Pain Management

Chronic pain in the Ehlers-Danlos syndromes (EDS) is common and may be severe. According to one study, nearly 90% of patients report some form of chronic pain. Pain, which is often one of the first symptoms to occur, may be widespread or localized to one region such as an arm or a leg. Studies on treatment modalities are few and insufficient to guide management. The following is a discussion of the evidence regarding the underlying mechanisms of pain in EDS. The causes of pain in this condition are multifactorial and include joint subluxations and dislocations, previous surgery, muscle weakness, proprioceptive disorders, and vertebral instability. Affected persons may also present with generalized body pain, fatigue, headaches, gastrointestinal pain, temporomandibular joint pain, dysmenorrhea, and vulvodynia. Pain management strategies may be focused around treating the cause of the pain (e.g., dislocation of a joint, proprioceptive disorder) and minimizing the sensation of pain. Ma...

Percutaneous vertebroplasty and sacroplasty are becoming common modalities of treatment for vertebral body compression fractures and sacral insufficiency fractures, respectively. The present report describes a case of a coccygeal fracture treated with injection of polymethylmethacrylate cement, which resulted in immediate relief of symptoms. It is suggested that this procedure be called coccygeoplasty. J Vasc Interv Radiol 2006; 17:909 -912

Long-term pain is a common comorbidity for people with acquired brain injury. This chapter explores what it is like to live with those two conditions, focusing on the meaning for the individual. The meaning of pain plays a part in determining people’s emotional reactions and behavioural choices, and it is central for the process of psychosocial adjustment to a life with functional, social, participatory, and emotional challenges. Meaning is also closely linked to the identity changes that typically happen once people are faced with the challenge of living with long-term conditions. The field of positive psychology has contributed valuable insights into this process and the roles of benefit-finding, resilience, and post-traumatic growth are discussed. Two significantly different case stories are used as an illustration of life with acquired brain injury and long-term pain. One case, Julie, illustrates the process of adaptation and the other case, Mark, illustrates the challenge of dealing with pain issues when insight and pain perception has been changed by a frontal lobe injury. In both cases, the meaning of pain is integral to the meaning of brain injury. Neither Julie nor Mark consider themselves to have long-term pain, they live with the long-term impact of their brain injury, where pain is just one aspect. In fact, Mark’s altered pain perception causes him to claim that he feels no pain, yet it is nevertheless a challenge for him. The chapter concludes with clinical recommendations, calling for access to systematic, psychosocial rehabilitation that includes meaning-based approaches. A holistic rehabilitation model is proposed, suggesting that traditional medical and rehabilitation approaches need to happen within the context of psychosocial adjustment and rehabilitation, rather than expecting psychosocial adjustment to happen by itself, as a “by-product” of medical, physical, cognitive, and occupational interventions.

D efinition of Palliative care: "Palliative care is an approach that improves the quality of life of patients and their families facing the problem associated with life-threatening illness, through the prevention and relief of suffering by interdisciplinary team taking into consideration physiological, psychosocial, and spiritual needs" (WHO, 2003) Suffering: Suffering is loss of meaning. Suffering occurs when there is a gap between expectation and reality. Principles of Palliative Care: Focus on quality rather than quantity of life. Effective communication at all levels. Respect for autonomy and choice. Effective symptom management. Holistic, multi-professional approach. Caring about the person and family. Palliative care is adding life to days, not adding days to life. It is the right of the patients not to feel pain, suffering or fear at all stages of the disease. Holistic approach is essentials for the relieve of suffering. Pain Management: Pain is an important and undertreated symptom of life-threatening illness. Correct use of analgesic medication, following the guidelines of the WHO step ladder, with the addition of adjuvant analgesics, should control the pain in nearly all cases. Attention should also be given to other aspects of pain, psychosocial or spiritual; Sometimes called "total pain". Bringing pain under control and keeping it there means assessing each aspect of pain and monitoring it. These are core skills of palliative care doctors and nurses. Medications are the foundation of pain control. Anti-inflammatory, anti-depressant and steroid medication may also have a complementary role for some patients and some sources of pain. Complementary measures are used as well as medical treatments. Wafa Qasem Ahmad has completed her Medical degree from Kuwait University in June 1989. She is working as a Consultant, Internist in a Private Clinic.

