Tiam1-mediated maladaptive plasticity underlying morphine tolerance and hyperalgesia.

Opioid pain medications, such as morphine, remain the mainstay for treating severe and chronic pain. Prolonged morphine use, however, triggers analgesic tolerance and hyperalgesia (OIH), which can last for a long period after morphine withdrawal. How morphine induces these detrimental side effects remains unclear. Here, we show that morphine tolerance and OIH are mediated by Tiam1-coordinated synaptic structural and functional plasticity in the spinal nociceptive network. Tiam1 is a Rac1 GTPase guanine nucleotide exchange factor that promotes excitatory synaptogenesis by modulating actin cytoskeletal dynamics. We found that prolonged morphine treatment activated Tiam1 in the spinal dorsal horn and Tiam1 ablation from spinal neurons eliminated morphine antinociceptive tolerance and OIH. At the same time, the pharmacological blockade of Tiam1-Rac1 signalling prevented the development and reserved the established tolerance and OIH. Prolonged morphine treatment increased dendritic spine density and synaptic NMDA receptor activity in spinal dorsal horn neurons, both of which required Tiam1. Furthermore, co-administration of the Tiam1 signalling inhibitor NSC23766 was sufficient to abrogate morphine tolerance in chronic pain management. These findings identify Tiam1-mediated maladaptive plasticity in the spinal nociceptive network as an underlying cause for the development and maintenance of morphine tolerance and OIH and provide a promising therapeutic target to reduce tolerance and prolong morphine use in chronic pain management.

The level of agreement between the numerical rating scale and visual analogue scale for assessing pain intensity in adults with chronic pain.

The numerical rating scale and visual analogue scale are used to quantify pain intensity. However, it has not yet been explored whether these scores are interchangeable in adults with chronic pain. Data from the prospective multicentre cross-sectional INTERVAL study were used to evaluate the one-dimensionality and agreement between numerical rating scale scores and visual analogue scale scores in adults with chronic pain. Pain intensity scores using the numerical rating scale and visual analogue scale were provided by 366 patients with chronic pain for current, average, minimal and maximal pain. To evaluate whether pain intensity scales are completed in accordance with each other, the proportion of patients who satisfied the following condition was calculated: minimal pain intensity ≤ maximal pain intensity. A factor analysis confirmed the one-dimensionality of the pain measures. A significant difference was found between numerical rating scale and visual analogue scale scores for average, current, minimum and maximum pain. Intra-class correlation coefficient estimates ranged from 0.739 to 0.858 and all measures failed to show sufficient and acceptable agreement at the 95% level. The strength of agreement between pain severity categories was classified as 'moderate' for average and minimal pain and 'substantial' for current and maximal pain. The proportion of patients who scored minimal pain ≤ maximal pain was 97.5% for the numerical rating scale and 89.5% for the visual analogue scale. This study failed to show an acceptable agreement between the numerical rating scale and visual analogue scale when pain intensity was rated by adults with chronic pain, despite showing both scales measure the same information.

Mindfulness for people with chronic pain: Factors affecting engagement and suggestions for programme optimisation.

INTRODUCTION: Chronic pain is a common, multifactorial condition and pharmacological treatments have limited benefits. Mindfulness is a holistic approach that might be of value in the management of chronic pain. However, attrition rates from mindfulness-based interventions are high and factors affecting engagement are unknown. The aim of this study was to inform the design of a mindfulness programme that would be accessible and acceptable for people with chronic pain. METHODS: Interpretative phenomenological analysis of interview data from people with chronic pain who had taken part in an 8-week mindfulness programme based on mindfulness-based stress reduction revealed factors affecting engagement with and suggestions for tailoring the programme. Factors were grouped into physical, psychological and social domains. Further suggestions for tailoring the programme to address these factors were generated through a nominal group of healthcare professionals and a focus group with service users who had chronic pain. FINDINGS: Physical factors included disability and discomfort with some practices; psychological factors included expectations of the mindfulness programme and understanding the relationship between mindfulness and pain; and social factors included loneliness and support from others. The proposed modifications to the mindfulness programme supported by healthcare professionals and/or service users to address these are described in this paper. PUBLIC CONTRIBUTION: This study involved public contributions at a number of stages. The University of Aberdeen Division of Applied Health Sciences Service User Group (who were members of the public with chronic pain) was involved in the design of the study. Patients with chronic pain recruited from general medical practice who took part in the mindfulness programme were interviewed on their experience of the programme. Patients with chronic pain who attended the mindfulness programme, and healthcare professionals with expertise in chronic pain and/or mindfulness, attended meetings to design a tailored mindfulness programme for people with chronic pain.

