Pain In Clinical Practice Research Articles

Low-value interventions to deimplement: A secondary analysis of a systematic review of low back pain clinical practice guidelines.

To perform a secondary review of low back pain (LBP) clinical practice guidelines (CPG) identified in a recently conducted systematic review and to synthesize and summarize low-value recommendations as practices that may be candidates for deimplementation. LBP (subacute or chronic) CPGs in English (symptom based, created by a governmental or professional society, published between January 1990 and May 2020) were previously identified using MEDLINE, EMBASE, CINAHL, Ortho Guidelines, CPG Infobase, Emergency Care Research Institute, Guidelines International Network, National Institute of Health and Care Excellence, and Scottish Intercollegiate Guideline Network. Twenty-one CPGs were reviewed from a systematic review (previously published). Full-text review of all 21 CPGs was conducted, and three recommendation categories indicative of low value (recommend strongly against, recommend weakly against, inconclusive/insufficient evidence) were identified using the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) language and approach. One hundred thirty-five low-value recommendations were identified and classified under eight intervention categories: orthotics/support, traction, physical modalities, pharmacological interventions, injections, surgery, bed rest, and miscellaneous. Traction, transcutaneous electrical nerve stimulation (TENS), therapeutic ultrasound (TUS), and selective serotonin reuptake inhibitors (SSRI) had the most CPGs recommend strongly against their usage. Opioids were recommended strongly against by four CPGs. No significant difference (p > .05) was found between CPG quality and a specific deimplementation recommendation or between CPG quality and the number of strongly against, weakly against, and inconclusive/insufficient evidence recommendations. Clinicians managing patients with chronic LBP should consider deimplementing these low-value interventions (traction, TENS, TUS, and SSRI).

Bilateral hand dystonia following high-velocity thrust manipulation: a case report.

Thrust manipulation is one of the most commonly used techniques for managing musculoskeletal pain in clinical practice. This involves the application of a high-velocity, low-amplitude force directed to the joints with the intent of achieving joint cavitation. This current case report describes a female in her mid-20s who presented with excessive bilateral and involuntary hand muscle contractions after bilateral thrust manipulation. Dystonia appeared both at rest and during voluntary movements but was aggravated by actions such as finger flexion or spreading and disappeared during sleep. A diagnosis of complex regional pain syndrome (CRPS) type I combined with dystonia was made. Prednisolone administered between 2 and 5 weeks after symptom onset significantly reduced CRPS symptoms, but intramuscular botulinum toxin injection 5 weeks after symptom onset was ineffective at controlling her symptoms. Seven weeks after symptom onset, the patient was administered 2 mg trihexyphenidyl oral twice a day, 2.5 mg diazepam oral twice a day and 5 mg baclofen oral three times a day for 1 month and this significantly reduced dystonia, but complete resolution was not achieved. Clinicians should be aware that dystonia is a rare complication of thrust manipulation.

Hemoglobin α-derived peptides VD-hemopressin (α) and RVD-hemopressin (α) are involved in electroacupuncture inhibition of chronic pain.

Knee osteoarthritis (KOA) is a chronic degenerative bone metabolic disease that primarily affects older adults, leading to chronic pain and disability that affect patients' daily activities. Electroacupuncture (EA) is a commonly used method for the treatment of chronic pain in clinical practice. Previous studies indicate that the endocannabinoid system is involved in EA analgesia, but whether endocannabinopeptide VD-hemopressin (α) and RVD-hemopressin (α) derived from hemoglobin chains are involved in EA analgesia is unclear. RNA-seq technology was used to screen which genes involved in EA analgesia. The expression of hemoglobin α chain and 26S proteasome were determined by Western blotting. The level of VD-hemopressin (α) and RVD-hemopressin (α) were measured by UPLC-MS/MS. Microinjection VD-Hemopressin (α), RVD-Hemopressin (α) and 26S proteasome inhibitor MG-132 into vlPAG, then observe mechanical and thermal pain thresholds. Therefore, we used RNA-seq to obtain differentially expressed genes Hba-a1 and Hba-a2 involved in EA analgesia in the periaqueductal gray (PAG), which were translated into the hemoglobin α chain. EA significantly increased the expression of the hemoglobin α chain and the level of hemopressin (α) and RVD-hemopressin (α). Microinjection of VD-hemopressin (α) and RVD-hemopressin (α) into the ventrolateral periaqueductal gray (vlPAG) mimicked the analgesic effect of EA, while CB1 receptor antagonist AM251 reversed this effect. EA significantly increased the expression of 26S proteasome in KOA mice. Microinjection of 26S proteasome inhibitor MG132 before EA prevented both the anti-allodynic effect and upregulation of the concentration of RVD-hemopressin (α) by EA treatment and upregulated the expression of the hemoglobin α chain. Our data suggest that EA upregulated the concentration of VD-hemopressin (α) and RVD-hemopressin (α) through enhancement of the hemoglobin α chain degradation by 26S proteasome in the PAG, then activated the CB1 receptor, thereby exerting inhibition of chronic pain in a mouse model of KOA. These results provide new insights into the EA analgesic mechanisms and reveal possible targets for EA treatment of chronic pain.

