Interventions For Management Of Chronic Pain Research Articles

A Systematic Review of Pharmacological Interventions for Chronic Pain Management

Estimates suggest that around 1.5 billion people worldwide suffer from chronic pain, exacerbated by aging demographics. Chronic conditions are linked to additional health issues and reduced quality of life, highlighting the importance of effective treatments. Our study reviewed current pharmacological interventions for chronic pain management using databases like CNKI, CBM, and Embase. Meta-analysis indicated significant pain reduction with compound analgesics compared to opioids, non-opioids, and placebos. Results suggest high efficacy in treating nociplastic, neuropathic, and nociceptive pain. Chronic pain is a significant public health issue requiring effective pharmacological treatments with better side-effect profiles to enhance therapeutic recommendations. A systematic understanding of pain prevalence among healthcare providers, policymakers, and researchers is crucial for addressing socioeconomic factors that aggravate the issue.

Music Therapy for Pain Management for People With Advanced Cancer: A Randomized Controlled Trial.

To improve mechanistic understanding, this randomized controlled trial examined anxiety, mood, emotional support, and pain-related self-efficacy as mediators of music therapy for pain management in people with advanced cancer. People with advanced cancer who had chronic pain were randomized (1:1) to 6 weekly individual music therapy or social attention control sessions. We measured mediators and pain outcomes (pain interference and pain intensity) using self-report measures at baseline, session 4, and post-intervention. We included outcome expectancy/treatment credibility, music reward, adult playfulness, and baseline pain interference and pain intensity as moderators. Participants (n=92) had a mean age of 56years. Most were female (71.7%), white (47.8%) or Black (39.1%), and had stage IV cancer (75%). Self-efficacy was found to be a significant mediator of music therapy for pain intensity (indirect effect ab=0.79, 95% CI 0.01-1.82) and pain interference (indirect effect ab=1.16, 95% CI 0.02-2.51), while anxiety, mood, and emotional support were not. The mediating effect of pain-related self-efficacy was significantly moderated by baseline pain interference but not by the other moderators. The findings suggest that the impact of music therapy on chronic pain is mediated by self-efficacy. This knowledge can help optimize music therapy interventions for chronic pain management for people with advanced cancer by capitalizing on teaching music-based self-management strategies. ClinicalTrials.gov identifier: NCT03432247.

Low-intensity transcranial focused ultrasound suppresses pain by modulating pain-processing brain circuits

AbstractThere is an urgent and unmet clinical need to develop nonpharmacological interventions for chronic pain management because of the critical side effects of opioids. Low-intensity transcranial focused ultrasound (tFUS) is an emerging noninvasive neuromodulation technology with high spatial specificity and deep brain penetration. Here, we developed a tightly focused 128-element ultrasound transducer to specifically target small mouse brains using dynamic focus steering. We demonstrate that tFUS stimulation at pain-processing brain circuits can significantly alter pain-associated behaviors in mouse models in vivo. Our findings indicate that a single-session focused ultrasound stimulation to the primary somatosensory cortex (S1) significantly attenuates heat pain sensitivity in wild-type mice and modulates heat and mechanical hyperalgesia in a humanized mouse model of chronic pain in sickle cell disease. Results further revealed a sustained behavioral change associated with heat hypersensitivity by targeting deeper cortical structures (eg, insula) and multisession focused ultrasound stimulation to S1 and insula. Analyses of brain electrical rhythms through electroencephalography demonstrated a significant change in noxious heat hypersensitivity-related and chronic hyperalgesia–associated neural signals after focused ultrasound treatment. Validation of efficacy was carried out through control experiments, tuning ultrasound parameters, adjusting interexperiment intervals, and investigating effects on age, sex, and genotype in a head-fixed awake model. Importantly, tFUS was found to be safe, causing no adverse effects on motor function or the brain’s neuropathology. In conclusion, the validated proof-of-principle experimental evidence demonstrates the translational potential of novel focused ultrasound neuromodulation for next-generation pain treatment without adverse effects.

