搜索结果：The Clinical journal of pain

ONE potential adverse outcome from surgery is chronic pain. Analysis of predictive and pathologic factors is important to develop rational strategies to prevent this problem. Additionally, the natural history of patients with and without persistent pain after surgery provides an opportunity to improve the understanding of the physiology and psychology of chronic pain.Ideally, studies of chronic postoperative pain should include (1) sufficient preoperative data (assessment of pain, physiologic and psychologic risk factors for chronic pain); (2) detailed descriptions of the operative approaches used (location and length of incisions, handling of nerves and muscles); (3) the intensity and character of acute postoperative pain and its management; and (4) follow-up at intervals to 1 yr or more. In addition, there would be information about postoperative interventions that may influence pain, such as radiation therapy or chemotherapy. At long-term follow-up visits, patient function, physical signs, and symptoms would be evaluated using a standardized algorithm, including quantitative and descriptive pain assessments. We found no studies that contain all of these data.For this review, we specifically sought population data that reflect the incidence of chronic postoperative pain or predictors (medical, physiologic, and psychologic) of chronic pain. We selected five groups of surgeries (limb amputations, breast surgery, gallbladder surgery, lung surgery, and inguinal hernia surgery). These surgeries were selected because the incidence of pain is known to be high, thus improving the probability of detecting predictive factors. They also represent a range of major surgical procedures.We performed a computerized search of the medical literature using the OVID search engine (OVID Technologies, Wolters Kluwer, Amsterdam, The Netherlands). The search was performed on the entire database in January 1999 and covered 1966 through most of 1998. Additional articles published during the review process have also been included. Terms were used in their “exploded” format. The term “pain” was combined with the other appropriate term (e.g., “cholecystectomy”); also the text words associated with the pain syndromes were searched, resulting in more than 1,700 citations. Letters to the editor were not reviewed. Additionally, articles known to the authors but not found in the search were used. If the article contained data about persistent pain (12 weeks or more after surgery), it was considered for inclusion in this review. To calculate the incidence of pain, we used the number of individuals responding at the time the chronic pain data was gathered, and only used data from articles in which the methods section indicated that there was systematic collection of long-term pain information from patients. Studies of fewer than 50 patients were excluded in the incidence data analysis for breast surgery, gallbladder surgery, and lung surgery. Studies of fewer than 100 patients were excluded from the data analysis for inguinal hernia surgery. Amputation studies of 25 subjects or more were included because of the higher incidence of chronic pain.The reported incidence of phantom limb pain varies from 30 to 81% (table 1). Finch et al . 1reported pain in 30% of 57 long-term survivors of amputation for vascular insufficiency. Fisher and Hanspal 2described 93 consecutive amputees referred to a prosthetic rehabilitation clinic; therefore, selection bias may be a factor. The remainder of the studies (table 1) report an incidence of phantom limb pain of more than 50%. Sherman et al. 3noted at least a 78% incidence of phantom limb pain, and perhaps as high as 85%; however, their questionnaire response rate was not high (55%). Stump pain was noted in 66% of patients with phantom pain and in half of those without phantom pain; therefore, the overall stump pain incidence exceeds 60%. Wartan et al . 4reported a 62% incidence of phantom limb pain and 63% for stump pain. Similar to Sherman et al., 66% of patients with phantom limb pain also have stump pain. Smith and Thompson 5reported that pain was more common after amputation for cancer than for trauma, but this study was a chart review (phantom pain noted in medical record), and there were only eight amputations for trauma. No large studies systematically evaluate the incidence of phantom limb pain after trauma, vascular disease, and cancer-related surgeries. The presence of intense preoperative pain in the extremity increases the probability of phantom limb pain (from 33 to 72% at 3 months). 6,7Some early reports 8,9indicated that the incidence of phantom limb pain decreased with prolonged (72 h) preoperative epidural pain control, followed by postoperative epidural pain control. Both studies were small (23 and 24 patients, respectively at 6 months follow-up), and neither was properly randomized. In a subsequent randomized controlled study, 10this observation was not confirmed, but preoperative pain control was limited to 18 h, and the extent and intensity of perioperative blockade was not sufficient to control pain without supplemental systemic opioids.The effect of anesthesia (epidural, spinal, or general) alone has not been studied. Surgical handling of the major nerves is rarely mentioned, so we cannot assess the effect of nerve ligation or clipping versus section alone.Administration of chemotherapy increases the incidence of phantom limb pain. 5Stump pain at 1 week is significantly associated with phantom pain at 1 week, 6and long-term stump pain predicts long-term phantom limb pain. 3There is also a correlation between nonpainful phantom sensations and phantom pain. 4Control of acute postoperative pain with nerve sheath infusion of local anesthetic decreased the incidence of phantom limb pain in one series of 11 patients, 11but a subsequent randomized controlled trial (n = 14 at long term follow-up) 12failed to confirm this finding. Both of these studies are small, and the negative study 12does not have the statistical power to conclude that there is no significant effect. There has also been a negative retrospective report of this technique (n = 21). 13As mentioned previously, data regarding epidural analgesia 8–10as a method to decrease the incidence of phantom limb pain conflict.Most authorities believe that phantom limb sensation and phantom limb pain are central phenomena and explain them using the neuromatrix theory expounded by Melzack. 14,15That is, there is a matrix in the central nervous system for the perception of a body part, and this matrix exists even when the body part does not. Sherman et al . 3emphasized that multiple etiologies may lead to phantom limb pain, based on the inconsistency of therapeutic responses.The incidence of phantom limb pain decreases during the first year after amputation, as does the frequency of painful episodes 7,16; however, about half the individuals with long-term phantom pain report no decrease in the intensity of this pain. 3Phantom limb pain is common after extremity amputation, and documented predictors of this pain include preamputation pain and persistent stump pain (acute and chronic). No conclusive studies have evaluated the effect of acute or subacute stump pain control on long-term stump pain or on long-term phantom limb pain. Also no psychologic studies have evaluated patients before amputation for predictors of chronic pain.Long-term pain after thoracotomy, the postthoracotomy pain syndrome (PTPS), may have an incidence of more than 50%. 17,18Six studies met our inclusion–exclusion criteria (table 2), assessing 878 patients, of whom 417 (47%) had PTPS. Katz et al . 2could not predict PTPS from preoperative psychologic testing (state or trait anxiety, depression inventory) or preoperative pain sensitivity as determined by pressure algometry. This study (n = 23) was the extension of a previous acute pain study; it therefore lacks statistical power and may be subject to selection bias. Perttunen et al . 19noted the presence of preoperative pain in 17% of their patients but did not analyze it as an independent risk factor.Several recent case series report that video-assisted thoracoscopic lung surgery (VATS) is associated with a low incidence of PTPS. Walker et al . 20reported only 1 case of 83 (1.2%), and Mouroux et al . 21noted a 3% incidence of PTPS, but neither group reports systematically looking for PTPS. In a large retrospective survey, Landreneau et al . 22(table 2) noted a lower incidence of pain in patients who had VATS compared with those who underwent lateral thoracotomy (30 vs. 44%); however, pain medication requirements did not differ. The difference in pain incidence was statistically significant only during the first year after surgery. In a small (n = 30), nonrandomized prospective study, Furrer et al. 23found a 36% incidence of PTPS in patients undergoing VATS wedge resection, and a 33% incidence of PTPS in a matched group of patients undergoing lobectomy by a classic posterolateral thoracotomy. However, the results are confounded because the thoracotomy group received thoracic epidural analgesia with local anesthetic and opioid, whereas the thoracoscopic group received intravenous patient-controlled opioids. Nomori et al. 24retrospectively and Benedetti et al. 25prospectively (case series) reported a decreased severity of chronic pain after anterolateral thoracotomy when compared with classic posterolateral thoracotomy (mean visual analog scale [VAS] score, 6 of 100 vs. 21 of 100). Both studies were small (24 and 42 patients), and chronic postoperative pain was not a primary outcome parameter. In descriptions of the surgical technique for posterolateral thoracotomy, details about whether a rib was resected or about how the intercostal nerves were handled were missing from most reports.A recent report by Obata et al . 26(table 2) found a significant effect of intraoperative plus postoperative epidural analgesia when compared with just postoperative epidural analgesia (decreasing the incidence of pain at 6 months from 67% to 33%). This is a prospective, randomized, single-blind study.The intensity of acute postoperative pain is a statistically significant predictor 18,27of PTPS (36 vs. 56% PTPS for minor vs. moderate to severe acute pain). As mentioned previously herein, the combination of intraoperative plus postoperative epidural analgesia with local anesthetic was associated with a decreased incidence of pain at 6 months. An attempt at preemptive analgesia 28had not improved analgesia on long-term follow-up. 18Another small study found that the type of postoperative analgesia affected the incidence of pain at 12 weeks (less pain with epidural analgesia or intercostal nerve cryoablation), but data of only 33 subjects divided among four treatment regimens were reported. 29Benedetti et al. 25,30showed that intercostal nerve dysfunction (loss of the superficial abdominal reflex) is associated with more acute, subacute, and chronic (3 months) pain. Of 23 patients with intact reflexes on postoperative day 1, none had pain at 2 to 3 months, whereas 50% of individuals with persistent loss of the reflex still had pain at this time.The etiology of PTPS may depend on nerve damage because it is more severe after chest wall resection, 31–33and the loss of superficial abdominal reflexes is associated with an increased probability of PTPS. 25,30Another contributing factor is recurrence of tumor. 31For thoracoscopic surgeries and posterolateral thoracotomy, Landreneau et al . 22noted a 30% decrease in the incidence in pain reported by patients more than 12 months after surgery compared with those 3–12 months after surgery. The prospective study by Perttunen et al . 19noted the incidence of pain at 3, 6, and 12 months to be decreasing (80, 75, and 61%, respectively). Of patients with long-term pain after thoracotomy, up to half describe their pain as moderate or severe, 18and 66% are prescribed analgesics for the pain. 27Postthoracotomy pain syndrome is common. The predictors of this syndrome (when tumor recurrence is excluded) include the extent of acute postoperative pain and intercostal nerve dysfunction (which may link more acute pain and persistent pain). One prospective, randomized controlled study 28found that the combination of intraoperative plus postoperative thoracic epidural analgesia decreases the incidence of PTPS at 6 months.Table 3summarizes various studies of pain after breast surgery. Women who undergo breast surgery experience chest wall, breast, or scar pain (range, 11–57%), phantom breast pain (13–24%), and arm and shoulder pain (12–51%). The incidence of pain in one or more of these sites is close to 50% 1 yr after breast surgery for cancer. The postmastectomy pain syndrome (PMPS) has recently been reviewed, 34with some disagreement about which pains to include in this syndrome. Husted et al . 35documented that, of 163 women who had undergone mastectomy with axillary node dissection, 45% reported cicatrix pain, 45% reported arm, neck, or shoulder pain, and only 21% were symptom free (symptoms included pain, paresthesia, lymphedema, and impaired shoulder function) 1–5 yr after surgery. Moderate to severe pain was reported by 16 patients (10%). Krøner et al . 36reported a significant relation between preoperative breast pain and postoperative phantom breast pain in a prospective study of 120 patients. In contrast, Tasmuth et al., 37,38in a prospective study of 93 patients, did not find the presence of preoperative pain to be a predictive but only patients had pain before surgery. depression and were more common in patients in whom chronic pain when compared with those in whom chronic pain did not statistical was not type of surgery may the incidence of pain. Tasmuth et al. that chronic pain was more common after breast surgery than after surgery in their large retrospective study, but did not confirm this in prospective et al., their questionnaire of women who had undergone breast surgery, found that mastectomy combined with of a breast a higher incidence of pain than did mastectomy alone et al . in the of the nerve at 3 months after axillary node in of women in whom the nerve was and in of women in whom it was et al . that axillary increased the of arm and of psychologic et al . found the extent of axillary with the incidence of arm pain and et al . a analysis of factors that the patient to chronic pain after breast cancer surgery. The extent of acute postoperative pain and the number of of postoperative analgesics were the predictors of persistent pain in the breast and the Additionally, postoperative radiation therapy was a risk factor for chronic pain in the breast and the et al . that axillary radiation therapy increased the incidence of arm pain and et al . Krøner et al . a relation between phantom breast sensations and radiation but their studies were and only sought a of of the pain after breast surgery has been to nerve whether from surgery or and that and sensation decreased nerve in the long-term in of women undergoing and of women undergoing but pain data were not reported. was in the of the nerve in of women undergoing axillary In in of women with these was associated with a higher incidence of arm pain and arm symptoms and were more common after breast surgery with axillary node The among pain, and preoperative psychologic have not been among women undergoing breast natural history of pain during the first year after surgery has not been In one study, the incidence of pain in the breast decreased from to from 3 weeks to 1 yr after surgery, whereas the incidence of decreased from to study, the incidence of arm pain decreased from 3 to months after surgery to respectively). incidence of phantom breast pain is from 3 weeks to 6 pain is common after breast surgery, and the major predictive factors are the extent of acute postoperative pain, the presence of pain before surgery, the type of surgery, nerve radiation and preoperative or abdominal pain after is common (range, but than the preoperative incidence of pain The syndrome has a number of in to abdominal pain, and may not have a factors include postoperative pain; pain by postoperative of pain by a other than gallbladder pain by a and other preoperative factors that the patient to an is a predictor of long-term pain and symptoms after other risk factors include symptoms before surgery. history of classic gallbladder symptoms is associated with risk of chronic pain and surgical to no significant difference in overall et al., a randomized controlled trial (n = noted that patients randomized to had more to whereas patients randomized to had more of scar pain and did not report pain incidence There to be no difference in chronic abdominal pain when is compared with et al . a 30% incidence of abdominal pain more than 1 yr after but this incidence did not include 16 patients with pain. et al . significantly more pain after than after surgery and that there was more intercostal nerve damage from the et al., a prospective study of 100 patients who underwent noted that pain at 6 weeks was a predictor of persistent pain and other symptoms at 1 yr and We found no studies that evaluated acute postoperative pain as a predictor of chronic are multiple etiologies of the including of and scar pain. The of factor has not been the frequency of persistent symptoms after patient after the is high, with authors that may to patient most patients with abdominal pain and believe that without surgery and that their improve after symptoms are common after as is chronic abdominal pain. factors include psychologic preoperative symptoms and pain at 6 weeks after surgery. studies of the syndrome have not scar pain and pain from other of chronic pain and number of studies have evaluated chronic pain after surgery, with the reported incidence of chronic pain from to (table The overall incidence from these studies is of pain was a primary outcome in only four these studies report a In a prospective study of surgery for a hernia had a higher incidence of moderate to severe pain at 12 months than did surgery for a primary for have a higher pain incidence at 6 months than those who are for by of vs. 1 of have had pain for a of time before data are about whether the surgical the incidence of chronic pain. et al., a prospective randomized controlled study that evaluated recurrence found a lower incidence of chronic pain after a when compared with an The study found a significantly lower incidence of pain at 12 months after a compared with an et al. no difference in the incidence of chronic pain in their prospective randomized controlled study that compared an to a and no difference in the incidence of pain in their case with and a incidence of chronic pain. of the studies that including pain, were more common early in their experience with hernia a prospective study, et al. not find statistically significant in chronic pain after or in a prospective analysis of et al., no significant in chronic pain between and in primary hernia surgery. the experience of the or the of is a factor in chronic pain or recurrence has been incidence of chronic pain in case series data from hernia is reports with higher of chronic pain from are no prospective studies of this extent of pain at 1 and weeks after surgery is a predictive factor pain at 1 length of type of the incidence of chronic pain. relation between postoperative dysfunction and chronic pain the that nerve damage is a pathologic factor. authors the pain is of the of the et al . the incidence of moderate to severe pain decreased from at weeks to at 1 Moderate to severe pain at 1 and weeks was the predictor of pain at 1 pain after hernia surgery is not but it to be common than chronic pain after the surgeries previously hernia surgery is a large number of individuals are affected by chronic pain. dysfunction has been to be a as has the intensity of early postoperative pain. The of acute pain therapy on the incidence of chronic pain is patient with surgical results is reported to be high, studies reported that chronic pain is common after these and this has been in a recent review. pain is to in of and and the of chronic pain after surgery should be is also there is significant in the incidence of chronic pain among these surgical for inguinal hernia and thoracic surgery). We believe that our review has been but the of search our search did not all articles known to the authors that to the or incidence of chronic pain after the selected surgeries. for this include in not included in the at the time of (e.g., et al . and or “pain” not as a or used in the or (e.g., et al. As a we are not that we all articles that contain data to this a number of risk factors for prolonged pain after surgery and these factors (1) preoperative (2) intraoperative and (3) postoperative factors (table pain is a predictor of chronic pain for pain, breast pain, abdominal pain and symptoms after of these the of the preoperative pain that chronic pain to be pain of 1 or more in is a risk factor for persistent pain after has not been evaluated in the other surgeries has also been found to predict outcome after surgery. damage is an intraoperative factor that to chronic postoperative pain. undergoing thoracotomy are to have intercostal nerve dysfunction and to have PTPS. breast surgery, is associated with damage of that and to the nerve are associated with a lower incidence of pain. nerve damage does not pain because the incidence of decreased sensation was higher than the incidence of pain in the of the nerve after axillary node Benedetti et al. chronic pain in only 50% of individuals with intercostal nerve dysfunction after thoracotomy. nerve dysfunction to be associated with chronic pain. most predictive postoperative factor is the severity of acute postoperative pain after breast surgery, surgery, hernia radiation therapy increases the risk of chronic pain after breast surgery, chemotherapy increases the risk of phantom limb pain. acute pain chronic pain has been a that and factors and the severity of acute pain as factors in the of chronic pain. we believe that from nerve increases acute pain and early months) chronic pain. in the nervous system associated with acute pain, with the that pain should be considered a of the nervous not a symptom of some other If persistent pain after surgery results from may be be Obata et al . this in thoracotomy patients with intraoperative plus postoperative epidural but other studies of preemptive analgesia are from factors are also predictors of chronic pain. Of the surgical we reviewed, the only psychologic predictor has been The questionnaire for psychologic a that with depression are preoperative predictors of chronic pain after surgery. et al . when to predict chronic pain in acute pain patients. They that is not associated with an increased risk of of chronic low pain, but may reflect or in that are to chronic pain. The of et al. with the psychologic in chronic pain is common after amputation, inguinal hernia surgery, breast surgery, gallbladder surgery, and lung surgery, and this is also in recent review. of these data may be as chronic pain as one of acute postoperative pain is a predictor of chronic pain. studies should the factors of in the from acute to chronic pain. may in more and more rational early We that, in some patients, the type of nerve may explain the in acute pain and the chronic pain, but the extent of pain be by other psychologic and physiologic factors that pain

