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Conditioned pain modulation as a biomarker of chronic pain: a systematic review of its concurrent validity. Pain 2019; 160:2679-2690. [DOI: 10.1097/j.pain.0000000000001664] [Citation(s) in RCA: 33] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/07/2023]
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Kuithan P, Heneghan NR, Rushton A, Sanderson A, Falla D. Lack of Exercise-Induced Hypoalgesia to Repetitive Back Movement in People with Chronic Low Back Pain. Pain Pract 2019; 19:740-750. [PMID: 31187932 DOI: 10.1111/papr.12804] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/19/2019] [Revised: 05/21/2019] [Accepted: 05/29/2019] [Indexed: 12/14/2022]
Abstract
PURPOSE To investigate whether people with chronic low back pain (LBP) show dysfunctional exercise-induced hypoalgesia (EIH) in response to repeated contractions of their back muscles during a lifting task. METHODS In this cross-sectional observational study conducted on asymptomatic participants (n = 18) and participants with chronic LBP (n = 21), quantitative sensory testing (QST) was applied extensively over the lumbar region and a remote area before and after a repeated task that involved lifting a 5-kg box for ~7 minutes. QST included pressure pain thresholds (PPTs), thermal detection, pain thresholds, and measures of temporal summation. Topographical maps of the percentage change in PPT detected at 16 locations over the lumbar region were generated to explore regional differences and compared between groups. RESULTS Mean (standard deviation) PPTs measured from 16 sites over the lower back changed significantly in asymptomatic participants (+29.78 kPa [41.4]) following task completion, indicative of EIH, whereas no significant change was observed for the low back pain (LBP) group (-14.87 kPa [61.2]). No changes were detected at the remote site for either group. No changes were revealed for the thermal tests. Temporal summation data revealed decreasing pain sensitivity as the test progressed, but the test response did not change after the exercise for either group. CONCLUSION(S) Unlike asymptomatic individuals, participants with LBP lacked EIH over the lumbar erector spinae muscles following repeated lifting. Although these results should be considered in relation to the study limitations, particularly the absence of a control group, the findings support impaired EIH in patients with LBP.
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Affiliation(s)
- Pauline Kuithan
- Centre of Precision Rehabilitation for Spinal Pain (CPR Spine), School of Sport, Exercise and Rehabilitation Sciences, University of Birmingham, Birmingham, U.K
| | - Nicola R Heneghan
- Centre of Precision Rehabilitation for Spinal Pain (CPR Spine), School of Sport, Exercise and Rehabilitation Sciences, University of Birmingham, Birmingham, U.K
| | - Alison Rushton
- Centre of Precision Rehabilitation for Spinal Pain (CPR Spine), School of Sport, Exercise and Rehabilitation Sciences, University of Birmingham, Birmingham, U.K
| | - Andy Sanderson
- Centre of Precision Rehabilitation for Spinal Pain (CPR Spine), School of Sport, Exercise and Rehabilitation Sciences, University of Birmingham, Birmingham, U.K
| | - Deborah Falla
- Centre of Precision Rehabilitation for Spinal Pain (CPR Spine), School of Sport, Exercise and Rehabilitation Sciences, University of Birmingham, Birmingham, U.K
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Walking increases pain tolerance in humans: an experimental cross-over study. Scand J Pain 2019; 19:813-822. [DOI: 10.1515/sjpain-2019-0070] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/29/2019] [Accepted: 06/06/2019] [Indexed: 01/27/2023]
Abstract
Abstract
Background and aims
Exercise is commonly used as treatment for chronic pain with positive long-term effects on pain and pain-related disability. In pain-free subjects, hypoalgesia following an acute bout of exercise compared with a control condition has consistently been demonstrated also known as exercise-induced hypoalgesia (EIH). Walking exercise, a low intensity aerobic exercise, is frequently used in clinical practice as an easily applicable intervention for patients with chronic pain. Walking exercise is furthermore recommended as an effective treatment for patients with chronic musculoskeletal pain conditions to alleviate pain and reduce disability, however, the effect of walking on pain sensitivity is currently unknown. The aims of the present study were to investigate (1) the acute effect of walking on pain sensitivity, and (2) the relative (between-subjects) and absolute (within-subject) test-retest reliability of the hypoalgesic response across two sessions separated by 1 week.
Methods
In this randomised experimental cross-over study including two identical sessions, 35 pain-free subjects performed a standardized 6 min walking test and a duration-matched quiet rest condition in a randomized and counterbalanced order in each session. Before and after both conditions, handheld pressure pain thresholds (PPTs) were assessed at the thigh and shoulder, and pressure pain thresholds (cPPT) and pain tolerance (cPTT) were assessed with computer-controlled cuff algometry at the lower leg. Change in the pain sensitivity measures were analysed with repeated-measures ANOVAs, and test-retest reliability with intraclass correlation coefficients (ICC) and agreements in classification of EIH responders/non-responders between the two sessions.
Results
All subjects completed the walking conditions in both session 1 and session 2. The perceived intensity of walking assessed with rating of perceived exertion (RPE) and walking distance did not differ significantly between session 1 (distance: 632.5 ± 75.2 meters, RPE: 10.9 ± 1.9) and session 2 (distance: 642.1 ± 80.2 meters, RPE: 11.0 ± 2.4) (p > 0.11). Moreover, RPE showed excellent relative reliability with an ICC value of 0.95 [95%CI: 0.90–0.97]. Walking increased pain tolerance (mean difference: 2.6 kPa [95%CI: 0.5–4.9 kPa; p = 0.02]), but not pain thresholds compared with rest in both sessions. Hypoalgesia after walking demonstrated fair to good relative reliability (ICC = 0.61), however the agreement in classification of EIH responders/non-responders (absolute reliability) across sessions was low and not significant (κ = 0.19, p = 0.30).
