TABLE 2.

Summary of clinical recommendations for mixed pain management.

Recommendation	Topic	Key elements
1	Mechanism-based classification	Classify mixed pain based on relative contributions of nociceptive, neuropathic, and nociplastic components to guide targeted therapeutic approaches
2	Central sensitization assessment	Routine evaluation for clinical signs of central sensitization (hyperalgesia, allodynia, temporal summation) in patients with suspected mixed pain
3	Validated screening tools	Use validated screening tools (DN4, PainDETECT, LANSS) in combination with comprehensive clinical assessment to identify neuropathic components
4	Comprehensive clinical assessment	Include detailed pain history, physical examination with sensory testing, and systematic assessment of functional impact and psychosocial factors
5	Imaging and electrophysiology	Use advanced imaging (MRI) and electrophysiological studies (EMG/NCS) selectively based on clinical presentation rather than routinely
6	Red and yellow flag assessment	Systematic screening for red flags (serious pathology) and yellow flags (psychosocial risk factors) during initial evaluation
7	Multimodal pharmacotherapy	Use multimodal pharmacotherapy combining agents with different mechanisms of action rather than monotherapy
8	First-line combination therapy	Combine NSAIDs or acetaminophen with gabapentinoids (gabapentin/pregabalin) or SNRIs (duloxetine) as first-line therapy
9	Dual-mechanism opioids	Consider opioids with dual mechanisms (tramadol or tapentadol) over traditional opioids when opioid therapy is indicated
10	Topical agents	Prioritize topical agents (lidocaine patches, capsaicin) for localized mixed pain, particularly in elderly patients or those with multiple comorbidities
11	Multimodal non-pharmacological approach	Integrate multiple non-pharmacological interventions (physical therapy, psychological support, patient education) alongside pharmacological treatment
12	Early psychological intervention and education	Early integration of psychological interventions (CBT, ACT, MBSR) for patients with high pain-related distress; provide comprehensive patient education
13	Team composition and communication	Interdisciplinary teams should include minimum: physician, nurse, pharmacist, physiotherapist, psychologist; establish regular team meetings
14	Multidimensional assessment	Use validated multidimensional assessment tools (Brief Pain Inventory, Oswestry Disability Index, Pain Catastrophizing Scale); implement structured follow-up schedules
15	Age-specific and population-based adaptations	Modify treatment approaches based on patient age (simplified regimens for elderly, family-centered approaches for pediatric); mechanism-based multimodal approaches for cancer patients; close collaboration between pain specialists and mental health professionals for patients with psychiatric comorbidities
16	Ethical and equitable care	Ground management in ethical principles including comprehensive informed consent, shared decision-making, and equitable access policies; establish professional competency standards through minimum qualifications and ongoing education