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We aimed to assess the tolerance of fentanyl pectin nasal spray (FPNS) when used to treat procedural pain caused by wound dressing or physiotherapy in patients older than 75 years with or without opioid background treatment.This is a prospective monocentric, noncontrolled, nonrandomized study conducted from December 2014 to October 2017 in 2 geriatric wards (rehabilitation and acute medicine).Fifty-seven patients were included and 314 procedures were monitored.For each patient, 6 procedures were monitored: the first 2 without specific treatment, then fentanyl was started at 100 μg with a titration over a few procedures up to 800 μg in non-opioid-naïve patients and 400 μg in opioid-naïve. Sedation and respiratory scale were monitored during the procedures. All adverse drug events occurring from inclusion to 5 days after the intervention were collected and their imputability was assessed separately by 2 pharmacovigilance experts.Overall, 14.4% of the sessions with FPNS administration resulted in adverse drug events. Main adverse drug events were nausea and vomiting, somnolence, and confusion. Most of them were of mild to moderate severity. Four severe adverse events were due to accidental overdoses. No unexpected adverse event occurred. Tolerance was similar for opioid-naïve and non-opioid-naïve patients (P value = .93).FPNS was overall well tolerated in geriatric patients. Given its interesting pharmacokinetics, fentanyl is a promising lead for procedural pain treatment in geriatric patients, even those who are opioid naïve.

There is no recommendation in Europe for the use of ketamine in patients with chronic pain. The heterogeneity of practice highlights the need to seek the advice of experts in order to establish a national consensus. This Delphi survey aimed to reach a national consensus on the use of ketamine in chronic pain in Pain clinics.A collaborative four-round internet-based questionnaire was used. It was created after literature search on ketamine administration in chronic pain and included about 96 items. It discussed utility and advantages, adverse events and deleterious aspects, methods of administration, concomitant treatments and assessment of results.Twenty-eight experts completed all rounds of the survey with a total of 81.3% items reaching a consensual answer. Neuropathic pain represents the first indication to use ketamine, followed, with a good to moderate utility, by other situations (fibromyalgia, complex regional pain syndrome, central neuropathic pain, peripheral neuropathic pain, nociceptive pain, sensitization, opioid withdrawal, palliative care, depression). Experts agreed on the rare occurrence of adverse events. Concerning routes of administration, intravenous infusion with doses of 0.5-0.9 mg/kg/d for 4 days of treatment is preferred. Place of care is hospital, as in- or out-patient, with a quarterly administration of ketamine. Finally, ketamine effectiveness is assessed 1 month after infusion, and experts encourage combination with non-pharmacological treatment.This Delphi survey established a consensus of pain specialists on the use of ketamine in refractory chronic pain, thus providing a basis for future comparative trials.This Delphi survey in chronic pain reached agreement on four main aspects: (1) Priority to treat neuropathic pain with evaluation of effectiveness at 1 month; (2) No deleterious effects in the majority of listed diseases/situations with the absence or3% of suggested adverse events; (3) 0.5-0.9 mg/kg/d IV infusion; (4) Combination with non-pharmacological treatment.

In humans, exposure to electromagnetic millimeter waves (MMW) has a hypoalgesic effect. In animals, this effect has been shown to depend on innervation density of the area exposed. This study aims to assess hypoalgesic and parasympathetic effects of MMW applied on the palmar side of the wrist in healthy participants. In a within-subject design, 10 healthy participants had the palmar side of their wrist exposed to MMW (61.25 GHz, 17 mW/cm

Fibromyalgia is a common chronic pain pathology with an incidence of 4.3 per 1,000 person-years. An open, randomized clinical trial of patients with fibromyalgia comparing an immediate vs. delayed 18-day spa therapy in five spa therapy care facilities in France enrolled 220 patients. Randomization was in blocks of four, stratified by center, severity of fibromyalgia and previous spa therapy. Patients continued usual treatment. The main endpoint was the number of patients achieving minimal clinically important difference at 6 months, defined as 14% change in their baseline fibromyalgia impact questionnaire score. The intention-to-treat analysis included 100 and 106 patients in the intervention and control groups, respectively. At 6 months, 45/100 (45.0%) and 30/106 (28.3%) patients in the intervention and control groups, respectively, achieved a minimal clinically important difference (P= .013). There was also a significant improvement in pain, fatigue, and symptom severity (secondary outcomes) in the intervention group but not for generic quality of life (QOL), sleep or physical activity. None of the 33 serious adverse events reported by 25 patients were related to the spa therapy. Our results demonstrate the benefit of spa treatment in patients with fibromyalgia. PERSPECTIVE: A 12-month, open, randomized clinical trial of 220 patients with fibromyalgia compared an immediate versus delayed (ie, after 6 months) 18-day spa therapy. The results showed a clinically significant improvement at 6 months for those who received immediate therapy which was maintained up to 12 months. TRIAL REGISTRATION NUMBER: ClinicalTrials.gov: NCT02265029.

