensions, which may be reflected in individual differences in the degree of manifestation of a chronic pain condition and in the response to treatment. Furthermore, tolerance and even addiction to some therapeutic approaches (eg, narcotic analgesics) may develop in some individuals, especially those who may be genetically prone. These individual differences thus can complicate chronic pain management and make it difficult to standardize diagnostic and therapeutic approaches. The multiple sensory and motor functions that characterize the orofacial region and the special meaning that the orofacial region has for humans and indeed most animals are factors that can also make it difficult to manage effectively chronic pain in this region. We utilize this region of the body for sensory and motor functions that are normally pleasurable and vital for sustaining life (eg, taste, chewing, swallowing) or that allow for communication with others through facial gestures and speech. Some chronic pain patients may experience difficulties in these functions; the taste impairment of many burning mouth patients and the jaw movement limitations of patients with temporomandibular disorders (TMD) are prime examples. Therefore, comprehensive management is needed to ensure that these sensorimotor problems that may be associated with the chronic pain are also dealt with appropriately. A further complication arises from the variety of comorbidities that are associated with many orofacial pain and headache conditions. Comorbid “psychological” conditions (eg, anxiety, depression, catastrophizing) and disturbed sleep are common in patients with chronic orofacial pain or headache. In addition, more than one pain may be manifested in the same patient. For example, signs or symptoms of TMD and headache may be manifested together, and in addition patients with one or both of these conditions may have a high incidence of pain in other body regions, eg, arthritis pain, back pain, fibromyalgia, irritable bowel. Many clinicians have limited knowledge, training, and expertise for not only managing successfully chronic pain per se but also for recognizing the various comorbidities that may accompany a chronic pain state in the orofacial region and in understanding the processes involved in them. Which brings me to the final group of factors that influence diagnosis and treatment of chronic pain conditions, namely research, education, and knowledge translation. The diagnosis and treatment of chronic orofacial pain and headache in many patients will remain challenging until research in humans and animal models elucidates the mechanisms underlying the etiology and pathogenesis of these conditions and their comorbidities and also provides new or improved assessment and therapeutic approaches that have a research base of strong evidence to support their use. This new knowledge needs to be synthesized and passed on effectively to clinicians and applied by them in the management of these conditions. Increased emphasis on research and on education linked to knowledge translation is integral to improving diagnostic and therapeutic approaches, for the benefit of the patient with a chronic orofacial pain or headache condition.

Secular Mindfulness-Based Interventions: Efficacy and Neurobiology.

IntroductionCurrent guidelines for pain treatment recommend a personalized, multimodal and interdisciplinary approach as well as the use of a combination of drug and non-drug therapies. Risk factors for chronification should already be reduced in patients with acute pain, e.g., after surgery or trauma. Auricular vagus nerve stimulation (aVNS) could be an effective non-drug therapy in the multimodal treatment of chronic and acute pain. The aim of this systematic review and meta-analysis is to evaluate the clinical efficacy and safety of aVNS in treating chronic and acute pain conditions.MethodsA systematic literature search was performed regarding the application of auricular electrical stimulation in chronic and acute pain. Studies were classified according to their level of evidence (Jadad scale), scientific validity and risk of bias (RoB 2 tool) and analyzed regarding indication, method, stimulation parameters, duration of treatment and efficacy and safety. A meta-analysis on (randomized) controlled trials (using different comparators) was performed for chronic and acute pain conditions, respectively, including subgroup analysis for percutaneous (pVNS—needle electrodes) and transcutaneous (tVNS—surface electrodes) aVNS. The visual analog pain scale (VAS) was defined as primary efficacy endpoint.ResultsA total of n = 1496 patients were treated with aVNS in 23 identified and analyzed studies in chronic pain, 12 studies in acute postoperative pain and 7 studies in experimental acute pain. Of these, seven studies for chronic pain and six studies for acute postoperative pain were included in the meta-analysis. In chronic pain conditions, including back pain, migraine and abdominal pain, a statistically significant reduction in VAS pain intensity for active compared to sham aVNS or control treatment with an effect size Hedges’ g/mean difference of − 1.95 (95% confidence interval [CI]: − 3.94 to 0.04, p = 0.008) could be shown and a more favorable effect in pVNS compared to tVNS (− 5.40 [− 8.94; − 1.85] vs. − 1.00 [− 1.55; − 0.44]; p = 0.015). In acute pain conditions, single studies showed significant improvements with aVNS, e.g., in kidney donor surgery or tonsillectomy but, overall, a non-statistically significant reduction in VAS pain intensity for active compared to sham aVNS or control with − 0.70 [− 2.34; 0.93] (p = 0.15) could be observed in the meta-analysis. In acute pain results vary greatly between studies depending especially on co-medication and timepoints of assessment after surgery. A significant reduction in analgesics or opiate intake was documented in most studies evaluating this effect in chronic and acute pain. In 3 of the 12 randomized controlled trials in patients with chronic pain, a sustainable pain reduction over a period of up to 12 months was shown. Overall, aVNS was very well tolerated.ConclusionThis systematic review and meta-analysis indicate that aVNS can be an effective and safe non-drug treatment in patients with specific chronic and acute postoperative pain conditions. Further research is needed to identify the influence of simulation parameters and find optimal and standardized treatment protocols while considering quality-of-life outcome parameters and prolonged follow-up periods. A more standardized approach and harmonization in study designs would improve comparability and robustness of outcomes.Supplementary InformationThe online version contains supplementary material available at 10.1007/s40122-024-00657-8.

