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Acute low back pain (LBP) is highly prevalent, with a presumed favorable prognosis; however, once chronic, LBP becomes a disabling and expensive condition. Acute to chronic LBP transition rates vary widely owing to absence of standardized operational definitions, and it is unknown whether a standardized prognostic tool (ie, Subgroups for Targeted Treatment Back tool [SBT]) can estimate this transition or whether early non-guideline concordant treatment is associated with the transition to chronic LBP. To assess the associations between the transition from acute to chronic LBP with SBT risk strata; demographic, clinical, and practice characteristics; and guideline nonconcordant processes of care. This inception cohort study was conducted alongside a multisite, pragmatic cluster randomized trial. Adult patients with acute LBP stratified by SBT risk were enrolled in 77 primary care practices in 4 regions across the United States between May 2016 and June 2018 and followed up for 6 months, with final follow-up completed by March 2019. Data analysis was conducted from January to March 2020. SBT risk strata and early LBP guideline nonconcordant processes of care (eg, receipt of opioids, imaging, and subspecialty referral). Transition from acute to chronic LBP at 6 months using the National Institutes of Health Task Force on Research Standards consensus definition of chronic LBP. Patient demographic characteristics, clinical factors, and LBP process of care were obtained via electronic medical records. Overall, 5233 patients with acute LBP (3029 [58%] women; 4353 [83%] White individuals; mean [SD] age 50.6 [16.9] years; 1788 [34%] low risk; 2152 [41%] medium risk; and 1293 [25%] high risk) were included. Overall transition rate to chronic LBP at six months was 32% (1666 patients). In a multivariable model, SBT risk stratum was positively associated with transition to chronic LBP (eg, high-risk vs low-risk groups: adjusted odds ratio [aOR], 2.45; 95% CI, 2.00-2.98; P < .001). Patient and clinical characteristics associated with transition to chronic LBP included obesity (aOR, 1.52; 95% CI, 1.28-1.80; P < .001); smoking (aOR, 1.56; 95% CI, 1.29-1.89; P < .001); severe and very severe baseline disability (aOR, 1.82; 95% CI, 1.48-2.24; P < .001 and aOR, 2.08; 95% CI, 1.60-2.68; P < .001, respectively) and diagnosed depression/anxiety (aOR, 1.66; 95% CI, 1.28-2.15; P < .001). After controlling for all other variables, patients exposed to 1, 2, or 3 nonconcordant processes of care within the first 21 days were 1.39 (95% CI, 1.21-2.32), 1.88 (95% CI, 1.53-2.32), and 2.16 (95% CI, 1.10-4.25) times more likely to develop chronic LBP compared with those with no exposure (P < .001). In this cohort study, the transition rate to chronic LBP was substantial and increased correspondingly with SBT stratum and early exposure to guideline nonconcordant care.

BackgroundMedical management of acute pain among hospital inpatients may be enhanced by mind-body interventions.ObjectiveWe hypothesized that a single, scripted session of mindfulness training focused on acceptance of pain or hypnotic suggestion focused on changing pain sensations through imagery would significantly reduce acute pain intensity and unpleasantness compared to a psychoeducation pain coping control. We also hypothesized that mindfulness and suggestion would produce significant improvements in secondary outcomes including relaxation, pleasant body sensations, anxiety, and desire for opioids, compared to the control condition.MethodsThis three-arm, parallel-group randomized controlled trial conducted at a university-based hospital examined the acute effects of 15-min psychosocial interventions (mindfulness, hypnotic suggestion, psychoeducation) on adult inpatients reporting “intolerable pain” or “inadequate pain control.” Participants (N = 244) were assigned to one of three intervention conditions: mindfulness (n = 86), suggestion (n = 73), or psychoeducation (n = 85).Key ResultsParticipants in the mind-body interventions reported significantly lower baseline-adjusted pain intensity post-intervention than those assigned to psychoeducation (p < 0.001, percentage pain reduction: mindfulness = 23%, suggestion = 29%, education = 9%), and lower baseline-adjusted pain unpleasantness (p < 0.001). Intervention conditions differed significantly with regard to relaxation (p < 0.001), pleasurable body sensations (p = 0.001), and desire for opioids (p = 0.015), but all three interventions were associated with a significant reduction in anxiety (p < 0.001).ConclusionsBrief, single-session mind-body interventions delivered by hospital social workers led to clinically significant improvements in pain and related outcomes, suggesting that such interventions may be useful adjuncts to medical pain management.Trial registrationTrial Registry: ClinicalTrials.gov; registration ID number: NCT02590029URL: https://clinicaltrials.gov/ct2/show/NCT02590029

