Background: Recurrent lumbar disc herniation (rLDH) significantly impairs outcomes following percutaneous endoscopic lumbar discectomy (PELD). Accurate individualized risk prediction remains challenging. This study aimed to develop and compare multiple machine learning models for predicting rLDH within two years post-surgery. Methods: A retrospective cohort of 1483 patients undergoing single-level PELD was analyzed. The primary outcome was symptomatic, magnetic resonance imaging-confirmed rLDH requiring reintervention. Candidate predictors included demographic, surgical, and radiographic parameters. The dataset was stratified by outcome and randomly split into training (70%, n = 1038) and validation (30%, n = 445) sets. Feature selection utilized univariate screening (p < 0.2) and least absolute shrinkage and selection operator regression. Six machine learning algorithms were trained and optimized via grid search. Performance was evaluated using the area under the receiver operating characteristic curve (AUC), F1-score, Brier score, calibration and decision curve analysis (DCA). Model interpretability was assessed using SHapley Additive exPlanations (SHAP). Results: The overall recurrence rate was 4.25% (63/1483). Logistic regression achieved the optimal F1-score (0.286), while light Gradient Boosting Machine (LightGBM) demonstrated superior discrimination (AUC = 0.768). DCA indicated clinical utility primarily at low threshold probabilities (<10%). SHAP analysis identified increased sagittal range of motion as the strongest risk factor, followed by reduced facet orientation, advanced age, type II Modic changes, and Michigan State University zone C. Conclusions: This study presents an exploratory, internally validated machine learning framework for rLDH risk stratification. While LightGBM demonstrated moderate discriminative ability, model sensitivity was constrained by the inherent rarity of recurrence events, precluding its use as a definitive standalone screening tool. Notably, clinical utility was restricted to low threshold probabilities (<10%), supporting a focused role in identifying high-risk subgroups for intensified preoperative counseling and postoperative monitoring. Beyond elucidating key radiological and demographic risk factors, our findings underscore that rigorous external prospective validation and probability calibration are indispensable before any future clinical deployment.

BACKGROUND:Fibromyalgia (FM) is a chronic condition characterized by widespread pain and a range of somatic and psychological symptoms that impose a substantial burden on patients. While pregabalin is an approved and effective monotherapy for many individuals with FM, the efficacy of this medication is often incomplete, particularly for symptoms like fatigue and anxiety. Combination therapy incorporating selective serotonin and norepinephrine reuptake inhibitors (SNRIs), such as duloxetine, has shown promise for enhancing therapeutic outcomes. Venlafaxine, an SNRI with demonstrated efficacy as an FM treatment, has a distinct pharmacological mechanism from pregabalin. However, the synergistic potential of pregabalin and venlafaxine in combination has not been formally evaluated. OBJECTIVES:This study protocol describes a trial designed to test the hypothesis that the combination of pregabalin and venlafaxine is superior to pregabalin monotherapy in providing pain relief to patients with FM. STUDY DESIGN:This is a multicenter, prospective, randomized, open-label, blinded-endpoint study. SETTING:This study will be conducted at 7 different hospitals. METHODS:We will recruit 750 adults with a diagnosis of FM and moderate-to-severe pain. Patients will be randomly assigned in a one-to-one ratio to receive either pregabalin monotherapy or combination therapy consisting of pregabalin and venlafaxine for 12 weeks. Both groups will follow a flexible, forced-titration schedule to achieve the maximum tolerated dose. While the patients and treating physicians will be aware of the treatment allocation, the outcome assessors will remain blinded. RESULTS:The primary outcome is the mean daily pain intensity at week 4, measured on an 11-point numeric rating scale. Secondary outcomes will be evaluated at baseline and at weeks one, 2, 4, 8, and 12 after the treatment initiation. Secondary outcomes include the worst pain intensity, the responder rates (≥ 30% and ≥ 50% pain reduction), the dose of pregabalin and/or venlafaxine, the Revised FM Impact Questionnaire, the Brief Pain Inventory severity and interference subscales, the 36-Item Short Form Survey (SF-36), the Medical Outcomes Study Sleep Scale, the Beck Depression Inventory-II, and adverse events (AEs) occuring throughout the study. Statistical analyses will be performed on the modified intention-to-treat population. LIMITATIONS:An open-label design will be employed, with patient follow-up limited to 12 weeks. CONCLUSION:If the combination of pregabalin and venlafaxine proves to be more effective and better tolerated than pregabalin monotherapy, the combination therapy could establish a new standard of care for FM patients who struggle to achieve sufficient pain relief through nonpharmacological therapies.

