SummaryPeripheral tissue damage or nerve injury often leads to pathological pain processes, such as spontaneous pain, hyperalgesia and allodynia, that persist for years or decades after all possible tissue healing has occurred. Although peripheral neural mechanisms, such as nociceptor sensitization and neuroma formation, contribute to these pathological pain processes, recent evidence indicates that changes in central neural function may also playa significant role. In this review, we examine the clinical and experimental evidence which points to a contribution of central neural plasticity to the development of pathological pain. We also assess the physiological, biochemical, cellular and molecular mechanisms that underlie plasticity induced in the central nervous system (eNS) in response to noxious peripheral stimulation. Finally, we examine theories which have been proposed to explain how injury or noxious stimulation lead to alterations in eNS function which influence subsequent pain experience.

Most patients who undergo surgery recover uneventfully and resume their normal daily activities within weeks. Nevertheless, chronic postsurgical pain develops in an alarming proportion of patients. The prevailing approach of focusing on established chronic pain implicitly assumes that information generated during the acute injury phase is not important to the subsequent development of chronic pain. However, a rarely appreciated fact is that every chronic pain was once acute. Here, we argue that a focus on the transition from acute to chronic pain may reveal important cues that will help us to predict who will go on to develop chronic pain and who will not. Unlike other injuries, surgery presents a unique set of circumstances in which the precise timing of the physical insult and ensuing pain are known in advance. This provides an opportunity, before surgery, to identify the risk factors and protective factors that predict the course of recovery. In this paper, the epidemiology of chronic postsurgical pain is reviewed. The surgical, psychosocial, socio-environmental and patient-related factors that appear to confer a greater risk of developing chronic postsurgical pain are described. The genetics of chronic postsurgical pain are discussed with emphasis on known polymorphisms in human genes associated with chronic pain, genetic studies of rodent models of pain involving surgical approaches, the importance of developing accurate human chronic postsurgical pain phenotypes and the expected gains for chronic postsurgical pain medicine in the post-genomic era. Evidence is then reviewed for a preventive multimodal analgesic approach to surgery. While there is some evidence that chronic postsurgical pain can be minimized or prevented by an analgesic approach involving aggressive perioperative multimodal treatment, other studies fail to show this benefit. The transition of acute postoperative pain to chronic postsurgical pain is a complex and poorly understood developmental process, involving biological, psychological and social-environmental factors.

I t is not atypical for patients with posttraumatic stress disorder (PTSD) to present with several concomitant physical and mental health problems. These most often include increased reporting of physical symptoms and physical health problems, increased alcohol consumption, and depressed mood (1,2). Recent evidence suggests that pain is one of the most commonly reported symptoms of patients with PTSD, regardless of the nature of their traumatic experience (for example, military combat, motor vehicle accident, or sexual assault). Similarly, patients who have persistent, chronic pain associated with musculoskeletal injury, serious burn injuries, and other pathologies (such as fibromyalgia, cancer, or AIDS) frequently present with symptoms of PTSD. In the past decade, investigation into the relation(s) between PTSD and the experience of pain has flourished. To a lesser degree, researchers have developed models that attempt to explain how the conditions may be linked (3). This paper has several purposes. First, we provide summary definitions of the conditions under discussion. Second, we highlight symptoms from each condition that have similar characteristics. Third, we summarize the literature on prevalence rates of pain experiences in PTSD populations, and vice versa. Fourth, we articulate potential explanations for the observed association between pain and PTSD. Finally, we discuss future directions for empirical investigation and clinical practice that stem from this line of inquiry. Clinical Implications· Clinicians treating patients with posttraumatic stress disorder (PTSD) need to pay careful attention to co-occurring symptoms of pain. · Likewise, those treating patients with chronic pain need to be aware of the potential influence of PTSD symptoms on clinical presentation. · Use of propranolol may be effective in simultaneous relief of co-occurring PTSD and pain symptoms. Limitation · The positions suggested in this review warrant careful empirical scrutiny.It is common for individuals with symptoms of posttraumatic stress disorder (PTSD) to present with cooccurring pain problems, and vice versa. However, the relation between these conditions often goes unrecognized in clinical settings. In this paper, we describe potential relations between PTSD and chronic pain and their implications for assessment and treatment. To accomplish this, we discuss phenomenological similarities of these conditions, the prevalence of chronic pain in patients with PTSD, and the prevalence of PTSD in patients with chronic pain. We also present several possible explanations for the co-occurrence of these disorders, based primarily on the notions of shared vulnerability and mutual maintenance. The paper concludes with an overview of future research directions, as well as practical recommendations for assessing and treating patients who present with co-occurring PTSD or chronic pain symptoms.

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a b s t r a c tNeedle fears are a documented barrier to immunization in children and adults. There is a paucity of data, however, regarding the prevalence of needle fears and their impact on immunization compliance. In this cross-sectional survey, a convenience sample of parents (n = 883) and children (n = 1024) attending a public museum in Toronto, Canada answered questions about needle fears and non-compliance with immunization due to needle fear. Altogether, 24% of parents and 63% of children reported a fear of needles. Needle fear was the primary reason for immunization non-compliance for 7% and 8% of parents and children, respectively. Interventions aimed at improving education about, and access to, analgesic interventions during immunization injections performed in childhood are recommended in order to prevent the development of needle fears and vaccine non-compliance.