Advancements in Health Research (#AHRjournal) has the aim to become a world-leading medical journal, initially published on a quarterly basis. It accepts, with an open-access policy, studies by highly ranked scientists worldwide, providing scientific material to a large global audience, and aiming to have an impact on health. The publication of this journal was decided by the Fondazione Paolo Procacci based on a large consensus experienced by the previous editorial initiatives of the Fondazione. Our goal is to make science easily available to all those interested. The ambition of #AHRjournal is to serve and aid in a transformation of society, providing an improved and ethical approach to research on health, with a preferential focus on Pain Medicine and Quality of Life. We would be proud to publish papers that provide a crucial contribution to science and human health. #AHRjournal invites the submission of original content, as well as narrative reviews, systematic reviews, and meta-analyses, which may contribute to advances in medical science and practice. Advancements in Health Research promotes open science and supports the early dissemination of research through recognized preprint platforms, facilitating rapid knowledge sharing within the global health research community.
A translational mathematical model linking systemic biomarkers to disease recurrence in diabetic macular edema: a proof-of-concept analysis
This study aimed to develop a translational mathematical model that links systemic biomarkers to diabetic macular edema (DME) dynamics and to provide a proof‑of‑concept assessment of its plausibility for informing anti‑vascular endothelial growth factor (anti‑VEGF) treatment strategies. A hybrid modeling approach was employed, combining mechanistic reasoning with a retrospective analysis of DRCR.net Protocol H data. A mechanistic model formalized the biological interaction between systemic drivers -glycated hemoglobin (HbA1c), systolic blood pressure (BP), and glycemic variability- and retinal VEGF dynamics, while an empirical penalty model translated these drivers into a framework for estimating personalized injection intervals (Imodel). Using data from 97 eyes treated with bevacizumab, we assessed the association between Imodel and a theoretical time to disease recurrence (Trec), defined as a >10% increase in central subfield thickness or a >5‑letter loss in visual acuity. The model’s hierarchical structure, which prioritized HbA1c, produced a shorter or equivalent interval compared to Trec in 63.6% of the overall cohort, and in a targeted subgroup where the model’s logic was fully applicable, the concordance rate was 77.6%. In Group E, simulating a post‑loading phase with two injections plus laser, the mean deviation between Imodel and Trec was minimal (-0.1 weeks) with reduced variability (SD=5.6 weeks). Sensitivity analysis confirmed the designed hierarchy, showing HbA1c exerted a 36‑fold greater influence on the model’s output than BP. These findings present a novel mathematical framework linking systemic metabolic and hemodynamic control to DME progression. The proof‑of‑concept analysis supports the biological plausibility of using HbA1c and BP to stratify recurrence risk and provides a transparent, interpretable foundation for future research. This model bridges systemic and ocular care and proposes a structured hypothesis for personalized treatment scheduling that warrants prospective validation in appropriately designed clinical cohorts.
Copyright (c) 2026 the Author(s) https://creativecommons.org/licenses/by-nc/4.0
Exercise pain and alexithymia: exploring the relationship
Alexithymia, a psychological trait characterized by impaired emotional awareness and regulation, has been linked to altered pain perception and emotional processing. Despite its established role in chronic pain and psychological disorders, little is known about its influence on exercise-induced pain. To investigate the relationship between alexithymia and exercise-induced pain perception, differences in pain intensity, perceived exertion, heart rate, and task endurance were measured during isometric exercise in alexithymic and control participants. Sixty participants were categorized into alexithymic and control groups based on the Alexithymia Scale. Participants performed an isometric contraction task, holding a mass of 20% of their one-repetition maximum (1RM) at a 90° elbow flexion for as long as they could, during which pain intensity, perceived exertion, and heart rate were recorded. Statistical analyses, including MANOVAs and correlation analyses, evaluated the effects of alexithymia on these outcomes. Alexithymic participants reported significantly higher pain intensity compared to controls across all time points. However, no significant differences were found between groups for perceived exertion, heart rate, or task endurance. These findings suggest that exercise-induced pain is increased in alexithymia, but without limiting muscular endurance. Targeted pain management interventions focusing on emotional processing deficits may benefit individuals with alexithymia. Future research should explore adaptive mechanisms over prolonged exposure and the development of tailored therapeutic interventions to improve emotional resilience and quality of life. This study is the first to demonstrate that alexithymia is associated with heightened pain perception during exercise, independent of exercise intensity and physiological response. These findings offer novel insights into the interplay between emotional processing and pain sensitivity, highlighting the need for targeted pain management interventions in alexithymic individuals. The results have potential implications for both psychological and physical rehabilitation strategies, improving therapeutic approaches for populations with emotional processing deficits.
Physiotherapeutic management of primary dysmenorrhea for adolescent students: a systematic review and meta-analysis
Primary dysmenorrhea (PD) affects up to 80% of adolescent girls, significantly impacting their school attendance and quality of life. This systematic review and meta-analysis evaluated the efficacy of physiotherapeutic interventions, including acupressure, massage, exercise, and transcutaneous electrical nerve stimulation (TENS), in managing PD among adolescents. Following PRISMA guidelines and utilizing the PICO framework, a comprehensive search was conducted across four electronic databases (Scopus, PubMed, Medline, and Cochrane Library) and grey literature for English-language randomized controlled trials (RCTs) published between May 2000 and May 2025. Ten RCTs involving 1,496 participants met the inclusion criteria, focusing on adolescents aged 10–19 years with PD. Pain reduction, measured using visual analogue scale (VAS) and numerical rating scale (NRS), was the primary outcome, with significant improvements observed across most interventions. A meta-analysis supported the effectiveness of these therapies, though heterogeneity in study designs and interventions was noted. The findings suggest that physiotherapy is a promising non-pharmacological approach for PD management, with potential benefits for both physical and psychological health. However, the findings should be interpreted with caution due to study heterogeneity and moderate methodological quality. Further high-quality trials are recommended to strengthen the evidence base and guide clinical practice. Trial Registration Number: PROSPERO 2025 CRD420251074405.
Hyperspectral retinal imaging for micro- and nanoplastics detection: a conceptual and methodological framework
This manuscript presents a conceptual and methodological framework rather than empirical results, outlining a pathway for applying hyperspectral retinal imaging (HSRI) to detect micro- and nanoplastics (MNPs). The retina, with its transparent optical media, layered architecture, and vascularization, offers an ideal biomedical model for adapting spectroscopic techniques that have been widely used in environmental and materials sciences. The framework consists of four staged phases: i) construction of a spectral library of common synthetic polymers; ii) phantom experiments that replicate retinal optical properties and are spiked with defined MNPs; iii) ex vivo validation in ocular tissues with Raman and Fourier-transform infrared spectroscopy as chemical ground truth; and iv) pilot in vivo studies in small-animal models to assess HSRI sensitivity, specificity, and safety. Machine-learning classifiers and spectral unmixing algorithms are incorporated to separate polymer-specific signals from endogenous chromophores such as hemoglobin, melanin, and lipofuscin. While no experimental data are presented, the framework anticipates the establishment of polymer spectral libraries, demonstration of separable spectral signatures, and translational feasibility for detecting polymer deposits under safe irradiance conditions. If validated, HSRI could enable the retina to serve as a sentinel organ for systemic pollutant exposure, bridging ophthalmology, toxicology, and environmental health with spectroscopy. ______________________________________________________________________________________________________________________________________________________ Graphical Abstract
Copyright (c) 2025 the Author(s) https://creativecommons.org/licenses/by-nc/4.0
Advancements in cardiovascular pharmacology
Cardiovascular pharmacology is entering a period of profound transformation, driven by novel therapies that extend far beyond traditional approaches. Recent advances include RNA-based drugs targeting lipoprotein(a) and angiotensinogen, new stabilizers for transthyretin amyloidosis, and selective aldosterone synthase inhibitors for resistant hypertension. These developments illustrate a decisive shift from symptomatic management toward disease modification and precision targeting. Yet, significant challenges remain. Translating biomarker reductions into hard outcomes such as reduced mortality, myocardial infarction, or stroke requires large, long-term clinical trials now underway. Equally critical is the need for rigorous monitoring of long-term safety, particularly for new platforms such as siRNA and gene therapies, where off-target effects and tolerability over decades remain uncertain. High cost and limited accessibility further threaten to widen global health inequities, while gaps in diagnostic infrastructure hinder appropriate patient selection. Regulatory frameworks, especially outside high-income regions, must also evolve to keep pace with these scientific advances. Despite these obstacles, the future is rich with promise. Gene editing and novel gene therapies hold the potential to correct underlying disease mechanisms, while long-acting drugs offer solutions to adherence challenges. Personalized, multimodal strategies, combining metabolic, anti-inflammatory, and genetic risk-modifying agents, may soon become standard, tailored to each patient’s biomarker and genetic profile. Importantly, early detection of subclinical disease could shift cardiovascular pharmacology from treating advanced illness toward prevention and preservation of health. The coming decade will determine whether these breakthroughs translate into equitable, lasting improvements in outcomes, heralding a new era in cardiovascular care.
