Traditional approaches of patient education often face barriers like limited time, access, resources and language barrier. Patient queries are often left incompletely answered in busy outpatient clinics. Artificial intelligence (AI) tools present promising opportunities to address these gaps. Few studies have explored the use of AI chatbots in patient. We developed an innovative interactive multilingual avatar to educate and empower patients about chronic pain, called Virtual Pain Companion Avatar (ViPaC). Patients can interact with the avatar in the real time, to obtain evidence based information in simple language of their choice.

A formal ethics committee approval was not required since this was validation of an AI generated tool, no clinical procedures were performed, and no patient interaction occurred in the study. This content validity study was conducted was conducted from April 2025 June 2025. The avatar was developed using an AI tool HeyGen.com by way of structured bprompt engineering. The knowledge base included evidence based literature on chronic pain, its management through pharmacological and non-pharmacological means. The avatar of a senior doctor was chosen and was prompted to have warm, professional empathetic tone and to communicate politely with the user in simple language without complex medical terminology. Resultant avatar: The resultant avatar can be accessed using this easy link- https://labs.heygen.com/interactive-avatar/share?share=eyJxdWFsaXR5IjoiaGlnaCIsImF2YXRhck5hbWUiOiJEZXh0ZXJfRG9jdG9yX1N0YW5kaW5nMl9w%0D%0AdWJsaWMiLCJwcmV2aWV3SW1nIjoiaHR0cHM6Ly9maWxlczIuaGV5Z2VuLmFpL2F2YXRhci92My84%0D%0AOGQ0MjFmOTM5MDQ0YmIwOGQ4OTJlODMzOTMxOTQ4Yl80NTU5MC9wcmV2aWV3X3RhbGtfMS53ZWJw%0D%0AIiwibmVlZFJlbW92ZUJhY2tncm91bmQiOmZhbHNlLCJrbm93bGVkZ2VCYXNlSWQiOiI4MWRlOWNh%0D%0AOWNjM2I0OGEzYjhhYjgzZDBmODk3OTdlNCIsInVzZXJuYW1lIjoiY2FlZmVlYTMzNWEzNDlmYTgx%0D%0AN2M5ZTRmZDNmMDVmZDMifQ%3D%3D Heygen supports communication in 28 different languages. These were verified by the authors using Google Translate application. Ten anaesthesiologists with a minimum of five years of clinical experience in management of acute and chronic pain were recruited to evaluate the ViPaC system across multiple domains relevant to chronic pain care. Each expert individually interacted with VIPAC, then rated the avatar's responses across four critical domains using a four-point Likert scale (1=Poor, 2=Fair, 3=Good, 4=Excellent). The domains were Clinical Accuracy, Language Simplicity, Educational Value and Empathy. Content validity was assessed using the Content Validity Index (CVI) methodology.13 Item-level CVI (I-CVI) and Scale-level CVI (S-CVI) were computed.

The avatar demonstrated strong consensus across all assessed domains. Eight of ten experts rated the avatar's medical information as good to excellent, while two experts provided fair ratings, indicating generally strong agreement regarding the clinical accuracy. All experts agreed that VIPAC effectively conveyed relevant health education information appropriate for chronic pain patients, with eight experts rating it as good and two as excellent. Nine of ten experts rated the avatar's empathetic responsiveness as acceptable or better, suggesting effective emotional support capabilities. Language Simplicity achieved good validity. This high S-CVI (0.88) indicates strong expert consensus that ViPaC demonstrates appropriate content validity across all evaluated domains.

This study provides strong evidence supporting ViPaC's appropriateness as a patient educational tool for patients living with chronic pain

Post-traumatic pain remains a major challenge in patients with complex wounds, particularly in combat-related injuries. While infection is a well-recognised factor impairing wound healing, its role in pain amplification and transition to chronic and neuropathic pain is insufficiently understood. To evaluate the association between wound infection characteristics and the severity and phenotype of post-traumatic pain.

