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Abstract: Graded exposure treatment (GET) is a theory-driven pain treatment that aims to improve functioning by exposing patients to activities previously feared and avoided. Combining key elements of GET with acceptance-based exposure, GET Living (GL) was developed for adolescents with chronic pain (GL). Based on robust treatment effects observed in our single-case experimental design pilot trial of GL (NCT01974791), we conducted a 2-arm randomized clinical trial comparing GL with multidisciplinary pain management (MPM) comprised of cognitive behavioral therapy and physical therapy for pain management (NCT03699007). A cohort of 68 youth with chronic musculoskeletal pain (M age 14.2 years; 81% female) were randomized to GL or MPM. Owing to COVID-19 restrictions, 54% of participants received zoom video delivered care. Assessments were collected at baseline, discharge, as well as at 3-month and 6-month follow-up. Primary outcomes were self-reported pain-related fear and avoidance. Secondary outcomes were child functional disability and parent protective responses to child pain. As hypothesized, GL improved in primary and secondary outcomes at 3-month follow-up. Contrary to our superiority hypothesis, there was no significant difference between GL and MPM. Patients reported both GL and MPM (in person and video) as credible and were highly satisfied with the treatment experience. Next steps will involve examining the single-case experimental design data embedded in this trial to facilitate an understanding of individual differences in treatment responses (eg, when effects occurred, what processes changed during treatment within the treatment arm). The current findings support GET Living and MPM for youth with chronic pain., (Copyright © 2023 International Association for the Study of Pain.)

Abstract: Chronic pancreatitis (CP) is associated with a high disease burden, extensive negative impact on quality of life, increased rates of depression and anxiety, and significant health care utilization and expenditures. Pain is a hallmark feature of CP, present in up to 90% of patients with this condition, and can lead to high rates of disability, hospitalization, and opioid medication use. Current perspectives on the management of CP have evolved to advocate a multidisciplinary approach which offers new pathways for helping patients manage symptoms. Psychologists play an important role in a multidisciplinary team effort by applying scientifically based psychological principles and techniques to improve pain and adaptation to chronic illness. This review will detail the fundamentals of delivering psychological interventions for adults with CP managed in an outpatient setting. Recommendations for integrating psychological care in multidisciplinary management of CP will be offered. Future directions for psychological care in CP multidisciplinary teams are also discussed., Competing Interests: G.T. serves as a consultant for Boston Scientific Corporation. The remaining authors declare no conflicts of interest., (Copyright © 2022 Wolters Kluwer Health, Inc. All rights reserved.)

Background: Brain tumors account for the majority of central nervous system tumors, and most are removed by craniotomies. Many postcraniotomy patients experience moderate or severe pain after surgery, but patient perspectives on their experiences with pain management in the hospital have not been well described., Objective: The aim of this study was to describe how patients who have undergone a craniotomy for brain tumor removal experience pain management while hospitalized., Methods: Qualitative descriptive methods using semistructured interviews were conducted with patients on a neurological step-down unit in an urban teaching hospital in the Midwest United States. Interviews focused on how patients experienced postcraniotomy pain and how it was managed. Narratives were analyzed with standard content analytic procedures., Results: Twenty-seven participants (median age, 58.5 years; interquartile range, 26-41 years; range, 21-83 years) were interviewed. The majority were white (n = 25) and female (n = 15) and had an anterior craniotomy (n = 25) with sedation (n = 17). Their pain experiences varied on 2 dimensions: salience of pain during recovery and complexity of pain management. Based on these dimensions, 3 distinct types of pain management experiences were identified: (1) pain-as-nonsalient, routine pain management experience; (2) pain-as-salient, routine pain management experience; and (3) pain-as-salient, complex pain management experience., Conclusions: Many postcraniotomy patients experience their pain as tolerable and/or pain management as satisfying and effective; others experience pain and pain management as challenging., Implications for Practice: Clinicians should be attuned to needs of patients with complex pain management experiences and should incorporate good patient/clinician communication., Competing Interests: The authors have no conflicts of interest to disclose., (Copyright © 2020 Wolters Kluwer Health, Inc. All rights reserved.)

This study conducted on 66 mothers aimed to investigate the effect of foot massages postpartum using an introductory information form, the Postpartum Comfort Scale, the visual analog scale, and a drug follow-up card. It was concluded that foot massages positively improved comfort, reduced pain levels, and reduced unnecessary medications., (Copyright © 2021 Wolters Kluwer Health, Inc. All rights reserved.)

Background: Music therapy and music-based interventions have been used widely in numerous medical procedures to reduce the physical and psychological disorders. However, the effect of music therapy on pain relief in hemodialysis patients still remains unclear., Methods: Electronic databases were comprehensively searched through MEDLINE, Web of Science, EMBASE, Cochrane, and WANFANG. All studies met inclusion criteria were eligible for systematic review and meta-analysis. Clinical variables were extracted and pooled results were obtained using STATA software., Results: A total of 10 studies with 722 participants were included for systematic review. Overall, music therapy showed a significantly favorable effect on reducing pain for patients undergoing hemodialysis (SMD: -0.90, 95%CIs: -1.25 to -0.55, P < .001). No publication bias was observed., Conclusions: Music-based interventions could significantly relieve pain for patients undergoing hemodialysis, which should be promoted as an effective and safe complementary method., Competing Interests: The authors have no conflicts of interest to disclose., (Copyright © 2021 the Author(s). Published by Wolters Kluwer Health, Inc.)

Objective: To explore the effect of modular transitional nursing intervention on the improvement of self-management of the patients with cancer pain., Method: This study will be conducted from March 2021 to May 2022 at Affiliated Hospital of Beihua University. The experiment was granted through the Research Ethics Committee of Affiliated Hospital of Beihua University (4348-019). Eighty patients are analyzed in our study. The patients will be included if they are between 18 and 70 years old and are diagnosed with cancer, the pain intensity score on moderate level, the pain lasts for more than 3 days, and the patients who have signed the written informed consent. While the patients will be excluded if they have a documented history of drug or alcohol abuse, and patients with limited performance, and patients have a surgery in the past 3 days. The primary result mainly expresses as intergroup differences in self-management disorders (Barriers Questionnaire-II) associated with the cancer pain. And the secondary results include the quality of life (QOL) and pain intensity. All the analyses are implemented with SPSS for Windows Version 20.0., Results: Table 1 will show the clinical outcomes between the 2 groups., Conclusion: A modular transitional nursing intervention appears to reduce pain in cancer patients., Trial Registration Number: researchregistry6262., Competing Interests: All of the authors approved the article and there is no conflict of interest., (Copyright © 2020 the Author(s). Published by Wolters Kluwer Health, Inc.)

This randomized trial compared the analgesic effect of 4 nonpharmacologic interventions (breastfeeding, oral sucrose, nonnutritive sucking, and skin-to-skin contact) on term newborns between 24 and 48 hours of age who underwent a heel lance. The Neonatal Pain, Agitation, and Sedation Scale was used to evaluate pain. The newborns (N = 226) were assigned to one of 4 intervention groups (n = 176) or a control group without pain intervention (n = 50). The results indicate that all intervention groups showed decreased pain levels when compared with the control group (P < .01). The oral sucrose group experienced a superior analgesic effect when compared with the skin-to-skin contact group (P < .01), but no difference was observed when compared with the breastfeeding group (P > .05) or the nonnutritive sucking group (P > .05). All intervention groups showed a shortened crying time (P < .01) and reduced procedural duration (P < .01) compared with the control group. All of these interventions are clinically applicable and acceptable when caring for a newborn during a minor painful procedure.