An exploration into the efficacy of virtual reality for managing pain in hospitalized patients, with a focus on cancer pain
Cancer pain is highly complex and associated with a great global and individual burden. Due to its multifactorial nature, it must be addressed with a combination of pharmacological and non-pharmacological approaches. Many people with cancer feel their pain is inadequately managed, pointing to the critical need for new management approaches. Virtual reality (VR) is a promising management strategy for a variety of pain conditions, at the forefront of research. This study aims to explore the use of VR in the management of pain in hospitalized patients, focusing on cancer-related pain. A systematic review was carried out on all eligible articles published before July 2025, in accordance with Preferred Reporting Items for Systematic Review and Meta-Analyses (PRISMA) guidelines. Randomized control trials that investigated VR in the pain management of hospitalized adult patients were included. Thirty-three (33) randomized control trials were included in the systematic review following selection processes. Outcome measures such as the visual analogue scale, the numerical rating scale, and graphic rating scale, were commonly used; 79% of articles reported a significant reduction in pain when using VR. None of the studies reported any significant adverse effects. VR is a safe and feasible option for adjunctive, non-pharmacological pain management in hospitalized patients. Few studies investigate the application of VR in the management of cancer pain, however, those available reveal promising results. Future randomized control trials that employ a double-blinded study design would be of benefit.
Evolving role of the Interleukin-5 antagonist mepolizumab for hypereosinophilic syndrome: pathogenesis and advances in therapy - A narrative review
Hypereosinophilic syndrome (HES) is a rare blood disorder characterized by hypereosinophilia greater than 1,500/μL on at least two separate occasions with some degree of associated end-organ damage and exclusion of other identifiable causes of hypereosinophilia. The systemic effects and damage seen in HES can be extensive, resulting in a variety of clinical presentations, but most commonly the affected organs include the lungs, heart, skin, and the gastrointestinal tract. After FDA-approval in 2020, mepolizumab (trade name Nucala) an interleukin-5 (IL-5) antagonist monoclonal antibody, is considered an effective treatment for HES given its ability to lower absolute eosinophil counts, improve the symptomatic burden, reduce the number of HES flares experienced, and limit the need for corticosteroids as a primary therapy. Also of benefit, Nucala has been shown to have a positive safety profile with limited adverse effects and no notable contraindications to treatment.
AURICULAR ACUPUNCTURE IN THE MANAGEMENT OF TENSION-TYPE HEADACHE: A PRELIMINARY STUDY
INTRODUCTION Tension-type headache (TTH) is a common form of primary headache, often managed with symptomatic treatment such as non-steroidal anti-inflammatory drugs (NSAIDs) and muscle relaxants. However, pharmacological approaches may lead to medication overuse and fail to address the underlying causes. Auricular acupuncture has shown promise in modulating pain pathways and muscle tension. This study aims to evaluate the efficacy and safety of auricular acupuncture in reducing the impact of TTH in adult women. METHODS A prospective observational study was conducted on 20 female patients aged 30 to 50 years with a positive history of TTH and ongoing symptomatic treatment with NSAIDs and muscle relaxants. Each participant underwent auricular acupuncture sessions using sterile, single-use needles (0.2 × 40 mm) applied bilaterally to specific auricular points: master cerebral point, thalamus point, paravertebral cervical musculature, occiput, and a muscle-relaxant point. Needles were retained for 20 minutes, followed by application of auricular plasters with embedded needles (0.15 × 0.6 mm), which were worn for 5 days and self-removed. Treatments were administered weekly during the first month and biweekly during the second month. To assess impact on quality of life and headache-related disability, patients completed the Headache-Attributed Lost Time (HALT) questionnaire: HALT-90 at baseline (T0), HALT-30 after 1 month, and again HALT-30 at 2 months. HALT-90 assesses disability over the prior 3 months, while HALT-30 evaluates the previous 30 days. RESULTS At baseline (T0), 15 patients reported moderate impact (Grade 3) and 5 reported mild impact (Grade 2) on the HALT-90 scale. After 1 month of treatment, HALT-30 scores indicated a reduction in disability: 5 patients showed moderate impact (Grade 2), and 15 showed mild impact (Grade 1). By the end of the second month, 15 patients reported mild impact (Grade 2), and 5 reported minimal impact (Grade 1). Additionally, all patients demonstrated a reduced need for symptomatic medication. No adverse effects or contraindications were observed throughout the study period. CONCLUSIONS Auricular acupuncture appears to be a safe and effective complementary approach in reducing the frequency and impact of tension-type headaches. This technique also contributes to a decreased reliance on symptomatic drugs. Further randomized controlled trials with larger sample sizes are recommended to validate these preliminary findings.
COMPLAINTS OBSERVED AMONG PATIENTS AFTER INVASIVE PROCEDURES ON CORONARY ARTERIES
Procedures included in the survey which are coronary angiography - CAG and percutaneous coronary intervention PCI, are commonly available nowadays (in 2022 there were over 3960 of CAG per 1 million citizens a year and 2300 of PCI per 1 million citizens a year). During both procedures a patient’s position is the same - on their back with straight arms and legs. The duration of the procedures is various - from 15 minutes to over 2 hours. A patient, while coronary interventions, is exposed to multiple discomforts that very often are not even connected with coronary procedure sensu stricto, such as: low temperature of the environment, after effects of surgical complications, enforced position of the body and necessary body immobility during the procedures. The latter discomfort is very often connected with intensified pain in a locomotor system which is a significant problem among elderly patients. They constitute a substantial percentage of cathlab’s patients. There are no precise recommendations or guidelines about sedation and/or analgesia during the procedures. The aim of the article is to assess the patients’ complaints, especially pain components while CAG and PCI. MATERIALS AND METHODS The survey involves patients after CAG and PCI. A self created questionnaire. NRS scale, The Beck Anxiety Inventory (BAI) (A.T. Beck, R.A. Steer) RESULTS The 50 patients’ statements have been obtained. The conclusions are: a patient, during the procedure, is subject to multiple discomforts. They are dependant on the duration of the procedure itself , the temperature of the environment and coexistent health problems which might cause pain complaints of a different matter. These complaints may be intensified by enforced, uncomfortable body position and a hard bed. Other factors which intensify complaints are anxiety, feeling of embarrassment and being aware of danger of life. CONCLUSIONS During CAG and PCI procedures the patients suffer from pain complaints not always resulting from the procedures but also from their coexistent chronic afflictions. There are biological and emotional factors which intensify pain during the procedures.
COMPARATIVE STUDY OF MENS AND TENS FOR PAIN RELIEF IN PATIENTS WITH PARTIAL ROTATOR CUFF TEAR (A ONE-YEAR FOLLOW-UP)
INTRODUCTION The aim of this study was to evaluate the effectiveness of a combined physiotherapy intervention (electrotherapy TENS or MENS - and kinesiotherapy) used to provide relief to patients suffering from partial thickness rotator cuff tears, and the comparison between the two alternative methods. METHODS Confirmation of partial thickness rotator cuff tears was made by ultrasound as to the category that caused the pain in patients participated in the study. A total of 42 patients were screened to ensure that they had not received recent medication that included non-steroidal anti-inflammatory drugs (NSAIDs) and were randomly assigned in two groups. First group receive TENS and kinesiotherapy, while the second received MENS and kinesiotherapy. Τhe tools used to assess pain intensity, disability and quality of life were the Shoulder Pain And Disability Index (SPADI), the numerical rating scale (NRS) and the Euro QoL questionnaire (EQ-5D: health today), respectively. The effectiveness of the intervention was evaluated with Anova repeated measurements analysis, within five time points (baseline, 1, 3, 6 and 12-months after the treatment) and between the two different groups of patients (TENS or MENS). In addition, we performed independent student's t and Mann Whitney-U tests to determine the existence of any statistically significant difference between the two methods used at each time point. Data are presented as means and standard deviation (SD). A P value <0.05 was defined as statistical significance. Statistical analyses were performed using the SPSS Statistics V.26 for Windows. RESULTS The results of the repeated measures analysis of variance showed significant improvement in the patients' pain scores, functionality and quality of life for both groups (p-values<0.001), right after the intervention. Although the MENS group had a higher improvement in pain level while the TENS group in disability and quality of life, differences between groups found no significant (p-values > 0.05) at baseline, 1 and 3 months after the intervention. In contrast to the quarterly measurements, independent t and Mann-Whitney tests, report statistically significant differences between groups 6 and 12 months after the treatment for: SPADI total (p=0.006 and p<0.001, respectively), SPADI pain (p=0.036 and p=0.001), SPADI disability (p=0.005 and p<0.001), EQ-5D: health today, NRS Now and NRS last week with p values < 0.001 for these time measurements. The MENS group results in higher improvement for all the examined variables. CONCLUSIONS The above study suggests that interventions that include a combination of MENS and kinesiotherapy, which are applied to rotator cuff tear suffers, show significant results in terms of pain relief, improved functionality and quality of life that can last up to one year after treatment.
