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Abstract Background Neurostimulation is a highly effective therapy for the treatment of chronic Intractable pain, however, due to the complexity of pain, measuring a subject’s long-term response to the therapy remains difficult. Frequent measurement of patient-reported outcomes (PROs) to reflect multiple aspects of subjects’ pain is a crucial step in determining therapy outcomes. However, collecting full-length PROs is burdensome for both patients and clinicians. The objective of this work is to identify the reduced set of questions from multiple validated PROs that can accurately characterize chronic pain patients’ responses to neurostimulation therapies. Methods Validated PROs were used to capture pain, physical function and disability, as well as psychometric, satisfaction, and global health metrics. PROs were collected from 509 patients implanted with Spinal Cord Stimulation (SCS) or Dorsal Root Ganglia (DRG) neurostimulators enrolled in the prospective, international, post-market REALITY study (NCT03876054, Registration Date: March 15, 2019). A combination of linear regression, Pearson’s correlation, and factor analysis were used to eliminate highly correlated questions and find the minimal meaningful set of questions within the predefined domains of each scale. Results The shortened versions of the questionnaires presented almost identical accuracy for classifying the therapy outcomes as compared to the validated full-length versions. In addition, principal component analysis was performed on all the PROs and showed a robust clustering of pain intensity, psychological factors, physical function, and sleep across multiple PROs. A selected set of questions captured from multiple PROs can provide adequate information for measuring neurostimulation therapy outcomes. Conclusions PROs are important subjective measures to evaluate the physiological and psychological aspects of pain. However, these measures are cumbersome to collect. These shorter and more targeted PROs could result in better patient engagement, and enhanced and more frequent data collection processes for digital health platforms that minimize patient burden while increasing therapeutic benefits for chronic pain patients.

Abstract Background Neurostimulation is an effective therapy for treating and management of refractory chronic pain. However, the complex nature of pain and infrequent in-clinic visits, determining subject’s long-term response to the therapy remains difficult. Frequent measurement of pain in this population can help with early diagnosis, disease progression monitoring, and evaluating long-term therapeutic efficacy. This paper compares the utilization of the common subjective patient-reported outcomes with objective measures captured through a wearable device for predicting the response to neurostimulation therapy. Method Data is from the ongoing international prospective post-market REALITY clinical study, which collects long-term patient-reported outcomes from 557 subjects implanted by Spinal Cord Stimulator (SCS) or Dorsal Root Ganglia (DRG) neurostimulators. The REALITY sub-study was designed for collecting additional wearables data on a subset of 20 participants implanted with SCS devices for up to six months post implantation. We first implemented a combination of dimensionality reduction algorithms and correlation analyses to explore the mathematical relationships between objective wearable data and subjective patient-reported outcomes. We then developed machine learning models to predict therapy outcome based on the subject’s response to the numerical rating scale (NRS) or patient global impression of change (PGIC). Results Principal component analysis showed that psychological aspects of pain were associated with heart rate variability, while movement-related measures were strongly associated with patient-reported outcomes related to physical function and social role participation. Our machine learning models using objective wearable data predicted PGIC and NRS outcomes with high accuracy without subjective data. The prediction accuracy was higher for PGIC compared with the NRS using subjective-only measures primarily driven by the patient satisfaction feature. Similarly, the PGIC questions reflect an overall change since the study onset and could be a better predictor of long-term neurostimulation therapy outcome. Conclusions The significance of this study is to introduce a novel use of wearable data collected from a subset of patients to capture multi-dimensional aspects of pain and compare the prediction power with the subjective data from a larger data set. The discovery of pain digital biomarkers could result in a better understanding of the patient’s response to therapy and their general well-being.

Background: Neurostimulation is a highly effective therapy for the treatment of chronic Intractable pain, however, due to the complexity of pain, measuring a subject's long-term response to the therapy remains difficult. Frequent measurement of patient-reported outcomes (PROs) to reflect multiple aspects of subjects' pain is a crucial step in determining therapy outcomes. However, collecting full-length PROs is burdensome for both patients and clinicians. The objective of this work is to identify the reduced set of questions from multiple validated PROs that can accurately characterize chronic pain patients' responses to neurostimulation therapies. Methods: Validated PROs were used to capture pain, physical function and disability, as well as psychometric, satisfaction, and global health metrics. PROs were collected from 509 patients implanted with Spinal Cord Stimulation (SCS) or Dorsal Root Ganglia (DRG) neurostimulators enrolled in the prospective, international, post-market REALITY study (NCT03876054, Registration Date: March 15, 2019). A combination of linear regression, Pearson's correlation, and factor analysis were used to eliminate highly correlated questions and find the minimal meaningful set of questions within the predefined domains of each scale. Results: The shortened versions of the questionnaires presented almost identical accuracy for classifying the therapy outcomes as compared to the validated full-length versions. In addition, principal component analysis was performed on all the PROs and showed a robust clustering of pain intensity, psychological factors, physical function, and sleep across multiple PROs. A selected set of questions captured from multiple PROs can provide adequate information for measuring neurostimulation therapy outcomes. Conclusions: PROs are important subjective measures to evaluate the physiological and psychological aspects of pain. However, these measures are cumbersome to collect. These shorter and more targeted PROs could result in better patient engagement, and enhanced and more frequent data collection processes for digital health platforms that minimize patient burden while increasing therapeutic benefits for chronic pain patients. [ABSTRACT FROM AUTHOR]

Background: Neurostimulation is an effective therapy for treating and management of refractory chronic pain. However, the complex nature of pain and infrequent in-clinic visits, determining subject's long-term response to the therapy remains difficult. Frequent measurement of pain in this population can help with early diagnosis, disease progression monitoring, and evaluating long-term therapeutic efficacy. This paper compares the utilization of the common subjective patient-reported outcomes with objective measures captured through a wearable device for predicting the response to neurostimulation therapy. Method: Data is from the ongoing international prospective post-market REALITY clinical study, which collects long-term patient-reported outcomes from 557 subjects implanted by Spinal Cord Stimulator (SCS) or Dorsal Root Ganglia (DRG) neurostimulators. The REALITY sub-study was designed for collecting additional wearables data on a subset of 20 participants implanted with SCS devices for up to six months post implantation. We first implemented a combination of dimensionality reduction algorithms and correlation analyses to explore the mathematical relationships between objective wearable data and subjective patient-reported outcomes. We then developed machine learning models to predict therapy outcome based on the subject's response to the numerical rating scale (NRS) or patient global impression of change (PGIC). Results: Principal component analysis showed that psychological aspects of pain were associated with heart rate variability, while movement-related measures were strongly associated with patient-reported outcomes related to physical function and social role participation. Our machine learning models using objective wearable data predicted PGIC and NRS outcomes with high accuracy without subjective data. The prediction accuracy was higher for PGIC compared with the NRS using subjective-only measures primarily driven by the patient satisfaction feature. Similarly, the PGIC questions reflect an overall change since the study onset and could be a better predictor of long-term neurostimulation therapy outcome. Conclusions: The significance of this study is to introduce a novel use of wearable data collected from a subset of patients to capture multi-dimensional aspects of pain and compare the prediction power with the subjective data from a larger data set. The discovery of pain digital biomarkers could result in a better understanding of the patient's response to therapy and their general well-being. [ABSTRACT FROM AUTHOR]

Importance: Chronic pain is a common condition for which efficacious interventions tailored to highly affected populations are urgently needed. People with HIV have a high prevalence of chronic pain and share phenotypic similarities with other highly affected populations., Objective: To evaluate the efficacy of a behavioral pain self-management intervention called Skills to Manage Pain (STOMP) compared to enhanced usual care (EUC)., Design, Setting, and Participants: This randomized clinical trial included adults with HIV who experienced at least moderate chronic pain for 3 months or more. The study was set at the University of Alabama at Birmingham and the University of North Carolina-Chapel Hill large medical centers from August 2019 to September 2022., Intervention: STOMP combined 1-on-1 skill-building sessions delivered by staff interventionists with group sessions co-led by peer interventionists. The EUC control group received the STOMP manual without any 1-on-1 or group instructional sessions., Main Outcomes and Measures: The primary outcome was pain severity and the impact of pain on function, measured by the Brief Pain Inventory (BPI) summary score. The primary a priori hypothesis was that STOMP would be associated with a decreased BPI in people with HIV compared to EUC., Results: Among 407 individuals screened, 278 were randomized to STOMP intervention (n = 139) or EUC control group (n = 139). Among the 278 people with HIV who were randomized, the mean (SD) age was 53.5 (10.0) years; 126 (45.0%) identified as female, 146 (53.0%) identified as male, 6 (2.0%) identified as transgender female. Of the 6 possible 1-on-1 sessions, participants attended a mean (SD) of 2.9 (2.5) sessions. Of the 6 possible group sessions, participants attended a mean (SD) of 2.4 (2.1) sessions. Immediately after the intervention compared to EUC, STOMP was associated with a statistically significant mean difference for the primary outcome, BPI total score: -1.25 points (95% CI, -1.71 to -0.78 points; P < .001). Three months after the intervention, the mean difference in BPI total score remained statistically significant, favoring the STOMP intervention -0.62 points (95% CI, -1.09 to -0.14 points; P = .01)., Conclusion and Relevance: The findings of this randomized clinical trial support the efficaciousness of STOMP as an intervention for chronic pain in people with HIV. Future research will include implementation studies and work to understand the optimal delivery of the intervention., Trial Registration: ClinicalTrials.gov Identifier: NCT03692611.