The effectiveness, acceptability, and sustainability of non-pharmacological interventions for chronic pain management in older adults in mainland China: A systematic review

ObjectivesThis systematic review aims to assess the effectiveness, acceptability, and sustainability of non-pharmacological pain management interventions for older adults in mainland China. Materials and MethodsArticles searching was conducted across six databases, including MEDLINE, PubMed, PsycINFO, Web of Science, China National Knowledge Infrastructure (CNKI), and WanFangdata. Quality appraisal was performed using the revised Cochrane risk of bias tool. ResultsA total of 26 articles met the inclusion criteria, involving 2,197 participants with a mean age of 69.19 years. The participants' ages ranged from 63.85 to 81.75 years. The evaluated non-pharmacological interventions included psychotherapy, acupuncture, exercise, massage, neurotherapy, and multidisciplinary interventions. The overall changes in pain intensity varied from -5.19 to -0.65 on a numeric rating scale ranging from zero to ten. ConclusionsNon-pharmacological interventions proved effective in alleviating pain intensity among older adults in mainland China. The findings suggest that mindfulness, exercise and pain education can be promoted as viable strategies for enhancing the well-being of the elderly population.

Oxytocin Modulation in Mindfulness-Based Pain Management for Chronic Pain.

In the context of chronic pain management, opioid-based treatments have been heavily relied upon, raising concerns related to addiction and misuse. Non-pharmacological approaches, such as Mindfulness-Based Pain Management, offer alternative strategies. We conducted a mechanistic clinical study to investigate the impact of an 8-week Mindfulness-Based Pain Management intervention on chronic pain, the modulation of inflammatory markers, stress physiology, and oxytocin, and their interplay with clinical pain symptoms and perception, in comparison to a patient wait-list active control. A total of 65 participants, including 50 chronic pain patients and 15 healthy controls, underwent salivary assays to assess endocrine markers, oxytocin, interleukin (IL)-1b, IL-6, IL-8, tumor necrosis factor (TNF)-a, and dehydroepiandrosterone sulphate (DHEA-S). Psychological assessments were also conducted to evaluate aspects of pain perception, mindfulness, mood, and well-being. Findings revealed significant differences between chronic pain patients and healthy controls in various clinical metrics, highlighting the psychological distress experienced by patients. Following Mindfulness-Based Pain Management, oxytocin levels significantly increased in chronic pain patients, that was not observed in the patient wait-list control group. In contrast, cytokine and DHEA-S levels decreased (not to statistically significant margins) supporting anti-inflammatory effects of Mindfulness-Based Pain Management. The fact DHEA-S levels, a marker of stress, did attenuate but not to statistically meaningful levels, suggests that pain reduction was not solely related to stress reduction, and that oxytocin pathways may be more salient than previously considered. Psychological assessments demonstrated substantial improvements in pain perception and mood in the intervention group. These results contribute to the growing body of evidence regarding the effectiveness of mindfulness-based interventions in chronic pain management and underscore oxytocin's potential role as a therapeutic target.

Nursing Interventions in Chronic Pain Management

This paper explores the impact of nursing interventions on pain management outcomes. The study highlights the crucial role of nurses in improving pain control and reducing pain intensity for patients. Through comprehensive pain assessments, medication administration, and implementation of non-pharmacological interventions, nurses contribute to enhanced quality of life and functional ability. Patient satisfaction and adherence to treatment plans are positively influenced by nursing interventions, as nurses prioritize patient education and involve patients in decision-making. The implications for nursing practice include individualized care, interdisciplinary collaboration, and advocacy for adequate resources. Future research should focus on investigating the effectiveness of specific nursing interventions and identifying barriers and facilitators to effective pain management.