ERECTOR SPINAE PLANE BLOCK AND OZONE THERAPY: THE INNOVATIVE ALLIANCE AGAINST CHRONIC DISCOGENIC BACK PAIN
INTRODUCTION The Erector Spinae Plane (ESP) block is a relatively recent locoregional anesthesia technique, increasingly used not only in postoperative spine surgery but also in the management of various acute and chronic pain conditions. Its mechanism of action is still under investigation, but most hypotheses suggest an interfascial spread affecting the dorsal rami of spinal nerves, with possible anterior diffusion into the paravertebral space. Simultaneously, ozone therapy has long been applied in the treatment of chronic discogenic low back pain (DLBP), thanks to its anti-inflammatory, antioxidant, anti-edema, and analgesic effects. However, the integration of ozone into ultrasound-guided locoregional techniques is still rarely documented. Combining ESP block and ozone may offer a novel, minimally invasive approach for patients unresponsive to conventional treatments. METHODS We describe the case of a patient with a history of chronic DLBP and acute onset of left-sided lumbosciatica (NRS 8–9). MRI revealed a median-paramedian L4-L5 disc herniation and an extruded L5-S1 disc in the left preforaminal space, with caudal migration. Initial treatment with oral methylprednisolone led to only partial improvement. After a subsequent relapse, pain was successfully managed with slow-release diclofenac (NRS 0), but recurred after discontinuation (NRS 4–5) with sciatica-like features extending from the left gluteal region to the foot, worsened by movement and positive Lasègue sign. As the patient refused epidural corticosteroid injections and was unsuitable for long-term NSAID therapy, we proposed an ultrasound-guided ESP block combined with ozone. A convex probe and a 50 mm needle were used to perform a left L4-L5 ESP block, injecting 20 ml of ozone at a concentration of 40 mcg/ml. RESULTS In the two days following the first ESP block, the patient experienced significant pain relief (NRS 2–3). This was followed by a transient increase in symptoms (NRS 4–5), but further gradual improvement was reported two weeks later (NRS 2–3). A second identical ESP block was performed one month later, resulting in complete resolution of pain (NRS 0), which was maintained at follow-up without the need for further pharmacological therapy. No adverse events were observed. CONCLUSIONS This case highlights the potential role of combining ESP block and ozone therapy in the management of chronic DLBP, particularly when standard treatments are ineffective or contraindicated. ESP block offers a technically simple, ultrasound-guided solution with a favorable safety profile, while ozone enhances the anti-inflammatory and analgesic effect through its biological properties. Although literature on this specific combination is still limited, our experience suggests it may represent a valuable and innovative tool in pain management. Further clinical studies are needed to validate its efficacy and optimize treatment protocols.
REDUCTION OF ANXIETY AND PROCEDURAL PAIN IN THE PAEDIATRIC PATIENT: THE ROLE OF NITROUS OXIDE IN VENOUS CANNULATION
BACKGROUND Procedural pain, often underestimated, is a type of pain caused by invasive diagnostic and therapeutic procedures, accompanied by emotional reactions such as anxiety, stress, and fear; it is a predictable pain that can therefore be pretreated1-2. Despite past beliefs, the perception of pain in children, especially the youngest, is high. Moreover, emotions play a pivotal role, hence healthcare professionals should prevent and control them accordingly3-4. The use of nitrous oxide (N2O), considered a possible form of analgosedation, allows to relieve pain and to reduce the procedure-related anxiety5-8. The purpose of this thesis is to test whether nitrous oxide is effective in reducing pain and procedural anxiety during peripheral venous access placement compared to standard placement in the pediatric patient (1 to 18 years old). MATERIALS A literature review was conducted in the databases PubMed, Cochrane Library, CINAHL, Embase, and TripDatabase between March and April 2024. Thirteen studies were selected, applying studies of pediatric patients undergoing minor painful procedures using N2O as inclusion criteria. RESULTS All selected studies confirm the efficacy and safety of N2O in reducing pain and anxiety in pediatric procedural settings, improving cooperation during the procedure and reducing the overall duration of the procedure5-9. N₂O is an easily manageable gas with rapid onset (1-5 minutes) and recovery (within 5 minutes of cessation of inhalation), making it suitable for its use also in the ambulatory setting. N2O administration via face mask appears to be simple and well tolerated6-7. Reported side effects are rare, mild, and transitory (e.g., nausea, dizziness, euphoria). Several studies showed that the combination of non-pharmacological (audiovisual distraction) and pharmacological techniques (local anesthetics, midazolam) further enhances its effectiveness6-8. The administered gas concentrations may vary, but the equimolar mixture (50% N₂O and 50% oxygen) appears to be the most common and safest6-9. N2O can be administered by properly trained nurses in safe and ventilated environments. Patient’s parents, once properly informed, reported high satisfaction levels with the procedure10. CONCLUSIONS N2O represents a safe, effectively analgosedative option in all the various concentrations, and its effect becomes more effective when combined with a local anesthetic or non-pharmacologic techniques7,8,10. Its adoption during venous cannulation improves the patient experience, facilitates the work of health care providers, and contributes to create a more serene environment for both the child and the family6-9. The spread of this practice requires specific local protocols, appropriate environments and adequate staff training. However, the extension of its use to ambulatory and non-hospital settings is desirable1,2,4.
PULSED RADIOFREQUENCY WITH ALGOCARE® TRANSDERMAL SYSTEM FOR BILATERAL GONALGIA DUE TO PAINFUL PROTHETICS: A CASE REPORT
BACKGROUND AlgoCare® is a non-invasive, single-use device that modulates cellular processes involved in inflammation and edema via Pulsed Electromagnetic Field (PEMF) therapy. The electromagnetic field induces a low-intensity current (no heat), penetrating tissue up to 5–7 cm, disrupting pro-inflammatory molecule synthesis. Widely used in orthopedics, plastic, and general surgery, it can be applied with one or two antennas depending on the area treated. Therapy duration is typically 100 hours over two weeks. CASE DESCRIPTION A 91-year-old woman with osteoporosis and bilateral knee arthroplasties (right 1983, left 2016) experienced persistent pain in her left knee. Bone scan and CT exclude infection or loosening. A genicular nerve block gave >50% relief. In December 2024, conventional radiofrequency denervation (RFD) was performed, yielding only temporary benefit. Three months later, RFD was repeated using transdermal ALGOCARE®, with full pain relief but residual stiffness. As pain worsened in the right knee, bilateral ALGOCARE® RFD was performed (20 min, 1.4 A, 50 V, 30 Ohm). After one month, the pain score dropped from 8 to 2, with QoL stable at 30%. MATERIALS AND METHODS Between June 2023 and June 2024, a double-blind randomized trial was conducted in Western Rajasthan, India, enrolling 180 patients (mean age 57) with knee osteoarthritis (ACR criteria, KL grades 2–4) and chronic pain >3 months. The study compared standard 3-nerve RFD (SMGN, SLGN, IMGN) to an extended 5-nerve protocol that added the infrapatellar saphenous nerve (IPBSN) and recurrent fibular nerve (RFN). RESULTS Pain (NRS), function (TUG), and QoL (KOOS subscale) were measured at baseline, 1 and 3 months. No significant differences emerged between groups, though both showed clinical improvement. The 5-nerve group had greater QoL gains at 3 months, suggesting possible long-term benefit. DISCUSSION PEMF use reduces pain, analgesic need, and anxiety, supporting faster recovery and lower costs. Broader nerve coverage via AlgoCare® may enhance outcomes versus standard RFD. CONCLUSIONS AlgoCare® appears effective for knee pain relief, possibly due to wider neuromodulation. Further studies should assess duration of effect and compare different RFD protocols.