Background: The utilization of Tuina as a therapeutic intervention for the management of chronic pain has experienced a gradually increase in its popularity, and the purpose of this bibliometric analysis is to offer a comprehensive understanding of the current state and frontier trends, as well as to provide recommendations for future research directions., Methods: Publications on Tuina for chronic pain published between 2004 and 2023 were retrieved from the Web of Science Core Collection (WoSCC). Microsoft Excel, CiteSpace, VOSViewer, and the R package "bibliometrix" were used to quantitatively analyse the annual publication volume, countries/regions, journals, institutions, cited references, authors, and keywords., Results: A total of 287 publications were retrieved. The number of annual publications on the use of Tuina for treating chronic pain has gradually increased. Most publications were published in China and the United States. Notably, the most productive institution and author were identified as Shanghai University of Traditional Chinese Medicine and Min Fang, respectively. Medicine ranked first as the most influential affiliate and most productive journal. These publications came from 1650 authors, among whom Edzard Ernst had the most co-citations. Keyword analysis revealed that the new research frontier was low back pain., Conclusion: The utilization of Tuina for the treatment of chronic pain has been gaining increasing recognition. Acupuncture, randomised controlled trials, systematic reviews, etc. were the main research subjects. Furthermore, low back pain is the new research frontier. This study provides an in-depth perspective on Tuina for chronic pain, which provides valuable reference material for clinicians with insights of therapeutic strategy, educators with valuable topics, and researchers with new research directions., Competing Interests: Declaration of Competing Interest None., (Copyright © 2024 The Authors. Published by Elsevier Ltd.. All rights reserved.)

Virtual reality (VR) holds unmeasured potential as a multicomponent tool for managing chronic pain by adapting conventional in-person biopsychosocial pain management strategies into one virtual space. We review recent evidence showcasing the successful integration of cognitive behavioural therapy, mindfulness-based stress reduction, embodiment techniques, and physical therapy into VR environments, demonstrating positive outcomes in patients with chronic pain. We propose that future clinical and basic research build on this by integrating pain neuroscience techniques to help better understand pathophysiological pain mechanisms and treatment response. This could help facilitate early assessment and personalised treatment of chronic pain using a VR-based biopsychosocial approach., (Copyright © 2024 British Journal of Anaesthesia. Published by Elsevier Ltd. All rights reserved.)

Objective: This meta-analysis synthesizes research on the impact of cognitive restructuring on chronic pain intensity, aiming to integrate diverse methodologies and findings while evaluating potential moderators., Methods: Following PRISMA guidelines, we systematically searched multiple databases (PubMed, Web of Science, JSTOR, Sage, Social Science Research Network, PsycArticles, ScienceDirect, and Education Resources Information Center) until July 2023. Studies involving adults (≥18 years) diagnosed with chronic conditions who underwent cognitive restructuring to reduce chronic pain intensity, were included. Eligible studies compared this intervention with a control group. We excluded studies incorporating cognitive restructuring within broader interventions, lacking statistical data, or not written in English. Study quality was assessed using the Cochrane Risk of Bias tool (RoB 2)., Results: After reviewing 18,312 studies, we selected 11 studies published between 1991 and 2022, involving 693 participants with chronic conditions. A significant large overall effect size was found (d = 0.94, 95% CI 0.48 to 1.40). Moderation analyses revealed significant differences based on sex and study quality, with effects less pronounced among females and more substantial in higher-quality studies., Conclusion: Despite limitations such as statistical instability due to a small number of studies in certain moderator categories and methodological variability, this meta-analysis highlights the robust effects of cognitive restructuring on chronic pain intensity. The findings are valuable for guiding power calculations and future research expectations. Clinically, these results support the significant effect of cognitive restructuring in both individual and group settings, regardless of age, particularly when facilitated by teams that include psychologists., Competing Interests: Declaration of competing interest The authors have no competing interests to report., (Copyright © 2024 Elsevier Inc. All rights reserved.)

Background: Recent evidence suggests neuro-immune mechanisms may link dietary patterns to chronic painful conditions (CPC). In the research field of oro-facial pain (OFP), studies focuses primarily on dietary mechanical limitations due to pain and dysfunction., Objective: This narrative review aimed to overview the role of nutrition on CPC, with emphasis on temporomandibular disorder (TMD), enlightening OFP researcher on dietary assessment possibilities and providing directions for studies in the field of OFP and nutrition., Methods: A PubMed database search was performed using the MeSH and non-MeSH descriptors: "temporomandibular joint disorder"; "orofacial pain"; "musculoskeletal pain"; "chronic pain disorders"; "nutrition"; "diet"; "dietary therapy"; "dietary intake" and "inflammation". No time restrictions were applied. Literature reviews, systematic reviews, meta-analyses and clinical and pre-clinical trials were included., Results: Exogenous oxidants from unhealthy dietary patterns may contribute to peripheral and central pro-inflammatory immune signalling leading to peripheral and central sensitization. Furthermore, diets rich in bioactive compounds are suggested to contribute to pain management of CPC. High dietary intake of ultra-processed foods impacts the quality of the diet and shows adverse health outcomes. In this context, the role of nutrition on TMD remains overlooked., Conclusion: Considering diet may influence CPC, allied with the scarcity of studies evaluating the role of nutrition on TMD, well-designed clinical trials based on dietary assessments and measurements capable of evaluating food quality, UPF consumption and nutrient adequacy-added to serum nutrient levels evaluation-are suggested., (© 2024 John Wiley & Sons Ltd.)

Objective: To pilot test the COMmunity of Practice And Safety Support for Navigating Pain (COMPASS-NP) intervention for home care workers experiencing chronic pain., Methods: Home care workers with chronic pain participated (n = 19; 2 groups) in a 10-week online group program focused on workplace safety and pain self-management. Primary outcomes were changes in pain interference with work and life. Other outcomes related to ergonomics, pain levels, opioid misuse risk, mental health, sleep, and physical activity., Results: The intervention produced a large reduction in pain interference with life ( d = -0.85) and a moderate reduction in pain interference with work time demands ( d = -0.61). Secondary outcomes showed favorable effect sizes, including a substantial increase in the use of ergonomic tools and techniques ( d = 1.47)., Conclusion: Findings were strongly encouraging. The effectiveness of COMPASS-NP will be evaluated in a future randomized controlled trial., Competing Interests: Conflict of interest: None declared., (Copyright © 2024 American College of Occupational and Environmental Medicine.)

Objectives: Different types of spinal cord stimulation (SCS) have been evaluated for the management of chronic nonsurgical refractory back pain (NSRBP). A direct comparison between the different types of SCS or between closed-loop SCS with conventional medical management (CMM) for patients with NSRBP has not been previously conducted, and therefore, their relative effectiveness and cost-effectiveness remain unknown. The aim of this study was to perform a systematic review, network meta-analysis (NMA) and economic evaluation of closed-loop SCS compared with fixed-output SCS and CMM for patients with NSRBP., Methods: Databases were searched to September 8, 2023. Randomized controlled trials of SCS for NSRBP were included. The results of the studies were combined using fixed-effect NMA models. A cost-utility analysis was performed from the perspective of the UK National Health Service with results reported as incremental cost per quality-adjusted life-year (QALY)., Results: Closed-loop SCS resulted in statistically and clinically significant reductions in pain intensity (mean difference [MD] 32.72 [95% CrI 15.69-49.78]) and improvements in secondary outcomes (Oswestry Disability Index [ODI] and health-related quality of life [HRQoL]) compared with fixed-output SCS at 6-month follow-up. Compared with CMM, both closed-loop and fixed-output SCS resulted in statistically and clinically significant reductions in pain intensity (closed-loop SCS vs. CMM MD 101.58 [95% CrI 83.73-119.48]; fixed-output SCS versus CMM MD 68.86 [95% CrI 63.43-74.31]) and improvements in secondary outcomes (ODI and HRQoL). Cost-utility analysis showed that closed-loop SCS dominates fixed-output SCS and CMM, and fixed-output SCS also dominates CMM., Discussion: Current evidence showed that closed-loop and fixed-output SCS provide more benefits and cost-savings compared with CMM for patients with NSRBP., Competing Interests: This work was supported by Saluda Medical. S.E. reports consultancy fees from Medtronic, and Mainstay Medical outside the submitted work. He has received department research funding from the National Institute of Health Research, Saluda Medical and Medtronic. S.N. reports consultancy fees from Saluda Medical. A.B. MTech Access was commissioned by Saluda Medical to participate in this project. N.A.M. reports receiving grants from Neuros, Mesoblast, and Vivex Biologics, as well as consulting as a medical monitor for Saluda Medical, Nevro, Vivex Biologics, Mainstay, Sollis Therapeutics, and Vertos outside the submitted work. C.G. reports consulting fees and stock options received from Mainstay, personal fees from Mainstay, Saluda Medical, Persica, and Iliad outside the submitted work, research funded by Sollis, expert witness testimony fees, and serves as Editor-in-Chief of Pain Practice. B.B. reports an educational grant from Saluda Medical and consultancy fees from Salvia Bioelectronics, Medtronic and Abbott outside the submitted work. P.S.S. has received consultancy fees from Medtronic, Saluda Medical, Nalu, and Biotronic outside the submitted work, and has stock options from Saluda Medical and Nalu. M.M. reports no conflicts of interest. N.S., A.L., and R.V.D. are employees of Saluda Medical. R.V.D. has previously received consultancy fees from Mainstay Medical, Medtronic, and Saluda Medical outside the submitted work., (Copyright © 2024 The Author(s). Published by Wolters Kluwer Health, Inc.)

