OBJECTIVES:Discuss the current status of advanced practice providers (APPs) onboarding to headache medicine (HM) practices in the United States and present recommendations of the American Headache Society (AHS) APP Work Group to improve the onboarding process. BACKGROUND:A high demand for care, national shortage of specialists, and multiple advancements in HM have led to an increasing interest and presence of APPs of various backgrounds in the field, currently without a unifying onboarding process. Efforts to standardize and optimize the onboarding process for APPs in HM practices are necessary, to ensure high standards in quality of care. METHODS:The APP Work Group of the AHS Practice Management Committee developed comprehensive recommendations through literature review, survey of AHS members, and expert consensus. A modified Delphi protocol was used to establish key onboarding goals, definitions, and best practice recommendations. RESULTS:Recommendations are made regarding duration of onboarding, appropriate supervision, formal education and procedural skills, scope of practice, grading and documentation of competence, and reciprocal feedback. CONCLUSION:Currently, there are no standard onboarding and training guidelines for APPs in the field of HM. We provide recommendations for a more systematic approach to help develop qualified providers and enhance their retention in HM practices.
Failed Back Surgery Syndrome (FBSS) represents a persistent clinical and public health challenge, characterized by chronic pain and functional impairment following spinal surgery. This review integrates current scientific evidence with expert insights from Mexico, Colombia, and Ecuador to examine the multidimensional nature of FBSS and its implications for diagnosis and management. Four analytic domains were explored: etiological factors, therapeutic utilization patterns, perceived treatment effectiveness, and patient progression through a multimodal management pathway. Findings reveal a significant mismatch between commonly used therapies and those perceived as most effective, with pharmacologic management dominating early care despite its limited long-term benefit. Rehabilitation, psychological interventions, and spinal cord stimulation demonstrate substantially higher effectiveness but remain underutilized due to systemic, logistical, and educational barriers. The progressive attrition observed along the care pathway highlights critical gaps in multidisciplinary integration, timely referral, and access to advanced neuromodulation. Collectively, the results support a shift toward a comprehensive biopsychosocial framework for FBSS, emphasizing early multidimensional evaluation, expanded access to evidence-based therapies, and alignment of clinical decision-making with proven long-term outcomes. This approach is particularly relevant for improving patient care within diverse healthcare systems across Latin America.
Chronic pain is increasingly recognized as a brain-based condition sustained by maladaptive neuroplasticity rather than persistent nociceptive input alone. This review integrates structural, functional, and connectomic evidence to examine how chronic pain reorganizes neural circuits involved in sensory processing, emotional regulation, cognitive control, and motivational learning. Findings from neuroimaging studies consistently demonstrate gray matter volume alterations, white matter microstructural changes, aberrant task-evoked activity, and disruptions in resting-state networks such as the default mode, salience, and sensorimotor systems. Predictive markers—including corticostriatal connectivity, corticolimbic anatomy, and prefrontal regulatory capacity—suggest that emotional reinforcement patterns and diminished cognitive modulation contribute to the transition from acute to chronic pain. These mechanisms highlight chronic pain as a self-reinforcing neural state shaped by interactions between sensory, cognitive, and affective processes. The review underscores the need for mechanism-based, interdisciplinary clinical approaches and emphasizes the relevance of these findings for diverse healthcare settings, particularly in Latin America. Future work should prioritize longitudinal, multimodal investigations to refine biomarker candidates and support personalized, neuroplasticity-informed interventions.