Background:Fibromyalgia (FM) is a chronic condition, imposing a substantial burden on patients. Pregabalin, a first-line treatment, offers incomplete efficacy for many and is associated with dose-limiting central nervous system adverse effects. Crisugabalin is a novel α2δ ligand with 23-fold higher binding affinity than pregabalin and has shown potentially fewer central nervous system adverse effects in animal models. While crisugabalin has shown efficacy in other neuropathic pain conditions, its efficacy in FM, particularly in a direct comparison with pregabalin, remains unclear. Methods and Analysis:This multicenter, prospective, randomized, pregabalin-controlled, open-label, blinded-endpoint study will be conducted at 10 hospitals in China. A total of 1116 adult patients with FM and a baseline average daily pain intensity of ≥4 on an 11-point numerical rating scale will be enrolled. Participants will be randomly assigned (1:1) to receive either crisugabalin or pregabalin for 12 weeks using a standardized, flexible-titration protocol. While participants and treating physicians will be aware of the treatment allocation, outcome assessors and data analysts will remain blinded. The primary outcome is the proportion of patients achieving at least a 50% reduction in average pain intensity from baseline at week 12. Secondary outcomes include pain intensity measures, study drug dosing and rescue analgesic utilization, Revised FM Impact Questionnaire, Brief Pain Inventory severity and interfere subscales, short-form 36 Health Survey, Patient Global Impression of Change Scale, Medical Outcomes Study Sleep Scale, Beck Depression Inventory-II, and incidence of adverse events. Analyses will be performed on the modified intention-to-treat and per-protocol populations. Ethics and Dissemination:This study, approved by the Institutional Review Board of Beijing Tiantan Hospital, Capital Medical University (KY2025-217-03), will be conducted in accordance with the Declaration of Helsinki. Written informed consent will be obtained from all participants, and findings will be disseminated through peer-reviewed publications and scientific conferences. Trial Registration:Clinical Trials.gov identifier: NCT07196657. Registered on September 29, 2025 (https://www.clinicaltrials.gov/search?term=NCT07196657).

Abstract Cancer pain, one of the most prevalent and distressing symptoms in cancer patients, is closely associated with cancer diagnosis, therapeutic interventions, quality of life, and survival outcomes. Effective cancer pain management requires multidisciplinary collaborative and multimodal approaches throughout the disease trajectory. To address this imperative, the Cancer Pain Integration Therapy Professional Committee of the China Anti-Cancer Association (CACA) convened domestic experts in oncology pain management. From the perspective of holistic integrative medicine (HIM), this guideline was developed to standardize pain assessment and diagnostic protocols, pharmacotherapy, minimally invasive analgesic techniques, palliative antitumor therapies and other adjunctive analgesic modalities, as well as definitions of treatment-related pain syndromes, refractory cancer pain syndromes, etc. This guideline aims to enhance health care professionals’ overall competency in cancer pain diagnosis, treatment, and comprehensive management through evidence-based, patient-centered, and system-integrated strategies.

OBJECTIVE:To develop an evidence-based patient version of guideline (PVG) for fibromyalgia, aiming to improve patients' understanding of disease symptoms and therapeutic options and to enhance their self-management abilities. METHODS:Following the World Health Organization Handbook for Guideline Development (2014), a multidisciplinary working group was established, including patient representatives, physicians, pharmacists, nurses, and methodologists. The process comprised (a) systematic retrieval of clinical practice guidelines and expert consensus statements to establish the evidence base; (b) integration of large language models (LLMs) with expert review to identify and refine key patient-centered concerns; (c) a three-round Delphi consensus guided by the Grading of Recommendations Assessment, Development and Evaluation approach to finalize clinical questions and formulate recommendations; and (d) evaluation of understandability using the Patient Education Materials Assessment Tool for Print Materials (PEMAT-P). RESULTS:The final PVG covers 13 clinical questions across seven domains, including disease awareness, diagnostic evaluation, pharmacological and non-pharmacological interventions, and long-term management. All recommendations were rated as strong. The guideline emphasizes the importance of pharmacological management, emotional regulation, and exercise in the comprehensive management of fibromyalgia. The PEMAT-P assessment showed an understandability score of 100%. CONCLUSIONS:Developed collaboratively by a multidisciplinary team and patient representatives, this PVG is based on 13 evidence-based fibromyalgia guidelines. Combining LLMs with expert review enhanced question generation and readability. The PVG provides a practical and accessible tool to support early self-management in fibromyalgia.