1. Introduction Chronic pain has been recognized as pain that persists past normal healing time5 and hence lacks the acute warning function of physiological nociception.35 Usually pain is regarded as chronic when it lasts or recurs for more than 3 to 6 months.29 Chronic pain is a frequent condition, affecting an estimated 20% of people worldwide6,13,14,18 and accounting for 15% to 20% of physician visits.25,28 Chronic pain should receive greater attention as a global health priority because adequate pain treatment is a human right, and it is the duty of any health care system to provide it.4,13 The current version of the International Classification of Diseases (ICD) of the World Health Organization (WHO) includes some diagnostic codes for chronic pain conditions, but these diagnoses do not reflect the actual epidemiology of chronic pain, nor are they categorized in a systematic manner. The ICD is the preeminent tool for coding diagnoses and documenting investigations or therapeutic measures within the health care systems of many countries. In addition, ICD codes are commonly used to report target diseases and comorbidities of participants in clinical research. Consequently, the current lack of adequate coding in the ICD makes the acquisition of accurate epidemiological data related to chronic pain difficult, prevents adequate billing for health care expenses related to pain treatment, and hinders the development and implementation of new therapies.10,11,16,23,27,31,37 Responding to these shortcomings, the International Association for the Study of Pain (IASP) contacted the WHO and established a Task Force for the Classification of Chronic Pain. The IASP Task Force, which comprises pain experts from across the globe,19 has developed a new and pragmatic classification of chronic pain for the upcoming 11th revision of the ICD. The goal is to create a classification system that is applicable in primary care and in clinical settings for specialized pain management. A major challenge in this process was finding a rational principle of classification that suits the different types of chronic pain and fits into the general ICD-11 framework. Pain categories are variably defined based on the perceived location (headache), etiology (cancer pain), or the primarily affected anatomical system (neuropathic pain). Some diagnoses of pain defy these classification principles (fibromyalgia). This problem is not unique to the classification of pain, but exists throughout the ICD. The IASP Task Force decided to give first priority to pain etiology, followed by underlying pathophysiological mechanisms, and finally the body site. Developing this multilayered classification was greatly facilitated by a novel principle of assigning diagnostic codes in ICD-11, termed “multiple parenting.” Multiple parenting allows the same diagnosis to be subsumed under more than 1 category (for a glossary of ICD terms refer to Table 1). Each diagnosis retains 1 category as primary parent, but is cross-referenced to other categories that function as secondary parents.Table 1: Glossary of ICD-11 terms.The new ICD category for “Chronic Pain” comprises the most common clinically relevant disorders. These disorders were divided into 7 groups (Fig. 1): (1) chronic primary pain, (2) chronic cancer pain, (3) chronic posttraumatic and postsurgical pain, (4) chronic neuropathic pain, (5) chronic headache and orofacial pain, (6) chronic visceral pain, and (7) chronic musculoskeletal pain. Experts assigned to each group are responsible for the definition of diagnostic criteria and the selection of the diagnoses to be included under these subcategories of chronic pain. Thanks to Bedirhan Üstün and Robert Jakob of the WHO, these pain diagnoses are now integrated in the beta version of ICD-11 (http://id.who.int/icd/entity/1581976053). The Task Force is generating content models for single entities to describe their clinical characteristics. After peer review overseen by the WHO Steering Committee,39 the classification of chronic pain will be voted into action by the World Health Assembly in 2017.Figure 1: Organizational chart of Task Force, IASP, and WHO interactions. The IASP Task Force was created by the IASP council and its scope defined in direct consultation of the chairs (R.D.T. and W.R.) with WHO representatives in 2012. The Task Force reports to the IASP Council on an annual basis.2. Classification of chronic pain Chronic pain was defined as persistent or recurrent pain lasting longer than 3 months. This definition according to pain duration has the advantage that it is clear and operationalized. Optional specifiers for each diagnosis record evidence of psychosocial factors and the severity of the pain. Pain severity can be graded based on pain intensity, pain-related distress, and functional impairment. 2.1. Chronic primary pain Chronic primary pain is pain in 1 or more anatomic regions that persists or recurs for longer than 3 months and is associated with significant emotional distress or significant functional disability (interference with activities of daily life and participation in social roles) and that cannot be better explained by another chronic pain condition. This is a new phenomenological definition, created because the etiology is unknown for many forms of chronic pain. Common conditions such as, eg, back pain that is neither identified as musculoskeletal or neuropathic pain, chronic widespread pain, fibromyalgia, and irritable bowel syndrome will be found in this section and biological findings contributing to the pain problem may or may not be present. The term “primary pain” was chosen in close liaison with the ICD-11 revision committee, who felt this was the most widely acceptable term, in particular, from a nonspecialist perspective. 2.2. Chronic cancer pain Pain is a frequent and debilitating accompaniment of cancer8 that as yet has not been represented in the ICD. The Task Force decided to list it as a separate entity because there are specific treatment guidelines.7,38 Chronic cancer pain includes pain caused by the cancer itself (the primary tumor or metastases) and pain that is caused by the cancer treatment (surgical, chemotherapy, radiotherapy, and others). Cancer-related pain will be subdivided based on location into visceral, bony (or musculoskeletal), and somatosensory (neuropathic). It will be described as either continuous (background pain) or intermittent (episodic pain) if associated with physical movement or clinical procedures. The treatment-related pain will be cross-referenced from the chapters on postsurgical pain and neuropathic pain. 2.3. Chronic postsurgical and posttraumatic pain Because pain that persists beyond normal healing is frequent after surgery and some types of injuries, the entity of postsurgical and posttraumatic pain was created. This is defined as pain that develops after a surgical procedure or a tissue injury (involving any trauma, including burns) and persists at least 3 months after surgery or tissue trauma26; this is a definition of exclusion, as all other causes of pain (infection, recurring malignancy) as well as pain from a pre-existing pain problem need to be excluded. In view of the different causality, as well as from a medicolegal point of view, a separation between postsurgical pain and pain after all other trauma is regarded as useful. Depending on the type of surgery, chronic postsurgical pain is often neuropathic pain (on average 30% of cases with a range from 6% to 54% and more).15 Pain including such a neuropathic component is usually more severe than nociceptive pain and often affects the quality of life more adversely.21 2.4. Chronic neuropathic pain Chronic neuropathic pain is caused by a lesion or disease of the somatosensory nervous system.20,22 The somatosensory nervous system provides information about the body including skin, musculoskeletal, and visceral organs. Neuropathic pain may be spontaneous or evoked, as an increased response to a painful stimulus (hyperalgesia) or a painful response to a normally nonpainful stimulus (allodynia). The diagnosis of neuropathic pain requires a history of nervous system injury, for example, by a stroke, nerve trauma, or diabetic neuropathy, and a neuroanatomically plausible distribution of the pain.22 For the identification of definite neuropathic pain, it is necessary to demonstrate the lesion or disease involving the nervous system, for example, by imaging, biopsy, neurophysiological, or laboratory tests. In addition, negative or positive sensory signs compatible with the innervation territory of the lesioned nervous structure must be present.36 Diagnostic entities within this category will be divided into conditions of peripheral or central neuropathic pain. 2.5. Chronic headache and orofacial pain The International Headache Society (IHS) has created a headache classification17 that is implemented in full in the chapter on neurology. This classification differentiates between primary (idiopathic), secondary (symptomatic) headache, and orofacial pain including cranial neuralgias. In the section on chronic pain, only chronic headache and chronic orofacial pain will be included. Chronic headache and chronic orofacial pain is defined as headaches or orofacial pains that occur on at least 50% of the days during at least 3 months. For most purposes, patients receive a diagnosis according to the headache phenotypes or orofacial pains that they currently present. The section will list the most frequent chronic headache conditions. The most common chronic orofacial pains are temporomandibular disorders,32 which have been included in this subchapter of chronic pain. Chronic orofacial pain can be a localized presentation of a primary headache.2 This is common in the trigeminal autonomic cephalalgias, less common in migraines, and rare in tension-type headache. Several chronic orofacial pains such as post-traumatic trigeminal neuropathic pain,3 persistent idiopathic orofacial pain, and burning mouth syndrome are cross-referenced to, eg, primary chronic pain and neuropathic pain. The temporal definition of “chronic” has been extrapolated from that of chronic headaches.1 2.6. Chronic visceral pain Chronic visceral pain is persistent or recurrent pain that originates from the internal organs of the head and neck region and the thoracic, abdominal, and pelvic cavities.24,33,34 The pain is usually perceived in the somatic tissues of the body wall (skin, subcutis, muscle) in areas that receive the same sensory innervation as the internal organ at the origin of the symptom (referred visceral pain).12 In these areas, secondary hyperalgesia (increased sensitivity to painful stimuli in areas other than the primary site of the nociceptive input) often occurs30; the intensity of the symptom may bear no relationship with the extent of the internal damage or noxious visceral stimulation.9 The section on visceral pain will be subdivided according to the major underlying mechanisms, ie, persistent inflammation, vascular mechanisms (ischemia, thrombosis), obstruction and distension, traction and compression, combined mechanisms (eg, obstruction and inflammation concurrently), and referral from other locations. Pain due to cancer will be cross-referenced to the chapter chronic cancer pain and pain due to functional or unexplained mechanisms to chronic primary pain. 2.7. Chronic musculoskeletal pain Chronic musculoskeletal pain is defined as persistent or recurrent pain that arises as part of a disease process directly affecting bone(s), joint(s), muscle(s), or related soft tissue(s). According to the constraints of the approach as described in the Introduction, this category is therefore limited to nociceptive pain and does not include pain that may be perceived in musculoskeletal tissues but does not arise therefrom, such as the pain of compression neuropathy or somatic referred pain. The entities subsumed in this approach include those characterized by persistent inflammation of infectious, autoimmune or metabolic etiology, such as rheumatoid arthritis, and by structural changes affecting bones, joints, tendons, or muscles, such as symptomatic osteoarthrosis. Musculoskeletal pain of neuropathic origin will be cross-referenced to neuropathic pain. Well-described apparent musculoskeletal conditions for which the causes are incompletely understood, such as nonspecific back pain or chronic widespread pain, will be included in the section on chronic primary pain. 3. Outlook Irrespective of its etiology, chronic pain is a major source of suffering and requires special treatment and care. Our proposal may not represent a perfect solution for the classification of all manifestations of chronic pain. However, it does represent the first systematic approach to implementing a classification of chronic pain in the ICD. It is based on international expertise and agreement, and consistent with the requirements of the ICD regarding the structure and format of content models. The 7 major categories of chronic pain were identified after considerable research and discussion. They represent a compromise between comprehensiveness and practical applicability of the classification system. Several clinically important conditions that were neglected in former ICD revisions will now be mentioned, eg, chronic cancer pain or chronic neuropathic pain. Etiological factors, pain intensity, and disability related to pain will be reflected. With the introduction of chronic primary pain as a new diagnostic entity, the classification recognizes conditions that affect a broad group of patients with pain and would be neglected in etiologically defined categories. We hope that this classification strengthens the representation of chronic pain conditions in clinical practice and research and welcome comments to improve it further. Conflict of interest statement Q. Aziz has attended advisory board meetings for Almirall pharmaceuticals and Grunenthal. He has also received funding for clinical trials from Ono Pharmaceutical and Protexin. M.I. Bennett has received consultancy or speaker fees from Pfizer, Bayer, Astellas, and Grunenthal in the last 5 years. M. Cohen has received honoraria for contributions to educational programs from Mundipharma Pty Limited and Pfizer. S. Evers received honoraria (as speaker and/or member of advisory boards) and research grants within the past 5 years by AGA Medical (now St Jude), Allergan, Almirall, Astra Zeneca, Berlin-Chemie, CoLucid, Desitin, Eisai, GlaxoSmithKline, Ipsen Pharma, Menarini, MSD, Novartis, Pfizer, Reckitt-Benckiser, UCB. N.B. Finnerup has received speaker's honoraria from Pfizer, Grunenthal, and Norpharma, research grant from Grünenthal, and consultancy fee from Astellas and is member of the IMI “Europain” collaboration where industry members of this are: Astra Zeneca, Pfizer, Esteve, UCB-Pharma, Sanofi Aventis, Grünenthal, Eli Lilly, Boehringer Ingelheim, Astellas, Abbott, and Lundbeck. M.B. First on the faculty of the Lundbeck International Neuroscience Foundation. In the past 2 years, M.A. Giamberardino received research funding or honoraria (participation in Advisory Board) from Bayer Healthcare, Helsinn, and Epitech Group. S. Kaasa declares no conflict of interest related to this work. In the past year he received honoraria from Helsinn related to participation in Advisory Board. E. Kosek has received consultancy and speaker fees in the past 24 months from Eli Lilly and Company and Orion and has ongoing research collaborations with Eli Lilly and Company and Abbott and Pierre Fabre. M. Nicholas received honoraria for contributing to educational sessions for Mundipharma and Pfizer in the last 5 years. S. Perrot received honoraria as a speaker and/or member of the advisory board in the past 5 years from Pfizer, BMS, Grunenthal, Elli Lilly, Sanofi, Daichi-Sankyo, Astellas, and Mundipharma. He has received grant support from BMS. W. Rief received honoraria (as speaker and/or member of advisory boards on topics such as adherence, placebo mechanisms) within the past 5 years from Berlin Chemie, Astra Zeneca, Bayer, Heel (research grant). J. Scholz has received speaker fees from Convergence, GlaxoSmithKline, Pfizer, St Jude Medical, and Zalicus. He has served on advisory boards or consulted for Convergence, Pfizer, Sanofi Aventis, and Zalicus Pharmaceuticals. He has received grant support from GlaxoSmithKline and Pfizer. In the last 5 years, the Anaesthesiology Unit of the University of Western Australia, but not S. Schug personally, has received research and travel funding and speaking and consulting honoraria from bioCSL, Bionomics, Eli Lilly, Grunenthal, Janssen, Mundipharma, Pfizer, Phosphagenics and iX Biopharma within the last 2 years. B.H. Smith has received lecture and consultancy fees, on behalf of his institution, from Pfizer, Grunenthal, Eli Lilly, and Napp. He has received unconditional educational grants from Pfizer Ltd; and he has received travel and accommodation support from Napp. P. Svensson served as a paid consultant for Sunstar Suisse SA. R.-D. Treede has received speaker's honoraria, research grants or consultancy fees from AbbVie, Acron, Astellas, Bauerfeind, Boehringer Ingelheim, Grünenthal, Hydra, Mundipharma, and Pfizer and is a member of the IMI “Europain” collaboration where industry members of this are: Astra Zeneca, Pfizer, Esteve, UCB-Pharma, Sanofi Aventis, Grünenthal, Eli Lilly, Boehringer Ingelheim, Astellas, Abbott, and Lundbeck. J.W.S. Vlaeyen is a member of the PHILIPS advisory board on pain management and declares no conflicts of interest with regard to this work. S.-J. Wang has served on the advisory boards of Allergan and Eli Lilly, Taiwan. He has received speaking honoraria from local companies (Taiwan branches) of Pfizer, Elli Lilly, and GSK. He has received research grants from the Novartis Taiwan, Taiwan Ministry of Science and Technology, Taipei-Veterans General Hospital and Taiwan Headache Society. The other authors have no conflicts of interest to declare. Acknowledgements The authors are members of the Classification of Pain Diseases Task Force of the International Association for the Study of Pain (IASP), which gave logistical and financial support to perform this work. We acknowledge the contributions of the following IASP Special Interest Groups (SIGs): Abdominal & Pelvic Pain SIG, Acute Pain SIG, Cancer Pain SIG, Neuropathic Pain SIG and the Orofacial Pain SIG, and the Classification Committee of the International Headache Society (IHS). Author contributions: R.-D. Treede, W. Rief, and A. Barke contributed equally to this topical review.