To evaluate if adding esketamine and clonidine has positive effects on postoperative pain, postoperative nausea and vomiting, and quality of recovery in patients who are at high risk for postoperative pain. Patient- and assessor-blinded, superiority, randomised controlled trial. Single centre between 2022 and 2024. 125 adult patients, ASA I – II, planned for elective laparoscopic surgery and risk-classified as high risk of pain, based on perceived pain associated with venous cannulation. Patients were randomised to either an anaesthesia protocol, including an intravenous bolus of esketamine (0.25 mg.kg−1) after induction and clonidine (1 μg.kg−1) during maintenance phase (EC), or standard of care (SOC) no esketamine or clonidine included. Primary outcome: worst pain intensity in the PACU. Secondary outcomes: worst pain, and proportion having NRS ≥ 4, at 24 h (during rest and movement), worst pain and proportion having NRS ≥ 1, at 3- and 6-months (during rest and movement), postoperative recovery at 24 h, PONV in the PACU and at 24 h. Rescue dose opioids in the PACU was an exploratory outcome. Worst pain scores in the PACU were 5.7 in the EC group and 5.5 in SOC group (P = 0.78). After 24 h, no difference in postoperative pain (rest; 5.8 vs 6.1, P = 0.35, movement; 6.1 vs 6.2, P = 0.68), postoperative recovery (P = 0.92) or PONV (P = 0.80) was found. Proportion of patients with NRS ≥ 4 in the PACU was 50 % vs 48 % (P = 0.55) and at 24 h 73 % vs 81 % at rest (P = 0.27) and 76 % vs 81 % during movement (P = 0.50). Rescue opioids in the PACU were similar (5.9 mg vs 6.6 mg, P = 0.47). There were no differences in persistent pain at 3 or 6 months at rest (P = 0.72, P = 0.12) or movement (P = 0.48, P = 0.18). Adding esketamine and clonidine, as an individualised multimodal anaesthesia strategy, did not influence acute or persistent postoperative pain, early recovery, need of rescue opioids or PONV in patients, who were assessed as high risk for APOP. [Display omitted] •Adding esketamine and clonidine did not improve APOP in patients predicted as high-risk for postoperative pain.•Adding esketamine and clonidine did not improve recovery or PONV in patients predicted as high-risk for postoperative pain.•The pursuit for individualised anaesthesia and analgesia needs further refinement.

Background Low back pain (LBP) is a public health concern because it is highly prevalent and the leading cause of disability worldwide. Psychologically informed physical therapy (PIPT) is a secondary prevention approach that first aims to identify individuals at high risk for transitioning to chronicity and then provides tailored treatment to reduce that risk. Training models that are feasible to implement with acceptable training quality are needed to improve scalability for widespread implementation of PIPT. This manuscript describes the PIPT training program that was developed for training physical therapists providing PIPT in the TARGET trial. Methods The PIPT training program was developed, tested, and modified using an iterative process. Content development consisted of stakeholder engagement, beta testing, modification of training, and confirmation of final course objectives. Methods of delivery consisted of a website that included brief online educational modules followed by a live 8-h workshop that included video-based mock case scenarios and case-based role playing. Attitudes, beliefs, and confidence in implementing PIPT principles were assessed before and immediately after training to measure training quality and impact. Results Early stakeholder engagement and beta testing indicated the need for increased emphasis on experiential learning opportunities and patient-centered communication training. Booster training varied extensively across TARGET sites with involvement of ‘clinician champions’ providing brief follow-up sessions identified as best practice. Favorable post-training changes in physical therapist attitudes and beliefs toward biopsychosocial treatment orientation and increased confidence in implementing PIPT principles were observed. Conclusions PIPT training for provider participation in the TARGET trial was feasible to deliver. Course content was acceptable to physical therapists and resulted in improved beliefs and confidence in applying PIPT skills during clinical practice. Ongoing consultation and site-based continuing education were methods by which specific TARGET sites maintained or augmented PIPT skill training; however, implementing ongoing training was challenging in general. Due to the pragmatic nature of the TARGET trial, it was not possible to directly measure the effect of PIPT training on treatment fidelity, which was a limitation of our approach. Trial registration ClinicalTrials.gov, NCT02647658 . Registered on 6 January 2016.

