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Shi Y, Cui S, Zeng Y, Huang S, Cai G, Yang J, Wu W. Brain Network to Placebo and Nocebo Responses in Acute Experimental Lower Back Pain: A Multivariate Granger Causality Analysis of fMRI Data. Front Behav Neurosci 2021; 15:696577. [PMID: 34566591 PMCID: PMC8458622 DOI: 10.3389/fnbeh.2021.696577] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/07/2021] [Accepted: 08/06/2021] [Indexed: 01/10/2023] Open
Abstract
Background and Objective: Placebo and nocebo responses are widely observed. Herein, we investigated the nocebo hyperalgesia and placebo analgesia responses in brain network in acute lower back pain (ALBP) model using multivariate Granger causality analysis (GCA). This approach analyses functional magnetic resonance imaging (fMRI) data for lagged-temporal correlation between different brain areas. Method: After completing the ALBP model, 20 healthy subjects were given two interventions, once during a placebo intervention and once during a nocebo intervention, pseudo-randomly ordered. fMRI scans were performed synchronously during each intervention, and visual analog scale (VAS) scores were collected at the end of each intervention. The fMRI data were then analyzed using multivariate GCA. Results: Our results found statistically significant differences in VAS scores from baseline (pain status) for both placebo and nocebo interventions, as well as between placebo and nocebo interventions. In placebo network, we found a negative lagged-temporal correlation between multiple brain areas, including the dorsolateral prefrontal cortex (DLPFC), secondary somatosensory cortex area, anterior cingulate cortex (ACC), and insular cortex (IC); and a positive lagged-temporal correlation between multiple brain areas, including IC, thalamus, ACC, as well as the supplementary motor area (SMA). In the nocebo network, we also found a positive lagged-temporal correlation between multiple brain areas, including the primary somatosensory cortex area, caudate, DLPFC and SMA. Conclusion: The results of this study suggest that both pain-related network and reward system are involved in placebo and nocebo responses. The placebo response mainly works by activating the reward system and inhibiting pain-related network, while the nocebo response is the opposite. Placebo network also involves the activation of opioid-mediated analgesia system (OMAS) and emotion pathway, while nocebo network involves the deactivation of emotional control. At the same time, through the construction of the GC network, we verified our hypothesis that nocebo and placebo networks share part of the same brain regions, but the two networks also have their own unique structural features.
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Affiliation(s)
- Yu Shi
- Department of Rehabilitation, Zhujiang Hospital, Southern Medical University, Guangzhou, China
| | - Shaoye Cui
- Department of Intensive Care Unit, Zhujiang Hospital, Southern Medical University, Guangzhou, China
| | - Yanyan Zeng
- Department of Rehabilitation, Zhujiang Hospital, Southern Medical University, Guangzhou, China
| | - Shimin Huang
- Department of Rehabilitation, Zhujiang Hospital, Southern Medical University, Guangzhou, China
| | - Guiyuan Cai
- Department of Rehabilitation, Zhujiang Hospital, Southern Medical University, Guangzhou, China
| | - Jianming Yang
- Department of Radiology, Zhujiang Hospital, Southern Medical University, Guangzhou, China
| | - Wen Wu
- Department of Rehabilitation, Zhujiang Hospital, Southern Medical University, Guangzhou, China
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Hölsken S, Krefting F, Schedlowski M, Sondermann W. Expectation-induced enhancement of pain, itch and quality of life in psoriasis patients: study protocol of a randomised controlled trial. BMJ Open 2021; 11:e047099. [PMID: 34475155 PMCID: PMC8413966 DOI: 10.1136/bmjopen-2020-047099] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/24/2022] Open
Abstract
