Iatrogenic Side Effects of Pain Therapies.

Pain regimens, particularly for chronic cancer and noncancer pain, must balance the important analgesic benefits against potential risks. Many effective and frequently used pain control regimens are associated with iatrogenic adverse events. Interventional procedures can be associated with nerve injuries, vascular injuries, trauma to the spinal cord, and epidural abscesses. Although rare, these adverse events are potentially catastrophic. Pharmacologic remedies for pain must also consider potential side effects that can occur even at therapeutic doses of over-the-counter remedies such as paracetamol (acetaminophen) or nonsteroidal anti-inflammatory drugs. Opioids are effective pain relievers but are associated with many side effects, some of which can be treatment limiting. A prevalent and distressing side effect of opioid therapy is constipation. Opioid-induced constipation is caused by binding to opioid receptors in the gastrointestinal system, making conventional laxatives ineffective. Peripherally acting mu-opioid receptor antagonists are a new drug class that offers the benefits of preserving opioid analgesia without side effects in the gastrointestinal system. An important safety concern, particularly among geriatric patients is the increasingly prevalent condition of polypharmacy. Many senior patients take five or more medications, including some that may be contraindicated in geriatric patients, duplicative of other drugs, have potential pharmacokinetic drug-drug interactions, or may not be the optimal choice for the patient's age and condition. Careful assessment of medications in the elderly, including possibly deprescribing with tapering of certain drugs, may be warranted but should be done systematically and under clinical supervision.

Is Fibromyalgia a Fashionable Diagnosis or a Medical Mystery?

Despite its prevalence, there is no clear-cut diagnostic path or treatment paradigm for fibromyalgia; this can lead to a multiplicity of symptoms and comorbid conditions that complicate care. "Overlapping symptoms" describe conditions that can occur concomitantly with fibromyalgia and include migraine, irritable bowel syndrome, obesity, and pelvic pain syndromes. A variety of pharmacologic and nonpharmacologic treatments are available for fibromyalgia, but treatment is best personalized for an individual and recognizes potential comorbidities. Opioids are not the recommended front-line treatment, cannabinoids hold promise but with limitations and nonpharmacologic options, such as aerobic or resistance exercise and cognitive behavior therapy, can play a very important but often underestimated role. Amitriptyline appears to be safe and effective in treating six of the main fibromyalgia domains: pain, disturbed sleep, fatigue, affective symptoms, functional limitations, and impaired cognition ("fibro fog"). Very low-dose naltrexone (2.5-4.5 mg) may offer analgesic and anti-inflammatory benefits to fibromyalgia patients, but further studies are needed. Fibromyalgia can be a devastating and debilitating condition for patients, and clinicians are challenged with its diagnosis and treatment as well. Further research as well as compassionate approaches to offering personalized care to those with fibromyalgia are required.

The Invasive Management of Pain: Diagnosis and New Treatment Options.

Both the diagnosis and treatment of pain are evolving, especially in interventional approaches. Diagnosis of low back pain combines old and new methodologies, in particular, it involves an expanded role for ultrasound. While low back pain is a common complaint, there are many etiologies to the condition which must be explored before a final diagnosis can be made and treatment planned. Tumors and infections are rarely involved in low back pain but should be ruled out in the initial phase itself since failing to address them early can have devastating consequences. Some invasive treatments seem promising in the management of low back pain. Treating musculoskeletal pain with regenerative medicine, such as platelet-rich plasma, holds great promise. Autologous blood products are safe and may help stimulate the body's own responses for regeneration. The so-called "orthobiologics" play a role in sports medicine and the treatment of musculoskeletal pain. Neuromodulation, especially spinal cord stimulation, is undergoing a renaissance with new waveforms, devices, and a greater albeit incomplete understanding of its mechanisms of action. Spinal cord stimulation is not a first-line therapy and not all patients or all back problems respond to this treatment. Nevertheless, the therapy can be safe, effective, and cost-effective with appropriate patient selection. Radiofrequency ablation of nerves in the form of neurotomy can be effective in reducing the pain of osteoarthritis. These procedures, including the newer cooled radiofrequency neurotomy, can restore function, reduce pain, and may potentially have an opioid-sparing effect. Technical expertise in nerve and anatomy is needed for the use of this technique. This review article aims to provide updated information on some invasive intervention techniques in pain management.

Advances in the Management of Acute Postsurgical Pain: A Review.