To evaluate the surgical outcomes of maxillary medication-related osteonecrosis of the jaw (MRONJ) at different disease stages and to analyze the comparative efficacy of different surgical techniques on the prognosis of stage &#x2162; patients. A detailed retrospective analysis was conducted on the clinical data of 136 patients with maxillary MRONJ who underwent surgical treatment in the Department of Oral and Maxillofacial Surgery of Peking University School and Hospital of Stomatology from April 2014 to February 2024. All patients were rigorously classified according to the 2022 American Association of Oral and Maxillofacial Surgeons (AAOMS) staging criteria: Stage &#x2160; (n=8), stage &#x2161; (n=30), and stage &#x2162; (n=98). The surgical interventions included local lesion resection with primary direct closure, buccal fat pad packing, and iodoform gauze packing. The patients were systematically followed up for a period of 1 year postoperatively to comprehensively assess several key outcome measures: Complete mucosal healing, resolution of pain, effective infection control, and radiological improvement of maxillary sinus inflammation based on serial computed tomography scans. Statistical analysis was performed using SPSS version 20.0. Continuous variables were expressed as mean&#xb1;standard deviation and compared using the t-test, while categorical variables were expressed as numbers and percentages and compared using the &#x3c7;2 test or Fisher' s exact test as appropriate. A P-value < 0.05 was considered statistically significant for all analyses. The overall short-term (3 months) cure rate was 91.2% (124/136), which improved to a long-term (1 year) cure rate of 94.9% (129/136). A stage-stratified analysis revealed excellent long-term cure rates: 100.0% (8/8) for stage &#x2160;, 96.7% (29/30) for stage &#x2161;, and 93.9% (92/98) for stage &#x2162;, with no statistically significant difference in outcomes across the different stages (P=0.611). Among the 98 stage &#x2162; patients, 34 were treated with buccal fat pad transfer (BFPT group) and 64 with iodine strip packing (ISP group), with no significant differences in baseline demographic or clinical characteristics between the two groups, ensuring comparability. The BFPT group demonstrated a statistically significant superior performance in achieving oroantral fistula closure both at the short-term (79.4% vs. 23.4%, P < 0.001) and long-term (85.3% vs. 54.7%, P=0.002) follow-up assessments. In contrast, the ISP group showed a markedly greater degree of improvement in maxillary sinus inflammation, as quantified by a standardized radiographic scoring system, with significantly greater reductions in inflammation scores at both the 3-month (P=0.029) and 12-month (P=0.014) follow-up intervals. Surgical management of maxillary MRONJ results in high rates of success with a favorable complication profile. For advanced (stage &#x2162;) disease, the choice of surgical technique entails a strategic trade-off: The buccal fat pad procedure is more conducive to achieving reliable soft tissue closure and oroantral fistula resolution, whereas iodoform gauze packing provides superior management and resolution of concomitant maxillary sinusitis. Consequently, the selection of surgical technique should be individualized, based on a careful consideration of the patient's specific anatomical defect, the extent of sinus involvement, and their overall clinical condition. &#x603b;&#x7ed3;&#x4e0a;&#x988c;&#x836f;&#x7269;&#x76f8;&#x5173;&#x6027;&#x988c;&#x9aa8;&#x574f;&#x6b7b;(medication-related osteonecrosis of the jaw, MRONJ)&#x7684;&#x624b;&#x672f;&#x6cbb;&#x7597;&#x6548;&#x679c;, &#x6bd4;&#x8f83;&#x4e0d;&#x540c;&#x624b;&#x672f;&#x65b9;&#x5f0f;&#x6cbb;&#x7597;&#x2162;&#x671f;&#x75c5;&#x53d8;&#x60a3;&#x8005;&#x9884;&#x540e;&#x7684;&#x5dee;&#x5f02;&#x3002; &#x56de;&#x987e;&#x6027;&#x5206;&#x6790;2014&#x5e74;4&#x6708;&#x81f3;2024&#x5e74;2&#x6708;&#x4e8e;&#x5317;&#x4eac;&#x5927;&#x5b66;&#x53e3;&#x8154;&#x533b;&#x9662;&#x988c;&#x9762;&#x5916;&#x79d1;&#x63a5;&#x53d7;&#x624b;&#x672f;&#x6cbb;&#x7597;&#x7684;136&#x4f8b;&#x4e0a;&#x988c;MRONJ&#x60a3;&#x8005;&#x7684;&#x4e34;&#x5e8a;&#x8d44;&#x6599;&#x3002;&#x6839;&#x636e;&#x7f8e;&#x56fd;&#x53e3;&#x8154;&#x988c;&#x9762;&#x5916;&#x79d1;&#x533b;&#x5e08;&#x534f;&#x4f1a;(American Association of Oral and Maxillofacial Surgeons, AAOMS)2022&#x5e74;&#x53d1;&#x5e03;&#x7684;&#x5206;&#x671f;&#x6807;&#x51c6;, &#x5c06;&#x60a3;&#x8005;&#x5206;&#x4e3a;&#x2160;&#x671f;(8&#x4f8b;)&#x3001;&#x2161;&#x671f;(30&#x4f8b;)&#x548c;&#x2162;&#x671f;(98&#x4f8b;)&#x4e09;&#x7ec4;&#x3002;&#x624b;&#x672f;&#x65b9;&#x5f0f;&#x5305;&#x62ec;&#x5c40;&#x90e8;&#x75c5;&#x53d8;&#x5207;&#x9664;&#x76f4;&#x63a5;&#x7f1d;&#x5408;&#x3001;&#x988a;&#x8102;&#x57ab;&#x586b;&#x585e;&#x53ca;&#x7898;&#x6761;&#x586b;&#x585e;&#x3002;&#x60a3;&#x8005;&#x672f;&#x540e;&#x968f;&#x8bbf;1&#x5e74;, &#x8bc4;&#x4f30;&#x9ecf;&#x819c;&#x6108;&#x5408;&#x3001;&#x75bc;&#x75db;&#x3001;&#x611f;&#x67d3;&#x63a7;&#x5236;&#x53ca;&#x4e0a;&#x988c;&#x7aa6;&#x708e;&#x75c7;&#x6539;&#x5584;&#x60c5;&#x51b5;&#x3002;&#x91c7;&#x7528;SPSS 20.0&#x8f6f;&#x4ef6;&#x8fdb;&#x884c;&#x7edf;&#x8ba1;&#x5b66;&#x5206;&#x6790;&#x3002; &#x5168;&#x90e8;&#x60a3;&#x8005;&#x77ed;&#x671f;(3&#x4e2a;&#x6708;)&#x603b;&#x6cbb;&#x6108;&#x7387;&#x4e3a;91.2%(124/136), &#x957f;&#x671f;(1&#x5e74;)&#x603b;&#x6cbb;&#x6108;&#x7387;&#x4e3a;94.9%(129/136)&#x3002;&#x2162;&#x671f;&#x60a3;&#x8005;&#x4e2d;, &#x988a;&#x8102;&#x57ab;&#x586b;&#x585e;&#x7ec4;&#x5728;&#x77ed;&#x671f;&#x548c;&#x957f;&#x671f;&#x968f;&#x8bbf;&#x4e2d;&#x7684;&#x53e3;&#x8154;&#x4e0a;&#x988c;&#x7aa6;&#x7618;&#x6d88;&#x9664;&#x7387;&#x5747;&#x663e;&#x8457;&#x9ad8;&#x4e8e;&#x7898;&#x6761;&#x586b;&#x585e;&#x7ec4;(79.4% vs. 23.4%, P < 0.001;85.3% vs. 54.7%, P=0.002)&#x3002;&#x7136;&#x800c;, &#x7898;&#x6761;&#x586b;&#x585e;&#x7ec4;&#x5728;&#x4e0a;&#x988c;&#x7aa6;&#x708e;&#x75c7;&#x6539;&#x5584;&#x65b9;&#x9762;&#x7684;&#x8868;&#x73b0;&#x66f4;&#x4f18;, &#x5176;&#x77ed;&#x671f;&#x548c;&#x957f;&#x671f;&#x708e;&#x75c7;&#x8bc4;&#x5206;&#x6539;&#x5584;&#x7a0b;&#x5ea6;&#x5747;&#x663e;&#x8457;&#x9ad8;&#x4e8e;&#x988a;&#x8102;&#x57ab;&#x586b;&#x585e;&#x7ec4;(P=0.029, P=0.014)&#x3002; &#x624b;&#x672f;&#x6cbb;&#x7597;&#x9002;&#x5b9c;&#x4e8e;&#x2160;~&#x2162;&#x671f;&#x7684;&#x4e0a;&#x988c;MRONJ&#x60a3;&#x8005;, &#x5bf9;&#x4e8e;&#x2162;&#x671f;&#x4e0a;&#x988c;MRONJ, &#x988a;&#x8102;&#x57ab;&#x586b;&#x585e;&#x66f4;&#x6709;&#x5229;&#x4e8e;&#x53e3;&#x8154;&#x4e0a;&#x988c;&#x7aa6;&#x7618;&#x7684;&#x95ed;&#x5408;, &#x800c;&#x7898;&#x6761;&#x586b;&#x585e;&#x5728;&#x4e0a;&#x988c;&#x7aa6;&#x708e;&#x75c7;&#x63a7;&#x5236;&#x65b9;&#x9762;&#x66f4;&#x5177;&#x4f18;&#x52bf;, &#x4e34;&#x5e8a;&#x5e94;&#x6839;&#x636e;&#x60a3;&#x8005;&#x5177;&#x4f53;&#x60c5;&#x51b5;&#x9009;&#x62e9;&#x4e2a;&#x4f53;&#x5316;&#x624b;&#x672f;&#x65b9;&#x6848;&#x3002;