Interactive music therapy for chronic pain management in people with advanced cancer: A mechanistic study.

e24119 Background: Chronic pain is one of the most feared symptoms in people with cancer. Although music therapy is frequently used for pain management in cancer care, there is a lack of knowledge of underlying mechanisms. Yet, it is well accepted that knowledge of mediators is essential for optimization of psychosocial treatment interventions. We conducted a multi-site randomized controlled trial to examine mediators hypothesized to account for the pain-reducing effects of interactive music therapy (IMT) in adults with advanced cancer. Methods: This study included adults with advanced cancer (stage III/IV) who had moderate to severe chronic pain caused by 1) locally advanced cancer that had extended to other organs/soft tissue or was impinging on/eroding the bone, 2) bone metastasis, or 3) soft tissue metastasis. We excluded adults with primary central nervous system (CNS) tumor, CNS metastatic disease, or hematologic malignancies. We randomized 92 participants to 6 individual IMT ( n = 45) or social attention control (SAC) ( n = 47) sessions. The mediators (anxiety, mood, pain-related self-efficacy and emotional support) and pain outcomes (pain intensity and pain interference) were measured at baseline, week 4, and week 6 using self-report measures. We included treatment expectancy, music reward, and adult playfulness as moderators. Follow-up interviews were conducted to examine congruence between the hypothesized mediation model and participants’ explanations of how IMT impacted their pain experience. Our target sample size was 100 to achieve 80% power to detect a medium effect at α = 0.05 and 28% attrition. We used ITT analyses and the mediation model per Preacher and Hayes to estimate the total and specific indirect effects of each hypothesized mediator individually. Interview transcripts were analyzed using thematic analysis. Results: Participants were 56±12 years old. Most were female (72%), white (44%) or Black (39%), and had stage IV cancer (75%). The most common types of cancer were breast (46%) and lung (13%). Self-efficacy was found to be a significant mediator for the effect of IMT on pain intensity (indirect effect ab = 0.79, 95% CI 0.01 to 1.82) and pain interference (indirect effect ab = 1.16, 95% CI 0.02 to 2.51), while anxiety, mood, and perceived support were not. The quantitative results were supported by the qualitative findings. None of the proposed moderators were found to be significant. However, we found that the mediating effect of pain-related self-efficacy on pain intensity and pain interference was significantly moderated by baseline pain interference. Conclusions: This study suggests that the impact of music therapy on chronic pain management is mediated through self-efficacy. This knowledge can help further optimize music therapy interventions for chronic pain management in people with advanced cancer by capitalizing on teaching music-based self-management techniques. Clinical trial information: NCT03432247 .

Percutaneous Spinal Interventions for Chronic Pain Management.

Chronic neck and back pain are two of the most common and disabling complaints seen in primary care and neurology practices. Most commonly these come in the form of cervical and lumbar radiculopathy, lumbar spinal stenosis, and cervical and lumbar facet arthropathy. Treatment options are widespread and include nonpharmacological, pharmacological, surgical, and interventional options. The focus of this review will be to discuss the most common interventional procedures performed for chronic cervical and lumbar back pain, common indications for performing these interventions, as well as associated benefits and risks. These interventions alone may not suffice to improve the quality of life in those suffering from chronic pain. However, an understanding of the interventional pain options available and the evidence behind performing these interventions can help providers incorporate these into a multimodal approach to provide effective pain management that may allow patients an improved quality of life.

Hypnosis and relaxation interventions for chronic pain management in cancer survivors: a randomized controlled trial.

Nonpharmacological interventions such as hypnosis show promising evidence for the self-management of pain and pain-related sequelae among cancer survivors. The purpose of this study was to evaluate the efficacy of a 4-week recorded hypnosis intervention in reducing pain intensity compared to a recorded relaxation intervention in cancer survivors with chronic pain. Adult cancer survivors were randomly assigned to listen to hypnosis (n = 55) or relaxation recordings (n = 54) daily for 28days. Primary (pain intensity) and secondary outcomes (pain interference, anxiety, depression, fatigue, sleep disturbance) measures were completed pre- and post-treatment. Treatment effects were evaluated using a series of analyses of covariance. Both hypnosis and relaxation provided significant and moderate to large improvements in the primary outcome and the secondary outcomes of pain interference and anxiety (ds = 0.44-0.88). The hypnosis group also experienced a moderate improvement in fatigue (d = 0.47) and sleep disturbance (d = 0.54). The effect size for pain reduction from pre- to post-treatment for the hypnosis group was d = 0.86 and for the relaxation group, d = 0.88. There were no significant between-group differences in primary and secondary outcomes from pre- to post-treatment. The results support that recorded hypnosis and relaxation interventions are similarly effective in reducing pain and the pain-related sequelae of pain interference and anxiety among cancer survivors with chronic pain. The hypnosis intervention also reduced fatigue and sleep disturbance. Audio recordings can provide a convenient delivery method of nonpharmacological interventions to self-manage chronic pain. ClinicalTrials.gov Identifier: NCT03867760, registered March 8, 2019.