Conclusions
Walking consistently increased pain tolerance but not pain thresholds compared with a duration-matched control condition with fair to good relative reliability between sessions. Based on classification of EIH responders/non-responders the absolute reliability between the two sessions was low indicating individual variance in the EIH response. Future studies should investigate the hypoalgesic effect of a walking exercise in a clinical pain population.
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Waller R, Smith A, Slater H, O’Sullivan P, Beales D, McVeigh J, Straker L. Associations of physical activity or sedentary behaviour with pain sensitivity in young adults of the Raine Study. Scand J Pain 2019; 19:679-691. [DOI: 10.1515/sjpain-2019-0038] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2019] [Accepted: 05/02/2019] [Indexed: 02/02/2023]
Abstract
Abstract
Background and aims
There is high level evidence for physical activity (PA) improving outcomes in persistent pain disorders and one of the mechanisms proposed is the effect of exercise on central nociceptive modulation. Although laboratory studies and small field intervention studies suggest associations between physical activity and pain sensitivity, the association of objectively measured, habitual PA and sedentary behaviour (SB) with pain sensitivity requires further investigation. Current evidence suggests PA typically lowers pain sensitivity in people without pain or with single-site pain, whereas PA is frequently associated with an increase in pain sensitivity for those with multisite pain. The aim of this study was to explore the relationships of PA and SB with pain sensitivity measured by pressure pain thresholds and cold pain thresholds, considering the presence of single-site and multisite pain and controlling for potential confounders.
Methods
Participants from the Western Australian Pregnancy Cohort (Raine) Study (n = 714) provided data at age 22-years. PA and SB were measured via accelerometry over a 7-day period. Pain sensitivity was measured using pressure pain threshold (4 sites) and cold pain threshold (wrist). Participants were grouped by number of pain areas into “No pain areas” (n = 438), “Single-site pain” (n = 113) and “Multisite pain” (n = 163) groups. The association of PA and SB variables with pain sensitivity was tested separately within each pain group by multivariable regression, adjusting for potential confounders.
Results
For those with “Single-site pain”, higher levels (>13 min/day) of moderate-vigorous PA in ≥10 min bouts was associated with more pressure pain sensitivity (p = 0.035). Those with “Multisite pain” displayed increased cold pain sensitivity with greater amounts of vigorous PA (p = 0.011). Those with “No pain areas” displayed increased cold pain sensitivity with decreasing breaks from sedentary time (p = 0.046).
Conclusions
This study was a comprehensive investigation of a community-based sample of young adults with “No pain areas”, “Single-site pain” and “Multisite pain” and suggests some associations of measures of PA and SB with pain sensitivity.
Implications
The findings suggest that the pattern of accumulation of PA and SB may be important to inform improved clinical management of musculoskeletal pain disorders. This study provides a baseline for follow-up studies using the Raine Study cohort. Future research should consider temporal influences of PA and SB on pain sensitivity, pain experience and consider using a broader range of pain sensitivity measures.
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Affiliation(s)
- Robert Waller
- School of Physiotherapy and Exercise Science , Curtin University , GPO Box 1987 , Perth , Western Australia 6845, Australia
| | - Anne Smith
- School of Physiotherapy and Exercise Science , Curtin University , Perth, Western Australia , Australia
| | - Helen Slater
- School of Physiotherapy and Exercise Science , Curtin University , Perth, Western Australia , Australia
| | - Peter O’Sullivan
- School of Physiotherapy and Exercise Science , Curtin University , Perth, Western Australia , Australia
| | - Darren Beales
- School of Physiotherapy and Exercise Science , Curtin University , Perth, Western Australia , Australia
| | - Joanne McVeigh
- School of Occupational Therapy, Social Work and Speech Pathology, Curtin University , Perth, Western Australia , Australia
- Exercise Laboratory, School of Physiology, University of Witwatersrand , Johannesburg , South Africa
| | - Leon Straker
- School of Physiotherapy and Exercise Science , Curtin University , Perth, Western Australia , Australia
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Rice D, Nijs J, Kosek E, Wideman T, Hasenbring MI, Koltyn K, Graven-Nielsen T, Polli A. Exercise-Induced Hypoalgesia in Pain-Free and Chronic Pain Populations: State of the Art and Future Directions. THE JOURNAL OF PAIN 2019; 20:1249-1266. [PMID: 30904519 DOI: 10.1016/j.jpain.2019.03.005] [Citation(s) in RCA: 213] [Impact Index Per Article: 42.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/20/2018] [Revised: 02/24/2019] [Accepted: 03/15/2019] [Indexed: 12/11/2022]
Abstract
Exercise is considered an important component of effective chronic pain management and it is well-established that long-term exercise training provides pain relief. In healthy, pain-free populations, a single bout of aerobic or resistance exercise typically leads to exercise-induced hypoalgesia (EIH), a generalized reduction in pain and pain sensitivity that occurs during exercise and for some time afterward. In contrast, EIH is more variable in chronic pain populations and is more frequently impaired; with pain and pain sensitivity decreasing, remaining unchanged or, in some cases, even increasing in response to exercise. Pain exacerbation with exercise may be a major barrier to adherence, precipitating a cycle of physical inactivity that can lead to long-term worsening of both pain and disability. To optimize the therapeutic benefits of exercise, it is important to understand how EIH works, why it may be impaired in some people with chronic pain, and how this should be addressed in clinical practice. In this article, we provide an overview of EIH across different chronic pain conditions. We discuss possible biological mechanisms of EIH and the potential influence of sex and psychosocial factors, both in pain-free adults and, where possible, in individuals with chronic pain. The clinical implications of impaired EIH are discussed and recommendations are made for future research, including further exploration of individual differences in EIH, the relationship between exercise dose and EIH, the efficacy of combined treatments and the use of alternative measures to quantify EIH. PERSPECTIVE: This article provides a contemporary review of the acute effects of exercise on pain and pain sensitivity, including in people with chronic pain conditions. Existing findings are critically reviewed, clinical implications are discussed, and recommendations are offered for future research.