Background: The quality of pain management in hospitalized older adult patients with dementia is a crucial issue in healthcare. The knowledge and beliefs of nurses are known to predict their pain management intentions toward this particularly vulnerable patient population., Purpose: This study was designed to evaluate the reliability and validity of the Chinese version of the Knowledge and Beliefs About Pain in Elderly Patients With Dementia (KBPED-C) questionnaire using a sample of hospital nurses., Methods: A cross-sectional study was conducted. The 17-item KBPED-C was distributed between September 2013 and August 2014 to 350 nurses working at a hospital in northern Taiwan. Consistency assessment was conducted using Cronbach's alpha, and construct validity was examined using principal component analysis. Three hundred five nurses (19 men and 286 women) were enrolled using convenience sampling., Results: The mean age of the participants was 30.8 ± 5.8 years. The Cronbach's alpha for internal consistency was .86. The item-total correlation was acceptable. The observed content validity was strong, with a content validity index of .86. Construct validity testing revealed a four-factor structure that accounted for 55.2% of the total variance. The four factors of the KBPED-C questionnaire were "general beliefs about pain and aging," "pain management in the workplace," "knowledge about pain management in older adult patients with dementia," and "beliefs about pain in older people.", Conclusions/implications for Practice: This preliminary validation study showed the high acceptability, reliability, and validity of the KBPED-C for hospital nurses. Future studies may use this questionnaire to explore the beliefs and knowledge of nurses regarding pain in older adult patients with dementia.

The complex mechanisms underlying migraine are not entirely understood. It has been suggested that descending endogenous pain modulation is an important contributing factor, although research is controversial. A frequently used method to quantify the inhibitory pain modulation system is offset analgesia (OA), defined as a disproportionally large decrease in pain perception in response to a small decrease of painful stimulation. The aim of this study is to evaluate the OA response in patients with migraine and healthy controls, measured at the forehead (trigeminal, V1) and forearm (extratrigeminal). Patients with episodic migraine during the headache-free interval (n = 26) and age- and sex-matched headache-free controls (n = 26) were included in this cross-sectional study. All participants underwent an individualized OA paradigm consisting of 3 stimulus offset trials and 3 constant temperature trials examined at both, a trigeminal and an extratrigeminal test site. Items from the quantitative sensory testing protocol were additionally included. In contrast to the extratrigeminal area, a reduced OA response was shown in the trigeminal area in patients with migraine compared with healthy controls (P < 0.01, mean difference: 13.7, 95% confidence interval: 3.8-23.6). Statistically significant differences between the trigeminal area and the extratrigeminal area were neither observed in healthy controls nor in patients with migraine (P > 0.05). Mechanical detection, mechanical pain threshold, warm detection, and heat pain threshold showed no significant differences between groups or test sites (P > 0.05). In summary, patients with episodic migraine in the headache-free interval exhibited somatotopically specific differences in endogenous pain modulation.

Pain-related fear is typically associated with avoidance behavior and pain-related disability in youth with chronic pain. Youth with elevated pain-related fear have attenuated treatment responses; thus, targeted treatment is highly warranted. Evidence supporting graded in vivo exposure treatment (GET) for adults with chronic pain is considerable, but just emerging for youth. The current investigation represents the first sequential replicated and randomized single-case experimental phase design with multiple measures evaluating GET for youth with chronic pain, entitled GET Living. A cohort of 27 youth (81% female) with mixed chronic pain completed GET Living. For each participant, a no-treatment randomized baseline period was compared with GET Living and 3- and 6-month follow-ups. Daily changes in primary outcomes fear and avoidance and secondary outcomes pain catastrophizing, pain intensity, and pain acceptance were assessed using electronic diaries and subjected to descriptive and model-based inference analyses. Based on individual effect size calculations, a third of participants significantly improved by the end of treatment on fear, avoidance, and pain acceptance. By follow-up, over 80% of participants had improved across all primary and secondary outcomes. Model-based inference analysis results to examine the series of replicated cases were generally consistent. Improvements during GET Living was superior to the no-treatment randomized baseline period for avoidance, pain acceptance, and pain intensity, whereas fear and pain catastrophizing did not improve. All 5 outcomes emerged as significantly improved at 3- and 6-month follow-ups. The results of this replicated single-case experimental phase design support the effectiveness of graded exposure for youth with chronic pain and elevated pain-related fear avoidance.

Background: Several recent studies have documented the effects of massage and acupressure in reducing labor pain and labor time and in satisfaction with the delivery. However, few studies have investigated the comparative effects of these two therapies., Purpose: The aim of this study was to compare the effects of massage and acupressure on labor-related pain management, duration, and satisfaction with delivery., Methods: This randomized controlled trial (n = 120) included three intervention groups (massage only, acupressure only, and massage + acupressure) and one control group, in which patients received no massage or acupressure treatment. A personal information form, Pregnant Watch Form, and Visual Analog Scale (VAS) were used to collect data. Frequency and percentage calculations, chi-square test, Student's t test, Tukey's honestly significant difference test, and one-way variance analysis were used for data analysis., Results: In the latent phase of labor, the mean VAS scores of the massage-only group and massage + acupressure group were lower (4.56 ± 1.36 and 4.63 ± 1.52, respectively) than that of the control group (6.16 ± 1.46; p < .01). In the active and transition phases, the mean VAS scores of the massage-only group, acupressure-only group, and massage + acupressure group were significantly lower than that of the control group (p < .01 and p < .001, respectively). During postpartum, the mean VAS score of the massage + acupressure group was lower (2.30 ± 0.70) than that of the control group (2.96 ± 0.72; p = .003). Cervical dilatation completion time and 1- and 5-minute Apgar scores were similar among all of the groups (p > .05). The three intervention groups reported relatively more positive feelings than the control group, and all three of the interventions were found to be effective in improving satisfaction., Conclusions/implications for Practice: The results of this study indicate that the dual application of massage and acupressure is relatively more effective than either therapy applied alone and that massage is more effective than acupressure.

We conducted a randomized controlled trial of an individually tailored, virtual perspective-taking intervention to reduce race and socioeconomic status (SES) disparities in providers' pain treatment decisions. Physician residents and fellows (n = 436) were recruited from across the United States for this two-part online study. Providers first completed a bias assessment task in which they made treatment decisions for virtual patients with chronic pain who varied by race (black/white) and SES (low/high). Providers who demonstrated a treatment bias were randomized to the intervention or control group. The intervention consisted of personalized feedback about their bias, real-time dynamic interactions with virtual patients, and videos depicting how pain impacts the patients' lives. Treatment bias was re-assessed 1 week later. Compared with the control group, providers who received the tailored intervention had 85% lower odds of demonstrating a treatment bias against black patients and 76% lower odds of demonstrating a treatment bias against low SES patients at follow-up. Providers who received the intervention for racial bias also showed increased compassion for patients compared with providers in the control condition. Group differences did not emerge for provider comfort in treating patients. Results suggest an online intervention that is tailored to providers according to their individual treatment biases, delivers feedback about these biases, and provides opportunities for increased contact with black and low SES patients, can produce substantial changes in providers' treatment decisions, resulting in more equitable pain care. Future studies should examine how these effects translate to real-world patient care and the optimal timing/dose of the intervention.