PAIN MANAGEMENT IN NURSE-LED EMERGENCY SERVICES: RESULTS OF A NATIONAL SURVEY
INTRODUCTION Acute pain effective management in a pre-hospital setting enables better care for patients in emergency situations. In Italy decision-making algorithms and operating protocols have been issued by the relevant authorities, such as 118 Emergency Medical Dispatch Centers (EMDC) and department or regional bodies. These tools regulate pain management procedures, even when carried out independently by emergency nurses. This study aimed to describe drugs used to treat acute pain in patients managed by nurse-led emergency services in Italy. A further objective was to determine the extent to which nurses can autonomously assess and treat acute pain during patient management. METHODS In April and May 2025, a questionnaire was sent to each Italian region's 118 EMDC. The questionnaire consisted of approximately ten closed and open-ended questions. The questionnaire investigated nursing algorithms for assessing and managing pain in adults and children. The questionnaire was completed online using Google Forms. RESULTS Out of a total of 21 118 EMDC to which the questionnaire was sent, 90.5% (n=19) responded. 89% (n=17) have decision-making algorithms in place for nurse-led emergency vehicles. In 12 of these centres, nurses can independently administer drugs in specific cases defined by the algorithms during emergency management. Of the 17 operational centres, 13 (76.4%) have specific nursing algorithms for managing pain in adults, and 12 (70.5%) have algorithms for managing pain in children. Twelve operational centres (70.5%) use nursing algorithms that include validated pain measurement scales such as the NRS (Numerical Rating Scale), VAS (Visual Analogue Scale), PAINAD (Pain Assessment in Advanced Dementia) and FACES. Nurses can independently administer the following drugs without authorisation from the 118 EMDC: paracetamol in eight cases, NSAIDs in three cases, morphine in four cases, fentanyl in four cases, ketamine in one case, and tramadol in one case. However other emergency response centres report that nurses can only administer these drugs after obtaining EMDC physician authorization. CONCLUSIONS The results highlighted inconsistencies in the management of acute pain in the out-of-hospital setting by nursing teams in Italy. Nevertheless, most emergency response centres have protocols for pain management in ambulances led by nurses. The use of appropriate tools for pain assessment and the ability to manage patients' pain independently or with prior authorisation from the emergency response centre, including the use of stronger analgesics, was also identified.
EFFICACY AND SAFETY OF A FIXED-DOSE COMBINATION OF TRAMADOL/PARACETAMOL 75 MG/650 MG IN REDUCING PAIN INTENSITY IN PATIENTS WITH LOW BACK PAIN: A REAL-WORLD RETROSPECTIVE STUDY
INTRODUCTION Low back pain (LBP) is a complex and multifactorial condition affecting a substantial portion of the population.1 Prevalence estimates suggest that up to 80% of adults will experience at least one episode of LBP during their lifetime.2 One promising approach for LBP management is the use of combination therapies, which allow for lower dosages of each active ingredient, potentially reducing the risk of side effects.3 Tramadol/paracetamol combinations have been used in clinical practice to manage various pain conditions.4-6 The multimodal action of tramadol, combining opioid and monoaminergic mechanisms, and paracetamol, an analgesic with minimal cyclooxygenase inhibitory activity, results in a comprehensive effect on pain by targeting both nociceptive and neuropathic components.7 This study aimed to assess the effectiveness and safety of a fixed-dose tramadol/paracetamol combination (75 mg/650 mg) for LBP management. METHODS In this real-world retrospective study, 100 adults with moderate-to-severe LBP were treated with tramadol/paracetamol over 15 days. Pain intensity through the NRS (Numeric Rating Scale), disability level through the ODI (Oswestry Disability Index) and patient satisfaction through a 4-point Likert scale, alongside the frequency and types of adverse events and dropout rate, were assessed. RESULTS A significant reduction in pain intensity, as measured by the NRS, was observed at T1 (day 7), with mean scores decreasing from 6.76 at baseline to 2.66 (p ≤ 0.05). This reduction was maintained at T2 (day 15), with a mean score of 2.35 (p ≤ 0.05) (Figure 1). The ODI improved from 37.5 at baseline to 4.06 at T2 (day 15) (p≤0.05) (Figure 1). Patient satisfaction on day 15 was moderate, with a score of 1.96 on a 4-point Likert scale. Adverse events, primarily nausea and constipation, were reported by 5% of patients. The dropout rate was also 5%, and in all cases, it was due to adverse events and not treatment inefficacy. CONCLUSIONS Tramadol/paracetamol (75 mg/650 mg) effectively reduced LBP intensity and led to improvements in functional disability with manageable adverse events. Although further studies are needed to confirm these findings in larger populations, the results indicate the key role of this combination to improve the quality of life of patients and the potential in reducing productivity loss and healthcare costs.
CHRONIC VISCERAL PAIN TREATED WITH 10 khz SPINAL CORD STIMULATION: A CASE REPORT
INTRODUCTION Visceral pain originates from thoracic, abdominal, or pelvic organs. It is typically diffuse, poorly localized, and described as cramping, pressure-like, or deep aching1. Pathophysiology involves activation of unmyelinated C fibers due to mechanical distension, ischemia, or inflammation. Signals are transmitted via autonomic pathways to the CNS. A key feature is spinal convergence of visceral and somatic afferents, resulting in referred pain. Autonomic symptoms (e.g., nausea, sweating, tachycardia) and strong emotional components are also common, due to limbic system involvement. Diagnosis and management are often complex, requiring multimodal approaches. CASE PRESENTATION A male patient was referred for chronic right hypochondrial pain. History included benign prostatic hyperplasia, right radiculopathy, and left coxalgia, previously treated with infiltrations. The patient reported 10 kg weight loss due to pain. Ongoing medications included buprenorphine patch (52 mcg/h), oxycodone/naloxone (20 mg TID), pregabalin (75 mg BID), duloxetine (30 mg daily), and vaporized high-THC cannabis (four times/day). Pain began eight years earlier, described as constant stabbing in the right hypochondrium, alleviated by walking and worsened by sitting. Flares improved with intramuscular diclofenac. MRI revealed right renal inflammatory changes; PET showed somatostatin receptor uptake in the duodenopancreatic area. Lumbar MRI was normal. Given the diagnosis of drug-resistant chronic visceral pain, the patient underwent two-stage high-frequency spinal cord stimulator (SCS 10 kHz) implantation between May and June 2024, without complications. Leads were placed between T3–T6 in a right median-paramedian position. RESULTS At 1, 3, 6, and 12-month follow-ups, the patient reported substantial pain relief (NRS reduced from 9/10 to 2/10), improved quality of life (EQ-5D-5L from 0,130 to 0,758), and decreased use of analgesics. The patient is currently receiving transdermal buprenorphine 20 mcg/h and duloxetine 30 mg; pregabalin, oxycodone/paracetamol, diclofenac and cannabinoids have been discontinued. Device function was stable and well-managed. CONCLUSIONS This case supports the efficacy of high-frequency (10 kHz) SCS in treating chronic, drug-resistant visceral pain. Results align with existing literature demonstrating benefits in reducing pain, enhancing quality of life, and minimizing opioid use2. High-frequency SCS represents a valuable tool in the multidisciplinary management of complex abdominal pain, particularly in patients with mixed neuropathic-visceral features3.