INTRODUCTION Experimental and clinical data demonstrate that skin diseases like psoriasis are affected by psychological factors and can be modulated by interventions other than conventional drug therapy. The expectation of patients towards the benefit of a forthcoming treatment as well as treatment pre-experiences have been demonstrated as crucial factors mediating placebo responses in inflammatory skin diseases. However, it is unknown whether and to what extent treatment outcomes of psoriasis patients under therapy with monoclonal antibodies like secukinumab can be experimentally modulated at subjective and physiological levels by modifying the expectation of patients via verbal instruction or prior experience. METHODS AND ANALYSIS Treatment expectations will be modulated in patients with moderate-to-severe psoriasis undergoing treatment with the anti-interleukin-17A monoclonal antibody secukinumab. Patients with a Psoriasis Area and Severity Index (PASI) >12 will be randomly allocated to one of three groups (N=40 each). As a standard schedule, patients in the pharmacological control group (group 1) will be treated weekly with 300 mg secukinumab, while patients in groups 2 and 3 will receive only 75 mg secukinumab (75% dose reduction) during all treatment weeks. In addition to the injections, patients in group 3 will ingest a novel tasting drink, with a cover story explaining that previous studies showed additional beneficial effects of this combination (drug and drink). Patients will be assessed and treated at nine visits over a 16-week period, during which the severity of pain and itch symptoms, skin lesions and quality of life will be analysed with standardised questionnaires and the PASI. ETHICS AND DISSEMINATION This study was approved by the Ethics committee of the Medical Faculty of the University Duisburg-Essen. Study outcomes will be published in peer-reviewed scientific journals.
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Affiliation(s)
- Stefanie Hölsken
- Institute of Medical Psychology and Behavioral Immunobiology, University Hospital Essen, University Duisburg-Essen, Essen, Germany
| | - Frederik Krefting
- Department of Dermatology, Venereology and Allergology, University Hospital Essen, University Duisburg-Essen, Essen, Germany
| | - Manfred Schedlowski
- Institute of Medical Psychology and Behavioral Immunobiology, University Hospital Essen, University Duisburg-Essen, Essen, Germany
- Department of Clinical Neuroscience, Osher Center for Integrative Medicine, Karolinska Institute, Stockholm, Sweden
| | - Wiebke Sondermann
- Department of Dermatology, Venereology and Allergology, University Hospital Essen, University Duisburg-Essen, Essen, Germany
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103
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Howick J. Unethical informed consent caused by overlooking poorly measured nocebo effects. JOURNAL OF MEDICAL ETHICS 2021; 47:590-594. [PMID: 32063581 DOI: 10.1136/medethics-2019-105903] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/23/2019] [Revised: 01/04/2020] [Accepted: 01/13/2020] [Indexed: 06/10/2023]
Abstract
Unlike its friendly cousin the placebo effect, the nocebo effect (the effect of expecting a negative outcome) has been almost ignored. Epistemic and ethical confusions related to its existence have gone all but unnoticed. Contrary to what is often asserted, adverse events following from taking placebo interventions are not necessarily nocebo effects; they could have arisen due to natural history. Meanwhile, ethical informed consent (in clinical trials and clinical practice) has centred almost exclusively on the need to inform patients about intervention risks with patients to preserve their autonomy. Researchers have failed to consider the harm caused by the way in which the information is conveyed. In this paper, I argue that the magnitude of nocebo effects must be measured using control groups consisting of untreated patients. And, because the nocebo effect can produce harm, the principle of non-maleficence must be taken into account alongside autonomy when obtaining (ethical) informed consent and communicating intervention risks with patients.