Purpose Paclitaxel is associated with an acute pain syndrome (P-APS- and chronic chemotherapy-induced peripheral neuropathy (CIPN). P-APS is associated with higher risk of CIPN. Omega-3 fatty acids have well-established anti-inflammatory and neuroprotective properties. The primary purpose of this pilot study was to assess whether omega-3 fatty acids could decrease P-APS and thus CIPN. Methods Patients scheduled to receive weekly paclitaxel for breast cancer were randomized to receive 4 g of omega-3 acid ethyl esters (Lovaza) or placebo, beginning 1 week prior and continued until paclitaxel was stopped. Patients completed acute pain questionnaires at baseline, daily after each treatment, and 1 month after completion of therapy. Results Sixty patients (49 evaluable) were randomized to treatment versus placebo. Seventeen (68.0%) patients receiving the omega-3 fatty acids intervention experienced P-APS, compared to 15 (62.5%) of those receiving placebo during the first week of treatment ( p = 0.77). Over the full 12-week study, 21 (84.0%) patients receiving the omega-3 fatty acid intervention experienced P-APS, compared to 21 (87.5%) of those receiving placebo ( p = 1.0). Secondary outcomes suggested that those in the intervention arm used more over-the-counter analgesics (OR: 1.65, 95% CI: 0.72–3.78, p = 0.23), used more opiates (OR: 2.06, 95% CI: 0.55–7.75, p = 0.28), and experienced higher levels of CIPN (12.8, 95% CI: 7.6–19.4 vs. 8.4, 95% CI: 4.6–13.2, p = 0.21). Conclusions The results of this pilot study do not support further study of the use of omega-3 fatty acids for the prevention of the P-APS and CIPN. Trial registration Number: NCT01821833

Pain affects millions worldwide, posing significant challenges in diagnosis and treatment. Despite advances in understanding pain mechanisms, there remains a critical need for validated biomarkers to enhance diagnosis, prognostication, and personalized therapy. This review synthesizes recent advancements in identifying and validating acute and chronic pain biomarkers, including imaging, molecular, sensory, and neurophysiological approaches. We emphasize the emergence of composite, multimodal strategies that integrate psychosocial factors to improve the precision and applicability of biomarkers in chronic pain management. Neuroimaging techniques like MRI and positron emission tomography provide insights into structural and functional abnormalities related to pain, while electrophysiological methods like electroencepholography and magnetoencepholography assess dysfunctional processing in the pain neuroaxis. Molecular biomarkers, including cytokines, proteomics, and metabolites, offer diagnostic and prognostic potential, though extensive validation is needed. Integrating these biomarkers with psychosocial factors into clinical practice can revolutionize pain management by enabling personalized treatment strategies, improving patient outcomes, and potentially reducing healthcare costs. Future directions include the development of composite biomarker signatures, advances in artificial intelligence, and biomarker signature integration into clinical decision support systems. Rigorous validation and standardization efforts are also necessary to ensure these biomarkers are clinically useful. Large-scale collaborative research will be vital to driving progress in this field and implementing these biomarkers in clinical practice. This comprehensive review highlights the potential of biomarkers to transform acute and chronic pain management, offering hope for improved diagnosis, treatment personalization, and patient outcomes.