Dietary Interventions Are Beneficial for Patients with Chronic Pain: A Systematic Review with Meta-Analysis.

The standard Western diet is high in processed hyperpalatable foods that displace nutrient-dense whole foods, leading to inflammation and oxidative stress. There is limited research on how these adverse metabolic drivers may be associated with maladaptive neuroplasticity seen in chronic pain and whether this could be attenuated by a targeted nutritional approach. The aim of this study was to review the evidence for whole-food dietary interventions in chronic pain management. A structured search of eight databases was performed up to December 2019. Two independent reviewers screened studies and evaluated risk of bias by using the National Institutes of Health assessment tool for controlled or pre-post studies and the Joanna Briggs checklist for case reports. A meta-analysis was performed in Review Manager. Forty-three studies reporting on 48 chronic pain groups receiving a whole-food dietary intervention were identified. These included elimination protocols (n = 11), vegetarian/vegan diets (n = 11), single-food changes (n = 11), calorie/macronutrient restriction (n = 8), an omega-3 focus (n = 5), and Mediterranean diets (n = 2). A visual analog scale was the most commonly reported pain outcome measure, with 17 groups reporting a clinically objective improvement (a two-point or 33% reduction on the visual analog scale). Twenty-seven studies reported significant improvement on secondary metabolic measures. Twenty-five groups were included in a meta-analysis that showed a significant finding for the effect of diet on pain reduction when grouped by diet type or chronic pain type. There is an overall positive effect of whole-food diets on pain, with no single diet standing out in effectiveness. This suggests that commonalities among approaches (e.g., diet quality, nutrient density, weight loss) may all be involved in modulating pain physiology. Further research linking how diet can modulate physiology related to pain (such as inflammation, oxidative stress, and nervous system excitability) is required.

RGSz1 actions in the periaqueductal gray modulate opioid reward and analgesic tolerance

Regulator of G protein signaling z1 (RGSz1), is a member of the RGS family of proteins, and present in several networks expressing mu opioid receptors. Previous studies in our lab have shown that RGSz1 knockout increases the analgesic efficacy of synthetic opioids, and delays the development of tolerance. On the other hand, knockout of RGSz1 decreases the rewarding efficacy of morphine in the place conditioning paradigm and prevents its locomotor sensitizing actions (Gaspari, et al, PNAS 2018). We further demonstrated the impact of RGSz1 in tolerance to synthetic opioids using a three‐week tolerance paradigm. These opposing roles of RGSz1 in reward versus analgesic efficacy make it an interesting target for the development of therapeutic interventions for chronic pain management. The goal of this work is to identify the RGSz1 circuits involved in the modulation of morphine’s rewarding and analgesic actions.To gain insight on the regional role of RGSz1 in the rewarding effects of morphine, we conditionally downregulated RGSz1 in the nucleus accumbens and in the ventrolateral periaqueductal gray (vlPAG). For these experiments, RGSz1fl\fl mice were infected in the vlPAG with adeno‐associated vectors expressing Cre recombinase. Downregulation of RGSz1 in the vlPAG of adult mice decreased sensitivity to the rewarding effects of morphine in the conditioned place preference (CPP) assay. Next, we hypothesized that RGSz1 actions in vlPAG projections to the ventral tegmental area (VTA) modulate the rewarding actions of opioids. We used a chemogenetic approach to test if activation of vlPAG‐VTA circuitry promotes morphine place preference. For these studies, the VTA of male C57BL/6 mice was infected with pAAV‐pkg‐Cre vectors and the vlPAG with pAAV‐hSyn‐DIO‐hM3D(Gq)‐mCherry (AAV8), and mice were tested in the CPP assay five weeks later. Activation of vlPAG‐VTA projections increased morphine reward sensitivity as pAAV‐hSyn‐DIO‐hM3D(Gq)‐mCherry expressing mice showed significant place preference to 3mg/kg, whereas control animals developed CPP to 5 mg/kg of morphine. Notably, this intervention did not affect the analgesic actions of morphine. Circuit‐specific gene down regulation approaches are currently used to test the hypothesis that RGSz1 actions in vlPAG‐VTA projections affect the rewarding efficacy of morphine. For these experiments, the VTA of RGSz1fl\fl mice was infected with pAAV‐EF1a‐fDIO‐Cre and the vlPAG with pAAV‐Ef1a‐Flpo vectors, and 5 weeks later mice are tested in the CPP assay.Overall, our studies have identified that RGSz1 actions in the vlPAG control the rewarding efficacy of opioid analgesics. Furthermore, we provide insight on the mechanism of RGSz1 action in vlPAG‐VTA circuit as an important pathway for mediating morphine’s rewarding actions. Therefore, targeting RGSz1 serves as potential avenue that optimizing the actions of prescription opioids.Support or Funding InformationSupported by R01 NS086444, R56 NS111351 NINDS, and P01 DA008227, NIDA

