OBJECTIVES:Spinal cord stimulation (SCS) is a surgical therapy for chronic neuropathic and mixed-origin pain refractory to conventional treatments. Patient selection considering both clinical and psycho-social factors is essential. This study prospectively validated an online e-health tool for SCS candidate selection and compared its recommendations with expert physician judgment. MATERIALS AND METHODS:A total of 80 patients (aged 18-85 years) with persistent spinal pain syndrome, complex regional pain syndrome, neuropathic pain syndromes, or ischemic pain syndromes were enrolled at a single pain unit (December 2020-May 2024). Clinical, demographic, and psycho-social variables were collected and entered into the SCS e-health tool, which provided implantation recommendations. Physicians blinded to the tool output rated the probability of trial success. The patients underwent a 45-day SCS trial, followed by implantation in responders. Agreement between tool recommendations and expert judgment was assessed using Fisher exact test and Cohen's κ. RESULTS:Overall, 69 patients (86.3%) showed positive trial results and were implanted. Success rates corresponded to tool recommendations: 100% for "strongly recommended," 86.2% for "recommended," and 57.1% for "rarely recommended" (p = 0.0214). One-year follow-up confirmed sustained benefits in the strongly recommended group. Agreement between the tool and physician judgment was moderate for clinical variables (unweighted κ = 0.51, weighted κ = 0.54) and fair/moderate when including psycho-social variables (unweighted κ = 0.38, weighted κ = 0.44). Pain intensity and disability were relieved over time. CONCLUSIONS:The SCS e-health tool is a reliable aid for selecting candidates, integrating clinical and psycho-social factors reflecting trial and long-term outcomes. It can guide clinicians in identifying patients most likely to benefit from SCS and support preimplant decision-making.

OBJECTIVES:Differential target multiplexed spinal cord stimulation (DTM-SCS) is a novel neuromodulation paradigm designed to modulate neuroglial interactions involved in chronic pain. This study tested the hypothesis that in a real-world clinical setting, DTM-SCS is associated with sustained improvements in pain intensity and related clinical outcomes in patients with persistent spinal pain syndrome type II (PSPS-II) and that early inflammatory biomarker modulation may reflect interindividual heterogeneity in treatment response. MATERIALS AND METHODS:This was a prospective, multicenter, observational cohort study conducted across eight Italian pain management centers. Adult patients with PSPS-II and severe low back pain (Numeric Rating Scale [NRS] > 5) were consecutively enrolled. All participants underwent a DTM-SCS stimulation. Clinical outcomes included pain intensity (NRS), functional disability (Oswestry Disability Index [ODI]), neuropathic pain symptoms (Douleur Neuropathique 4 [DN4]), pain catastrophizing (PCS), and health-related quality of life (Patient-Reported Outcomes Measurement Information System [PROMIS]). Assessments were performed at baseline and at four, 12-, and 24 weeks. Peripheral inflammatory cytokines were measured at baseline and four weeks, and exploratory cluster analysis was applied. Longitudinal changes were analyzed using repeated-measures comparisons and mixed-effects models. RESULTS:A total of 71 patients were enrolled, with 67 evaluable at the primary end point (12 weeks). Mean NRS decreased significantly from baseline (8.35 ± 1.39) to 12 weeks (5.34 ± 2.03; mean difference -3.01, p < 0.0001), with sustained improvement at 24 weeks. At 12 weeks, 51.47% of patients achieved a ≥50% reduction in pain. Significant improvements also were observed in ODI, DN4, PCS, and selected PROMIS domains (all p < 0.0001). Exploratory cytokine analysis identified three clusters; one cluster characterized by coordinated cytokine modulation showed greater pain reduction at 12 weeks (p = 0.025). The safety profile was consistent with established SCS therapy. CONCLUSIONS:In routine clinical practice, DTM-SCS was associated with sustained improvements in pain, function, and patient-reported outcomes in PSPS-II, with an acceptable safety profile. Exploratory biomarker findings suggest biological heterogeneity that may influence treatment trajectories, supporting further controlled and biomarker-informed studies.

Background:Pain chronicization is commonly used to describe the transition from acute to chronic pain driven by central mechanisms. Objective:To reassess its clinical relevance by comparing neurobiological models with patient observation. Methods:Conceptual analysis integrating experimental data and clinical experience. The analysis particularly considers animal models, human neuroimaging and ICD‑11 chronic pain categories. Results:While central sensitization is well established experimentally, clinical observation rarely shows a clear transition from acute to chronic pain. Chronic pain is typically heterogeneous, discontinuous and influenced by multiple factors. Neuroimaging findings are largely associative and lack temporal and causal definition. The distinction between chronic primary and secondary pain is clinically useful but does not demonstrate a biological conversion. Conclusion:Pain chronicization should be considered a theoretical construct rather than a clinically demonstrable process, and interpreted with caution in individual patients.