Virtual Reality for Chronic Pain Management Among Historically Marginalized Populations: Systematic Review of Usability Studies.

BACKGROUND: Virtual reality (VR) has potential to improve chronic pain management outcomes. However, the majority of studies assessing VR are conducted in predominantly White populations in well-resourced settings, thus leaving a gap in knowledge of VR use among diverse populations who experience a significant chronic pain burden. OBJECTIVE: This review aims to examine the extent to which usability of VR for chronic pain management has been studied within historically marginalized patient groups. METHODS: We conducted a systematic search to identify studies with usability outcomes located in high-income countries that included a historically marginalized population, defined by a mean age greater than or equal to 65 years, lower educational attainment (greater than or equal to 60% having attained high school education or less), and being a racial or ethnic minority (less than or equal to 50% non-Hispanic White people for studies based in the United States). RESULTS: Our analysis included 5 papers, which we used to conduct a narrative analysis. Three studies examined VR usability as a primary outcome. All studies assessed VR usability using different measures, of which 4 found VR to be usable by their respective study population. Only 1 study found a significant improvement in pain levels post-VR intervention. CONCLUSIONS: The use of VR shows promise for chronic pain management, but few studies include populations that are older, have limited educational attainment, or have racial or ethnic diversity. Additional studies with these populations are needed to further develop VR systems that work best for diverse patients with chronic pain.

Opinions of Health Care Providers About Neuromodulation for Pain: Results of an Online Survey at the 2nd Joint Congress of the International Neuromodulation Society European Chapters.

INTRODUCTION: Neuromodulation for pain has been successfully applied for decades, in that the goals and expectations that patients aim to achieve are clearly described. Nevertheless, the point of view of health care providers is less clear. Therefore, this study aimed to explore the goals, expectations, and definition of success for neuromodulation for pain according to health care providers. MATERIALS AND METHODS: An online survey was developed and spread at the 2nd Joint Congress of the International Neuromodulation Society (INS) European Chapters in September 2021 in Paris. Respondents were asked 1) to select the goals to treat patients with neuromodulation for pain, 2) to indicate factors that they expect to change according to neuromodulation for pain, and 3) to provide their definition of success of neuromodulation for pain. RESULTS: We approached 101 respondents, of whom 88 health care providers at least partly completed the survey. Increasing mobility/functionality (26.7%), decreasing pain intensity (24.5%), and decreasing medication use (16.6%) were the most frequently reported goals of neuromodulation. The same top three variables were selected as factors that health care providers expected to change. For the definition of success, quality of life of patients outranked other definitions. Other highly ranked definitions, in descending order, were obtaining pain relief, increasing functionality, and increasing patient satisfaction. DISCUSSION: Goals and expectations of health care providers are not completely in line with previously explored goals of patients that are related to pain relief and improving walking abilities. Health care providers seem to put a high emphasis on the quality of life of the patient when evaluating the success of neuromodulation, which is not completely aligned with the currently used reimbursement rules that are mainly focusing on pain relief instead of incorporating health-related quality of life. CLINICAL TRIAL REGISTRATION: The Clinicaltrials.gov registration number for the study is NCT05013840.

The applications of cryoneurolysis for acute and chronic pain management.