Abstract: Many patients suffer from chronic pain despite the absence of injury or sufficient biomedical disease to explain their pain. These pains are highly resistant to treatment. Psychological therapies designed to help patients undermine the negative thought and behavioral patterns that maintain pain provide only modest pain relief, leading to suspicion that such pain might be maintained by unconscious processes. An article in this issue of Psychosomatic Medicine provides the first experimental evidence that unconscious negative memories can increase pain unpleasantness. These findings are exciting, but the effect sizes are small, which is consistent with the small effects of psychological therapy. It seems that pain stubbornly resists psychological manipulation, but this work provides some hope that psychological therapy for pain can be improved to provide more effective pain relief., (Copyright © 2024 by the American Psychosomatic Society.)

Pain science education (PSE) can be used as part of treatment and prevention for chronic pain in children. We assessed the effectiveness of PSE on knowledge, beliefs, attitudes, and behaviors in children and the people that care for children. We set a minimum criterion for education to address pain biology knowledge. We included studies aimed at both treatment and prevention of chronic pain. We conducted searches using 5 databases. We assessed the risk of bias using the Cochrane Risk of Bias 2 tool. Data were pooled using a random-effects meta-analysis or assessed using a narrative synthesis. The certainty of evidence was assessed using the Grading of Recommendations, Assessment, Development and Evaluation. We screened 14,505 records and included 7 studies involving 351 caregivers and 1,285 children. Four studies were included in meta-analyses. We found low-certainty evidence that PSE has a large beneficial effect on caregiver knowledge and beliefs compared with alternative education (standardized mean difference = 1.14 [95% confidence interval: .88-1.42]; I 2 = 0%). We found no difference in functional disability in children with chronic pain after PSE (Functional Disability Inventory score mean difference = .73 [95% confidence interval: -.81 to 2.27; I = 0%]). Narrative syntheses showed low-certainty evidence for improved knowledge and beliefs in children with preventative and treatment effects. Overall, we found few studies, and along with high risk of bias, this significantly contributed to the low certainty of findings. The effect of learning pain science for both preventative and treatment effects in children, carers, and the child/carer dyad remains mostly unknown. This review was prospectively registered with The international Prospective register of systematic reviews (CRD42022344382) on July 22, 2022. PERSPECTIVE: This review examines the effect of PSE on pain-related knowledge, beliefs, attitudes, and behaviors in children and the people that care for children (0-18). The findings contribute to knowledge about pain treatments and health promotion for caregivers and their children with and without chronic pain., (Copyright © 2024 United States Association for the Study of Pain, Inc. Published by Elsevier Inc. All rights reserved.)

Objective: To investigate the predictive value of thoracic sympathetic ganglion block (TSGB) in response to ketamine infusion therapy (KIT) and spinal-cord stimulation (SCS) in patients with chronic upper-extremity pain including complex regional pain syndrome (CRPS)., Design: Retrospective., Setting: Tertiary hospital single-center., Subjects: Patients who underwent TSGB receiving KIT or SCS within a 3-year window., Methods: Positive TSGB outcomes were defined as ≥2 0-10 Numerical Rating Scale (NRS) score reduction at 2 weeks post-procedure. Positive KIT and SCS outcomes were determined by ≥2 NRS score reduction at 2-4 weeks post-KIT and ≥4 NRS score reduction at 2-4 weeks post-SCS implantation, respectively., Results: Among 207 patients who underwent TSGB, 38 received KIT and 34 underwent SCS implantation within 3 years post-TSGB; 33 patients receiving KIT and 32 patients receiving SCS were included. Among 33 patients who received KIT, 60.6% (n = 20) reported a ≥ 2 0-10 NRS pain-score reduction. Positive response to TSGB occurred in 70.0% (n = 14) KIT responders, significantly higher than that in 30.8% (n = 4) KIT non-responders. Multivariable analysis revealed a positive association between positive responses to TSGB and KIT (OR 7.004, 95% CI 1.26-39.02). Among 32 patients who underwent SCS implantation, 68.8% (n = 22) experienced short-term effectiveness. Positive response to TSGB was significantly higher in SCS responders (45.5%, n = 10) than in non-responders (0.0%). However, there were no associations between pain reduction post-TSGB and that post-KIT or post-SCS., Conclusions: A positive response to TSGB is a potential predictor for positive KIT and SCS outcomes among patients with chronic upper-extremity pain, including CRPS., (© The Author(s) 2024. Published by Oxford University Press on behalf of the American Academy of Pain Medicine. All rights reserved. For permissions, please e-mail: journals.permissions@oup.com.)

Chronic pain exerts a significant impact on the quality of life, giving rise to both physical and psycho-social vulnerabilities. It not only leads to direct costs associated with treatments, but also results in indirect costs due to the reduced productivity of affected individuals. Chronic conditions can be improved by reducing modifiable risk factors. Various educational programs, including the Chronic Disease Self-Management Programme (CDSMP), have demonstrated the advantages of enhancing patient empowerment and health literacy. Nevertheless, their efficacy in addressing pain symptoms has received limited attention, especially concerning vulnerable populations. This research aims to assess the effectiveness of the CDSMP in alleviating pain among socio-economically vulnerable participants with chronic conditions. By accounting for a wide range of variables, and using data from the EFFICHRONIC project (EU health programme), we investigated the changes in pain levels after the intervention, among 1070 participants from five European countries. Our analyses revealed a significant reduction in pain following the intervention. This finding supports the notion that training programs can effectively ameliorate pain and alleviate its impact on the quality of life, particularly in vulnerable populations. Younger participants, as well as those with higher education levels and individuals experiencing higher levels of pain at baseline, were more likely to experience a reduction in their pain levels. These findings underscore the importance of recognising the social determinants of health. The study was registered at ClinicalTrials.gov (ISRCTN70517103)., (© 2024 The Authors. The International Journal of Health Planning and Management published by John Wiley & Sons Ltd.)

Background: There is clear evidence demonstrating the benefits of physical activity (PA) on pain and overall health, however, PA is challenging for many individuals living with chronic pain. Even non-exercise specialists can (cost) effectively promote PA, but many health professionals report a number of barriers in providing guidance on PA, suggesting that it is not consistently promoted. This expert position paper summarizes the evidence and provides five recommendations for health professionals to assess, advise and support individuals living with any chronic pain condition with a long life expectancy in adopting and sustaining physically active lifestyles., Methods: This position paper was prepared by the 'On The Move' Task Force of the European Pain Federation EFIC. Final recommendations were endorsed by the European Pain Forum, Pain Alliance Europe and the Executive Board of EFIC., Results: We recommend that all health professionals (1) Take a history of the persons' PA levels, and put PA on the agenda, (2) Advise that PA is important and safe for individuals living with chronic pain, (3) Deliver a brief PA intervention and support individuals living with chronic pain in becoming physically active, (4) Discuss acceptable levels of PA-related soreness and pain and (5) Provide ongoing support in staying physically active., Significance: Physical activity is safe and offers several advantages, including general health benefits, low risk of side effects, low cost and not requiring access to healthcare. Adoption of these recommendations can improve the quality of care and life of individuals living with chronic pain and reduce their overall health risks., (© 2024 The Authors. European Journal of Pain published by John Wiley & Sons Ltd on behalf of European Pain Federation ‐ EFIC ®.)

This study used data from a randomized controlled trial on the efficacy of hypnosis with analgesic suggestions relative to hypnosis with nonspecific suggestions to explore two areas. The first was the immediate effects of each hypnosis session and their relevance to the treatment induced change in pain intensity. The second was the identification of variables associated with the beneficial effects of hypnosis treatment in the form of reducing pain intensity and pain quality. The predictive value of the initial treatment response, hypnotizability, and the dichotomous variable of pain medication use were examined. Both interventions resulted in similar significant reductions in pain intensity after each session, but without a cumulative effect. The initial response correlated positively and moderately with pain intensity decreases induced by the complete hypnosis treatment. There was only a weak association between hypnotizability and pain quality improvement. Only participants not taking pain medications achieved a meaningful reduction in pain outcomes. Each hypnosis session results in an immediate reduction in chronic nociplastic pain intensity, and a fruitful first session may be a positive signal to continue therapy. Even patients with low hypnotizability can obtain beneficial outcomes. Pain medication use may become a new predictor in hypnosis research, as significant decreases in pain intensity and pain quality occurred only in the absence of pharmacotherapy. However, the results of this study require confirmation in further research with longer treatment periods.