Neuropathic pain, defined by the International Association for the Study of Pain as “pain caused by a lesion or disease of the somatosensory system”, has an estimated prevalence of 7–9.2% in the general population and is associated with poorer health-related quality of life than other types of pain. Diagnosis can be improved by the use of diagnostic algorithms, but treatment remains rather unsatisfactory, with only 30–40% of patients achieving an acceptable response. Some authors have suggested that the poor results in the treatment of neuropathic pain may be related to the different mechanisms present in each patient and have tried to correlate them with clinical characteristics in order to evaluate possible targeted treatments. This approach has been used in some studies evaluating the response to specific pharmacotherapies in clusters of patients, with encouraging results but still limited applicability to clinical practice. In this narrative review, we attempt to analyse the literature suggesting possible pathogenetic mechanisms manifested along the nociceptive pathway due to a lesion or disease of the nervous system; aware of the limitations of exploring such a wide field, we look for conditions that could be targeted by the available pharmacological or interventional treatment options. Functional changes may occur in the nociceptive system from the periphery to the cerebral cortex, in particular in the nociceptive terminals, along the first-order neuron and the dorsal root ganglion, at the first synapses, or at supraspinal levels. Clinical assessment is the first step in the study of anatomical and functional changes; the diagnostic hypothesis should be confirmed, if possible, by instrumental studies or diagnostic blocks or procedures to guide an individualised therapeutic algorithm from less to more invasive treatments.

BACKGROUND:We discuss the diagnostic benefit of pulsed radiofrequency (PRF) of the dorsal root ganglion (DRG) in a case series of patients with different pathologies. We expand the diagnostic potential of DRG stimulation beyond paresthesia mapping by using DRG stimulation to help determine the role of the DRG in the patient's pain and narrow down the etiology. In some cases, DRG stimulation was also part of the treatment plan. METHODS:Six patients underwent DRG radiofrequency as a diagnostic/therapeutic step before considering implantation of a DRG neurostimulator. First, patients underwent a basic bedside neurological evaluation. Next, an electrode was placed in the epidural space through the sacral hiatus or between vertebral laminae. Then, sensory stimulation was applied at 50 Hz and gradually increased from 0.1 V until the patient reported paresthesia or until a maximum intensity of 2 V was reached. Patients were asked to describe where the stimulation was felt and outline the anatomical area the paresthesia covered. Then a motor stimulation was applied at 2 Hz until muscle twitching was reported by the patient or observed by the physician. RESULTS:The information obtained helped diagnose the type of lesion as principally preganglionic, ganglionic, or postganglionic. This information guided patient management. CONCLUSION:PRF of the DRG can provide valuable diagnostic information and is a useful step before ganglionic electrode implantation. In all cases, PRF of the DRG provided valuable diagnostic information and guided management options.

Abstract Background Persistent idiopathic facial pain (PIFP) can be challenging, both in its diagnosis, which appears to be purely exclusionary, and in its treatment, which currently lacks a gold standard. Amitriptyline is considered a first-line therapy, although not always effective. Recent insights into the role of dopamine in facial pain suggest that a novel therapeutic approach could target the dopamine system. Methods This study aimed to retrospectively evaluate the efficacy of treatment with amitriptyline–perphenazine association in patients with severe PIFP. Thirty-one patients were given a regimen dose of amitriptyline–perphenazine at dosages ranging between 10/2 and 20/4 mg and were then retrospectively analyzed. We evaluated the following outcomes, referred to the last week prior to follow-up visits: NRS score for pain intensity (minimum, maximum, and average), the number of attacks, and SF-36 questionnaire for quality of life. Comparisons were made between pre- and post-treatment. Results Thirty-one patients over 35 were screened. At baseline, average NRS was 5 ± 0.93 (CI 95%: 4.6–5.3), and the median number of breakthrough episodes over last week was 5 ± 1.57 (CI 95%: 4–6) with a maximum NRS = 9 ± 0.89 (CI 95%: 8–9). After treatment, average NRS was 4.1 ± 0.93 (CI 95%: 3.8–4.5; p < 0.001), maximum NRS was 6.1 ± 1.60 (CI 95%: 5.5–6.6), and the median number of attacks was 4 ± 0.99 (IC 95%: 3–4) (p < 0.001). Regarding SF-36 questionnaire, the most improved parameters were quality of life related to pain (25.89 ± 12.48 vs 31.19 ± 13.44; p < 0.001) and physical function (69.56 ± 17.84 vs 84.17 ± 20.99; p < 0.001). Conclusion Despite limitations, the pain scores, the frequency of the attacks, and quality of life were found to be significantly improved after treatment. Although results are not broad based given the small sample size, the combination of amitriptyline and perphenazine may be an effective and well-tolerated treatment in patients with PIFP. It is abundantly clear that dopaminergic pathways play a key role in pain modulation, yet the underlying mechanisms have not been fully understood, requiring further investigation.