BACKGROUND: Cryoneurolysis is a term used to describe the application of extreme cold to targeted nerve tissue. The primary goal of the application of a thermal neurolytic technique is to disrupt the conduction of pain signals from the periphery to the central nervous system and eliminate or diminish the experience of pain. Recent advancements in ultrasound technology coupled with the development and approval of handheld devices specifically designed to deliver cryoneurolysis has expanded the use of this modality in the perioperative setting. APPLICATION: Surgical procedures including total knee arthroplasties, shoulder arthroplasties, thoracotomies, and mastectomies have all demonstrated long-term pain relief benefits when cryoneurolysis has been administered days to weeks prior to the planned procedure. In addition, the newly designed handheld device allows for office-based clinical use and has been utilized for various chronic pain conditions including neuropathic and phantom limb pain. CONCLUSION: The evidence clearly demonstrates that cryoneurolysis has a low risk profile and when administered appropriately, provides prolonged analgesia without promoting motor blockade. This narrative review article describes the unique mechanism of action of cryoneurolysis for prolonged pain relief and provides emerging evidence to support its applications in both acute and chronic pain management.

A Review of Laser Therapy and Low-Intensity Ultrasound for Chronic Pain States.

PURPOSE OF REVIEW: Chronic pain management therapies have expanded quickly over the past decade. In particular, the use of laser therapy and ultrasound in the management of chronic pain has risen in recent years. Understanding the uses of these types of therapies can better equip chronic pain specialists for managing complicated chronic pain syndromes. The purpose of this review was to summarize the current literature regarding laser radiation and ultrasound therapy used for managing chronic pain syndromes. RECENT FINDINGS: In summary, there is stronger evidence supporting the usage of laser therapy for managing chronic pain states compared to low-intensity ultrasound therapies. As a monotherapy, laser therapy has proven to be beneficial in managing chronic pain in patients with a variety of pain syndromes. On the other hand, LIUS has less clear benefits as a monotherapy with an uncertain, optimal delivery method established. Both laser therapy and low-intensity ultrasound have proven beneficial in managing various pain syndromes and can be effective interventions, in particular, when utilized in combination therapy.

"So, you must understand that that group changed everything": perspectives on a telehealth group intervention for individuals with chronic pain.

BACKGROUND: The Patient Education Empowerment Programme (PEEP) is an interdisciplinary group intervention for people living with chronic pain. As a result of the COVID-19 pandemic, lockdown and restrictions on in-person group-based health care delivery in South Africa, PEEP was modified to a telehealth electronic format (ePEEP) and offered to patients on a waiting list at two interdisciplinary chronic pain clinics in Cape Town, South Africa. The purpose of this study was to explore the feasibility and acceptability of ePEEP through the perspectives of individuals with chronic pain who participated in ePEEP.  METHODS: A qualitative, exploratory descriptive study was conducted. One month after completion of the 6-week ePEEP programme, individuals who participated, were recruited for the study. Data were collected through semi-structured interviews. Data analysis followed an iterative process of inductive content analysis.  RESULTS: Six individuals, all women, consented and participated in the study. Three main themes emerged from the data. Theme one focussed on how ePEEP initiated a journey of personal development and discovery within the participants. In theme two, participants reflected on the importance and value of building peer and therapeutic relationships as part of ePEEP. In theme 3, participants shared that the online learning environment had features which influenced learning about pain in different ways. CONCLUSION: ePEEP was found to be acceptable, feasible and valuable for the participants. ePEEP facilitated self-discovery, empowerment, relationship building and transformation in the participants, through experiential learning. Although barriers and facilitators to learning were present, both enhanced the learning experience. The positive reception of this telehealth initiative indicates potential for enhanced access to chronic pain management services in the South African setting.

Social Determinants and Comorbidities in Non-pharmacological Interventions for Chronic Pain in Community- Dwelling Older Adults: A Scoping Review of Randomized Controlled Trials.

