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Dianne Crellin,1– 3 Denise Harrison,1,2,4 Nick Santamaria,1 Franz E Babl2,3,5 1Department of Nursing, The University of Melbourne, Melbourne, VIC, Australia; 2Murdoch Children’s Research Institute, Melbourne, VIC, Australia; 3Royal Children’s Hospital, Melbourne, VIC, Australia; 4Children’s Hospital of Eastern Ontario and University of Ottawa, Ottawa, ON, Canada; 5Department of Paediatrics, The University of Melbourne, Melbourne, VIC, AustraliaCorrespondence: Dianne Crellinc/o Emergency Department, Royal Children’s Hospital, Flemington Road Parkville, Melbourne, VIC, 3052, AustraliaTel +61 39345 5331Fax +61 9345 5983Email dianne.crellin@rch.org.auPurpose: The purpose of this study was to compare the psychometric data and feasibility and clinical utility of the Face Legs, Activity, Cry and Consolability scale (FLACC), the Modified Behavioral Pain Scale (MBPS) and the Visual Analogue Scale for observers (VASobs) used to assess procedural pain in infants and young children.Patients and Methods: Twenty-six clinicians assessed videorecorded segments of 100 infants and young children who underwent a painful and/or distressing procedure in the emergency department using the FLACC scale, the MBPS and the VASobs pain and VASobs distress.Results: VASobs pain scores were lowest across all procedures and phases of procedures (p < 0.001). Inter-rater reliability was lowest for VASobs pain scores (ICC 0.55). Sensitivity and specificity were highest for FLACC scores (94.9% and 72.5%, respectively) at the lowest cut-off score (pain score two). Observers changed their MBPS scores more often than they changed FLACC or VASobs scores, but FLACC scores were more often incomplete. Reviewers did not consider any scale of use for procedural pain measurement.Conclusion: The reliability and sensitivity of the FLACC and MBPS were supported by study data but concerns about the capacity of these scales to distinguish between pain- and non-pain-related distress were raised. The VASobs cannot be recommended. Despite its limitations, the FLACC scale may be better suited than other scales for procedural pain measurement.Keywords: pain measurement, infants, validity, reliability

Gerardo Beltran Serrano,1– 3 Laura Pooch Rodrigues,2 Bruno Schein,1,2 Maxciel Zortea,1,2 Iraci Lucenada Silva Torres,1,4,5 Felipe Fregni,6 Wolnei Caumo1,2,5 1Post-Graduate Program in Medical Sciences, School of Medicine, Universidade Federal Do Rio Grande Do Sul (UFRGS), Porto Alegre, Brazil; 2Laboratory of Pain and Neuromodulation at Hospital De Clínicas De Porto Alegre (HCPA), Porto Alegre, Brazil; 3Psychology Department, Universidad Catolica De Cuenca, UCACUE, Cuenca, Ecuador; 4Department of Pharmacology, Institute of Health Sciences (ICBS), Universidade Federal Do Rio Grande Do Sul (UFRGS), Porto Alegre, Brazil; 5Pharmacology of Pain and Neuromodulation: Pre-Clinical Investigations Research Group, Universidade Federal Do Rio Grande Do Sul (UFRGS), Porto Alegre, Brazil; 6Department of Neurology, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, USACorrespondence: Wolnei Caumo Fax + (55) 51- 3359.8083Email wcaumo@hcpa.edu.brObjective: We evaluated whether active(a)-tDCS combined with hypnotic analgesia suggestion (HS) would be more effective than a single active(a)-tDCS, and/or sham-(s)-tDCS and s-tDCS/HS on the following outcomes: function of descending pain modulatory system (DPMS) during the conditioned pain modulation test (CPM-test) (primary outcome), heat pain threshold (HPT), heat pain tolerance (HPTo) and cold pressor test (CPT) (secondary outcomes). We also examined whether their effects are related to neuroplasticity state evaluated by serum brain-derived-neurotropic factor (BDNF).Materials and Methods: Forty-eight females received one session of one of the four interventions (a-tDCS/HS, s-tDCS/HS, a-tDCS, and s-tDCS) in an incomplete randomized crossover sequence. The a-tDCS or s-tDCS was applied over the left dorsolateral prefrontal cortex (DLPFC) for 30 minutes at 2mA.Results: A generalized linear model revealed a significant main effect for the intervention group (P < 0.032). The delta-(Δ) pain score on the Numerical Pain Scale (NPS0-10) during CPM-test in the a-tDCS/HS group was − 0.25 (0.43). The (Δ) pain score on NPS (0– 10) during CPM-test in the other three groups was a-tDCS=− 0.54 (0.41), HS − 0.01 (0.41) and s-tDCS/HS=− 0.19 (0.43). A-tDCS/HS intervention increased the CPT substantially compared to all other interventions. Also, higher baseline levels of BDNF were associated with a larger change in CPT and HPTo.Conclusion: These findings indicate that the HS combined with a-tDCS mitigated the effect of the a-tDCS on the DPMS. The a-tDCS up-regulates the inhibition on DPMS, and the HS improved pain tolerance. And, together they enhanced the reaction time substantially upon the CPT.Clinical Trial Registration: www.ClinicalTrials.gov, identifier NCT03744897.Keywords: tDCS, hypnotic analgesia, conditioned pain modulation, pain perception