Background Fibromyalgia patients can benefit from music approaches as complementary treatments. In the literature, it was shown that these interventions managed pain conditions as well as reduced complaints, increased relaxation, and improved moods. Objective This study aimed at evaluating music therapy, in the form of therapeutic music listening, specifically for patients with fibromyalgia, to treat chronic pain by reducing pain perception, increasing well-being, and improving quality of life. Methods Twenty-four patients with fibromyalgia were recruited to take part in this feasibility pilot study that adopted a between-subject and within-subject design. Participants were randomised into three groups: (1) standard care, (2) standard care plus preferred music listening, (3) standard care plus Melomics-Health music listening, composed by an algorithm. Participants in experimental groups listened to 30 min of music at home, twice a day for a month. Patients' perceptions of changes following the listening, the intensity of pain and its interference in their lives, physical and mental well-being, and reported attitudes towards listening to music were evaluated respectively through the patients' global impression of change, the brief pain inventory, the Short Form Healthy Survey-12, and the cognitive behavioural assessment-outcome evaluation. Results The study showed that music listening can significantly affect mental well-being compared to no music. Moreover, the effects in the Melomics-Health group are maintained at follow-up. No significant effect on pain perception was noted. Conclusions The study provides information supporting a possible role of music listening in improving well-being of patients with fibromyalgia.

Background: Trigeminal neuralgia present an incidence rates ranging between 5.9 and 12.6 per 100.000 persons; although not frequent, it is a pathology often characterized by intense pain, an extremely significant reduction in quality of life and medical therapy is not always effective or tolerated. In these cases, the patient can undergo interventional treatments including radiofrequency thermocoagulation. There are still doubts regarding the effectiveness over time, the injury parameters and the repeatability of the procedure. Materials and Methods: We analyze patients with trigeminal pain undergo retrogasserian radiofrequency in a single center over a period of 8 years. The procedure was performed with the following parameters: Lesion time 60 sec, lesion temperature 70°C for first thermolesion 72°C for subsequent thermolesions. Duration of benefit, number of repetitions of the maneuver, and incidence of adverse events were assessed. Results: Totally, 122 patients with essential trigeminal neuralgia and 20 patients with trigeminal neuralgia secondary to multiple sclerosis were analyzed; almost all patients (96.5%) showed a significant reduction in pain after one or more procedures over time; 96.5 of the patients showed excellent pain relief after 1 (40%) or more procedures (60%). The average time between one procedure and the next was 26 months. Conclusion: The use of time and temperature parameters chosen shows excellent efficacy, in line with the literature, with very low incidence of adverse events. The pain-free time between one procedure and the next does not seem to be a significant prognostic criterion which may or may not indicate the repetition of the procedure.

Osteoarthritis (OA) is a leading cause of disability among older adults worldwide. Treatment aims are to alleviate inflammatory pain and improve physical function through non-pharmacological and pharmacological interventions. Non-steroidal anti-inflammatory drugs (NSAIDs) are recommended as first-line therapy. However, selection is challenged by patient age, comorbidities and polypharmacy, and by the drug’s benefit/risk balance, all of which together influence the risk of cardiovascular (CV), gastrointestinal (GI) and renal adverse events (AEs). While the efficacy profile of the various NSAIDs is delineated, the differences in their safety profile are not straightforward. This narrative review provides practical indications by a multidisciplinary Italian expert panel for general practitioners and specialists managing OA patients with chronic inflammatory pain; the goal is to maximize therapy efficacy while reducing untoward effects caused by inappropriate NSAID use. The discussion on the best approach to NSAIDs spanned the following topics: (1) patient evaluation: investigate pain origin, duration and components together with possible risk factors for CV, GI and renal AEs; (2) non-pharmacological interventions: the physiatrist provides a person-centered, holistic approach accounting for all patient aspects; (3) pharmacological interventions: patient profile and drugs’ pharmacological properties affect NSAID selection, which drugs to be used in combination or to be avoided, formulation and therapy duration; (4) the pharmacologist’s, general practitioner’s and pain therapist’s points of view; (5) NSAID safety: the individual baseline risk and the drug’s safety profile are major determinants of CV, GI and renal risk; consider possible drug–drug interactions; (6) periodical re-evaluation of treatment response and adherence, using scales to assess pain and function.