Phantom limb pain (PLP), defined as neuropathic pain perceived in the missing portion of an amputated limb, represents a common and refractory condition significantly impairing patient rehabilitation and quality of life. Its pathogenesis is multifactorial, involving complex interactions between peripheral mechanisms (e.g., neuroma formation, ectopic discharges), central nervous system reorganization (including cortical remapping and spinal cord sensitization), and psychological components. Patients frequently present with heterogeneous pain descriptors, such as burning, shooting, or cramping sensations, which often coexist with residual limb pain, complicating clinical assessment. Despite the availability of diverse therapeutic interventions-ranging from pharmacotherapy (e.g., gabapentinoids, antidepressants, NMDA receptor antagonists) and physical modalities (e.g., transcranial magnetic stimulation, mirror therapy) to interventional procedures (e.g., nerve blocks, neuromodulation) and psychological approaches-treatment outcomes remain variable, and standardized clinical guidelines are lacking. This consensus, formulated by a panel of Chinese pain specialists, systematically reviews contemporary evidence on the epidemiology, pathophysiology, diagnosis, and management of PLP. It aims to establish practical, evidence-based recommendations to guide the standardized diagnosis and stratified treatment of PLP, thereby optimizing therapeutic efficacy and improving functional outcomes for affected individuals.

BackgroundThe learning curve for percutaneous endoscopic transforaminal discectomy (PETD) is steep, especially for the puncturing and localization procedures. The implementation of 3D printing technology may solve this problem.MethodsA novel individualized 3D-printing template (3D-PT) was designed and utilized in PETD. A prospective randomized controlled trial was performed. A total of 28 patients with lumbar disc herniation treated with PETD were analyzed. Of these, 14 patients were treated with the assistance of 3D printing technology (3D-PT group) in conjunction with fluoroscopy, while the remaining 14 patients were treated exclusively under the guidance of C-arm fluoroscopy (control group).ResultsThe number of puncture attempts in the 3D-PT group was significantly less than in the control group (1.36 ± 0.63 vs. 6.07 ± 3.08, p = 0.000). The 3D-PT group exhibited a significant reduction in both intraoperative puncture fluoroscopies (2.71 ± 1.27 vs. 12.14 ± 6.15, p = 0.000) and the overall number of fluoroscopies (2.71 ± 1.27 vs. 17.43 ± 6.27, p = 0.000). In the 3D-PT group, there was a significant reduction in both the puncture time (5.77 ± 1.82 vs. 13.99 ± 4.36, p = 0.000) and the total operation time (60.39 ± 9.78 vs. 76.25 ± 17.78, p = 0.007). Complications were not observed in either group.ConclusionThe application of the novel individualized 3D-PT for PETD is effective and safe. The technique has substantial potential and is worth widely promoting.

Transversus abdominis plane block is an anesthesia method that injects local anesthetics into the abdominal muscle fascia to produce analgesic effects. It is widely used in abdominal surgery and in pain management. This expert consensus introduces the relevant anatomy, and systematically describes the various techniques, common drugs, indications, contraindications and complications of transversus abdominis plane block, to guide the application of this method in the clinic.

Nerve block is an important part of postoperative multimodal analgesia. Rectus sheath block is one of the commonly used nerve block methods in clinical practice, which mainly blocks the anterior cutaneous branch of intercostal nerves. This method has a clear analgesic effect on midline abdominal incision, and has a good application in pain diagnosis and treatment. This expert consensus introduces the related anatomical structure, blocking method, commonly used drugs, complications and clinical application of rectus sheath block in order to guide the clinical practice.

The Coronavirus has infected up to 900 million people as of 11 Jan 2023 in China Mainland, which is more than 60% of the population. The sudden and unprecedented nature of pandemic has resulted in a range of psychosomatic issues among the population. These issues can manifest in a variety of ways and it is important to address these issues as they can have serious consequences for individuals' mental and physical health. The lifting of lockdown measures in China presents an opportunity to address these issues and provide support to those who have been affected.