SHORT-WAVE DIATHERMY IN THE REHABILITATION MANAGEMENT OF TENSION-TYPE HEADACHE ASSOCIATED WITH NECK PAIN: A CASE CONTROL STUDY
INTRODUCTION Tension-type headache is the most common neurological disorder worldwide and is often associated with neck pain. Cervical musculoskeletal dysfunctions are frequently observed in this patients, suggesting a potential role for physical rehabilitation. Short-wave diathermy (SWD) is a deep-heating technique known to raise pain thresholds, reduce muscle spasms, and improve soft tissue flexibility. This single-center retrospective case-control study aims to evaluate the effectiveness of SWD as an adjunct to conventional rehabilitation in adults with tension-type headache and neck pain. MATERIALS AND METHODS The study was conducted at the Neurorehabilitation Unit of the University of Verona. The study population consisted of 42 adults with persistent tension-type headache and neck pain. Participants were divided into two groups. SWD was administered using the ProNexibus Plus® device (focusMED srl, Montegrotto Terme, Italy). The case group received 20 minutes of short-wave diathermy and 20 minutes of myofascial release (pompage), while the control group underwent 20 minutes of pompage followed by 20 minutes of therapeutic neck exercises. Both groups completed a total of 10 rehabilitation sessions, each lasting 45 minutes, for 5 weeks. Inclusion criteria were: age ≥18 years; persistent headache associated with neck pain for more than 8 weeks at the time of inclusion; pain intensity ≥2 on the Numerical Pain Rating Scale (NPRS); and stable pharmacological treatment. Exclusion criteria included: participation in other clinical trials; diagnosed specific causes of headache or cervical pain (e.g., trauma, rheumatic or systemic disorders); presence of central or peripheral neurological signs; cognitive impairment; prior cervical spine surgery; and known or suspected disorders affecting sensory or vascular pathways (e.g., migraine, hypertension). Patients were evaluated at two time points: before treatment (T0) and one week after the completion of the intervention (T1). The primary outcome of the study was pain intensity, measured using the NPRS. Secondary outcomes included disability, assessed with the Neck Disability Index (NDI) and the Pressure Pain Threshold (PPT). Statistical analysis was performed by an independent statistician using the Statistical Package for the Social Sciences (SPSS) for Macintosh, version 27.0 (IBM Corp., Armonk, NY, USA). The level of statistical significance was set at P <0.05. RESULTS After treatment, the Case group showed significantly greater improvements compared to controls in neck pain (P=0.03) and disability (P=0.04). No significant between-group differences were observed in pressure pain threshold measurements at cervical sites. CONCLUSIONS Preliminary findings suggest that short-wave diathermy may serve as a useful adjunct when added to conventional rehabilitation programs of adults with tension-type headache associated with neck pain. Larger randomized controlled studies are needed to confirm these results.
A SURVEY OF NURSING ASSESSMENTS OF PAIN AND NON-PHARMACOLOGICAL MANAGEMENT METHODS FOR PATIENTS ADMITTED TO INTENSIVE CARE UNITS
INTRODUCTION Pain assessment and management for patients admitted to intensive care is a complex healthcare issue. The Behavioural Pain Scale (BPS) and the Critical Care Pain Observation Tool (C-CPOT) are recommended by guidelines as suitable tools for adequately assessing pain in such patients. When it comes to pain management, it may be more beneficial to use pharmacological and non-pharmacological methods synergistically. This study aimed to investigate nurses' approach to pain when caring for critically ill patients who require sedation and/or mechanical ventilation, and who are unable to communicate about pain. METHODS Between August and October 2022, a questionnaire was administered to 260 nurses working in intensive care units in the Sardinia region. The questionnaire consisted of 32 closed and open-ended questions. It investigated the tools used to measure patients' pain, such as behavioural and quantitative scales, and the care interventions used to manage it. The questionnaire was completed anonymously via an online form. Data analysis was performed using Excel®. RESULTS A total of 136 nurses (52.3%) responded to the questionnaire. Of these, 95 were female (69.9%), mainly aged up to 40 years (61.7%), and had worked in intensive care for between two and five years (41.2%). The nurses believed that sedated patients admitted to intensive care experienced pain only sometimes (M = 3.27; 1-5 = Never-Always) and reported that they could recognise patients' pain only sometimes (M = 3.80; 1-5 = Never-Always). Of the nurses, 41.9% (n = 57) stated that they use pain assessment scales during care. However, only 25% of the entire sample (n = 34) reported using the BPS, C-CPOT, or both scales (28 nurses use the BPS, and 11 use the C-CPOT). The remaining 23 nurses only use quantitative scales (VAS - Visual Analogue Scale and NRS - Numerical Rating Scale). Other tools associated with the above include the VRS (Verbal Rating Scale), vital sign monitoring, and observation of behavioural changes. In terms of pain management, 58.8% (n = 80) reported implementing non-pharmacological interventions in addition to those prescribed by a doctor. Physical interventions (n = 51) and creating a comfortable environment (n = 44) were particularly common, as well as providing emotional and cognitive behavioural support. 49.2% of respondents (n = 67) reported experiencing moderate difficulty in managing the pain of their patients (M = 5.6 on a scale of 1-10). Furthermore, they are dissatisfied with the pain assessment and management methods used in their workplace (M = 2.8; 1-5 = Not at all - Very much). They have also proposed some possible strategies for improvement. CONCLUSIONS The results show that the use of behavioural scales to assess pain is still limited and that non-pharmacological pain management could be implemented in the context studied. Nurses report that they need to use non-pharmacological techniques and appropriate pain assessment scales more, but would also like to participate in specific training courses and introduce an operational protocol on pain management.
PROCEDURAL ANALGOSEDATION WITH INTRAVENOUS KETAMINE PERFORMED BY PEDIATRICIANS IN THE PEDIATRIC EMERGENCY DEPARTMENT: THE REGINA MARGHERITA CHILDREN’S HOSPITAL EXPERIENCE
INTRODUCTION Recognizing and managing pain is a key objective in every pediatric Emergency Department (ED). Preventing pain during procedures is equally important, and procedural analgosedation (PAS) is an effective mean of achieving this. Among the drugs used for moderate to deep PAS, ketamine stands out due to its analgesic, sedative, and dissociative properties, while maintaining cardiovascular and respiratory stability. These characteristics make it suitable for use by non-anesthesiologist medical staff, provided they receive appropriate training in its administration and in managing potential side effects1. The aims of this retrospective study are: 1. To describe the training completed by ED pediatricians at the Regina Margherita Children’s Hospital (OIRM) in Turin for the administration of intravenous (IV) ketamine for PAS 2. To analyze the use of ketamine in the pediatric ED in order to identify potential areas for improvement. METHODS The study was conducted in the pediatric ED of OIRM, which treats approximately 40,000 patients annually. Pediatricians at the OIRM ED underwent a structured training program consisting of three 4-hour theoretical and practical sessions, held within the hospital and supervised by an anesthesiologist experienced in PAS. Key topics included drug interactions, monitoring systems, and the assessment of vital function recovery following PAS. During training, pediatricians were mentored by anesthesiologists and progressively gained autonomy in performing IV ketamine PAS. Upon successfully completing a final assessment, they were authorized to independently administer IV ketamine for PAS in the ED, in accordance with the regional protocol “Management of acute and procedural pain in children in out-of-hospital settings, emergency departments, and pediatric units of Piedmont hospitals”. RESULTS Between July 1, 2023, and April 30, 2025, 7 pediatricians completed the training. The training focused on identifying suitable candidates for PAS, understanding the pharmacodynamics and pharmacokinetics of IV ketamine, monitoring and evaluating full recovery post-PAS, and managing potential adverse effects. All participating pediatricians were PALS certified. A total of 24 IV ketamine PAS procedures were performed. All patients were classified as ASA I or II. The mean dosage was 1.4 mg/kg (SD 0.48). In 22 out of 24 cases, ketamine was combined with other sedative or analgesic agents, administered either locally or systemically. Only one mild adverse event (regurgitation) was recorded. Patients were monitored during and after PAS, and the sedation was considered effective in all but one case. However, a standardized sedation scale (Pediatric Sedation State Scale, PSSS) was explicitly documented in only two cases. CONCLUSIONS Ketamine has proven to be a safe and effective agent for PAS when administered by appropriately trained pediatricians. Expanding this training to all ED pediatricians is crucial. PAS implementation should include standardized methods for data collection and consistent use of validated sedation assessment tools2.
PHYSIOTHERAPY TREATMENT OF SPINAL CORD INJURY PAIN: A SCOPING REVIEW
INTRODUCTION Pain - whether nociceptive, neuropathic, or nociplastic - is a key clinical concern in physiotherapy and a major challenge in the management of individuals with spinal cord injury (SCI). In this population, pain may present in diverse forms: neuropathic, reflex, below-level, above-level, as well as paradoxical and dysreflexic responses to nociceptive stimuli. These complex patterns often compromise rehabilitation outcomes and quality of life. Non-pharmacological strategies, particularly physiotherapy, are central in SCI pain management. Physiotherapists play a crucial role within multidisciplinary and interprofessional teams, offering personalized and evidence-based interventions such as therapeutic exercise, neuromodulation, electrotherapy, neurodynamic techniques, hydrotherapy, and manual therapy. Mapping these approaches is essential to guide clinical decision-making and ensure equitable access to effective treatments. This scoping review aims to systematically explore and describe the range, characteristics, and extent of physiotherapy interventions for SCI-related pain, identify gaps in knowledge, and support integrated non-pharmacological pain management strategies. MATERIALS AND METHODS The review was conducted according to the PRISMA-ScR (Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for Scoping Reviews) guidelines. A structured search strategy based on the PIO (Population, Intervention, Outcome) framework was applied. The databases consulted were PubMed, PEDro, and the Cochrane Library. Inclusion criteria comprised studies addressing physiotherapy interventions for pain management in SCI, regardless of study design. Two independent reviewers performed screening and data charting. RESULTS Screening and extraction are ongoing. Preliminary data reveal a wide use of physiotherapy modalities, with therapeutic exercise being the most frequently studied and evidence-supported. Other interventions include electrostimulation, hydrotherapy, neurodynamic mobilization, and manual therapy. The literature reflects heterogeneity in study design, populations, and pain types, highlighting the need for integrated frameworks. CONCLUSIONS Initial findings suggest that physiotherapy offers diverse and promising tools for managing SCI-related pain. Despite heterogeneity, a growing body of evidence supports its clinical relevance. This review will provide a valuable synthesis to inform practice, enhance professional collaboration, and raise awareness of physiotherapy’s role in non-pharmacological pain care. Promoting knowledge of these approaches is crucial to ensure that patients with SCI receive comprehensive, effective, and patient-centered treatment pathways.