Every palliative care patient should have the expectation that acute and chronic pain management will be an integral part of their overall care. However, in all too many instances, the pain of cancer is often grossly under-treated. This issue is of concern because more than 80% of patients with cancer pain can ®nd adequate relief through the use of simple pharmacological methods. It is even more troubling to note that women and minority groups have their cancer pain under-treated more frequently. Physicians with the basic skills of assessment and treatment will be able to control the symptoms in the majority of cancer pain patients. However, there are still some patients who may require other modalities to control their moderate to severe pain. A thorough understanding of all pain management options will help the gynaecological oncologist to maintain an acceptable quality of life for their patients throughout the therapeutic and palliative phases of care.

Background: Shoulder pain is a very common presentation in primary care. Evidence of benefit for subacromial corticosteroid injection is inconclusive and confined largely to studies with short follow-up. We plan a large, definitive, primary-care-based trial to determine efficacy and safety in patients with rotator cuff tendinopathy, and conducted a pilot trial to explore feasibility. Methods: Six general practitioners (GPs) from Oxfordshire, UK underwent update training in assessing painful shoulders and injecting the subacromial space. Each then recruited patients aged 35 to 74 years from primary care complaining of shoulder pain lasting no more than 6 months. Eligible participants were randomized to receive either methylprednisolone acetate 40 mg with lidocaine 1% (total volume 1 ml), or lidocaine 1% alone (total volume 1 ml), injected into the subacromial space. The participants were blinded to treatment allocation. Feasibility outcomes were rates of recruitment, withdrawal, adherence to the protocol, completeness of follow-up, and success of patient masking. Clinical outcomes were the Oxford Shoulder Score (OSS) at baseline and at 4 and 12 weeks, and responses to three satisfaction questions at 2, 4 and 12 weeks. Outcome data were collected by postal questionnaires. Results: A total of 40 participants were randomized (80% of the target 50 participants) over 26 weeks giving an overall recruitment rate of 1.5 participants per week. Rates of follow-up were maintained to a high level for the full 12 weeks. Four participants requested a 'rescue' corticosteroid injection but no patients withdrew. The trial GPs gave high scores for their confidence that the patient had remained blinded to treatment allocation during the procedure. The OSS at 4 and 12 weeks and the responses to the satisfaction questions are reported. Conclusions: It is feasible to recruit participants with shoulder pain in the primary care setting for a blinded, randomized trial of corticosteroid injection. Online randomization of participants from the practice is also feasible, and postal questionnaires provide an effective means of gathering outcome data in this area of study. The lessons learned from this pilot will usefully inform the design of a large, definitive efficacy trial in primary care.

Purpose of the Review-The present review is intended to give an overview of fibromyalgia for the anesthesiologist. While the basics of the treatment of fibromyalgia are included, the intent is to provide context to discuss the potential implications in perioperative management. Recent Findings-One of the most important changes in the last year is the new criteria established by the American College of Rheumatology for the diagnosis of fibromyalgia. Instead of a combination of self-report and a tender point examination, there is a new self-report questionnaire that is now used diagnose fibromyalgia. This tool incorporates aspects of widespread body pain and some of the known comorbid symptoms. A score of 0-31 is given, which allows for the disease to be viewed as a continuum of sensitivity and symptomatology, instead of as a binary diagnosis. This continuum has been termed "fibromyalgia-ness." This article also reviews the advances in understanding of the pathophysiology and emerging therapies. Little is known about the impact of fibromyalgia in the perioperative period. Summary-The impact of fibromyalgia on anesthesia care is not known. Years of quality research have clearly demonstrated multiple pathophysiologic changes that could impact anesthesia care and future study is needed.

There is much evidence to suggest that gender is an important factor in the modulation of pain. Literature data strongly suggest that men and women differ in their responses to pain: they are more variable in women than men, with increased pain sensitivity and many more painful diseases commonly reported among women. Gender differences in pharmacological therapy and non-pharmacological pain interventions have also been reported, but these effects appear to depend on the treatment type and characteristics. It is becoming very evident that gender differences in pain and its relief arise from an interaction of genetic, anatomical, physiological, neuronal, hormonal, psychological and social factors which modulate pain differently in the sexes. Experimental data indicate that both a different modulation of the endogenous opioid system and sex hormones are factors influencing pain sensitivity in males and females. This brief review will examine the literature on sex differences in experim...