Background Anteroposterior (AP) and lateral fluoroscopies are often used to evaluate the intraoperative location and angulation of the trajectory in percutaneous endoscopic transforaminal lumbar discectomy (PETLD). Although the location of the trajectory shown in fluoroscopy is absolutely accurate, the angulation is not always reliable. This study aimed to evaluate the accuracy of the angle shown in the AP and lateral fluoroscopic views. Methods A technical study was performed to assess the angulation errors of PETLD trajectories shown in AP and lateral fluoroscopic views. After reconstructing a lumbar CT image, a virtual trajectory was placed into the intervertebral foramen with gradient-changing coronal angulations of the cephalad angle plane (CACAP). For each angulation, virtual AP and lateral fluoroscopies were taken, and the cephalad angles (CA) of the trajectory shown in the AP and lateral fluoroscopic views, which indicated the coronal CA and the sagittal CA, respectively, were measured. The angular relationships among the real CA, CACAP, coronal CA, and sagittal CA were further demonstrated with formulae. Results In PETLD, the coronal CA is approximately equal to the real CA, with a small angle difference and percentage error, whereas the sagittal CA shows a rather large angle difference and percentage error. Conclusion The AP view is more reliable than the lateral view in determining the CA of the PETLD trajectory.

BACKGROUND:The puncture procedure in percutaneous endoscopic lumbar discectomy (PELD) is non-visual, and the learning curve for PELD is steep.METHODS:An augmented reality surgical navigation (ARSN) system was designed and utilized in PELD. The system possesses three core functionalities: augmented reality (AR) radiograph overlay, AR puncture needle real-time tracking, and AR navigation. We conducted a prospective randomized controlled trial to evaluate its feasibility and effectiveness. A total of 20 patients with lumbar disc herniation treated with PELD were analyzed. Of these, 10 patients were treated with the guidance of ARSN (ARSN group). The remaining 10 patients were treated using C-arm fluoroscopy guidance (control group).RESULTS:The AR radiographs and AR puncture needle were successfully superimposed on the intraoperative videos. The anteroposterior and lateral AR tracking distance errors were 1.55 ± 0.17 mm and 1.78 ± 0.21 mm. The ARSN group exhibited a significant reduction in both the number of puncture attempts (2.0 ± 0.4 vs. 6.9 ± 0.5, p = 0.000) and the number of fluoroscopies (10.6 ± 0.9 vs. 18.5 ± 1.6, p = 0.000) compared with the control group. Complications were not observed in either group.CONCLUSIONS:The results indicate that the clinical application of the ARSN system in PELD is effective and feasible.

目的:本研究旨在探索疼痛感知与睡眠障碍共病的关系及潜在的脑影像学机制.方法:通过人类连接组计划,共纳入1043名受试者,收集一般人口学数据、7天内疼痛程度平均分、匹兹堡睡眠质量指数(Pittsburgh sleep quality index,PSQI)及磁共振等数据.运用偏相关探索睡眠情况与疼痛情况的相关性,使用多元线性回归探索与睡眠、疼痛相关的脑区结构,并应用中介分析探索脑区与疼痛、睡眠三者关联性.结果:发现疼痛程度评分与PSQI评分呈正相关,并且右侧内嗅皮质厚度与疼痛程度评分和PSQI评分均呈负相关,疼痛对睡眠的影响可通过右侧内嗅皮质介导.结论:疼痛症状与睡眠障碍的发生相关,疼痛评分越高,睡眠质量越差,并且右侧内嗅皮质厚度降低是疼痛情况和睡眠障碍共病的潜在神经机制.