Sickle cell disease (SCD) is a medical condition in which chronic pain is common and negatively impacts psychosocial function and quality of life. Although the brain mechanisms underlying chronic pain are well studied in other painful conditions, the brain mechanisms underlying chronic pain and the associated psychosocial comorbidities are not well established in SCD. A growing literature demonstrates the effect of treatment of chronic pain, including pharmacological and nonpharmacological treatments, on brain function. The present systematic review aimed to (1) determine the effects of chronic pain and psychosocial comorbidities on brain function of patients with SCD; (2) summarize pharmacological and nonpharmacological approaches to treat these symptoms; and (3) identify areas for further investigation of potential beneficial effects of treatments on brain function. Titles were screened using predefined criteria, including SCD, and abstracts and full texts were reviewed by 2 independent reviewers. A total of 1167 SCD articles were identified, and 86 full articles were included covering 3 sections: chronic pain (4 studies), psychosocial comorbidities (11 studies), and pharmacological and nonpharmacological treatments (71 studies). Neuroimaging evidence demonstrates aberrant neural processing related to chronic pain and psychosocial comorbidities in SCD beyond ischemic stroke and cerebral hemorrhage. Although neuroimaging studies show an important role for psychological factors, pain management is nearly exclusively based on opioids. Behavior therapy seems useful to improve psychological symptoms as well as chronic pain and quality of life. Further investigation is required with larger cohorts, matched controls, and examination of treatment-related neural mechanisms.

Supportive touch has remarkable benefits in childbirth and during painful medical procedures. But does social touch influence pain neurophysiology, ie, the brain processes linked to nociception and primary pain experience? What other brain processes beyond primary pain systems mediate their analgesic effects? In this study, women (N = 30) experienced thermal pain while holding their romantic partner's hand or an inert device. Social touch reduced pain and attenuated functional magnetic resonance imaging activity in the Neurologic Pain Signature (NPS)-a multivariate brain pattern sensitive and specific to somatic pain-and increased connectivity between the NPS and both somatosensory and "default mode" regions. Brain correlates of touch-induced analgesia included reduced pain-related activation in (1) regions targeted by primary nociceptive afferents (eg, posterior insula, and anterior cingulate cortex); and (b) regions associated with affective value (orbitofrontal cortex), meaning (ventromedial prefrontal cortex [PFC]), and attentional regulation (dorsolateral PFC). Activation reductions during handholding (vs holding a rubber device) significantly mediated reductions in pain intensity and unpleasantness; greater pain reductions during handholding correlated with greater increases in emotional comfort, which correlated with higher perceived relationship quality and (a trend toward) greater perceived closeness with the romantic partner. The strongest mediators of analgesia were activity reductions in a brain circuit traditionally associated with stress and defensive behavior in mammals, including ventromedial and dorsomedial PFC, rostral anterior cingulate cortex, amygdala/hippocampus, hypothalamus, and periaqueductal gray matter. Social touch affects core brain processes that contribute to pain and pain-related affective distress in females, and should be considered alongside other treatments in medical and caregiving contexts.

Background: Males and females have significant differences in certain medical outcomes. However, little research has explored the gender differences in cancer patient perceptions of analgesics, the relationship between gender and analgesic adherence, or the effectiveness of pain management., Objective: The objectives of this study were to compare gender differences associated with hesitancy to use analgesics, analgesic adherence, or pain management effectiveness and to examine whether gender can precisely predict analgesic adherence., Methods: The study was conducted in the outpatient oncology department of a medical center in Taiwan. A descriptive and cross-sectional design was used. The study samples were collected from 362 cancer patients. The participants completed the short version of the Barriers Questionnaire-Taiwan, the Morisky Analgesics Adherence Measure-Taiwan version, the Brief Pain Inventory-Chinese version, the Pain Management Index, and a demographic and disease questionnaire., Results: The pain intensity and hesitancy to use analgesics scores were significantly higher among females than among males. The Pain Management Index results indicated that a larger percentage of males had adequate pain management. In addition, being male was a significant predictor of higher analgesic adherence (odds ratio, 1.93; P < .05)., Conclusions: Gender could precisely predict cancer patients' medication adherence. Women experienced significantly greater pain than did men but also had more hesitancy to use analgesics, lower adherence, and inadequate pain management., Implications for Practice: Healthcare professionals should consider women as a high-risk group for inadequate pain control. It is crucial for health providers to consider the gender discrepancy when attempting to improve cancer pain management.

Patients after cardiac surgery experience significant pain, but cannot communicate effectively due to opioid analgesia and sedation. Identification of pain with validated behavioral observation tool in patients with limited abilities to self-report pain improves quality of care and prevents suffering. Aim of this study was to validate Polish version of behavioral pain scale (BPS) in intubated, mechanically ventilated patients sedated with dexmedetomidine and morphine after cardiac surgery.Prospective observational cohort study included postoperative cardiac surgery patients, both sedated with dexmedetomidine and unsedated, observed at rest, during a nociceptive procedure (position change) and 10 minutes after intervention. Pain control was achieved using morphine infusion and nonopioid coanalgesia. Pain intensity evaluation included self-report by patient using numeric rating scale (NRS) and BPS assessments carried out by 2 blinded observers.A total of 708 assessments were performed in 59 patients (mean age 68 years), predominantly men (44/59, 75%). Results showed very good interrater correlation between raters (interrater correlation scores >0.87). Self-report NRS scores were obtained from all patients. Correlation between NRS and BPS was relatively strong during nociceptive procedures in all patients for rater A and rater B (Spearman R > 0.65, P < .001). Both mean NRS and BPS scores were significantly higher during nociceptive procedures as compared to assessments at rest, in both sedated and unsedated patients (P < .001).The results of this observational study show that the Polish translation of BPS can be regarded as a useful and validated tool for pain assessment in adult intubated patients. This instrument can be used in both unsedated and sedated cardiac surgery patients with limited communication abilities.

Objectives: Social and interpersonal factors may impact chronic pain self-care and self-management; however, no integrated measure exists to assess the interplay of these factors. We developed and tested a measure designed to assess salient interpersonal factors, including relationship guilt and worry, and difficulty prioritizing self-care in chronic pain., Methods: We tested self-report items broadly relevant to locus of care, limit-setting capacity, and worry/guilt about relationships in 3 discrete chronic pain samples (total N=1,452): (1) online sample of chronic pain clinic patients (N=729; 21 candidate CARE items, sociodemographics, and measures of psychological and physical functioning). Analytic results supported a final 7-item CARE scale that was next tested in (2) an anonymous online sample of 578 adults with chronic pain. (3) Finally, preliminary validation of the CARE scale was performed in a tertiary pain clinic sample (N=145)., Results: Exploratory factor analysis revealed a 7-item, 2-factor solution (difficulty prioritizing self-care and guilt/worry) that accounted for a combined total of 58% of the variance. CARE scale-7 had modest convergent validity with pain intensity, pain-related interference, and emotional distress. Extreme difficulty with both factors was reported by about one-third of the total sample, suggesting that relationship factors significantly impact pain management and self-care., Discussion: Social factors are gaining attention for their influence on the trajectory of chronic pain. The CARE scale is a brief, integrated measure that may be used to reveal specific interpersonal and personal impediments to self-care, and identify important therapeutic targets to optimize self-management behaviors.