Aim. To estimate the prevalence of painful temporomandibular disorders (TMD-P) among adolescents and to investigate correlations with health, environment, and lifestyle factors. Methods. For this cross-sectional case-control study, 562 patients were consecutively recruited at their yearly revision control from four dental clinics in Rogaland County, Norway. Patients completed a questionnaire on general health, socioeconomics, demographics, and lifestyle factors. Responses to two screening questions identified patients with TMD-P, who then underwent clinical examination to verify the TMD diagnosis. Pain intensity was assessed on a visual analogue scale. Patients without TMD-P constituted the control group and were not clinically examined. Results. 7% experienced TMD-P. The female-to-male ratio is 3:1; median age is 17 years. Patients at urban clinics had higher prevalence compared with those at rural clinics. TMD-P patients had headache and severe menstrual pain compared to controls....

The unsatisfactory results associated with conventional treatments for symptoms of diabetic peripheral neuropathy (DPN) demonstrate a need for research into alternative therapies. The purpose of this study was to determine the efficacy of whole body vibration therapy (WBV) as a treatment for pain associated with DPN. Participants (n Z 8) with painful DPN received three treatment sessions per week for four weeks. Each session consisted of four bouts of 3 min of vibration (frequency 25 Hz, amplitude 5 mm). The primary outcome measures were changes in the visual analog pain scale (VAS) and changes in the neuropathic pain scale (NPS). WBV demonstrated a significant (p < 0.05) acute pain reduction in the VAS, and a significant chronic reduction in both the VAS and NPS scales. No side-effects were observed during this study. WBV appears to be an effective, non-invasive treatment for pain associated with DPN.

A 41-year-old woman with breast cancer was referred to the pain management clinic for a course of acupuncture for intense pain following a subcutaneous mastectomy and a latissimus dorsi flap reconstruction. She was treated with a standard course of acupuncture for breast pain, using paravertebral segmental points, trigger points, plus contralateral LI4 on the non-lymphoedematous arm. She experienced an episode of galactorrhoea six days following the first treatment and during the second treatment. She had not previously lactated for four years. CT and MRI of the brain revealed no focal abnormality. Acupuncture has been used in to promote lactation in the Traditional Chinese literature using the ‘Tianzong’ acupoint SI11. This acupoint coincided with a trigger point over infraspinatus that was included in the neurophysiologically based acupuncture treatment. Quantitative analysis has shown an increase in the production of prolactin and oxytocin following acupuncture. These hormones ar...

Judgments about an individual&#39;s pain can be profoundly important to sufferers. Relatively few studies have examined variables that may affect observers&#39; judgments of the pain of others. The present article reports two studies investigating the relationship between different kinds of exposure to pain problems and observers&#39; ratings of the pain intensity of patients. In the first study, 82 observers were classified into groups with positive and negative family histories of chronic pain. They viewed a videotape showing the facial expressions of shoulder pain patients undergoing physiotherapy assessments and rated the pain experienced by the subjects. In the second study, the data from observers having no experience with pain problems were compared with data collected from therapists having considerable experience with pain problems. Observers with a positive family history of chronic pain attributed greater pain to the patients than those with a negative family history of c...

Spinal cord stimulation is currently used to treat a variety of chronic intractable painful conditions. We report a case of severe Raynaud&#39;s phenomenon in the hands refractory to conservative treatment and responsive to diagnostic stellate ganglion block that was effectively treated with a spinal cord stimulator placed in the cervical epidural space. After capturing the affected areas with paresthesias, blood flow in the left hand and fingers significantly improved as evidenced by an increase in skin temperature, a change from cyanotic to pink appearance and concomitant reduction in pain. Moreover, the patient reported that limb ischemia and pain could be managed overnight with stimulation intensities that were below sensory perception thresholds. Thus it seems, at least in the overnight period, paresthesias were not required to maintain pain relief. This case presents a potential divergence between a requirement for paresthesias and pain relief in spinal cord stimulation therap...