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Affiliation(s)
- David Rice
- Health and Rehabilitation Research Institute, Auckland University of Technology, Auckland, New Zealand; Waitemata Pain Services, Department of Anaesthesiology and Perioperative Medicine, Waitemata District Health Board, Auckland, New Zealand.
| | - Jo Nijs
- Pain in Motion International Research Group(#); Department of Physiotherapy, Human Physiology and Anatomy, Faculty of Physical Education & Physiotherapy, Vrije Universiteit Brussel, Brussels, Belgium; Department of Physical Medicine and Physiotherapy, University Hospital Brussels, Brussels, Belgium
| | - Eva Kosek
- Department of Clinical Neuroscience, Karolinska Institutet, Stockholm, Sweden; Stockholm Spine Center, Löwenströmska Hospital, Upplands Väsby, Sweden
| | - Timothy Wideman
- School of Physical and Occupational Therapy, McGill University, Montreal, Canada
| | - Monika I Hasenbring
- Department of Medical Psychology and Medical Sociology, Faculty of Medicine, Ruhr-University of Bochum, Bochum, Germany
| | - Kelli Koltyn
- Department of Kinesiology, University of Wisconsin-Madison, Madison, Wisconsin
| | - Thomas Graven-Nielsen
- Center for Neuroplasticity and Pain (CNAP), Department of Health Science and Technology, Faculty of Medicine, Aalborg University, Aalborg, Denmark
| | - Andrea Polli
- Pain in Motion International Research Group(#); Department of Physiotherapy, Human Physiology and Anatomy, Faculty of Physical Education & Physiotherapy, Vrije Universiteit Brussel, Brussels, Belgium; Department of Physical Medicine and Physiotherapy, University Hospital Brussels, Brussels, Belgium; Research Foundation - Flanders (FWO), Brussels, Belgium
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Peterson JA, Schubert DJ, Campbell J, Bemben MG, Black CD. Endogenous Pain Inhibitory Function: Endurance-Trained Athletes vs Active Controls. PAIN MEDICINE 2019; 20:1822-1830. [DOI: 10.1093/pm/pnz014] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
Abstract
Objective
Athletes are at risk for developing chronic pain conditions, but the role of exercise in the modulation of pain in athletes has not been well established. The aim of this study was to investigate conditioned pain modulation (CPM) and exercise-induced hypoalgesia (EIH) responses between 13 endurance-trained athletes and 13 normally active controls.
Methods
In a cross-sectional, nonrandomized study with two independent groups of college-aged males and females, pressure pain thresholds (PPTs) were assessed in the vastus lateralis (VL) and brachioradialis (BR) using a pressure algometer before and after a conditioning stimulus, an isometric hand grip exercise to failure, and a 30-minute run.
Results
PPTs increased following the conditioning stimulus, indicating a CPM response, to a similar degree in the BR (19.3% ± 26.5% vs 18.6% ± 16.2%, P = 0.93) and VL (18.9% ± 25.9% vs 28.7% ± 27.4%, P = 0.73) in the athletes and controls. PPTs increased following isometric exercise to a similar extent in athletes and controls in the BR (23.9% ± 22.8% vs 28.2% ± 24.0%, P = 0.75) and VL (15.8% ± 14.8% vs 15.5% ± 11.6%, P = 0.94). Following 30 minutes of running, EIH was similar between athletes and controls in the VL (21.2% ± 17.2% vs 13.8% ± 13.3%, P = 0.23) but was attenuated in the BR of the athletes (6.1% ± 16.9% vs 20.9% ± 20%, P = 0.047).
Conclusions
Athletes and controls exhibited similar endogenous pain inhibitory function both locally and systemically following CPM and isometric, upper body exercise. After the 30-minute run, BR EIH was reduced in the athletes compared with controls, suggesting a reduced systemic response following familiar exercise—perhaps due to the exercise being perceived as less painful and/or effortful.
