Investigating the Role of Having an Avatar in Virtual Reality on Pain Alleviation and Embodiment in Patients With Pain Using Electroencephalogram: A Neuroimaging Protocol

Chronic Pain (CP) is prevalent in industrialized countries and stands among the top 10 causes of disability. Given the widespread problems of pharmacological treatments such as opioids, a need to find alternative therapeutic approaches has emerged. Virtual Reality (VR) has shown potential as a non-pharmacological alternative for controlling pain over the past 20 years. The effectiveness of VR has been demonstrated in treating CP, and it has been suggested that VR’s analgesic effects may be associated with the Sense of Embodiment (SoE): the sensation of being inside, having and controlling a virtual body in VR. Studies have shown correlations among brain signals, reported pain and a SoE, and correlations have been observed between using an avatar in VR and pain alleviation among CP patients. However, little has been published about the changes in brain physiology associated with having an avatar in VR, and current published studies present methodological issues. Defining a proper methodology to investigate the underlying brain mechanisms of pain, a SoE associated with having an avatar in VR, and its effect on reducing pain in CP patients is key to the emerging field of VR-analgesia. Here, we propose an intervention trial design (test/intervention/test) to evaluate the effects of having a virtual avatar in VR on pain levels and SoE in CP patients using Electroencephalogram (EEG) recordings. Resting-state EEG recordings, perceived pain levels, and SoE scores will be collected before and after the VR intervention. Patients diagnosed with CP will be recruited from local pain clinics and pseudo-randomly assigned to one of two groups—with or without an avatar. Patients will experience a 10-min VR intervention built to treat CP while their EEG signals are recorded. In articulating the study procedure, we propose a framework for future studies that explores the mechanisms of VR-analgesia in patients with chronic pain.

Hypothesizing in the Face of the Opioid Crisis Coupling Genetic Addiction Risk Severity (GARS) Testing with Electrotherapeutic Nonopioid Modalities Such as H-Wave Could Attenuate Both Pain and Hedonic Addictive Behaviors

In the United States, amid the opioid overdose epidemic, nonaddicting/nonpharmacological proven strategies are available to treat pain and manage chronic pain effectively without opioids. Evidence supporting the long-term use of opioids for pain is lacking, as is the will to alter the drug-embracing culture in American chronic pain management. Some pain clinicians seem to prefer classical analgesic agents that promote unwanted tolerance to analgesics and subsequent biological induction of the “addictive brain”. Reward genes play a vital part in modulation of nociception and adaptations in the dopaminergic circuitry. They may affect various sensory and affective components of the chronic pain syndromes. The Genetic Addiction Risk Severity (GARS) test coupled with the H-Wave at entry in pain clinics could attenuate pain and help prevent addiction. The GARS test results identify high-risk for both drug and alcohol, and H-Wave can be initiated to treat pain instead of opioids. The utilization of H-Wave to aid in pain reduction and mitigation of hedonic addictive behaviors is recommended, notwithstanding required randomized control studies. This frontline approach would reduce the possibility of long-term neurobiological deficits and fatalities associated with potent opioid analgesics.

Development and Validation of the Health Literacy Assessment Instrument for Patients with Chronic Pain

A suitable health literacy assessment instrument for patients with chronic pain (HLCP) in China with good instrument’s psychometric properties is required. A theoretical framework for the HLCP was developed by adopting the hierarchical model of health literacy proposed by Nutbeam. The reliability and validity of the HLCP were tested in a cross-sectional survey of 237 chronic pain patients from three pain clinics and wards of Grade-3A hospitals in Zhejiang Province, China. The discriminant degree method, correlation analysis method, factor analysis method (exploratory factor analysis), half reliability, and other methods were utilized to screen items for inclusion in the final version of HLCP, and the fitness of the model was subsequently evaluated by confirmatory factor analysis. Cronbach’s alpha value and test-retest with two-week intervals were used to test the internal consistency and retest reliability of the HLCP. In the exploratory factor analysis, three domains, functional health literacy (10 items), interactive health literacy (14 items), and critical health literacy (7 items), comprising 31 items in total, were finally loaded; the model was determined to explain 70.9% of the total variance. HLCP’s effective assessment of the health literacy level of patients with chronic pain and its acceptable reliability and validity were revealed through the results.