PAIN DURING DRESSING CHANGES BASED ON THE ETIOLOGY OF SKIN ULCER
INTRODUCTION Pain associated with chronic skin ulcers, particularly during dressing changes, remains an underestimated issue. In recent decades, medical research has primarily focused on wound healing with the aim of improving the effectiveness of dressings and treatments and reducing the healing time. However, other important patient concerns, such as pain during treatment, have been largely overlooked. The 2004 EWMA Position Document was specifically developed to provide guidelines on how to assess and manage pain during dressing changes for chronic wounds. OBJECTIVE This master's thesis project aims to identify and compare the scientific evidence available in databases regarding this topic and to propose a training program for healthcare personnel, as well as the collection of clinical case data in the future within the Internal Medicine Department of the AOU San Luigi of Orbassano. RESULTS Patients with venous, arterial, mixed vascular lesions, and burns experience the most pain during dressing removal. Surgical wounds, on the other hand, tend to be the least painful. Pain-inducing procedures during dressing changes include touching the wound, cleaning the wound, applying a new dressing, and the waiting time before the procedure begins, which may trigger anticipatory psychological distress due to negative and painful memories of previous dressing changes. DISCUSSION The literature does not contain articles that clearly and significantly differentiate the level of pain between skin lesions of different etiologies. A few articles, although of little statistical value, indicate which types of skin lesions are more painful during dressing removal—findings that have been confirmed in the small clinical data collection conducted on Internal Medicine patients. CONCLUSIONS Nursing staff must be professionally competent, well-trained, and motivated to act in the patient's best interest. Currently, there is a large amount of information, methods, techniques, and materials available to help managing pain during dressing removal, which need to be utilized effectively. One positive outcome of this work has been the learning and training experience it provided to the Internal Medicine nursing team, helping them focus on the pain reported by the patient and the characteristics of the periwound skin when choosing treatments and dressings.
TOWARDS EARLY PERSONALIZED TREATMENT OF LUMBAR DISC HERNIATION: DEVELOPMENT OF A SUPERVISED DEEP LEARNING PREDICTIVE MODEL
BACKGROUND Aside from severe neurological deficits, choosing surgery versus conservative care for lumbar disc herniation (LDH) is poorly supported by current evidence. Randomized trials exclude early-surgery patients, require 6–8 weeks of conservative therapy before enrollment, and suffer high dropout/crossover rates, limiting applicability. Moreover, “conservative treatment” lacks standardization and often conflates acute and chronic presentations. As a result, guidelines defer surgery until 6 weeks–4 months of failed conservative care—potentially extending work disability, raising costs, and heightening pain chronification. PURPOSE To develop and validate a supervised deep learning model that leverages easily obtainable anamnesis data to predict the 6-month clinical outcomes of conservative treatment in patients with lumbar disc herniation. The ultimate goal is to support early clinical decision-making by identifying, at the first evaluation, patients most likely to benefit from conservative management. METHODS Patients with lumbar disc herniation are being prospectively enrolled at the Hospital of Trento, with detailed anamnesis and clinical data collected at baseline. Six months after either conservative treatment or surgery, patients are re-evaluated to determine the Oswestry Disability Index (ODI), which serves as the primary outcome. A supervised deep learning model is constructed using a compact neural network architecture, trained using stratified tenfold cross-validation with cyclical learning rates. Model performance is evaluated both as a continuous ODI prediction and within clinically meaningful score ranges. RESULTS Although data collection is ongoing, the study is designed to evaluate model performance both as a continuous ODI prediction and as a categorical prediction within 5–6 clinically meaningful score ranges. This classification approach aims to enhance interpretability and better reflect real-world decision-making thresholds. Additionally, the model will estimate the expected ODI for each patient under the alternative treatment option, allowing direct comparison between predicted outcomes of surgical and conservative care. CONCLUSIONS Our ongoing study suggests that supervised deep learning can help predict the most appropriate initial therapy for patients with lumbar disc herniation, potentially avoiding unnecessary suffering and delays. Despite a small dataset, promising results are achievable thanks to high-quality data collection, tailored neural network architectures and the efficiency of supervised training. This approach may be extended to other medical fields where decision-making is complex and large datasets are not available.
MUSCULOSKELETAL INFLAMMATORY PAIN MANAGEMENT WITH LOW-DOSE DICLOFENAC AND MICROPEA ASSOCIATION: TWO CASE REPORTS
INTRODUCTION Inflammatory pain management is a common problem representing a clinical challenge. While non-steroidal anti-inflammatory drugs (NSAIDs), such as diclofenac, are widely used, their long-term or high-dose use should be limited due to the risk of dose-dependent side effects1. Protracted pain can lead to exhaustion of palmitoylethanolamide (PEA), an endogenous molecule with anti-inflammatory, analgesic and neuroprotective properties attributable to its ability to modulate mast cells and microglia. Then, PEA administration becomes essential to restore its endogenous levels and body homeostasis2. The association of diclofenac and PEA, particularly in its micronized and ultramicronized (m/umPEA) formulations (microPEA), could represent an innovative strategy for pain relief, combining efficacy and safety. Preliminary preclinical evidence demonstrated that combining microPEA with diclofenac enhanced the analgesic effect of the latter, allowing a reduction of its effective dose3. Here we reported the cases of two patients with musculoskeletal inflammatory pain, treated with the aforementioned association. METHODS A 32-year-old man (case 1) and a 55-year-old woman (case 2) suffering from pain associated with previous shoulder dislocation and tendinopathy respectively, were treated with mPEA 300 mg + umPEA 600 mg (Normast® MPS microgranules) 2 sachets/day in combination with diclofenac prolonged-release tablets, at the low dose of 75 mg/day for 10 days. MicroPEA treatment was then prolonged at the same dosage for another 20 days. Throughout the treatment period, patient 1 was also managed with conservative physical rehabilitation (FKT every other day for 10 sessions) and magnetotherapy, while patient 2 performed exercises independently at home. Pain severity (Numeric Rating Scale, NRS) and blood pressure were self-monitored by patients daily. Patients’ subjective impression and clinician’s opinion about patient’s global improvement were assessed at the end of the treatment through the Patient (PGIC) and Clinical (CGIC) Global Impression of Change. Side effects (especially gastrointestinal and cardiovascular ones) were monitored during the whole observation. RESULTS Both patients reported an evident improvement in pain. Patient 1 experienced a reduction from severe (NRS 10) to mild pain (NRS 2) after diclofenac plus microPEA treatment, further improving to a score of 1 at the end of the observation (Fig 1a). Patient 2 initially reported a slight increase in pain from moderate (NRS 6) to a score of 7 after 10 days, then achieving complete pain relief (NRS 0) at 30 days (Fig 1b). At the end of the treatment, both patients’ global status was described as "extremely improved" by their self-impressions and the clinician’s evaluation. No clinically notable changes in blood pressure were observed, and only patient 2 experienced occasionally mild gastrointestinal events throughout the observation period. CONCLUSIONS The association of microPEA and diclofenac effectively controlled pain, even with low doses of NSAID, minimizing its associated side effects and suggesting a probable synergistic effect. This innovative approach may offer a well-tolerated strategy for managing musculoskeletal inflammatory pain. Further research is needed to fully investigate this promising association. Figure 1. Change in pain intensity over time Case 1 (a) and Case 2 (b).