A prospective observational study included 212 patients with combat-related traumatic wounds. Clinical assessment of infection was based on standard criteria, including local inflammatory signs and exudate characteristics. Microbiological analysis was performed to identify pathogen profiles. Pain intensity was assessed using the Numeric Rating Scale (NRS), and neuropathic pain was evaluated using the DN4 questionnaire. Statistical analysis included correlation testing and multivariate regression to identify independent predictors of pain outcomes.

Infection was identified in approximately 40% of patients and was significantly associated with increased pain severity. Mean pain intensity was higher in infected wounds compared to non-infected wounds (5.9 ± 1.6 vs 3.4 ± 1.5, p < 0.001). Neuropathic pain (DN4 ≥4) was more frequent in patients with infection (48% vs 21%, p = 0.002). Infection severity correlated with both NRS (r = 0.41, p < 0.001) and DN4 scores (r = 0.36, p < 0.001). Multivariate analysis identified infection as an independent predictor of neuropathic pain (OR 2.8, 95% CI 1.5–5.2, p = 0.002), along with mixed microbiota (OR 3.1, p = 0.001) and purulent exudate (OR 2.3, p = 0.01). Gram-negative bacterial profiles and antimicrobial resistance were associated with higher pain scores and increased neuropathic features.

Wound infection is a significant and independent driver of post-traumatic pain, including neuropathic pain. These findings highlight the importance of early identification and targeted management of infection as a potential strategy to reduce pain chronification and improve outcomes in trauma patients.

Post-mastectomy pain syndrome (PMPS) affects 20-68% of breast cancer patients undergoing mastectomy, with most studies reporting prevalence between 36-44%. While repetitive transcranial magnetic stimulation (rTMS) modulates pain-processing cortical circuits through effects on motor cortex, dorsolateral prefrontal cortex (DLPFC), and descending inhibitory pathways, its prophylactic potential in preventing PMPS remains unexplored.The primary objective was to assess the effect of preoperative rTMS on PMPS incidence using the Short Form McGill Pain Questionnaire (SF-MPQ) at 3-month follow-up. Secondary objectives included 24-hour postoperative opioid consumption and postoperative pain intensity using the Numeric Pain Rating Scale (NRS).

This single-center, double-blind RCT enrolled 60 adult females undergoing elective unilateral breast surgery, randomized 1:1 to active rTMS (n=30) or sham (n=30). The intervention comprised five daily preoperative sessions of 1-Hz rTMS targeting the right dorsolateral prefrontal cortex, administered within seven days before surgery.

55 patients completed follow-up (per-protocol analysis: rTMS n=29, Sham n=26). At 3-month follow-up, the rTMS group demonstrated significantly lower SF-MPQ scores (5.83 ± 2.02 vs. 7.92 ± 2.33; mean difference −2.09, 95% CI −3.28 to −0.90; p=0.0008; Cohen's d=−0.965, large effect). Quality of life was markedly better in the rTMS group (EQ-5D-5L: 0.882 ± 0.050 vs. 0.80 ± 0.09; mean difference +0.082, 95% CI 0.04 to 0.12; p=0.0001; d=+1.113, large effect)16,17. The EQ-5D-5L improvement (Δ=+0.153) exceeded the established Minimal Clinically Important Difference (MCID = 0.037) by 4.1-fold. Twenty-four-hour postoperative morphine consumption was approximately 50% lower in the rTMS group (2.40 ± 0.56 mg vs. 4.77 ± 0.97 mg; mean difference −2.37 mg, 95% CI −2.81 to −1.93; p<0.0001; d=−2.981, very large effect). NRS pain scores were significantly lower at 24 hours (4.93 ± 2.77 vs. 6.90 ± 2.20; mean difference −1.97, 95% CI −3.32 to −0.62; p=0.0035; d=−0.776, large effect) and at 3 months (1.10 ± 0.62 vs. 2.23 ± 1.27; mean difference −1.13, 95% CI −1.69 to −0.57; p=0.0003; d=−1.146, very large effect).

