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OBJECTIVE: Persistent Idiopathic Facial Pain (PIFP) is a pain syndrome with missing evidence-based therapy recommendations. According to the biopsychosocial pain model, multidisciplinary pain treatment (MPT) offers a promising therapeutic option for chronic pain syndromes. MPT is an interprofessional treatment procedure, consisting of medical, physiotherapeutic and psychotherapeutic treatment units, which has not yet been studied in PIFP. METHODS: This retrospective study included 25 patients with PIFP, who had been treated with MPT. Pain intensity on the numerical rating scale (NRS), perceived disability, habitual well-being, as well as anxiety/depression and stress scales were recorded. Moreover, the patients evaluated the efficacy of each type of the single therapeutic interventions. RESULTS: There was a highly significant decrease in the characteristic pain intensity. Also habitual well-being improved significantly, as did anxiety and depression. The perceived disability and stress also improved, but without statistical significance. Physiotherapy was rated as the most effective therapeutic unit. Among the medical measures, consultations took first place (40% of the participants). Nearly three-fourths of the patients (72%) would recommend MPT. CONCLUSION: The present study shows beneficial outcomes in patients with PIFP following MPT. Patients evaluate physiotherapeutic treatment as particularly efficacious. Therefore, MPT can be considered as a therapeutic option in patients with PIFP.

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BACKGROUND: Chronic pain is a complex biopsychosocial phenomenon. Lifestyle, behavioral, socioeconomic, and psychosocial factors such as depression and perceived injustice are often associated with the development of chronic pain and vice versa. We sought to examine the interaction of these factors with opioid intake. METHODS: At our institution, 164 patients with chronic pain undergoing an interdisciplinary assessment within a three-month period participated in the study and completed the Injustice Experience Questionnaire (IEQ). Data regarding opioid intake, pain levels, pain diagnosis, depression, anxiety, stress, quality of life, pain-related disability, habitual well-being, occupational status, and ongoing workers compensation litigation were extracted from the patients' charts. RESULTS: Approximately one-fourth of the patients used opioids. The IEQ total was significantly higher in patients using Schedule III opioids. Depression, but not the anxiety and stress scores, were significantly higher in patients using opioids. There were no significant differences regarding pain-related disability, habitual well-being, and the coded psychosocial diagnoses. In the patient group without opioids, the percentage of employed persons was significantly higher but there were no significant differences regarding work leave, pension application, or professional education. CONCLUSIONS: Opioid use appears to be more closely related to psychological factors and single social determinants of pain than to somatic factors.

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BACKGROUND: Worldwide, the COVID-19 pandemic has a significant impact on daily life. First studies describe a negative impact of pandemic stressors even on individuals without previous mental illnesses. The home lockdown and the shutdown of pain clinics make it difficult for all patients to get the healthcare they need. OBJECTIVES: The aim of this study was to investigate to what extent patients with chronic pain felt affected by the pandemic and its consequences on pain treatments, focussing on the beginning of the outbreak. STUDY DESIGN: A prospective noninterventional study. SETTING: Medical University Center . METHODS: One-hundred and forty-nine patients, suffering from chronic pain, treated at a large German interdisciplinary pain center, were studied over a period of 2 months at the beginning of the pandemic. Data from patient charts and questionnaires were evaluated. Patients were asked about postponements or cancellations of pain therapy, the possible effect on pain levels, depression, anxiety and stress, and the impact of intensified hygiene measures. Results were compared to those from standardized and validated questionnaires from the same patients (German version of the depression, anxiety, and stress scale = DASS) at the time of the first contact in the pain clinic. RESULTS: Eighty-four (56.4%) patients reported cancelled or postponed treatments during the pandemic. Those chronic pain patients with delayed or cancelled treatments reported significantly more pain and psychological distress. The delay or discontinuation of treatments resulted in a deterioration of symptoms. From the patients' point of view this deterioration was unrelated to the timing of treatment and not secondary to increased hygiene measures. In both groups, patients showed a significant amelioration of the DASS values compared to the values they had at the beginning of treatment, despite the negative effects of the COVID-19 pandemic on care structures. The majority of the patients do not think that the quality of pain treatment was significantly affected by the intensified hygiene requirements. LIMITATIONS: The limitations of the study are the small number of patients because of the limitation to a short period of time at the beginning of the pandemic and the return rate of 40.2% of the study consents. CONCLUSIONS: Even in the event of a pandemic-related restriction of the care structures, patients with chronic pain benefit from pain therapy. Limitations such as the increased hygiene measures caused by the pandemic were not considered detrimental to the therapeutic measures.