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Affiliation(s)
- Jessica A Peterson
- Department of Health and Exercise Science, University of Oklahoma, Norman, Oklahoma, USA
| | - Daniel J Schubert
- Department of Health and Exercise Science, University of Oklahoma, Norman, Oklahoma, USA
| | - Jason Campbell
- Department of Health and Exercise Science, University of Oklahoma, Norman, Oklahoma, USA
| | - Michael G Bemben
- Department of Health and Exercise Science, University of Oklahoma, Norman, Oklahoma, USA
| | - Christopher D Black
- Department of Health and Exercise Science, University of Oklahoma, Norman, Oklahoma, USA
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Clinical Outcomes and Central Pain Mechanisms are Improved After Upper Trapezius Eccentric Training in Female Computer Users With Chronic Neck/Shoulder Pain. Clin J Pain 2019; 35:65-76. [DOI: 10.1097/ajp.0000000000000656] [Citation(s) in RCA: 25] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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58
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Vaegter HB, Bjerregaard LK, Redin MM, Rasmussen SH, Graven-Nielsen T. Hypoalgesia after bicycling at lactate threshold is reliable between sessions. Eur J Appl Physiol 2018; 119:91-102. [DOI: 10.1007/s00421-018-4002-0] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/24/2018] [Accepted: 10/01/2018] [Indexed: 12/11/2022]
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59
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Palsson TS, Boudreau SA, Krebs HJ, Graven-Nielsen T. Experimental Referred Pain Extends Toward Previously Injured Location: An Explorative Study. THE JOURNAL OF PAIN 2018; 19:1189-1200. [DOI: 10.1016/j.jpain.2018.04.018] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/29/2018] [Revised: 04/30/2018] [Accepted: 04/30/2018] [Indexed: 12/22/2022]
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Young females with long-standing patellofemoral pain display impaired conditioned pain modulation, increased temporal summation of pain, and widespread hyperalgesia. Pain 2018; 159:2530-2537. [DOI: 10.1097/j.pain.0000000000001356] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
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61
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Kermavnar T, Power V, de Eyto A, O'Sullivan L. Cuff Pressure Algometry in Patients with Chronic Pain as Guidance for Circumferential Tissue Compression for Wearable Soft Exoskeletons: A Systematic Review. Soft Robot 2018; 5:497-511. [PMID: 29957130 DOI: 10.1089/soro.2017.0088] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022] Open
Abstract
In this article, we report on a systematic review of the literature on pressure-pain thresholds induced and assessed by computerized cuff pressure algometry (CPA). The motivation for this review is to provide design guidance on pressure levels for wearable soft exoskeletons and similar wearable robotics devices. In our review, we focus on CPA studies of patients who are candidates for wearable soft exoskeletons, as pain-related physiological mechanisms reportedly differ significantly between healthy subjects and patients with chronic pain. The results indicate that circumferential limb compression in patients most likely becomes painful at ∼10-18 kPa and can become unbearable even below 25 kPa. The corresponding ranges for healthy control subjects are 20-42 kPa (painful limits) and 34-84 kPa (unbearable levels). In addition, the increase of pain with time tends to be significantly higher, and the adaptation to pain significantly lower, than in healthy subjects. The results of this review provide guidance to designers of wearable robotics for populations with chronic pain regarding rates and magnitudes of tissue compression that may be unacceptable to users.
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Affiliation(s)
- Tjaša Kermavnar
- School of Design and Health Research Institute, University of Limerick , Limerick, Ireland
| | - Valerie Power
- School of Design and Health Research Institute, University of Limerick , Limerick, Ireland
| | - Adam de Eyto
- School of Design and Health Research Institute, University of Limerick , Limerick, Ireland
| | - Leonard O'Sullivan
- School of Design and Health Research Institute, University of Limerick , Limerick, Ireland
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Kinesiophobia is associated with pain intensity but not pain sensitivity before and after exercise: an explorative analysis. Physiotherapy 2018; 104:187-193. [DOI: 10.1016/j.physio.2017.10.001] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/09/2016] [Accepted: 10/08/2017] [Indexed: 12/25/2022]
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63
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Vaegter HB, Lyng KD, Yttereng FW, Christensen MH, Sørensen MB, Graven-Nielsen T. Exercise-Induced Hypoalgesia After Isometric Wall Squat Exercise: A Test-Retest Reliabilty Study. PAIN MEDICINE 2018; 20:129-137. [DOI: 10.1093/pm/pny087] [Citation(s) in RCA: 26] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Affiliation(s)
- Henrik Bjarke Vaegter
- Pain Research Group, Pain Center, Department of Anesthesiology and Intensive Care Medicine, University Hospital Odense, Odense, Denmark
- Department of Clinical Research, Faculty of Health Sciences, University of Southern Denmark
| | | | | | | | | | - Thomas Graven-Nielsen
- Department of Health Science and Technology, Faculty of Medicine, Center for Neuroplasticity and Pain (CNAP), SMI, Aalborg University, Aalborg, Denmark
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Lemming D, Börsbo B, Sjörs A, Lind EB, Arendt-Nielsen L, Graven-Nielsen T, Gerdle B. Cuff Pressure Pain Detection Is Associated with Both Sex and Physical Activity Level in Nonathletic Healthy Subjects. PAIN MEDICINE 2018; 18:1573-1581. [PMID: 28053139 DOI: 10.1093/pm/pnw309] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
Purpose The aim of this study was to evaluate pressure pain sensitivity on leg and arm in 98 healthy persons (50 women) using cuff algometry. Furthermore, associations with sex and physical activity level were investigated. Method Normal physical activity level was defined as Godin Leisure-Time Exercise Questionnaire (GLTEQ) score ≤ 45 and high activity level as GLTEQ > 45. A pneumatic double-chamber cuff was placed around the arm or leg where a single chamber was inflated. The cuff inflation rate (1 kPa/s) was constant, and pain intensity was registered continuously on a 10 cm electronic visual analogue scale (VAS). The pain detection threshold (PDT) was defined as when the pressure was perceived as painful, and pain tolerance (PTT) was when the subject terminated the cuff inflation. For PTT, the corresponding VAS score was recorded (VAS-PTT). The protocol was repeated with two chambers inflated. Result Only single cuff results are given. For women compared with men, the PDT was lower when assessed in the arm ( P = 0.002), PTTs were lower in the arm and leg ( P < 0.001), and the VAS-PTT was higher in the arm and leg ( P < 0.033). Highly active participants compared with less active had higher PDT ( P = 0.027) in the leg. Women showed facilitated spatial summation ( P < 0.014) in the arm and leg and a steeper VAS slope (i.e., the slope of the VAS pressure curve between PDT and PPT) in the arm and leg ( P < 0.003). Conclusion This study indicates that reduced pressure pain sensitivity is associated both with male sex and physical activity level.