Insufficient analgesia affects around 50% of emergency department patients. The use of a protocol helps to reduce the risk of oligoanalgesia in this context. Our objective was to describe the feasibility and efficacy of a multimodal analgesia protocol (combining paracetamol, oxycodone, and inhaled methoxyflurane) initiated by triage nurse. We performed a prospective, observational study in an emergency department (Grenoble Alpes University Hospital, France) between December 2017 and April 2018. Adult non-severe trauma patients with a numerical pain rating scale (NRS) score ≥ 4 were included. The primary efficacy criterion was the proportion of patients with an NRS score ≤ 3 at 15 min. Pain intensity was measured for 60 min and during radiography. Data on adverse events and satisfaction were recorded. A total of 200 adult patients were included (median [interquartile range (IQR)] age: 32 [23-49] years; 126 men (63%)). Sixty-six patients (33%) reported an NRS score ≤ 3 at 15 min. The time required to achieve a decrease of at least 2 points in the NRS score was 10 (5-20) min. The median [IQR] pain intensity was 4 [2-5] before radiography and 4 [2-6] during radiography. Adverse events were frequent (n = 128, 64%). No serious adverse events were reported. The patients and caregivers reported good levels of satisfaction. The administration of a nurse-driven multimodal analgesia protocol (combining paracetamol, oxycodone, and methoxyflurane) was feasible on admission to the emergency department. It rapidly produced long-lasting analgesia in adult trauma patients.Trial registration: NCT03380247.

Interventional therapies are important to consider when facing cancer pain refractory to conventional therapies. The objective of the current review is to introduce these effective strategies into dynamic interdisciplinary pain management, leading to an exhaustive approach to supportive oncology. Critical reflection based on literature analysis and clinical practice. Interventional therapies act on the nervous system via neuromodulation or surgical approaches, or on primitive or metastatic lesions via interventional radiotherapy, percutaneous ablation, or surgery. Interventional therapies such as neuromodulations are constantly evolving with new technical works still in development. Nowadays, their usage is better defined, depending on clinical situations, and their impact on quality of life is proven. Nevertheless their availability and acceptability still need to be improved. To start with, a patient’s interdisciplinary evaluation should cover a wide range of items such as patient’s performance and psychological status, ethical considerations, and physiochemical and pharmacological properties of the cerebrospinal fluid for intrathecal neuromodulation. This will help to define the most appropriate strategy. In addition to determining the pros and cons of highly specialized interventional therapies, their relevance should be debated within interdisciplinary teams in order to select the best strategy for the right patient, at the right time. Ultimately, the use of the interventional therapies can be limited by the requirement of specific trained healthcare teams and technical support, or the lack of health policies. However, these interventional strategies need to be proposed as soon as possible to each patient requiring them, as they can greatly improve quality of life.

Following a series of articles reviewing the basics of cancer pain management, in this article, we develop the guiding principle of our philosophy: the concept of multimorphic pain and how to integrate it as the innovative cornerstone of supportive care in cancer.Critical reflection based on literature analysis and clinical practice.This model aims to break with standard approaches, offering a more dynamic and exhaustive vision of cancer pain as a singular clinical entity, taking into account its multimorphic characteristics (cancer pain experience can and will change during cancer: aetiology, physiopathology, clinical presentation and consequences of pain) and the disruptive elements that can occur to influence its evolution (cancer evolution, concomitant treatments, pain from associated diseases, comorbidities and complications, or modifications in the environment). Our model establishes the main key stages for interdisciplinary management of cancer pain: Early, personalised management that is targeted and multimodal; Identification, including in advance, of potential disruptive elements throughout the care pathway, using an exhaustive approach to all the factors influencing pain, leading to patient and caregiver education; Optimal analgesic balance throughout the care pathway; Integration of this concept into a systemic early supportive care model from the cancer diagnosis.Given the difficulties still present in the management of pain in cancer, and whilst cancer is often considered as a chronic condition, the concept of multimorphic pain proposes a practical, optimised and innovative approach for clinicians and, ultimately, for patients experiencing pain.

Numerous studies on cancer patients have shown that cancer pain still remains underestimated, poorly assessed, and under-treated. Pain relief should be considered as early as possible within personalized care and as an integral part of quality healthcare in many countries. Nevertheless, personalized care is still insufficiently taken into consideration, partly due to improper or incomplete assessment of cancer pain. The objective of this article is to propose a practical approach to this complex assessment, as the first step to improving patients’ quality of life. Critical reflection based on literature analysis and clinical practice. Assessment of cancer pain means evaluating the pain intensity over time, the dimensions of pain (sensory-discriminative, cognitive, emotional, and behavioral), the pathophysiological nature of pain (neuropathic, nociceptive, and nociplastic), the etiology, and the patient’s perception (diffuse, localized, global). Cancer patients may have simple or multiple forms of pain (mixed, overlapped, combined, and associated). Furthermore, with the use of new specific therapies, the symptomatology of pain is also changing, and certain cancers are becoming chronic. Thus, cancer pain is an archetype of multimorphic pain, and its dynamic assessments (regular and repeated) require a multimodal and targeted approach in order to offer personalized pain management. Multimodal pain treatment must be adapted to the elements that disrupt cancer pain, to the patient’s cancer and to the specific treatments. The dynamic assessments of pain demand the simplest, and the most complete possible procedure, to avoid feasibility problems or self-/hetero-assessment excesses that might lead to less precise and less reliable results. Multimodal and interdisciplinary approaches are being developed, making it possible to optimize cancer pain management.