Editorial.

The year 2020 has been designated as the “Year of the Nurse and Midwife” by the World Health Organization, in honor of the 200th anniversary of the birth of Florence Nightingale. Although midwives are only occasionally involved in the care of individuals with MS, the essential role of nursing professionals in the comprehensive management of the disease cannot be overemphasized. Indeed, nurses are often at the forefront, ensuring optimal continuity and coordination of care and providing ongoing communication with the patients and their families, and with other health care professionals. While we have been publishing articles specifically dedicated to nursing research and nursing practice in IJMSC, I do hope to see more submissions from our nurse colleagues in 2020.The article selected for continuing education credits in this issue focuses on an alternative treatment used and contemplated by some people with MS: helminth immunotherapy. Along with increasingly potent disease-modifying therapies targeting the immune system, other less conventional treatment avenues are being proposed, and are often the source of heated discussions on public online forums. Our patients expect us to educate them about all options available, yet the evidence regarding alternative treatments is often limited or conflicting. Donkers and colleagues give us insight into patients' thoughts about helminth immunotherapy, which is an important first step in fostering better conversations and educational opportunities.Outcome measurement is an increasingly common discussion topic in clinical practice nowadays. Two articles in this issue reflect ongoing work on the validity and clinical relevance of outcome scales in MS, whether they are clinician-administered such as the Expanded Disability Status Scale (Alonso and colleagues) or self-administered such as the Multiple Sclerosis Self-Management Scale–Revised (Saadat and colleagues).I often explain to health care professionals in training that a diagnosis of MS does not describe the impact of the disease on a person's daily activities. The study by Goverover and colleagues reminds us of the pervasive decrease in activity participation experienced by patients with MS and of the association between neurologic deficits (such as motor and cognitive impairment) and comorbidities (such as depression) and these limitations. Fortunately, we also know that physical activity and exercise can help fight the consequences of MS, as illustrated by the articles from Canning and Hicks and from Kasser and colleagues. Another common consequence of MS is chronic pain. The results from the randomized controlled trial of cognitive behavioral therapy reported by Gromisch and colleagues suggest that this therapy could be a useful intervention, at a time when nonpharmacologic interventions for chronic pain management are increasingly sought after.I am delighted to announce that Dr. Alissa Willis, Chair of the Department of Neurology at the University of Mississippi Medical Center, has joined our editorial team as Associate Editor starting January 2020 after having served as a board member for many years. Our entire team wishes you a happy and fulfilling year.

Meeting Physician Compliance Recommendations in the Management of Opioids in Chronic Pain: The Chronic Pain Management Registry (CPMR).