Background: In oncology, pain control is a persistent problem. Significant barriers to cancer pain management are patient related. Pain self-management support interventions have shown to reduce pain intensity and patient-related barriers. Comparative effectiveness research is a suitable approach to test whether effects are sustained in clinical practice., Objective: In this pilot randomized controlled trial, the implementation of the ANtiPain intervention into clinical practice was tested to assess the effects on pain intensity, function-related outcomes, self-efficacy, and patient-related barriers to pain management to prepare a larger effectiveness trial., Methods: Within 14 months, 39 adult oncology patients with pain scores of 3 or higher on a 10-point numeric rating scale were recruited in an academic comprehensive cancer center in Southern Germany. Patients in the control group (n = 19) received standard care. Patients in the intervention group (n = 20) received ANtiPain, a cancer pain self-management support intervention based on 3 key strategies: provision of information, skill building, and nurse coaching. An intervention session was performed in-hospital. After discharge, follow-up was provided via telephone calls. Data were collected at baseline and 1 and 6 weeks after discharge. Effect sizes were calculated for all outcomes., Results: Large effects were found for activity hindrance (Cohen d = 0.90), barriers (d = 0.91), and self-efficacy (d = 0.90). Small to moderate effects were found for average and worst pain (Cohen d = 0.17-0.45)., Conclusions: Key findings of this study involved function-related outcomes and self-efficacy., Implications for Practice: Because these outcomes are particularly meaningful for patients, the integration of ANtiPain to routine clinical practice may be substantial. A larger study will be based on these findings.

This assessor-, therapist-, and participant-blinded randomised controlled trial evaluated the effects of an automated internet-based pain coping skills training (PCST) program before home exercise for people with clinically diagnosed hip osteoarthritis. One hundred forty-four people were randomised to either the PCST group or the comparator group. In the first 8 weeks, the PCST group received online education and PCST, whereas the comparison group received online education only. From weeks 8 to 24, both groups visited a physiotherapist 5 times for home exercise prescription. Assessments were performed at baseline, 8, 24, and 52 weeks. Primary outcomes were hip pain on walking (11-point numerical rating scale) and physical function (Western Ontario and McMaster Universities Osteoarthritis Index [WOMAC]) at 24 weeks. Secondary outcomes were other measures of pain, quality-of-life, global change, self-efficacy, pain coping, pain catastrophizing, depression, anxiety, stress, physical activity, and adverse events. Primary outcomes were completed by 137 (95%), 131 (91%), and 127 (88%) participants at 8, 24, and 52 weeks, respectively. There were no significant between-group differences in primary outcomes at week 24 (change in: walking pain [mean difference 0.5 units; 95% confidence interval, -0.3 to 1.3] and function [-0.9 units; 95% confidence interval, -4.8 to 2.9]), with both groups showing clinically relevant improvements. At week 8, the PCST group had greater improvements in function, pain coping, and global improvement than comparison. Greater pain coping improvements persisted at 24 and 52 weeks. In summary, online PCST immediately improved pain coping and function but did not confer additional benefits to a subsequent exercise program, despite sustained pain coping improvements.

Background: Postpartum depression (PPD) is associated with pain during and after delivery, with studies showing reduced rates among women delivering with labor epidural analgesia (LEA). We hypothesized that women who intend to deliver with LEA but do not receive it are at higher risk for PPD at 6 weeks due to the combined experience of untreated labor pain and unmatched expectations during labor, and evaluated the interaction between labor plans related to LEA, satisfaction with pain control when actually delivering with LEA, and PPD at 6 weeks after delivery., Methods: A total of 1497 women with a vaginal delivery were enrolled into this prospective longitudinal study. Women's initial intention to deliver with or without LEA, how they subsequently delivered, and satisfaction with pain relief were recorded on postpartum day 1. Primary aim was selected as PPD at 6 weeks among women intending to deliver with but subsequently delivering without LEA compared with the rest of the cohort. Primary outcome was PPD at 6 weeks using the Edinburgh Postnatal Depression Scale; PPD was defined with a score ≥10 (scale from 0 to 30). Demographic and obstetric data were recorded. Fisher exact test was used for comparisons between groups. The interaction between intention and actual delivery with regard to LEA and PPD was tested., Results: Overall, 87 of 1326 women completing the study at 6 weeks had PPD (6.6%). For the primary aim, 439 (29.3%) delivered without LEA, of which 193 (12.9%) had intended to deliver with LEA; the PPD rate among these women was 8.1%, which was not statistically different from the rest of the cohort (6.3%; odds ratio [OR], 1.30; 95% confidence interval [CI], 0.72-2.38; P = .41). A total of 1058 women (70.7%) delivered with LEA and 439 (29.3%) delivered without; therefore, 1169 (78.1%) delivered as intended and 328 (21.9%) did not (unmatched expectations). Evaluating the interaction between effects, there was a strong negative additive interaction between intending to deliver without LEA and actually delivering with LEA (risk difference = -8.6%, 95% CI, 16.2%-1.6%; P = .014) suggesting that unmatched intention effect is significantly associated with negative outcome. In multiple regression analysis, while intending to deliver with LEA (OR, 1.06; 95% CI, 1.01-1.11; P = .029) and actually delivering with LEA (OR, 1.07; 95% CI, 1.01-1.13; P = .018) both increased the odds for PPD, the multiplicative interaction was protective (OR, 0.92; 95% CI, 0.86-0.99; P = .022), after adjusting for cofactors., Conclusions: Our study results did not demonstrate a significant increase in the odds for PPD at 6 weeks among women who intended to deliver with LEA but subsequently delivered without. However, we identified a protective interaction between intended LEA use and actual use on the incidence of PPD. Our data suggest an increased risk when women do not deliver as intended, particularly when not initially intending to deliver with LEA. The relationship between unplanned LEA and PPD may be mediated by a physically difficult delivery rather than or in addition to negative emotions related to unmet expectations or a sense of personal failure; therefore, counseling women after delivery to address any negative perceptions may be useful.