To evaluate the short-term effectiveness of a visual treatment solution (VTS)-assisted total hip arthroplasty (THA) in patients with Crowe type &#x2162;-&#x2163; developmental dysplasia of the hip (DDH). A retrospective analysis was conducted on the clinical data of 43 patients with Crowe type &#x2162;-&#x2163; DDH who were treated between June 2023 and December 2024 and met the eligibility criteria. Of these, 22 patients underwent conventional THA (traditional group), and 21 underwent VTS-assisted THA (VTS group). There was no significant difference ( P>0.05) between the two groups in baseline data, including gender, age, side, Crowe classification, preoperative visual analogue scale (VAS) score, or Harris score. The operation time, intraoperative blood loss, postoperative drainage volume, length of hospital stay, and postoperative complications were recorded and compared between the two groups. Functional recovery and pain relief were assessed using the Harris score preoperatively and at 1 week, 3 months, and 6 months postoperatively, as well as the VAS score preoperatively and at 1 week and 1 month postoperatively. The acetabular cup anteversion and abduction angles were measured, and cup position was assessed with reference to the Lewinnek safe zone. Limb length discrepancy was measured, and acetabular coverage as well as the matching rates between the preoperatively planned and actually implanted prosthesis sizes were calculated. The operation time, intraoperative blood loss, and postoperative drainage volume were all significantly lower in the VTS group than in the traditional group ( P<0.05), whereas no significant difference was found in length of hospital stay ( P>0.05). All patients were followed up 6-9 months, with a mean time of 7.4 months. Primary wound healing was achieved in both groups, and no poor wound healing or neurovascular injury occurred. Deep venous thrombosis developed in 2 patients in the VTS group and 4 patients in the traditional group; 1 patient in the traditional group experienced prosthetic dislocation. No other complication, including dislocation or thrombosis, was observed during follow-up. There was no significant difference in the overall complication incidence between the two groups ( P>0.05). In both groups, acetabular anteversion and abduction angles were within the Lewinnek safe zone, but their distributions were more concentrated in the VTS group than in the traditional group. Compared with the traditional group, the VTS group showed significantly smaller postoperative limb length discrepancy and significantly greater anteversion angle and acetabular coverage ( P<0.05). No significant difference was found between the two groups in abduction angle, acetabular prosthesis matching rate, or femoral stem prosthesis matching rate ( P>0.05). Harris scores at 3 and 6 months postoperatively and VAS scores at 1 week and 1 month postoperatively were significantly better in the VTS group than in the traditional group ( P<0.05), whereas no significant difference was observed at the other time points ( P>0.05). VTS-assisted THA for Crowe type &#x2162;-&#x2163; DDH yields favorable short-term effectiveness by improving implant positioning accuracy, reducing surgical trauma, and promoting early pain relief and functional recovery. &#x9a8c;&#x8bc1;&#x53ef;&#x89c6;&#x5316;&#x5bfc;&#x822a;&#x7cfb;&#x7edf;&#xff08;visual treatment solution&#xff0c;VTS&#xff09;&#x8f85;&#x52a9;&#x4eba;&#x5de5;&#x5168;&#x9acb;&#x5173;&#x8282;&#x7f6e;&#x6362;&#x672f;&#xff08;total hip arthroplasty&#xff0c;THA&#xff09;&#x6cbb;&#x7597;Crowe&#x2162;&#xff5e;&#x2163;&#x578b;&#x53d1;&#x80b2;&#x6027;&#x9acb;&#x5173;&#x8282;&#x53d1;&#x80b2;&#x4e0d;&#x826f;&#xff08;developmental dysplasia of the hip&#xff0c;DDH&#xff09;&#x60a3;&#x8005;&#x7684;&#x65e9;&#x671f;&#x4e34;&#x5e8a;&#x7597;&#x6548;&#x3002;. &#x56de;&#x987e;&#x6027;&#x5206;&#x6790;2023&#x5e74;6&#x6708;&#x2014;2024&#x5e74;12&#x6708;&#x6536;&#x6cbb;&#x4e14;&#x7b26;&#x5408;&#x9009;&#x62e9;&#x6807;&#x51c6;&#x7684;43&#x4f8b;Crowe&#x2162;&#xff5e;&#x2163;&#x578b;DDH&#x60a3;&#x8005;&#x4e34;&#x5e8a;&#x8d44;&#x6599;&#xff0c;&#x5176;&#x4e2d;22&#x4f8b;&#x91c7;&#x7528;&#x4f20;&#x7edf;THA&#x6cbb;&#x7597;&#xff08;&#x4f20;&#x7edf;&#x7ec4;&#xff09;&#x3001;21&#x4f8b;&#x91c7;&#x7528;VTS&#x8f85;&#x52a9;&#x4e0b;THA&#x6cbb;&#x7597;&#xff08;VTS&#x7ec4;&#xff09;&#x3002;&#x4e24;&#x7ec4;&#x60a3;&#x8005;&#x6027;&#x522b;&#x3001;&#x5e74;&#x9f84;&#x3001;&#x4fa7;&#x522b;&#x3001;Crowe&#x5206;&#x578b;&#x53ca;&#x672f;&#x524d;&#x75bc;&#x75db;&#x89c6;&#x89c9;&#x6a21;&#x62df;&#x8bc4;&#x5206;&#xff08;VAS&#xff09;&#x3001;Harris&#x8bc4;&#x5206;&#x7b49;&#x57fa;&#x7ebf;&#x8d44;&#x6599;&#x6bd4;&#x8f83;&#x5dee;&#x5f02;&#x5747;&#x65e0;&#x7edf;&#x8ba1;&#x5b66;&#x610f;&#x4e49;&#xff08; P>0.05&#xff09;&#x3002;&#x8bb0;&#x5f55;&#x5e76;&#x6bd4;&#x8f83;&#x4e24;&#x7ec4;&#x60a3;&#x8005;&#x624b;&#x672f;&#x65f6;&#x95f4;&#x3001;&#x672f;&#x4e2d;&#x51fa;&#x8840;&#x91cf;&#x3001;&#x672f;&#x540e;&#x5f15;&#x6d41;&#x91cf;&#x3001;&#x4f4f;&#x9662;&#x65f6;&#x95f4;&#x53ca;&#x672f;&#x540e;&#x5e76;&#x53d1;&#x75c7;&#x53d1;&#x751f;&#x60c5;&#x51b5;&#xff1b;&#x91c7;&#x7528;&#x672f;&#x524d;&#x53ca;&#x672f;&#x540e;1&#x5468;&#x3001;3&#x4e2a;&#x6708;&#x3001;6&#x4e2a;&#x6708;Harris&#x8bc4;&#x5206;&#xff0c;&#x672f;&#x524d;&#x53ca;&#x672f;&#x540e;1&#x5468;&#x3001;1&#x4e2a;&#x6708;VAS&#x8bc4;&#x5206;&#x8bc4;&#x4ef7;&#x529f;&#x80fd;&#x53ca;&#x75bc;&#x75db;&#x6062;&#x590d;&#x60c5;&#x51b5;&#x3002;&#x6d4b;&#x91cf;&#x9acb;&#x81fc;&#x5047;&#x4f53;&#x7684;&#x524d;&#x503e;&#x89d2;&#x3001;&#x5916;&#x5c55;&#x89d2;&#xff0c;&#x5e76;&#x5224;&#x65ad;&#x5047;&#x4f53;&#x662f;&#x5426;&#x4f4d;&#x4e8e;Lewinnek&#x5b89;&#x5168;&#x533a;&#xff1b;&#x6d4b;&#x91cf;&#x4e0b;&#x80a2;&#x957f;&#x5ea6;&#x5dee;&#x5f02;&#xff0c;&#x5e76;&#x8ba1;&#x7b97;&#x9acb;&#x81fc;&#x8986;&#x76d6;&#x7387;&#x4ee5;&#x53ca;&#x672f;&#x524d;&#x89c4;&#x5212;&#x4e0e;&#x5b9e;&#x9645;&#x5e94;&#x7528;&#x5047;&#x4f53;&#x5339;&#x914d;&#x7387;&#x3002;. VTS&#x7ec4;&#x60a3;&#x8005;&#x624b;&#x672f;&#x65f6;&#x95f4;&#x3001;&#x672f;&#x4e2d;&#x51fa;&#x8840;&#x91cf;&#x53ca;&#x672f;&#x540e;&#x5f15;&#x6d41;&#x91cf;&#x5747;&#x5c11;&#x4e8e;&#x4f20;&#x7edf;&#x7ec4;&#xff08; P<0.05&#xff09;&#xff0c;&#x4e24;&#x7ec4;&#x60a3;&#x8005;&#x4f4f;&#x9662;&#x65f6;&#x95f4;&#x5dee;&#x5f02;&#x65e0;&#x7edf;&#x8ba1;&#x5b66;&#x610f;&#x4e49;&#xff08; P>0.05&#xff09;&#x3002;&#x4e24;&#x7ec4;&#x60a3;&#x8005;&#x5747;&#x83b7;&#x968f;&#x8bbf;&#xff0c;&#x968f;&#x8bbf;&#x65f6;&#x95f4;6&#xff5e;9&#x4e2a;&#x6708;&#xff0c;&#x5e73;&#x5747;7.4&#x4e2a;&#x6708;&#x3002;&#x4e24;&#x7ec4;&#x5207;&#x53e3;&#x5747;&#x2160;&#x671f;&#x6108;&#x5408;&#xff0c;&#x65e0;&#x5207;&#x53e3;&#x6108;&#x5408;&#x4e0d;&#x826f;&#x3001;&#x8840;&#x7ba1;&#x795e;&#x7ecf;&#x635f;&#x4f24;&#x7b49;&#x53d1;&#x751f;&#x3002;VTS&#x7ec4;&#x548c;&#x4f20;&#x7edf;&#x7ec4;&#x5206;&#x522b;&#x6709;2&#x4f8b;&#x548c;4&#x4f8b;&#x53d1;&#x751f;&#x4e0b;&#x80a2;&#x6df1;&#x9759;&#x8109;&#x8840;&#x6813;&#x5f62;&#x6210;&#xff0c;&#x4f20;&#x7edf;&#x7ec4;1&#x4f8b;&#x53d1;&#x751f;&#x5047;&#x4f53;&#x8131;&#x4f4d;&#xff0c;&#x5176;&#x4f59;&#x60a3;&#x8005;&#x968f;&#x8bbf;&#x671f;&#x95f4;&#x65e0;&#x8131;&#x4f4d;&#x3001;&#x8840;&#x6813;&#x5f62;&#x6210;&#x7b49;&#x5e76;&#x53d1;&#x75c7;&#x53d1;&#x751f;&#x3002;&#x4e24;&#x7ec4;&#x60a3;&#x8005;&#x5e76;&#x53d1;&#x75c7;&#x53d1;&#x751f;&#x7387;&#x6bd4;&#x8f83;&#x5dee;&#x5f02;&#x65e0;&#x7edf;&#x8ba1;&#x5b66;&#x610f;&#x4e49;&#xff08; P>0.05&#xff09;&#x3002;&#x4e24;&#x7ec4;&#x60a3;&#x8005;&#x7684;&#x524d;&#x503e;&#x89d2;&#x4e0e;&#x5916;&#x5c55;&#x89d2;&#x5747;&#x4f4d;&#x4e8e;Lewinnek&#x5b89;&#x5168;&#x533a;&#x4e2d;&#xff0c;&#x4f46;VTS&#x7ec4;&#x60a3;&#x8005;&#x7684;&#x524d;&#x503e;&#x89d2;&#x53ca;&#x5916;&#x5c55;&#x89d2;&#x5206;&#x5e03;&#x8f83;&#x4f20;&#x7edf;&#x7ec4;&#x66f4;&#x96c6;&#x4e2d;&#x3002;VTS&#x7ec4;&#x53cc;&#x4e0b;&#x80a2;&#x957f;&#x5ea6;&#x5dee;&#x5f02;&#x5c0f;&#x4e8e;&#x4f20;&#x7edf;&#x7ec4;&#xff0c;&#x524d;&#x503e;&#x89d2;&#x53ca;&#x9acb;&#x81fc;&#x8986;&#x76d6;&#x7387;&#x5747;&#x5927;&#x4e8e;&#x4f20;&#x7edf;&#x7ec4;&#xff0c;&#x5dee;&#x5f02;&#x6709;&#x7edf;&#x8ba1;&#x5b66;&#x610f;&#x4e49;&#xff08; P<0.05&#xff09;&#xff1b;&#x4e24;&#x7ec4;&#x5916;&#x5c55;&#x89d2;&#x53ca;&#x9acb;&#x81fc;&#x5047;&#x4f53;&#x5339;&#x914d;&#x7387;&#x3001;&#x80a1;&#x9aa8;&#x67c4;&#x5047;&#x4f53;&#x5339;&#x914d;&#x7387;&#x6bd4;&#x8f83;&#x5dee;&#x5f02;&#x5747;&#x65e0;&#x7edf;&#x8ba1;&#x5b66;&#x610f;&#x4e49;&#xff08; P>0.05&#xff09;&#x3002;VTS&#x7ec4;&#x672f;&#x540e;3&#x3001;6&#x4e2a;&#x6708;Harris&#x8bc4;&#x5206;&#x53ca;&#x672f;&#x540e;1&#x5468;&#x3001;1&#x4e2a;&#x6708;VAS&#x8bc4;&#x5206;&#x4f18;&#x4e8e;&#x4f20;&#x7edf;&#x7ec4;&#xff0c;&#x5dee;&#x5f02;&#x6709;&#x7edf;&#x8ba1;&#x5b66;&#x610f;&#x4e49;&#xff08; P<0.05&#xff09;&#xff1b;&#x5176;&#x4f59;&#x65f6;&#x95f4;&#x70b9;&#x4e24;&#x7ec4;&#x5404;&#x8bc4;&#x5206;&#x5dee;&#x5f02;&#x65e0;&#x7edf;&#x8ba1;&#x5b66;&#x610f;&#x4e49;&#xff08; P>0.05&#xff09;&#x3002;. VTS&#x8f85;&#x52a9;&#x6cbb;&#x7597;Crowe &#x2162;&#xff5e;&#x2163;&#x578b;DDH&#x7684;&#x65e9;&#x671f;&#x7597;&#x6548;&#x663e;&#x8457;&#xff0c;&#x5176;&#x80fd;&#x63d0;&#x9ad8;THA&#x5047;&#x4f53;&#x5b9a;&#x4f4d;&#x7cbe;&#x5ea6;&#x3001;&#x51cf;&#x5c11;&#x521b;&#x4f24;&#xff0c;&#x6709;&#x6548;&#x51cf;&#x8f7b;&#x672f;&#x540e;&#x75bc;&#x75db;&#x5e76;&#x4fc3;&#x8fdb;&#x65e9;&#x671f;&#x529f;&#x80fd;&#x6062;&#x590d;&#xff0c;&#x662f;&#x590d;&#x6742;THA&#x7684;&#x53ef;&#x9760;&#x6280;&#x672f;&#x652f;&#x6301;&#x3002;.