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Affiliation(s)
- Dag Lemming
- Pain and Rehabilitation Centre and Department of Medical and Health Sciences, Linköping University, Linköping, Sweden
| | - Björn Börsbo
- Pain and Rehabilitation Centre and Department of Medical and Health Sciences, Linköping University, Linköping, Sweden
| | - Anna Sjörs
- Pain and Rehabilitation Centre and Department of Medical and Health Sciences, Linköping University, Linköping, Sweden
| | - Eva-Britt Lind
- Pain and Rehabilitation Centre and Department of Medical and Health Sciences, Linköping University, Linköping, Sweden
| | - Lars Arendt-Nielsen
- Laboratory for Experimental Pain Research.,Center for Neuroplasticity and Pain, Center for Sensory-Motor Interaction, Department of Health Science and Technology, Aalborg University, Aalborg, Denmark
| | - Thomas Graven-Nielsen
- Center for Neuroplasticity and Pain, Center for Sensory-Motor Interaction, Department of Health Science and Technology, Aalborg University, Aalborg, Denmark
| | - Björn Gerdle
- Pain and Rehabilitation Centre and Department of Medical and Health Sciences, Linköping University, Linköping, Sweden
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Increased Pain Sensitivity in Accident-related Chronic Pain Patients With Comorbid Posttraumatic Stress. Clin J Pain 2018; 34:313-321. [DOI: 10.1097/ajp.0000000000000543] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/27/2023]
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Gajsar H, Nahrwold K, Titze C, Hasenbring MI, Vaegter HB. Exercise does not produce hypoalgesia when performed immediately after a painful stimulus. Scand J Pain 2018; 18:311-320. [DOI: 10.1515/sjpain-2018-0024] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/29/2018] [Accepted: 02/05/2018] [Indexed: 11/15/2022]
Abstract
Abstract
Background and aims:
Exercise-induced hypoalgesia (EIH) and conditioned pain modulation (CPM) are assumed to reflect descending pain inhibition. Potential interactions between EIH and CPM may be important in the therapy of chronic pain, as reduced CPM and increased pain after exercise are frequently observed. This study compared the EIH response after CPM was activated using a cold pressor task with the EIH response after a control condition.
Methods:
Thirty-one participants (age: 27.7±9.8; 15 female) completed two sessions: a cold pressor task (CPT) session, i.e. testing EIH with preceding CPM activation induced using a 2 min CPT at approximately 2°C, and a control session, i.e. testing EIH after a control condition (2 min of quiet rest). EIH was induced using a 15 min bicycling exercise at a target heart rate corresponding to 75% VO2 max. Repeated measures ANOVAs on pressure pain thresholds (PPTs) at the hand, back and leg were used to determine the effects of exercise after the cold pressor test and control condition. Furthermore, correlations between CPM and EIH, in the CPT session as well as control session, were calculated at each assessment site.
Results:
A significant time x condition interaction (F(1, 30)=43.61, p<0.001, partial η2=0.59), with Bonferroni-corrected post-hoc t-tests showed that PPTs increased after exercise in the control session (p<0.001), but not in the CPT session (p=0.125). Furthermore, there was a small positive correlation of EIH in the control session and CPM at the hand (r=0.37, p=0.043). There was a moderate negative correlation of EIH in the CPT session and CPM at the hand (r=−0.50, p=0.004), and smaller negative correlations at the back (r=−0.37, p=0.036) and at the leg (r=−0.35, p=0.054).
Conclusions:
Attenuated EIH after the CPM activation in comparison to a control condition suggests that EIH and CPM may share underlying pain inhibitory mechanisms on a systemic level. This assumption is further supported by the finding of small to moderate significant correlations between EIH and CPM at the hand. The attenuated EIH response furthermore suggests that these mechanisms are exhaustible, i.e. that its effects decline after a certain amount of inhibition.
Implications:
In patients with chronic pain, assessing the current capacity of the descending pain inhibitory system – as indicated by the CPM response – may aid to make better predictions about how patients will respond to exercise with respect to acute pain reduction.
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Affiliation(s)
- Hannah Gajsar
- Mind and Pain in Motion Group, Department of Medical Psychology and Medical Sociology , Ruhr-University of Bochum , Bochum , Germany
| | - Katharina Nahrwold
- Mind and Pain in Motion Group, Department of Medical Psychology and Medical Sociology , Ruhr-University of Bochum , Bochum , Germany
| | - Christina Titze
- Mind and Pain in Motion Group, Department of Medical Psychology and Medical Sociology , Ruhr-University of Bochum , Bochum , Germany
| | - Monika I. Hasenbring
- Mind and Pain in Motion Group, Department of Medical Psychology and Medical Sociology , Ruhr-University of Bochum , Bochum , Germany
| | - Henrik B. Vaegter
- Pain Research Group, Pain Center South, Odense University Hospital , Odense , Denmark
- Department of Clinical Research, Faculty of Health Sciences , University of Southern Denmark , Odense , Denmark
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Vaegter HB, Dørge DB, Schmidt KS, Jensen AH, Graven-Nielsen T. Test-Retest Reliabilty of Exercise-Induced Hypoalgesia After Aerobic Exercise. PAIN MEDICINE 2018; 19:2212-2222. [DOI: 10.1093/pm/pny009] [Citation(s) in RCA: 27] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/12/2023]
Affiliation(s)
- Henrik Bjarke Vaegter
- Pain Center South, Department of Anaesthesiology and Intensive Care Medicine, University Hospital Odense, Denmark
- Faculty of Health Sciences, Institute of Clinical Research, University of Southern Denmark, Odense, Denmark
| | | | | | | | - Thomas Graven-Nielsen
- Faculty of Medicine, Department of Health Science and Technology, Center for Neuroplasticity and Pain (CNAP), SMI, Aalborg University, Aalborg, Denmark
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Office-Cycling: A Promising Way to Raise Pain Thresholds and Increase Metabolism with Minimal Compromising of Work Performance. BIOMED RESEARCH INTERNATIONAL 2018; 2018:5427201. [PMID: 29607323 PMCID: PMC5828532 DOI: 10.1155/2018/5427201] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 08/14/2017] [Revised: 12/01/2017] [Accepted: 12/19/2017] [Indexed: 11/17/2022]
Abstract
Aim Establishing the effects of low intensity cycling (LC), moderate intensity cycling (MC), and standing at a simulated office workstation on pain modulation, work performance, and metabolic expenditure. Methods 36 healthy adults (21 females), mean age 26.8 (SD 7.6) years, partook in this randomized 3 × 3 crossover trial with 75 minutes of LC on 20% of maximum aerobic power (MAP) output, 30 minutes of MC on 50% of MAP, and standing 30 minutes with 48-hour wash-out periods. Outcome measures were pain modulation (pressure pain threshold (PPT) and thermal pain threshold)), work performance (transcription, mouse pointing, and cognitive performance), and metabolic expenditure. Results PPTs increased in all conditions. PPT trapezius showed the highest increase after LC, 39.3 kilopascals (kPa) (15.6; 78.6), compared to MC, 17.0 kPa (2.8; 49.9), and standing, 16.8 kPa (-5.6; 39.4), p = 0.015. Transcription was reduced during LC and MC. Mouse pointing precision was best during standing and worst and slowest during MC. Cognitive performance did not differ between conditions. Metabolic expenditure rates were 1.4 (1.3; 1.7), 3.3 (2.3; 3.7), and 7.5 (5.8; 8.7) kcal/minute during standing, LC, and MC, respectively (p < 0.001). Conclusions LC seems to be the preferred option; it raised PPTs, more than doubled metabolic expenditure, whilst minimally influencing work performance.