Background: Using labor, epidural analgesia has been linked to a reduced risk of postpartum depression, but the role of labor pain relief in this association remains unclear. The goal of this study was to test the hypothesis that effective epidural analgesia during labor is associated with reduced postpartum depression symptomatology., Methods: A single, institutional, retrospective, observational cohort design was chosen. The primary outcome was Edinburgh postnatal depression scale (EPDS) score, measured at the 6-week postpartum visit. Subjects included in the final analysis had (1) received labor epidural analgesia; (2) pain assessed during labor both before and during initiation of labor epidural analgesia by 0-10 numeric rating scores; and (3) depression risk assessed by the EPDS and documented at their 6-week postpartum visit. Simple and multiple linear regression was used to identify the best model for assessing the association between pain improvement, defined as percent improvement in pain (PIP), and depression, after adjusting for a history of anxiety or depression, other psychiatric history, abuse, trauma, mode of delivery, and other maternal or fetal comorbid diseases., Results: Two hundred one patients were included in the final analysis. Women with higher improvements in pain were associated with lower EPDS scores (r = 0.025; P = .002). Variables known to be associated with depression (body mass index, anxiety and/or depression, third- and fourth-degree perineal lacerations, and anemia) were significantly correlated with EPDS score and included in the final model. After we adjusted for these covariates, PIP remained a significant predictor of EPDS score (r = 0.49; P = .008), accounting for 6.6% of the variability in postpartum depression scores. The full model including pain, body mass index, anxiety and/or depression, perineal lacerations, and anemia explained 24% of the variability in postpartum depression scores., Conclusions: Although the extent of labor pain relief by epidural analgesia predicts lower postpartum depression scores, the relative contribution of PIP to risk for postpartum depression symptoms may be less than other established risk factors for depression. These data support that the clinical significance of labor analgesia in the development of postpartum depression needs to be more clearly defined.

We aimed to obtain greater understanding of dentists' distress when they diagnose and treat patients with temporomandibular disorders (TMD), and to explore ways in which TMD can be better treated.We conducted a cross-sectional study based on a questionnaire survey of dentists (n = 148). Dentists were queried using an open-ended questionnaire about distress they experienced when treating patients with TMD. Survey responses were analyzed using mixed methods. Associations between specific dentist and patient characteristics and types of distress were analyzed by one way analysis of variance and residual analysis.One hundred thirteen clinicians responded to the questionnaire, giving a 76% response rate. Thematic analysis identified 6 major themes: difficulty in predicting therapeutic effect and prognosis; difficulty in diagnosis; difficulty in the decision about whether to do occlusal adjustment; difficulty in specifying a cause; difficulty in communicating with patients and mental factors; and health insurance system barriers. Clinicians who reported difficulty in deciding whether to do occlusal adjustment saw significantly more patients who experienced shoulder stiffness and headache (P = .008 and P = .022, respectively). Dentists' knowledge of TMD guidelines was associated with a lower percentage of difficulty in predicting therapeutic effect and prognosis (residual analysis; P = .010).These findings provide important insights into clinician's perception of difficulties with patients experiencing TMD-related pain. Knowledge of the existence of TMD clinical practice guidelines may lower dentist distress, particularly with regard to prognosis. Further studies are needed to decrease dentist's distress and to overcome the evidence-practice gap in TMD treatment., (Copyright © 2017 The Authors. Published by Wolters Kluwer Health, Inc. All rights reserved.)

Objective: To quantify physician prescribing patterns and patient opioid use in the 2 weeks after hysterectomy at an academic institution and to determine whether patient factors predict postsurgical opioid use and pain recovery., Methods: We conducted a prospective quality initiative study by recruiting all English-speaking patients undergoing hysterectomy for benign, nonobstetric indications at a university hospital between August 2015 and December 2015, excluding those with major medical morbidities or substance abuse. Before hysterectomy, patients completed the Fibromyalgia Survey, a validated measure of centralized pain. After hysterectomy, opioid use (converted to oral morphine equivalents) and pain scores (0-10 numeric rating scale) were collected by a daily diary and a structured telephone interview 14 days after surgery. Primary outcomes were total opioid prescribed and consumed in the 2 weeks after hysterectomy. Secondary outcomes included daily opioid use and daily pain severity for 14 days after hysterectomy., Results: Of 103 eligible patients, 102 (99%) agreed to participate, including 44 (43.1%) laparoscopic, 42 (41.2%) vaginal, and 16 (15.7%) abdominal hysterectomies. Telephone surveys were completed on 89 (87%) participants; diaries were returned from 60 (59%) participants. Diary nonresponders had different baseline characteristics than nonresponders. Median amount of opioid prescribed was 200 oral morphine equivalents (interquartile range 150-250). Patients reported using approximately half of the opioids prescribed with a median excess of 110 morphine equivalents (interquartile range 40-150). The best fit model of total opioid consumption identified preoperative Fibromyalgia Survey Score, overall body pain, preoperative opioid use, prior endometriosis, abdominal hysterectomy (compared with laparoscopic), and uterine weight as significant predictors. Highest tertile of Fibromyalgia Survey Score was associated with greater daily opioid consumption (13.9 [95% CI 3.0-24.8] greater oral morphine equivalents at baseline, P=.02)., Conclusion: Gynecologists at a large academic medical center prescribe twice the amount of opioids than the average patient uses after hysterectomy. A personalized approach to prescribing opioids for postoperative pain should be considered.

Objective: Assess patient-physician agreement on management goals for chronic musculoskeletal pain and its associations with patient and physician visit experiences., Materials and Methods: Pre-visit and post-visit questionnaires for 87 primary care visits that involved patients taking opioids for chronic musculoskeletal pain and primary care resident physicians. After each visit, patients and physicians independently ranked 5 pain treatment goals from most to least important., Results: In total, 48% of patients ranked reducing pain intensity as their top priority, whereas 22% ranked finding a diagnosis as most important. Physicians ranked improving function as the top priority for 41% of patients, and ranked reducing medication side effects as most important for 26%. The greatest difference between patient and physician rankings was for reducing pain intensity. In regression analyses, neither overall agreement on goals (ie, the physician's first or second priority included the patient's top priority) nor difference in patient versus physician ranking of pain intensity was significantly associated with patient-reported visit experience (β for overall agreement, -0.08; 95% confidence interval [CI], -0.45 to 0.30; P=0.69; β for intensity, -0.06; 95% CI, -0.17 to 0.04; P=0.24) or physician-reported visit difficulty (β for overall agreement, 1.92; 95% CI, -2.70 to 6.55; P=0.41; β for intensity, 0.42; 95% CI, -0.87 to 1.71; P=0.53)., Discussion: Patients and physicians prioritize substantially different goals for chronic pain management, but there is no evidence that agreement predicts patient experience or physician-reported visit difficulty. Primary care physicians may have adapted to new recommendations that emphasize functional goals and avoidance of long-term opioid therapy, whereas patients continue to focus on reducing pain intensity.

Medical cannabis (MC) is used for a variety of conditions including chronic pain. The goal of this report was to provide an in-depth qualitative exploration of patient perspectives on the strengths and limitations of MC. Members of MC dispensaries (N = 984) in New England including two-thirds with a history of chronic pain completed an online survey. In response to "How effective is medical cannabis in treating your symptoms or conditions?," with options of 0% "no relief" to 100% "complete relief," the average was 74.6% ± 0.6. The average amount spent on MC each year was $3064.47 ± 117.60, median = $2320.23, range = $52.14 to $52,140.00. Open-ended responses were coded into themes and subthemes. Analysis of answers to "What is it that you like most about MC?" (N = 2592 responses) identified 10 themes, including health benefits (36.0% of responses, eg, "Changes perception and experience of my chronic pain."), the product (14.2%, eg, "Knowing exactly what strain you are getting"), nonhealth benefits (14.1%), general considerations (10.3%), and medications (7.1%). Responses (N = 1678) to "What is it that you like least about MC?" identified 12 themes, including money (28.4%, eg, "The cost is expensive for someone on a fixed income"), effects (21.7%, eg, "The effects on my lungs"), the view of others (11.4%), access (8.2%), and method of administration (7.1%). These findings provide a patient-centered view on the advantages (eg, efficacy in pain treatment, reduced use of other medications) and disadvantages (eg, economic and stigma) of MC.

