Pain Medicine最新文献

Background: Spinal cord stimulation (SCS) systems that deliver fixed amplitudes expose target tissue to varying electrical fields due to the changing lead-to-cord distance accompanying postural shifts and other body movements. Inconsistent stimulation results in periods of overstimulation or under-stimulation perceived by patients as discomfort or potentially inadequate pain relief. CL-SCS may be applied to provide a comfortable level of perception down to imperceptible stimulation, commonly preferred in higher frequency and multiplexed programming. Here we report outcomes from a study evaluating a closed-loop (CL) SCS system that uses spinal evoked compound action potentials to adjust stimulation.

Methods: This ongoing study combines the evaluation of pain-related outcomes (for ≤24 months) with in-clinic randomized, crossover testing of CL performance.

Results: Sixty subjects have been implanted with the CL-SCS system, and 54 subjects have completed the 3-month visit. Sixty percent preferred below-perception waveforms for therapy during at-home use. The study successfully met its primary endpoint with 89.3% of subjects in the Primary Analysis Set (n = 28) reporting reduction in overstimulation with CL-SCS relative to OL-SCS at 1 month (P < .001; binomial exact test); at 3 months, 86% of subjects with low-back/leg pain (n = 51); and all 3 with upper limb pain reported ≥50% reduction in pain, relative to baseline.

Conclusions: The data presented here support the performance of a flexible CL-SCS system that can deliver a variety of waveforms, with amplitude programmed to patient comfort and automatically adjusted up to 50 times per second, to improve the consistency of therapy experience.

Registration: This study is registered on ClinicalTrials.gov number NCT05177354 https://clinicaltrials.gov/search? term=NCT05177354.

Objective: Symptomatic lumbar disc herniation is a major cause of low back pain and sciatica in adults, significantly affecting quality of life and creating economic burdens. Minimally invasive percutaneous intradiscal techniques, such as percutaneous laser disc decompression (PLDD), have been developed as alternatives to open surgery; however, their efficacy remains debated.

Design, setting, and subjects: This study evaluated the effectiveness of PLDD in patients with lumbar disc protrusions and contained herniations by assessing quantitative changes in herniated disc area on axial and sagittal MR images.

Methods: A total of 58 patients with lumbar radiculopathy due to disc herniation underwent MRI two months after PLDD to evaluate changes in disc area. Axial and sagittal MR images with the greatest protrusion and neural compromise were analyzed, and patient pain severity, clinical outcomes, and satisfaction were recorded.

Results: Results showed a statistically significant reduction in both axial and sagittal disc areas post-PLDD. The initial mean axial disc area of 0.51 cm2 (0.44-0.58) decreased to 0.29 cm2 (0.25-0.37), reflecting a median reduction of 35.9% (P < 0.0001). Similarly, the sagittal disc area decreased from a mean of 0.37 cm2 (0.33-0.43) to 0.19 cm2 (0.13-0.25), with a median reduction of 49.3% (P < 0.0001). All patients showed reductions in disc area, with a median reduction ratio of 52.7% (IQR: 45.2-56.2).

Conclusions: These findings suggest that PLDD is an effective option for reducing herniated disc size in carefully selected patients with contained disc herniations who have not responded to conservative treatment. Although not a substitute for open surgery, PLDD offers a statistically significant reduction in herniated disc size, making it a valuable therapeutic option for symptomatic contained lumbar disc herniation.

Objectives: To evaluate the impact of health-service (payor type and authorization delays), clinical, and psychosocial domains on outcomes at 6 months following 60-day peripheral nerve stimulation (PNS).

Design: Prospective, single-center observational cohort study.

Setting: Academic health system-based outpatient pain clinics.

Subjects: 121 adult patients with chronic pain treated with temporary PNS between December 1st, 2023, through December 1st, 2024.

Methods: Baseline assessments included demographic characteristics, pain, and disability scores. The primary outcome was response to PNS characterized as responders (≥50% relief) and high responders (≥80% relief) at 60-days and 6-month follow-up. Insurance delays were categorized as no delay, short (1-14 days), or long (≥15-day) delay. Multivariate logistic regression identified predictors of response with sensitivity analyses.