Chronic spinal pain and physical–mental comorbidity in the United States: results from the national comorbidity survey replication

Immune activation and autoimmunity in chronic pain conditions and response to immunoglobulin G.

Participant withdrawals were unusually distributed in randomized trials with integrity concerns: a statistical investigation

Chronic Pain: Management Strategies That Work

The comorbidity of mental and physical disorders with self-reported chronic back or neck pain: Results from the China Mental Health Survey

This is a review of current concepts of chronic post-traumatic neck and head pain. In this article, I will emphasize the physiological and sociological aspects of these disorders. The pathophysiology of chronic post-traumatic neck and head pain has not been well understood. Some have emphasized the organic factors and others the psychogenic aspects of these conditions. Only in recent years have this dichotomy been integrated with sociocultural concepts. The history of chronic post-traumatic head and neck pain is reviewed. Paradoxes are discussed, ie, the great differences in prevalence around the world, the inconsistent relationship of symptoms to degree of trauma, the curious phenomena of structural disease without symptoms, and symptoms without structural disease. The organic and pathophysiologic factors are reviewed, then those factors that modulate pain in these conditions are discussed. Chronic post-traumatic neck and head pain is rarely either organic or psychogenic. Rather physiological, social, and cultural factors play major roles in modulating pain and either perpetuate or ameliorate these chronic pain conditions.

To the Editor: The role played by the brain's dopamine system in pain control has garnered attention in recent years.1 Herein, we report 4 cases of long-term chronic pain (pain disorder [DSM-IV-TR]) that improved dramatically following administration of a low dose of aripiprazole, a partial dopamine agonist. None of these 4 patients satisfied the DSM-IV-TR diagnostic criteria for schizophrenia. Case 1. Mr A, a 42-year-old man, had a chief complaint of chronic head and neck pain that had persisted for 10 years and was refractory to administration of morphine 70 mg/d. He visited our department in December 2008 and was diagnosed with pain disorder and pervasive developmental disorder. Although fluvoxamine treatment was started, with the dosage gradually increased to 200 mg/d, it was ineffective and the pain exacerbated. Upon switching to aripiprazole 3 mg/d, the pain improved dramatically, and the patient was able to discontinue morphine. After increasing the dose to 6 mg/d, the patient became able to go fishing for the first time in a few years, and his motivation increased. Case 2. Mr B, a 35-year-old man, had chronic back and leg pain that had persisted for 15 years and particularly worsened following sexual intercourse. He had visited over 20 medical institutions in the past and had not responded to antidepressants. He visited our department in March 2009 and was diagnosed with pain disorder. Pain disappeared after initiation of aripiprazole 2 mg/d, and the patient's passion for his work in computer software development improved. As aripiprazole was effective in the treatment of pain disorder in Cases 1 and 2, we subsequently also used it for Cases 3 and 4, and it was effective. Below are concise descriptions of Cases 3 and 4. Case 3. Ms C, an 83-year-old woman, had developed Parkinson's disease and back and leg pain (pain disorder) 4 years before. She visited our department in August 2009. Pain improved following administration of aripiprazole 3 mg/d, and the patient began going out rather than staying home as she had been, and her level of activity improved. Case 4. Ms D, a 68-year-old woman, had developed pain at the top of the head (pain disorder) a year before she visited our department in October 2009. Pain disappeared after we added aripiprazole 2 mg/d to sertraline 100 mg/d, and the patient's motivation toward housework improved. These 4 patients were characterized by reduction of pain and improved motivation following low-dose aripiprazole administration. Dopamine plays a role in pain processing via μ opioids.1 Dopamine-related diseases often exhibit pain-related symptoms. For example, pain is a common complaint among patients with Parkinson's disease,2 and those with schizophrenia are known to have a reduced pain sensitivity.3 In other words, the degree of dopamine system activation is inversely proportional to the degree of pain. These 4 cases suggest that aripiprazole, a dopamine system stabilizer, may be a therapeutic option for chronic pain.