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Physical Activity May Be Associated with Conditioned Pain Modulation in Women but Not Men among Healthy Individuals. Pain Res Manag 2017; 2017:9059140. [PMID: 29081683 PMCID: PMC5634578 DOI: 10.1155/2017/9059140] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/13/2017] [Revised: 07/27/2017] [Accepted: 08/20/2017] [Indexed: 12/30/2022]
Abstract
Background Conditioned pain modulation (CPM), a phenomenon also known as diffuse noxious inhibitory control, is thought to be affected by various factors, including sex and level of physical activity. However, the involvement of these factors in CPM remains unclear. Methods Eighty-six healthy young subjects (M/F, 43/43) participated in this study. Participants were assessed on the basis of their mechanical pressure pain threshold (PPT), CPM response, body mass index (BMI), basal metabolic rate (BMR), and duration of moderate-to-vigorous physical activity (MVPA) over a week, using a motion counter. Response to CPM was evaluated as PPT during painful cold stimulation relative to baseline PPT. Results Men showed significantly higher baseline PPT than women; however, this difference was no longer significant after controlling for confounders. Stepwise multiple linear regression analyses revealed BMR to be a significant contributor towards baseline PPT in the entire study population. In contrast, although there were no significant contributors to CPM response among men and in the overall study group, MVPA was positively associated with CPM response among women (β = 0.397). Conclusions These results suggest that, among healthy young individuals, CPM response may be associated with moderate-to-vigorous physical activity in women but not in men.
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Balaguier R, Madeleine P, Rose-Dulcina K, Vuillerme N. Effects of a Worksite Supervised Adapted Physical Activity Program on Trunk Muscle Endurance, Flexibility, and Pain Sensitivity Among Vineyard Workers. J Agromedicine 2017; 22:200-214. [PMID: 28402188 DOI: 10.1080/1059924x.2017.1317683] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Abstract
OBJECTIVES In viticulture, the prevalence of low back pain is particularly high among vineyard workers exposed to sustained and awkward postures. One promising setting for low back pain prevention resides in the implementation of workplace physical activity. METHODS This nonrandomized pilot study aims at evaluating the effects of a worksite supervised adapted physical activity program among 17 vineyard workers volunteered to enter either an intervention group (n = 10) or a control group (n = 7).The intervention group followed a physical activity program for 8 weeks involving (1) 15 minutes of warm-up every working day and (2) two weekly 1-hour adapted physical activity sessions targeting trunk muscle endurance and flexibility. The control group was advised to continue normal physical activity. Evaluations were carried out at weeks 0, 4, 8, and 12. Physical capacity was assessed using flexibility tests for the trunk, along with trunk muscle flexor and extensor endurance tests. Finally, pain sensitivity was evaluated by assessing pressure pain thresholds over 14 anatomical locations in the low back region. RESULTS For the intervention group, the endurance of the trunk extensor and flexor significantly increased from baseline to week 8 as well as the pressure pain thresholds. No change was observed for the control group over the same period. CONCLUSIONS These encouraging results in combination with the high adherence rate set interesting foundations for the promotion of worksite supervised adapted physical activity and, most likely, offer a new promising approach to prevent low back pain among vineyard workers.