Background and Objective: The development, evaluation and implementation of digital self-management interventions for chronic pain have increased exponentially. While intervention outcomes appear promising to improve well-being and functioning in target populations, it is unclear how the development and evaluation processes were structured and how implementation was planned and executed. The aim of this systematic review is to provide a comprehensive overview of implementation frameworks used to guide and evaluate scientific innovation in chronic pain., Databases and Data Treatment: Four bibliography databases (Medline, Web of Science, PsycInfo, CINAHL) and two registries (PubMed Central, MedaRxiv) were systematically searched. Hits (n = 6830) and full texts (n = 351) were screened and read by two independent reviewers. Peer-reviewed articles that met the inclusion criteria were included in the narrative synthesis., Results: In total, 10 studies were identified that report on seven distinct interventions. Five implementation frameworks were utilized across these studies: Behavioural Interventions using Technology (BIT); Consolidated Framework for Implementation Research (CFIR); mHealth Agile and User-Centered Research and Development Lifecycle; Medical Research Council (MRC); Reach, Effectiveness, Adoption Implementation, and Maintenance (RE-AIM). Frameworks were operationalized using qualitative and quantitative methods, evaluating the innovation on various levels (e.g., individual vs. organizational) and applying a variety of study designs (e.g., single-arm or large trials)., Conclusions: By utilizing implementation frameworks, access to evidence-based chronic pain care may be increased. Although the evidence on the utility of implementation frameworks to guide and evaluate digital self-management interventions is still limited, the body of literature is increasing. Future studies are urged to operationalize, communicate and discuss the innovation process, to promote transparency and replicability., Significance: The use of implementation frameworks to guide and evaluate digital self-management interventions for chronic pain is a recent development in the field. Several promising examples exist and are presented in this review. Currently, the evidence is still limited, and prospective studies need to transparently operationalize, communicate and discuss their efforts. By utilizing an implementation framework, promising interventions can be made available to end-users, closing the research-to-clinical practice gap and increasing access to evidence-based care to people with chronic pain., (© 2024 The Authors. European Journal of Pain published by John Wiley & Sons Ltd on behalf of European Pain Federation ‐ EFIC ®.)

Purpose: During follow-up, patients in remission after oral or oropharyngeal cancer are few to express pain, depression or anxiety, their chief complain are dry mouth and difficulties to chewing. The aim of the study is to estimate prevalence of pain, quality of life and their evolution over four years., Methods: This prospective observational study included 21 patients between June and September 2017. Clinical examination, neurosensory examination and questionnaires (using visual analogic scale DN4, PCS-CF, HADS EORTC QLQ30 and H&N 35) were performed and a second time 4 years later., Results: After 4 years, 17 patients could be reviewed. In 2017 as in 2021, two patients (11.8 %) experience neuropathic pain. In 2017, 14 (82.3 %) reported paresthesia or dysesthesia or hypo/anesthesia, none of them have provoked pain to a mechanical or thermal stimulus. In 2021, only 9 (53 %) still report those symptoms. Global analysis of the questionnaire QLQC30 reveals a significant increase quality of life of all 17 patients (p = 0.0003). For the two questionnaires QLQC30 and QLQ-H&N 35, dry mouth, sticky saliva, difficulties for eating and relation with food, are strong grievances which an absence of amelioration or a degradation., Conclusions: Neurosensory disturbance is a frequent symptom but pain concerns only 11.8 % of patients. Quality of life increase globally, yet difficulties concerning oral cavity functions endure., Implications for Cancer Survivors: For remission patients, pain is an unfrequent situation unlike neurosensory disturbance. Support care improve life quality. In case of onset of pain, recurrence and osteoradionecrosis should be mentioned immediately., Competing Interests: Declaration of competing interest The authors have no relevant financial or non-financial interests to disclose., (Copyright © 2024. Published by Elsevier Masson SAS.)

Transgender and gender diverse (TGD) youth with chronic pain may be at unique risk for psychological distress and associated functional impairment, yet research on the intersection of chronic pain and gender identity is lacking. In a retrospective chart review of 491 participants admitted to a pediatric intensive interdisciplinary pain treatment (IIPT) program in the midwestern United States over an approximately 4-year period, 6.11% were TGD. TGD participants who completed the IIPT program reported significant and large improvements in anxiety, depression, pain catastrophizing, and functional ability. At baseline, TGD participants presented as more emotionally distressed and functionally impaired compared to age-matched, cisgender peers. When accounting for baseline scores, TGD participants who completed the IIPT program reported similar scores to cisgender peers at discharge, yet TGD youth were significantly less likely than cisgender peers to complete the IIPT program. Future directions and implications for clinical practice are discussed., (© 2024. The Author(s), under exclusive licence to Springer Science+Business Media, LLC, part of Springer Nature.)

Introduction: Chronic hip pain is a common painful condition in the elderly population. A mini invasive technique that is increasingly being considered for management of CHP is the percutaneous denervation of hip articular branches via radiofrequency ablation. We described a new ultrasound-guided technique based on the combination of 90° ultrasound-guided anterior radiofrequency ablation of the articular branches of femoral nerve, accessory obturator nerve and obturator nerve for anterior hip, combined with 90° ultrasound-guided ablation of the articular branches of the nerve of the quadratus femoris for posterior pericapsular neurolysis of the hip., Material E Methods: We retrospectively analyzed the medical records of patients from September 2022 to September 2023 treated for chronic hip pain in the ambulatory of Pain Management, identifying 22 patients who underwent ultrasound guided radiofrequency denervation of anterior hip articular branches alone (Group B); and 22 patients in which was also applied a radiofrequency denervation of the posterior articular branches, in addition to the anterior denervation (Group A). We analysed the pain intensity of both groups measured with numeric rating scale., Result: The combined anterior plus posterior approach ensured that the results obtained were maintained 6 months after the procedure (T3) with excellent pain control and an average NRS of 1455 for group A. While for the group B, with the anterior approach alone, the NRS at six months showed an upward trend with an average NRS of 3818. The dual approach is more effective in pain relief at 6 months with a statistically significant difference in NRS values (p < 0.001)., Conclusion: This retrospective observational study highlighted the greater impact of the double approach (anterior plus posterior) in the denervation of the hip joint, compared to anterior neurolysis alone., (© 2024. Società Italiana di Ultrasonologia in Medicina e Biologia (SIUMB).)

Objective: Previous studies evaluating interdisciplinary multimodal interventions for chronic spinal pain often excluded patients with comorbid mental disorders. This study aims to assess the effectiveness of an outpatient secondary care interdisciplinary multimodal integrative healthcare program for individuals experiencing co-occurring chronic spinal pain and mental disorders., Methods: Participants were 944 patients with chronic spinal pain and comorbid mental disorders. Primary outcomes were health-related quality of life, assessed using the Research and Development-36 (RAND-36), and pain-related disability, assessed using the Quebec Back Pain Disability Scale (QBPDS). Secondary outcomes included pain intensity, pain catastrophizing, kinesiophobia, fatigue, lumbar mobility, and isometric strength. Data were collected during the healthcare program at four time points: pretreatment (T0), midway through 20-week treatment (T1), end of 20-week treatment (T2), and at completion of 12-month relapse prevention program (T3). Multilevel regression analyses were conducted to examine the effects of the healthcare program on primary outcomes over time., Results: The 20-week treatment period yielded significant improvements in both mental ( B = 0.44, t (943) = 19.42, p < .001) and physical component summary scores ( B = 0.45, t (943) = 18.24, p < .001) of the RAND-36, as well as in QBPDS total score ( B = -0.77, t (943) = -26.16 p < .001). Pretreatment scores indicated the presence of problematic fatigue, kinesiophobia, and clinical levels of pain catastrophizing, all of which resolved by the end of the 12-month relapse prevention program., Conclusions: An interdisciplinary multimodal integrative healthcare program seems effective for patients with chronic spinal pain and comorbid mental disorders., (Copyright © 2024 by the American Psychosomatic Society.)

Positive treatment expectations demonstrably shape treatment outcomes regarding pain and disability in patients with chronic low back pain. However, knowledge about positive and negative treatment expectations as putative predictors of interindividual variability in treatment outcomes is sparse, and the role of other psychological variables of interest, especially of depression as a known predictor of long-term disability, is lacking. We present results of the first prospective study considering expectations in concert with depression in a sample of 200 patients with chronic low back pain undergoing an inpatient interdisciplinary multimodal pain therapy. We analyzed the characteristics of pain and disability, treatment expectation, and depression assessed at the beginning (T0), at the end of (T1), and at 3-month follow-up (T2) of interdisciplinary multimodal pain therapy. Treatment expectations did emerge as a significant predictor of changes in pain intensity and disability, respectively, showing that positive expectations were associated with better treatment outcomes. Mediation analyses revealed a partially mediating effect of treatment expectations on the relation between depression and pain outcomes. PERSPECTIVE: These results expand knowledge regarding the role of treatment expectations in individual treatment outcome trajectories in chronic pain patients, paving the way for much-needed efforts toward optimizing patient expectations and personalized approaches in clinical settings., (Copyright © 2024 United States Association for the Study of Pain, Inc. Published by Elsevier Inc. All rights reserved.)

Chronic pain is a common disorder with enormous sociomedical importance. A major part of primary and secondary costs of illness is caused by the various pain syndromes. Nociception - the sensory perception of a painful stimulus - is a complex process relying on an intricate system of anatomical, neurophysiological and biochemical networks. This applies even more so to pain - the state of experiencing a nociceptive event, of interpreting it in terms of meaning for the affected individual and of suffering a range of emotions it elicits. This intricacy renders it obvious, that the empirical medical sciences alone cannot explain all aspects of pain. Hence, it has also become a focus of phenomenological research. One aspect of these investigations is the interaction of pain and the perception of the lived body's spatiality. The focus of this article will build on these concepts to develop a construct of the alteration of temporality caused by chronic pain and the effects this spells out for the affected subject. To this end, I will primarily draw on Merleau-Ponty's ideas of the lived body as well as on theories of enactivism and embodiment. I will also point out parallels to neuroscientific data, thereby demonstrating the proximity of phenomenology and neuroscience. A possible partial solution to the pain dilemma may be derived from psychology: techniques relying on cognitive behavioural intervention, awareness training, and existential analysis may provide alleviation to patients suffering from chronic pain., (© 2024. The Author(s).)