Effect of Intra-articular Atelocollagen Injections for Patients With Knee Osteoarthritis: A Retrospective Chart Review.

Background Osteoarthritis (OA) is a prevalent and exhausting condition often requiring long-term management. While there is a steady growth in the use of collagen-based treatment for OA, there is a lack of studies assessing the safety and efficacy of repeated administration of injectable atelocollagen for OA. Objective This study aims to evaluate the clinical efficacy and safety of repeated administration of injectable atelocollagen in reducing knee pain for patients with knee OA. Methods Clinical records of 91 patients from five hospitals were reviewed for this retrospective study. All 91 patients had received repeated administration of injectable atelocollagen (CartiPRO®, Dalim Tissen Co., Ltd., South Korea) as a treatment for knee OA for seven months. The efficacy of injectable atelocollagen was evaluated by physicians at least 30 days after the last administration, with outcomes categorized as "effective", "moderately effective", or "not effective". For analysis purposes, both "effective" and "moderately effective" were grouped as "effective"while "not effective" was classified as "ineffective". Safety was assessed by monitoring the incidence of adverse events (AEs) reported within six months following the re-administration of atelocollagen. Results Among the 91 patients, 96.7% (88 patients) experienced effective pain relief following the re-administration of CartiPRO®, with 3.3% (three patients) reporting ineffectiveness. In terms of safety assessment, 35 patients reported AEs, totaling up to 44 events, with no serious or unexpected device-related AEs. Conclusion The repeated use of atelocollagen was found to be both safe and effective in managing knee pain for patients with knee OA. These findings support the repeated use of injectable atelocollagen as a reliable treatment option for managing knee OA pain in clinical practice.

Measurement Error, Minimal Detectable Change, and Minimal Clinically Important Difference of the Short Form-36 Health Survey, Hospital Anxiety and Depression Scale, and Pain Numeric Rating Scale in Patients With Chronic Pain

In both pain research and clinical practice, patient-reported outcome measures are used to assess dimensions of health. Interpreting these instruments requires understanding their measurement error and what magnitude of change has subjective importance for patients. This study estimated the standard error of measurement, 1-year minimal detectable change, and 1-year minimal clinically important difference (MCID) for the Short Form-36 Health Survey physical component summary and mental component summary, the Hospital Anxiety and Depression Scale subscales for anxiety symptoms and depression symptoms, and the numeric rating scale for past-week average pain intensity. MCIDs for these instruments have not previously been estimated in a large sample of chronic pain patients participating in interdisciplinary pain rehabilitation. Data were drawn from the Swedish Quality Registry for Pain Rehabilitation (n = 8,854 patients). MCID was estimated as average change and change difference based on 3 different anchors. MCID estimates were 2.62 to 4.69 for Short Form-36 Health Survey physical component summary, 4.46 to 6.79 for Short Form-36 Health Survey mental component summary, .895 to 1.48 for numeric rating scale, 1.17 to 2.13 for anxiety symptoms in the Hospital Anxiety and Depression Scale, and 1.48 to 2.54 for depression symptoms in the Hospital Anxiety and Depression Scale. The common assumption of an identical standard error of measurement for pre- and post-treatment measurements was not always applicable. When estimating MCID, researchers should select an estimation method and anchor aligned with the study’s context and objectives. PerspectiveThis article presents estimates of MCID and minimal detectable change for several commonly used patient-reported outcome measures among patients with chronic pain. These estimates can help clinicians and researchers to determine when a measured health improvement is subjectively important to the patient and greater than measurement error.