A primary goal in managing pain is to reduce pain and increase physical function (PF). This goal is also tied to continuing payment for treatment services in many practice guidelines. Pain interference (PI) is often used as a proxy for measurement and reporting of PF in these guidelines. A common assumption is that reductions in PI will translate into improvement in PF over time. This assumption needs to be tested in a clinical environment. Consequently, we used the patient-reported outcomes measurement information system (PROMIS) to describe the topology of the longitudinal relationship between PI in relation to PF. Longitudinal data of 389 people with chronic pain seeking health care demonstrated that PI partially explained the variance in PF at baseline (r = -0.50) and over 90 days of care (r = -0.65). The relationship between pain intensity and PF was not significant when PI was included as a mediator. A parallel process latent growth curve model analysis showed a weak, unidirectional relationship (β = 0.18) between average PF scores and changes in PI over the course of 90 days of care, and no relationship between average PI scores and changes in PF across time. Although PI and PF seem moderately related when measured concurrently, they do not cluster closely together across time. The differential pathways between these 2 domains suggest that therapies that target both the consequences of pain on relevant aspects of persons' lives, and capability to perform physical activities are likely required for restoration of a vital life.

Synthetic cannabinoids are becoming a public health concern. No data are apparently available concerning use of synthetic cannabinoids in the elderly. We report two cases of elderly individuals who used synthetic cannabinoids and were admitted to a psychiatric hospital.

Objective: The present meta-analysis investigates whether the magnitude of placebo analgesia is different in patients compared with healthy individuals and whether placebo analgesia is different in experimentally induced pain compared with clinical pain in patients., Methods: A literature search in Web of Science (ISI) on the terms "placebo analgesia" and "placebo analgesic" was conducted. The search resulted in 71 studies, including 4239 participants. Fifty-five studies included healthy individuals and 16 studies included patients. Of the 16 studies with patients, five studies investigated clinical pain and 11 studies investigated experimentally induced pain., Results: The average effect size was 1.24 for healthy individuals and 1.49 for patients. In the studies with patients, the average effect sizes of placebo treatment were 1.73 for experimentally induced pain and 1.05 for clinical pain. A χ test revealed that there were relatively more studies with patients compared with healthy volunteers in which there was a clinically significant reduction in pain (p = .040)., Conclusions: The findings suggest that patients benefited from placebo treatment to a greater degree than healthy individuals did and that studies on healthy individuals may underestimate the magnitude of the placebo analgesic effect in patients. Patients' clinical pain and experimentally induced pain respond to placebo to the same degree.

As healthcare teams have worked to improve infant survival rates, the management of painful events experienced by these hospitalized neonates has increased and yet pain management remains highly variable between healthcare institutions. At the same time, emerging evidence suggests that these early painful experiences may alter the trajectory of development for pain-processing pathways both peripherally and centrally. This concise review highlights findings from both the basic and clinical science literature supporting the hypothesis that early painful experiences can have long-lasting negative effects on biological, psychological, and socioemotional functions. Implications for pain management in neonates and considerations for evidence-based practice change are discussed.

Persistent vulvar pain is a complex disorder that frequently is frustrating to the patient and the clinician. It can be difficult to treat and rapid resolution is unusual, even with appropriate therapy. Vulvar pain can be caused by a specific disorder or it can be idiopathic. Idiopathic vulvar pain is classified as vulvodynia. Although optimal treatment remains unclear, consider an individualized, multidisciplinary approach to address all physical and emotional aspects possibly attributable to vulvodynia. Specialists who may need to be involved include sexual counselors, clinical psychologists, physical therapists, and pain specialists. Patients may perceive this approach to mean the practitioner does not believe their pain is "real"; thus, it is important to begin any treatment approach with a detailed discussion, including an explanation of the diagnosis and determination of realistic treatment goals. Future research should aim at evaluating a multimodal approach in the treatment of vulvodynia, along with more research on the etiologies of vulvodynia.

Acceptance of chronic pain has increasingly become a significant issue in the field of pain management. Many researchers have suggested that patients with better acceptance of pain are more likely to have better functioning both in physical and psychological status. In many countries, the Chronic Pain Acceptance Questionnaire (CPAQ) and CPAQ-8 have been validated and utilized frequently to measure the pain acceptance of patients with chronic pain. However, the CPAQ and CPAQ-8 yet have not been introduced and validated in Mainland China.In this study, we aimed to translate the English version of the CPAQ into simplified Chinese, make proper cross-cultural adaptations, and validate the psychometric properties of the Chinese version of the CPAQ and the CPAQ-8.The English version of the CPAQ was first linguistically translated and cross-culturally adapted to formulate a Chinese version. Then, we recruited 224 patients from a pain clinic and every participant was asked to finish a series of questionnaires. Finally, statistical analysis was performed to test the psychometric properties of the CPAQ and the CPAQ-8.Both confirmatory factor analysis (CFA) and principal component analysis (PCA) confirmed a 2-factor structure for the CPAQ and the CPAQ-8. Nine out of 10 of the hypotheses were validated for construct validity. The overall intraclass correlation coefficient (ICC) value for the CPAQ and CPAQ-8 were 0.92 and 0.89, respectively. In addition, the Cronbach α values for both the CPAQ and the CPAQ-8 showed excellent test-retest reliability.In conclusion, the original CPAQ was successfully developed into the Chinese version of the CPAQ and CPAQ-8 with excellent validity and reliability. The scores of the CPAQ or CPAQ-8 might be a strong predictor for the physical and psychological function of chronic pain patients. In addition, to improve the satisfaction of surgery patients, we recommend measuring patients' pain acceptance using the CPAQ or CPAQ-8 before and after the surgery. For patients with lower acceptance, psychological interventions may be more effective than treatment that simply reduces symptoms. Finally, we suggest that the Chinese version of the CPAQ and CPAQ-8 are appropriate for use in clinical settings or fundamental research in Mainland China.

Objectives: Evidence-based pain-limiting strategies for pediatric immunizations remain underutilized, with barriers identified to date mostly pertaining to health care providers and systems of care. The present study sought to quantify and investigate parent attitudes toward pain management as another potential barrier to the routine use of pain-mitigating strategies during immunizations., Materials and Methods: Questionnaires measuring parent attitudes, willingness to pay, and perceived barriers for using pain management for immunizations were completed by 259 parent/guardians of children ages 0 to 5 years attending appointments at an urban primary care clinic in the Midwestern United States., Results: Parent attitudes toward pain management for immunization were relatively normally distributed and varied from strongly positive to negative, with 33% of parents disagreeing that they were concerned about the pain their child may experience and 50% agreeing that there are no lasting negative effects from immunization pain. Negative parent attitudes were associated with willingness to spend less in money or time for pain management and with greater perceived significance of cost, time, and other barriers for using pain-mitigating strategies., Discussion: Some parents perceive limited value in trying to reduce pain during immunizations such that they may be hesitant to invest much time or effort in interventions. Greater success of translating evidence-based pain management into practice therefore may require accounting for differences in parent attitudes by tailoring educational efforts and pain management options accordingly.