BACKGROUND: Chronic pain frequently exists with other comorbid conditions in older adults, yet little is known about the effectiveness of non-pharmacologic interventions. A scoping review was conducted to provide an overview of the nature of the published evidence on the nonpharmacological interventions for chronic pain in communitydwelling older adults with comorbid conditions. METHODS: A literature search of relevant databases was conducted using PRISMA guidelines. Studies were included if they were intervention studies, used a randomized controlled trial design, and met criteria of the critical appraisal. RESULTS: Eleven studies were identified as high quality. Most studies did not quantify a comorbidity index and/or burden, nor reported the specific comorbid conditions of participants with chronic pain. In addition, none of the identified studies measured change in participant comorbidity and/or burden. CONCLUSION: Future research should address the effects of non-pharmacological interventions on pain, comorbidities, and other health outcomes.

Rediscovery of Methadone to Improve Outcomes in Pain Management.

Clinically, methadone is most known for its use in the treatment of opioid maintenance therapy. However, methadone's pharmacological profile makes it an excellent analgesic that can enhance acute and chronic pain management. It is a potent µ-receptor agonist with a longer elimination half-life than most clinically used opioids. In addition, methadone inhibits serotonin and norepinephrine uptake, and it is an N-methyl-D-aspartate antagonist. These distinct analgesic pathways mediate hyperalgesic, allodynic, and neuropathic pain. Its unique analgesic properties provide several essential benefits in perioperative use, neuropathic pain, cancer, and noncancer pain. Despite these proven clinical utilities, methadone has not been used widely to treat acute and chronic pain in opioid naïve patients. This article describes the unique pharmacology of methadone and provides emerging evidence to support its application in acute and chronic pain management. Pain management options and guidelines for surgical patients on methadone are discussed as well.

Multidisciplinary Approach for Managing Complex Pain and Addiction in Primary Care: A Qualitative Study.

PURPOSE: Primary care providers (PCPs) may feel ill-equipped to effectively and safely manage patients with chronic pain, an addiction, or both. This study evaluated a multidisciplinary approach of supporting PCPs in their management of this psychosocially complex patient population, to inform subsequent strategies clinics can use to support PCPs. METHODS: Four years ago, at our academic community health safety-net system, we created a multidisciplinary consultation service to support PCPs in caring for complex patients with pain and addiction. We collected and thematically analyzed 66 referral questions to understand PCPs' initially expressed needs, interviewed 14 referring PCPs to understand their actual needs that became apparent during the consultation, and identified discrepancies between these sets of needs. RESULTS: Many of the PCPs' expressed needs aligned with their actual needs, including needing expertise in the areas of addiction, safe prescribing of opioids, nonopioid treatment options, and communication strategies for difficult conversations, a comprehensive review of the case, and a biopsychosocial approach to management. But several PCP needs emerged after the initial consultation that they did not initially anticipate, including confirming their medical decision-making process, emotional validation, feeling more control, having an outside entity take the burden off the PCP for management decisions, boundary setting, and reframing the visit to focus on the patient's function, values, and goals. CONCLUSIONS: A multidisciplinary consultation service can act as a mechanism to meet the needs of PCPs caring for psychosocially complex patients with pain and addiction, including unanticipated needs. Future research should explore the most effective ways to meet PCP needs across populations and health systems.

Chronic opioid use and complication risks in women with endometriosis: A cohort study in US administrative claims.

BACKGROUND: Women with endometriosis are prescribed opioids for pain relief but may be vulnerable to chronic opioid use given their comorbidity profile. METHODS: A cohort study was conducted in the Clinformatics™ DataMart database between 2006 and 2017 comparing women aged 18-50 years with endometriosis (N = 36 373) to those without (N = 2 172 936) in terms of risk of chronic opioid use, opioid dependence diagnosis, and opioid overdose. Chronic opioid use was defined as ≥120 days' supply dispensed or ≥10 fills of an opioid during any 365-day interval. Among women with endometriosis, we evaluated factors associated with higher risk of chronic opioid use and quantified the risk of complications associated with the use of opioids. RESULTS: Women with endometriosis were at greater risk for chronic opioid use (OR: 3.76; 95%CI: 3.57-3.96), dependence (OR: 2.73, 95%CI: 2.38-3.13) and overdose (OR: 4.34, 95%CI: 3.06-6.15) compared to women without. Chronic users displayed dose escalation and increase in days supplied over time, as well as co-prescribing with benzodiazepines and sedatives. Approximately 34% of chronic users developed constipation, 20% experienced falls, and 8% reported dizziness. Among endometriosis patients, women in younger age groups, those with other comorbidities associated with pain symptoms, as well as those with depression or anxiety were at a higher risk of developing chronic opioid use. CONCLUSIONS: Women with endometriosis had a four times greater risk of chronic opioid use compared to women without. Multimorbidity among these patients was associated with the elevated risk of chronic opioid use and should be taken into account during treatment selection.