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Patients often adhere to intrathecal opioid therapy (IOT) for many years, despite the lack of scientific evidence for its efficacy and the scarce knowledge about long-term effects. Moreover, there is no knowledge on how the efficacy of IOT is influenced by cultural factors. We assessed the long-term efficacy and frequency of side effects of IOT in two culturally different patient samples. A chart review was conducted of all patients with IOT, who had been treated in interdisciplinary pain centers in Freiburg and in Tehran in a 15-year span. Personal data, diagnosis, duration of pain disease, pump type in use, revision operations, and opioid doses were recorded. Patients completed a questionnaire containing pain scores, pain-related disability (PDI), anxiety, depression, and unwanted side effects. Fourteen Iranian and 36 German patients (32 m/18 f) were studied. Mean duration of IOT was 10.2 years. Pain levels prior to IOT were 7.64 (NRS) (range 4-10, SD 1.64), 3.86 (range 0-9, SD 2.32) directly after pump implantation, and 4.17 (range 0-10, SD 2.11) at time of follow-up. Iranian patients had significantly lower pain levels directly after implantation, depression scores, and pain-related disability. Frequent side effects were obstipation, sexual dysfunction, urinary retention, and fatigue. Most side effects were significantly less frequent in the Iranian sample. There were no severe complications or permanent neurological deficit. Our study demonstrates the effectiveness of IOT also for long-term application. Differences in clinical efficacy are partially due to cultural factors. Side effects are frequent but not limiting patient satisfaction.

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Objectives Cooled radiofrequency (cRF) is an effective treatment for sacroiliac pain. In contrast to conventional radiofrequency denervation, this technique allows enlarging the area of denervation by cooling the radiofrequency probe. However, there is sparse knowledge about the impact of interventional procedures like cRF treatment of sacroiliac joint pain on psychological comorbidities. The aim of this retrospective study was to evaluate the outcome of cRF in chronic pain patients regarding the psychological outcomes anxiety, depression, sleep quality and pain related disability. Methods In this retrospective observational study 29 interventions were performed over a period of two years in 28 patients. Pre- and post-interventional pain levels, depression and anxiety scores, pain-related disability, treatment satisfaction and sleep quality were assessed by standardized and validated questionnaires. Pain medication was recorded prior to the intervention and at follow-up. Results Hospital Anxiety and Depression Scale (HADS-D) scores for depression showed a statistically significant reduction after therapy which did not remain significant after Bonferroni-Holm correction. Anxiety as measured by the HADS-A score did not show a statistically significant change. No statistically significant improvement was observed in the pain disability index. Patients reported fewer sleep disorders after treatment. Mean pain (NRS) was statistically significantly reduced 1 week post intervention and at time of follow-up. There was no clear reduction of analgesic medication. Conclusions Besides pain reduction, our data show a positive influence on sleep quality, possibly on depression, but not on anxiety and pain disability.

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BACKGROUND: Intrathecal opioid pumps have been used in the management of severe chronic pain for more than 40 years. Numerous studies have shown significant therapeutic effects alongside tolerable side effects. In the last decades, life expectancy has increased in many countries in the world. With an aging population, the question arises whether effects equal to those in younger patients can also be achieved in elderly patients. MATERIALS AND METHODS: This study is an in-depth re-analysis of data published previously. 36 patients were analyzed. The sample included 18 elderly patients (> 65 years) and 18 younger patients. RESULTS: No differences between the two samples were found with regard to pain intensity under intrathecal opioid therapy and prior to implantation of the opioid pump. Likewise, there were no differences in anxiety/depression scores and pain-related disability. Side effects were reported at similar rates by the elderly patients and by the younger patients. Elderly patients showed a tendency towards lower opioid doses and slower dose increases. CONCLUSION: Our data hint at a consistent efficacy of intrathecal opioid therapy in elderly patients even after long-term treatment. Side effects of the treatment are relatively frequent but mild and no side effects were particularly frequent in elderly people.