Background: Depression and chronic pain frequent co-occur, exacerbating each other's symptoms and hindering treatment. Emerging studies have highlighted abnormal gut microbiota in both conditions. Previous studies have demonstrated the clinical effectiveness of electro-acupuncture (EA) in managing these conditions, yet the underlying mechanisms remain elusive., Methods: Spared nerve injury (SNI) was employed to induce chronic pain and depression-like behavior. Rats were randomly assigned to sham SNI (SS), SNI, and EA groups. SNI surgery was performed on all rats, except those in SS group, which underwent sham SNI surgery. Then EA group received 5 weeks of EA treatment. Pain and depression-like behavior were assessed through paw withdrawal threshold, sucrose-preference test, and forced swim test. Gut microbiota composition was analyzed via 16S rDNA sequencing. Brain-Derived Neurotrophic Factor (BDNF) and acetylation-related proteins in the medial prefrontal cortex (mPFC) were evaluated through enzyme-linked immunosorbent assay and western blot., Results: EA treatment significantly ameliorated pain and depression-like behavior. The 16S rDNA sequencing showed EA modulated gut microbiota composition, increased short-chain fatty acids (SCFAs)-producing bacteria, including Akkermansi, Ruminococcaceae and Lachnospiraceae family, particularly Akkermansia. Furthermore, EA increased BDNF, AcH3 and decreased HDAC2 in mPFC. Notably, SCFAs-producing bacteria exhibited a negative correlation with HDAC2 levels., Limitations: This study exclusively investigated microbiota differences resulting from EA stimulation, without delving into the functional variations brought about by these microbial distinctions., Conclusions: The therapeutic effects of EA on the comorbidity of chronic pain and depression may involve the modulation of the gut microbiota, resulting in histone acetylation changes and upregulation of BDNF., Competing Interests: Declaration of competing interest The authors declared that there was no conflict of interest regarding the publication of this paper., (Copyright © 2024. Published by Elsevier B.V.)

Objectives: To investigate the effect of emotion regulation skills-focused (ERSF) interventions to reduce pain intensity and improve psychological outcomes for people with chronic pain and to narratively report on safety and intervention compliance., Methods: Six databases and four registries were searched for randomized controlled trials (RCTs) up to 29 April 2022. Risk of bias was evaluated using the Cochrane RoB 2.0 tool, and certainty of evidence was assessed according to the Grading, Assessment, Development and Evaluation (GRADE). Meta-analyses for eight studies (902 participants) assessed pain intensity (primary outcome), emotion regulation, affect, symptoms of depression and anxiety, and pain interference (secondary outcomes), at two time points when available, post-intervention (closest to intervention end) and follow-up (the first measurement after the post-intervention assessment)., Results: Compared to TAU, pain intensity improved post-intervention (weighted mean difference [WMD] = -10.86; 95% confidence interval [CI] [-17.55, -2.56]) and at follow-up (WMD = -11.38; 95% CI [-13.55, -9.21]). Emotion regulation improved post-intervention (standard mean difference [SMD] = 0.57; 95% CI [0.14, 1.01]), and depressive symptoms improved at follow-up (SMD = -0.45; 95% CI [-0.66, -0.24]). Compared to active comparators, anxiety symptoms improved favouring the comparator post-intervention (SMD = 0.10; 95% CI [0.03, 0.18]), and compared to CBT, pain interference improved post-intervention (SMD = -0.37; 95% CI [-0.69, -0.04]). Certainty of evidence ranged from very low to moderate., Significance: The findings provide evidence that ERSF interventions reduce pain intensity for people with chronic pain compared to usual treatment. These interventions are at least as beneficial to reduce pain intensity as the current gold standard psychological intervention, CBT. However, the limited number of studies and certainty of evidence mean further high-quality RCTs are warranted. Additionally, further research is needed to identify whether ERSF interventions may be more beneficial for specific chronic pain conditions., (© 2024 The Authors. European Journal of Pain published by John Wiley & Sons Ltd on behalf of European Pain Federation ‐ EFIC ®.)

Comorbid chronic neuropathic pain and anxiety is a common disease that represents a major clinical challenge. The underlying mechanisms of chronic neuropathic pain and anxiety are not entirely understood, which limits the exploration of effective treatment methods. Glutamatergic neurons in the ventrolateral periaqueductal gray (vlPAG) have been implicated in regulating pain, but the potential roles of the vlPAG in neuropathic pain-induced anxiety have not been investigated. Herein, whole-cell recording and immunofluorescence showed that the excitability of CamkIIα neurons in the vlPAG (vlPAG CamkIIα+ neurons) was decreased in mice with spared nerve injury (SNI), while electroacupuncture (EA) activated these neurons. We also showed that chemogenetic inhibition of vlPAG CamkIIα+ neurons resulted in allodynia and anxiety-like behaviors in naive mice. Furthermore, chemogenetic activation of vlPAG CamkIIα+ neurons reduced anxiety-like behaviors and allodynia in mice with SNI, and EA had a similar effect in alleviating these symptoms. Nevertheless, EA combined with chemogenetic activation failed to further relieve allodynia and anxiety-like behaviors. Artificial inhibition of vlPAG CamkIIα+ neurons abolished the analgesic and anxiolytic effects of EA. Overall, our study reveals a novel mechanism of neuropathic pain-induced anxiety and shows that EA may relieve comorbid chronic neuropathic pain and anxiety by activating vlPAG CamkIIα+ neurons., Competing Interests: The authors declare no competing financial interests., (Copyright © 2024 Zhu et al.)

Objective: To develop and internally validate a prognostic model to predict chronic pain after a new episode of acute or subacute non-specific idiopathic, non-traumatic neck pain in patients presenting to physiotherapy primary care, emphasising modifiable biomedical, psychological and social factors., Design: A prospective cohort study with a 6-month follow-up between January 2020 and March 2023., Setting: 30 physiotherapy primary care practices., Participants: Patients with a new presentation of non-specific idiopathic, non-traumatic neck pain, with a duration lasting no longer than 12 weeks from onset., Baseline Measures: Candidate prognostic variables collected from participants included age and sex, neck pain symptoms, work-related factors, general factors, psychological and behavioural factors and the remaining factors: therapeutic relation and healthcare provider attitude., Outcome Measures: Pain intensity at 6 weeks, 3 months and 6 months on a Numeric Pain Rating Scale (NPRS) after inclusion. An NPRS score of ≥3 at each time point was used to define chronic neck pain., Results: 62 (10%) of the 603 participants developed chronic neck pain. The prognostic factors in the final model were sex, pain intensity, reported pain in different body regions, headache since and before the neck pain, posture during work, employment status, illness beliefs about pain identity and recovery, treatment beliefs, distress and self-efficacy. The model demonstrated an optimism-corrected area under the curve of 0.83 and a corrected R 2 of 0.24. Calibration was deemed acceptable to good, as indicated by the calibration curve. The Hosmer-Lemeshow test yielded a p-value of 0.7167, indicating a good model fit., Conclusion: This model has the potential to obtain a valid prognosis for developing chronic pain after a new episode of acute and subacute non-specific idiopathic, non-traumatic neck pain. It includes mostly potentially modifiable factors for physiotherapy practice. External validation of this model is recommended., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2024. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)

Background: Virtual reality (VR) in different immersive conditions has been increasingly used as a nonpharmacological method for managing chronic musculoskeletal pain., Objective: We aimed to assess the effectiveness of VR-assisted active training versus conventional exercise or physiotherapy in chronic musculoskeletal pain and to analyze the effects of immersive versus nonimmersive VR on pain outcomes., Methods: This systematic review of randomized control trials (RCTs) searched PubMed, Scopus, and Web of Science databases from inception to June 9, 2024. RCTs comparing adults with chronic musculoskeletal pain receiving VR-assisted training were included. The primary outcome was pain intensity; secondary outcomes included functional disability and kinesiophobia. Available data were pooled in a meta-analysis. Studies were graded using the Cochrane Risk-of-Bias Tool version 2., Results: In total, 28 RCTs including 1114 participants with some concerns for a high risk of bias were identified, and 25 RCTs were included in the meta-analysis. In low back pain, short-term outcomes measured post intervention showed that nonimmersive VR is effective in reducing pain (standardized mean difference [SMD] -1.79, 95% CI -2.72 to -0.87; P<.001), improving disability (SMD -0.44, 95% CI -0.72 to -0.16; P=.002), and kinesiophobia (SMD -2.94, 95% CI -5.20 to -0.68; P=.01). Intermediate-term outcomes measured at 6 months also showed that nonimmersive VR is effective in reducing pain (SMD -8.15, 95% CI -15.29 to -1.01; P=.03), and kinesiophobia (SMD -4.28, 95% CI -8.12 to -0.44; P=.03) compared to conventional active training. For neck pain, immersive VR reduced pain intensity (SMD -0.55, 95% CI -1.02 to -0.08; P=.02) but not disability and kinesiophobia in the short term. No statistical significances were detected for knee pain or other pain regions at all time points. In addition, 2 (8%) studies had a high risk of bias., Conclusions: Both nonimmersive and immersive VR-assisted active training is effective in reducing back and neck pain symptoms. Our study findings suggest that VR is effective in alleviating chronic musculoskeletal pain., Trial Registration: PROSPERO CRD42022302912; https://www.crd.york.ac.uk/prospero/display&#95;record.php?RecordID=302912., (©Hermione Hin Man Lo, Mengting Zhu, Zihui Zou, Cho Lee Wong, Suzanne Hoi Shan Lo, Vincent Chi-Ho Chung, Samuel Yeung-Shan Wong, Regina Wing Shan Sit. Originally published in the Journal of Medical Internet Research (https://www.jmir.org), 19.08.2024.)