Pre-Visit Education on Pain Management Options Prior to the First Clinic Visit Improves Chronic Pain Patient Satisfaction with Proposed Treatment Plans.

OBJECTIVE: This study sought to evaluate if actively informing new chronic pain patients about treatment options and setting realistic expectations for care, through the use of a pre-visit informational handout prior to the first clinic visit, improved patient satisfaction with subsequently proposed treatment plans. METHODS: The study was divided into two 3-month periods. During the first 3 months, with our current pain clinic practices in place, new patients (n = 147) were given surveys to establish a baseline of patient satisfaction with treatment plans proposed on their first visit. During the second 3 months, a different group of new patients (n = 156) was given a detailed informational handout which described our clinic's multimodal approach to pain management and therapeutic expectations prior to their visit with a provider. Patient satisfaction with subsequently proposed treatment plans was then assessed and compared with the baseline group. RESULTS: The average patient satisfaction score for the group of patients given the informational handout was 4.21 (on a 5-point Likert scale), compared to an average score of 3.25 for the baseline group (P < .0001, unpaired t-test). 77.6% of patients given the informational handout said their proposed treatment plan met their expectations compared to 46.3% of patients in the baseline group (χ2= 31.61, two-tailed P < .0001). CONCLUSIONS: Patient satisfaction with proposed chronic pain treatment plans was improved when clinic approaches to pain were explicitly outlined and therapeutic expectations were clearly established in the form of an informational handout at the outset of the first visit.

Longitudinal Dose Trajectory Among Patients Tapering Long-Term Opioids.

OBJECTIVE: To evaluate the dose trajectory of new opioid tapers and estimate the percentage of patients with sustained tapers at long-term follow-up. DESIGN: Retrospective cohort study. SETTING: Data from the OptumLabs Data Warehouse® which includes de-identified medical and pharmacy claims and enrollment records for commercial and Medicare Advantage enrollees, representing a diverse mixture of ages, ethnicities, and geographical regions across the United States. SUBJECTS: Patients prescribed stable, higher-dose opioids for ≥12 months from 2008 to 2018. METHODS: Tapering was defined as ≥15% relative reduction in average MME/day during any of six overlapping 60-day periods in the initial 7 months of follow-up after the period of stable baseline dosing. Average monthly dose was ascertained during consecutive 60-day periods up to 16 months of follow-up. Linear regression estimated the geometric mean relative dose by tapering status and follow-up duration. Poisson regression estimated the percentage of tapered patients with sustained dose reductions at follow-up and patient-level predictors of failing to sustain tapers. RESULTS: The sample included 113,618 patients with 203,920 periods of stable baseline dosing (mean follow-up = 13.7 months). Tapering was initiated during 37,170 follow-up periods (18.2%). After taper initiation, patients had a substantial initial mean dose reduction (geometric mean relative dose .73 [95% CI: .72-.74]) that was sustained through 16 months of follow-up; at which point, 69.8% (95% CI: 69.1%-70.4%) of patients who initiated tapers had a relative dose reduction ≥15%, and 14.2% (95% CI: 13.7%-14.7%) had discontinued opioids. Failure to sustain tapers was significantly less likely among patients with overdose events during follow-up (adjusted incidence rate ratio [aIRR]: .56 [95% CI: .48-.67]) and during more recent years (aIRR: .93 per year after 2008 [95% CI: .92-.94]). CONCLUSIONS: In an insured and Medicare Advantage population, over two-thirds of patients who initiated opioid dose tapering sustained long-term dose reductions, and the likelihood of sustaining tapers increased substantially from 2008 to 2018.

