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Key Points Chronic pain is common and has substantial negative consequences for individuals and society As the brain is ultimately the organ that processes pain information, treatments that target brain activity have the potential to provide pain relief Solid evidence indicates that hypnosis has short-term and long-term benefits for a variety of pain problems, and should be considered as a first-line treatment given its demonstrated efficacy and positive side-effect profile Training in meditation shows promise for reducing chronic pain, although more research is needed to confirm the initial findings Noninvasive brain stimulation is potentially effective for reducing chronic pain in the short term, but preliminary evidence suggests that brain stimulation alone might not have long-term benefits Neurofeedback has some potential for reducing chronic pain, although the research findings suggest weak effects when this technique is used alone Chronic pain is a common problem that incurs substantial costs to the individual and society as a whole. The efficacy of currently available medications is limited, prompting the exploration of alternative therapeutic approaches. Here, Jensen et al . summarize the state of knowledge regarding the efficacy and mechanisms of four different neuromodulatory interventions—hypnosis, meditation training, noninvasive brain stimulation, and neurofeedback—for the treatment of chronic pain. Chronic pain is common, and the available treatments do not provide adequate relief for most patients. Neuromodulatory interventions that modify brain processes underlying the experience of pain have the potential to provide substantial relief for some of these patients. The purpose of this Review is to summarize the state of knowledge regarding the efficacy and mechanisms of noninvasive neuromodulatory treatments for chronic pain. The findings provide support for the efficacy and positive side-effect profile of hypnosis, and limited evidence for the potential efficacy of meditation training, noninvasive electrical stimulation procedures, and neurofeedback procedures. Mechanisms research indicates that hypnosis influences multiple neurophysiological processes involved in the experience of pain. Evidence also indicates that mindfulness meditation has both immediate and long-term effects on cortical structures and activity involved in attention, emotional responding and pain. Less is known about the mechanisms of other neuromodulatory treatments. On the basis of the data discussed in this Review, training in the use of self-hypnosis might be considered a viable 'first-line' approach to treat chronic pain. More-definitive research regarding the benefits and costs of meditation training, noninvasive brain stimulation and neurofeedback is needed before these treatments can be recommended for the treatment of chronic pain.

The majority of previous research that has examined the validity of pain intensity rating scales has been conducted in western and developed countries. Research to evaluate the generalizability of previous findings in non-developed countries is necessary for identifying the scales that are most appropriate for use in international research. The aims of the current study were to (1) evaluate the validity and utility of four commonly used measures of pain intensity in a sample of patients with chronic pain from Thailand and (2) compare findings in the current sample with published findings from research conducted in other countries, in order to identify the measure or measures which might be most appropriate for cross-country research. Three hundred and sixty patients with chronic pain seen in a hospital in Bangkok, Thailand, were asked to rate their current pain and average, worst, and least pain intensity in the past week using the Visual Analogue Scale (VAS), 6-point Verbal Rating Scale (VRS-6), 0-10 Numerical Rating Scale (NRS-11), and Faces Pain Scale-Revised (FPS-R). We evaluated the utility and validity of each measure by examining the (1) rates of correct responding and (2) association of each measure with a factor score representing the variance shared across measures, respectively. We also evaluated the associations between incorrect response rates and both age and education level, and then compared the findings from this sample with the findings from research conducted in other countries. The results indicated support for the validity of all measures among participants who were able to use these measures. However, there was variability in the incorrect response rates, with the VAS having the highest (45%) and the NRS-11 having the lowest (15%) incorrect response rates. The VAS was also the least preferred (9%) and the NRS-11 the most preferred (52%) scale. Education and age were significantly associated with incorrect response rates, and education level with scale preference. The findings indicate that the NRS-11 has the most utility in our sample of Thai individuals with chronic pain. However, when considered in light of the findings from other countries, the results of this study suggest that the FPS-R may have the most utility for use in cross-cultural and international research. Research in additional samples in developing countries is needed to evaluate the generalizability of the current findings.