Background Although cesarean delivery is one of the most commonly performed surgical procedures, robust data regarding post-cesarean pain is still lacking. Recent studies showed an association between pain upon local anesthetic (LA) injection for spinal anesthesia, or the use of a "three simple questions", and acute post-cesarean pain. Nevertheless, these assessments have yet to be validated further, despite their relative ease of use. We aimed to assess the association between pain score upon LA injection with acute post-cesarean pain after 24 hours at rest (primary outcome) and sub-acute post-cesarean pain lasting for 4 weeks or more (secondary outcome). Methods Women undergoing cesarean delivery under spinal anesthesia were given pre-operative questionnaires on pain and psychological vulnerability. We also assessed the pain score upon LA injection and mechanical temporal summation. Univariate and multivariable logistic regressions were performed. Results The incidence of moderate-to-severe acute post-cesarean pain at 24 hours was 21.0% (95% CI=16.6-27.6%) (48 of 217 patients). Pain score upon LA injection was not significantly associated with acute post-cesarean pain after 24 hours at rest (unadjusted OR=1.10, 95% CI=0.95-1.27, P=0.21). However, pain score upon LA injection was significantly associated with sub-acute post-cesarean pain (adjusted OR=1.29, 95% CI=1.07-1.55, P=0.0089) with significant covariate of increased pre-operative central sensitization inventory (CSI) scores (adjusted OR=1.05, 95% CI=1.01-1.09, P=0.0111; area under the curve (AUC)=0.691). Conclusion There was no association between increased pain score upon LA injection and acute post-cesarean pain, but it was associated with sub-acute post-cesarean pain. Further work is needed to define pain score upon LA injection as a convenient pragmatic measure of risk stratifying patients predisposed to sub-acute post-cesarean pain.

Bruce Parsons,1 Xiaoping Pan,2 Li Xie,3 YuXuan Chen,3 Marie Ortiz,1 Ed Whalen1 1Pfizer, New York, NY, USA; 2Guangzhou First People’s Hospital, Guangzhou Medical University, Guangzhou, Guangdong Province, China; 3Pfizer China, Beijing, China Purpose: Pregabalin is indicated for postherpetic neuralgia (PHN) in multiple countries, including China. This analysis compared pregabalin efficacy and safety in Chinese and international patients with PHN. Patients and methods: Data from Chinese and international randomized, double-blind, placebo-controlled trials were compared. Pregabalin was administered at fixed (150, 300, or 600 mg/day) or flexible (150–600 mg/day) doses. The main efficacy measure was mean pain score change at endpoint on an 11-point numeric rating scale ranging from 0 = no pain to 10 = worst possible pain. Secondary efficacy measures included proportions of 30% and 50% pain responders, pain-related sleep interference (PRSI) scores, and proportions of Patient Global Impression of Change (PGIC) responders. The incidences of serious adverse events (SAEs) and adverse events (AEs) were used to assess safety. The effect of baseline pain severity on efficacy was tested. The proportions of patients with severe baseline pain who had moderate or mild pain at endpoint were also assessed. Results: A total of 1166 patients were analyzed: 312 Chinese and 854 international. Overall, results were similar between Chinese and international patients. Pregabalin statistically significantly improved mean pain score versus placebo (least squares mean difference [95% CIs]: Chinese, –0.8 [–1.2, –0.5]; international, –1.3 [–1.6, –1.0]; both p

