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BACKGROUND: Pain is essential for survival, but it is also a major clinical, social, and economic problem that demands adequate management. The latter involves timely and accurate assessment, so several efforts have been made to develop accurate and reliable pain assessment tools. Advances in objective pain assessment include a large body of work focused on determining whether autonomic-mediated peripheral responses can be used to predict pain intensity. However, there is still no clinically validated autonomic marker for objective pain assessment. OBJECTIVES: In order to identify possible causes of this situation, the present study reviews the most recent advances examining peripheral autonomic markers' ability to describe pain intensity. STUDY DESIGN: Systematic literature review. METHODS: We conducted an online search on PubMed using terms such as "pain assessment," "experimental pain," "autonomic arousal," "heart rate," "heart rate variability," "electrodermal activity," "pupillary diameter," and "blood pressure." Articles published from 2010 through 2020 examining the abilities of peripheral autonomic markers to describe experimental pain intensity were collected and reviewed. From each of the included studies, we extracted information regarding autonomic parameters and stimulation modalities used by experimenters, as well as the sample size, gender, and health condition of the patients. RESULTS: Twenty-six articles were included for analysis, from which only 2 studies reported the use of multiple modalities. Half of the documents reported sample sizes ranging from 20 to 50 patients, and only 3 studies used formal power calculation to determine the sample size. Most of the articles included only healthy patients, so the influence of age, gender, and pre-existing health conditions on the autonomic peripheral parameters' capabilities to reflect the experience of pain remains unexplored. LIMITATIONS: It is possible that several documents were not retrieved due to a potential search engine bias or the use of very specific terms. Furthermore, only studies reporting pain intensity as a unique measure of its severity were included. CONCLUSION: The measurement of autonomic responses elicited by experimentally induced pain is one crucial step toward the development of reliable pain assessment tools. Still, several issues need to be addressed before continuing to explore the use of autonomic parameters for the assessment of pain. It is also recommended that future research endeavors in capturing the singularity of the pain experience involve the measurement of both peripheral (end organs) and central (brain) autonomic responses to pain.

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Resumen La investigación en medicina tiene por objetivo generar nuevos conocimientos que ayuden al diagnóstico, el tratamiento y la prevención de enfermedades. Pero la medicina no es una ciencia exacta, sino una actividad humana heterogénea que se basa solo parcialmente en la ciencia, con varios factores no científicos que influyen en la forma de desarrollar esta actividad. El dolor, como síntoma o como enfermedad, es probablemente el trastorno que más afecta y preocupa a las personas y el que con mayor frecuencia motiva una consulta médica. A pesar de la magnitud del problema, y del interés médico y social por el dolor, la atención y el tratamiento de las personas con dolor crónico es un tema infravalorado o tratado inadecuadamente. Con base en múltiples preguntas que se plantean a lo largo del desarrollo del presente documento, nuestro objetivo es, por un lado, el de señalar que los cambios que se han producido en el manejo del dolor crónico hacen de los llamados protocolos de consenso un ejercicio obsoleto en la medicina del siglo XXI. Por otro lado, en términos de bioética, responder a la pregunta ¿se ajustan los protocolos de consenso al principio de beneficencia del paciente individual?

Abstract Research in medicine is intended to generate new knowledge to help in the diagnosis, treatment and prevention of disease. However, medicine is not an exact science; rather, it is a heterogeneous human activity based only partially on science and involves several non-scientific factors that influence the way it is developed. Pain, as a symptom or as a disease, is probably the disorder that most affects and worries people, and is what most often prompts medical consultation. Despite the magnitude of the problem, and the medical and social interest in pain, the care and treatment of persons with chronic pain is an issue that is undervalued or inadequately addressed. Based on variety of questions posed throughout this document, the objective is, on the one hand, to point out that the changes that have occurred in the way chronic pain is managed make the so-called consensus protocols an obsolete exercise in 21st century medicine. On the other hand, in terms of bioethics, the authors answer the question: Do consensus protocols conform to the principle of beneficence for the individual patient?

Resumo A pesquisa em medicina tem por objetivo gerar novos conhecimentos que ajudem no diagnóstico, tratamento e prevenção de doenças. Porém, a medicina não é uma ciência exata, mas sim uma atividade humana heterogênea que está apenas parcialmente baseada na ciência, com vários fatores não científicos que influenciam na maneira em que essa atividade é desenvolvida. A dor, como sintoma ou como doença, é provavelmente o transtorno que mais afeta e preocupa as pessoas e o que com maior frequência motiva uma consulta médica. Apesar da magnitude do problema e do interesse médico e social pela dor, o atendimento e o tratamento das pessoas com dor crônica é um tema subestimado ou tratado inadequadamente. Com base em múltiplas perguntas que são levantadas ao longo do desenvolvimento do presente trabalho, nosso objetivo é, por um lado, indicar que as mudanças que ocorreram na abordagem da dor crônica fazem dos chamados "protocolos de consenso" um exercício obsoleto na medicina do século XXI. Por outro lado, em termos de bioética, buscamos responder à pergunta: os protocolos de consenso se ajustam aos princípios de beneficência do paciente individual?

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OBJECTIVE: To compare the immediate effects of electroacupuncture and manual acupuncture on pain, mobility and muscle strength in patients with knee osteoarthritis. METHODS: Sixty patients with knee osteoarthritis, with a pain intensity of ≥2 on the pain Numerical Rating Scale, were included. The patients were randomised into two groups: manual acupuncture and electroacupuncture. Pain intensity, degree of dysfunction (Timed Up and Go (TUG) test), maximal voluntary isometric contraction and pressure pain threshold were assessed before and after a single session of manual acupuncture or electroacupuncture treatments. RESULTS: Both groups showed a significant reduction in pain intensity (p<0.001) and time to run the TUG test after the acupuncture treatment (p=0.005 for the manual acupuncture group and p=0.002 for the electroacupuncture group). There were no differences between the groups regarding pain intensity (p=0.25), TUG test (p=0.70), maximum voluntary isometric contraction (p=0.43) or pressure pain threshold (p=0.27). CONCLUSIONS: This study found no difference between the immediate effects of a single session of manual acupuncture and electroacupuncture on pain, muscle strength and mobility in patients with knee osteoarthritis. TRIAL REGISTRATION NUMBER: RBR-9TCN2X.

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