Chronic pain is a significant global health issue. For most individuals with chronic pain, biomedical treatments do not provide adequate relief. Given the evidence that neurophysiological abnormalities are associated with pain, it is reasonable to consider treatments that target these factors, such as neurofeedback (NF). The primary objectives of this review were to summarize the current state of knowledge regarding: (1) the different types of NF and NF protocols that have been evaluated for pain management; (2) the evidence supporting each NF type and protocol; (3) if targeted brain activity changes occur with NF training; and (4) if such brain activity change is associated with improvements on treatment outcomes. Inclusion criteria were intentionally broad to encompass every empirical study using NF in relation to pain. We considered all kinds of NF, including both electroencephalogram- (EEG-) and functional magnetic resonance imagining- (fMRI-) based. We searched the following databases from inception through September 2019: Pubmed, Ovid, Embase, Web of Science, PsycINFO. The search strategy consisted of a combination of key terms referring to all NF types and pain conditions (e.g., neurofeedback, rt-fMRI-NF, BOLD, pain, migraine). A total of 6,552 citations were retrieved; 24 of these that were included in the review. Most of the studies were of moderate quality, included a control condition and but did not include a follow-up. They focused on studying pain intensity (83%), pain frequency, and other variables (fatigue, sleep, depression) in samples of adults ( = 7-71) with headaches, fibromyalgia and other pain conditions. Most studies (79%) used EEG-based NF. A wide variety of NF types and protocols have been used for pain management aiming to either increase, decrease or regulate brain activity in certain areas theoretically associated with pain. Given the generally positive results in the studies reviewed, the findings indicate that NF procedures have the potential for reducing pain and improving other related outcomes in individuals with chronic pain. However, the current evidence does not provide definitive conclusions or allow for reliable recommendations on which protocols or methods of administration may be the most effective. These findings support the need for continued - but higher quality - research in this area.

Background Resilience is an individual’s ability to recover or “bounce back” from stressful events. It is commonly identified as a protective factor against psychological dysfunctions in wide range of clinical conditions including chronic pain. Resilience is commonly assessed using the Connor Davidson Resilience Scale (CD-RISC). Translation and cross-cultural adaptation of the CD-RISC into Nepali will allow for a deeper understanding of resilience as an important domain in health in Nepal, and will allow for cross-cultural comparison with other cultures. Therefore, the aims of the study were to translate and culturally adapt 10- and 2-item versions of the CD-RISC into Nepali and evaluate their psychometric properties. Methods After translating the measures, we performed exploratory and confirmatory factor analyses of the 10-item version in two independent samples (ns = 131 and 134) of individuals with chronic pain. We then evaluated the internal consistency, test-retest stability, and construct validity of the 10- and 2-item measures in these samples. We also evaluated the internal consistency, and the construct and concurrent validity of the 2-item version in an additional sample of 140 individuals. Results The results supported a single factor model for the 10-item measure; this measure also evidenced good to excellent internal consistency and excellent test-retest stability. Construct validity was supported via moderate associations with pain catastrophizing. The internal consistency of 2-item version was marginal, although construct validity was supported via weak to moderate associations with measures of pain catastrophizing, depression and anxiety, and concurrent validity was supported by strong association with the 10-item CD-RISC scale. Conclusion The findings support the reliability and validity of the 10-item Nepali version of the CD-RISC, and use of the 2-item version in survey studies in individuals with chronic pain. The availability of these translated measures will allow for cross-cultural comparisons of resilience in samples of individuals with chronic pain.