Chronic pain is a public health priority that affects about 20% of the general population, causing disability and impacting productivity and quality of life. It is often managed in the primary care setting. Chronic pain management is most effective when the pain mechanism has been identified and addressed by appropriate therapy. This document provides an overview of pharmacological therapy for chronic non-cancer pain in the primary care setting, with the aim of improving treatment decisions based on the underlying pain mechanisms and pain neuroscience.

Introduction Neuropathic pain (NP) is caused by a lesion or disease of the somatosensory system, which can severely impact patients' quality of life. The current-approved treatments for NP comprise of both centrally acting agents and topical drugs, including capsaicin 8% dermal patches, which is approved for the treatment of peripheral NP. Areas covered The authors summarize literature data regarding capsaicin use in patients who suffer from NP and discuss the clinical applications of this topical approach. Expert opinion Overall, the capsaicin 8% dermal patch is as effective in reducing pain intensity as other centrally active agents (i.e. pregabalin). Some studies have also reported fewer systemic side effects, a faster onset of action and superior treatment satisfaction compared with systemic agents. In our opinion, capsaicin 8% dermal patches also present additional advantages, such as a good systemic tolerability, the scarcity of adverse events, the possibility to combine it with other agents, and a good cost-effective profile. It is important to note that, as the mechanism of action of capsaicin 8% is the 'defunctionalization' of small afferent fibers through interaction with TRPV1 receptors, the peripheral expression of this receptor on nociceptor fibers, is crucial to predict patient's response to treatment.

Chronic pain is considered a public health priority by the World Health Organization and European health institutions. It has reached alarming proportions in terms of disability, consumption of health and social resources, and impact on primary and specialist care services. Primary care physicians are often called on to manage this condition. Chronic pain management can be challenging due to its complexity. It has traditionally been considered to include nociceptive pain that that persists longer than the normal healing time, neuropathic pain lasting more than 3 months, or a combination of these. More recently, a third descriptor, nociplastic (primary) pain, was added to classify patients with chronic pain conditions such as fibromyalgia, nonspecific back pain, or mixed pain that persists or other conditions in which altered central pain modulation results in central sensitization and chronic pain in the absence of actual or threatened damage to tissues, including in the somatosensory nervous system. This document provides an overview of pain types and their underlying mechanisms. Successful pain management is facilitated by identification of the pain type. A set of diagnostic tools and a pain algorithm are presented to guide the clinician toward the correct diagnosis. The algorithm identifies cases that may require referral to a pain specialist. Once the site of origin of the pain (the "pain generator") is identified, or a primary pain syndrome is suspected, the accompanying article provides information and rationale to support treatment decisions based on patient characteristics.

Chronic pain impacts on many aspects of patient life affecting autonomy, sleep, social activities and also employment. Adequate pain control is often challenging in patients with chronic pain, despite the availability of many medications and interventional techniques. Limitations to successful pain treatment are the poor understanding of contributing mechanisms and the lack of a mechanism based approach in clinical practice. The purpose of this article is to identify the factors contributing to pain generation in order to guide a personalized treatment. We analyze tissue specificity for chemical and physical stresses potentially causing pain, the changes that occur in the peripheral and central pain pathways during disease, the stimuli that, acting on a pathological pain pathway, can trigger pain. The pain generating factors should be recognized in each patient and addressed with pharmacological, rehabilitation and invasive interventions.

Introduction: Adequate pain control is often challenging, especially in patients with chronic pain, despite the availability of many medications and interventional techniques. Pain diagnosis is mainly based on the differentiation between nociceptive and neuropathic pain but, while for neuropathic pain the literature offers pharmacological algorithms, for nociceptive pain the pharmacological treatment recommendations are often based only on intensity or etiological diagnosis. The purpose of this study is to identify the factors contributing to pain generation in order to target pharmacological, interventional and rehabilitation treatments. Areas Covered: Literature was searched on the peculiarity of nociception of different tissues, pathogenetic mechanisms modifying pain perception, stimuli evoking pain in physiological and pathological conditions. A search was made also for possible treatment options targeting the different factors. Expert Opinion: We consider, in pain diagnosis, the different factors contributing to pain generation in order to guide the treatment algorithm. We analyze tissue specificity for chemical and physical stresses potentially causing pain, the changes that intervene in the peripheral and central pain pathways during disease, the stimuli that, acting on a pathological pain pathway, can trigger pain. The pain generating factors should be diagnosed and addressed with pharmacological, rehabilitation and interventional techniques.

