Background Clinical heterogeneity in fibromyalgia (FM) results in highly variable therapeutic responses to transcranial direct current stimulation (tDCS). Identifying predictors and temporal response patterns is crucial to transform personalized neuromodulation strategies. This secondary analysis integrated supervised prediction, pain-trajectory modeling, and causal inference to characterize individual response profiles to anodal tDCS in women with FM. Methods Secondary analysis of a randomized, controlled, triple-blind clinical trial including 35 women allocated to active anodal M1 tDCS (2 mA, 20 min, 10 sessions) or sham stimulation. Pain (VAS) was assessed at baseline, D10, D30, and D90; functional, fatigue, mood, and QoL measures at baseline and D30. Six supervised algorithms were trained toclassify responders (≥30% VAS reduction). Pain-trajectory clusters were derived using Dynamic Time Warping with k-means. A T-learner framework estimated Conditional Average Treatment Effects (CATE) to detect treatment-effect modifiers. The Research Ethics Committee of the Centro Universitário da Grande Dourados under registration number Certificado de Apresentação de Apreciação Ética approved this research:36444920.5.0000.5159. The study was registered in The Brazilian Registry of Clinical Trials with the identifier RBR-8wc8rjq. Results Active tDCS elicited greater pain reduction than sham at D10, D30, and D90 ( p < .001). Predictive models demonstrated stable discrimination (AUC 0.78–0.84). WHOQOL-Physical and WHOQOL-Psychological domains were the strongest positive predictors, while higher FIQ and antidepressant use lowered response probability. Three exclusive pain-trajectory phenotypes were identified—rapid responders, progressive responders, and non-responders—with distinct sustainability at D90. CATE analyses indicated higher treatment advantage among participants with higher psychological QoL, moderate baseline VAS (6–8), and no antidepressant use. Conclusion The integration of machine-learning models, longitudinal trajectory analysis, and causal estimation revealed heterogeneous response dynamics and specific clinical profiles with higher likelihood of therapeutic gain from tDCS. These findings may support refinement of personalized stimulation protocols, early monitoring strategies, and targeted candidate selection in FM.
Pain management is a critical component of cancer care, yet the influence of sociodemographic and clinical factors on prescribing patterns for opioids, non-opioid medications, and non-pharmacological interventions remains underexplored. This cross-sectional study using the 2018-2020 Medical Expenditure Panel Survey (MEPS) characterizes clinical and sociodemographic factors associated with opioid, non-opioid, and non-pharmacological pain management in individuals with a history of cancer. Adults aged ≥18 years with a self-reported cancer diagnosis (N = 7,035) were characterized by sociodemographic factors, including race/ethnicity, income, insurance type, and English proficiency, and clinical variables such as cancer type, comorbidities, and depression were surveyed. Main outcomes included receipt of prescription opioids, non-opioid pain medications, and non-pharmacological pain interventions. Adjusted relative risks (aRR) for pain management approaches were estimated using quasi-Poisson regression. Among 7,035 participants, 19.99% received opioids, 51.15% non-opioid medications, and 20.73% non-pharmacological interventions. Opioid prescription was significantly lower among Asian participants (aRR 0.18, 95% CI 0.05, 0.67) and those with limited English proficiency (aRR 0.22; 95% CI 0.11, 0.43). Depression was associated with increased use of opioids (aRR 1.26, 95% CI 1.09, 1.46) and non-opioid medications (aRR 1.26, 95% CI 1.18, 1.34). Non-opioid and non-pharmacological interventions were more likely among females (aRR 1.21 and 1.49, respectively) but less frequent among individuals with lower income and education. Significant differences in cancer pain management were found based on sociodemographic and clinical factors. Further research is needed to determine whether disparities in opioid and non-opioid prescribing persist across race, sex, English language proficiency, and mental health comorbidities.