Preoperative rTMS is a safe, non-invasive neuromodulatory intervention that significantly reduces post-mastectomy pain at 3 months while attenuating acute postoperative pain intensity and opioid consumption, with concurrent improvement in quality of life. This trial demonstrates that targeted preoperative neuromodulation can prevent rather than merely treat PMPS, fundamentally shifting the management paradigm from reactive palliation to pre-emptive prophylaxis.

Pain in pediatric oncology is multifactorial, arising from tumor burden, diagnostic procedures, and treatment-related interventions. Approximately 70% of children with cancer experience moderate to severe pain during their disease course, particularly in advanced stages. Opioids remain the cornerstone of cancer pain management; however, their use is associated with significant adverse effects, including sedation, constipation, nausea, tolerance, and potential for hyperalgesia. These limitations have led to increasing interest in multimodal and opioid-sparing strategies. Interventional pain techniques, including peripheral nerve blocks and neuraxial analgesia, offer targeted approaches by interrupting nociceptive pathways or delivering analgesics directly to spinal receptors. Advances in ultrasound-guided regional anesthesia have improved precision, safety, and feasibility in pediatric populations. Despite these advances, the role of interventional techniques in pediatric oncology remains poorly defined due to limited high-quality evidence and reliance on adult data extrapolation. This review aims to evaluate current literature and identify key gaps in knowledge.

A PRISMA-informed narrative review was conducted. PubMed and Scopus databases were searched for studies published between January 2015 and March 2025. Search Strategy Keywords included: pediatric oncology, cancer pain, regional anesthesia, nerve block, epidural, intrathecal, interventional pain. Inclusion Criteria • Pediatric patients (≤18 years) • Oncology-related pain • Interventional pain techniques • Reviews, observational studies, case series Exclusion Criteria • Adult-only studies • Non-English publications • Non-interventional pain management studies A total of 132 records were identified. After screening and eligibility assessment, 25 studies were included.

The final analysis included 25 studies comprising narrative reviews, observational studies, and case series. The evidence base was dominated by low- to moderate-quality studies, with limited prospective data. Peripheral nerve blocks provide site-specific analgesia by interrupting nociceptive transmission. They are particularly useful in: • Postoperative pain management • Tumor-related localized pain • Palliative care settings Available evidence suggests that peripheral nerve blocks reduce opioid requirements and improve pain scores. Continuous catheter techniques have demonstrated sustained analgesia in both perioperative and end-of-life contexts. Ultrasound guidance has significantly improved safety and accuracy. However, most data are derived from small observational studies and case reports, limiting generalizability. Neuraxial analgesia, including epidural, caudal and intrathecal techniques, provides potent analgesia through direct action on spinal nociceptive pathways. These techniques are particularly useful in: • Extensive tumor-related pain • Refractory cancer pain • Major surgical procedures Evidence suggests improved analgesia and reduced systemic opioid exposure. However, their use is limited by concerns regarding infection risk, thrombocytopenia, and technical complexity in pediatric oncology patients. Safety is a major consideration in pediatric oncology. Immunosuppression and thrombocytopenia increase the risk of complications such as infection and bleeding. While large pediatric regional anesthesia datasets suggest low complication rates, oncology-specific safety data remain limited. Careful patient selection, adherence to anticoagulation guidelines, and multidisciplinary coordination are essential. Emerging Techniques Emerging modalities such as cryoneurolysis, interventional radiology-guided procedures, and advanced fascial plane blocks represent promising future directions. These techniques may expand the role of interventional pain management in refractory pediatric cancer pain.

Interventional pain techniques, including peripheral nerve blocks and neuraxial analgesia, represent promising but underutilized tools in pediatric oncology pain management. They provide targeted, opioid-sparing analgesia, particularly in postoperative and palliative settings. However, their broader implementation is limited by insufficient pediatric-specific evidence and reliance on extrapolated adult data. Future progress depends on well-designed prospective studies, standardized protocols, and pediatric-focused research to define their optimal role within multidisciplinary pain management pathways.