We aimed to evaluate the effectiveness of balneotherapy in fibromyalgia management. Fifty women with fibromyalgia under pharmacological treatment were randomly assigned to either the balneotherapy (25) or the control (25) group. Four patients from the balneotherapy group and one patient from the control group left the study after randomization. The patients in the balneotherapy group (21) had 2 thermomineral water baths daily for 2 weeks in Tuzla Spa Center. The patients in the control group (24) continued to have their medical treatment and routine daily life. An investigator who was blinded to the study arms assessed the patients. All patients were assessed four times; at the beginning of the study, at the end of the 2nd week, the 1st month, and the 3rd month after balneotherapy. Outcome measures of the study were pain intensity, Fibromyalgia Impact Questionnaire (FIQ), Beck Depression Inventory (BDI), patient's global assessment, investigator's global assessment, SF-36 scores, and tender point count. Balneotherapy was found to be superior at the end of the cure period in terms of pain intensity, FIQ, Beck Depression Inventory, patient's global assessment, investigator's global assessment scores, and tender point count as compared to the control group. The superiority of balneotherapy lasted up to the end of the 3rd month, except for the Beck Depression Inventory score and the investigator's global assessment score. Significant improvements were observed in PF, GH, and MH subscales of SF-36 during the study period in the balneotherapy group; however, no such improvement was observed in the control group. Balneotherapy was superior only in VT subscale at the end of therapy and at the end of the third month after the therapy as compared to the controls. It was concluded that balneotherapy provides beneficial effects in patients with fibromyalgia.

This article reviews the various settings in which infants, children, and adolescents experience pain during acute medical procedures and issues related to referral of children to pain management teams. In addition, self-report, reports by others, physiological monitoring, and direct observation methods of assessment of pain and related constructs are discussed and recommendations are provided. Pharmacological, other medical approaches, and empirically supported cognitive behavioral interventions are reviewed. Salient features of the interventions are discussed, and recommendations are made for necessary components of effective treatment interventions.

n Abstract: Phantom pain is pain caused by elimination or interruption of sensory nerve impulses by destroying or injuring the sensory nerve fibers after amputation or deafferentation. The reported incidence of phantom limb pain after trauma, injury or peripheral vascular diseases is 60% to 80%. Over half the patients with phantom pain have stump pain as well. Phantom pain can also occur in other parts of the body; it has been described after mastectomies and enucleation of the eye.

Objectif : Les objectifs de cette étude étaient double : (1) d'explorer les obstacles à la gestion de la douleur et ceux associés à la mise en oeuvre d'un programme de gestion de la douleur en soins de longue durée (SLD) et (2) de développer une approche interprofessionelle afi n d'améliorer la gestion de la douleur en soins de longue durée. Méthodes : Une étude de cas a inclus tous les deux éléments, quantitatifs et qualitatifs. Nous avons recueilli des données sur deux sites LTC à l'aide de sept groupes de discussion pour les infi rmières autorisées, fournisseurs de soins non réglementés, et médecins, et 10 entretiens avec des autres groupes de fournisseurs de soins de santé, l'administration et des résidents. Nous avons examiné les documents et administré un sondage à court aux participants à l'étude pour évaluer les perceptions des obstacles à la gestion de la douleur. Résultats : Les résultats ont révélé des obstacles à la gestion effi cace de la douleur au niveau des soins de longue durée des résidents et des familles, des fournisseurs de soins de santé, et des systèmes de santé. Nous avons ensuite élaboré un modèle à six niveaux, avec les interventions proposées pour surmonter ces obstacles. Conclusions : Ce modèle peut guider le développement d'approches novatrices pour améliorer la gestion de la douleur dans les établissements de soins de longue durée.