Background Chronic pain affects approximately 30% of the general population, severely degrades quality of life (especially in older adults) and professional life (inability or reduction in the ability to work and loss of employment), and leads to billions in additional health care costs. Moreover, available painkillers are old, with limited efficacy and can cause significant adverse effects. Thus, there is a need for innovation in the management of chronic pain. Better characterization of patients could help to identify the predictors of successful treatments, and thus, guide physicians in the initial choice of treatment and in the follow-up of their patients. Nevertheless, current assessments of patients with chronic pain provide only fragmentary data on painful daily experiences. Real-life monitoring of subjective and objective markers of chronic pain using mobile health (mHealth) programs can address this issue. Objective We hypothesized that regular patient self-monitoring using an mHealth app would lead physicians to obtain deeper understanding and new insight into patients with chronic pain and that, for patients, regular self-monitoring using an mHealth app would play a positive therapeutic role and improve adherence to treatment. We aimed to evaluate the feasibility and acceptability of a new mHealth app called eDOL. Methods We conducted an observational study to assess the feasibility and acceptability of the eDOL tool. Patients completed several questionnaires using the tool over a period of 2 weeks and repeated assessments weekly over a period of 3 months. Physicians saw their patients at a follow-up visit that took place at least 3 months after the inclusion visit. A composite criterion of the acceptability and feasibility of the eDOL tool was calculated after the completion of study using satisfaction surveys from both patients and physicians. Results Data from 105 patients (of 133 who were included) were analyzed. The rate of adherence was 61.9% (65/105) after 3 months. The median acceptability score was 7 (out of 10) for both patients and physicians. There was a high rate of completion of the baseline questionnaires and assessments (mean 89.3%), and a low rate of completion of the follow-up questionnaires and assessments (63.8% (67/105) and 61.9% (65/105) respectively). We were also able to characterize subgroups of patients and determine a profile of those who adhered to eDOL. We obtained 4 clusters that differ from each other in their biopsychosocial characteristics. Cluster 4 corresponds to patients with more disabling chronic pain (daily impact and comorbidities) and vice versa for cluster 1. Conclusions This work demonstrates that eDOL is highly feasible and acceptable for both patients with chronic pain and their physicians. It also shows that such a tool can integrate many parameters to ensure the detailed characterization of patients for future research works and pain management. Trial Registration ClinicalTrial.gov NCT03931694; http://clinicaltrials.gov/ct2/show/NCT03931694

BACKGROUND Chronic pain affects approximately 30% of the general population, severely degrades quality of life (especially in older adults) and professional life (inability or reduction in the ability to work and loss of employment), and leads to billions in additional health care costs. Moreover, available painkillers are old, with limited efficacy and can cause significant adverse effects. Thus, there is a need for innovation in the management of chronic pain. Better characterization of patients could help to identify the predictors of successful treatments, and thus, guide physicians in the initial choice of treatment and in the follow-up of their patients. Nevertheless, current assessments of patients with chronic pain provide only fragmentary data on painful daily experiences. Real-life monitoring of subjective and objective markers of chronic pain using mobile health (mHealth) programs can address this issue. OBJECTIVE We hypothesized that regular patient self-monitoring using an mHealth app would lead physicians to obtain deeper understanding and new insight into patients with chronic pain and that, for patients, regular self-monitoring using an mHealth app would play a positive therapeutic role and improve adherence to treatment. We aimed to evaluate the feasibility and acceptability of a new mHealth app called eDOL. METHODS We conducted an observational study to assess the feasibility and acceptability of the eDOL tool. Patients completed several questionnaires using the tool over a period of 2 weeks and repeated assessments weekly over a period of 3 months. Physicians saw their patients at a follow-up visit that took place at least 3 months after the inclusion visit. A composite criterion of the acceptability and feasibility of the eDOL tool was calculated after the completion of study using satisfaction surveys from both patients and physicians. RESULTS Data from 105 patients (of 133 who were included) were analyzed. The rate of adherence was 61.9% (65/105) after 3 months. The median acceptability score was 7 (out of 10) for both patients and physicians. There was a high rate of completion of the baseline questionnaires and assessments (mean 89.3%), and a low rate of completion of the follow-up questionnaires and assessments (63.8% (67/105) and 61.9% (65/105) respectively). We were also able to characterize subgroups of patients and determine a profile of those who adhered to eDOL. We obtained 4 clusters that differ from each other in their biopsychosocial characteristics. Cluster 4 corresponds to patients with more disabling chronic pain (daily impact and comorbidities) and vice versa for cluster 1. CONCLUSIONS This work demonstrates that eDOL is highly feasible and acceptable for both patients with chronic pain and their physicians. It also shows that such a tool can integrate many parameters to ensure the detailed characterization of patients for future research works and pain management. CLINICALTRIAL ClinicalTrial.gov NCT03931694; http://clinicaltrials.gov/ct2/show/NCT03931694