Introduction: Standard medical intervention for chronic pain may be less effective in the presence of co-occurring PTSD. Functional restoration programs (FRPs), which combine psychological interventions and progressive exercise rehabilitation, represent an alternative to standard medical intervention for chronic pain. The objective of the current study is to evaluate a FRP serving Active Duty Service Members with chronic pain and to examine whether co-occurring PTSD symptoms are associated with differential treatment response., Methods: This is a retrospective observational study of data previously collected at Naval Medical Center San Diego approved by the Naval Medical Center San Diego Institutional Review Board. The study included 81 Active Duty Service Members, primarily Sailors and Marines, who completed a FRP, and examined pre- to post-treatment changes in Pain Impact Score-a composite measure of pain intensity, pain interference, and physical functioning-as well as measures of mental health and pain cognitions. Co-occurring PTSD symptoms were examined as a potential moderator of treatment response., Results: Twenty-three patients (28.4%) screened positive for PTSD during baseline assessments. Repeated measures analysis of variance showed statistically significant improvement in Pain Impact Score for the full sample (P <.001). Although no significant interactions with probable PTSD were demonstrated for measures of pain intensity and physical functioning (both Ps >.05), patients screening positive for PTSD demonstrated a lesser decrease in pain interference compared to patients screening negative for PTSD (P <.01). Improvements in measures of mental health and pain cognitions were also statistically significant for the full sample (all P values <.05) and did not differ as a function of PTSD symptoms (all P values >.05)., Conclusion: This FRP primarily serving Sailors and Marines contributed to broad overall improvements in the domains of pain and functioning as well as mental health and pain cognitions. Co-occurring PTSD symptoms were not associated with poorer treatment response on most measured outcomes., (© The Association of Military Surgeons of the United States 2024. All rights reserved. For commercial re-use, please contact reprints@oup.com for reprints and translation rights for reprints. All other permissions can be obtained through our RightsLink service via the Permissions link on the article page on our site–for further information please contact journals.permissions@oup.com.)

Background: Chronic pain often clusters in families, where parents and their offspring both experience chronic pain conditions. Young children of parents with irritable bowel syndrome (IBS) represent an at-risk group for the development of abdominal pain, disability, and excess health care visits in later childhood. Parental solicitous responses to children's expressions of discomfort and maternal modeling of their own illness behavior contribute to a greater focus on somatic sensations, leading to illness behaviors in children. This randomized controlled trial will test the effectiveness of an early preventive web-based psychosocial intervention (REACH)[TM] vs. an educational web-based safety comparison condition delivered to parents with IBS to alter parental responses and lead to improved child health and decreased health care costs., Methods: Parents with IBS who have children ages 4-7 years are recruited via community-based approaches (e.g., social media advertisements, school electronic distribution, research networks) and health care providers. The target sample is 460 parents randomized to REACH, a web-based social learning and cognitive behavior therapy (SLCBT) intervention or an educational web-based safety comparison condition (EC). Participants will be assessed at baseline, 6-week (immediate post-intervention), 6-month, 12-month, and 18-month follow-up periods (months post-completion of intervention). The primary outcome is change in parental solicitous/protective behaviors. Secondary outcomes include parent risk and protective factors, child health and symptom outcomes, and health care utilization and cost savings., Discussion: This study adapts a validated, parent-delivered intervention to treat chronic pain in children to a web-based application designed to prevent the development of chronic pain in very young, high-risk children. If successful, this strategy can both prevent adverse sequelae of this condition from developing as well as be widely accessible. Furthermore, the availability of a prevention model for parent training could result in significant short- and long-term health benefits across a broad spectrum of conditions., Trial Registration: ClinicalTrials.gov NCT05730491. Registered on February 15, 2023., (© 2024. The Author(s).)

Background: Mobile technologies are increasingly being used in health care and public health practice for patient communication, monitoring, and education. Mobile health (mHealth) tools have also been used to facilitate adherence to chronic musculoskeletal pain (CMP) management, which is critical to achieving improved pain outcomes, quality of life, and cost-effective health care., Objective: The aim of this systematic review was to evaluate the 25-year trend of the literature on the adherence, usability, feasibility, and acceptability of mHealth interventions in CMP management among patients and health care providers., Methods: We searched the PubMed, Cochrane CENTRAL, MEDLINE, EMBASE, and Web of Science databases for studies assessing the role of mHealth in CMP management from January 1999 to December 2023. Outcomes of interest included the effect of mHealth interventions on patient adherence; pain-specific clinical outcomes after the intervention; and the usability, feasibility, and acceptability of mHealth tools and platforms in chronic pain management among target end users., Results: A total of 89 articles (26,429 participants) were included in the systematic review. Mobile apps were the most commonly used mHealth tools (78/89, 88%) among the included studies, followed by mobile app plus monitor (5/89, 6%), mobile app plus wearable sensor (4/89, 4%), and web-based mobile app plus monitor (1/89, 1%). Usability, feasibility, and acceptability or patient preferences for mHealth interventions were assessed in 26% (23/89) of the studies and observed to be generally high. Overall, 30% (27/89) of the studies used a randomized controlled trial (RCT), cohort, or pilot design to assess the impact of the mHealth intervention on patients' adherence, with significant improvements (all P<.05) observed in 93% (25/27) of these studies. Significant (judged at P<.05) between-group differences were reported in 27 of the 29 (93%) RCTs that measured the effect of mHealth on CMP-specific clinical outcomes., Conclusions: There is great potential for mHealth tools to better facilitate adherence to CMP management, and the current evidence supporting their effectiveness is generally high. Further research should focus on the cost-effectiveness of mHealth interventions for better incorporating these tools into health care practices., Trial Registration: International Prospective Register of Systematic Reviews (PROSPERO) CRD42024524634; https://www.crd.york.ac.uk/prospero/display&#95;record.php?RecordID=524634., (©Jenny Lin-Hong Shi, Regina Wing-Shan Sit. Originally published in the Journal of Medical Internet Research (https://www.jmir.org), 16.08.2024.)

Background: Spinal Cord Stimulation (SCS) may provide pain relief in patients with therapy-refractory Persistent Spinal Pain Syndrome Type II (PSPS-T2). Despite the evidence that SCS can reduce disability and reduce pain medication usage, only 25% of the patients is able to completely omit pain medication usage after 12 months of SCS. To tackle the high burden of patients who consume a lot of pain medication, tapering programs could be initiated before starting a trajectory with SCS. The current objective is to examine whether a pain medication tapering program before SCS alters disability in PSPS-T2 patients compared to no tapering program., Methods and Design: A three-arm, parallel-group multicenter randomized controlled trial will be conducted including 195 patients who will be randomized (1:1:1) to either (a) a standardized pain medication tapering program, (b) a personalized pain medication tapering program, or (c) no tapering program before SCS implantation, all with a follow-up period until 12 months after implantation. The primary outcome is disability. The secondary outcomes are pain intensity, health-related quality of life, participation, domains affected by substance use, anxiety and depression, medication usage, psychological constructs, sleep, symptoms of central sensitization, and healthcare expenditure., Discussion: Within the PIANISSIMO project we propose a way to reduce the risks of adverse events, medication-induced hyperalgesia, tolerance, and dependence by providing pain medication tapering before SCS. Due to the lack of a commonly accepted in-hospital tapering approach, two different tapering programs will be evaluated in this study. If pain medication tapering programs are deemed to be more effective than no tapering on disability, this would add to the evidence towards an improved patient-centered care model in this patient group and set a clear path to advocate for pain medication tapering before SCS as the new standard treatment guideline for these patients., Trial Registration: ClinicalTrials.gov NCT05861609. Registered on May 17, 2023., Competing Interests: Lisa Goudman is a postdoctoral research fellow funded by the Research Foundation Flanders (FWO), Belgium (project number 12ZF622N). Maarten Moens has received speaker fees from Medtronic, Nevro and Saluda Medical. STIMULUS received independent research grants from Medtronic. There are no other conflicts of interest to declare., (Copyright: © 2024 Moens et al. This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.)

Background: Sex is an important factor influencing the development and treatment of chronic pain, but the extent of its influence is still unclear. Other demographic factors as well as nonpharmacological interventions might influence pain sensitivity differently in men and women., Objective: In this study, we aimed to investigate the influence of sex and other demographic, lifestyle, behavioral, clinical, and environmental factors on pain sensitivity in the Dutch population. Different films were used to investigate how they would impact pain sensitivity and what influence sex and other variables have on the effect of this simple intervention., Methods: We performed a study consisting of 2 parts: (1) a cross-sectional research to investigate pain sensitivity differences between men and women and the influence of other demographic variables on the pain sensitivity in a Dutch cohort and (2) an internet intervention study to determine whether a short film could skew pain sensitivity., Results: All respondents filled in a web-based demographic questionnaire and were randomized into 4 groups. The control group filled in the Pain Sensitivity Questionnaire without watching a preliminary film. A cross-sectional analysis was performed in the control group (n=1746). The other 3 groups watched short films: one group watched a film with scenes of nature (n=2650), another group watched a film on laughing people (n=2735), and the last group watched a film on physically painful events (n=2708). Immediately after the film viewing, participants were directed to the Pain Sensitivity Questionnaire to measure their pain sensitivity. The Pain Sensitivity Questionnaire score was stated as a mean per question on the numeric rating scale from 0-1. The cross-sectional study revealed no significant differences between men and women but showed male-female differences in the Pain Sensitivity Questionnaire when specific background factors were present. Watching a short film had a positive impact on the pain sensitivity of the respondents who had chronic pain, with a higher effect observed in female respondents., Conclusions: Scientists performing pain research need to account for factors that can influence the outcome of their study and be aware that these factors can be sex-dependent, and pain sensitivity should be analyzed accordingly. Even relatively small interventions such as watching a film can impact pain sensitivity, especially in respondents with current chronic pain. This effect can vary as well when different background factors are present. Our findings warrant further explorations of the possibilities that simple interventions bring for patients in personalized medicine., Trial Registration: Landelijk Trial Register NTR-new NL8182; https://onderzoekmetmensen.nl/en/trial/29537., (©Rachel J H Smits, Selina E I van der Wal, Regina L M van Boekel, Hans Timmerman, Ewald M Bronkhorst, Diana Abrar, Kris C P Vissers, Esmeralda N Blaney Davidson, Monique A H Steegers. Originally published in the Journal of Medical Internet Research (https://www.jmir.org), 09.08.2024.)