Background: This prospective study was carried out to compare the role of epidural 6% aqueous phenol in management of pain in pelvic malignancies by intermittent and bolus injection and to study the analgesic effect and complications by neurolytic phenol block. Patients & Methods: The present study was carried out on 78 patients of pelvic malignancies of both sexes (11 were males and 67 were females). Patients randomly received either 6% aqueous phenol injected epiduraly in intermittent doses (Group I) or in bolus injection (Group II).All the patients were followed monthly for any recurrence of pain, if present and to assess general condition. Results: Intermittent epidural phenol provides better pain relief in comparison to bolus injection and the incidence of complications is also less, as the dose can be titrated according to the pain response and onset of any complication in the patient. Conclusion: Intermittent epidural neurolytic block with phenol is superior to bolus epidural phenol for intractable pain in pelvic malignancies.

The Neuromodulation Appropriateness Consensus Committee (NACC) of the International Neuromodulation Society (INS) evaluated evidence regarding the safety and efficacy of neurostimulation to treat chronic pain, chronic critical limb ischemia, and refractory angina and recommended appropriate clinical applications. The NACC used literature reviews, expert opinion, clinical experience, and individual research. Authors consulted the Practice Parameters for the Use of Spinal Cord Stimulation in the Treatment of Neuropathic Pain (2006), systematic reviews (1984 to 2013), and prospective and randomized controlled trials (2005 to 2013) identified through PubMed, EMBASE, and Google Scholar. Neurostimulation is relatively safe because of its minimally invasive and reversible characteristics. Comparison with medical management is difficult, as patients considered for neurostimulation have failed conservative management. Unlike alternative therapies, neurostimulation is not associated with medi...

Background To assess the psychometric properties, including internal consistency, construct validity, criterion validity, criterion-group validity, and responsiveness, the Reviewed McGill Quality of Life Questionnaire (MQOL-R), into Brazilian Portuguese-(BrP). Also, to analyze the relationship of the BrP-MQOL-R with the scores on the Karnofsky Performance Scale (KPS) and on the Numerical Pain Scale (NPS 0–10). Methods The BrP-MQOL-R was administered to a sample of 146 adults (men = 78). A team of experts translated the MQOL-R according to international guidelines. Convergent validity and Confirmatory factor analysis (CFA) was performed. Results The BrP-MQOL-R Cronbach’s alpha was 0.85. CFA supported the original four-factor structure, with the following revised model fit-indices: PCLOSE = 0.131, Tucker-Lewis Index (TLI) rho 2 = 0.918, incremental fit index (IFI) delta 2 = 0.936. The convergence validity is supported by a significant correlation between BrP-MQOL-R total scores and th...

This paper presents an in-depth, idiographic study examining the lived experience of chronic pain following spinal cord injury (SCI). Neuropathic pain (NP) occurs in a large majority of the SCI population and is particularly intractable to treatment. It can be both psychologically and physically debilitating. This study examines how the experience of NP is mediated by its meaning to the sufferer. Method: Semi-structured interviews were conducted with eight people with SCI and chronic NP, attending outpatient clinics at a specialist SCI Centre in the UK. Verbatim transcripts were subjected to interpretative phenomenological analysis in order to further understand the experience. Results: Analysis suggested that NP has powerful consequences upon the sufferer's physical, psychological, and social well-being, in line with a biopsychosocial understanding of pain. Three super-ordinate themes were identified: a perceived gap between treatments received and participants' views of what they wanted and needed; a fight for life control and acceptance; and feeling understood by others with SCI, but isolated from the non-understanding able-bodied. Conclusions: The results are discussed in terms of the possible application of acceptance-based therapy to NP and the potential for the alleviation of the debilitating consequences of NP.

Objective: To assess the effect of Eutectic Mixture of Local Anaesthetics cream and rattle on soothing the vaccination pain on four-month-infants. Methods: The single blind randomised clinical trial was conducted from May 2012 to February 2013 at a clinic under the Gonabad University of Medical Sciences, Iran, and comprised four-month infants who were selected randomly and divided into three groups. In one group, 2g of eutectic mixture of local anaesthetics cream was rubbed on the injection spot before administration; for the other group, the rattle was shaken from 30s to 15s before injection. The last group consisted of controls. The infants were filmed after vaccination. Afterward, a pain questionnaire was filled out by a trained observer. SPSS 11.5 was used for statistical analysis. Results: Of the 50 subjects in the study 16(32%) each were in the cream and rattle groups, while the rest (36%) were in the control group. The severity of the pain before intervention in the control, cream and rattle groups was 2.22±0.88, 2.12±0.95 and 2.25±1.06 respectively, which were not statistically significant (p<0.93). Likewise, the mean severity of pain at the moment of intervention in the three above groups were 8.67±0.77, 7.12±0.5 and 7.87±0.96 respectively, which was significantly different (p<0.001). The severity of pain 15seconds after the intervention in the groups was 5.06±1.51, 4.87±1.31 and 4.19±1.94 respectively, which were not statistically different (p<0.27). Conclusion: The eutectic mixture of local anaesthetics cream and shaking rattle were effective in attenuating pain of vaccination among the infants, but the latter was not as significant as the former.