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Intrathecal drug delivery (IDD) was first described in 1981 by Onofrio, who used a pump for continuous and intrathecal delivery of morphine to treat cancer pain. Over the following four decades, many reports supported this treatment method with implanted pumps for cancer and non-cancer pain. To date, more than 300,000 pumps for pain therapy and spasticity have been implanted worldwide. This article reviews current knowledge regarding intrathecal opioid therapy, focusing particularly on the use of IDD in elderly patients. Current literature is presented, and the arguments in favor of and against this therapy in elderly patients are discussed.

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INTRODUCTION: Placebo effects can be very effective in certain pain conditions, but their use is still highly controversial. Several studies show that patients would accept a placebo treatment under certain circumstances, particularly when they are informed prior to the treatment or when there are no effective treatment alternatives. This study examines the question, which factors influence the degree of acceptability of a hypothetical placebo application. METHODS: Patients filled in a questionnaire dealing with placebo applications. Moreover general data, diagnosis, duration of pain, pain ratings and anxiety/depression/stress scores, sleep disorders and opioid intake were collected from the patients` charts. 129 patients (44 men / 85 women, mean age 51.5 years, 18.0-80.9 years) entered the study. All patients had chronic pain syndromes and were treated in an universitary academic interdisciplinary pain center. Mean duration of pain was 14.7 years. RESULTS: The study did not show significant differences in placebo acceptability among patients with different pain diagnoses or accompanying psychological diagnoses or disorders. Hidden placebo application was considered much more unacceptable for the patients than the enhanced placebo or the open placebo application. An improved condition was associated with less feeling of deception, more trust and less negative mood than an unchanged or worsened condition. CONCLUSION: Acceptance of placebo as pain therapy is much more dependent on the way of application (hidden or open) or on the resulting condition (improved, unchanged or worsened) than on factors inherent in the individual patients.

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OBJECTIVE: Neck pain has an annual prevalence of 30%. A frequent cause of neck pain is cervical facet joint pain. In cases of refractory cervical facet joint pain, radiofrequency can be employed, but the grade of evidence attested in systematic reviews is fair. Cryoneurolysis has been reported to induce favorable outcomes in lumbar facet joint pain. We sought to examine the feasibility of cervical facet joint cryoneurolysis. SETTING: Tertiary academic pain center. PATIENTS AND METHODS: We report here the operative technique of cervical facet joint cryoneurolysis for patients with cervical facet joint pain. The procedure is performed under CT-guidance. The lesion points are defined with the help of sensory stimulation. RESULTS: Six cervical facet joint denervations were carried out in five patients. All patients had an uneventful course with adequate pain relief. Apart from soreness of the paravertebral muscles no severe side effects were encountered. CONCLUSION: This is the first report of cryoneurolysis for the treatment of cervical facet joint pain. The technique is feasible and warrants further studies.

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OBJECTIVES: Many patients with intrathecal opioid pumps do adhere to the therapy for many years but there is scarce knowledge about the long-term effects of intrathecal opioid therapy (IOT) of more than three years. We sought to assess the long-term efficacy and the presence of typical side-effects and complications of IOT. METHODS: A chart review was conducted on all patients with intrathecal opioid pumps that had been treated at our institution between 1.11.1990 and 31.12.2014. Information regarding age, gender, diagnosis, age at time of implant, duration of disease, pump type in use, revision operations, and opioid doses over time was recorded. Moreover, a questionnaire was given to the patients containing the following items: pain scores on the NRS with and without IOT, pain related disability, unwanted side-effects of opioid therapy, anxiety, and depression. RESULTS: Thirty-six patients (21 m/15 f, mean age 62.9 years, range 30.5-83.9 years, SD 11.0 years) were studied. Mean duration of intrathecal therapy at time of study was 11.8 years. Thirty-two patients had gas-driven pumps and four patients had programmable pumps. The mean actual dose in those patients receiving morphine sulfate was 4.6 mg/day (range 0.2-11.1 mg, SD 2.63 mg). Pain levels prior to pump implantation were 7.98 (NRS) (range 4-10, SD 1.62). Pain levels directly after pump implantation were 4.87 (range 2-7, SD 1.86) and at time of follow-up 4.44 (range 0-9, SD 2.03). The most common unwanted side-effects reported by the patients were fatigue, obstipation, urinary retention, and sexual dysfunction. There was no life-threatening complication or permanent neurological deficit. CONCLUSIONS: IOT seems to be effective also for long-term application. Clinically unwanted side-effects are relatively frequent but not the limiting factor for patient satisfaction.