Intra- and Inter-rater Reliability of the Lumbar-Locked Thoracic Rotation Test in Patients With Neck Pain.

Neck pain is a common musculoskeletal disorder. Therefore, establishing effective physical therapy for neck pain is one of the most important issues. In addition, in physical therapy for neck pain, it is important to evaluate the thoracic spine, which is an adjacent region of the neck. The lumbar-locked rotation test is designed to evaluate the rotational range of the thoracic spine. However, the reliability of the test when performed on patients with neck pain has not been confirmed. We aimed to determine the intra- and inter-rater reliability of the lumbar-locked rotation test in patients with neck pain. In this study involving 43 patients, two separate examiners measured thoracic spine rotation. Both examiners conducted three measurements for each side, before and after a five-minute interval. Reliability was assessed using various intra-class correlation coefficient (ICC) models. The intra-rater reliability showed ICC values of 0.99 for both examiners. The inter-rater reliability showed ICC values of 0.98 for both right and left thoracic rotations. The findings strongly suggest that the lumbar-locked rotation test has high within-session intra- and inter-rater reliability for patients with neck pain. This test can be considered a reliable method of measuring the thoracic spine rotational range of motion in patients with neck pain in clinical practice.

Shedding light on neuropathic pain: Current and emerging tools for diagnosis, screening, and quantification.

Ensuring the proper management of neuropathic pain is a contemporary challenge for professionals who care for patients with this type of pain. The estimated prevalence of neuropathic pain in Europe is 7%-8%. The objective of this study was to perform a non-systematic review on the diagnosis, screening, and quantification of neuropathic pain. For this purpose, a search was conducted of the PubMed/Medline, ScienceDirect, OVID, and SciELO databases for available evidence. The findings highlight the common occurrence of chronic neuropathic pain in clinical practice. However, diagnosing and managing this type of pain pose challenges due to its complexity and the individualized nature of cases. Precise diagnosis is crucial for effective management, involving therapeutic approaches that go beyond traditional pain treatments. It is noteworthy that until recent times, general questionnaires were utilized to assess neuropathic pain, lacking the ability to distinguish it from nociceptive pain or evaluate its broader impact on well-being. Biomarker pain panels hold promise in identifying treatable pain causes and evaluating treatment effectiveness. In conclusion, this review describes the diagnostic methods and tools for screening and quantifying neuropathic pain.

The role of stigma in health and functioning in chronic pain: Not just catastrophizing.

People with chronic pain are frequently exposed to stigma, which is typically distressing and may lead to internal stigmatizing thoughts. The thought content associated with stigma has similarities to pain catastrophizing, although these concepts differ in that stigma is arguably more social in origin. Stigma can be measured by the Stigma Scale for Chronic Illness - 8-item version (SSCI-8). In this study, we first demonstrate the validity of this measure in Swedish. We then examine the role of stigma in the health and functioning of people with chronic pain, particularly beyond the role played by pain catastrophizing. Adult participants (N = 404) with chronic pain recruited online completed measures of pain, stigma, catastrophizing, pain interference, work and social adjustment and depression on two occasions. A one-factor solution had an overall good model fit as long as residuals were allowed to covary, indicating some redundancy in the items. The SSCI-8 demonstrated good internal consistency and moderate temporal stability, and SSCI-8 scores demonstrated medium-to-large correlations with the measures of health and functioning. Furthermore, stigma was found to significantly contribute to explained variance in pain interference, work and social adjustment and depression, uniquely adding to the explained variance in these outcomes even after accounting for pain catastrophizing. The SSCI-8 provides an adequate measure to capture stigma experiences. Stigma is uniquely associated with pain-related outcomes and should be further considered in pain research and clinical practice in the future. This study points to the importance of a social perspective on pain-related outcomes. We may need to more fully appreciate the way that people with chronic pain are treated by both health care providers and others can have an impact on their well-being. Potential negative impacts of stigmatizing responses to people with chronic pain are highlighted by the current results.