Background:Guidelines do not recommend lumbar spine surgery for people with chronic low back pain (CLBP). It remains unknown how these guidelines are implemented, and which factors affect the decision to offer surgery. Objectives:This study examined factors associated with patients reporting that lumbar spine surgery was recommended during specialist consultation for CLBP. Methods:Clinical, demographic and psychosocial factors were measured pre-consultation in people referred with CLBP for their first consultation with orthopaedic spine clinicians in secondary care in eight hospitals. Patients reporting leg pain, previous spinal surgery, or other specific spinal pathology were excluded. Data were analysed using binomial logistic regression. In addition, three surgeons independently rated a subsample of the MRI reports as suitable or unsuitable for lumbar spine surgery, blinded to clinical background of patients and to the consultation outcome. Results:A total of 424 patients were included in the analysis, of whom 96 reported being offered lumbar spine surgery. Patients were more likely to report being offered surgery if they were older, had a longer pain duration, had consulted more widely, and had stronger positive expectations of surgery. Pain intensity, disability, depression, and anxiety were not associated with the decision to offer surgery. The model correctly classified 80.6% of cases. In the subsample analysis based on MRI reports alone, the proportion judged as potentially suitable for lumbar spine surgery (20%) was similar to the actual consultations (22%), but concordance on who was offered surgery was poor (27%). Conclusion:In this cohort of people with CLBP without leg pain, patient perception that surgery was offered during the consultation was associated with a longer history of pain and a greater number of prior consultations. Surgical offer was patient-reported and surgeons' rationale was not captured. Subsample findings suggest that MRI findings alone should not drive surgical decision-making in CLBP.
Background:Postherpetic neuralgia (PHN) is a chronic neuropathic pain condition following herpes zoster, occurring particularly in elderly or immunosuppressed individuals. It is often difficult to treat and may significantly impair quality of life. Case Report:We report the single-blinded treatment of refractory thoracic PHN with onabotulinumtoxinA (BoNT/A). A total of 200 IU was injected into the affected area across 40 injection points (5 IU per site), while one corner of the affected area was injected with saline as an intra-individual blinded comparator. A remaining painful area was treated with a further 100 IU BoNT/A 24 days later. Results:Pain intensity decreased progressively from severe pain with attacks up to 10/10 on the numeric rating scale (NRS) to 5/10 in the BoNT/A-treated area, while the saline-injected area showed no noteworthy improvement. Following the second BoNT/A injection, the remaining painful area reduced further to a coin-sized spot. The clinical effect lasted approximately 3 months and repeated treatment stabilised substantial pain reduction for almost 1 year. Conclusion:BoNT/A may be an effective treatment option in selected patients with refractory focal PHN, particularly when established first- and second-line treatments are ineffective, poorly tolerated or contraindicated. Further controlled studies are required to clarify efficacy, duration of benefit and repeat-treatment strategies.
Introduction Prevalence rates for cancer-related pain are 40-50%. Provision of multi-disciplinary chronic pain services for those with cancer-related pain is poorly understood. Aim To identify provision of multi-disciplinary chronic pain services for those with cancer-related pain across England. Methods Acute/Hospital and Community NHS Trusts in England ( n = 190) were sent Freedom of Information requests asking if a multi-disciplinary chronic pain service was provided by the Trust, and numbers of people seen in previous 24 months with (a) tumour-related pain and (b) cancer-related late effects pain or pain caused by cancer treatments. Demographic information was requested. If no response was received within 10 weeks, a follow up request was sent. Quantitative data were analysed using descriptive statistics. Results In total, 171 NHS Trusts responded. Almost half, ( n = 74, 43.3%) reported providing a multi-disciplinary chronic pain service. Of these, 17 (23.0%) were able to provide attendance data for people with tumour-related pain and eight (10.8%) with late effects pain. Demographic information could be provided by seven (9.5%) Trusts for those with tumour-related pain and four (5.4%) for late effects pain. The main reason Trusts could not provide demographic information was because such data were not routinely collected. Conclusions People with cancer-related pain appear to have limited access to multi-disciplinary chronic pain support in England. However, lack of standardised methods of coding and recording cancer-related pain as reasons for attending multi-disciplinary chronic pain services mean reporting accurate figures is challenging. It is essential that there is an accurate reporting system so the scale of cancer-related pain can be understood to help guide the provision and development of services, education and research.