In a recent commentary in INNOVATIONS in Pharmacy, details were given on a recently released Chronic Pain Management Registry (CPMR). The CPMR was designed to provide a tracking and audit framework for evaluating claims made for therapy interventions in chronic pain management. At the same time, the CPMR was seen as a key element in monitoring physician and practice compliance with requirements for the prescribing of opioids and other scheduled substances. The purpose of the present commentary is to expand upon the role of the CPMR in the management of opioids in detailing the concordance of the CPMR data collection requirements with the latest recommendations of the American Society of Interventional Pain Physicians (ASIPP) for responsible, safe and effective opioid prescribing in chronic non-cancer pain. Given ongoing concerns with opioid misuse and abuse, the opioid epidemic, physician practices are at risk for what may be judged as poor therapy decisions in evaluating medical necessity and a failure to monitor effectively response to therapy. Adoption of a platform such as the CPMR may, through providing a comprehensive evidence base and tracking capability, support more effective prescribing decisions and adherence to therapy. At the same time, the ability to justify decisions through a CPMR documentation audit may not only alleviate physician concerns if their decisions are challenged but also lead to improved outcomes in the treatment of chronic pain.

Clinical Pharmacy Services in a Multidisciplinary Specialty Pain Clinic.

To describe a model of clinical pharmacy services as part of a multidisciplinary specialty pain clinic by discussing (1) the role of a clinical pharmacist in a specialty setting, including clinical interventions implemented, and (2) how integration of a clinical pharmacist may translate into an improved patient care model for the management of chronic pain. A retrospective chart review was conducted of pharmacist visits from October 1, 2013, to September 30, 2015, in a specialty pain clinic at an academic medical center in Los Angeles, California. Data were collected regarding medication-related problems (MRPs) identified by the pharmacist, interventions implemented to resolve the MRPs, and types of medication care coordination activities (MCCAs) performed by the pharmacist, such as responding to medication refill requests and insurance issues. Descriptive statistics were used. Institutional review board approval was obtained prior to initiating the study. At least 1 MRP was identified in 98.7% of the 380 visits. Problems identified by the clinical pharmacist were divided into 5 categories: medication refills needed (43%), medication appropriateness/effectiveness (18%), miscellaneous (17%), safety (16%), and nonadherence/patient variables (6%). Interventions focused on referral to appropriate providers, medication counseling, medication initiation, dose adjustment, and medication discontinuation. The most common MCCA was responding to refill requests. A clinical pharmacist can identify many MRPs and implement interventions in chronic pain management. Integration of clinical pharmacy services may improve practice management by facilitating the completion of MCCAs and increase access to patients' needs outside the clinic.

Use of Self-management Interventions for Chronic Pain Management: A Comparison between Rural and Nonrural Residents

Individuals with chronic pain who live in rural communities often lack access to pain specialists and rely on primary care providers who may be less prepared. Research has indicated that rural residents with chronic pain are more likely to receive an opioid prescription than nonrural residents. Although self-management approaches are available for chronic pain management, it is unclear to what extent rural residents use these interventions. This study compares usage of self-management interventions and opioid-based analgesics for chronic pain management between rural and nonrural residents. This study is a secondary analysis of baseline data from a randomized controlled trial evaluating a telehealth intervention for chronic pain management. Participants, recruited from primary care clinics, were 65 rural residents and 144 nonrural residents with similar demographic characteristics. Differences in the use of self-management interventions, pain intensity, and opioid dose were evaluated between rural and nonrural residents. Rural residents (n = 50, 77%) were less likely to use self-management interventions compared with nonrural residents (n = 133, 92%) (p = .019). Opioids were taken for pain relief by 76% of the rural residents compared with 52% of the nonrural residents. A disparity exists in the use of self-management interventions for chronic pain management by rural residents compared with nonrural residents. Further study is needed to determine if this is related to the lack of access to specialists and/or pain management training of primary care providers. Nurses can play an essential role in addressing this disparity by educating patients about self-management interventions.

Tailored Web-Based Interventions for Pain: Systematic Review and Meta-Analysis.