Ferroptosis, a novel type of cell death mediated by the iron-dependent lipid peroxidation, contributes to the pathogenesis of the intervertebral disc degeneration (IDD). Increasing evidence demonstrated that melatonin (MLT) displayed the therapeutic potential to prevent the development of IDD. Current mechanistic study aims to explore whether the downregulation of ferroptosis contributes to the therapeutic capability of MLT in IDD. Current studies demonstrated that conditioned medium (CM) from the lipopolysaccharide (LPS)-stimulated macrophages caused a series of changes about IDD, including increased intracellular oxidative stress (increased reactive oxygen species and malondialdehyde levels, but decreased glutathione levels), upregulated expression of inflammation-associated factors (IL-1β, COX-2 and iNOS), increased expression of key matrix catabolic molecules (MMP-13, ADAMTS4 and ADAMTS5), reduced the expression of major matrix anabolic molecules (COL2A1 and ACAN), and increased ferroptosis (downregulated GPX4 and SLC7A11 levels, but upregulated ACSL4 and LPCAT3 levels) in nucleus pulposus (NP) cells. MLT could alleviate CM-induced NP cell injury in a dose-dependent manner. Moreover, the data substantiated that intercellular iron overload was involved in CM-induced ferroptosis in NP cells, and MLT treatment alleviated intercellular iron overload and protected NP cells against ferroptosis, and those protective effects of MLT in NP cells further attenuated with erastin and enhanced with ferrostatin-1(Fer-1). This study demonstrated that CM from the LPS-stimulated RAW264.7 macrophages promoted the NP cell injury. MLT alleviated the CM-induced NP cell injury partly through inhibiting ferroptosis. The findings support the role of ferroptosis in the pathogenesis of IDD, and suggest that MLT may serve as a potential therapeutic approach for clinical treatment of IDD.

慢性原发性腰痛是临床常见的疾病之一,病因不明且致残率高,已成为导致疾病负担上升的全球性公共卫生问题.近年来,慢性原发性腰痛的发病机制研究逐渐深入,治疗方法层出不穷,诊疗指南不断更新,但仍存在许多争议.本文对慢性原发性腰痛的最新临床研究进展进行综述,为临床诊疗提供借鉴和参考.

高强度聚焦超声(high intensity focused ultrasound,HIFU)是近年来逐渐兴起的一种无创超声治疗技术.MR引导下的HIFU(MR-guided HIFU,MRgHIFU)能实现对病变靶点的精准消融,其兼具的测温功能还可对消融区温度进行实时监测.MRgHIFU的这些优势使其处理病变的同时极大减少了周围组织损伤风险,显现出良好的有效性和安全性.MRgHIFU作为不同疾病状态的一种多模式治疗选择,在肿瘤学、神经系统、整形外科及康复医学等多领域的临床应用和临床前期研究中已有广泛报道.慢性疼痛是增加全球经济与疾病负担的主要病症,脊柱与骨关节疼痛是导致机体功能障碍的重要原因之一.MRgHIFU作为一种重要的非侵袭性治疗方法可能在脊柱与骨关节疼痛的综合治疗中发挥举足轻重的作用,本文对相关研究进展进行综述,以期为脊柱与骨关节疼痛的微创治疗选择提供重要参考.

Background Transforaminal epidural steroid injection (TFESI) or dorsal root ganglion pulsed radiofrequency (PRF) are alternative treatments for lumbosacral radicular pain (LSRP). This study aimed to investigate the clinical efficacy of TFESI combined with dorsal root ganglion PRF using bipolar technology to treat LSRP in patients with pain duration ≥ 2 years. Methods This prospective single-armed cohort study included 20 patients with LSRP duration ≥ 2 years, who underwent treatment of TFESI combined with bipolar PRF. The primary outcomes included numerical rating scale (NRS) and successful treatment rate (pain relief ≥50%). The secondary outcomes included Oswestry Disability Index (ODI), patient satisfaction using the modified MacNab criteria, severe complications, hospital stay and total costs. The final follow-up was 6 months postoperatively. Results The successful treatment rate and average pain relief at 6 months postoperatively were 80% and 73.0% ± 17.5%, respectively. The successful treatment rates in patients with and without prior intervention history at 6 months postoperatively were 77.8% and 81.8%, respectively. The mean NRS score significantly decreased from 6.5 ± 0.8 to 1.1 ± 0.7 at 2 weeks postoperatively, to 1.3 ± 0.7 at 3 months postoperatively, and to 1.7 ± 1.0 at 6 months postoperatively (all P < 0.001), while the mean ODI score significantly decreased from 43.5 ± 2.5 to 22.5 ± 4.3 at 2 weeks postoperatively, to 20.0 ± 3.5 at 3 months postoperatively, and to 19.5 ± 3.6 at 6 months postoperatively (all P < 0.001). The excellent and good patient satisfaction at 6 months postoperatively was 85%. No severe complications were observed in this cohort. The average hospital stay and total costs were 3.0 ± 0.5 days and 3.36 ± 0.77 thousand dollars, respectively. Conclusion The treatment of TFESI combined with PRF using bipolar technology might be an alternative option to treat chronic LSRP in patients with pain duration ≥ 2 years after a failure of conservative treatments, with a favorable 6-month efficacy and inexpensive total costs. However, long-term outcomes and superiority of bipolar procedure over monopolar procedure in patients with longer pain duration should be further investigated in future studies.

