There has been an increasing focus on development of new routes of drug administration to provide tailored treatments for patients, without decreasing efficacy of analgesia, in proportion to the progression of the knowledge of pain mechanisms. While acute pain acts as an alarm, chronic pain is a syndrome requiring meticulous selection of analgesic drugs of high bioavailability for long-term use. Such criteria are challenges that topical medications aim to overcome, allowing progressive delivery of active component, maintaining stable plasma levels, with a good safety profile. This review presents recent findings regarding topical formulations of the most widely used drugs for pain treatment, such as nonsteroidal anti-inflammatory agents, anesthetics, and capsaicin, and the role of physical agents as delivery enhancers (phonophoresis and iontophoresis). Although the number of topical agents is limited for use in peripheral conditions, increasing evidence supports the efficacy of these preparations in blocking nociceptive and neuropathic pain. Patient adherence to medical treatment is also a challenge, especially in chronic painful conditions. It is known that reduction of treatment complexity and pill burden are good strategies to increase patient compliance, as discussed here. However, the role of topical presentations, when compared to traditional routes, has not yet been fully explored and thus remains unclear.

Fibromyalgia is a primary brain disorder or a result of peripheral dysfunctions inducing brain alterations, with underlying mechanisms that partially overlap with other painful conditions. Although there are methodologic variations, neuroimaging studies propose neural correlations to clinical findings of abnormal pain modulation in fibromyalgia. Growing evidences of specific differences of brain activations in resting states and pain-evoked conditions confirm clinical hyperalgesia and impaired inhibitory descending systems, and also demonstrate cognitive-affective influences on painful experiences, leading to augmented pain-processing. Functional data of neural activation abnormalities parallel structural findings of gray matter atrophy, alterations of intrinsic connectivity networks, and variations in metabolites levels along multiple pathways. Data from positron-emission tomography, single-photon-emission-computed tomography, blood-oxygen-level-dependent, voxel-based morphometry, diffusion tensor imaging, default mode network analysis, and spectroscopy enable the understanding of fibromyalgia pathophysiology, and favor the future establishment of more tailored treatments.

Purpose: To describe the effects of a rehabilitation program in a neurological inpatient unit in terms of independence for activities of daily living and return to work. Method: Retrospective study with 148 adults with stroke, traumatic brain injury (TBI), spinal cord injury, and Guillain–Barré syndrome admitted as rehabilitation inpatients within a 1-year period for hospitalization at the Instituto de Reabilitação Lucy Montoro, Brazil. According to their diagnostic groups, subjects undergone semi-standardized models of intensive multidisciplinary rehabilitation for 4–6 weeks. Primary outcome measures: Functional Independence Measure (FIM™), Modified Rankin scale (Rankin), and Glasgow Outcome Scale (GOS Subjects were evaluated at admission, discharge, and 6 months after discharge. Results: Improvement in motor FIM™, Rankin and GOS was observed in all groups. Cognitive FIM™ increase was less evident in TBI patients. After 6 months, 37.6% of patients were unemployed, 34% underwent outpatient rehabilitation, and 65.2% maintained gains. Conclusions: This is the first report on the effects from an inpatients rehabilitation model in Brazil. After a short intensive rehabilitation, there were motor and cognitive gains in all groups. Heterogeneity in functional gains suggests more individualized programs may be indicated. Controlled studies are required with larger samples to compare inpatient and outpatient programs.Implications for RehabilitationThe proposed brief model of rehabilitation for stroke, traumatic brain injury, spinal cord injury, and Guillain–Barre syndrome inpatients shows promising results in terms of functional improvement.Apparent improvements in cognitive and motor levels can be observed after 30 d of the intensive hospital-based program five times a week focusing on caregiver and patients training.After 6 months of discharge, more than one third of patients remained out of work, but appeared to have kept the benefits attained during hospitalization, and performed physical activities in the community as outpatients.

BackgroundStudies on functional magnetic resonance imaging (fMRI) have shown that adults with musculoskeletal pain syndromes tolerate smaller amount of pressure (pain) as well as differences in brain activation patterns in areas related to pain.The objective of this study was to evaluate, through fMRI, the brain activation in adolescents with idiopathic musculoskeletal pain (IMP) while performing an experimental paradigm of pain.MethodsThe study included 10 consecutive adolescents with idiopathic musculoskeletal pain (average age 16.3±1.0) and 10 healthy adolescents age-matched. fMRI exams were performed in a 3 T scanner (Magnetom Trio, Siemens) using an event-related design paradigm. Pressure stimuli were performed in the nondominant hand thumb, divided into two stages, fixed pain and variable pain.The two local Research Ethics Committees (Ethics Committee from Universidade Federal de São Paulo- Brazil, process number 0688/11, on July 1st, 2011 and Ethics Committee from Hospital Israelita Albert Einsten – Brazil, process number 1673, on October 19th, 2011) approved the study.ResultsThe idiopathic musculoskeletal pain (IMP) group showed a reduced threshold for pain (3.7 kg/cm2 versus 4.45 kg/cm2, p = 0.005). Control group presented increased bain activation when compared to IMP group in the following areas: thalamus (p = 0.00001), precentral gyrus (p = 0.0004) and middle frontal gyrus (p = 0.03). In intragroup analysis, IMP group showed greater brain activation during the unpredictable stimuli of the variable pain stage, especially in the lingual gyrus (p = 0.0001), frontal lobe (p = 0.0001), temporal gyrus (p = 0.0001) and precentral gyrus (p = 0.03), when compared to predictable stimulus of fixed pain. The same intragroup analysis with the control group showed greater activation during the unpredictable stimuli in regions of the precentral gyrus (p = 0.0001), subcallosal area (p = 0.0001), right and left occipital fusiform gyrus (p = 0.0001; (p = 0.0007), middle gyrus (p = 0.01) and precuneus p = (0.02).ConclusionAdolescents with idiopathic musculoskeletal pain (IMP) tend to request higher brain function in cognitive-emotional areas when interpreting unpredictable sensory-perceptual situations. Therefore, it is assumed that this difference in pain processing in adolescents with IMP make the subjective experience of pain something more intense and unpleasant.

The objective of this prospective study was to perform a cross-cultural adaptation of the Functional Assessment Measure (FAM) into Brazilian Portuguese, and to assess the test-retest reliability. The instrument was translated, back-translated, pretested, and reviewed by a committee. The Brazilian version was assessed in 61 brain-injury patients. Intrarater and interrater reliability was verified by a test-retest procedure (intraclass correlation). Intrarater reliability was moderate-to-excellent; interrater reliability was moderate-to-excellent, with the exception of one item. The Brazilian version of the FAM has acceptable test-retest reliability. Results suggest the use of the Brazilian version of the FAM in the Brazilian population, for disability evaluation and outcome assessment. Further research is required to evaluate the psychometric properties of the scale.