Panax notoginseng saponins inhibits oxidative stress- induced human nucleus pulposus cell apoptosis and delays disc degeneration in vivo and in vitro

Ethnopharmacological relevancePanax notoginseng (Burk) F. H. Chen has been a popular traditional Chinese medicine with a long history of treating low back pain. Its main active ingredient, Panax notoginseng saponins (PNS), can be found in several Chinese patent medicines that are frequently used to treat blood stasis type low back pain. Intervertebral disc degeneration (IDD) is the most common cause of back pain, and the injection of PNS has been used to relieve IDD-induced back pain in clinical practice. Despite its effectiveness, the exact mechanisms of action for PNS injections remain unclear. Aim of the studyIDD as a consequence of aging involves apoptosis of nucleus pulposus (NP) cells and imbalanced degradation of extracellular matrix (ECM) induced by several factors including oxidative stress. We hypothesized that PNS may have a therapeutic effect on IDD via inhibiting apoptosis of NP cells and degradation of ECM under oxidative stress. Materials and methodsIn this study, network pharmacology was initially employed to predict the targets of PNS against IDD. Subsequently, commercial PNS was analyzed by high-performance liquid chromatography to confirm the ingredients for in vitro and in vivo experiments. In vitro experiments were conducted on human nucleus pulposus (HNP) cells, including CCK-8, RT-PCR, Western blot, immunofluorescence staining, autophagic flux detection, and TUNEL assay. In vivo experiments were also performed on rats with IDD of tail discs induced by annular fibrosus needle puncture, which involved MRI, HE staining, and immunohistochemistry. ResultsOur study demonstrated the theoretical targets of PNS against IDD, including Caspase 3, MMP13, Akt, and autophagy, based on network pharmacology. Subsequently, in vitro experiments revealed that PNS attenuated cellular apoptosis of NP by suppressing the expression of cleaved-caspase 3 and the ratio of Bax/Bcl-2 under H2O2 stimulation. Autophagy was also inhibited by PNS treatment, and the protective effect was abolished with rapamycin, an autophagy inducer, indicating that autophagy inhibition was involved in the protective effect of PNS on IDD. Furthermore, Akt/mTOR pathway activation was observed in HNP cells responding to H2O2 with PNS treatment, which played a role in autophagy downregulation. PNS was also shown to promote the expression of anabolic genes such as COL2A1 and ACAN while inhibiting the expression of catabolic gene MMP13 in HNP cells. In addition, the in vivo study revealed that PNS treatment could ameliorate IDD in a puncture-induced rat tail model. The development of IDD was significantly reduced, and there was decreased MMP13 expression, as well as increased COL2A1 protein expression in NP tissues. ConclusionOur study showed that PNS could protect HNP cells against apoptosis via autophagy inhibition and ameliorate disc degeneration in vivo, indicating its potential to be a therapeutic agent for IDD.

Design and Evaluation of Deep Learning Models for Continuous Acute Pain Detection Based on Phasic Electrodermal Activity.

The current method for assessing pain in clinical practice is subjective and relies on self-reported scales. An objective and accurate method of pain assessment is needed for physicians to prescribe the proper medication dosage, which could reduce addiction to opioids. Hence, many works have used electrodermal activity (EDA) as a suitable signal for detecting pain. Previous studies have used machine learning and deep learning to detect pain responses, but none have used a sequence-to-sequence deep learning approach to continuously detect acute pain from EDA signals, as well as accurate detection of pain onset. In this study, we evaluated deep learning models including 1-dimensional convolutional neural networks (1D-CNN), long short-term memory networks (LSTM), and three hybrid CNN-LSTM architectures for continuous pain detection using phasic EDA features. We used a database consisting of 36 healthy volunteers who underwent pain stimuli induced by a thermal grill. We extracted the phasic component, phasic drivers, and time-frequency spectrum of the phasic EDA (TFS-phEDA), which was found to be the most discerning physiomarker. The best model was a parallel hybrid architecture of a temporal convolutional neural network and a stacked bi-directional and uni-directional LSTM, which obtained a F1-score of 77.8% and was able to correctly detect pain in 15-second signals. The model was evaluated using 37 independent subjects from the BioVid Heat Pain Database and outperformed other approaches in recognizing higher pain levels compared to baseline with an accuracy of 91.5%. The results show the feasibility of continuous pain detection using deep learning and EDA.