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Affiliation(s)
- Jeremy Howick
- Faculty of Philosophy, University of Oxford, Oxford OX2 6GG, UK
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104
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Placebo Response Reduction and Accurate Pain Reporting Training Reduces Placebo Responses in a Clinical Trial on Chronic Low Back Pain: Results From a Comparison to the Literature. Clin J Pain 2021; 36:950-954. [PMID: 32841968 DOI: 10.1097/ajp.0000000000000873] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
Abstract
OBJECTIVE A literature review was conducted to compare placebo responses in a recent trial-which implemented an accurate pain reporting (APR) and placebo response reduction (PRR) training program-with placebo responses in similar previous trials in chronic lower back pain (CLBP) that did not use such training. METHODS A literature search was performed to find parallel design, randomized, controlled trials of pharmacological treatments administered orally or through intravenous injection for CLBP. Studies were assessed for the proportion of placebo responders, defined as the proportion of patients in the placebo group with ≥30% reduction in pain intensity. A χ analysis was performed on the proportion of responders from the SPRINT trial and from other similar studies. RESULTS Of 844 studies identified in the initial screening process, 16 studies were included for comparison. The percentage of placebo responders was statistically significantly lower in the SPRINT study (19.1%) compared with other CLBP trials (38.0%) (P=0.003). Our results show that the placebo response was lower in the SPRINT trial than other comparable studies on CLBP. DISCUSSION These findings are consistent with results from other studies showing that neutralizing subject and study staff expectations of therapeutic benefit can decrease the placebo response in clinical trials. The results of this study suggest training participants and staff to improve pain reporting accuracy, neutralize expectations, and decrease external cues that may bias participants' pain ratings in clinical trials may effectively decrease the placebo response leading to increased assay sensitivity.
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105
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Hamani C, Fonoff ET, Parravano DC, Silva VA, Galhardoni R, Monaco B, Navarro J, Yeng LT, Teixeira MJ, Ciampi de Andrade D. Motor cortex stimulation for chronic neuropathic pain: results of a double-blind randomized study. Brain 2021; 144:2994-3004. [PMID: 34373901 DOI: 10.1093/brain/awab189] [Citation(s) in RCA: 31] [Impact Index Per Article: 10.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/25/2021] [Revised: 04/04/2021] [Accepted: 04/26/2021] [Indexed: 11/13/2022] Open
Abstract
Motor cortex stimulation (MCS) via surgically implanted electrodes has been used as an off-label treatment for chronic neuropathic pain (cNeP) but its efficacy has not been fully established. We aimed to objectively study the efficacy of MCS and characterize potential predictors of response. In this randomised, double-blind, sham-controlled, single centre trial, we recruited 18 cNeP patients who did not adequately respond to conventional treatment and had a numerical rating pain scale (NRS) score ≥ 6. Patients were initially assigned to receive three months of active ("on") or sham ("off") stimulation in a double-blind cross-over phase. This was followed by a 3-month single-blind phase, and 6 months of open-label follow-up. A meaningful response in our trial was defined as a ≥ 30% or 2-point reduction in NRS scores during active stimulation. Using Bayesian statistics, we found a 41.4% probability of response towards "on" vs. "off" MCS. The probability of improvement during active stimulation (double-blind, single-blind and open label phases) compared to baseline was of 47.2-68.5%. 39% of patients were long-term responders, 71.4% of whom had facial pain, phantom limb pain, or complex regional pain syndrome. In contrast, 72.7% of non-responders had either post-stroke pain or pain associated with brachial plexus avulsion. 39% of patients had a substantial post-operative analgesic effect after electrode insertion in the absence of stimulation. Individuals with diagnoses associated with a good postoperative outcome or those who developed an insertional effect had a near 100% probability of response to MCS. In summary, we found that approximately 40% of patients responded to MCS, particularly those who developed an insertional effect or had specific clinical conditions that seemed to predict an appropriate postoperative response.