Analysis on chronic pain management: Focus on the Italian network.

The Italian Law 38/2010, 'Dispositions to guarantee access to Palliative Care and Pain Management' orders that the health care systems of Italian regions create dedicated structures for palliative care and pain therapies, according to a specific organizational model called 'Hub-Spoke', to ensure the diagnostic-therapeutic continuity of patients affected by chronic pain (CP). The aim of our study was to investigate the Italian pain therapy network, 8 years following the approval of the Law. We sent a questionnaire to the national health representatives operating in CP management. The main result emerging from the analysis concerns the management of mini-invasive procedures, showing that 93.2% of the responding facilities carry out invasive procedures, 6.8% do not perform them and that 100% of the facilities belonging to 12 regions provided these procedures, while in eight regions more than 80%. Finally, only 38.5% of facilities declared to have a shared protocol with the relevant territorial facilities in order to guarantee the process of care and assistance of patients affected by CP. In conclusion, our study demonstrated the efficacy of the organizational model in most of the responding facilities, although the territorial management of patients after their hospital discharge should be strengthened.

[Evaluation of outpatient medical pain management in Germany : Results of an internet-based cross-sectional survey among pain specialists in outpatient departments]. / Bewertung der ambulanten ärztlichen Schmerztherapie in Deutschland : Ergebnisse einer internetbasierten Querschnittsbefragung unter ambulant tätigen Schmerzmedizinern.

BACKGROUND: On 31 December 2016, a total of 1206 physicians participated in the outpatient care of chronic pain patients according to the criteria of a special pain management program (QSV). Because of the largely existing shortage of treatment resources for chronic pain patients, there is a lack of data regarding the evaluation of outpatient pain management by highly specialized pain therapists. METHODS: In a hybrid Delphi procedure, a questionnaire concerning the content, structural and personal assessment of outpatient pain management in Germany was developed. With the help of this instrument, an internet-based cross-sectional survey of 281 QSV pain therapists from four German states (Berlin, Lower Saxony, Saxony, Baden-Württemberg) and of all the heads of university outpatient pain services (n = 36) in Germany was conducted. RESULTS: The adjusted response rate of the survey was 35.9%. The response rate of the heads of university outpatient pain services was 66.7%. In 91% of the respondents the proportion of chronic pain patients in the medical practices was more than 70%. Whereas 67.3% were satisfied with the situation in their medical practice, 63.4% were dissatisfied with the current organizational structure of the pain management in Germany. They expressed their dissatisfaction especially in terms of budgeting regulations (69.3%), the cooperation with psychotherapists (69.3%) and interdisciplinary networking (50.5%). The 1­year specialist training in pain management (87.1%) and the completion of a psychosomatic basic care course (90.1%) were assessed as a good preparation for the later profession. A multitude of free comments indicated that the pain specialist training is too short and insufficient. Most of the respondents considered the establishment of a specialist board certification for pain management more suitable from the perspective of physicians (61.4%) and the patients (54.5%). Of the heads of university outpatient pain services 70.8% expressed the wish for autonomous structures with separate budgets and 75.0% indicated that under the current conditions their outpatient pain services are not working profitably. Only 39.7% of the QSV pain therapists provided fellowship training for physicians and 57.6% were planning to retire during the next 10 years. CONCLUSION: Highly specialized pain therapists are dissatisfied because of the lack of independence of the organizational structure of pain management care and the insufficient interdisciplinary network in outpatient pain management. A possible solution for a better pain management care and the recruitment problems may be the establishment of a board certification for pain management.

Assessment and Management of HIV Distal Sensory Peripheral Neuropathy: Understanding the Symptoms.