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Affiliation(s)
- Romain Balaguier
- a Autonomy, Gerontology, E-health, Imaging and Society (AGEIS), Faculty of Medicine , Grenoble Alpes University , Grenoble , France.,b Physical Activity and Human Performance Group, Centre for Sensory Motor Interaction (SMI), Department of Health Science and Technology , Aalborg University , Aalborg , Denmark
| | - Pascal Madeleine
- b Physical Activity and Human Performance Group, Centre for Sensory Motor Interaction (SMI), Department of Health Science and Technology , Aalborg University , Aalborg , Denmark
| | - Kévin Rose-Dulcina
- a Autonomy, Gerontology, E-health, Imaging and Society (AGEIS), Faculty of Medicine , Grenoble Alpes University , Grenoble , France
| | - Nicolas Vuillerme
- a Autonomy, Gerontology, E-health, Imaging and Society (AGEIS), Faculty of Medicine , Grenoble Alpes University , Grenoble , France.,b Physical Activity and Human Performance Group, Centre for Sensory Motor Interaction (SMI), Department of Health Science and Technology , Aalborg University , Aalborg , Denmark.,c Institut Universitaire de France , Paris , France
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Vaegter HB, Palsson TS, Graven-Nielsen T. Facilitated Pronociceptive Pain Mechanisms in Radiating Back Pain Compared With Localized Back Pain. THE JOURNAL OF PAIN 2017; 18:973-983. [DOI: 10.1016/j.jpain.2017.03.002] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/07/2016] [Revised: 02/20/2017] [Accepted: 03/13/2017] [Indexed: 12/22/2022]
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Preoperative Hypoalgesia After Cold Pressor Test and Aerobic Exercise is Associated With Pain Relief 6 Months After Total Knee Replacement. Clin J Pain 2017; 33:475-484. [DOI: 10.1097/ajp.0000000000000428] [Citation(s) in RCA: 60] [Impact Index Per Article: 8.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
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73
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Trunk kinematics and low back pain during pruning among vineyard workers-A field study at the Chateau Larose-Trintaudon. PLoS One 2017; 12:e0175126. [PMID: 28384277 PMCID: PMC5383154 DOI: 10.1371/journal.pone.0175126] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/02/2016] [Accepted: 03/21/2017] [Indexed: 12/19/2022] Open
Abstract
The prevalence of low back disorders is dramatically high in viticulture. Field measurements that objectively quantify work exposure can provide information on the relationship between the adopted trunk postures and low back pain. The purposes of the present study were three-fold (1) to carry out a kinematics analysis of vineyard-workers’ pruning activity by extracting the duration of bending and rotation of the trunk, (2) to question separately the relationship between the duration of forward bending or trunk rotation with low back pain intensity and pressure pain sensitivity and (3) to question the relationship between the combined duration of forward bending and trunk rotation on low back pain intensity and pressure pain sensitivity. Fifteen vineyard-workers were asked to perform pruning activity for 12 minutes with a wireless triaxial accelerometer placed on their trunk. Kinematic analysis of the trunk showed that vineyard-workers spent more than 50% of the time with the trunk flexed greater than 30° and more than 20% with the trunk rotated greater than 10°. These results show that pruning activity lead to the adoption of forward bended and rotated trunk postures that could significantly increase the risk of work related musculoskeletal disorders in the low back. However, this result was mitigated by the observation of an absence of significant association between the duration of forward bending and trunk rotation with low back pain intensity or pressure pain sensitivity. Even if prospective field measurements and studies assessing the effects of low back pain confounders are needed, this field study provides new genuine information on trunk kinematics during pruning activity.
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Exercise induced hypoalgesia is elicited by isometric, but not aerobic exercise in individuals with chronic whiplash associated disorders. Scand J Pain 2017; 15:14-21. [DOI: 10.1016/j.sjpain.2016.11.007] [Citation(s) in RCA: 34] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/26/2016] [Revised: 11/07/2016] [Accepted: 11/13/2016] [Indexed: 01/09/2023]
Abstract
Abstract
Background and aims
Reduced pain sensitivity following exercise is termed exercise induced hypoalgesia (EIH). Preliminary evidence suggests that impairment of EIH is evident in individuals with whiplash associated disorders (WAD) following submaximal aerobic exercise. This study aimed to compare EIH responses to isometric and aerobic exercise in patients with chronic WAD and healthy controls and investigate relationships between EIH, conditioned pain modulation (CPM) and psychological factors in patients with chronic WAD.
Methods
A cross sectional pre-post study investigated the effect of a single session of submaximal aerobic cycling exercise and a single session of isometric timed wall squat exercise on EIH in a group of participants with chronic WAD (n = 21) and a group of asymptomatic control participants (n = 19). Bivariate analyses between EIH and baseline measures of CPM and psychological features (fear of movement, pain catastrophization and posttraumatic stress symptoms) were also investigated.
Results
The isometric wall squat exercise but not the aerobic cycling exercise resulted in EIH in both groups (P < .023) with no between-group differences (P > .55) demonstrated for either exercise. There were no significant associations measured between EIH (for either exercise performed), and CPM, or any of the psychological variables.
Conclusions
This study showed that individuals with chronic WAD and mild to moderate pain and disability, and no evidence of dysfunctional CPM, demonstrated reduced pain sensitivity, both in the cervical spine and over the tibialis anterior following an isometric, timed wall squat exercise. Cycling exercise did not increase pain sensitivity.
Implications
Individuals with chronic WAD and mild to moderate levels of neck pain and disability may experience less pain sensitivity both locally and remotely following an exercise program directed at nonpainful muscles performing isometric exercises. Individuals cycling for 30 min at 75% of age-predicted heart rate maximum do not experience increased pain sensitivity.
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Courtney CA, Fernández-de-Las-Peñas C, Bond S. Mechanisms of chronic pain - key considerations for appropriate physical therapy management. J Man Manip Ther 2017; 25:118-127. [PMID: 28694674 DOI: 10.1080/10669817.2017.1300397] [Citation(s) in RCA: 32] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023] Open
Abstract
In last decades, knowledge of nociceptive pain mechanisms has expanded rapidly. The use of quantitative sensory testing has provided evidence that peripheral and central sensitization mechanisms play a relevant role in localized and widespread chronic pain syndromes. In fact, almost any patient suffering with a chronic pain condition will demonstrate impairments in the central nervous system. In addition, it is accepted that pain is associated with different types of trigger factors including social, physiological, and psychological. This rational has provoked a change in the understanding of potential mechanisms of manual therapies, changing from a biomechanical/medical viewpoint, to a neurophysiological/nociceptive viewpoint. Therefore, interventions for patients with chronic pain should be applied based on current knowledge of nociceptive mechanisms since determining potential drivers of the sensitization process is critical for effective management. The current paper reviews mechanisms of chronic pain from a clinical and neurophysiological point of view and summarizes key messages for clinicians for proper management of individuals with chronic pain.