Paweł Sokal,1 Marek Harat,2 Piotr Zieliński,3 Sara Kierońska1 1Department of Neurosurgery, Military Research Hospital, Bydgoszcz, 2Department of Public Health, Ludwik Rydygier Collegium Medicum, Bydgoszcz, Nicolaus Copernicus University, Toruń, 3Department of Sports Medicine, University of Physical Education and Sport, Gdansk, Poland Abstract: Peripheral neuropathic pain (PNP) and complex regional pain syndrome (CRPS) can be effectively treated with peripheral nerve stimulation. In this clinical trial report, effectiveness of novel, miniature, wirelessly controlled microstimulator of tibial nerve in PNP and CRPS was evaluated. In this pilot study the average preoperative visual analog scale (VAS) score in six patients was 7.5, with 1, 3 and 6 months: 2.6 (p=0.03), 1.6 (p=0.03), and 1.3 (p=0.02), respectively. The mean average score in the six patients a week preceding the baseline visit was 7.96, preceding the 1, 3 and 6 month visits: 3.32 (p=0.043), 3.65 (p=0.045), and 2.49 (p=0.002), respectively. The average short-form McGill pain score before surgery was 23.8, and after 1, 3 and 6 months it was 11.0 (p=0.45), 6.3 (p=0.043), and 4.5 (p=0.01), respectively. Applied therapy caused a reduction of pain immediately after its application and clinical improvement was sustained on a similar level in all patients for six months. No complications of the treatment were observed. Intermittent tibial nerve stimulation by using a novel, miniature, wirelessly controlled device can be effective and feasible in PNP and CRPS. It is a safe, minimally invasive, and convenient neuromodulative method. Keywords: tibial nerve stimulation, peripheral nerve stimulation, miniature stimulator, peripheral neuropathic pain, complex regional pain syndrome&nbsp

Zi Xuan Wang,1 Lin Li,1 Feng Ying Tao2 1Department of Interventional Radiology, Qingdao Municipal Hospital, Qingdao, Shandong, People’s Republic of China; 2Department of Oncology, Qingdao Municipal Hospital, Qingdao, Shandong, People’s Republic of China Aim: Psychological intervention has been proved a complementary approach to drug analgesia. Another study suggested that health knowledge is associated with psychological symptoms in patients with liver cancer. This study is conducted to assess whether improving the health education (HE) alleviates the postembolization pain during transarterial chemoembolization (TACE). Materials and methods: One hundred and fifteen patients, who required TACE for hepatocellular carcinoma (HCC) and suffered postembolization pain, were randomized into control group (n=63) and HE group (n=52). The health knowledge was scaled with the health knowledge questionnaire (HKQ). The postembolization pain was scored using a 0–10 numeric rating scale (NRS-10) after arterial embolization in both groups. Results: There were no statistical differences between male and female in all HKQ scores (P>0.05). The HKQ scores of young people (≤45 years old) were significantly higher than those of elders (>45 years old; P

Soukaina Tawfiq Ryalat,1 Mohammad H Al-Shayyab,1 Wala Amin,2 Saif Aldeen AlRyalat,3 Nosaiba Al-Ryalat,4 Faleh Sawair1 1Department of Oral and Maxillofacial Surgery, Oral Medicine, and Periodontology, Faculty of Dentistry, University of Jordan, Amman, Jordan; 2Department of Prosthodontics, Faculty of Dentistry, University of Jordan, Amman, Jordan; 3Department of Ophthalmology, Faculty of Medicine, University of Jordan, Amman, Jordan; 4Department of Radiology and Nuclear Medicine, University of Jordan, Amman, Jordan Introduction: Infiltration anesthesia (IA) is the method to anaesthetize maxillary teeth successfully. In contrast, intraligamentary anesthesia (ILA) has been used as supplementary anesthesia during tooth extraction, particularly when regional block anesthesia has failed. In this study, we compare the efficacy of and patient satisfaction with ILA vs IA when extracting maxillary first molar teeth. Methods: Forty patients were enrolled in this study and 80 maxillary first molars extracted. All patients served as their own control, with ILA as the experimental side and IA as the control side. The two techniques were compared for efficacy using a visual analog scale (VAS) and patient satisfaction compared using a verbal rating scale (VRS). Results: The mean VAS pain score for extraction using ILA was lower than that for IA (20.30±3.18 and 13.93±1.95 mm, respectively; P