Introduction: Chronic pain increases the risk of prescription opioid misuse or opioid use disorder (OUD). Non-pharmacological treatments are needed to dually address pain and opioid risks. The purpose of the Mobile and Online-Based Interventions to Lessen Pain (MOBILE Relief) study is to compare a one-session, video-based, on-demand digital pain relief skills intervention for chronic pain ('Empowered Relief' (ER); tailored to people at risk for opioid misuse or with opioid misuse/OUD) to a one-session digital health education intervention ('Living Better'; no pain management skills)., Methods and Analysis: MOBILE Relief is an international online randomised controlled clinical trial. Study participants are adults with chronic, non-cancer pain (≥6 months) with daily pain intensity ≥3/10, taking ≥10 morphine equivalent daily dose and score ≥6 on the Current Opioid Misuse Measure. Participants are recruited through clinician referrals and clinic advertisements. Study procedures include electronic eligibility screening, informed consent, automated 1:1 randomisation to the treatment group, baseline measures, receipt of assigned digital treatment and six post-treatment surveys spanning 3 months. Study staff will call participants at baseline and 1-month and 3 months post-treatment to verify the opioid prescription. The main statistical analyses will include analysis of covariance and mixed effects model for repeated measurements regression., Main Outcomes: Primary outcomes are self-reported pain catastrophising, pain intensity, pain interference, opioid craving and opioid misuse at 1-month and 3 months post-treatment. We will determine the feasibility of ER (≥50% participant engagement, ≥70% treatment appraisal ratings). We hypothesise the ER group will be superior to the Living Better group in the reduction of multiprimary pain outcomes at 1-month post-treatment and opioid outcomes at 1-month and 3 months post-treatment., Ethics and Dissemination: The study protocol was approved by the Stanford University School of Medicine Institutional Review Board (IRB 61643). We will publish results in peer-reviewed journals; National Institute of Drug Abuse (funder) and MOBILE Relief participants will receive result summaries., Trial Registration Number: NCT05152134., Competing Interests: Competing interests: Stanford University receives fees for continuing medical education ER clinician certification workshops; BD receives no personal monies for the ER certification workshops, nor for dissemination or adoption of ER. BD is the Chief Science Advisor at Applied VR, and her consulting role with this company (personal fees) is unrelated to the current research. BD receives royalties for four pain treatment books she has authored or coauthored. She is the principal investigator for two pain research awards from the Patient-Centered Research Outcomes Research Institute, one of which involves the study of ER. BD is the principal investigator for two NIH grants that are investigating the efficacy of ER (one is the MOBILE Relief study). BD serves on the Board of Directors for the Institute for Brain Potential (which is licensed by Stanford University to offer ER clinician certification workshops), and is on the Medical Advisory Board for the Facial Pain Association. BD is a scientific member of the NIH Interagency Pain Research Coordinating Committee, a former member of the Centers for Disease Control and Prevention Opioid Workgroup (2020–2021), and a current member of the Pain Advisory Group of the American Psychological Association. SM receives research funding from the NIH, Food and Drug Administration and Patient-Centered Outcomes Research Institute (administered through Stanford University). He is an unpaid advisor to both ACTTION (Analgesic, Anesthetic, and Addiction Clinical Trial Translations, Innovations, Opportunities and Networks) on their oversight committee and the American Chronic Pain Association (ACPA) for their scientific oversight. All other authors report no disclosures or conflicts of interest., (© Author(s) (or their employer(s)) 2024. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)

Background & Objective: Psychologically informed care has been proposed to improve treatment outcomes for chronic pain and aligns with a person-centered approach. Yet implementation lags behind, and studies suggest that a lack of competency leads to poor results. It is unclear what training clinicians require to deliver this care. We examine how we might improve psychologically informed care guided by the needs of the patient and in congruence with the scientific literature with a particular focus on how competencies might be upgraded and implementation enhanced., Methods: We selectively review the literature for psychologically informed care for pain. The patient's view on what is needed is contrasted with the competencies necessary to meet these needs and how treatment should be evaluated., Results: Patient needs and corresponding competencies are delineated. A number of multi-professional skills and competencies are required to provide psychologically informed care. Single-subject methodologies can determine whether the care has the desired effect for the individual patient and facilitate effectiveness. We argue that becoming a competent "pain clinician" requires a new approach to education that transcends current professional boundaries., Conclusions: Providing person-centered care guided by the needs of the patient and in line with the scientific literature shows great potential but requires multiple competencies. We propose that training the pain clinician of the future should focus on psychologically informed care and the competencies required to meet the individual's needs. Single-subject methodology allows for continual evaluation of this care., (© 2024 the author(s), published by De Gruyter.)

Background: Most patients with cervical radiculopathy improve within the first months without treatment or with non-surgical treatment. A systematic review concluded that these patients improve, regardless of their intervention. Still, many patients are offered surgery, despite limited evidence regarding the indications for surgical treatments. The aim of this article is to describe the intervention that is going to be followed in the non-surgical treatment arm of a randomised controlled trial (RCT) comparing the effectiveness of surgical and non-surgical treatment for patients with cervical radiculopathy., Methods: The non-surgical intervention is a functional intervention within a cognitive approach founded on previous experiences, and current recommendations for best practice care of musculoskeletal pain and cervical radiculopathy. It is based on the biopsychosocial rather than a biomedical perspective, comprises an interdisciplinary approach (physicians, physiotherapy specialists), and includes brief intervention and graded activities. The intervention consists of 6 sessions over 12 weeks. The primary goals are first, to validate the patients´ symptoms and build a therapeutic alliance, second, to explore the understanding and promote alternatives, and third, to explore problems and opportunities based on patients´ symptoms and function. Motivational factors toward self-management are challenging. We will attempt shared decision-making in planning progress for the individual patient and emphasise learning of practical self-help strategies and encouragement to stay active (reinforcing the positive natural course). General physical activities such as walking will be promoted along with simple functional exercises for the neck- and shoulder region. We will also explore social activity, comorbidities, pain location, sleep, and work-related factors. The health providers will set individualised goals together with each patient., Discussion: The aim of the intervention is to describe a functional intervention within a cognitive approach for patients with chronic cervical radiculopathy. The effectiveness of the present program will be compared to surgery in a randomised controlled trial., (© 2024. The Author(s).)

Objective: Rehabilitation interventions for chronic pain typically include education, cognitive behavioural therapy, and exercise therapy, or a combination of these. A systematic review and meta-analysis of rehabilitation interventions for neuropathic pain was conducted., Design: Randomized controlled trials were identified in PubMed, EMBASE, Cochrane Central Register of Controlled Trials, and PsycINFO databases from inception up to 3 March 2022., Subjects/patients: Adults with chronic (> 3 months) neuropathic pain., Methods: Primary outcomes were pain intensity, pain-related disability, and work participation. Secondary outcomes were quality of life, emotional strain, insomnia, and adverse outcomes, according to VAPAIN guidelines. Analyses were made post-intervention, which was defined as the assessment point immediately following the intervention or at the first-time measurement conducted after the intervention period., Results: In total, 15 studies (total population, n = 764) were incorporated. Most common interventions were cognitive behavioural programmes including acceptance and commitment therapy (n = 4), mindfulness-based interventions (n = 5), and yoga (n  =  2). Psychological interventions reduced both pain intensity (SMD -0.49, 95% CI -0.88 to -0.10) and pain-related disability (SMD -0.51, 95% CI -0.98 to -0.03), whereas other interventions had an effect on pain intensity but not on pain-related disability., Conclusion: Rehabilitation interventions, and psychological interventions in particular, seem to be of value for patients with chronic neuropathic pain.

People living with chronic primary or secondary musculoskeletal pain conditions such as low back pain, fibromyalgia, and inflammatory arthritis typically experience wide-ranging impacts on their physical function, activity participation, and psychosocial wellbeing. These can extend to negative impacts on a person's sexual function and their intimate relationships. While sexual function is an important component of wellbeing, it is often not considered within musculoskeletal pain care. Without awareness or targeted training, physical therapists may lack the confidence and skills to screen, assess, and manage the impacts that pain may be having on a person's sexual function and can miss the opportunity to tailor their care and optimize wellbeing. This article seeks to raise awareness among physical therapists of how living with chronic musculoskeletal pain can impact a person's sexual function and intimate relationships, and provide guidance on how to consider these issues within a person-centered approach to care. It describes why considering sexual function and intimate relationship issues as part of a person's lived musculoskeletal pain experience may be relevant, outlines the use of validated patient-reported outcome measures to assess sexual dysfunction, and suggests practical strategies for sensitively raising sexual function in consultations. Management approaches and possible referral pathways are also presented, to assist physical therapists in understanding available care options. This article seeks to support holistic care by improving physical therapists' knowledge and understanding of sexual dysfunction and its management in people living with chronic musculoskeletal pain., Impact: Considering sexual function as a valued functional activity, together with other activities of daily living, will assist physical therapists to provide more holistic and person-centered care. This article covers the main considerations for raising sexual function and intimate relationship issues with people living with chronic musculoskeletal pain, as well as management options and potential referral pathways. Physical therapists are encouraged to seek targeted training to improve their confidence and skills in this area, and to use inclusive, respectful language for discussions around sexual function and intimate relationships., (© The Author(s) 2024. Published by Oxford University Press on behalf of the American Physical Therapy Association.)