Acute and subacute low back pain (LBP) often progresses to a chronic impactful back problem in patients with elevated risk. The most effective way to prevent this progression is unknown. To determine the effectiveness of spinal manipulation and clinician-supported biopsychosocial self-management vs medical care for preventing chronic impactful LBP. This 2&#x2009;&#xd7;&#x2009;2 factorial randomized clinical trial was conducted in research clinics at the University of Minnesota and the University of Pittsburgh, Pennsylvania, from November 2018 to May 2023, with follow-up concluding in June 2024. Adults with acute or subacute LBP with a moderate to high risk of chronicity were included. Four interventions were applied for 8 weeks: spinal manipulation therapy; supported self-management; combined spinal manipulation therapy and supported self-management; and guideline-based medical care. Spinal manipulation and supported self-management were provided by physical therapists and chiropractors. Mean LBP impact score per the US National Institutes of Health Task Force on Chronic LBP scale (8 [best] to 50 [worst]) during 10 to 12 months, responder analyses of group differences in the proportion of participants with at least 50% reductions. A reduction of 30% was considered the minimal clinically important within-patient difference. Secondary outcomes included measures of chronicity and LBP burden (ie, health care and medication use, productivity), important patient-reported outcomes (eg, improvement, satisfaction), biopsychosocial measures (eg, Patient-Reported Outcomes Measurement Information System), and potential mediating psychosocial measures (eg, self-efficacy, kinesiophobia, pain catastrophizing). Of the 1000 participants (mean [SD] age, 47 [16] years; 577 females [58%]) randomized, 928 (93%) completed the trial. An omnibus test of the primary outcome was statistically significant (P&#x2009;=&#x2009;.006). Group differences in mean LBP impact scores were small but statistically significant: supported self-management vs medical care, -1.7 (95% CI, -2.7 to -0.6); combined self-management and spinal manipulation vs medical care, -1.3 (95% CI, -2.5 to 0). Spinal manipulation therapy and medical care did not differ: -0.3 (95% CI, -1.5 to 1.0). Adding spinal manipulation to supported self-management did not provide additional benefit. The supported self-management group had a significantly higher proportion with at least 50% reduction in LBP impact vs medical care (64% vs 55%). Supported self-management also performed better on most secondary outcomes compared to medical care, including 12% fewer reporting chronic pain that frequently interfered with regular activities. Mediation analyses showed changes in psychosocial factors at 6 months and explained 76% of supported self-management effects at 1 year. This randomized clinical trial found that for patients with acute or subacute LBP at increased risk of chronic impactful LBP, clinician-supported biopsychosocial self-management resulted in a lower mean LBP impact score at 10 to 12 months vs medical care; spinal manipulation and medical care did not differ. While the LBP impact difference was small, the consistent results of the responder analyses and most secondary outcomes suggest differences between clinician-supported self-management and medical care are clinically relevant. ClinicalTrials.gov Identifier: NCT03581123.