Results: At 60-days, 66.9% achieved ≥50% relief and 28.9% ≥80%. At 6 months, 78.5% and 44.6% met these thresholds, respectively. Insurance delay and high baseline disability predicted worse outcomes. Each 10-day delay reduced the odds of ≥ 50% and ≥80% relief by 89% and ≥80%, respectively. 60-day response strongly predicted 6-month benefit. Psychological and health service factors predominated at 60 days, whereas clinical (opioid use) and demographic variables (including morbid obesity) emerged at 6 months. Delayed response trajectories were observed: 62.5% of 60-day non-responders achieved ≥50% relief and 45.3% reached ≥80% relief at 6 months.

Conclusions: Insurance-related delays, high opioid burden, baseline disability and morbid obesity negatively influenced PNS outcomes, while psychological resilience conferred benefit. Delayed onset responders/high responders highlight the need for longitudinal follow-up and caution against premature discontinuation of PNS therapy.

Objective: Evaluate the efficacy of an online standard prenatal education intervention with the addition of pain neuroscience education in women with pregnancy-related lumbopelvic pain, compared to standard prenatal education intervention alone on pain intensity, disability, kinesiophobia, physical activity, pain catastrophizing, anxiety, and depression.

Design: A multicentre randomized controlled trial was designed.

Setting: It was conducted in the Gynecology and Obstetrics departments of three hospitals in the Valencian Community, Spain.

Subjects: A total of 211 participants were randomly assigned to either the standard prenatal education + pain neuroscience education group (n = 111) or the standard prenatal education-only group (n = 100).

Methods: Participants were randomly assigned to receive either 12 written standard prenatal education lessons or 12 written standard prenatal education lessons plus 12 audiovisual pain neuroscience education lessons over one month.

Results: Post-intervention between-group differences were observed in pain intensity (mean difference = -0.5, 95% CI -1.0 to 0.0; p = 0.05) and kinesiophobia (mean difference = -1.4, 95% CI -2.3 to -0.4; p = 0.005), both favouring the standard prenatal education + pain neuroscience education group, while within-group improvements were found in disability and pain catastrophizing in both groups.

Conclusions: Incorporating pain neuroscience education into standard prenatal education may offer additional benefits, particularly in reducing pain intensity and kinesiophobia in women with pregnancy-related lumbopelvic pain.

Objective: Management of refractory chronic low back pain (CLBP) includes a range of treatments (e.g., physical therapy, injections, ablations, neurostimulation, surgery) with varying utilization and effectiveness. This pragmatic randomized controlled trial (RCT) evaluated the effectiveness of one treatment option, percutaneous 60-day peripheral nerve stimulation (PNS), compared to usual care with standard interventional management for CLBP.

Methods: Two hundred thirty patients with CLBP were randomized in a 1:1 ratio to Group #1 (percutaneous 60-day PNS) or Group #2 (physician-directed usual care with standard interventional management). The Primary Clinical Endpoint evaluated the proportion of participants with ≥50% reductions in CLBP at 3 months post-treatment compared to baseline.

Results: At the Primary Endpoint, a greater proportion of participants receiving percutaneous 60-day PNS (55%; n = 112; 95% confidence interval [CI] = [45, 65]) experienced ≥50% pain relief compared to usual care with standard interventional management (26%; n = 110; 95% CI = [17, 34]; p < 0.001). Concordant with the Primary Endpoint, percutaneous 60-day PNS also produced greater improvements in patient-centric secondary endpoints, including disability, pain interference, health-related quality of life, and analgesic consumption. Reductions in pain and resulting improvements in function were sustained through 6 months with percutaneous 60-day PNS.

Conclusions: This prospective multicenter pragmatic RCT met its Primary Clinical Endpoint and found that more participants with CLBP reported pain relief at 3 months after receiving percutaneous 60-day PNS as compared to usual care with standard interventional management. Participants treated with 60-day PNS showed greater reductions in pain and more substantial improvements in functional outcomes through 6 months.

Introduction: Opioids are suggested to serve as an emotional substitute for social attachments, why patients with persistent back pain and high levels of attachment-avoidance may be vulnerable to long-term opioid treatment (LTOT).

Aims: The primary aim was to assess the association between attachment insecurity and LTOT and secondary to assess the associations between attachment insecurity, pain, and disability.

Methods: A 5-year follow-up study of patients with persistent back pain. Questionnaire data on attachment insecurity, psychological distress, pain intensity, and disability were collected and combined with longitudinal register data on prescriptions of opioids.