BackgroundEfforts have multiplied in the past decade to underline the importance of pain management. For both acute and chronic pain management, various barriers generate considerable treatment accessibility issues, thereby providing an opportunity for alternative intervention formats to be implemented. Several systematic reviews on Web-based interventions with a large emphasis on chronic pain and cognitive behavioral therapy have been recently conducted to explore the influence of these interventions on pain management However, to our knowledge, the specific contribution of tailored Web-based interventions for pain management has not been described and their effect on pain has not been evaluated.ObjectiveThe primary aim of this systematic review was to answer the following research question: What is the effect of tailored Web-based pain management interventions for adults on pain intensity compared with usual care, face-to-face interventions, and standardized Web-based interventions? A secondary aim was to examine the effects of these interventions on physical and psychological functions.MethodsWe conducted a systematic review of articles published from January 2000 to December 2015. We used the DerSimonian-Laird random effects models with 95% confidence intervals to calculate effect estimates for all analyses. We calculated standardized mean differences from extracted means and standard deviations, as outcome variables were measured on different continuous scales. We evaluated 5 different outcomes: pain intensity (primary outcome), pain-related disability, anxiety, depression, and pain catastrophizing. We assessed effects according to 3 time intervals: short term (<1 month), medium term (1-6 months), and long term (6-12 months).ResultsAfter full-text review, we excluded 31 articles, resulting in 17 eligible studies. Only 1 study concerned acute pain and was removed from the meta-analysis, resulting in 16 studies available for quantitative assessment. Compared with standard care or a waiting list, tailored Web-based intervention showed benefits immediately after, with small effect sizes (<0.40) for pain intensity (10 randomized controlled trials [RCTs], n=1310, P=.003) and pain-related disability (6 RCTs, n=953, P<.001). No other improvements were observed at follow-up in the medium and long terms. Compared with the active control group, no improvements were found for the primary outcome (pain intensity) or any of the outcomes except for a small effect size on pain catastrophizing (2 RCTs, n=333, P<.001) immediately after the intervention.ConclusionsTailored Web-based interventions did not prove to be more efficacious than standardized Web-based interventions in terms of pain intensity, pain-related disability, anxiety, and depression. An interesting finding was that some efficacy was shown on pain catastrophizing compared with active control interventions. Considering the diversity of approaches used in tailored Web-based interventions for chronic pain management, their efficacy is yet to be explored. Moreover, their contribution to acute pain management is embryonic.Trial RegistrationInternational prospective register of systematic reviews (PROSPERO): CRD42015027669; http://www.crd.york.ac.uk/PROSPERO/display_record.php?ID=CRD42015027669 (Archived by WebCite at http://www. webcitation.org/6uneWAuyR)

Brief Psychological and Hypnotic Interventions in Chronic Pain Management

This article will explore how brief psychological approaches using hypnosis and imagery can be used with patients with chronic pain, predominantly in a Primary Care setting, although much that is discussed here could be applied in the Secondary sector. Chronic pain is defined as pain which endures for more than 6 months and may last for months or years. It serves no physiological purpose and persists after the time that ‘normal’ healing would be supposed to have taken place. Chronic pain may also range from that of cancer or arthritis, to that which seems to have no single or obvious physical causation. Teaching self-hypnosis and use of imagery can give these patients tools that they can use to help themselves, not only with pain, but also with the emotional distress that so often accompanies and exacerbates it. Unlike medication, self-hypnosis has only positive side effects and can give back some measure of control to patients who feel helpless and hopeless.

Differential fMRI Activation Patterns to Noxious Heat and Tactile Stimuli in the Primate Spinal Cord.