Pain Management at the End of Life in the Emergency Department: A Narrative Review of the Literature and a Practical Clinical Approach

Access to pain management is a fundamental human right for all people, including those who are at the end of life (EOL). In end-stage patients, severe and uncontrolled pain is a common cause of admission to the emergency department (ED), and its treatment is challenging due to its complex, often multifactorial genesis. The aim of this narrative review was to identify the available literature on the management of severe EOL pain in the ED. The MEDLINE, SCOPUS, EMBASE, and CENTRAL databases were searched from inception to 1 April 2023 including randomised controlled trials, observational studies, systemic or narrative reviews, case reports, and guidelines on the management of EOL pain in the ED. A total of 532 articles were identified, and 9 articles were included (5 narrative reviews, 2 retrospective studies, and 2 prospective studies). Included studies were heterogeneous on the scales used and recommended for pain assessment and the recommended treatments. No study provided evidence for a better approach for EOL patients with pain in the ED. We provide a narrative summary of the findings and a review of the management of EOL pain in clinical practice, including (i) the identification of the EOL patients and unmet palliative care needs, (ii) a multidimensional, patient-centred assessment of the type and severity of pain, (iii) a multidisciplinary approach to the management of end-of-life pain, including an overview of non-pharmacological and pharmacological techniques; and (iv) the management of special situations, including rapid acute deterioration of chronic pain, breakthrough pain, and sedative palliation.

Pain associated with psoriasis: a qualitative study.

Pain is a major factor in the psychosocial impact of psoriasis. There is a paucity of qualitative reports of dermatologists' views on psoriasis-related pain. The aim of this study was to explore the views of dermatologists on the presence and importance of pain associated with psoriasis. This qualitative study, based on semi-structured interviews, included dermatologists from different cities working in the hospital and private sector in Croatia between May and July, 2022. We collected demographic and occupational data on participants and information about their experiences and attitudes toward psoriasis-related pain. Data were analysed by applying interpretative descriptive and thematic analysis using the 4-stage method for systematic text condensation. We included 19 dermatologists, all women, aged 38 (range: 31 to 63 years). Most dermatologists acknowledged the presence of pain in patients with psoriasis. They indicated that they sometimes do not sufficiently address this pain in daily practice. Some indicated that pain was a neglected symptom in psoriasis, while for others it was not crucial. Most indicated that it is necessary to focus more on psoriasis-related pain in clinical practice, to disambiguate between skin pain and joint pain in psoriatic conditions, and to better educate family physicians about psoriasis-related pain. They emphasized the importance of considering pain during psoriatic patient assessment and management. Further research on psoriasis-related pain was suggested. More emphasis is needed on psoriasis-related pain for effective management of psoriasis, informing decision-making in the context of patient-centric care and improving the quality of life in patients with psoriasis.

746 Burn Provider Perceptions Before and After Implementation of a Pain and Sedation Clinical Practice Guideline

Abstract Introduction Pain and sedation management is a crucial yet challenging aspect of burn care. We sought to survey a multidisciplinary group of nurses (RN), physicians (MD), advanced practice providers (APP), and therapists (PT/OT) to determine perceptions of pharmacologic pain and sedation management before and after the implementation of a standardized clinical practice guideline (CPG) at our institution. Methods A 28-question survey assessing knowledge, pain and sedation practices, and therapy participation was distributed to all intensive care unit (ICU) and non-ICU burn care providers at our institution before (n=135, 2019) and after (n=185, 2022) CPG implementation. Comparison of proportions was calculated using Chi-squared test. Results Survey response was 61 (45%) before and 51 (28%) after CPG, with 18 participating in both. Most respondents (63%) had 0-5 years of experience caring for burn patients. Patients were perceived to have significant background pain >50% of the time by 69% of RN before vs 55% after (p=0.26). Intermittent opioid boluses were preferred to continuous infusions in intubated patients before (57%) and after (59%) CPG implementation (p=0.87). Perceived utilization of multimodal pain management was high (82%) amongst all responders, except for ICU RN (53%) (p=0.05). While < 30% of all providers believed analgesics were underutilized for procedural pain, non-ICU RN consistently reported patients were in significant pain 50-75% of the time during procedures (78% before vs 85% after, p=0.61). Perceptions of sedative underutilization were unchanged before and after CPG (ICU RN 58% vs 33%, p=0.15; non-ICU RN 69% vs 71%, p=0.91; MD/APP 69% vs 71%, p=0.95). PT/OT reported pain as the most common reason for nonparticipation in therapy sessions with one-third reporting underutilization of analgesics in both surveys. In the after survey, 50% agree we manage pain effectively. Areas for improvement included open communication between disciplines regarding pain and sedation plan, increased use of intermittent sedatives compared to continuous, and less IV opioid utilization with more focus on nonopioid therapy. Fifty percent of after survey respondents were aware of the CPG. Conclusions Implementation of a CPG did not change perceptions of pain and sedation at our institution. This may be due to limited education surrounding CPG and overall lack of utilization. Future efforts should focus on education and communication between disciplines. Applicability of Research to Practice Variability in provider perceptions of pain and sedation management in patients with burn injury remain despite implementation of a CPG.