Objectives: Pain and its disruptive impact on daily life are common reasons that patients seek primary medical care. Pain contributes strongly to psychopathology, and pain and depressive symptoms are often comorbid in primary care patients. Not all those who experience pain develop depression, suggesting that the presence of individual-level characteristics, such as positive and negative affect, that may ameliorate or exacerbate this association., Methods: We assessed the potential moderating role of positive and negative affect on the pain-depression linkage. In a sample of 101 rural, primary care patients, we administered the Brief Pain Inventory, NEO Personality Inventory-Revised positive and negative affect subclusters, and the Center for Epidemiology Scale for Depression., Results: In moderation models, covarying age, sex, and ethnicity, we found that positive affect, but not negative affect, was a significant moderator of the relation between pain intensity and severity and depressive symptoms., Discussion: The association between pain and depressive symptoms is attenuated when greater levels of positive affects are present. Therapeutic bolstering of positive affect in primary care patients experiencing pain may reduce the risk for depressive symptoms.

Patients' expectations are important predictors of the outcome of analgesic treatments, as demonstrated predominantly in research on placebo effects. Three commonly investigated interventions that have been found to induce expectations (verbal suggestion, conditioning, and mental imagery) entail promising, brief, and easy-to-implement adjunctive procedures for optimizing the effectiveness of analgesic treatments. However, evidence for their efficacy stems mostly from research on experimentally evoked pain in healthy samples, and these findings might not be directly transferable to clinical populations. The current meta-analysis investigated the effects of these expectation inductions on patients' pain relief. Five bibliographic databases were systematically searched for studies that assessed the effects of brief verbal suggestion, conditioning, or imagery interventions on pain in clinical populations, with patients experiencing experimental, acute procedural, or chronic pain, compared with no treatment or control treatment. Of the 15,955 studies retrieved, 30 met the inclusion criteria, of which 27 provided sufficient data for quantitative analyses. Overall, a medium-sized effect of the interventions on patients' pain relief was observed (Hedges g = 0.61, I = 73%), with varying effects of verbal suggestion (k = 18, g = 0.75), conditioning (always paired with verbal suggestion, k = 3, g = 0.65), and imagery (k = 6, g = 0.27). Subset analyses indicated medium to large effects on experimental and acute procedural pain and small effects on chronic pain. In conclusion, patients' pain can be relieved with expectation interventions; particularly, verbal suggestion for acute procedural pain was found to be effective.

Objectives: Ineffective analgesic decisions in the home may jeopardize the safety and comfort of children, yet little is known about factors influencing parental decisions. This study explored how parents' analgesic understanding influenced their hypothetical decisions to give opioids when faced with important trade-off dilemmas where pain and adverse drug event (ADE) symptoms were both present., Methods: A total of 514 parents whose children required opioids after discharge completed surveys assessing their Gist ADE Understanding (ie, knowledge of opioid-related ADEs and their seriousness) and other comparative analgesic perceptions. Parents then made hypothetical decisions to give or withhold prescribed opioids to a postoperative child with varying pain levels and serious (oversedation) and nonserious (nausea) ADE symptoms., Results: Gist ADE Understanding influenced decisions to withhold opioids for a child with nausea/vomiting (β=0.85 [95% confidence interval (CI), 0.74-0.98]) or oversedation (β=0.86 [95% CI, 0.77-0.97]), but not for one with no ADE (β=1.00 [95% CI, 0.98-1.02]). However, while perceived higher seriousness of oversedation influenced withholding opioids when this ADE was present (mean difference=0.36 [95% CI, 0.11-0.61], P=0.005), knowledge that oversedation was possible did not by itself affect behavior (odds ratio=0.80 [95% CI, 0.50-1.29], P=0.362)., Discussion: These data suggest that gist understanding of ADE seriousness, not just its possible presence, is needed to facilitate safe analgesic decisions. Importantly, higher overall ADE understanding did not influence parents' opioid decisions in the presence of high pain and absence of ADEs. Thus, risk information about specific ADEs is unlikely to dissuade parents from efforts to manage pain but may improve their decisions if ADEs should occur.

This systematic review and meta-analysis critically examined the evidence for bodily illusions to modulate pain. Six databases were searched; 2 independent reviewers completed study inclusion, risk of bias assessment, and data extraction. Included studies evaluated the effect of a bodily illusion on pain, comparing results with a control group/condition. Of the 2213 studies identified, 20 studies (21 experiments) were included. Risk of bias was high due to selection bias and lack of blinding. Consistent evidence of pain decrease was found for illusions of the existence of a body part (myoelectric/Sauerbruch prosthesis vs cosmetic/no prosthesis; standardized mean differences = -1.84, 95% CI = -2.67 to -1.00) and 4 to 6 weeks of mirror therapy (standardized mean differences = -1.11, 95% CI = -1.66 to -0.56). Bodily resizing illusions had consistent evidence of pain modulation (in the direction hypothesized). Pooled data found no effect on pain for 1 session of mirror therapy or for incongruent movement illusions (except for comparisons with congruent mirrored movements: incongruent movement illusion significantly increased the odds of experiencing pain). Conflicting results were found for virtual walking illusions (both active and inactive control comparisons). Single studies suggest no effect of resizing illusions on pain evoked by noxious stimuli, no effect of embodiment illusions, but a significant pain decrease with synchronous mirrored stroking in nonresponders to traditional mirror therapy. There is limited evidence to suggest that bodily illusions can alter pain, but some illusions, namely mirror therapy, bodily resizing, and use of functional prostheses show therapeutic promise.

Background: Painful procedures are common in the ED setting and beyond. Although these procedures are often essential to patient management, they can also be distressing for children, parents, and health providers. As such, it is imperative that effective pain and anxiety-minimizing strategies be used consistently in all settings where painful procedures take place for children., Objectives: This review article aims to provide a summary of several strategies, which are supported by definitive and systematically reviewed evidence, that can be implemented alone or in combination to reduce procedural pain and anxiety for children in the ED and beyond., Results: For neonates, breastfeeding, nonnutritive sucking, swaddling, and sucrose administration have all been shown to decrease pain during painful interventions. For neonates, venipuncture is much less painful than heel lance for blood draws. For infants, there is some support for sucrose use. For infants and older children, there is strong evidence for distraction techniques. In addition, the use of fast-acting topical anesthetic creams as an alternative or adjunct to infiltrating anesthetic before laceration repair or vascular access/venipuncture is recommended. Further, buffering of lidocaine can decrease pain during injection. Lastly, if a laceration is amenable to the use of tissue adhesive, this should be preferentially used., Conclusions: In summary, there currently remains a knowledge-to-practice gap in the treatment of children's procedure-related pain. This article has identified multiple age-specific methods to improve the treatment of procedural pain. These simple interventions can improve the care provided to ill and injured children.