Mobile health (mHealth) technology has been utilized to offer self-management tools to people with pain, including symptom tracking. Existing mobile tracking applications (apps) for chronic pain management have demonstrated reliability, feasibility, improved coping, and reduced health care utilization. Unfortunately, adherence in using a pain app can be problematic with many not using or discontinuing its use early. The current study aimed to investigate the impact that pain self-efficacy, pain conceptualizations, and patient perception of pain care providers, have on engagement with a mobile pain tracking app. Seventy-six (N=76) individuals with chronic pain downloaded a pain app and completed questionnaires assessing their pain and use of a pain app 3 months after they had downloaded the app. Associations with engagement with the app, defined as the number of daily diaries completed, and demographic and self-report questionnaire data were examined. Results showed that engagement with the app was unrelated to self-efficacy and pain conceptualization but significantly related to positive perceptions of their pain care providers. Patients with more severe pain were found to have lower self-efficacy, less understanding of the biopsychosocial model of pain, and lower satisfaction with their involvement in their pain care decisions. Surprisingly, those who engaged more with the app demonstrated lower self-efficacy as compared with those who used the pain app less. These findings highlight the importance of the patient-provider relationship in engaging with mHealth technology for pain management. Results further imply that longer-term use of mHealth tools may not be perceived as adaptive or clinically helpful for certain individuals.