Breast and/or thoracic pain is a frequent event after breast surgery and is a source of deterioration of patients' quality of life. The development of fibrosis and scar areas around the cutaneous branches of the intercostal nerves is a common cause of pain. Proper clinical investigation associated with the use of ultrasound-guided intercostal nerve cryoablation could be a solution to achieve significant analgesic results.

Chronic pain is a common condition related to many diseases. In Italy, as in the rest of Europe, about 20 percent of adults report moderate to severe chronic pain, but very few patients refer to pain specialists and nearly half receive inadequate pain management. This leads to low health-related quality of life and psychological problems with costly issues in the Italian Health Care system. Epidemiologic studies, through an understanding of chronic pain characteristics, report the development, targeting and evaluation of interventions. In this retrospective observational study we analyzed the clinical and demographic data of a population referred for the first time, in 2014, to a specialist, in the second level Pain Unit, Fondazione Salvatore Maugeri, Pavia. The aim was also to evaluate the improvement of pain management in our country after the approval of Law 38/2010 on the institution of the network for Palliative care, comparing the results with a previous similar survey in 2008. We conclude that in Italy patients refer to a Pain clinic very late which causes an increase in the duration of pain and the risk of overlapping factors toward chronicity, even though we noted an improvement compared to 2008.

Pain PracticeVolume 18, Issue 2 p. 283-283 Letter to the Editor Fibromyalgia: A “Chronic Pain Condition” or a True “Chronic Pain Disease”? Cesare Bonezzi MD, Cesare Bonezzi MD Pain Unit, Clinical Scientific Institutes Maugeri, Pavia, ItalySearch for more papers by this authorMatteo L.G. Leoni MD, Matteo L.G. Leoni MD matteo.leoni@icsmaugeri.it Pain Unit, Clinical Scientific Institutes Maugeri, Pavia, ItalySearch for more papers by this authorGaetano Terranova MD, Gaetano Terranova MD Pain Unit, Clinical Scientific Institutes Maugeri, Pavia, Italy Department of Pathophysiology and Transplantation, University of Milan, Milan, ItalySearch for more papers by this author Cesare Bonezzi MD, Cesare Bonezzi MD Pain Unit, Clinical Scientific Institutes Maugeri, Pavia, ItalySearch for more papers by this authorMatteo L.G. Leoni MD, Matteo L.G. Leoni MD matteo.leoni@icsmaugeri.it Pain Unit, Clinical Scientific Institutes Maugeri, Pavia, ItalySearch for more papers by this authorGaetano Terranova MD, Gaetano Terranova MD Pain Unit, Clinical Scientific Institutes Maugeri, Pavia, Italy Department of Pathophysiology and Transplantation, University of Milan, Milan, ItalySearch for more papers by this author First published: 28 May 2017 https://doi.org/10.1111/papr.12592Read the full textAboutPDF ToolsRequest permissionExport citationAdd to favoritesTrack citation ShareShare Give accessShare full text accessShare full-text accessPlease review our Terms and Conditions of Use and check box below to share full-text version of article.I have read and accept the Wiley Online Library Terms and Conditions of UseShareable LinkUse the link below to share a full-text version of this article with your friends and colleagues. Learn more.Copy URL Share a linkShare onFacebookTwitterLinkedInRedditWechat No abstract is available for this article. Volume18, Issue2February 2018Pages 283-283 RelatedInformation

Pain evoked by tangential movement across the skin is usually defined as dynamic mechanical allodynia (DMA). Some patients complain of DMA as troublesome as spontaneous pain and refer a marked interfering with activities of daily living and sleep. Pathophysiology of DMA is complex and can be related to several mechanisms, both nociceptive and neuropathic. Five exemplificative clinical cases of DMA are presented, each associated to a possible specific mechanism: injured skin DMA, peri-injured skin DMA, far injury DMA, nerve-confined DMA and fear DMA (pseudo allodynia). The identification of these subcategories of DMA can stimulate further studies aimed at evaluating the usefulness of a mechanism-based therapy for the different clinical forms of DMA.