Despite the millions of surgeries performed every year around the world, postoperative pain remains prevalent and is often addressed with inadequate or suboptimal treatments. Chronic postsurgical pain is surprisingly prevalent, and its rate varies with the type of surgery, as well as with certain patient characteristics. Thus, better clinical training is needed as well as patient education. As pain can be caused by more than one mechanism, multimodal or balanced postsurgical analgesia is appropriate. Pharmacological agents such as opioid and nonopioid pain relievers, as well as adjuvants and nonpharmacologic approaches, can be combined to provide better and opioid-sparing pain relief. Many specialty societies have guidelines for postoperative pain management that emphasize multimodal postoperative analgesia. These guidelines are particularly helpful when dealing with special populations such as pregnant patients or infants and children. Pediatric pain control, in particular, can be challenging as patients may be unable to communicate their pain levels. A variety of validated assessment tools are available for diagnosis. Related to therapy, most guidelines agree on the fact that codeine should be used with extreme caution in pediatric patients as some may be "rapid metabolizers" and its use may be life-threatening. Prehabilitation is a preoperative approach that prepares patients in advance of elective surgery with conditioning exercises and other interventions to optimize their health. Prehabilitation may have aerobic, strength-training, nutritional, and counseling components. Logistical considerations and degree of patient adherence represent barriers to effective prehabilitation programs. Notwithstanding all this, acute postoperative pain represents a clinical challenge that has not yet been well addressed.

Play as a Stress-Coping Method Among Children in Light of the COVID-19 Pandemic: A Review.

The COVID-19 pandemic, which started in early 2020, has been a great source of stress for almost every person all around the world. However, this is particularly true for children. It is necessary to fully address the stress-related psychosocial issues connected with the pandemic, solely in children. Play is important for children's development, as it is a natural activity for every child. Through play and play-based interventions, children can communicate non-verbally, symbolically, and in an action-oriented manner. Therefore, play-based interventions may have the potential to be one of the coping strategies used by children who experience stress, especially during the COVID-19 pandemic. The aim of this narrative review was to show how play-based activities could help children deal with stress related to the COVID-19 pandemic in the non-clinical population. A systematic search of the literature in various databases was performed. The initial search provided 5,004 potentially eligible studies in various databases, and 42,201 records identified from Google Scholar. After excluding studies not meeting the inclusive criteria, nine papers were selected for this narrative review. This narrative review showed findings that play-based activities can have a positive effect during the COVID-19 pandemic on different stress levels in the children population. Additionally, the findings of this review highlight the importance of further research and implementation of play into many aspects of children's life.

Map of pain education in Latin America: current state and perspectives.

The Latin American Map of Pain Education initiative has developed steadily in recent years. A recent survey yields important new data on the current state and allows outlining of the next steps to improve pain education in Latin American countries. A survey conducted by Federación Latinoamericana de Asociaciones para el Estudio del Dolor (FEDELAT) with data from 19 Latin American countries showed that a generally observed barrier is the lack of adequately trained pain professionals and the insufficient number of pain centers. There is a need for formal programs of pain education and palliative care in undergraduate and graduate programs. These programs should be accessible not only to physicians but to all types of healthcare professionals involved in the management of pain patients. The article includes some recommendations that will certainly be helpful in improving pain education over the next decade in Latin America.

Pain Management and COVID-19: A Latin American Perspective.

Vaccinations and therapeutics have been developed for COVID-19, but vaccine uptake varies markedly among countries. Public health responses have also varied, in particular, with lockdown efforts and school closing. All over the world, the pandemic exposed healthcare and economic weaknesses. COVID-19 exacerbated mental health issues by exposing the population to prolonged periods of fear, anxiety, financial stress, psychological uncertainties, and sometimes isolation from even family and friends. Chronic pain patients have been disproportionately affected. The pandemic-associated stresses may have exacerbated their already painful symptoms while at the same time interrupting their access to care. The ramifications of the COVID-19 post-viral syndrome ("long COVID-19") are not yet known. COVID-19 viral infection has been associated with neuropathic pain symptoms. Tele-triage and telehealth applications can help manage chronic pain patients in the COVID-19 era, but many interventional procedures, injections, or other treatments have been delayed. The role of palliative care for patients with terminal cases of infection must be re-examined. Palliative care is a relatively new medical specialty and allows terminally ill patients to die in as much comfort and peace as can be afforded to them. More training in palliative care for all clinicians is urgently needed. COVID-19 exposed much that is wrong or weak or inadequate in our healthcare systems, but it also allowed us to embrace new technologies and develop better systems to manage the challenge of a pandemic.

What Is New in the Clinical Management of Low Back Pain: A Narrative Review.

Low back pain (LBP) is a prevalent condition associated with disability. Treating patients with LBP becomes further complicated by the potential presence of underlying conditions, such as cancer or traumatic injury, or biopsychosocial aspects. LBP usually has a neuropathic component that must be assessed and treated appropriately. Pharmacological management of LBP requires a thorough knowledge of the available agents and the mechanisms of the LBP. Although there are effective pharmacological treatments for LBP, it is important to consider safety issues. Fixed-dose combination products may be helpful, as they can reduce opioid consumption without sacrificing analgesic benefits. Neuromodulation is an important and sometimes overlooked treatment option for LBP and may be appropriate for chronic LBP requiring long-term treatment. Imaging studies support neuroplastic changes in the brain as a result of neuromodulation. Interventional approaches to chronic LBP are numerous and must be appropriately selected based on the individual patient. Evidence in support of epidural injections for LBP is strong for short-term pain control but moderate to limited for long-term relief. Rehabilitation for LBP can be an important element of long-term care, and new forms of rehabilitation programs are being developed using telemedicine. A variety of new and established treatments are available for patients with LBP, and clinicians and patients may benefit from emerging new treatment modalities.