Headaches associated with COVID-19

Headache is a common symptom of both the acute and post-COVID-19 periods which often persists for a long time. Headache is the leading symptom among all the neurological manifestations of COVID-19, and it also can be a severe deconditioning disorder in about one fifth of patients. A new type of headache may occur or an existing primary cephalal gia pattern may worsen in a patient with COVID-19. During the acute period of infection, cephalgia in most patients can be considered as a headache associated with acute viral infections. However, other forms such as a cough headache, exertional headache, etc. are often considered. In these cases, cephalgic manifestations correlate with other COVID-19 symptoms. The long-term persistent headaches, as one of the most frequent and persistent symptoms of the post-COVID syndrome, often occur according to the type of tension headaches and migraines and are significantly more often detect ed in people with a prior history of cephalalgia. The diversity of headache phenotypes in COVID-19 requires the involve ment of universal strategies for their management. Non-steroidal anti-inflammatory drugs (NSAIDs) are the most widely investigated and commonly used to relieve pain in clinical practice, as well as fever and other symptoms of infection. The long-term experience with the use of NSAIDs in clinical practice, the availability of clinical data and the results of special studies reveal the possibility of their usage in patients with COVID-19 and complaints of headaches. However, a thorough analysis of current records of their use in patients with COVID-19 is required for the effective and safe use of NSAIDs in this category of patients.

Gut microbiota in chronic pain: Novel insights into mechanisms and promising therapeutic strategies.

Chronic pain remains one of the world's most persistent and unsolved clinical challenges that severely affect patients' quality of life. Presently, considering that the mechanisms underlying chronic pain are not fully understood, there is a lack of effective drugs and interventions to treat chronic pain in clinical practice. Therefore, exploring the pathogenic mechanism of chronic pain and establishing potential targets are the keys to treating chronic pain. Substantial evidence has indicated that gut microbiota plays a crucial role in modulating chronic pain, which has opened up a new frontier for investigating the pathogenesis of chronic pain. The gut microbiota is a pivotal junction point between the neuroimmune-endocrine and the microbiome-gut-brain axes that could directly or indirectly affect chronic pain. Different signaling molecules (such as metabolites, neuromodulators, neuropeptides, and neurotransmitters) from the gut microbiota regulate the progress of chronic pain by modulating the peripheral and central sensitization by targeting the corresponding receptors. Furthermore, gut microbiota dysbiosis is associated with the progress of different chronic pain disorders, such as visceral pain, neuropathic pain, inflammatory pain, migraine, and fibromyalgia. Therefore, the present review attempted to systematically summarize the action of the gut microbiota toward regulating the pathological mechanisms of chronic pain and discussed the beneficial effects of probiotics supplementation or fecal microbiota transplantation (FMT) to restore the gut microbiota in chronic pain patients so as to provide a new strategy for targeting the gut microbiota for alleviating chronic pain issues.

EARLY DIAGNOSIS OF OVARIAN ENDOMETRIOSIS

In the algorithm of management of women with external genital endometriosis, it is advisable to include a study of the quality of life using the developed questionnaire "Health profile of patients with endometriosis", as well as the use of a visual analog scale (VAS) when assessing pain syndrome as a simple and objective criterion for assessing pain in clinical practice.