To evaluate if opioid-free anaesthesia (OFA), is non-inferior to standard of care (SOC), in patients at low risk for acute postoperative pain (APOP). Design: Patient- and assessor-blinded, non-inferiority, randomised, controlled trial. Single centre between March 2022 to February 2024. 154 adult patients, ASA I – II, planned for elective laparoscopic surgery and risk-classified as low risk for APOP based on perceived pain during venous cannulation (VAS < 2.0). Patients were randomised to receiving OFA, including sevoflurane, dexmedetomidine, esketamine and lidocaine, or standard of care (SOC), a traditional GABAA and opioid-based strategy. Patients were subjected to the intervention from time to arrival at the day of surgery until discharge from the PACU. Primary outcome: worst pain intensity in the PACU. Secondary outcomes: worst pain, and proportion having NRS ≥ 4, at 24 h (during rest and movement), worst pain and proportion having NRS ≥ 1, at 3- and 6-months (during rest and movement), postoperative recovery at 24 h, PONV in the PACU and at 24 h. Rescue dose opioids in the PACU was an exploratory outcome. Pain scores were 4.8 in the OFA group and 4.6 in SOC group (P = 0.67). At 24 h, worst pain at rest was 5.7 vs 5.0 (P = 0.11), and during movement 5.6 vs 5.3 (P = 0.43). Proportion of patients with NRS ≥ 4 in the PACU was 66 % vs 69 % (P = 0.65) and at 24 h 76 % vs 60 % at rest (P = 0.042) and 73 % vs 69 % during movement (P = 0.65). There was no significant difference in PPOP at 3 or 6 months, either at rest (P = 0.51, P = 0.56) or movement (P = 0.72, P = 0.48), PONV (PACU: P = 0.93), at 24 h: (P = 0.52) or postoperative recovery at 24 h (99 vs 102, P = 0.44). OFA group required less rescue opioids in the PACU (3.4 mg vs 5.1 mg, P = 0.039). When individualising anaesthesia based on predicted risk for APOP, OFA is non-inferior to a traditional GABAA and opioid-based anaesthesia strategy, for patients with a low risk for APOP undergoing laparoscopic surgery. No secondary advantages, i.e. lower PONV, less PPOP, better quality of recovery, was associated with OFA. [Display omitted] •Opioid-free anaesthesia, including esketamine, dexmedetomidine and lidocaine is non-inferior to opioid-based anaesthesia in terms of acute postoperative pain, for adult patients, predicted as at low-risk for postoperative pain.•Opioid-free anaesthesia, including esketamine, dexmedetomidine and lidocaine did not improve postoperative recovery, postoperative nausea and vomiting or persistent pain when comparing with a traditional opioid-based anaesthesia strategy.•Opioid-free anaesthesia can be considered in adult ASA I – II patients, predicted as low risk for acute postoperative pain, planned for laparoscopic surgery.

Acute postoperative pain is associated with the development of persistent postsurgical pain, but it is unclear which aspect is most estimable. To identify patient clusters based on acute pain trajectories, preoperative psychosocial characteristics associated with the high-risk cluster, and the best acute pain predictor of remote outcomes. A secondary analysis of the Stanford Accelerated Recovery Trial randomized, double-blind clinical trial was conducted at a single-center, tertiary, referral teaching hospital. A total of 422 participants scheduled for thoracotomy, video-assisted thoracoscopic surgery, total hip replacement, total knee replacement, mastectomy, breast lumpectomy, hand surgery, carpal tunnel surgery, knee arthroscopy, shoulder arthroplasty, or shoulder arthroscopy were enrolled between May 25, 2010, and July 25, 2014. Data analysis was performed from January 1 to August 1, 2018. Patients were randomized to receive gabapentin (1200 mg, preoperatively, and 600 mg, 3 times a day postoperatively) or active placebo (lorazepam, 0.5 mg preoperatively, inactive placebo postoperatively) for 72 hours. A modified Brief Pain Inventory prospectively captured 3 surgical site pain outcomes: average pain and worst pain intensity over the past 24 hours, and current pain intensity. Within each category, acute pain trajectories (first 10 postoperative pain scores) were compared using a k-means clustering algorithm. Fifteen descriptors of acute pain were compared as predictors of remote postoperative pain resolution, opioid cessation, and full recovery. Of the 422 patients enrolled, 371 patients (≤10% missing pain scores) were included in the analysis. Of these, 146 (39.4%) were men; mean (SD) age was 56.67 (11.70) years. Two clusters were identified within each trajectory category. The high pain cluster of the average pain trajectory significantly predicted prolonged pain (hazard ratio [HR], 0.63; 95% CI, 0.50-0.80; P < .001) and delayed opioid cessation (HR, 0.52; 95% CI, 0.41-0.67; P < .001) but was not a predictor of time to recovery in Cox proportional hazards regression (HR, 0.89; 95% CI, 0.69-1.14; P = .89). Preoperative risk factors for categorization to the high average pain cluster included female sex (adjusted relative risk [ARR], 1.36; 95% CI, 1.08-1.70; P = .008), elevated preoperative pain (ARR, 1.11; 95% CI, 1.07-1.15; P < .001), a history of alcohol or drug abuse treatment (ARR, 1.90; 95% CI, 1.42-2.53; P < .001), and receiving active placebo (ARR, 1.27; 95% CI, 1.03-1.56; P = .03). Worst pain reported on postoperative day 10 was the best predictor of time to pain resolution (HR, 0.83; 95% CI, 0.78-0.87; P < .001), opioid cessation (HR, 0.84; 95% CI, 0.80-0.89; P < .001), and complete surgical recovery (HR, 0.91; 95% CI, 0.86-0.96; P < .001). This study has shown a possible uniform predictor of remote postoperative pain, opioid use, and recovery that can be easily assessed. Future work is needed to replicate these findings. ClinicalTrials.gov Identifier: NCT01067144.