Background and aims Pain is common in older individuals. In order to understand and treat pain in this group, reliable and valid measures are needed. This study aimed to evaluate: (1) the validity, utility, incorrect response rates and preference rates of 5 pain rating scales in older individuals; and (2) the associations between age, education level, and cognitive function and both (a) incorrect response and (b) preference rates. Methods Two hundred and one orthopedic clinic outpatients ≥ 65 years old were asked to rate their current pain, and least, average, and worst pain intensity in the past week using 5 scales: Verbal Numerical Rating Scale (VNRS), Faces Pain Scale - Revised (FPS-R), Verbal Rating Scale (VRS), Numerical Rating Scale (NRS), and Visual Analogue Scale (VAS). Participants were also asked to indicate scale preference. We computed the associations between each measure and a factor score representing the shared variance among the scales, the incorrect response and scale preference rates, and the associations between incorrect response and preference rates and age, education level, and cognitive function. The incorrect responses included being unable to respond, providing more than one response, responses outside a range, providing range answers rather than fixed answers, and responses indicating ‘least > average,’ ‘least > worst,’ and ‘average > worst’. Results The findings support validity of all 5 scales in older individuals who are able to use all measures. The VNRS had the lowest (2%) and the VAS had the highest (6%) incorrect response rates. The NRS was the most (35%) and the VAS was the least (5%) preferred. Age was associated with the incorrect response rates of the VRS and VAS, such that older individuals were less likely to use these scales correctly. Education level was associated with the incorrect response rates of the FPS-R, NRS and VAS, such that those with less education were less likely to use these measures correctly. Cognitive function was not significantly associated with incorrect response rates. Age, education level and cognitive function were not significantly associated with scale preference. Conclusions Although all five scales are valid, the VNRS evidences the best overall utility in this sample of older individuals with pain. The NRS or FPS-R would be fine alternatives if it is not practical or feasible to use the VNRS.

This systematic review examined the extent to which measures of religiosity/spirituality (R/S): (1) are associated with pain, function, pain-related beliefs (beliefs), coping responses, and catastrophizing in people with chronic pain; and (2) moderate the association between beliefs, coping and catastrophizing, and pain and function. Experimental and observational studies examining at least one of these research questions in adults with chronic pain were eligible. Two reviewers independently performed eligibility screening, data extraction, and quality assessment. Twenty studies were included. Most studies focused on the association between R/S and pain or function. When significant associations emerged, those between R/S and psychological function were weak to strong and positive; those between religious/spiritual well-being and pain and physical dysfunction were negative, but weak. Few studies examined the associations between R/S and beliefs/coping/catastrophizing; none examined the moderation role of R/S. The findings suggest that R/S is associated with pain and psychological function in people with chronic pain, and that viewing oneself as being “spiritual,” regardless of religion, may contribute to positive psychological adjustment. More research is needed to determine the reliability of this finding. PROSPERO registry CRD42018088803.

We aimed to evaluate the potential anxiolytic effects of premedication with pregabalin, compared with diazepam and placebo. We conducted this non-inferiority, double-blind, randomized controlled trial in ASA classification I-II patients aged 18–70 years, scheduled for elective surgery under general anesthesia. They were allocated to receive pregabalin (75 mg the night before surgery and 150 mg 2 h before surgery), diazepam (5 and 10 mg in the same manner) or placebo. Preoperative anxiety was evaluated using verbal numerical rating scale (VNRS) and Amsterdam Preoperative Anxiety and Information Scale (APAIS) before and after premedication. Sleep quality, sedation level, and adverse effects were assessed as secondary outcomes. A total of 231 patients were screened and 224 completed the trial. The mean change (95%CI) in anxiety scores from before to after medication in pregabalin, diazepam, and placebo groups for VNRS were − 0.87 (− 1.43, − 0.30), − 1.17 (− 1.74, − 0.60), and − 0.99 (− 1.56, − 0.41), and for APAIS were − 0.38 (− 1.04, 0.28), − 0.83 (− 1.49, − 0.16), and − 0.27 (− 0.95, 0.40). The difference in change for pregabalin versus diazepam was 0.30 (− 0.50, 1.11) for VNRS and 0.45 (− 0.49, 1.38) for APAIS, exceeding the limit of inferiority for APAIS of 1.3. Sleep quality was statistically different between pregabalin and placebo groups ( p  = 0.048). Sedation in pregabalin and diazepam groups were significantly higher than placebo group ( p  = 0.008). No significant differences of other side effects, except dry mouth was higher in placebo group compared with diazepam ( p  = 0.006). The study filed to provide evidence at non-inferiority of pregabalin compared to diazepam. Furthermore, premedication with either pregabalin or diazepam did not significantly reduce the preoperative anxiety in comparison to placebo, despite the fact that both resulted in higher levels of sedation. Clinicians should weigh the benefits and risks of premedication with these 2 drugs. Thai Clinical Trials Registry: TCTR20190424001 (24/04/2019) Registry URL: https://www.thaiclinicaltrials.org/ .