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Affiliation(s)
- Carol A Courtney
- Department of Physical Therapy, University of Illinois at Chicago, Chicago, IL, USA
| | - César Fernández-de-Las-Peñas
- Department of Physiotherapy, Universidad Rey Juan Carlos, Alcorcon, Spain.,Center for Sensory-Motor Interaction (SMI), Aalborg University, Aalborg, Denmark
| | - Samantha Bond
- Department of Physical Therapy, University of Illinois at Chicago, Chicago, IL, USA
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Vaegter HB. Exercising non-painful muscles can induce hypoalgesia in individuals with chronic pain. Scand J Pain 2017; 15:60-61. [PMID: 28850347 DOI: 10.1016/j.sjpain.2016.12.005] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/05/2023]
Affiliation(s)
- Henrik Bjarke Vaegter
- Pain Research Group, Pain Center South, Odense University Hospital, Odense, Denmark.,Department of Clinical Research, Faculty of Health Sciences, University of Southern Denmark, Odense, Denmark
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Imai Y, Petersen KK, Mørch CD, Arendt Nielsen L. Comparing test-retest reliability and magnitude of conditioned pain modulation using different combinations of test and conditioning stimuli. Somatosens Mot Res 2016; 33:169-177. [PMID: 27650216 DOI: 10.1080/08990220.2016.1229178] [Citation(s) in RCA: 82] [Impact Index Per Article: 10.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
Abstract
This study aimed to compare the reliability and magnitude of conditioned pain modulation (CPM) by applying different test stimuli (TS) and conditioning stimuli (CS). Twenty-six healthy male participants were recruited in the study of two identical sessions. In each session, four TS (electrical, heat, handheld, and cuff pressure algometry) were applied before and during CS (cold pressor test (CPT) or cuff algometry). The same procedure was repeated with 45-min intervals, but with the other CS. Five thresholds were measured including four pain detection thresholds from four TS and pain tolerance threshold from cuff TS (cuff PTT). Intraclass correlation coefficient (ICC (3,1)) and coefficient of variation (CV) were calculated as measures of reliability. The reliability of TS before and during CS was good for all combinations (ICC: 0.60-0.96, CV: 2.2-22.9%), but the reliability of the CPM effect varied (ICC: 0.04-0.53, CV: 63.6-503.9%). The most reliable combinations were considered to be the handheld pressure pain threshold with CPT (ICC: 0.49, CV: 63.6%) and the cuff pressure pain threshold with CPT (ICC: 0.44, CV: 107.6%). Significant CPM effects were found for all combinations, except the combinations of electrical and heat pain thresholds with cuff CS, which indicates the novel classification of the CPM mechanism. The combinations of handheld pressure and heat pain threshold with CPT would provide the minimum sample size to detect the significant CPM changes in further studies. It is beneficial to provide and compare both ICC and CV to design further clinical trials.
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Affiliation(s)
- Y Imai
- a Department of Health Science and Technology , Aalborg University , Aalborg , Denmark.,b Clinical Development Department , Asahi Kasei Pharma Corporation , Tokyo , Japan
| | - K K Petersen
- a Department of Health Science and Technology , Aalborg University , Aalborg , Denmark
| | - C D Mørch
- a Department of Health Science and Technology , Aalborg University , Aalborg , Denmark
| | - L Arendt Nielsen
- a Department of Health Science and Technology , Aalborg University , Aalborg , Denmark
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79
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Gajsar H, Titze C, Hasenbring MI, Vaegter HB. Isometric Back Exercise Has Different Effect on Pressure Pain Thresholds in Healthy Men and Women. PAIN MEDICINE 2016; 18:917-923. [DOI: 10.1093/pm/pnw176] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
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80
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Blickenstaff C, Pearson N. Reconciling movement and exercise with pain neuroscience education: A case for consistent education. Physiother Theory Pract 2016; 32:396-407. [DOI: 10.1080/09593985.2016.1194653] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
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81
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Vaegter H, Hoeger Bement M, Madsen A, Fridriksson J, Dasa M, Graven-Nielsen T. Exercise increases pressure pain tolerance but not pressure and heat pain thresholds in healthy young men. Eur J Pain 2016; 21:73-81. [DOI: 10.1002/ejp.901] [Citation(s) in RCA: 26] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/09/2016] [Indexed: 12/18/2022]
Affiliation(s)
- H.B. Vaegter
- Pain Research Group; Pain Center South; Odense University Hospital; Denmark
- Institute of Clinical Research; Faculty of Health Sciences; University of Southern Denmark
| | - M. Hoeger Bement
- Department of Physical Therapy; College of Health Sciences; Marquette University; Milwaukee USA
| | - A.B. Madsen
- School of Physiotherapy; University College Lillebaelt; Odense Denmark
| | - J. Fridriksson
- School of Physiotherapy; University College Lillebaelt; Odense Denmark
| | - M. Dasa
- School of Physiotherapy; University College Lillebaelt; Odense Denmark
| | - T. Graven-Nielsen
- Center for Neuroplasticity and Pain (CNAP); SMI; Department of Health Science and Technology; Faculty of Medicine; Aalborg University; Aalborg Denmark
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Pain modulatory phenotypes differentiate subgroups with different clinical and experimental pain sensitivity. Pain 2016; 157:1480-1488. [DOI: 10.1097/j.pain.0000000000000543] [Citation(s) in RCA: 77] [Impact Index Per Article: 9.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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