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Affiliation(s)
- Clement Hamani
- Division of Functional Neurosurgery, Department of Neurology, Faculdade de Medicina, Universidade de São Paulo, São Paulo, Brazil.,Harquail Centre for Neuromodulation, Division of Neurosurgery, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, ON, Canada
| | - Erich T Fonoff
- Division of Functional Neurosurgery, Department of Neurology, Faculdade de Medicina, Universidade de São Paulo, São Paulo, Brazil
| | - Daniella C Parravano
- Division of Functional Neurosurgery, Department of Neurology, Faculdade de Medicina, Universidade de São Paulo, São Paulo, Brazil
| | - Valquiria A Silva
- Pain Center, LIM-62, Department of Neurology, Faculdade de Medicina, Universidade de São Paulo, São Paulo, Brazil
| | - Ricardo Galhardoni
- Pain Center, LIM-62, Department of Neurology, Faculdade de Medicina, Universidade de São Paulo, São Paulo, Brazil
| | - Bernardo Monaco
- Division of Functional Neurosurgery, Department of Neurology, Faculdade de Medicina, Universidade de São Paulo, São Paulo, Brazil
| | - Jessie Navarro
- Division of Functional Neurosurgery, Department of Neurology, Faculdade de Medicina, Universidade de São Paulo, São Paulo, Brazil
| | - Lin T Yeng
- Pain Center, LIM-62, Department of Neurology, Faculdade de Medicina, Universidade de São Paulo, São Paulo, Brazil
| | - Manoel J Teixeira
- Division of Functional Neurosurgery, Department of Neurology, Faculdade de Medicina, Universidade de São Paulo, São Paulo, Brazil.,Pain Center, LIM-62, Department of Neurology, Faculdade de Medicina, Universidade de São Paulo, São Paulo, Brazil
| | - Daniel Ciampi de Andrade
- Division of Functional Neurosurgery, Department of Neurology, Faculdade de Medicina, Universidade de São Paulo, São Paulo, Brazil.,Pain Center, LIM-62, Department of Neurology, Faculdade de Medicina, Universidade de São Paulo, São Paulo, Brazil
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106
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Bajcar EA, Wiercioch-Kuzianik K, Farley D, Buglewicz E, Paulewicz B, Bąbel P. Order does matter: the combined effects of classical conditioning and verbal suggestions on placebo hypoalgesia and nocebo hyperalgesia. Pain 2021; 162:2237-2245. [PMID: 34256381 PMCID: PMC8280968 DOI: 10.1097/j.pain.0000000000002211] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/11/2020] [Revised: 01/03/2021] [Accepted: 01/20/2021] [Indexed: 12/19/2022]
Abstract
ABSTRACT In most experimental studies in which verbal suggestion and classical conditioning are implemented together to induce placebo effects, the former precedes the latter. In naturally occurring situations, however, the information concerning pain does not always precede but often follows the pain experience. Moreover, this information is not always congruent with experience. This study investigates whether the chronology of verbal suggestion and conditioning, as well as their congruence, affects placebo hypoalgesia and nocebo hyperalgesia. The effects induced in 15 groups were compared. The participants in 8 experimental groups were presented with verbal suggestions that were either congruent or incongruent with classical conditioning. The verbal suggestions were provided either before or after conditioning. In 2 other experimental groups, placebo conditioning or nocebo conditioning was implemented without any verbal suggestion; in 2 groups, verbal suggestion of hypoalgesia or hyperalgesia without conditioning was applied. The control groups without any suggestions or conditioning were also included. Placebo hypoalgesia induced by congruent procedures was significantly stronger when the suggestion of hypoalgesia preceded rather than followed conditioning. The order of the congruent procedures did not affect the magnitude of nocebo hyperalgesia. In the groups in which incongruent procedures were implemented, placebo hypoalgesia or nocebo hyperalgesia was in line with the direction of the last-used procedure, regardless of whether it was conditioning or verbal suggestion. The results show that not the type of the procedure (verbal suggestion or conditioning), but the direction of the last-used procedure shapes pain-related expectancies and determines placebo effects.