Results: A total of 3,102 patients was included. Patients in LTOT (9.3%) were significantly more avoidantly attached compared to non-opioid users. For every one-point increase on attachment-avoidance, the odds of LTOT increased by 4%. When adjusting for covariates, only age, pain, and depression were significantly associated with LTOT. Both attachment-avoidance and attachment-anxiety were significantly associated with pain intensity and disability.

Conclusion: Attachment insecurity may be associated with an increased risk of LTOT, pain, and disability. Acknowledging that unmet attachment needs and emotional distress can be linked to an increased risk of LTOT highlights the importance of considering these factors before prescribing the first opioid.

Objective: Although higher baroreflex sensitivity (BRS) is typically associated with reduced pain sensitivity, we previously reported that elevated preoperative BRS predicted greater postoperative pain after cardiothoracic surgery, a finding that challenges existing experimental evidence. This exploratory secondary analysis tested whether perioperative changes in BRS (ΔBRS) better predict postoperative pain severity.

Design: Exploratory secondary analysis of a prospective observational cohort.

Subjects: Seventy-two adults undergoing elective minimally invasive cardiothoracic surgery.

Methods: Spontaneous cardiovagal BRS was measured preoperatively (pain-free baseline) and on postoperative days (POD) 1 and 2 (during ongoing pain). Pain severity was assessed using the PEG scale. Inflammatory biomarkers (C-reactive protein, cytokines, albumin) were also measured. Multivariable regression models evaluated associations between BRS metrics and pain, adjusting for demographic, surgical, analgesic, and psychological covariates.

Results: Higher preoperative BRS was associated with greater postoperative BRS decline (ΔBRS) by POD2 (R2 = 0.12, p = 0.008) and with more severe pain on POD2 (R2 = 0.15, p = 0.003). ΔBRS was independently and inversely associated with pain severity (R2 = 0.09, p = 0.025) even after covariate adjustment. Although inflammatory markers increased postoperatively, they did not mediate these associations.

Conclusions: Steep perioperative BRS declines, particularly among individuals with initially high values, may reflect autonomic destabilization and reduced baroreflex-mediated inhibition of nociception. These findings identify ΔBRS as a dynamic and mechanistically informative predictor of postoperative pain. Perioperative BRS monitoring could support individualized risk stratification and guide interventions aimed at stabilizing autonomic function to improve recovery outcomes.

Objective: The aims of this study are to assess the preliminary outcomes of the NOPAIN treatment, which is an ACT-based treatment performed in the early postoperative period after Total Knee Arthroplasty (TKA), aimed to prevent the onset of chronic postsurgical pain, as well as to evaluate the predictors of the presence of moderate-to-severe pain after three months.

Design: Non-controlled preliminary trial.

Setting: Division of Rehabilitation Medicine within an Italian tertiary care hospital.

Subjects: Eighty patients undergoing postoperative rehabilitation after TKA.

Methods: Before the treatment, patients underwent a baseline assessment of pain intensity (Numeric Rating Scale), knee pain, stiffness and function (WOMAC), as well as of potential predictors of the effects of the treatment, namely sex, age, pain duration, catastrophizing (Pain Catastrophizing Scale), psychological distress (Hospital Anxiety and Depression Scale), presence of central sensitization (Central Sensitization Inventory), cognitive flexibility (Wisconsin Card Sorting Test) and heart rate variability. Then, all patients underwent the NOPAIN treatment. Pain intensity, knee pain, stiffness and function, catastrophizing and psychological distress were also assessed after three months.

Results: Participation rate was 72% and retention was high, with 81.3% of participants completing all four sessions of the NOPAIN treatment. Pain intensity (p < 0.01), knee pain (p < 0.01), knee stiffness (p < 0.01) and knee function (p < 0.01) improved over time. Female sex and age were associated with lower odds of moderate-to-severe pain at three months, whereas presence of central sensitization, baseline pain intensity, rumination, helplessness and changes in helplessness were associated with higher odds.

Conclusion: This study shows that the NOPAIN treatment is feasible, that it can be integrated into standard rehabilitative care, and that it might contribute to the prevention of chronic post-surgical pain. The results of this preliminary study will be the basis for the improvement of the intervention.