Background:Pressure pain threshold (PPT) testing is a widely used quantitative sensory testing method to assess mechanical pain sensitivity. While reference values for PPT at articular-/joint-related and osseous landmarks are available, data on measurement reliability remain limited. This study aimed to determine the intra- and inter-rater reliability of PPT measurements and to report the standard error of measurement (SEM) for joint PPT. Methods:Healthy participants aged 18-40 years were included in a two-part study. In Part A (N = 40), intra-rater reliability was assessed through three repeated PPT measurements by the same examiner. In Part B (N = 40), inter-rater reliability was evaluated with two different examiners. PPT was measured at joints (elbow, knee, ankle) and reference landmarks (sternum, forehead) using a digital algometer. ICCs (2,k model) and SEM were calculated for each landmark. Results:Intra-rater reliability was excellent at all landmarks (ICCs ≥ 0.926) except the elbow with a good reliability (ICC = 0.848). Inter-rater reliability was excellent at the sternum (ICC = 0.950) and good at the ankle, knee, elbow, and forehead (ICCs ≥ 0.813). SEM values varied across landmarks, with lowest values observed at reference landmarks sites (e.g., sternum and forehead). ICCs are similar between sexes. Conclusions:PPT measurements at articular (joints) and bony reference landmarks show good to excellent reliability. These findings support the use of joint PPT in standardized pain sensitivity assessments and provide a basis for clinical and research applications. However, findings are limited to pain-free participants and should be replicated in broader populations.
Background:Low back pain (LBP) is a leading cause of global disability, with a heavier burden in low and low-middle Socio-Demographic Index (SDI) regions. Women aged ≥55 years are vulnerable due to dual labor loads, yet LBP burden attributed to occupational ergonomic factors, smoking, and high Body Mass Index (BMI) in this subgroup remains understudied. Objective:This study analyzed the 30-year LBP burden and its drivers in this population to inform targeted prevention. Method:Using Global Burden of Diseases (GBD) 2023 data (1992-2023), we employed Joinpoint regression, decomposition, and frontier analyses to assess LBP-related disability-adjusted life years (DALYs) across low/low-middle SDI regions. Result:Absolute DALYs increased consistently across all risk factors; age-standardized DALY rates (ASDR) declined with age, peaking at 55-59 years. Population growth was the primary driver which contributed >100%. High BMI-associated LBP grew most prominently with 579% in low-middle SDI regions, and ASDR rises in low SDI regions. Decomposition and frontier analyses revealed unique regional contribution patterns and intercountry disparities. Conclusion:This study indicates that the burden of LBP attributable to three factors may be increasing in low and low-middle SDI regions, with population growth and aging likely acting as primary drivers. Occupational ergonomic factors emerge as the most pressing risk factors, while high BMI is potentially the fastest-growing contributor. Notable intercountry disparities within each SDI tier underscore both challenges and opportunities for targeted prevention.
Background Chronic pain is a leading cause of long-term disability, yet prevalence estimates vary widely due to differences in operational definitions. Although a 3-month duration criterion is commonly used, it may not adequately reflect the functional burden of chronic pain. This study compared prevalence estimates derived from alternative chronic pain definitions and evaluated which best identify individuals with impaired health-related quality of life (HRQoL). Methods Data were drawn from a population-based sample of adults (n = 5557). Pain was assessed using the Brief Pain Inventory, and HRQoL was measured with the Short Form 12 Health Survey (SF-12v2). Six definitions were examined: duration-only (≥3 months), pain pattern (constant or daily intermittent), pain severity thresholds (≥3 and ≥4), and pain interference thresholds (≥3 and ≥4). Results Prevalence estimates varied substantially by definition, ranging from 40.1% using duration alone to 12.0% using pain interference ≥4. Increasingly restrictive definitions were associated with progressively lower physical and mental health scores. Effect sizes for physical health impairment increased from Cohen’s d = 0.81 for the duration-only definition to 1.68 for the most restrictive interference-based definition. Definitions incorporating pain interference most clearly distinguished individuals with reduced HRQoL. Conclusions The operational definition of chronic pain strongly influences both prevalence estimates and identification of clinically meaningful impairment. Definitions incorporating functional impact more accurately identify high-burden chronic pain than duration alone, supporting the integration of temporal and functional dimensions in standardised definitions.