Cryotherapy: A paragon for endodontic therapy

Patients undergoing endodontic treatment may develop post-endodontic pain, leading to pain and inflammation. Cryotherapy is a remedial procedure widely used in the field of medicine and dentistry, considered to be effective at reducing edema, pain, bleeding and inflammation. In endodontics, it is relatively new and may be beneficial in the prevention and treatment of post-endodontic pain. Additionally, cryogenic treatment is considered a key factor in strengthening rotary NiTi endodontic files. Further well-designed clinical studies will be conducted to establish the effective use of cryotherapy in the control of post-endodontic pain in clinical practice. This article describes the concept of cryotherapy and its potential clinical implications in endodontics.

Possible Neuropathic Pain in Clinical Practice—Review on Selected Diagnostic Tools and Its Further Challenges

Neuropathic pain (NeP) is a wide group of conditions provoked by many different causes and with different patterns. The creation of a grading system was intended to determine the level of certainty that the pain is of neuropathic nature. The aim of this review is to update previously published data on some NeP questionnaires and their measurement properties. The selection of articles is based on the basic neurological units. To assess the usefulness and credibility of the questionnaires, the authors searched for a commonly used measure of reliability, as well as sensitivity and specificity. Studies regarding the usefulness and credibility of questionnaires used in NeP were realized. Different patient cohorts, etiologies and sample sizes, do not allow for an unambiguous comparison of the presented scales; however, all of these studies found good measures of reliability, specificity and sensitivity. NeP tools seem to be beneficial screening instruments that should be utilized by specialists and general practitioners to improve the recognition of "possible" NeP and to determine the epidemiology of this disorder. They have been developed to distinguish perceived pain into neuropathic and non-neuropathic, and, therefore, patients with a mixed pain can still present a diagnostic challenge. Clinical examination and interview play an essential role in the diagnostic process and monitoring, and cannot be neglected.

Assessment of visceral pain with special reference to chronic pancreatitis.

A thorough pain assessment is of utmost importance when managing pain in clinical practice as it is the foundation for defining pain in need of treatment, either interventional or pharmacological. Pain characteristics can also guide interventional strategies and help evaluate the effect of treatment. In research settings, standardized pain assessment is crucial to improve comparability across studies and facilitate meta-analysis. Due to the importance of thorough visceral pain assessment, this manuscript describes the key elements of pain evaluation focusing on chronic pancreatitis. Most studies in pain assessment have focused on somatic pain, and although chronic pain often shares characteristics between etiologies, some differences must be addressed when assessing visceral pain. Especially differences between somatic and visceral pain are apparent, where visceral pain is diffuse and difficult to localize, with referred pain aspects and often autonomic symptoms dominating the clinical picture. These aspects need to be incorporated into the pain assessment instrument. The manuscript will discuss the different ways of assessing pain, including unidimensional measurement scales, multidimensional questionnaires, and quantitative sensory testing. The advantages and challenges linked to the different methods will be evaluated.

The treatment lottery of chronic back pain? A case series at a multidisciplinary pain centre.

Despite the number of people affected by chronic back pain, and the many available treatment options, even the best modalities provide limited pain reduction on a group level, often without simultaneous improvements in functioning or health-related quality of life. The objective was to provide an overview of the treatment of chronic back pain in clinical practice at a multidisciplinary pain centre, and to study patient and pain characteristics in different treatment groups. 104 chronic back pain patients (primary ICD-10-SE-diagnosis M53.0-M54.9 excluding M54.1 and M54.3), referred to the Pain and Rehabilitation Centre, University Hospital, Linköping in 2015, were studied using data from the Swedish Quality Registry for Pain Rehabilitation, self-reported medication data, and a retrospective medical record review. The following treatment groups were identified: rehabilitation (n=21), analgesics (n=33), invasive intervention (n=14), and no treatment (n=35). Significant differences between groups were found with regards to age, sick leave, education level, persisting pain duration, punishing responses by significant other, previous invasive intervention, receiving sub-clinic, physician speciality and referring care level. Overall, patient demographics were associated with treatment strategy to a higher degree than patient-reported outcome measures. Moreover, physician speciality and organisational factors seemed to play a role in treatment choice.