Opioid analgesics are commonly used for acute low back pain and neck pain, but supporting efficacy data are scarce. We aimed to investigate the efficacy and safety of a judicious short course of an opioid analgesic for acute low back pain and neck pain. OPAL was a triple-blinded, placebo-controlled randomised trial that recruited adults (aged ≥18 years) presenting to one of 157 primary care or emergency department sites in Sydney, NSW, Australia, with 12 weeks or less of low back or neck pain (or both) of at least moderate pain severity. Participants were randomly assigned (1:1) using statistician-generated randomly permuted blocks to guideline-recommended care plus an opioid (oxycodone–naloxone, up to 20 mg oxycodone per day orally) or guideline-recommended care and an identical placebo, for up to 6 weeks. The primary outcome was pain severity at 6 weeks measured with the pain severity subscale of the Brief Pain Inventory (10-point scale), analysed in all eligible participants who provided at least one post-randomisation pain score, by use of a repeated measures linear mixed model. Safety was analysed in all randomly assigned eligible participants. The trial was registered with the Australian New Zealand Clinical Trials Registry (ACTRN12615000775516). Between Feb 29, 2016, and March 10, 2022, 347 participants were recruited (174 to the opioid group and 173 to the placebo group). 170 (49%) of 346 participants were female and 176 (51%) were male. 33 (19%) of 174 participants in the opioid group and 25 (15%) of 172 in the placebo group had discontinued from the trial by week 6, due to loss to follow-up and participant withdrawals. 151 participants in the opioid group and 159 in the placebo group were included in the primary analysis. Mean pain score at 6 weeks was 2·78 (SE 0·20) in the opioid group versus 2·25 (0·19) in the placebo group (adjusted mean difference 0·53, 95% CI –0·00 to 1·07, p=0·051). 61 (35%) of 174 participants in the opioid group reported at least one adverse event versus 51 (30%) of 172 in the placebo group (p=0·30), but more people in the opioid group reported opioid-related adverse events (eg, 13 [7·5%] of 174 participants in the opioid group reported constipation vs six [3·5%] of 173 in the placebo group). Opioids should not be recommended for acute non-specific low back pain or neck pain given that we found no significant difference in pain severity compared with placebo. This finding calls for a change in the frequent use of opioids for these conditions. Australia's National Health and Medical Research Council, University of Sydney Faculty of Medicine and Health, and ReturnToWorkSA.

The study analysed the Visual Analogue Scale (VAS), the Verbal Rating Scale (VRS) and the Numerical Rating Scale (NRS) to determine: 1. Were the compliance and usability different among scales? 2. Were any of the scales superior over the other(s) for clinical use? A systematic review of currently published studies was performed following standard guidelines. Online database searches were performed for clinical trials published before November 2017, on the comparison of the pain scores in adults and preferences of the specific patient groups. A literature search via electronic databases was carried out for the last fifteen years on English Language papers. The search terms initially included pain rating scales, pain measurement, pain intensity, VAS, VRS, and NRS. Papers were examined for methodological soundness before being included. Data were independently extracted by two blinded reviewers. Studies were also assessed for bias using the Cochrane criteria. The initial data search yielded 872 potentially relevant studies; of these, 853 were excluded for some reason. The main reason for exclusion (33.7%) was that irrelevance to comparison of pain scales and scores, followed by pediatric studies (32.1%). Finally, 19 underwent full-text review, and were analysed for the study purposes. Studies were of moderate (n=12, 63%) to low (n=7, 37%) quality. All three scales are valid, reliable and appropriate for use in clinical practice, although the VAS is more difficulties than the others. For general purposes the NRS has good sensitivity and generates data that can be analysed for audit purposes.