Christopher M Aiudi,1 W Michael Hooten,2 Rebecca A Sanders,2 James C Watson,2 Susan M Moeschler,2 Halena M Gazelka,2 Bryan C Hoelzer,2 Jason S Eldrige,2 Wenchun Qu,3 Tim J Lamer2 1Mayo Clinic School of Medicine, 2Division of Pain Medicine, Department of Anesthesia and Perioperative Medicine, Mayo Clinic, 3Department of Physical Medicine and Rehabilitation, Mayo Clinic, Rochester, MN, USA Objective: Intra-articular injections of the C1–2 joint are an effective therapeutic option for pain generated from degenerative and inflammatory conditions affecting the joint. Limited information exists about the adverse events (AEs) associated with these injections. The primary aim of this study is to describe the frequency and type of AEs associated with C1–2 joint injections. The secondary aim is to identify clinical factors associated with the occurrence of AEs of C1–2 joint injections. Design/methods: A retrospective chart review was conducted on all C1–2 joint injections performed at the Mayo Pain Medicine Clinic in Rochester, MN, from January 1, 2005 through July 31, 2015. AE data were extracted from procedural and post-procedural clinical notes. Analysis was conducted to determine correlations between any AE and demographic and clinical characteristics. Using univariate and multivariate logistic regression analyses, associations were determined. Results: From January 1, 2005 to July 31, 2015, 135 C1–2 injections were performed on 72 patients. Overall, at least 1 AE was reported in 18.5% of the injections. The most common AEs were post-procedural increase in pain and procedural vascular contrast uptake. There was a significant association between AE occurrence and greater pre-procedural maximum pain score. Conclusions: AEs from C1–2 joint injections occurred commonly, but there were no persistent or serious AEs associated with these injections. The data also demonstrate that patients with higher pre-procedural maximum pain scores are more likely to experience an AE. Keywords: C1–2 joint, facet, injection, adverse event

Michael Serpell,1 Mark Latymer,2 Mary Almas,3 Marie Ortiz,4 Bruce Parsons,4 Rita Prieto5 1University Department of Anaesthesia, Stobhill Ambulatory Care Hospital, Glasgow, 2Pfizer Ltd, Tadworth, UK; 3Pfizer, Groton, CT, 4Pfizer, New York, NY, USA; 5Pfizer GEP SLU, Madrid, Spain Background: Pregabalin is an effective treatment option for many patients with neuropathic pain. Higher doses of pregabalin have been shown to be more effective in improving pain outcomes but, in practice, failing to appropriately increase the dose can leave patients under-treated.Methods: This was a pooled analysis of 6 flexible-dose clinical trials of pregabalin in patients with neuropathic pain (diabetic peripheral neuropathy, peripheral herpetic neuralgia, posttraumatic pain, or postsurgical pain). Patients were divided into “dose pathway” groups based on their weekly pregabalin dose from the start of their trial to the first week of their maintenance phase. These were: 150 mg/day only; 150 to 300 mg/day; 150 to 300 to 450 mg/day; 150 to 300 to 450 to 600 mg/day; 150 to 300 to 600 mg/day; 300 to 600 mg/day. Pain outcomes assessed for each group at each new dose were proportion of 30% and 50% responders (≥30% or ≥50% reduction in mean pain score from baseline) and mean change in pain score. Percent change in mean pain score from baseline was assessed using a marginal structural model.Results: Seven hundred and sixty-one patients treated with flexible-dose pregabalin were included in the analysis. For each dose pathway group, there was a notably greater proportion of 30% and 50% responders and change in pain score, at each escalating dose. As assessed by the marginal structural model, higher doses of pregabalin were estimated to result in a significantly greater change in mean pain score at each week. This dose response with flexible-dose pregabalin was consistent with that previously observed with fixed-dose pregabalin.Conclusion: Many patients who do not respond to lower doses of pregabalin will respond with notable improvements in pain outcomes when the dose is escalated. These data should encourage physicians treating patients with neuropathic pain to escalate pregabalin to the dose that delivers optimal analgesia and tolerable side effects. Keywords: neuropathic pain, pregabalin, dosing