Extent of sleep problems and relationship with severity of chronic pain using three validated sleep assessment tools

Objective Chronic pain can impact on sleep, but the extent and nature of sleep problems in patients with chronic pain are incompletely clear. Several validated tools are available for sleep assessment but they each capture different aspects. We aimed to describe the extent of sleep issues in patients with chronic non-malignant pain using three different validated sleep assessment tools and to determine the relationship of sleep issues with pain severity recorded using the Brief Pain Inventory (BPI), a commonly used self-assessment tool in pain clinics. The BPI has a single question on the interference of pain on sleep and we also compared this with the validated sleep tools. Design Prospective, cross-sectional study. Setting Pain management clinic at a large teaching hospital in the United Kingdom. Subjects Adult patients (with chronic non-malignant pain of at least 3 months’ duration) attending clinic during a 2-month period. Methods Participants completed the Pittsburgh Sleep Quality Index (PSQI), the Pain and Sleep Questionnaire-3 (PSQ-3) and the Verran Snyder-Halpern (VSH) sleep scale, plus the BPI. Duration and type of pain, current medications and demographic data were recorded. Results We recruited 51 patients and 82% had poor sleep quality as shown by PSQIscores above five. PSQI ( p = 0.0002), PSQ-3 ( p = 0.0032), VSH sleep efficiency ( p = 0.012), sleep disturbance ( p = 0.0014) and waking after sleep onset ( p = 0.0005) scores were associated with worse BPI pain scores. BPI sleep interference scores concurred broadly with the validated sleep tools. Median [range] sleep duration was 5.5 [3.0–10.0] hours and was also related to pain score ( p = 0.0032). Conclusion Chronic pain has a marked impact on sleep regardless of the assessment tool used. The sleep interference question in the BPI could be used routinely for initial identification of sleep problems in patients with chronic pain.

Telehealth Increases Access to Brief Behavioral Interventions in Orofacial Pain Clinic during COVID-19 Pandemic: A Retrospective Study

Objective Aim of the study was to test if orofacial pain patients were more likely to start and complete a brief psychological intervention for managing certain chronic orofacial pain conditions (physical self-regulation, PSR) via telehealth (during the COVID-19 pandemic) vs. in-person (prior to the COVID-19 pandemic). Exploratory aim was to describe demographic factors that may influence the patients to start and complete PSR. Methods Retrospective medical charts of all patients seen at a university-affiliated tertiary orofacial pain clinic between July–December 2019 (in person, pre-pandemic) and July–December 2020 (telehealth, during pandemic) were reviewed. Charts were examined for demographic information and to compare the number of patients who started and completed PSR during each study period (chi-squared test). Results Of 248 new patients seen in the clinic during 2019 period, 25 started PSR in-person (10.08%). Of 252 new patients seen during 2020 period, 53 started PSR via telehealth (21.03%). Patients were more likely to start PSR (OR = 6.21, p<.001, CI = 2.499 to 15.435) and more likely to complete all three sessions of PSR (OR = 5.69, p<.001, CI = 2.352 to 13.794) when it was offered via telehealth than in-person. Among those who started PSR via telehealth, patients from metropolitan areas were more likely to start the intervention than those from non-metropolitan areas (p=.045). Conclusions Offering brief psychological pain interventions via telehealth in tertiary orofacial pain clinics has demonstrated feasibility and may improve willingness to participate in psychological treatments. Results need to be replicated with prospective data as modality was confounded with pandemic in the current study.

Nepalese version of Douleur Neuropathique 4 (DN4) questionnaire for Assessment of Neuropathic pain: A Validation Study