Medication-related osteonecrosis of the jaw (MRONJ) represents a major clinical challenge for oral and maxillofacial surgery departments as well as dental practices. With increasing life expectancy and the more frequent use of medications associated with osteonecrosis, the incidence of MRONJ continues to rise. To date, there are no uniform treatment standards with scientifically proven effectiveness for this condition. To evaluate the impact of platelet-rich fibrin (PRF) on the outcomes of MRONJ treatment and to identify factors that may influence the effectiveness of PRF therapy, we conducted a comparative prospective study including 22 patients divided into two groups: patients treated with PRF and patients treated without PRF. PRF was prepared according to the PRF Duo Quattro Process protocol for PRF (Nice, France). The study was registered at ClinicalTrials.gov (NCT07464678). The following parameters were assessed: age, smoking status, gender, lesion location, body mass index (BMI), C-reactive protein (CRP) concentration, pain intensity, presence or absence of fistulas, soft tissue healing and radiological findings. Patients were evaluated preoperatively and postoperatively at 14 days, 6 weeks, and 6 months. The study demonstrated a reduction in pain after surgery among patients treated with PRF. In addition, the use of PRF resulted in improved healing outcomes in patients with elevated CRP. Higher BMI was associated with poorer therapeutic response to PRF. Improvements in soft tissue healing and disease stage were observed in the PRF group; however, these differences did not reach statistical significance. All findings should be interpreted with caution due to the limited sample size. There is still no standardized treatment for MRONJ. The use of platelet-rich fibrin as an inexpensive and safe adjunctive therapy may provide clinical benefits for patients, particularly through a significant reduction in pain. Further large-scale, multicenter studies are required to confirm these findings.

Comprehensive pain management in children requires a specialized skillset, with a limited number of clinicians possessing the level of expertise required to successfully navigate the complexities of holistic care. The emergence of pediatric anesthesia fellowship programs in sub-Saharan Africa presents an opportunity to embed a pediatric pain curriculum for trainees, improving the availability of specialist skill and knowledge in the field. Existing pain curricula fall short in addressing the sociocultural aspects of pediatric pain identified through research as being unique to the African context, and do not include elements of leadership and advocacy training required to navigate the complexities of resource-constrained healthcare settings. A Delphi survey including literature review, iterative rounds of surveys and expert consensus was used to establish a pediatric pain curriculum for pediatric anesthesia fellows undertaking advanced training in sub-Saharan Africa. The 22-member expert panel included anesthetists, nurses, surgeons, pharmacists, pediatricians, a physiotherapist and a patient-caregiver dyad with a lived experience of pain. After completing three rounds of surveys, a steering committee of five members was assembled to resolve outstanding items to achieve the final curriculum. The process yielded a curriculum containing 20 knowledge items and 23 skills items. Attitudes are a key component of the curriculum and were grouped into six themes. A further aspect of the process was the identification of foundational knowledge with which trainees should enter a fellowship training program. This was termed the foundational curriculum. Using a Delphi method, consensus has been achieved on a pediatric pain curriculum for pediatric anesthesia fellows in sub-Saharan Africa with potential to meet the identified need for transformative pain care in this patient population.

To explore the efficacy and safety of pulsed radiofrequency combined with sympathetic radiofrequency ablation of dorsal root ganglion in the treatment of acute herpetic neuralgia. A total of 116 patients diagnosed with acute herpetic neuralgia were randomly assigned to two groups: a dorsal root ganglion pulsed radiofrequency group (Group C) and a dorsal root ganglion pulsed radiofrequency combined with sympathetic radiofrequency ablation group (Group H). The treatment effects were evaluated using the Numerical Rating Scale, the Pittsburgh Sleep Quality Index, the proportion of patients utilizing tramadol, and the Current Perception Threshold detection. Additionally, serum levels of Galectin-3 and Interleukin-6 were measured as objective biological indicators to assess the therapeutic efficacy. The incidence of Postherpetic Neuralgia and any complications were recorded for both groups. Data showed that compared with group C, the Numerical Rating Scale, Pittsburgh Sleep Quality Index score, the proportion of patients using tramadol, and serum Galectin-3 and Interleukin-6 levels were significantly decreased, and Current Perception Threshold was significantly increased in group H (P<0.05). The incidence of Postherpetic Neuralgia in group H was significantly lower than that in group C. No serious adverse reactions occurred in the two groups after treatment. Dorsal root ganglion pulsed radiofrequency combined with sympathetic radiofrequency ablation is more effective in the treatment of acute herpetic neuralgia. Compared with PRF therapy alone, it provides patients with longer lasting pain relief, reduces the incidence of PHN, and improves the quality of life.

To validate the Patients Endorsement of the Biopsychosocial Model of Chronic Pain (PEB) Scale in young adults with chronic pain, assessing psychometric properties and associations with pain beliefs and readiness for pain self-management. A cross-sectional survey was administered to 240 young adults with chronic pain (&#x2265;3 months) via Prolific. Participants completed the PEB Scale and measures assessing readiness for pain self-management, pain beliefs, psychological variables, and pain characteristics. Reliability, factor structure, convergent/discriminant validity, and incremental validity were all assessed. In the sample, the PEB Scale had a good internal consistency (Cronbach's &#x3b1;=.88). Factor analysis confirmed an unifactorial structure. Convergent validity was supported through a moderate correlation between the PEB Scale and readiness for pain self-management (PSOCQ Contemplation subscale, r=.32, P=.001). The scale also showed small-moderate correlations with pain interference (r=.25, P=.001) and psychological measures. Hierarchical regression analyses revealed the PEB Scale was associated with an increased chance to be in the contemplation phase (&#xf062;&#xf020;=.042, P<.001) or action/maintenance phase (&#xf062;&#xf020;=.021, P<.05) of pain self-management, when controlling for demographics, pain characteristics, beliefs, and psychological factors. Higher PEB scores were associated with greater contemplation of and engagement in the self-management of chronic pain. The scale appears to be conceptually different from existing pain belief and psychological measures. Limitations include the use of self-report measures, limited effect sizes and demographic homogeneity of our sample. Future studies should test the scale in diverse groups, explore its sensitivity to change, and clinical utility.

Chronic musculoskeletal pain is reported by 1 of 4 adolescents worldwide. Pain-related functioning is negatively affected by pain itself but also related to depressive symptoms. Although the association between pain-related functioning and depressive symptoms is established, there is a lack of longitudinal studies that establish the direction of the association. The aim was to analyse the temporal association between depressive symptoms and pain-related functioning among adolescents with recurrent musculoskeletal pain. This longitudinal sample comprised 604 adolescents in seventh and eighth grade (M = 13.7 y) who reported recurrent musculoskeletal pain at baseline, defined as occurring at least every week over the previous 6 months. The adolescents were followed yearly for 2 consecutive years (T1, T2, and T3). Temporal associations of self-reported pain-related functioning and depressive symptoms were analysed. Using cross-lagged panel modelling, 4 models were estimated: autoregressive; depressive symptoms predicting pain-related functioning; pain-related functioning predicting depressive symptoms; and a bidirectional model. Pain intensity was entered as a covariate. The results indicate high stability of depressive symptoms and pain-related functioning over time. Although the strength of the prediction was strongest in the autoregressive paths, cross-lagged paths revealed that depressive symptoms at T1 and T2 significantly predicted pain-related functioning at T2 and T3, respectively. Conversely, pain-related functioning at T1 and T2 did not predict depressive symptoms at T2 and T3, respectively. The model where depressive symptoms predict pain-related functioning provided the best model fit and thus, in this general population sample, depressive symptoms drive pain-related functioning more than vice versa. Screening for and targeting depressive symptoms might be essential in affecting the functional consequences of pain.

People with chronic pain often experience symptoms of pain-related distress (kinesiophobia, catastrophizing) and general distress (depression, anxiety). Identifying distinct profiles of distress among patients seeking pain psychology treatment can inform personalized pain psychology interventions. Among adults seeking pain psychology treatment, the current study applied latent profile analysis (LPA) to (1) identify distinct patient symptom profiles (based on kinesiophobia, catastrophizing, depression, anxiety) and (2) characterize pain-related symptoms and demographics of each profile. Adults scheduled for a pain psychology evaluation who completed a clinical battery of patient-reported outcome measures were included. LPA was applied to identify distinct subgroups of patients based on psychological symptoms. The resulting groups were compared on pain-related and demographic factors. Participants were 548 adults (Mean Age=51.1; predominantly white [66.6%] and female [67.5%]). Two profiles were identified: "Global Distress" (67.2%, elevated clinical symptoms in all domains) and "Localized and Mild Kinesiophobia" (32.8%, sub-clinical symptoms in all domains, except mild kinesiophobia). The "Global Distress" group was younger (d=.23) and had higher levels of area deprivation (d=.23). They had higher pain intensity (d=.76), functional disability (d=.72), and opioid misuse risk (d=1.21). Among adults seeking pain psychology treatment, most experienced elevated distress across pain-specific and general domains. A minority experienced sub-clinical symptoms, with focal and mild kinesiophobia. The findings highlight a wide range of pain psychology needs among adults with chronic pain seeking psychology treatment, and highlight the value in treatment options that span intensity and breadth.