Arvid Yung,1 Arlyne Thung,1,2 Joseph D Tobias,1–31Department of Anesthesiology and Pain Medicine, Nationwide Children's Hospital, 2Department of Anesthesiology and Pain Medicine, 3Department of Pediatrics, The Ohio State University College of Medicine, Columbus, OH, USA Background: During the perioperative care of infants with hypertrophic pyloric stenosis, an opioid-sparing technique is often advocated due to concerns such as postoperative hypoventilation and apnea. Although the rectal administration of acetaminophen is commonly employed, an intravenous (IV) preparation is also currently available, but only limited data are available regarding IV acetaminophen use for infants undergoing pyloromyotomy. The objective of the current study was to compare the efficacy of IV and rectal acetaminophen for postoperative analgesia in infants undergoing laparoscopic pyloromyotomy. Methods: A retrospective review of the use of IV and rectal acetaminophen in infants undergoing laparoscopic pyloromyotomy was performed. The efficacy was assessed by evaluating the perioperative need for supplemental analgesic agents, postoperative pain scores, tracheal extubation time, time in the postanesthesia care unit, time to oral feeding, and time to hospital discharge. Results: The study cohort included 68 patients, of whom 34 patients received IV acetaminophen and 34 received rectal acetaminophen. All patients also received local infiltration of the surgical site with 0.25% bupivacaine. No intraoperative opioids were administered. There was no difference between the two groups with regard to postoperative pain scores, need for supplemental analgesic agents, time in the postanesthesia care unit, or time in the hospital. There was no difference in the number of children who tolerated oral feeds on the day of surgery or in postoperative complications. Conclusion: Our preliminary data suggest that there is no clinical difference or advantage with the use of IV versus rectal acetaminophen in infants undergoing laparoscopic pyloromyotomy. Keywords: postoperative pain management, neonatal anesthesia, pyloric stenosis, pain score, length of hospital stay, length of postanesthesia care unit stay

Arnold R Gammaitoni,1 Henry T Goitz,2 Stephanie Marsh,2 Thomas B Marriott,3 Bradley S Galer1 1Pain Group, Nuvo Research US, West Chester, PA, USA; 2Sports Medicine, Detroit Medical Center, Warren, MI, USA; 3Pain Group, Nuvo Research US, Salt Lake City, UT, USA Introduction: The pain of patellar tendinopathy (PT) may be mediated by neuronal glutamate and sodium channels. Lidocaine and tetracaine block both of these channels. This study tested the self-heated lidocaine-tetracaine patch (HLT patch) in patients with PT confirmed by physical examination to determine if the HLT patch might relieve pain and improve function. Methods: Thirteen patients with PT pain of ≥14 days' duration and baseline average pain scores ≥4 (on a 0–10 scale) enrolled in and completed this prospective, single-center pilot study. Patients applied one HLT patch to the affected knee twice daily for 2–4 hours for a total of 14 days. Change in average pain intensity and interference (Victorian Institute of Sport Assessment [VISA]) scores from baseline to day 14 were assessed. No statistical inference testing was performed. Results: Average pain scores declined from 5.5 ± 1.3 (mean ± standard deviation) at baseline to 3.8 ± 2.5 on day 14. Similarly, VISA scores improved from 45.2 ± 14.4 at baseline to 54.3 ± 24.5 on day 14. A clinically important reduction in pain score (≥30%) was demonstrated by 54% of patients. Conclusion: The results of this pilot study suggest that topical treatment that targets neuronal sodium and glutamate channels may be useful in the treatment of PT. Keywords: patellar tendinopathy, patellar tendinosis, heated lidocaine/tetracaine patch, topical analgesic patch, knee pain

Farhan Taghizadeh, Timothy Ellison, Mimi Traylor-KnowlesLifestyle Lift Innovation Center, Albuquerque, NM, USAPurpose: To evaluate the use of the CoolSkin® (Elbio, Seoul, Korea) skin-cooling device to reduce injection pain during rhytidectomy.Method: Nineteen patients underwent rhytidectomy using the CoolSkin at -4°C on the first side lateral injection. The second side was then started without the cooling. Patients were offered cooling if they desired it on the second side. Surveys were administered 24 hours after the procedure, comparing pain (scale 0–5) and investigating treatment preferences. Patient healing was tracked for 6 weeks.Results: Mean pain score for the untreated side was 4.63 versus 2.37 for the CoolSkin-treated side (P < 0.001). All patients asked for the second side to be cooled, and 89% were in favor of the chilling procedure when surveyed 24 hours afterwards. Sixty eight percent of patients stated that this device reduced fear of future injections. No flap loss or healing sequelae were noted from device use.Conclusion: The CoolSkin device is an effective tool to reduce injection pain laterally during rhytidectomy.Keywords: pain, cooling, rhytidectomy, CoolSkin®, facial injections, face lift