Imagery has been used as a healing practice since ancient times. Its reemergence in modern medicine began in the second half of the 20th century, when research suggested that imagery could help reduce patients' pain and anxiety and improve their quality of life and outlook on their illness. While current evidence is insufficient to support claims that imagery affects disease progression, research suggests that this method of inducing relaxation encourages patients' healing process and gives them a greater sense of autonomy in relation to disease and its management. Because imagery is noninvasive, the risks associated with its use are minimal and it is now widely used in integrative nursing. The author discusses imagery's uses and benefits, as well as the potential pitfalls in its use, and describes an imagery technique she has found effective in practice, providing a sample script and explaining how the technique might be used to help patients in various settings.

Objectives: The aim of this article is to expose common myths and misconceptions regarding pain assessment and management in critically ill patients that interfere with effective care. We comprehensively review the literature refuting these myths and misconceptions and describe evidence-based strategies for improving pain management in the ICU., Data Sources: Current peer-reviewed academic journals, as well as standards and guidelines from professional societies., Study Selection: The most current evidence was selected for review based on the highest degree of supportive evidence., Data Extraction: Data were obtained via medical search databases, including OvidSP, and the National Library of Medicine's MEDLINE database via PubMed., Data Synthesis: After a comprehensive literature review, conclusions were drawn based on the strength of evidence and the most current understanding of pain management practices in ICU., Conclusions: Myths and misconceptions regarding management of pain in the ICU are prevalent. Review of current evidence refutes these myths and misconceptions and provides insights and recommendations to ensure best practices.

This comparative focus group study explored nurses' experiences and perceptions regarding parental participation in infant pain management in the neonatal intensive care unit (NICU). A total of 87 nurses from 7 NICUs in Finland, Sweden, and the United States participated in focus-group interviews (n = 25). Data were analyzed using deductive and inductive thematic analysis. Nurses' experiences and perceptions varied considerably, from nurses being in control, to nurses sharing some control with parents, to nurse-parent collaboration in infant pain management. When nurses controlled pain management, parents were absent or passive. In these cases, the nurses believed this led to better pain control for infants and protected parents from emotional distress caused by infant pain. When nurses shared control with parents, they provided information and opportunities for participation. They believed parent participation was beneficial, even if it caused nurses or parents anxiety. When nurses collaborated with parents, they negotiated the optimal pain management approach for an individual infant. The collaborative approach was most evident for the nurses in the Swedish NICUs and somewhat evident in the NICUs in Finland and the United States. Further research is needed to address some nurses' perceptions and concerns and to facilitate greater consistency in the application of evidence-based best practices.

Background: The rate of neuraxial analgesia during labor in France is one of the highest among high-income countries: 77% of vaginal deliveries in 2010. In this context, the question of how women's preferences for delivering without neuraxial analgesia relate to actual use is of interest. Our objective was to study the factors associated with women's initial preference for labor without neuraxial analgesia and those associated with its use in women who initially preferred not to have it., Methods: We used data from the 2010 French National Perinatal Survey, a cross-sectional study of a representative sample of all births in France. Data were collected from interviews with mothers in the postpartum ward and from medical records. Our sample included 7123 women who had vaginal deliveries and were at low risk for cesarean delivery. The factors analyzed were maternal sociodemographic characteristics, prenatal care, childbirth class attendance, labor management, and organization of maternity units. Multilevel Poisson regression models were used to study factors associated with women's initial preference in the overall population and to study factors associated with actual use of neuraxial analgesia in the group of women who initially preferred not to have it., Results: Initially, 26% of our population (n = 1835) preferred to deliver without neuraxial analgesia; this preference was associated with high parity, unfavorable social conditions, and delivery in a public maternity unit. Among these women, 52% (n = 961) delivered with neuraxial analgesia. This discrepancy between initial preference and actual use was significantly associated with nulliparity (adjusted relative risk [aRR] = 1.4; 95% confidence interval [CI], 1.3-1.6), oxytocin augmentation of labor (aRR = 2.4; 95% CI, 2.1-2.7), presence of an anesthesiologist in the unit 24/7 (aRR = 1.4; 95% CI, 1.2-1.6; compared with delivery in hospitals without an anesthesiologist on site 24/7), and high midwife workload (aRR = 1.1; 95% CI, 1.0-1.2). There was no clear association with maternal educational level., Conclusions: Our results suggest that parity, the management of labor, and availability of anesthesiologists play a major role in the intrapartum decision to use neuraxial analgesia for women who initially preferred not to have it. Further research is necessary in the clinical circumstances leading to this decision and the role of women's demands and medical staff attitudes throughout labor.

Cognitive impairment (CI) can develop during the course of ageing and is a feature of many neurological and neurodegenerative diseases. Many individuals with CI have substantial, sustained, and complex health care needs, which frequently include pain. However, individuals with CI can have difficulty communicating the features of their pain to others, which in turn presents a significant challenge for effective diagnosis and treatment of their pain. Herein, we review the literature on responsivity of individuals with CI to experimental pain stimuli. We discuss pain responding across a large number of neurological and neurodegenerative disorders in which CI is typically present. Overall, the existing data suggest that pain processing is altered in most individuals with CI compared with cognitively intact matched controls. The precise nature of these alterations varies with the type of CI (or associated clinical condition) and may also depend on the type of pain stimulation used and the type of pain responses assessed. Nevertheless, it is clear that regardless of the etiology of CI, patients do feel noxious stimuli, with more evidence for hypersensitivity than hyposensitivity to these stimuli compared with cognitively unimpaired individuals. Our current understanding of the neurobiological mechanisms underpinning these alterations is limited but may be enhanced through the use of animal models of CI, which also exhibit alterations in nociceptive responding. Further research using additional behavioural indices of pain is warranted. Increased understanding of altered experimental pain processing in CI will facilitate the development of improved diagnostic and therapeutic approaches for pain in individuals with CI.

Overactivity (activity engagement that significantly exacerbates pain) is a common term in the chronic pain literature. Overactivity is accepted clinically as a behaviour that adversely affects an individual's daily functioning and is the target of one of the most widely endorsed pain management strategies among health professionals (ie, activity pacing). Little research, however, has investigated links between overactivity behaviour and indicators of patient functioning, and activity pacing has not been evaluated as a stand-alone treatment specifically for individuals with chronic pain who are habitually overactive. Two studies, using qualitative research designs and interpretative phenomenological analyses, were conducted to provide insight into (1) why certain individuals develop habitual overactivity patterns in response to pain, (2) the impact of overactivity on daily functioning, and (3) the value of activity pacing as a treatment strategy for this population. Findings suggest that overactivity behaviour is complex, influenced by multiple factors, and negatively impacts on multiple quality-of-life domains. Some participants who were followed up 3 to 6 months after a pain management program were able to learn pacing strategies and enact behaviour change with health professional support; however, the majority reported difficulties changing their behaviour after treatment. It is suggested that provision of pacing education, alone, to chronic pain patients who engage in overactivity behaviour may not be effective in eliciting behavioural change. Key factors that participants believed to contribute to the development and maintenance of their overactive behaviour in this study should be considered in future clinical approaches and empirical investigations.