International audience; ABSTRACT: Nitrous oxide (N2O) is an odorless and colorless gas routinely used as an adjuvant of anesthesia and for short-duration analgesia in various clinical settings mostly in the form of an N2O/O2 50%-50% equimolar mixture (EMONO). Experimental studies have suggested that EMONO could also induce long-lasting analgesic effects related to the blockade of N-methyl-D-aspartate receptors. We designed the first international multicenter proof of concept randomized, placebo-controlled study to assess the efficacy and safety of a 1-hour administration of EMONO or placebo (medical air) on 3 consecutive days up to 1 month after the last administration in patients with chronic peripheral neuropathic pain. A total of 240 patients were recruited in 22 centers in France and Germany and randomly assigned to 1 study group (120 per group). Average pain intensity (primary outcome), neuropathic pain characteristics (Neuropathic Pain Symptom Inventory), Patient Global Impression of Change, anxiety, depression, and quality of life were systematically assessed before and after treatment. The changes in average pain intensity between baseline and 7 days after the last administration were not significantly different between the 2 groups. However, evoked pain intensity (predefined secondary endpoint) and Patient Global Impression of Change (exploratory endpoint) were significantly improved in the EMONO group, and these effects were maintained up to 4 weeks after the last treatment administration. Mostly transient side effects were reported during the treatment administration. These encouraging results provide a basis for further investigation of the long-term analgesic effects of EMONO in patients with neuropathic pain. Copyright

Objective To assess the long-term analgesic effects of high-frequency repetitive transcranial magnetic stimulation (rTMS) of the motor cortex in patients with chronic pain syndrome. Methods The study included 57 patients (orofacial pain, n = 26, pudendal neuralgia, n = 18, and neuropathic limb pain, n = 13) with an “induction phase” of 12 daily rTMS sessions for 3 weeks, followed by a “maintenance phase” of bi-monthly sessions for the next five months. Results All pain measures significantly decreased from baseline to the end of the induction phase. Analgesic response, defined as pain intensity decrease ≥ 30% compared to baseline, was observed in 39 patients (68%), who could be differentiated from non-responders from the 7th rTMS session. At the end of the maintenance phase (D180), 27 patients (47%) were still responders. Anxio-depressive symptoms and quality of life also improved. The analgesic response at the end of the induction phase was associated with lower pain score at baseline, and the response at the end of the maintenance phase was associated with lower anxio-depressive score at baseline. Conclusion The analgesic efficacy of motor cortex rTMS can be maintained in the long term in various chronic pain conditions. Patients with high pain level and severe anxio-depressive symptoms may have a less favorable profile to respond to the procedure. Significance The overall impact of rTMS treatment on daily life requires a multidimensional evaluation that goes beyond the analgesic effect that can be achieved.

Resume Introduction Le syndrome fibromyalgique est un trouble frequent, percu comme un modele de douleur chronique. Dans une conception biopsychosociale, nous voulons preciser en quoi l’approche cognitive, comportementale et emotionnelle peut aider a comprendre et traiter la fibromyalgie. Methode Cette revue de litterature utilise la base de donnees MedLine sur la periode janvier 2000–janvier 2017. Certains mots cles explores sont : fibromyalgie, depression, anxiete, stress, strategie d’adaptation, evitement et peur du mouvement. Resultats Colere, tristesse et anxiete contribuent a aggraver les perceptions douloureuses. La douleur, conceptualisee comme un stresseur chronique, permet d’appliquer le modele transactionnel du stress de Lazarus et Folkman, et etablir ainsi un lien entre douleur et souffrance emotionnelle. Le catastrophisme, phenomene emotionnel et cognitif, est une strategie adaptative dysfonctionnelle frequemment retrouvee dans la fibromyalgie. L’evitement et, a l’inverse, le maintien excessif du mouvement sont egalement des facteurs comportementaux deleteres dans la fibromyalgie. Ces differents facteurs justifient des programmes therapeutiques graduels, individualises, associant notamment des approches psychocorporelles et les psychotherapies. Ces dernieres ameliorent la gestion du stress et le sentiment d’efficacite personnelle par une implication active des patients. Des techniques (therapies comportementales et cognitives, therapie de pleine conscience, therapie d’acceptation et d’engagement) permettent de cibler les strategies adaptatives dysfonctionnelles (catastrophisme, kinesiophobie, hyperactivite) pour en diminuer l’impact negatif et developper des strategies plus fonctionnelles comme la distraction, la relaxation et l’acceptation. Discussion Les resultats confirment l’importance des mecanismes psychologiques dans l’entretien des symptomes de la fibromyalgie. A l’avenir, les facteurs psycho-comportementaux pourraient permettre de definir des sous-groupes de patients et d’etablir des prises en charges plus specifiques a chaque profil ainsi defini.