Mesoscale local functional organizations of the primate spinal cord are largely unknown. Using high-resolution fMRI at 9.4 T, we identified distinct interhorn and intersegment fMRI activation patterns to tactile versus nociceptive heat stimulation of digits in lightly anesthetized monkeys. Within a spinal segment, 8 Hz vibrotactile stimuli elicited predominantly fMRI activations in the middle part of ipsilateral dorsal horn (iDH), along with significantly weaker activations in ipsilateral (iVH) and contralateral (cVH) ventral horns. In contrast, nociceptive heat stimuli evoked widespread strong activations in the superficial part of iDH, as well as in iVH and contralateral dorsal (cDH) horns. As controls, only weak signal fluctuations were detected in the white matter. The iDH responded most strongly to both tactile and heat stimuli, whereas the cVH and cDH responded selectively to tactile versus nociceptive heat, respectively. Across spinal segments, iDH activations were detected in three consecutive segments in both tactile and heat conditions. Heat responses, however, were more extensive along the cord, with strong activations in iVH and cDH in two consecutive segments. Subsequent subunit B of cholera toxin tracer histology confirmed that the spinal segments showing fMRI activations indeed received afferent inputs from the stimulated digits. Comparisons of the fMRI signal time courses in early somatosensory area 3b and iDH revealed very similar hemodynamic stimulus-response functions. In summary, we identified with fMRI distinct segmental networks for the processing of tactile and nociceptive heat stimuli in the cervical spinal cord of nonhuman primates. Significance statement: This is the first fMRI demonstration of distinct intrasegmental and intersegmental nociceptive heat and touch processing circuits in the spinal cord of nonhuman primates. This study provides novel insights into the local functional organizations of the primate spinal cord for pain and touch, information that will be valuable for designing and optimizing therapeutic interventions for chronic pain management.

Future implications of eHealth interventions for chronic pain management in underserved populations.

Many underserved communities, especially those in rural settings, face unique challenges that make high quality healthcare less accessible. The implementation of eHealth technologies has become a potentially valuable option to disseminate interventions. The authors' work in rural Alabama Federally Qualified Health Centers provide insights into the access to technology as well as the likelihood of utilizing eHealth technology in underserved communities. This paper will review current challenges related to digital dissemination of behavioral health interventions for chronic pain. Two major concerns are the lack of technological resources and the lack of appropriate materials for patients who may have low levels of reading, health and/or digital literacy. We will propose some recommendations to address common barriers faced by those providing care.

Assessment of the Escalating Growth of Facet Joint Interventions in the Medicare Population in the United States from 2000 to 2011

Background: Both the Office of Inspector General (OIG) and reports from studies of the utilization of facet joint interventions have expressed that explosive increases in facet joint interventions provided to spinal pain patients are a major concern. Study Design: The study is designed to assess the growth of facet joint interventions in managing spinal chronic pain in Medicare beneficiaries from 2000 to 2011. Objective: To assess the use of facet joint interventions in chronic pain management. Methods: The study was performed utilizing the Centers for Medicare and Medicaid Services (CMS) physician supplier procedure summary master data from 2000 to 2011. Results: The utilization of all types of facet joint interventions increased enormously from 2000 to 2011, with an overall increase of 308% per 100,000 Medicare beneficiaries and a 13.6% average annual increase. In addition, the highest increases were seen for cervical/ thoracic radiofrequency neurotomy with 836%, followed by an increase of 662% for lumbar/ sacral radiofrequency neurotomy, a 359% increase in cervical/thoracic facet joint injections, and 228% increase in lumbosacral facet joint injections. In reference to the number of procedures performed, however, the highest numbers were in the lumbosacral region with 990,449 total procedures of lumbar facet joint blocks and 406,378 lumbosacral radiofreqency neurotomies in 2011. Cervical and thoracic facet joint nerve blocks were 317,220, whereas cervical and thoracic radiofrequency neurotomies were 97,526 in 2011. The data also showed that there were enormous increases in the proportion of procedures performed by the specialty of physical medicine and rehabilitation, with an increase of 781% and an annual increase of 21.9% excluding physicians of physical medicine and rehabilitation enrolled as interventional pain management or pain management. Even though the numbers were very low for nurse anesthetists, nurse practitioners, and physician assistants, the increases were from 143 in 2000 to 21,263 in 2011, providing an annual increase of 55.2%, an overall increase of 12,460%. Limitations: The limitations of this study included a lack of inclusion of Medicare participants in Medicare Advantage plans, as well as potential documentation, coding, and billing errors. Furthermore, the data provided for state utilizations is based on claims data for that state which also may include patients from contiguous or other states receiving services in those states. Conclusions: The explosive increase in the number of lumbar facet joint interventions performed began to wane in 2008. From 2008 to 2010, the utilization of facet joint interventions declined by 6%. Key Words: Chronic spinal pain, interventional pain management, interventional techniques, facet joint injections, medial branch blocks, radiofrequency neurotomy