During the pandemic era, quarantines might potentially have negative effects and disproportionately exacerbate health condition problems. We conducted this cross-sectional, national study to ascertain the prevalence of constant pain symptoms and how quarantines impacted the pain symptoms and identify the factors associated with constant pain to further guide reducing the prevalence of chronic pain for vulnerable people under the pandemic. The sociodemographic data, quarantine conditions, mental health situations and pain symptoms of the general population were collected. After adjusting for potential confounders, long-term quarantine (≥15 days) exposures were associated with an increased risk of constant pain complaints compared to those not under a quarantine (Odds Ratio (OR): 1.26; 95% Confidence Interval (CI): 1.03, 1.54; p = 0.026). Risk factors including unemployment (OR: 1.55), chronic disease history (OR: 2.38) and infection with COVID-19 (OR: 2.15), and any of mental health symptoms including depression, anxiety, insomnia and PTSD (OR: 5.44) were identified by a multivariable logistic regression. Additionally, mediation analysis revealed that the effects of the quarantine duration on pain symptoms were mediated by mental health symptoms (indirect effects: 0.075, p < 0.001). These results advocated that long-term quarantine measures were associated with an increased risk of experiencing pain, especially for vulnerable groups with COVID-19 infection and with mental health symptoms. The findings also suggest that reducing mental distress during the pandemic might contribute to reducing the burden of pain symptoms and prioritizing interventions for those experiencing a long-term quarantine.

Objective To explore the application effect of diversified teaching mode in ultrasound-guided interventional procedures for treatment of pain. Methods Thirty learners who studied in the Department of Pain, Peking University Third Hospital from January 2018 to December 2020 were enrolled as participants, and were divided into control group and observation group. The control group adopted conventional teaching mode, while the observation group adopted diversified teaching mode. The clinical skill assessments, teaching quality and satisfaction scores of the two groups were compared. Results The excellent and good rate of clinical skill assessments in the observation group was 93.3%, which was higher than that in the control group, which was 73.3%(P＜0.05). Scores of mastering basic theoretical knowledge, improving clinical thinking ability, motivating learning interests and improving disease diagnosis and treatment ability in observation group were higher than those in control group (P＜0.01). Conclusions Diversified teaching mode improves ultrasound-guided interventional pain management skills, and supports the capacity building of clinical treatment.The method may function as a innovative clinical training pathway for other medical schools and healthcare institutions.

Background While there is an extensive body of research regarding pain and its treatment in developed countries, little research on this topic has been performed in developing countries. This study aimed to investigate the diagnosis, treatment, and treatment satisfaction in individuals with pain in urban China using real-world data. Methods All respondents from the 2013, 2015, and 2017 China National Health and Wellness Survey were included in the analysis and were classified into diagnosed and undiagnosed groups according to their self-reported physician diagnosis or experience in the past month. The following five categories of pain were analysed: headache, cancer-associated pain, musculoskeletal pain, neuropathic pain, and fibromyalgia. Rates for diagnosis, treatment, and satisfaction with medication were calculated overall and for each pain type. Results A total of 3802 respondents reported experience of at least one type of pain in the past month. Among those, 61.2% were diagnosed with a pain-related condition, the majority of which (84.0%) were receiving treatment. For diagnosed respondents taking over-the-counter and/or prescription medication, 70.3% were satisfied with their treatment. Comparing between pain types, the diagnosis rates for cancer-associated pain (32.7%) and fibromyalgia (22.8%) were relatively low, whereas respondents with musculoskeletal pain has the highest diagnosis rate (61.1%). Respondents with cancer-associated pain had the lowest satisfaction (30.0%) with over-the-counter and prescription medication, while respondents with headache (76.2%) had the highest satisfaction rate with such medications. Conclusion Our study highlights the importance of raising awareness for pain management as well as education and training for healthcare providers and patients.