Pain interventions for low back pain are widely performed globally and are generally regarded as low-risk interventions. Despite this, complication rates and terminology in the literature vary significantly with heterogeneous safety data. While catastrophic complications are agreed to be rare, there is ongoing uncertainty regarding how such adverse events are defined, reported, and in turn communicated to patients. This lack of consistency limits discussions around risk and affects the meaningfulness of the shared decision process with patients. This study explores the variation in clinicians’ perceptions of complications, consent and safety processes for commonly performed low back pain interventions in the United Kingdom.

We conducted a cross-sectional electronic survey administered via the Faculty of Pain Medicine and PainTrain -a trainee-led research group-, to clinicians working in pain settings across community, secondary, tertiary and quaternary care within the National Health Service (NHS). We surveyed clinician experience, institutional setting, imaging modality, monitoring, sedation and practice patterns for low back pain interventions including: interlaminar, transforaminal, and caudal epidural injections; intra-articular facet and sacroiliac joint injections; medial branch blocks; and radiofrequency ablation of medial branch and sacroiliac joint lateral branches. In addition, respondents were asked to classify 23 predefined complications (categorised by clinical severity) as either: expected, not a complication, minor, or major. Additional questions explored which complications were routinely discussed during consent, temporal relationships for complications, and access to formal safety and reporting systems.

A total of 132 responses were analysed. Responses were predominantly from consultant level pain physicians (>90%), with approximately 65% reporting more than five years of independent procedural practice. Waiting times from consent to intervention were prolonged, with around 60% reporting delays of ≥6 months and 24% exceeding 12 months. Fluoroscopy was available in >95% of centres and was the primary imaging modality for all procedures. Although ultrasound was available in over half of services, fewer than 20% used it for lumbar procedures such as sacroiliac joint injections or radiofrequency ablation. On average, monitoring practices varied significantly: full AAGBI monitoring (blood pressure, SpO₂ and ECG) was reported by 45%, SpO₂ alone in 30%, and no routine monitoring in 25% of practitioners. Substantial heterogeneity was observed in the classification of complications across respondents. Vasovagal symptoms were categorised inconsistently: dizziness was considered “not a complication” by 26%, an “expected event” by 16%, and a “minor complication” by 58%. Hypotension and transient loss of consciousness related to vasovagal episodes were also variably classified, with transient syncope frequently labelled a “major complication” despite likely representing part of the same physiological spectrum. Marked variation was also seen in the interpretation of neurological symptoms. Transient neurological symptoms lasting <24 hours were classified as “not a complication” by 12%, “expected” by 29%, and a “minor complication” by 53%. When symptoms persisted for 24 hours to 7 days, 57% considered them a minor complication and 35% a major complication. Symptoms lasting >7 days were more consistently regarded as serious, with 79% classifying them as a major complication. Other commonly encountered adverse events were similarly discordant. Dural puncture without headache was considered “not a complication” by 16%, a minor complication by 67%, and a major complication by 13%. Post-dural puncture headache was evenly divided, with 50% classifying it as minor and 50% as major. Intravascular injection without clinical sequelae was considered a minor complication by 41% and a major complication by 47%. Post-procedural pain exacerbation was viewed as “not a complication” by 15%, “expected” by 63%, and a minor complication by 22%. Deep haematoma was classified as a minor complication by 26% and a major complication by 69%, while infection at the injection site was considered minor by 56% and major by 36%. In contrast, there was strong consensus regarding catastrophic complications. Permanent neurological injury, local anaesthetic systemic toxicity, epidural haematoma, deep infection, visceral injury, anaphylaxis, and wrong-site procedures were classified as major complications by >90% of respondents. (Image 1) However, this agreement was not consistently reflected in consent practice. Nearly 40% of respondents reported that they did not routinely discuss the majority of these major but rare complications during the consent process. (Image 2) On average, temporal relationships for new symptoms varied widely, from ≤48 hours (29%) to 1-2 weeks (55%), influencing whether delayed events were considered procedure-related and risking unattributed delayed harm (image 3). Additionally, 7% of respondents reported not routinely using a formal WHO safety checklist.