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Affiliation(s)
- Elżbieta A. Bajcar
- Jagiellonian University, Institute of Psychology, Pain Research Group, Kraków, Poland
| | | | - Dominika Farley
- Jagiellonian University, Institute of Psychology, Pain Research Group, Kraków, Poland
| | - Ewa Buglewicz
- Jagiellonian University, Institute of Psychology, Pain Research Group, Kraków, Poland
| | | | - Przemysław Bąbel
- Jagiellonian University, Institute of Psychology, Pain Research Group, Kraków, Poland
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107
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Bedford T, Adediran T, Haycock NR, Mullins CD, Medeiros M, Wright T, Curatolo M, Hamlin L, Colloca L. Patient and Provider Acceptability of a Patient Preauthorized Concealed Opioid Reduction. PAIN MEDICINE 2021; 22:1651-1659. [PMID: 33674821 DOI: 10.1093/pm/pnaa454] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
OBJECTIVE Limited research of how to best taper opioids brings about an ethical and clinical dilemma. Experiments using overt and concealed administration of opioids have demonstrated the benefits of a concealed reduction to eliminate negative expectations and prolong analgesic benefits. This may allow for opioid tapering without significant increases in pain. Based on this, we investigated patient and provider acceptance of a concealed opioid reduction for chronic pain. METHODS We conducted a cross-sectional survey via REDcap with 74 patients, who are currently taking or have taken high dose opioids, and 49 providers using a validated questionnaire based on two hypothetical clinical trials comparing a patient preauthorized concealed opioid reduction vs standard tapering. RESULTS We found that patients and providers have positive attitudes toward a concealed reduction of opioid dosages. More than 60% of providers and patients surveyed viewed the hypothetical clinical trial as helpful to reduce pain, side effects, and withdrawal symptoms. Sixty-one percent of patients and 77.6% of providers recognized that there would be differences in pain relief depending upon which group the hypothetical participants would be enrolled in. CONCLUSIONS Patients and providers appear to understand the benefits of a concealed opioid reduction. Our findings support future randomized controlled trials that compare concealed and overt opioid tapering in patients with chronic pain. More research is needed to understand the difference in attitudes between research and clinical practice and to test the acceptability of a concealed reduction following a participation in an active clinical trial.
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Affiliation(s)
- Theresa Bedford
- Uniformed Services University of the Health Sciences, Graduate School of Nursing, Bethesda, Maryland, USA
| | - Timileyin Adediran
- Department of Epidemiology and Human Genetics, School of Medicine, University of Maryland, Baltimore, Maryland, USA
| | - Nathaniel R Haycock
- Department of Pain and Translational Symptom Science, School of Nursing, University of Maryland, Baltimore, Maryland, USA
| | - C Daniel Mullins
- School of Pharmacy, University of Maryland, Baltimore, Maryland, USA
| | - Michelle Medeiros
- School of Pharmacy, University of Maryland, Baltimore, Maryland, USA
| | - Thelma Wright
- Department of Anesthesiology, School of Nursing, University of Maryland, Baltimore, Maryland, USA
| | - Michele Curatolo
- Department of Anesthesiology & Pain Medicine, University of Washington, School of Medicine, Seattle, USA
| | - Lynette Hamlin
- Uniformed Services University of the Health Sciences, Graduate School of Nursing, Bethesda, Maryland, USA
| | - Luana Colloca
- Department of Pain and Translational Symptom Science, School of Nursing, University of Maryland, Baltimore, Maryland, USA.,Department of Anesthesiology, School of Nursing, University of Maryland, Baltimore, Maryland, USA.,Center to Advance Chronic Pain Research, University of Maryland, Baltimore, Maryland USA
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108
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Case L, Adler-Neal AL, Wells RE, Zeidan F. The Role of Expectations and Endogenous Opioids in Mindfulness-Based Relief of Experimentally Induced Acute Pain. Psychosom Med 2021; 83:549-556. [PMID: 33480666 PMCID: PMC8415135 DOI: 10.1097/psy.0000000000000908] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Abstract
OBJECTIVE Expectations contribute to cognitive pain modulation through opioidergically mediated descending inhibition. Mindfulness meditation reduces pain independent of endogenous opioids, engaging unique corticothalamocortical mechanisms. However, it remains unknown whether expectations for pain relief predict mindfulness-induced analgesia and if these expectations are modified by endogenous opioids. METHODS In this secondary analysis of previously published work, 78 pain-free participants (mean age, 27 ± 7 years; 50% women) were randomized to a four-session mindfulness meditation or book listening regimen. Expectations for intervention-induced pain relief were assessed before and after each intervention. Pain ratings were examined after meditation or rest (control group) during noxious heat (49°C) and intravenous administration of saline placebo or the opioid antagonist naloxone (0.15 mg/kg bolus + 0.1 mg kg-1 h-1 infusion. RESULTS Mindfulness significantly lowered pain during saline and naloxone infusion. Higher expected pain relief from mindfulness predicted lower pain intensity (r(40) = -0.41, p = .009). The relationship between meditation-related expectations and pain intensity reductions was exhibited during naloxone (r(20) = -0.76, p < .001) but not saline (r(20) = -0.22, p = .36). Expectations for book listening-based analgesia did not significantly predict pain changes during saline (r(20) = -0.37, p = .11) or naloxone (r(18) = 0.26, p = .30) in the control group. CONCLUSIONS These novel findings demonstrate a significant role for expectations in mindfulness-based pain relief. However, this role was minimal during saline and stronger during opioid blockade, despite similar pain reductions. This supports growing evidence that mindfulness engages multiple mechanisms to reduce pain, suggesting that mindfulness might be an effective pain-reducing technique even for individuals with low expectations for pain relief.