Resume Introduction L’etude QualiPec visait a decrire en pratique medicale courante, chez des patients atteints de cancer et traites par fentanyl nasal pectine (FPNS) pour leurs acces douloureux paroxystiques (ADP), la satisfaction au traitement, l’efficacite, la tolerance, les modalites d’utilisation du FPNS et la qualite de vie des patients. Methodes Deux cent cinquante-neuf patients ont ete inclus par 51 medecins dans cette etude non interventionnelle prospective francaise. Les donnees ont ete recueillies sur 4 semaines a partir de l’instauration du FPNS. Resultats Parmi les 233 patients analyses (âge moyen : 61 ± 12 ans, hommes : 58 %, Eastern Cooperative Oncology Group-Performance Status > 2 : 50 %, principales localisations cancereuses : ORL : 26 %, poumon : 22 %, sein : 16 %, prostate : 7 % ; metastases osseuses : 44 %), 122 patients (52 %) ont atteint une dose efficace de FPNS, dans les 2 premiers jours de traitement dans 66 % des cas. Cette dose etait de 100 μg par episode chez 59 % de ces patients. Ces 122 patients ont rapporte 1114 episodes d’ADP traites jusqu’au jour 7 ± 2. Pour 912 episodes (82 % ; intervalle de confiance [IC] 95 % : [80–84]), le traitement par le FPNS a ete juge satisfaisant ou tres satisfaisant, sans difference selon l’existence ou non de metastases osseuses (85 %, IC 95 % = [82–87] versus 81 %, IC 95 % = [77–85 %]). L’evaluation des 2976 episodes rapportes par les patients sur 4 semaines de traitement etait similaire (satisfaction dans 84 % des cas). Aucun nouveau signal de pharmacovigilance n’est apparu. Discussion QualiPec a confirme en pratique medicale courante la satisfaction des patients atteints de cancer vis-a-vis du traitement de leurs ADP par le FPNS.

Current therapeutic modalities for fibromyalgia (FM) do not provide satisfactory results and new approaches have to be explored.To assess efficacy and safety of adding a phytotherapy treatment (Fib-19-01) to the current therapeutic regimen in patients with FM.Double-blind controlled trial: women with active FM (Fibromyalgia Index Questionnaire FIQ40) were randomised to receive Fib-19-01 or a food supplement (FS) undistinguishable from Fib-19-01 or no supplementary treatment (NoST). All continued the conventional therapy throughout the 6 month follow-up. Primary endpoint: change in FIQ between Day 0 and month 6 (M6). Secondary Criteria: variation over time FIQ ( repeated measurements), change in Pichot fatigue scale, Pittsburgh Sleep Quality Index (PSQI), SF-12 and Hospital Anxiety and Depression (HAD) scales.100 patients (Intent-To-Treat population) were analyzed. FIQ decreased significantly only in the Fib-19-01 group (P.001) at both week 12 and 24. Improvement was higher for Fib-19-01 (-13.4 ± 18.9) than in the 2 other groups (-5.5 ± 15.6 and -5.6 ± 11.3) despite there was no statistical between-group difference at week 24 in FIQ score (P = .08 and P = .09 respectively). Analysis of variance in repeated measurements of FIQ showed a significant difference between Fib-19-01 and FS throughout the follow-up period (P = .03). Fib-19-01 was superior to both FS and NoST for Pichot scale decrease over time: -4.6 (range -6.9; -2.28), -0.29 (-2.7; 2.1) and -0.72 (-3.1; 1.66) (P = .013 and 0.023 respectively), mental and social SF12 [+8.1 (range 3.5; 12.6), -0.27(range -5.3; 4.8 ) and -0.02 (range -5.0; 4.9 ) P = .02 and 0.018)],HAD depression [-2.0 (range -3.3; -0.7), +0.5 (range -0.9; 1.9 ) and +0.71 (range -0.7; 2.1) P = .013 and 0.007]. No significant difference was found between FS and NoST groups for any outcome. All treatments were well and similarly tolerated.In patients with FM taking conventional therapy, Fib-19-01 has a therapeutic effect on fatigue, emotion and social life, and depression associated with the disease.

Background and objectivePain, a symptom often present in patients with Chronic Obstructive Pulmonary Disease (COPD), alters quality of life. COPD exacerbation augments several mechanisms that may cause pain (dyspnea, hyperinflation and inflammation) and therefore we hypothesized that pain might be increased during exacerbation.MethodsA prospective cohort study was conducted in patients admitted for acute exacerbations of COPD (AECOPD) in two emergency departments in France and Canada. Patients with cancer-related pain or recent trauma were not included. The Short Form McGill Pain Questionnaire (SF-MPQ) and the Brief Pain Inventory (BPI) scale were used to evaluate pain intensity and location. Patients also completed the Borg Dyspnea Scale and Hospital Anxiety and Depression Scale. The questionnaires were completed again during an outpatient assessment in the stable phase. The primary outcome was difference in pain intensity (SF-MPQ) between the exacerbation and stable phases.ResultsFifty patients were included. During exacerbation, 46 patients (92%) reported pain compared to 29 (58%) in the stable phase (pConclusionThe frequency and intensity of pain were higher during AECOPD, with a specific distribution. Pain should therefore be routinely assessed and treated in patients with AECOPD.