ObjectiveThis study aimed to translate and validate DN4 questionnaire into Nepalese version.DesignAn observational study design was adopted.SettingA tertiary level teaching hospital of Kathmandu, NepalParticipantsWe included 166 purposively selected patients visiting pain clinics of the hospital over one year timeMethodsThe Nepalese version of the DN4 questionnaire was used to detect neuropathic pain among the chronic pain patients of the hospital. The English version of the questionnaire was translated into Nepali based on the standard guideline with the help of linguistic experts. The patients diagnosed with nociceptive or neuropathic pain were interviewed twice in two weeks interval. We analyzed test-retest reliability and strength of the test by using Intra-class correlation coefficient (ICC) and Receiver Operating Characteristics (ROC) Curve, respectively. Internal Consistency reliability was assessed using Cronbach’s alpha (∞). Diagnostic accuracy was assessed through measures like sensitivity, specificity, positive and negative predictive values, and positive and negative likelihood ratio.ResultsThe study showed a good test-retest reliability (ICC=0.877) and internal consistency reliability (∞=0.710). The AUC were 0.932 (0.894-0.971) for the first test, and 0.955 (0.921-0.990) for the second test. The sensitivity and specificity values were found highest at the 4 cut-off point (4 score out of 10), that are 75% and 95.3% for test 1, and 76.2% and 98.8% for test 2. Similarly positive and negative predictive values are 93.8% and 80.4% respectively for the first test and 98.4% and 81.7% respectively for the second test.ConclusionsThe Nepalese version of DN4 questionnaire is a valid and reliable tool for the diagnosis of neuropathic pain. This can be used for screening neuropathic and non-neuropathic pain in clinical as well as epidemiological settings.Article SummaryStrengths and Limitations of this StudyThis study validated Nepalese version of DN4 questionnaire, so, it can be used as a standard tool to assess neuropathic pain among the Nepalese population.As interview was conducted with the patients, this might minimize the reliability and validity issue.This questionnaire is only applicable to those who can communicate properly in Nepalese language.There can be problem of understanding among the participants as few words do not have exact Nepali words with the same meaning.

Pain medication use for musculoskeletal pain among children and adolescents: a systematic review

Objectives Musculoskeletal pain is common among children and adolescents. Despite the lack of evidence regarding harms and benefits, musculoskeletal pain is often managed with pain medication. The aim of this systematic review is to assess the prevalence of pain medication use for musculoskeletal pain among children and adolescents and the factors and side effects associated with use. Content Three databases (EMBASE, CINAHL and PsychINFO) were systematically searched to identify studies designed to examine the prevalence, frequency or factors associated with the use of pain medication for musculoskeletal pain in children and adolescents (aged 6–19 years). The included studies were assessed for study quality and data were extracted. Summary The search initially provided 20,135 studies. After screening titles, abstracts and full-texts, 20 studies were included. In school settings, 8–42% of children used pain medication for musculoskeletal pain, and 67–75% of children in sports clubs and from pain clinics used pain medication. The most consistent factors associated with the use of pain medications were pain characteristics and psychological factors (e.g. being bullied, low-self-esteem), while mixed evidence was found for increasing age and female gender. Only two studies reported on the duration of use and only one study on adverse effects related to the use of pain medication. Outlook We found that 8–42% of adolescents from school-based samples use pain medication for MSK pain, while the prevalence among adolescents from sports clubs and pain clinics is higher (67–75%). Pain characteristics (pain duration, severity, intensity, disability levels and the presence of ≥2 pain conditions or multisite pain) and psychological factors were associated with a higher use of pain medication, while for higher age and female gender the evidence of association was mixed. Future studies should systematically collect information on the type, duration of use of pain medication and side effects to confirm the findings of this review.

Evaluating Telehealth Implementation in the Context of Pediatric Chronic Pain Treatment during COVID-19

Telehealth has emerged as a promising healthcare delivery modality due to its ability to ameliorate traditional access-level barriers to treatment. In response to the onset of the novel coronavirus (COVID-19) pandemic, multidisciplinary pain clinics either rapidly built telehealth infrastructure from the ground up or ramped up existing services. As the use of telehealth increases, it is critical to develop data collection frameworks that guide implementation. This applied review provides a theoretically-based approach to capitalize on existing data sources and collect novel data to inform virtually delivered care in the context of pediatric pain care. Reviewed multisource data are (1) healthcare administrative data; (2) electronic chart review; (3) clinical health registries; and (4) stakeholder feedback. Preliminary telehealth data from an interdisciplinary pediatric chronic pain management clinic (PPMC) serving youth ages 8–17 years are presented to illustrate how relevant implementation outcomes can be extracted from multisource data. Multiple implementation outcomes were assessed, including telehealth adoption rates, patient clinical symptoms, and mixed-method patient-report telehealth satisfaction. This manuscript provides an applied roadmap to leverage existing data sources and incorporate stakeholder feedback to guide the implementation of telehealth in pediatric chronic pain settings through and beyond COVID-19. Strengths and limitations of the modeled data collection approach are discussed within the broader context of implementation science.