This article presents the development and initial testing of a comprehensive pain chart for the assessment, management and documentation of pain in older people in subacute and residential aged care. The pain chart was developed from existing assessment scales and pain indicators, and is targeting needs of older people in residential care and geriatric hospital settings with high prevalence of cognitive impairments. The chart is based on self-report of pain but allows for observation of pain-related behaviours for those unable to report pain. The chart consists of one evaluative and one documentation dimension, and was evaluated by a group of clinicians in geriatric hospital care (n = 15) and residential aged care (n = 6). The chart was found to be content valid, informative and easy to use, facilitating clinical assessments and monitoring, and assisting visual readings of patients’ temporal pain trends.

To assess the pain management by medical team, emergency room (ER) team and Acute Pain team in a tertiary care hospital. The cross-sectional study was done in Medical Ward, Surgical Ward and Emergency Room of Aga Khan University, Karachi, in March-April 2010. The assigned research medical officer visited the three locations every day and selected patients by way of convenient sampling. The study comprised 75 patients; 25 each in three groups. Information was collected on patient&#39;s demographics, general characteristics, type of drugs and modalities used. Specific queries about pain were sorted out like adequacy of pain assessment done by primary physician, pain intensity, any intervention done and pain relief post-intervention. SPSS version 17, analysis of variance and Chi square test were used for statistical purpose. The mean current pain score on the visual analogue score (VAS) was lowest in the Surgical Ward which was being managed by the Acute Pain Management Service (APMS) ...

With a longer life expectancy of the population, there was also an increase in the incidence of cancer. In addition, advances in high-performance molecular diagnosis and personalized therapy for cancer patients have provided longer survival for these patients. With that, there was a change in the paradigm of cancer pain treatment, since pain is one of the main symptoms that affect the quality of life of these patients. Thus, the multimodal treatment is very important to patients with cancer pain. This review found studies that address several pharmacological and non-pharmacological cancer pain treatment options, although some have shown weak evidence in their results. Knowing these options and the results of these interventions is essential for health professionals who deal with pain management. Among the pharmacological options, opioids remain the foundation of treatment, however, because of their known adverse effects, the range of associations with other classes of drugs (cannabinoids, bisphosphonates and adjuvants) expanded. The use of other drug administration routes, such as intrathecal devices, has also been shown to be beneficial in pain control and in reducing side effects. Interventional procedures, even with positive results, are underused due to lack of training and knowledge. Multiple interventions of Integrative medicine (mind-body practices, acupuncture, music etc.) showed to be effective in reduce anxiety, depression, phobia and cancer pain. They can be used to complement pain management. As there are few randomized double-blind studies with a large number of patients regarding the effectiveness of these interventions, more systematic studies are needed.

Objective. Some reports suggest that education programs help arthritis patients better manage their symptoms and improve function. This review of the published literature was undertaken to assess the effect of such programs on pain and disability.

Objectives: To explore the efficacy of reflexology on acute pain induced in healthy human subjects using a sham TENS control. Design: An ice-pain experiment was undertaken in which the volunteers (n ¼ 15; 11 female and 4 male with a mean AE SEM age of 37.7 AE 2.6 years) were required to immerse their non-dominant hand in a container of ice-slurry whilst two indices of pain, i.e. threshold, (the time taken for subjects to experience the first pain sensation) and tolerance, (the time when the subject is unable to tolerate any further pain), were measured. Results: Compared to control data, reflexology increased acute pain threshold (F (1,14) ¼ 4.5958, p < 0.05) and tolerance (F (1,14) ¼ 5.1095, p < 0.05). Conclusions: These findings demonstrate that reflexology produces antinociceptive effects in a controlled experiment and suggest the possibility that reflexology may be useful on its own or as an adjunct to medication in the treatment of pain conditions in man.