OBJECTIVE Fibromyalgia (FM) is a chronic painful condition partly due to alterations in pain modulation by the central nervous system. Multicomponent therapy (MT) and repetitive transcranial magnetic stimulation (rTMS) have both been reported as pain modulators in patients with FM. The aim of this study was to compare the effects of rTMS on pain with a combination of MT and rTMS versus MT alone. METHODS Thirty-nine FM patients with visual analog scale (VAS) results for pain of ≥40 mm were randomized to active or sham rTMS (high-frequency, primary motor cortex M1) plus 12 weeks of MT (3 sessions per week combining aerobic training, pool-based exercises, and relaxation). Repetitive TMS was started 2 weeks prior to MT and maintained until the end of the program (week 14). Assessments were achieved at baseline, at week 14, and at 6 months (week 40) after completion of the program. The main criterion was pain reduction, as assessed by the weekly mean self-reported level of pain (reported daily). Secondary outcomes were cardiorespiratory fitness (graded maximal exercise test), cardiac autonomic adaptations, and FM impact (using scales for FM impact, depression, sleep efficiency, and pain catastrophizing). RESULTS The reduction of the weekly mean of pain reported daily did not differ significantly between groups (using repeated measures of analysis of variance [ANOVA]). Two-way ANOVAs showed that pain VAS results, as well as cardiorespiratory fitness, quality of life, depression, and catastrophizing, improved significantly at week 14 and remained stable until week 40. Neither cardiac autonomic adaptations nor sleep efficiency changed significantly. CONCLUSION Repetitive TMS did not reduce pain in patients with FM who followed the MT program.

Despite progress in treatments, cancer pain remains underestimated, poorly assessed and under-treated. Prescribing strong opioids, because of their specificities, requires precision in management considering their pharmacology but also a clear understanding of recommendations. Some clinicians highlight the risk of addiction, excessive sedation and respiratory depression and their need for information. Our objective in this review is to suggest some clinical guidance for the positioning and daily use of opioids within cancer pain management. Critical reflection based on literature analysis and clinical practice. Strong opioids may be initiated as soon as pain diagnosis is defined. Factors to consider are pain aetiology, opioid pharmacokinetics and pharmacodynamics, genetic polymorphism, physiology (age, gender, weight and pregnancy), comorbidities (especially renal, hepatic, cardiovascular diseases), chronobiology, environmental factors, medication interference and treatment adherence. Achieving the best-balanced opioid treatment for background pain is complex, mainly due to the variable benefit/risk ratio between individuals and the experience of breakthrough cancer pain. Opioid initiation alongside a dynamic reassessment of pain should be fully integrated into the patient’s management to optimise analgesia. The efficacy and safety of a strong opioid treatment need to be re-evaluated and adapted to individuals constantly as it varies over time. Cancer pain is multimorphic and permanently changing due to disease evolution, curative treatments and disruptive events (concomitant treatments, pain from associated disease, comorbidities and complications, modifications of the environment). Well-managed opioids are the cornerstone of a complex environment requiring multidisciplinary dynamic assessments integrated into the patient’s care pathway.

Most cancer patients experience many pain episodes depending on disruptive elements, leading them to the emergency room. The objective of the article is to describe common pitfalls that need to be avoided, as well as opportunities to be seized for repositioning patients back on their care pathway. Critical reflection based on literature analysis and clinical practice. Most forms of cancer are now chronic, evolving diseases, and patients are treated with high-technology targeted therapies with iatrogenic effects. Moreover, the multimorphic nature of cancer-related pain requires dynamic, interdisciplinary assessments addressing its etiology, its pathophysiology, its dimensions (sensory-discriminatory, cognitive, emotional, and behavioral), and the patient’s perception of it, in order to propose the most adapted therapies. However, for most patients, cancer pain remains underestimated, poorly assessed, and under-treated. In this context, the key steps in emergency cancer pain management are as follows: • Quick relief of uncontrolled cancer pain: after eliminating potential medical or surgical emergencies revealed by pain, a brief questioning will make the use of carefully titrated morphine in most situations possible. • Assessment and re-assessment of the pain and the patient, screening specific elements, to better understand the situation and its consequences. • Identification of disruptive elements leading to uncontrolled pain, with an interdisciplinary confrontation to find a mid to long-term approach, involving the appropriate pharmaceutical and/or non-pharmaceutical strategies, possibly including interventions. Pain emergencies should be part of the cancer care pathway and, through supportive care, provide an opportunity to help cancer patients both maintain their physical, psychological, and social balance and anticipate further painful episodes.