Background:Chronic pain (CP) and severe mental illness (SMI) frequently co-occur, exacerbating clinical outcomes and healthcare burden. The influence of diagnostic sequence, that is, whether CP precedes SMI or vice versa, on mental health and hospitalization remains underexplored. This study investigates how the temporal order of CP and SMI diagnoses impacts illness burden, mental health comorbidities, and hospital admissions. Methods:Using linked electronic health records from primary care, mental health, and acute care in South London, we identified 1112 patients with comorbid CP and SMI (e.g. schizophrenia). Patients were grouped by diagnostic order: CP before SMI (CP-SMI, n = 413) versus SMI before CP (SMI-CP, n = 699). Outcomes included illness burden, mental health comorbidities, and hospital admissions, which were analysed via multivariable regression, adjusting for confounders. Results:Compared to the CP-SMI group, the SMI-CP group exhibited significantly lower odds of self-injury (OR = 0.55, 95% CI: 0.31-0.98), substance misuse (OR = 0.55, 95% CI: 0.34-0.86), depressive mood (OR = 0.63, 95% CI: 0.44-0.89), and depression diagnosis (OR = 0.58, 95% CI: 0.43-0.78). Among the SMI-CP group, older age reduced the odds of self-injury, substance misuse, and depressive mood but increased the risks of cognitive and physical problems. No significant differences were observed in psychiatric or general hospital admissions or physical comorbidities, though ethnic disparities persisted in psychiatric admissions. Conclusion:Patients diagnosed with CP before SMI experience worse mental health outcomes. This is likely due to delayed psychiatric intervention, therefore routine psychiatric screening aiming to improve outcomes and reduce healthcare burden at CP diagnosis should be evaluated.
Aims: A qualitative process evaluation was embedded into the pilot phase of the RADICAL randomised controlled trial of radiofrequency denervation for chronic and moderate-severe low back pain. The aim was to rapidly understand recruitment processes and inform development of strategies to overcome recruitment challenges. Methods: Audio recording of recruitment consultations between recruiting staff and potential patient participants, and interviews with patients who had consented to participate in the RADICAL trial. We used rapid thematic analysis to identify what information was provided, understanding of trial processes and potential challenges to recruitment. Results: Recruitment staff needed more support to clearly and effectively explain trial participation. Specific challenges included communicating trial procedures, explaining treatment equipoise and randomisation, and navigating the complex recruitment pathway. These findings led to the development of support materials for recruiters, including a process diagram and targeted training sessions to optimise information provision and informed consent. Conclusion: Embedding qualitative process evaluations within an RCT pilot can generate rapid insights into communication challenges and recruitment barriers. These insights can inform the development of practical support materials and process refinements to enhance recruitment, potentially strengthening trial viability.
Background:Understanding patient preferences for migraine treatments is essential for patient-centered care and for informing the development and optimization of therapeutic options. Although individual preference-elicitation studies exist, evidence has not been systematically synthesized across methods and treatment contexts. Methods:We conducted a scoping review in accordance with PRISMA 2020 guidelines. PubMed, Scopus, Web of Science, and Google Scholar were searched for peer-reviewed studies that elicited patient preferences regarding acute or preventive migraine pharmacotherapies. Eligible studies employed qualitative or quantitative preference-elicitation methods. Results:20 studies comprising 6435 participants were included. Across preventive and acute treatment contexts, efficacy-related outcomes were consistently prioritized by patients. For preventive treatments, key valued attributes included reduction in migraine frequency, durability of effect, tolerability, and convenience, with preferences varying by prior treatment experience and disease severity. For acute treatments, rapid onset of action, complete pain relief, functional recovery, and minimal adverse events were most important. Preferences regarding route of administration were heterogeneous and context-dependent, reflecting trade-offs between convenience, invasiveness, and perceived effectiveness. Conclusions:Patient preferences for migraine treatments are multifactorial and vary across treatment goals, modalities, and patient subgroups. While methodological limitations across studies constrain definitive conclusions, this review highlights consistent priority attributes that may inform shared decision-making, outcome selection in clinical trials, and patient-centered aspects of migraine therapy development.