Peripheral pain and ataxic tremor can appear suddenly following thalamic stroke and can significantly alter a patient&#39;s psychological, social, and physical functioning. The present paper reports the case of a 70-year-old Caucasian female who sustained an acute left posterior cerebral artery infarction involving the thalamus and left mesiotemporal regions. She subsequently developed Central Poststroke Pain and ataxic movement of her right arm and hand in addition to a significant right-side claudication. She was treated over 16 weeks (6 weeks of EMG biofeedback and 10 weeks of psychotherapy) with a combination of EMG biofeedback, progressive muscle relaxation, behavioral pain coping skills training, Forced Use Therapy, and Cognitive Behavioral Therapy 7 years after her initial cerebral accident. The case demonstrates the utility of biofeedback when combined as part of a comprehensive treatment program to address the multiple complications associated with thalamic stroke.

The WHO guidelines on cancer pain management recommend a sequential three-step analgesic ladder. However, conclusive data are lacking as to whether moderate pain should be treated with either step II weak opioids or low-dose step III strong opioids. In a multicenter, 28-day, open-label randomized controlled study, adults with moderate cancer pain were assigned to receive either a weak opioid or low-dose morphine. The primary outcome was the number of responder patients, defined as patients with a 20% reduction in pain intensity on the numerical rating scale. A total of 240 patients with cancer (118 in the low-dose morphine and 122 in the weak-opioid group) were included in the study. The primary outcome occurred in 88.2% of the low-dose morphine and in 57.7% of the weak-opioid group (odds risk, 6.18; 95% CI, 3.12 to 12.24; P &lt; .001). The percentage of responder patients was higher in the low-dose morphine group, as early as at 1 week. Clinically meaningful (≥ 30%) and highly mean...

Several pain syndromes, which may be related to the diagnostic procedures, to the treatments, or to disease itself, may be recorded during the disease course of most haematological malignancies. So far, the painful complication occurring in this setting has been poorly investigated. Pain arising from skeletal and bone marrow (BM) involvement represents the most frequent disease-related painful states observed in this setting, while patients undergoing treatments with curative intent, such as BM transplantation, usually experienced painful stomatitis. Additionally, more than one pathologic process may coexist simultaneously in one patient and the pathophysiology of pain and hypersensitivity may change over time. An accurate diagnostic assessment and the identification of the underlying pathogenetic mechanism may dictate the treatment approach. For most patients in pain, the World Health Organisation's three-step analgesic scale provides adequate relief with oral options. Pain left unrelieved may induce an aberrant peripheral activity and central functional alterations, generating chronic neuropathic pain. In the aim to summarize the current knowledge on this topic, the pertinent literature and the current guidelines for the pain management were reviewed by a group of haematologists, experienced in palliative care and by a skilled algologist, involved as consultant in this clinical setting.

Objective: To explore the long-term outcomes of CONECSI (COping with NEuropathiC Spinal cord Injury pain), a multidisciplinary cognitive behavioural treatment programme in persons with spinal cord injury.Design: Long-term follow-up pre-post-intervention design.Subjects: A total of 29 subjects with a spinal cord injury and chronic neuropathic pain from 4 Dutch rehabilitation centres.Methods: Primary outcomes were pain intensity and pain-related disability (Chronic Pain Grade questionnaire). Secondary outcomes were mood (Hospital Anxiety and Depression Scale), participation in activities (Utrecht Activities List), and life satisfaction (Life Satisfaction Questionnaire). Random coefficient analysis was used for the analyses of measurements before (t1), immediate post-intervention (t2), and 6 (t3), 9 (t4), and 12 (t5) months follow-up.Results: The analyses showed significant improvements on pain intensity (t1–t2 and t1–t5) and pain-related disability (t1–t2, t1–t4, and t1–t5), anxiety a...