Introduction: Despite the growing body of literature on sacral neuromodulation (SNM) outcomes, research focusing on male patients remains limited and often represented by small cohorts nested within a larger study of mostly women. Herein, we evaluated the outcomes of SNM in a male-only cohort with overactive bladder (OAB), fecal incontinence (FI), chronic bladder pain, and neurogenic lower urinary tract dysfunction (NLUTD)., Materials and Methods: This retrospective cohort study included 64 male patients who underwent SNM insertion between 2013 and 2021 at a high-volume tertiary center. Indications for SNM therapy included OAB, FI, chronic pelvic pain, and NLUTD. Descriptive statistics, Fisher's and t-test were used in analysis., Results: The mean age was 57.7 ± 13.4 years, and the most frequent reason for SNM insertion was idiopathic OAB (72%), FI (16%), pelvic pain (11%), and NLUTD (11%). A majority (84%) of men received treatment prior to SNM insertion. 84% reported satisfaction and 92% symptom improvement within the first year, and these improvements persisted beyond 1 year in 73% of patients. Mean follow up was 52.7 ± 21.0 months. The complication rate was 23%, and the need for adjunct treatments was significantly reduced (73% to 27%, p < 0.001). Treatment outcomes did not differ significantly between various indications for SNM therapy or the presence of benign prostatic hyperplasia (BPH)., Conclusion: SNM is an effective and safe procedure for male patients with neurogenic and non-neurogenic OAB, pelvic pain, and FI. Over 70% of patients experienced symptomatic improvement and remained satisfied in the mid to long term follow up. BPH does not seem to hinder treatment outcomes.

Importance: Insomnia is highly prevalent in patients with nonspecific chronic spinal pain (nCSP). Given the close interaction between insomnia and pain, targeting sleep problems during therapy could improve treatment outcomes., Objective: To evaluate the effectiveness of cognitive behavioral therapy for insomnia (CBTi) integrated in best-evidence pain management (BEPM) vs BEPM only in patients with nCSP and insomnia., Design, Setting, and Participants: A multicenter randomized clinical trial with 1-year follow-up was conducted between April 10, 2018, and April 30, 2022. Data and statistical analysis were performed between May 1, 2022, and April 24, 2023. Patients with nCSP and insomnia were evaluated using self-report and at-home polysomnography, to exclude underlying sleep pathologic factors. Participants were treated at the University Hospital Brussels or University Hospital Ghent, Belgium. Intention-to-treat analysis was performed., Interventions: Participants were randomized to either CBTi-BEPM or BEPM only. Both groups received 18 treatment sessions over 14 weeks. The CBTi-BEPM treatment included 6 CBTi sessions and 12 BEPM sessions. The BEPM treatment included pain neuroscience education (3 sessions) and exercise therapy (9 sessions in the CBTi-BEPM group, 15 sessions in the BEPM-only group)., Main Outcomes and Measures: The primary outcome was change in mean pain intensity (assessed with Brief Pain Inventory [BPI]) at 12 months after the intervention. Exploratory secondary outcomes included several pain- and sleep-related outcomes. Blinded outcome assessment took place at baseline, posttreatment, and at 3-, 6-, and 12-month follow-up., Results: A total of 123 patients (mean [SD] age, 40.2 [11.18] years; 84 women [68.3%]) were included in the trial. In 99 participants (80.5%) with 12-month BPI data, the mean pain intensity at 12 months decreased by 1.976 points (reduction of 40%) in the CBTi-BEPM group and 1.006 points (reduction of 24%) points in the BEPM-only group. At 12 months, there was no significant difference in pain intensity change between groups (mean group difference, 0.970 points; 95% CI, -0.051 to 1.992; Cohen d, 2.665). Treatment with CBTi-BEPM resulted in a response for BPI average pain with a number needed to treat (NNT) of 4 observed during 12 months. On a preliminary basis, CBTi-BEPM was, consistently over time and analyses, more effective than BEPM only for improving insomnia severity (Cohen d, 4.319-8.961; NNT for response ranging from 2 to 4, and NNT for remission ranging from 5 to 12), sleep quality (Cohen d, 3.654-6.066), beliefs about sleep (Cohen d, 5.324-6.657), depressive symptoms (Cohen d, 2.935-3.361), and physical fatigue (Cohen d, 2.818-3.770). No serious adverse effects were reported., Conclusions and Relevance: In this randomized clinical trial, adding CBTi to BEPM did not further improve pain intensity reduction for patients with nCSP and comorbid insomnia more than BEPM alone. Yet, as CBTi-BEPM led to significant and clinically important changes in insomnia severity and sleep quality, CBTi integrated in BEPM should be considered in the treatment of patients with nCSP and comorbid insomnia. Further research can investigate the patient characteristics that moderate the response to CBTi-BEPM in terms of pain-related outcomes, as understanding of these moderators may be of utmost clinical importance., Trial Registration: Clinical Trials.gov Identifier: NCT03482856.

Introduction: Similar to chronic pain conditions, individuals with endometriosis can be affected by central sensitization syndrome (CSS), which is characterized by a loss of analgesia and central amplification of pain. Transcranial direct current stimulation (tDCS) has shown potential as an effective intervention to improve pain generated by other chronic pain conditions impacted by CSS, such as fibromyalgia and chronic pelvic issues. This study aims to evaluate the effectiveness of tDCS on pain, fatigue, and quality of life among patients affected by endometriosis., Methods: This is a single-center, parallel, double-blinded, randomized, controlled clinical trial protocol study. We aim to recruit 40 participants affected by endometriosis (active group, n = 20; sham group, n = 20). Anodal tDCS will be delivered at an intensity of 2mA, applied over the primary motor cortex for 20 minutes per day for 10 consecutive days. There will be four assessment times: 1 week before beginning the intervention; on the 10th day following the last tDCS session; and 1 and 2 months after the last tDCS session. Pain evaluated by the algometry will be the primary outcome. Pain intensity, quality of life, fatigue, and global perception of change will be the secondary outcomes. We will calculate the effects of the active versus sham stimulation on primary and secondary outcomes by using generalized estimated equations or mixed model analysis. The effect size calculation will represent the effect measure. We expect that only the active group show reductions in pain, fatigue, and quality of life. The results of this trial will produce an important first step in providing evidence on the effectiveness of neuromodulation for the management of pain and will provide data to support new studies on tDCS., Registration: Brazilian Clinical Trials Registry (RBR-4q69573)., Competing Interests: The authors have declared that no competing interests exist., (Copyright: © 2024 Camila de Lima Alves da Silva et al. This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.)

Background: A growing number of studies has combined transcranial direct current stimulation (tDCS) with other non-invasive non-pharmacological therapies (NINPT) to enhance effects in pain reduction. However, the efficacy of these combined approaches in treating chronic primary pain (CPP) warrants thorough investigation., Objective: This study aims to evaluate the efficacy of tDCS in conjunction with other NINPT in alleviating pain severity among CPP patients., Methods: We conducted a systematic search for randomized controlled trials (RCTs) comparing the efficacy of tDCS combined with NINPT against control treatments in adult CPP patients. The search spanned multiple databases, including PubMed, EMBASE, LILACS, Scopus, Web of Science, and CENTRAL., Results: Our systematic review included 11 RCTs with a total of 449 participants. In our meta-analysis, which comprised 228 participants receiving active-tDCS and 221 receiving sham-tDCS, we found a significant reduction in pain intensity (Standard Mean Difference = -0.73; 95% Confidence Interval (CI) = -1.18 to -0.27; P  = .002) with the use of active-tDCS combined with NINPT., Conclusion: These findings substantiate the therapeutic potential of combining tDCS with other NINPT, highlighting it as an effective treatment modality for reducing pain intensity in CPP patients., Competing Interests: Declaration of Conflicting InterestsThe author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Introduction: For over 60 years, spinal cord stimulation has endured as a therapy through innovation and novel developments. Current practice of neuromodulation requires proper patient selection, risk mitigation and use of innovation. However, there are tangible and intangible challenges in physiology, clinical science and within society., Areas Covered: We provide a narrative discussion regarding novel topics in the field especially over the last decade. We highlight the challenges in the patient care setting including selection, as well as economic and socioeconomic challenges. Physician training challenges in neuromodulation is explored as well as other factors related to the use of neuromodulation such as novel indications and economics. We also discuss the concepts of technology and healthcare data., Expert Opinion: Patient safety and durable outcomes are the mainstay goal for neuromodulation. Substantial work is needed to assimilate data for larger and more relevant studies reflecting a population. Big data and global interconnectivity efforts provide substantial opportunity to reinvent our scientific approach, data analysis and its management to maximize outcomes and minimize risk. As improvements in data analysis become the standard of innovation and physician training meets demand, we expect to see an expansion of novel indications and its use in broader cohorts.