Background:Patients with fibromyalgia syndrome (FMS) often report prolonged diagnostic pathways and inadequate care, prompting reliance on self-management and online health information. This study aimed to quantify the association between specific clinical experiences and the sources and extent of health information-seeking behaviours in people with FMS. Methods:A cross-sectional online survey was completed by adults who self-reported a diagnosis of FMS. Measures assessed symptom severity, diagnostic and treatment experiences, frequency and duration of symptom flares, perceived stigma and caring from healthcare professionals, and engagement with health information sources, including traditional and digital platforms. Associations between clinical experiences and health information-seeking behaviours were examined using non-parametric tests and hierarchical regression analyses. Results:A total of 384 adults completed the survey (75.3% female; median age 41 years). Most participants reported experiencing symptom flares (88.0%), occurring approximately every 2-3 weeks and lasting a median of 3 days. Participants reported significantly more negative than neutral experiences across multiple diagnostic and treatment variables, including diagnostic difficulty and challenges accessing specialist care. Most respondents (84.1%) actively sought health information, most commonly from healthcare professionals, websites, and online network platforms. Nearly half reported difficulties accessing satisfactory health information. Greater diagnostic difficulty, difficulty finding a specialist, and higher perceived caring from healthcare professionals independently predicted engagement with a wider range of health information sources. Conclusions:Patients with FMS frequently report dissatisfaction with their clinical experiences. Positive and negative diagnostic and treatment experiences are associated with the extent of health information-seeking among people with FMS. These findings highlight the importance of clinical experiences in shaping how patients seek health information and underscore the role of supportive clinical relationships in fostering informed and collaborative care.
Background The utility of exercise testing in an interdisciplinary paediatric chronic pain assessment is unknown. The aims of this study were to explore exercise testing results in a paediatric chronic pain cohort and associations with baseline patient-reported outcome measures (PROMs), including various measures of pain experience and functioning.Methods There were 153 participants, aged 6-17 years, attending the Sydney Children's Hospital Interdisciplinary Chronic and Complex Pain Clinic with data analysed retrospectively. Exercise tests included the six-minute walk test (6MWT), plank, prone extension and pushups. Results were described and stratified by age, and Spearmen correlation coefficients (rs) were determined between baseline exercise testing results and PROMs, and between different exercise tests.Results The 6MWT distances were greater in the younger subgroup, however, there were no other differences in exercise tests between age groups. Associations between baseline exercise testing results and baseline PROMs ranged from very weak to moderate (rs's = .18-.40). Associations between different exercise testing results ranged from very weak to moderate (rs's = .17-.52). The 6MWT, plank and pushups each had at least five weak to moderate associations with PROMs and the prone extension test had one weak association.Conclusions Exercise testing results in a paediatric chronic pain cohort are presented, including with age stratification. The results of the current study suggest that exercise testing provides unique information to supplement other forms of assessment. There is a need for standardised exercise protocols with normative datasets, so that clinical and research findings are more comparable across settings.
Background:Opioid analgesia is frequently prescribed after surgery, with the expectation that patients will cease use within weeks, yet up to 25% of opioid-naïve patients may develop persistent postoperative opioid use. Opioid stewardship interventions are increasingly used to mitigate this risk, but little is known of the psychological factors influencing successful opioid cessation in the community after surgery in the UK. Aim:To identify psychological factors influencing opioid use and cessation after discharge following surgery in the UK. Design:Interviews with post-surgical patients 3 months after discharge; qualitative framework analysis summarised as themes. Methods:Opioid-naïve patients discharged on opioids after all-type surgery were invited three months later to a telephone interview that explored their experience of reducing opioids at home, and what influenced these decisions. Data were transcribed and qualitatively analysed. Results:48 participants were interviewed: all had ceased opioid use within one month of surgery. Four themes, comprising 15 subthemes, described diverse considerations: relationship with opioids - balance of benefits and risks; relationship with pain; relationship with clinicians; and views about addiction, including moral perspectives. Conclusion:Those interviewed made complex decisions on tapering opioids drawing on beliefs and previous experiences, relationships to healthcare, and prior experiences of pain. The themes identified lend further support, in the UK healthcare setting, to specific opioid stewardship interventions, especially patient education, pack-size limitation, and transitional pain services.