SIGNIFICANT PAIN RELIEF AND QUALITY OF LIFE IMPROVEMENT IN REFRACTORY CHRONIC MIGRAINE PATIENT TREATED WITH HIGH-FREQUENCY SPINAL CORD STIMULATION
INTRODUCTION A significant number of chronic migraine patients fail conventional medical treatment, becoming highly disabled. High-Frequency 10 kHz Spinal Cord Stimulation (10kHz SCS) have been used as a physical therapy for refractory migraine in a limited number of patients, showing promising results1-4. We report the case study of a young patient with a long history of severe and invalidating migraine treated with cervical 10kHz SCS. METHODS The subject underwent a 2 weeks cervical HF10 SCS trial followed by a permanent system implant as subjective pain reduction was reported during the trial. Two leads were placed at the C1-C2 level. Stimulation parameters included 10-kHz frequency, 30-μs pulse width delivered via bipole, and amplitude range of 0.5 to 3.5 mA. Optimal bipole location and amplitude were adjusted per patient feedback. At permanent implantation, a second program was added for neck and shoulder pain and patient was instructed to activate it as needed. RESULTS The patient is a 43 years old woman with a familiarity for headache and chronic migraine since the age of 8. Migraine was diagnosed as without aura but episodes with aura were present as the condition progressed in recent years. The subject had undergone several multi pharmacological conventional treatments with limited relief, and Greater Occipital and Peripheral Occipital Nerve Block, Greater Occipital and Peripheral Bilateral Pulsed Radiofrequency with no benefit. At the time of SCS implantation, the patient was treated with monoclonal antibody galcanezumab, therapeutic cannabis, venlafaxine, pregabalin, delorazepam, estrogen-progestin, and ibuprofen. Pain manifested daily as a continuous pain, flaking frequently as invalidating events (up to 14 per month) with pulsing unilateral periorbital or occipital-nape pain associated with photophobia, phonophobia, nausea, vomit, tinnitus, and vertigo. After a month of neurostimulation with 10kHz SCS, the patient self-reports a 50% pain relief with no change in medication regime. The patient declares an improvement in quality of life and less time spent bed-ridden. While a continuous headache is still present, the intensity is reduced compared to pre-implantation. CONCLUSIONS Neurostimulation with cervical 10kHz SCS can be a safe and effective therapeutic option for chronic migraine refractory to conventional pharmacological and physical treatments.
CHALLENGING THE FLARE: CENTRAL AND PERIPHERAL NERVE BLOCK AS AN ACUTE INTERVENTION IN PEDIATRIC ERYTHROMELALGIA
Erythromelalgia (EM) is a rare and debilitating syndrome characterized by episodes of burning pain, erythema, and warmth, affecting the distal extremities. Attacks are precipitated by heat or exertion and relieved by cooling. EM may be classified as primary, most often linked to SCN9A mutations, or secondary to systemic conditions, mostly myeloproliferative diseases. The pathophysiology involves hyperexcitable nociceptive neurons and vasomotor dysregulation due to sympathetic hypoactivity. Diagnosis is clinical, based on the characteristic symptoms. Treatment remains challenging: there is no curative approach, and pharmacologic therapies yield inconsistent results. In particular, acute episodes resistant to conventional pain management demand alternative strategies. Despite the pathophysiological rationale, there is scarce literature addressing procedural interventions like central and peripheral nerve blocks (PNBs), especially in the pediatric population. Nerve blocks directly inhibit nociceptor transmission and can interrupt the pain-autonomic feedback loop contributing to symptom perpetuation. We present the case of a 17-year-old boy with first-onset primary EM, unresponsive to standard analgesia and adjuvant medications. His clinical course was marked by progressive, unremitting pain in all four limbs, associated with cutaneous hyperemia, edema over the course of forty days. Diagnostic investigations were unremarkable, and multiple therapeutic attempts failed, therefore he was subsequently referred to our center. The patient arrived to our attention in disabling conditions, unable to walk, with a significant degree of weight loss (10 kg), in profound psychological distress, including insomnia and anti-conservative ideation. He was already in therapy with tapentadol, gabapentin and mexiletine. Given the severity and refractoriness of symptoms, an early procedural approach was adopted. Bilateral upper limb PNBs (median, ulnar, radial nerves) with perineural catheter placement were performed, along with the insertion of an intradural catheter at L2–L3. Continuous infusion of levobupivacaine (0.25% for upper limbs, 0.125% for lower limbs) was initiated, accompanied by low-dose clonidine sedation giving immediate pain relief. Within 36 hours there was complete resolution of pain and dysautonomic symptoms (hyperemia and edema). A multimodal therapy was introduced, including fluoxetine, gabapentin, mexiletine, physiotherapy, and hypnosis. The patient was followed by an interdisciplinary team, including anesthesiologists, pediatricians, nurses, psychologists and psychomotricists. His recovery was gradual but consistent, with restoration of function within two weeks and by the third week he was discharged. This case underscores the potential role of peripheral nerve block as a safe and effective first-line intervention at the onset of EM in pediatric patients. When administered early, it may abort the vicious cycle of neurogenic inflammation, nociceptor sensitization, and psychological suffering. We advocate for further investigation and consensus on procedural pain control in EM to guide early and effective management strategies.
EFFECTIVENESS OF REIKI IN PAIN MANAGEMENT IN PEDIATRIC PATIENTS UNDERGOING HEMATOPOIETIC STEM CELL TRANSPLANTATION
BACKGROUND Reiki, recognized by the WHO among complementary treatments, supports and integrates conventional therapy in various hospital settings. Studies have confirmed the positive results produced by Reiki in terms of psychophysical well-being in adult patients suffering from oncological pathologies, while the literature regarding the pediatric oncology population is currently scarce. OBJECTIVES This study intends to evaluate the feasibility and effectiveness of Reiki in providing pain relief among pediatric patients undergoing hematopoietic stem cell transplant hospitalized in the Pediatric Oncohematology Department. METHODS This pilot study enrolled pediatric patients undergoing hematopoietic stem cell transplantation to examine the impact of Reiki on pain. The changes in pain at different times were analyzed: during the Reiki session, before and after the session, and on the day of the session compared to a day of rest. RESULTS The pilot study analyzed 88 Reiki sessions conducted with nine patients. The results indicate a significant decrease in pain in the short and medium term with a sustained effect in the long term. CONCLUSIONS This study investigates the application of Reiki as a supportive intervention for pediatric patients during hematopoietic stem cell transplantation. Preliminary results suggest that the integration of Reiki into clinical practice, administered by trained pediatric nurses, may promote well-being and alleviate suffering in children with cancer.
PORTABLE PERCUTANOUS ELECTRODE NERVE STIMULATION AS A HOME-BASED THERAPY FOR TRIGEMINAL NEURALGIA, A CASE REPORT
INTRODUCTION Trigeminal neuralgia is a painful condition characterized by intense and recurrent episodes of facial pain. Various therapeutic options have been explored, including Percutaneous Electrical Nerve Stimulation (PENS) at the emergence points of the affected branches of the trigeminal nerve. The possibility of performing the treatment at home using PENS devices allows for long-term, non-invasive pain management with few or no side effects. MATERIALS AND METHODS A 67-year-old woman presented for consultation due to a severe neuralgia experienced in the second and third branches of the trigeminal nerve scoring her pain as a NRS 6/10. Her medical history includes depression under treatment with mirtazapine 15 mg/day. In 2006, she underwent extraction of an impacted upper right third molar and one month after she developed neuralgia in the maxillary and mandibula branches on the right side. In 2016, she underwent microvascular decompression for marked neurovascular conflict, which resolved the symptoms but left a burning sensation exacerbated by chewing, oral hygiene, and speech. Maxillofacial evaluation did not reveal any pathological conditions explaining this symptomatology. Pharmacological management attempts over the years were unsuccessful due to persistence of symptoms or significant side effects from medications (pregabalin, carbamazepine, duloxetine). Two trials of pulsed radiofrequency (PRF) on the emergence of the trigeminal nerve were carried out (2020 and 2023) achieving about 60% of pain relief each time but symptoms gradually recurred in the following months. An adjunctive therapy was prescribed, including B-group vitamins, alpha-lipoic acid, and Palmitoylethanolamide (PEA). In January 2025 follow-up visit, patient reported persistent neuropathy and difficulties with speech and chewing, despite the absence of pain paroxysms. Medical therapy with duloxetine 30 mg was started, and the patient underwent a PENS session with percutaneous electrode arrays (Biowave PENS Monopolar), initially at the right cheekbone (with paresthesias appearing at 8% intensity and increasing to 27%) and then at the right mental region (paresthesias starting at 6% and gradually increasing to 25%). RESULTS During follow-up visit in March 2025, the patient reported a clear clinical benefit, with about 80% pain relief within the first ten days after the PENS session and almost complete disappearance of paresthesias in the trigeminal nerve territory. She repeated the treatment in April 2025 in our centre and she was advised to continue medical therapy with duloxetine 30 mg/day. Due to the efficacy of PENS treatment on her pain management she continues to perform cyclic PENS treatments at home with the portable PENS device with benefits, now scoring pain as a NRS 1/10. CONCLUSIONS PENS can become a key non-invasive treatment of refractory trigeminal neuralgias unresponsive to medication and invasive procedures and the possibility to undergo this treatment at home by using PENS portable device makes it a valid tool in the long-term management of this painful condition.