To assess the feasibility of greater occipital nerve (GON) intermediate site infiltration with MRI guidance. Eleven consecutive patients suffering from chronic refractory cranio-facial pain who underwent 16 GON infiltrations were included in this prospective study. All of the procedures were performed on an outpatient basis in the research facility of our institution, with a 1.5 T scanner. The fatty space between inferior obliquus and semispinalis muscles at C1-C2 level was defined as the target. Technical success was defined as the ability to accurately inject the products at the target, assessed by post-procedure axial and sagittal proton density-weighted sequences. Clinical success was defined as a 50% pain decrease at 1 month. Technical success was 100%. GON was depicted in 6/11 cases on planning MRI sequences. Mean duration of procedure was 22.5 min (range 16–41). Clinical success was obtained in 7/11 included patients (63.6%) with a mean self-reported improvement of 78%. Interventional MR-guidance for GON infiltration is a feasible technique offering similar results to an already established effective procedure. It may appear as a useful tool in specific populations, such as young patients and repeat infiltrations, and should be considered in these settings. • MR guidance for GON infiltration is a feasible technique. • Preliminary results are in agreement with other guidance modalities. • MR guidance may be seen as a useful tool in specific populations. • Specific populations include young patients and repeat infiltrations. • Target patients may also include patients with potentionally previously reported complications (torticollis).

Objective To assess technical feasibility of cryoneurolysis of the greater occipital nerve in the management of occipital neuralgia. Methods Six patients suffering from unilateral refractory greater occipital neuralgia and who underwent 7 GON cryoneurolysis were assessed between October 2015 and January 2017. All procedures were performed under CT guidance and local anesthesia. A planning CT was performed with contrast enhancement to plan needle target and identify surrounding major vascular structures. A 12G coaxial needle (Inomed) was then inserted and targeted the first bend of the GON under and lateral to the obliquus capitis inferior muscle. A 2.0 mm cryoprobe was then inserted in the coaxial and sensitive stimulation at 100 Hz was performed. One to three freezing cycles were performed in one session. Results Technical feasibility was 100% as cryoneurolysis could be performed in all 7 cases with accurate sensitive nerve stimulation prior to freezing cycle. One patient benefited from a second session after failure of the first session. More than 50% pain reduction was achieved at day 7 in all cases, and 5 of 6 cases at one and three months follow-up. Conclusion Cryoneurolysis of the GON in the management of refractory GON neuralgia is feasible. Initial results are promising as 5/7 cases benefited from a 3-month pain alleviation period.

Resume La fibromyalgie reste une pathologie dont la physiopathologie est mal connue et le traitement particulierement difficile. L’utilisation croissante de la ketamine dans cette indication hors AMM souleve des incertitudes. Afin d’evaluer les pratiques locales, une etude observationnelle retrospective a ete menee au CHU de Grenoble aupres de patients fibromyalgiques traites, de facon chronique (plus de 3 mois) par ketamine en ambulatoire. Cinquante-neuf patients ont ete inclus dont la moitie etaient traites depuis plus de quatre a cinq ans avec des doses moyennes hebdomadaires superieures ou egales a 100 mg/semaine pour 55 % d’entre eux. L’efficacite globale ressentie etait satisfaisante pour plus de 80 % des patients. Il a ete necessaire pour 80 % des patients d’augmenter les doses de ketamine (dont 53 % au cours des 6 premiers mois de traitement). Enfin, 50 % des patients ont ressenti des effets indesirables majoritairement neuropsychodysleptiques. Quatre cas de syndrome de sevrage sont survenus a l’arret, meme progressif, du traitement. Cet etat des lieux a souleve differents points critiques : valider des schemas posologiques integrant le poids des patients, tracer les autres traitements antalgiques associes, utiliser des outils d’evaluation d’efficacite standardises, organiser la surveillance et la gestion des effets indesirables, des phenomenes de tolerance pharmacodynamique et de pharmacodependance. Les professionnels de sante impliques souhaitent structurer et coordonner leurs actions et travaillent a etablir un consensus de pratiques pour rediger un protocole de soins destine a la prise en charge du patient fibromyalgique traite par ketamine a domicile.

The original version of this article, published on 12 July 2017, unfortunately contained mistakes. The following corrections have therefore been made in the original.

Resume Nous rapportons notre experience de l’utilisation de la stimulation magnetique transcrânienne repetitive (SMTr) dans le traitement des douleurs faciales rebelles chroniques et refractaires. Notre objectif est d’evaluer l’efficacite de la SMTr dans cette indication et de determiner les modalites du suivi et du traitement a long terme. Treize patients souffrant de douleurs faciales refractaires ont ete inclus (sept nevralgies trigeminales, quatre algies vasculaires de la face, deux douleurs post-zosteriennes) avec une douleur de fond moyenne de 5,9 sur 10 et de crise de 9,2 sur 10. La cure de SMTr a permis une diminution de la douleur de fond evaluee a j90 a 2,5 sur 10 (disparition des douleurs chez quatre patients). Parmi les patients, 53,1 % ne presentaient plus de crises et 23,1 % des crises moins intenses. Pour 38,5 % des patients, l’espacement des seances entraine un soulagement moindre des douleurs. Chez les patients repondeurs, cette technique parait un outil interessant permettant d’obtenir un effet antalgique cumulatif par la repetition prolongee des seances.