Very few validated instruments measure a child's concept of pain. The Conceptualization of Pain Questionnaire (COPAQ) is a unidimensional instrument measuring this construct, developed in Catalan and translated into English. The clinimetric properties of the English version have not been evaluated. We conducted a Rasch analysis to evaluate its structural validity and internal consistency, and a Confirmatory Factor Analysis (CFA) to evaluate its structural validity. We analyzed an existing data set from a previous study. Item fit was evaluated using INFIT and OUTFIT statistics, item difficulty was estimated using Rasch coefficients, and internal consistency using Cronbach alpha. Structural validity was measured using item loadings from the CFA. We included data from 497 adolescents (average age 14&#xa0;y [SD 1.28], 51% male). There was a wide range of difficulty across items. One item demonstrated excessive positive outfit, and 2 items were close to the cutoff for excessive negative outfit. The COPAQ demonstrated poor overall fit to the unidimensional Rasch Model and did not demonstrate adequate internal consistency (Cronbach alpha=0.6). Results from the CFA suggest the items do not measure the single construct they intend to measure. The English version of the COPAQ did not have adequate internal consistency or structural validity. More work is required to assess the content validity of current instruments measuring a child's concept of pain. Developing validated instruments measuring a child's concept of pain aligned with the biopsychosocial model should be prioritized.

This article presents a Delphi consensus developed by a panel of editors-in-chief of anaesthesiology and pain medicine journals to guide the responsible use of large language models (LLMs) in academic publishing. LLMs offer potential benefits for scientific writing, including language editing, summarisation, translation, information organisation, and support for non-native English speakers, but their misuse raises concerns about accuracy, transparency, confidentiality, and research integrity. Through a three-round modified Delphi process involving 53 editors-in-chief or their delegates, 59 statements were generated and categorised into guidance for authors, editors, reviewers, and publishers with a particular attention to LLM disclosure practices and perceived risks. The consensus recognises that LLMs are useful tools in academic publishing for authors, reviewers, and editors. However, their use must be guided by ethics, legality, and principles of transparency and accountability. LLMs may assist with limited editorial and authorial tasks provided that their use is fully disclosed and all outputs are verified by humans. The consensus also emphasises the inappropriateness of using LLMs to generate original or ideative content, which should remain a strictly human responsibility. Moreover, LLMs must not generate data, references, conclusions, or entire manuscripts, nor be used for editorial decisions or peer-review reports. Editors expressed concerns about 'hallucinations', erosion of critical skills, confidentiality breaches, and the proliferation of low-quality LLM-generated manuscripts. The resulting guidance highlights transparency, human accountability, and careful verification as essential principles for integrating LLMs into scholarly workflows while preserving the integrity of scientific publishing.

Operant approach activity pacing (undertaking activities according to quotas, e.g. amount/time/goal rather than according to symptom severity) is advised for chronic pain. There is no standardised intervention that addresses all the components of operant approach activity pacing. This systematic review aimed to identify operant approach activity pacing interventions for chronic pain and explore their components, effectiveness, feasibility and acceptability. Eligible studies included any type of evaluation (e.g. randomised controlled trials, feasibility/pilot, qualitative) among adults with chronic pain. Ineligible studies included interventions based on energy conservation/envelope theory/adaptive pacing therapy/symptom-contingency, and non-English language. Databases included: MEDLINE, Embase, CINAHL, AMED, PsycINFO, Cochrane CENTRAL, PEDro, OTseeker and Web of Science (from database inception to 26th March 2025). Two independent reviewers extracted data, including descriptions of interventions (TIDieR checklist), appraised risk of bias (Joanna Briggs Institute checklists) and evaluated confidence in the research (GRADE). Findings were synthesised narratively. Nine studies (10 interventions; 11 papers) were included (873 participants). Interventions were heterogeneous in content, length (2-11 sessions) and tailored/untailored to participants' baseline behaviours. Common intervention components were pre-planning, activity-rest cycling/using rests and alternating activities/positions. Direction of effect (vote counting) was towards improved function, but mixed findings for pain/fatigue. Studies showed mixed findings across outcomes, syntheses were limited to vote counting, with very low confidence in the evidence; limiting conclusions about effectiveness. The multiple components of activity pacing can be considered to further develop and test the effectiveness of operant activity pacing for chronic pain. Funder: NIHR School for Primary Care Research. (PROSPERO:CRD42023451469).

This study aimed to evaluate pain distribution in people with acute whiplash associated disorders (WAD) and explore its association with neuropathic pain and assumed central sensitization features. Although widespread pain is common after a whiplash injury, the relationship between pain extent (the area of the body perceived as painful) and underlying pain-related mechanisms in acute WAD remains poorly understood. In this cross-sectional study, 124 individuals (mean age: 39.7&#xb1;11.2&#xa0;y; 67 females) with acute WAD grade II (7-30&#xa0;d post-injury) completed questionnaires assessing neck pain intensity, disability, neuropathic pain (S-LANSS), and assumed central sensitization (CSI). Pain drawings were analyzed with a validated image-processing algorithm to quantify pain extent. Correlation and multiple linear regression analyses were performed to identify predictors of pain extent. Bivariate correlations showed that pain extent was significantly associated with all clinical variables, with the strongest correlation observed between pain extent and S-LANSS (&#x3c1;=0.816, P<.001). In the multiple regression model, only S-LANSS was a significant predictor of PE (&#x3b2;=0.705, P<.001), explaining 64% of the variance. A moderate correlation (&#x3c1;=0.437) was found between CSI and pain extent, but the CSI did not independently predict pain extent. No sex differences were observed for any clinical variable. This is the first study to show a strong association between neuropathic pain features and widespread pain in people with acute WAD. These findings highlight the potential utility of assessing pain extent and neuropathic pain features to identify pain phenotypes early after injury which may support more individualized treatment approaches.

This study aimed to identify phenotypes of people with frozen shoulder (FS) based on baseline measures including pain intensity, disability, pain-related psychological factors, and measures of central pain processing. A secondary objective was to evaluate whether these baseline phenotypes were associated with distinct longitudinal trajectories of pain intensity and disability over 9 months. People with FS were assessed at baseline for clinical (pain intensity and disability) and psychophysical variables (pain catastrophizing and hypervigilance, self-reported symptoms related to central sensitization, primary and secondary allodynia and hyperalgesia, and pain modulation). A latent profile analysis was conducted using baseline clinical and psychophysical variables. Linear mixed models were then used to examine longitudinal trajectories of pain intensity and disability across phenotypes over 3, 6, and 9 months. A total of 149 people with FS were recruited. Two distinct phenotypes were identified, of which phenotype 2 (n=70) presented higher intensity of pain, greater disability, and higher scores for pain catastrophizing, hypervigilance, and central sensitization-related symptoms at baseline compared to phenotype 1 (n=79). Over 9 months, trajectories differed by phenotype. Phenotype 2 exhibited a greater absolute reduction in both pain and disability, yet phenotype 1 remained lower at all time points, including 9 months, for both outcomes. This study highlights two distinct phenotypes in people with FS based on baseline clinical and psychophysical variables. These phenotypes showed distinct trajectories of pain and disability over 9 months, supporting the relevance of baseline phenotyping for understanding clinical heterogeneity in FS.

To investigate if psychological/cognitive aspects and executive functions can influence conditioned pain modulation (CPM) activity in elderly people with and without chronic pain. A cross-sectional unifactorial repeated measures case-control study with 19 adults (89.5% women, age: 73.2&#xb1;5.6&#xa0;y) with chronic primary musculoskeletal pain and 38 adults (74.5% women, age: 74.3&#xb1;4.4&#xa0;y) without chronic pain was conducted. Pain features, psychological/cognitive (anxiety, depression, pain hypervigilance, and pain catastrophizing), and 2 executive functions (working memory, mental inhibition) were assessed. Subsequently, CPM was evaluated on changes obtained in mechanical (pressure pain threshold-PPT) stimuli with the cold-pressor test paradigm. A significant group X time interaction after controlling all cofounders was found: PPTs were higher after the conditioned stimulus in individuals without chronic pain (CPM increase 15%&#xb1;10%), whereas PPTs were lower after the conditioned stimulus in those with chronic pain (CPM decrease -11%&#xb1;7%) when compared with PPTs at baseline. In elderly people with chronic pain, pain intensity and catastrophizing accounted for 28.6% of the variance of the CPM activation index. In elderly people without chronic pain, just pain catastrophizing had significant predictive value accounting for 10.6% of the variance of CPM activation index. Elderly people with chronic musculoskeletal pain exhibited impaired CPM activation as compared with adults without chronic pain. Thus, CPM activation was associated with the intensity of pain and, in a lesser extent, with pain catastrophizing, but not with anxiety/depressive levels and executive functions.

This systematic review and meta-analysis examined the efficacy of pain neuroscience education (PNE) on pain, sleep parameters and psychosocial factors in chronic musculoskeletal pain conditions in adults and adolescents. The review was conducted in accordance with PRISMA guidelines. A systematic search was performed using the databases of Medline (PubMed), Scopus, PEDro and Web of Science. The qualitative assessment was done by using Physiotherapy Evidence Database (PEDro) scale and Cochrane's risk of bias (ROB 2.0) tool. The quantitative analysis was performed using the Rev Man 5.4.1 using a random effects model, SMD with 95% confidence intervals and certainty of evidence was evaluated using GRADEpro/GDT. Twelve randomised-controlled trials (n=1485) met the inclusion criteria. The meta-analysis showed statistically significant effect in favour of PNE on reducing pain intensity (SMD: -0.27 [95% CI, -0.5 to 0.00; I2=67%]) and total sleep time with small to medium effect size (SMD: 0.42 [95% CI, 0.12 to 0.71; I2=0%]). However, no statistically significant differences were observed for other sleep parameters and psychosocial outcomes, despite some outcomes indicating a moderate clinical effect. The findings suggest that PNE alone can reduce pain intensity, but greater improvements in sleep and psychosocial outcomes are seen when it is combined with interventions such as CBT and therapeutic exercises. These results highlight the potential role of PNE within a multimodal approach to pain management, while also underscoring the need for further research on its impact on sleep parameters in a specific population.