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Neuropathic pain constitutes a significant portion of chronic pain. Patients with neuropathic pain are usually more heavily burdened than patients with nociceptive pain. They suffer more often from insomnia, anxiety, and depression. Moreover, analgesic medication often has an insufficient effect on neuropathic pain. Spinal cord stimulation constitutes a therapy alternative that, to date, remains underused. In the last 10 to 15 years, it has undergone constant technical advancement. This review gives an overview of the present practice of spinal cord stimulation for chronic neuropathic pain and current developments such as high-frequency stimulation and peripheral nerve field stimulation.

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BACKGROUND: Despite the good clinical results elicited by spinal cord stimulation (SCS), the physiological basis of action of SCS is widely unknown. Inhibition of somatosensory evoked potential (SEP) amplitudes by SCS has been described, but it is unclear whether this displays dose dependency. Moreover, it is unknown whether the pain-relieving effect elicited by SCS correlates with the inhibition of SEPs. Finally, this study aimed to answer the question whether there is a difference in the effect on SEPs between SCS and transcutaneous electrical nerve stimulation (TENS), thus between central nervous system stimulation and peripheral nervous system stimulation. METHODS: Ten patients (4 men and 6 women, age range 40-77 years) with neuropathic lower limb pain were included in the study. All patients had implanted SCS systems with percutaneous type electrodes. Cortical SEPs under SCS and TENS were measured without stimulation, under stimulation at perception threshold (PT), and at maximal threshold (MT) in a crossover design. RESULTS: Cortical SEP amplitudes were significantly inhibited by SCS. Stimulation at PT and at MT both led to a statistically significant inhibition of the SEP amplitude. The difference between amplitude reduction at PT and MT showed a tendency towards significance. The degree of SEP amplitude inhibition did not correlate with pain relief. Inhibition of SEP amplitudes by TENS was weaker than that elicited by SCS. The average percentage of amplitude reduction at MT was twice as high under SCS as it was under TENS. No effects on SEP latencies were seen. CONCLUSIONS: SCS exerts a significantly stronger inhibition of SEP amplitudes than TENS. The data hint at a dose dependency of SCS-induced SEP amplitude inhibition. No correlation between SEP amplitude inhibition and pain relief was found.

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BACKGROUND: For more than 3 decades, spinal cord stimulation (SCS) has successfully been employed to treat neuropathic pain. Psychological factors are assumed to be important for the efficacy of SCS. However, the impact of psychological factors on the outcome of SCS has only rarely been studied. OBJECTIVES: The aim of this study was to determine the influence of psychological factors such as anxiety and depression, perceived disability, and self efficacy on the outcome of SCS in a representative clinical sample. STUDY DESIGN: Retrospective study. SETTING: Academic university interdisciplinary pain center. METHODS: We reviewed the records of 60 consecutive patients who had been treated at our institution with lumbar, thoracic, or cervical neurostimulators between July 1, 2008, and June 30, 2012. Information with respect to age, gender, diagnosis, age at time of implantation, disease duration, the preoperative Hospital Anxiety and Depression Test, German Version (HADS-D), the Pain Disability Index (PDI) and preoperative pain scores on an 11 point Numeric Rating Scale (NRS) were recorded. In addition, a questionnaire was mailed to participants that contained the following items: pain scores on the NRS with and without stimulation, time intervals of stimulation, paresthesia coverage, treatment satisfaction and medication intake, anxiety/depression (HADS-D and Beck Depression Index II [BDI-II]), PDI, and self efficacy using the Fragebogen zur Erfassung der schmerzspezifischen Selbstwirksamkeit (FESS). RESULTS: Preoperative HADS-D, PDI, and NRS pain scores were not different in those patients with an unsuccessful trial and those who underwent IPG implantation. Long-term outcomes were not affected by pre-implantation HADS-D or PDI scores. FESS scores showed a strong inverse correlation with HADS-D, BDI-II, and PDI scores and showed a tendency towards correlation with the percentage of pain reduction. HADS-D and PDI scores improved after SCS therapy. LIMITATIONS: Retrospective study. CONCLUSION: The outcome of SCS therapy could not be predicted on the basis of tested psychological factors anxiety/depression and pain-related disability. FESS correlated inversely with HADS-D, BDI-II, and PDI scores and showed a tendency towards correlation with the percentage of pain reduction. Further research is needed to define the impact of psychological factors on SCS outcomes.