New Insights Into the Pharmacological Management of Postoperative Pain: A Narrative Review.

Postoperative pain is prevalent and often undertreated. There is a risk that untreated or suboptimally treated postoperative pain may transition into chronic postoperative pain, which can be challenging to treat. Clinical guidelines recommend the use of multimodal analgesia, including non-steroidal anti-inflammatory drugs (NSAIDs), acetaminophen, and, in some cases, opioids. NSAIDs are a broad class of drugs with different attributes such as cyclo-oxygenase (COX)-1 or COX-2 selectivity, onset of action, and analgesic potency. NSAIDs are associated with gastrointestinal and cardiovascular side effects and should be administered at the lowest effective dose for the shortest effective duration but can be effective in postoperative pain. The role of opioids in postoperative analgesia is long-standing but has recently come under scrutiny. Opioids are often used in multimodal analgesic combinations in such a way as to minimize the total consumption of opioids without sacrificing analgesic benefit. Special clinical considerations are required for surgical patients already on opioid regimens or with opioid use disorder. A particularly useful fixed-dose combination product for postoperative analgesia is dexketoprofen-tramadol, which confers safe and effective postoperative pain control and reduces the risk of persistent postoperative pain.

Bloqueo del plano del erector espinal como manejo de dolor neuropático en paciente pediátrico postquemado / Erector spinalis plane block as a neuropathic pain management in post-burned pediatric patient

El manejo del dolor es una pieza crítica en el cuidado general del niño quemado. El dolor neuropático es una de sus consecuencias frecuentes, el cual puede aparecer al inicio o durante el proceso de cicatrización de heridas, acompañándose de sintomatología predominantemente por estimulación del sistema nervioso simpático, siendo su manejo un reto importante. El bloqueo del plano del erector espinal (ESP) es una técnica regional novedosa que se ha utilizado en diferentes tipos de cirugía, con resultados prometedores. Actualmente, el bloqueo ESP en la población pediátrica se viene realizando para cirugías de tórax, abdomen, cadera y genitales, con solo pocos informes. Hasta donde sabemos, el bloqueo ESP para dolor neuropático en niños aún no se ha reportado. El presente informe sugiere que el bloqueo ESP torácico realizado a nivel T4 podría proporcionar una analgesia amplia y efectiva en el dolor neuropático además de regular la sintomatología simpática, secundaria a los cambios fisiopatológicos relacionados con el grado de quemadura

Pain management is a critical piece in the general care of the burned child. Neuropathic pain is one of its frequent consequences, which may appear at the beginning or during the wound healing process, accompanied by symptoms predominantly due to stimulation of the sympathetic nervous system, its management being an important challenge. The spinal erector plane (ESP) block is a novel regional technique that has been used in different types of surgery, with promising results. Currently, the ESP block in the pediatric population has been performed for thorax, abdomen, hip and genital surgeries, with only a few reports. As far as we know, ESP block for neuropathic pain in children has not yet been reported. The present report suggests that the thoracic ESP blockade performed at the T4 level could provide a wide and effective analgesia in neuropathic pain in addition to regulating sympathetic symptomatology, secondary to the pathophysiological changes related to the degree of burn

Tratamiento de dolor en niños / Treatment of pain in children

El alivio del dolor en el niño se ha caracterizado durante años por la insuficiente atención en el ambientepediátrico y médico en general.

Lidocaina peritoneal en el manejo del dolor postoperatorio en cirugía laparoscópica / Perytoneal lydocaine in the postoperative management of pain in laparoscopic surgery

Desde julio de 1995 a junio de 1996 se trataron a 10 pacientes de 18, con quiste sinovial de la muñeca, con la técnica de punto transfixiante percutáneo, en el servicio de Ortopedia y Traumatología del Hospital Obrero No.1 de La Paz. El máximo tiempo de seguimiento ha sido de 10 meses y el míniimo de 2 meses. Del total solo hubo una recidiva (10 porciento) y el resto del (90 porciento) hasta la fecha con resultado satisfactorio tanto médico como estético. El (10 porciento) de resultado malo es inferior a recidivas por tratameinto quirúrgico, según estadísticas extranjeras. En general se obtuvo buen resultado con este métido siendo un procedimiento de fácil ejecución, buena tolerancia por parte del paciente, bajo costo en relación al tratamiento quirúrgico, tratamiento efectuado en consultorio y con anestesia local y estéticamente con buen resultado. Se recomienda este procedimiento en aquellos pacientes con quiste sinovial que cumplan los requisitos establecidos, estando contraindicado con quistes pequeños por el peligro de lesionar las estructuras vecinas, como tendón, al efectuar el punto transfixiante