Abstract Objective Spectral power analyses of EEG recordings are reported to distinguish the cortical activity of individuals with chronic pain from those of controls. Further study of these spectral patterns may provide a greater understanding of the processes associated with chronic pain, in addition to providing potential biometric markers of chronic pain for use in both clinical and research settings. However, sleep deprived groups have demonstrated similar characteristics in their spectral power characteristics, particularly in alpha bandwidth power activity. Methods 103 individuals with chronic pain provided resting awake EEG data in addition to ratings of pain and sleep quality. Two Principal Axis Factor analyses using Promax rotation produced one pain and one sleep factor from relevant questionnaire data provided by participants. These factors were then used to test hypothesized relationships with alpha and theta bandwidth power at the frontal and parietal areas of the cortex. Results Our findings suggest that reductions in alpha bandwidth power are independently associated with both chronic pain intensity ratings and measures of sleep deficits. Conversely, theta bandwidth power was not found to be associated with either chronic pain or sleep quality measures. Conclusions This study’s findings support that chronic pain intensity and sleep deficits are related to the Alpha spectral bandwidth activity in individuals with chronic pain.

This article summarizes the state-of-science knowledge regarding the associations between hypnosis and brain oscillations. Brain oscillations represent the combined electrical activity of neuronal assemblies, usually measured as specific frequencies representing slower (delta, theta, alpha) and faster (beta, gamma) oscillations. Hypnosis has been most closely linked to power in the theta band and changes in gamma activity. These oscillations are thought to play a critical role in both the recording and recall of declarative memory and emotional limbic circuits. The authors propose that this role may be the mechanistic link between theta (and perhaps gamma) oscillations and hypnosis, specifically, that the increases in theta oscillations and changes in gamma activity observed with hypnosis may underlie some hypnotic responses. If these hypotheses are supported, they have important implications for both understanding the effects of hypnosis and for enhancing response to hypnotic treatments.

Background: The measurement of spasticity as a symptom of neurologic disease is an area of growing interest. Clinician-rated measures of spasticity purport to be objective but do not measure the patient's experience and may not be sensitive to changes that are meaningful to the patient. In a patient with clinical spasticity, the best judge of the perceived severity of the symptom is the patient. Objectives: The aim of this study was to assess the validity and reliability, and determine the clinical importance, of change on a 0–10 numeric rating scale (NRS) as a patient-rated measure of the perceived severity of spasticity. Methods: Using data from a large,randomized,doubleblind, placebo-controlled study of an endocannabinoid system modulator in patients with multiple sclerosis-related spasticity, we evaluated the test-retest reliability and comparison-based validity of a patient-reported 0-10 NRS measure of spasticity severity with the Ashworth Scale and Spasm Frequency Scale. We estimated the level of change from baseline on the 0–10 NRS spasticity scale that constituted a clinically important difference (CID) and a minimal CID (MCID) as anchored to the patient's global impression of change (PGIC). Results: Data from a total of 189 patients were included in this assessment (114 women, 75 men; mean age, 49.1 years). The test-retest reliability analysis found an interclass correlation coefficient of 0.83 ( P < 0.001) between 2 measures of the 0–10 NRS spasticity scores recorded over a 7- to 14-day period before randomization. A significant correlation was found between change on 0–10 NRS and change in the Spasm Frequency Scale ( r = 0.63; P < 0.001), and a moderate correlation was found between the change on 0–10 NRS and the PGIC ( r = 0.47; P < 0.001). A reduction of ∼30% in the spasticity 0–10 NRS score best represented the CID and a change of 18% the MCID. Conclusions: The measurement of the symptom of spasticity using a patient-rated 0-10 NRS was found to be both reliable and valid. The definitions of CID and MCID will facilitate the use of appropriate responder analyses and help clinicians interpret the significance of future results.