USE OF COOLED RADIOFREQUENCY IN ULTRASOUND‑GUIDED NEUROABLATION OF SENSORY ARTICULAR BRANCHES OF THE SHOULDER: A PRELIMINARY STUDY
INTRODUCTION Pulsed and/or thermal radiofrequency (RF) is used to treat chronic shoulder pain, with results that are sometimes inconsistent1. Recent anatomical studies have determined the precise location of the articular branches of the main nerves innervating the joint capsule: suprascapular, lateral pectoral, and axillary nerves. Cooled radiofrequency is a neuroablative treatment modality that has proven effective in various anatomical sites. Targeting these nerves, combined with the larger lesion size, may lead to a longer-lasting pain relief2. The aim of this study is to evaluate the effectiveness of ultrasound-guided cooled radiofrequency for the treatment of chronic shoulder pain. METHODS We conducted a retrospective study. All patients aged between 18 and 90 who provided informed consent, underwent a positive diagnostic block, and subsequently received cooled radiofrequency treatment of the suprascapular, lateral pectoral, and axillary nerves under ultrasound guidance for chronic shoulder pain. The treatments were performed between 04/2024 and 11/ 2024 at Bellaria Hospital in Bologna. Demographic data were collected, and pain and quality of life were assessed using the Numerical Rating Scale (NRS) and the Brief Pain Inventory (BPI) questionnaire, respectively, at baseline (T0) and at 1, 3, and 6 months post-procedure. Quantitative variables were expressed as mean and standard deviation after checking for normal distribution using the Shapiro-Wilk test. A Linear Mixed Model for repeated measures was used to evaluate the trend of the outcomes over time, as well as the change in outcomes. In each model, the timepoints were considered fixed effects, while the patients were treated as random effects. RESULTS Eight patients were included in the study group. The mean age was 76 ± 6.3 years, and 87.5% of the participants were female. Table 1 describes the trends of mean NRS, BPI Pain, and BPI Quality of Life over time. The Linear Mixed Model for repeated measures showed a statistically significant reduction in mean NRS (p = 0.002), BPI Pain (p < 0.001), and BPI Quality of Life (p = 0.003). However, no statistically significant differences were observed when comparing the reductions in outcome values at 1 month, 3 months, and 6 months from baseline. CONCLUSIONS Despite the limitations related to the small sample size, ultrasound-guided cooled radiofrequency ablation of the articular branches of the suprascapular, axillary, and lateral pectoral nerves results in a significant and lasting reduction in pain, as well as a significant improvement in quality of life in patients suffering from chronic shoulder pain. To date, the treatment of these nerves has been validated in the literature using radiographic or mixed imaging techniques2,3. Further data collection standardized by nerve target, type of neuroablation, and follow-up duration beyond 6 months will be necessary to validate the long-term pain relief achieved by this technique.
EFFICACY OF MULTIMODAL OZONE THERAPY IN PATIENT WITH ANKYLOSING SPONDYLITIS: CASE STUDY
INTRODUCTION Ankylosing spondylitis is a chronic inflammatory disease that primarily affects the sacroiliac joints and the spine, leading to stiffness, pain, and functional limitation. The rationale for multimodal ozone therapy includes: GAET, topical application of a rechargeable biodynamic and transdermal tape with gradual release of Ozoile (stable ozonides), and infiltrative ozone therapy. The protocol is proposed to modulate inflammation, control pain, and improve quality of life. Case Presentation: A 48-year-old patient with ankylosing spondylitis came to our for poorly controlled pain, insomnia, confusional state, and hallucinations. The patient had been on Methotrexate and Fentanyl TTS 50 µg/h for 2 years. Due to insufficient analgesic response and adverse effects, an integrated treatment plan was initiated with multimodal ozone therapy and equianalgesic transdermal buprenorphine (70 µg/h). The objective of this study is to highlight the specific analgesic action of multimodal ozone therapy, considering the high baseline pain levels and disease impact1. MATERIALS AND METHODS Outcomes evaluated: Pain (VAS), physical function (BASFY index), sleep quality and side effects were monitored through structured clinical interviews. Clinical controls were evaluated weekly for 60 days. Treatment protocol: • GAET: 1 session/week, 100 ml of ozone at 25 µg/ml in 100 ml of blood (1st session), 30 µg/ml (subsequent sessions); • Transdermal tape: 2 applications/week of rechargeable taping with microcells for gradual release of Ozoile; • Ozone infiltrations: 1 infiltration/week in the lumbosacral region (12 µg) RESULTS VAS score dropped from 8 to 6 after the first session, and progressively to 2. Insomnia, confusion, and hallucinations resolved. BASFI improved from 120 to 50. CONCLUSIONS Improvements in reduction of pain, sleep quality, and resolution of the confusional state and hallucinations, occurred in close temporal correlation with the start of treatment. GAET decreased disease activity1 and acted by modulating systemic inflammation and oxidative stress without any side effects. The application of Ozoile-based patches contributed to a prolonged local analgesic effect, improving peripheral symptoms and subjective pain perception. Ozone infiltrations provided a targeted anti-inflammatory and analgesic effect at the site of maximum pathological activity2. Furthermore, the combination of multimodal ozone therapy with buprenorphine TTS produced a synergistic effect, enhancing pain control, considering that, at the same equianalgesic dose, buprenorphine, as a partial agonist of µ-opioid receptors, has lower analgesic efficacy compared to fentanyl, which acts as a full agonist and is more potent in terms of pain relief3. Therefore, in the described case, multimodal ozone therapy performed an anti-inflammatory action and contributed to a significant attenuation of painful symptoms and an improvement in the patient's quality of life.
ITALIAN VALIDATION OF THE PEDIATRIC NURSES’ KNOWLEDGE AND ATTITUDES SURVEY REGARDING PAIN: A CROSS-SECTIONAL STUDY
INTRODUCTION Pediatric pain management remains a critical issue in clinical practice, with underassessment and suboptimal management frequently reported, often due to healthcare providers' limited knowledge and cultural misconceptions. This leads to long-term physical, emotional, and psychological consequences. In Italy, no validated tool currently exists to systematically assess nurses’ knowledge and attitudes regarding pediatric pain. This study aimed to translate, culturally adapt and validate the Italian version of the PNKAS, revised by Riemann et al. (2007), applicable to nurses who care for pediatric patients not only in the oncology setting. METHODS The study followed ISPOR guidelines (Wild et al., 2005) for the linguistic and cultural validation process. A cross-sectional multicenter validation study was then conducted with a convenience sample of 298 Italian registered nurses working in pediatric settings. Psychometric analyses included item difficulty, internal consistency, Confirmatory Factor Analysis (CFA), and test-retest reliability using Intraclass Correlation Coefficients (ICC). RESULTS The Italian version PNKAS demonstrated good psychometric properties. Internal consistency reached a satisfactory level (Cronbach’s α = 0.728) and test-retest reliability showed high stability (r = 0.712; ICC = 0.801). CFA supported a three-factor model (assessment, treatment, epidemiology), with strong fit indices (CFI = 0.92; TLI = 0.91; RMSEA = 0.06). The scale demonstrated good item coherence (Infit/Outfit MnSq between 0.85–1.35) with difficulty ranging from −2.64 to 2.51. Despite this, the proportion of correct answers was 59.8%, with no respondent scoring ≥80%. Items related to pharmacology and pain assessment were particularly challenging. Notably, pediatric specialization was associated with higher scores compared to general nursing education or years of experience alone. CONCLUSIONS The Italian PNKAS is a valid and reliable tool to evaluate pediatric pain management knowledge and attitudes among Italian nurses. Findings underscore significant educational gaps, particularly in pharmacologic management and objective assessment of pediatric pain, highlighting the urgent need for targeted training and continuous professional development.