Background Effective management of cancer-related pain (CRP) requires support from knowledgeable healthcare professionals. Existing literature states that healthcare professionals' knowledge of CRP is poor. However, there is no consistency in how knowledge and attitudes are assessed or the standards against which they are measured. This systematic review evaluates the cancer-related content and psychometric properties of surveys used to assess knowledge of CRP.Method Using JBI methodology for Systematic Reviews of Measurement Properties, the search was conducted in MEDLINE, EMBASE, CINAHL and PsycINFO (limited to 2011-2024). Screening and extraction were completed by two researchers using the COVIDENCE system. The COSMIN Risk of Bias checklist was used to assess psychometric properties, and additional data were extracted on content feasibility.Results A total of 1024 papers were identified, and 37 were included in the final analysis. Sixteen different surveys were found, with four being used in multiple studies. No survey was deemed superior, and all were rated poorly using the COSMIN Risk of Bias checklist. The CRP content within the surveys varied significantly, with none capturing the complexity of CRP. The feasibility of administering these surveys in practice was not reported in the studies examined.Conclusion The wide variation in the design and content of surveys identified makes it difficult to assess the current state of healthcare professionals' knowledge of CRP. This raises questions about the validity and reliability of their conclusions, as they lack a robust evaluation of psychometric properties. Further research is needed to accurately assess healthcare professionals' knowledge of CRP.
Objective:We aimed to explore the factors associated with disability in women with chronic pelvic pain (CPP). Methods:This is a cross-sectional study conducted in Brazil with women with CPP, between 18 and 45 years old. Disability was measured using the World Health Organisation Disability Assessment Scale (WHODAS 2.0). Socioeconomic and clinical data were collected, and instruments to assess pain intensity and catastrophising, sexual function, kinesiophobia, depression, physical activity and the sit-to-stand test were applied. Correlations of Spearman, Student's t-test and multiple linear regression were used for data analysis (α = 0.05). Results:168 women with a median age of 36 (IQR 29 - 40) years were evaluated. Those with greater pain intensity and catastrophising, sexual dysfunction, kinesiophobia, depression, who do not practice regular physical activity and with worse performance in the sit-to-stand test had greater disability on correlation analysis. However, only pain catastrophising (β = 6.40; 95%CI 0.44 - 12.36) and depression (β = 12.03; 95%CI 6.61 - 17.45) were predictors of disability (p < 0.05) in the adjusted linear regression model. Conclusion:Our results indicate that psychosocial factors (pain catastrophising and depression) have a stronger relationship with disability than pain intensity or physical factors (sit to stand and physical activity). Therefore, all clinicians involved in the care of women with CPP could systematically assess and address pain catastrophising and depression as part of comprehensive management to prevent disability.
Adverse childhood experiences (ACEs) are well-documented risk factors for later health problems, such as chronic pain and mental illness. We aimed to synthesise the impact of childhood trauma on psycho-emotional disorders, pain perception and cognitions, and quality of life in individuals with chronic pain. A systematic review was conducted following PRISMA guidelines for systematic reviews and meta-analyses. Eligible studies were identified by searching PubMed, PsychINFO, Embase, and Web of Science, with publication dates from 1988 to April 2023. Inclusion criteria were formulated according to the PECOS framework, and relevant research articles were screened for inclusion. Evidence from 18 studies highlights the significant impact of ACEs (and their typologies) on patients' psycho-emotional well-being, pain outcomes, and overall quality of life, with a cumulative effect emerging. However, significant methodological limitations, such as the lack of standardised measures to classify childhood adversity, prevent us from drawing definitive conclusions about the reported associations. The findings underscore the importance of integrated approaches to pain management that centre on the patient's life history and psycho-emotional status. Future research should address current limitations to strengthen our understanding of the role of ACEs in chronic pain research.