This national survey demonstrates that heterogeneity in reported complication rates for low back pain interventions arises not only from procedural risk, but from an individual and system-level variability on how complications are defined, classified, attributed, and communicated. It also shows that while clinicians show strong agreement regarding the severity of catastrophic complications, these risks are frequently not communicated to patients during consent, and non-catastrophic events remain inconsistently classified and recorded, leading to significant variation in interventional pain practice in the UK. This lack of standardisation undermines reliable risk estimation, limits comparison between services, and sheds inconsistencies during shared decision-making with patients. A national prospective safety study is required to inform future standardised complication framework and procedure-specific consent guidelines. This will invariably lead to improvements in shared decision-making patient education, and clinical governance in low back pain interventions.

Healthcare contributes significantly to global carbon emissions, with patient travel representing a substantial proportion of outpatient-related emissions. Telemedicine has consistently been shown to reduce healthcare-associated carbon emissions by reducing travel, with reported savings ranging from 0.7 to 372 kg CO₂e per consultation depending on context. In pain medicine, where many follow-up consultations are suitable for remote review, virtual clinics may offer a sustainable alternative to traditional face-to-face appointments. This study aimed to evaluate the impact of introducing virtual clinics on patient travel distance, carbon emissions, and travel time within a pain medicine service.

A prospective service evaluation was conducted following the introduction of virtual clinics in a pain medicine service. Data were collected for patients scheduled for appointments between 7/4/26 and 28/4/26. Variables included patient eircode, estimated travel distance avoided, associated carbon emissions using the Sustainable Energy Authority of Ireland conversion factor (0.171 kg CO₂/km), and estimated travel times based on Google Maps live traffic data.

One hundred patients were included in the evaluation. Virtual clinics avoided a total travel distance of 6,179.8 km, averaging 61.8 km per consultation. This corresponded to an estimated reduction of 1,057 kg CO₂e, equivalent to the annual CO₂ absorption of approximately 22–106 mature trees. Average emissions saved per patient were 10.8 kg CO₂e. Total patient travel time saved was 95 hours, averaging 57 minutes per consultation.

Virtual clinics significantly reduced patient travel distance, carbon emissions, and travel time within a pain medicine service. Virtual care represents a practical and scalable approach to reducing the environmental impact of healthcare while maintaining patient-centred care.

Painful diabetic neuropathy is heterogeneous, and treatment response may vary by sensory phenotype. We systematically reviewed intravenous lidocaine for painful diabetic neuropathy, focusing on analgesic efficacy, durability, safety, and responder phenotypes.

A PRISMA-compliant systematic review was conducted using MEDLINE, Embase, Web of Science, ClinicalTrials.gov, and the EU Clinical Trials Register. Randomized and observational studies evaluating intravenous lidocaine/lignocaine in adults with painful diabetic neuropathy were included. Because of substantial heterogeneity in study design, pain measures, follow-up duration, and responder definitions, results were synthesized narratively by time window and phenotype findings.

Four studies were included: three randomized double-blind placebo-controlled crossover trials and one open-label observational cohort. Lidocaine demonstrated its clearest comparative analgesic signal immediately after infusion, with greater 60–120-minute pain reduction versus placebo in Todorovic et al., and short-term benefit over days 1–8 in Kastrup et al. Longer-duration benefit was less consistent. Viola et al. reported improvement to 28 days in a responder-enriched cohort, while Wilkinson et al. reported mean benefit lasting 6.83 weeks among responders without a comparator arm. Phenotype analyses suggested that response may be more likely in patients with preserved or hyperexcitable sensory function, including irritable nociceptor phenotype, dynamic mechanical allodynia, increased wind-up ratio, and less abnormal cold detection thresholds; however, baseline QST measures did not reliably predict response in the placebo-controlled trial. Adverse events were generally mild-to-moderate.

Intravenous lidocaine may provide rapid, variably durable analgesia in selected patients with painful diabetic neuropathy. Phenotype-guided treatment selection is promising but remains unvalidated.