Distal sensory peripheral neuropathy (HIV-DSP) affects upwards of 50% of people living with HIV. Causing often debilitating symptoms of tingling, numbness and burning, HIV-DSP can result in disability, unemployment and low quality of life. Comorbidities further complicate nursing care, heightening risk of polypharmacy and symptom exacerbation. Therefore, a neurological sensory assessment, combined with the patient's self-report of symptoms, can help nurse practitioners visualize, quantify and understand symptoms. Common pharmacological interventions include antiepileptics, antidepressants, analgesics and medical marijuana. The complexity of care for individuals with HIV-DSP merits a comprehensive approach. Implications for practice include interdisciplinary management with neurologists, podiatrists, mental health providers, and nurse-led counseling inclusive of patient safety teaching.

Expanding Role of the Erector Spinae Plane Block for Postoperative and Chronic Pain Management.

PURPOSE OF REVIEW: The erector spinae plane block (ESPB), first described in 2016, offers the promise of becoming a safe, less invasive, and technically less demanding alternative to conventional thoracic regional anesthetic techniques including thoracic epidurals and traditional paravertebral blocks. Clinical and cadaveric studies suggest that ESPB acts on the ventral rami of spinal nerves in the paravertebral space via penetration of the intertransverse connection tissues and moreover achieves visceral analgesia via the rami communicantes and sympathetic chain. RECENT FINDINGS: The block has garnered considerable appeal related to an inherently lower risk of neurovascular and pleural injury, low risk of local anesthetic systemic toxicity, and relative technical simplicity in comparison with epidural or paravertebral blockade. It has been utilized in the treatment of acute perioperative pain in a variety of clinical applications including breast, thoracic, and abdominal surgeries and trauma and may even offer some benefit in spine surgery. Given the combination of its efficacy and decreased associated risk when performed for perioperative pain, use of ESPB should be further explored for the management of chronic pain. Current literature at this time is limited to case studies and series performed by select groups. Though it is important to consider ESPB for chronic pain, further studies are needed to evaluate the efficacy and safety of the ESPB in the management of both acute and chronic pain.

Recent Advances in the Understanding and Management of Carpal Tunnel Syndrome: a Comprehensive Review.

PURPOSE OF REVIEW: Carpal tunnel syndrome (CTS) is an entrapment neuropathy that involves the compression of the median nerve at the wrist and is considered the most common of all focal entrapment mononeuropathies. CTS makes up 90% of all entrapment neuropathies diagnosed in the USA and affects millions of Americans. RECENT FINDINGS: Age and gender likely play a role in the development of CTS, but additional studies may further elucidate these associations. Of known associated risk factors, diabetes mellitus seems to have the greatest association with CTS. One of the most commonly reported symptoms in CTS is a "pins-and-needles" sensation in the first three fingers and nocturnal burning pain that is relieved with activity upon waking. Treatment for CTS is variable depending on the severity of symptoms. Conservative management of CTS is usually considered first-line therapy. In cases of severe sensory or motor deficit, injection therapy or ultimately surgery may then be considered. Still CTS is often difficult to treat and may be reoccurring. Novel treatment modalities such as laser and shockwave therapy have demonstrated variable efficacy though further studies are needed to assess for safety and effect. Given the unknown and potentially complex etiology of CTS, further studies are needed to explore combinations of diagnostic and therapeutic modalities.

A Research Agenda for Advancing Non-pharmacological Management of Chronic Musculoskeletal Pain: Findings from a VHA State-of-the-art Conference.

Chronic pain is widely prevalent among Veterans and can have serious negative consequences for functional status and quality of life among other domains. The Veterans Health Administration (VHA) convened a state-of-the-art (SOTA) conference to develop research priorities for advancing the science and clinical practice of non-pharmacological management of chronic musculoskeletal pain. In this perspective article, we present the methods and consensus recommendations for research priorities emanating from the SOTA. In the months leading up to the SOTA, a core group of researchers defined four areas of focus: psychological/behavioral therapies; exercise/movement therapies; manual therapies; and models for delivering multi-modal pain care and divided into workgroups. Each workgroup, in their respective areas of focus, identified seminal studies capturing the state of the evidence. Herein, we present consensus recommendations ranging from efficacy to effectiveness to implementation/dissemination research depending on the state of the evidence as assessed by participants, including commentary on common elements across workgroups and future areas of innovation in study design, measurement, and outcome ascertainment.