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Neurostimulation techniques for the treatment of primary headache syndromes, particularly for chronic cluster headache (CCH), have received much interest in the recent years. Occipital nerve stimulation (ONS) has yielded favourable clinical results, and is becoming a routine treatment for refractory chronic cluster headache in specialized centres. Meanwhile, other promising techniques, such as spinal cord stimulation (SCS) or sphenopalatine ganglion stimulation, are emerging. This article reviews the current state of clinical research for neurostimulation techniques for chronic cluster headache, and particularly the pros and cons of SCS and ONS.

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Neurostimulation techniques for the treatment of primary headache syndromes, particularly for chronic cluster headache (CCH), have received much interest in the recent years. Occipital nerve stimulation (ONS) has yielded favourable clinical results, and is becoming a routine treatment for refractory chronic cluster headache in specialized centres. Meanwhile, other promising techniques, such as spinal cord stimulation (SCS) or sphenopalatine ganglion stimulation, are emerging. This article reviews the current state of clinical research for neurostimulation techniques for chronic cluster headache, and particularly the pros and cons of SCS and ONS.

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BACKGROUND: For more than 3 decades, spinal cord stimulation has successfully been employed to treat neuropathic pain. Cervical spinal cord stimulation, despite now being standard in many hospitals, has only rarely been subjected to a critical review within the literature. OBJECTIVES: The aim of this study was to determine the efficacy of cervical spinal cord stimulation (SCS) in a representative clinical sample. We also wanted to evaluate how factors such as stimulation parameters, unwanted paresthesia of the trunk and legs, and changes in paresthesia status due to head movement and how they affect SCS effectiveness. STUDY DESIGN: Retrospective study. SETTING: Academic university interdisciplinary pain center. METHODS: We reviewed the records of patients who had been treated at our institution with cervical neurostimulators from November 1, 2001 through October 31, 2011. Information regarding age, gender, diagnosis, age at time of implantation, duration of disease, lead position, hardware in use, revision operations, and stimulation parameters were recorded. In addition, a short telephone interview was conducted, which contained the following items: pain scores on the numeric analog scale (NAS) with and without stimulation, time intervals of stimulation, paresthesia coverage, changes in paresthesia coverage by head movements, unwanted paresthesia of the trunk and legs, treatment satisfaction, and medication intake. RESULTS: Twenty-three patients were treated. Eighteen patients proceeded to an implantable pulse generator (IPG) implant. In one patient, the system was removed after 4 years despite optimal function, because the patient was no longer experiencing pain. Average NAS pain scores were 6.8 (range 5.5 - 10.0, standard deviation [SD] 1.7) without, and 2.8 (range 0 - 7.5, SD 2.2) with neurostimulation. Fourteen revisions (5 due to lead dislocation, 5 due to lead breakage and 4 IPG revisions) were necessary in 9 of the 18 patients during a mean follow-up of 6.2 years. Most patients reported complete paresthesia coverage. Four patients reported unwanted paresthesia of the trunk or lower limb and 11 patients reported changes in paresthesia with head movements. In both instances, pain reduction was not affected. LIMITATIONS: Retrospective study. CONCLUSIONS: Cervical spinal cord stimulation appears to be effective in the treatment of neuropathic upper limb pain. Complications are not significantly more frequent than in SCS for lower limb pain. Changes in paresthesia with head movements and unwanted paresthesia did not affect the outcome.

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Neurostimulation techniques for the treatment of primary headache syndromes, particularly of chronic cluster headache, have received much interest in recent years. Occipital nerve stimulation (ONS) has yielded favourable clinical results and, despite the limited numbers of published cases, is becoming a routine treatment for refractory chronic cluster headache in specialized centres. Meanwhile, other promising techniques such as spinal cord stimulation (SCS) or sphenopalate ganglion stimulation have emerged. In this article the current state of clinical research for neurostimulation techniques for chronic cluster headache is reviewed.