Resume Nous rapportons le cas d’un patient atteint d’un cancer du rein metastatique au niveau du bassin ayant necessite une analgesie perimedullaire au long cours a domicile, compliquee par une infection du dispositif. La place des techniques interventionnelles dans l’arsenal therapeutique des douleurs du cancer et leur impact sur la survie sont discutes a partir du cas clinique.

Depuis 2007, notre equipe developpe la rTMS dans les protocoles de recherche clinique et le traitement des douleurs chroniques refractaires. Indications : algies faciales (AF), douleurs post-AVC, membre fantome, avulsion du plexus brachial, glossodynie, nevralgie pudendale. Notre protocole therapeutique actuel utilise les parametres de stimulation suivants : intensite a 80 % du seuil moteur, frequence 10 Hz, trains 5 s, inter-trains 25 s, soit 2000 stimulations/20 min. Cible de stimulation : aire corticale motrice de la zone algique. Les seances sont guidees par un systeme de neuronavigation, sauf dans les nevralgies pudendales (utilisation d’une sonde MagVenture B70 (Mag2Health, France), adaptee pour stimuler le cortex moteur bilateral correspondant aux territoires pelvi-perineaux). Nombre et rythme des seances : une « phase d’induction » : 1 seance/jour pendant 5 jours, 2 semaines consecutives (S1–S2), puis 2 seances (S3). Une « phase de maintien » chez les repondeurs (amelioration ≥ 30 %) : 1 seance (S4), puis 1 seance/15 jours pendant 5 mois. Si remission incomplete : seances mensuelles pendant 6 mois. Si reponse faible ou recidive en cours du protocole : arret des seances de maintien. Avantages : maintien de l’effet antalgique a long terme. Inconvenients : seances frequentes et temps medical incompressible. L’analyse de la litterature confirme l’efficacite de la rTMS dans les douleurs neuropathiques chroniques [3] . En general, les etudes sont de courte duree. Quelques etudes ont observe une meilleure reponse a la rTMS dans les AF, par rapport a d’autres sites douloureux [2] . Etude de notre centre [1] : 55 patients souffrant d’AF chroniques, effet antalgique ≥ 30 % obtenu chez 73 % des patients a j15 et 40 % a j180. L’effet antalgique est moindre apres l’espacement mensuel des seances. Une diminution de la duree des seances de 20 a 10 min (nombre identique de stimulations) est moins efficace.

CBSM is a learning technique for stress management combining a cognitive-behavioral approach with relaxation. It improves the quality of life of patients with chronic diseases. The studies carried out in the context of cancer treatment have shown its effectiveness. Cognitive-behavioral techniques and relaxation have also shown a benefit in the management of chronic pain. This document describes the implementation of the program at CHUGA with patients with chronic pain related to cancer, its evaluation, the difficulties encountered and the first results of the study. Since January 2017, 36 patients mainly women (90%) followed in oncology for cancers (all stages combined), have participated in the program. The attendance rate at the sessions was, 75%. The positive feedback from the participants motivated the continuation and evaluation of the CBSM program. As part of the research protocol, perceived stress (PSS14) was assessed as the primary endpoint; participation percentage, pain, anxiety, depression, and quality of life as secondary endpoints. From 01/09/2018 to 15/02/2019, the study was proposed to 28 patients. Twenty-four (86%) were include. Fifteen (56%) have already attended the first sessions with an attendance rate of 90%. No patient has completed all sessions to date. On a qualitative level, patients had positive feedback on their participation in this program. As the study is not completed yet, it is not possible to draw conclusions. Nevertheless, the patients’ attendance rate as well as their overall satisfaction are very encouraging.; Le CBSM est une technique d'apprentissage de la gestion du stress associant une approche cognitivo-comportementale à de la relaxation. Il améliore la qualité de vie des patients porteurs de maladie chroniques. Les études menées dans le cadre de la prise en charge de cancers ont montré son efficacité. Les technique cognitivo-comportementales et la relaxation ont également montré un bénéfice dans la gestion des douleurs chroniques en lien avec le cancer, son évaluation, les difficultés rencontrées et les premiers résultats de l'étude. Depuis Janvier 2017, 36 patients principalement des femmes (90%) suivis en cancérologie pour des cancers (tout stade confondu), ont participé au programme. Le taux de présence aux séances était de 75%. Les retours positifs ont motivés la poursuite et l'évaluation du CBSM. Dans le cadre du protocole de recherche, le stress perçu (PSS14) a été évalué comme critère de jugement principal ; le pourcentage de participation, la douleur, l'anxiété, la dépression et la qualité de vie comme critère de jugement secondaires. Du 01/09/2018 au 15/02/2019, l'étude a été proposée à 28 patients. Vingt-quatre (86%) ont été inclus. Quinze (56%) ont déjà participé aux séances avec un taux de présence de 89%. Aucun patient n'a réalisé la totalité des séances à ce jour. Sur un plan qualitatif, les patients ont eu des retours positifs quant à leur participation à ce groupe. L'étude n'étant pas terminée, il n'est pas possible de tirer de conclusion. Néanmoins, le taux de présence des patients ainsi que leur satisfaction globale sont très encourageants.