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Affiliation(s)
- Laura Case
- Department of Anesthesiology, University of California at San Diego
| | | | | | - Fadel Zeidan
- Department of Anesthesiology, University of California at San Diego
- Department of Neurobiology and Anatomy, Wake Forest School of Medicine
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109
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Colloca L, Kisaalita NR, Bizien M, Medeiros M, Sandbrink F, Mullins CD. Veteran engagement in opioid tapering research: a mission to optimize pain management. Pain Rep 2021; 6:e932. [PMID: 34104838 PMCID: PMC8177869 DOI: 10.1097/pr9.0000000000000932] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/26/2021] [Revised: 04/10/2021] [Accepted: 04/17/2021] [Indexed: 02/01/2023] Open
Affiliation(s)
- Luana Colloca
- Departments of Pain and Translational Symptom Science
- Anesthesiology, School of Nursing, University of Maryland, Baltimore, MD, USA
- Center to Advance Chronic Pain Research, University of Maryland, Baltimore, MD, USA
| | - Nkaku R. Kisaalita
- Mental Health Service Line, Orlando Veterans Affairs Medical Center, Orlando, FL, USA
| | - Marcel Bizien
- Veterans Affairs Cooperative Studies Program, Clinical Research Pharmacy, Coordinating Center, Albuquerque, NM, USA
- College of Pharmacy, University of New Mexico, Albuquerque, NM, USA
| | - Michelle Medeiros
- Pharmaceutical Health Services Research Department, School of Pharmacy, University of Maryland, Baltimore, MD, USA
| | - Friedhelm Sandbrink
- Department of Neurology, Washington DC Veterans Affairs Medical Center, Washington DC, USA
- Department of Neurology, George Washington University, Washington DC, USA
| | - C. Daniel Mullins
- Pharmaceutical Health Services Research Department, School of Pharmacy, University of Maryland, Baltimore, MD, USA
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110
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Capella-Peris C, Cosgrove MM, Chrismer IC, Razaqyar MS, Elliott JS, Kuo A, Emile-Backer M, Meilleur KG. Understanding Symptoms in RYR1-Related Myopathies: A Mixed-Methods Analysis Based on Participants' Experience. PATIENT-PATIENT CENTERED OUTCOMES RESEARCH 2021; 13:423-434. [PMID: 32329019 DOI: 10.1007/s40271-020-00418-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
BACKGROUND In rare diseases such as ryanodine receptor 1-related myopathies (RYR1-RM), health-related quality of life (HRQoL) measures are critically important so clinicians and researchers can better understand what symptoms are most important to participants, with the ultimate goal of finding tangible solutions for them. OBJECTIVES The main objective of this study was to characterize symptoms in individuals with RYR1-RM to inform future research. A secondary objective of this study was to analyze positive and negative sentiments regarding symptoms and treatment effects post N-acetylcysteine (NAC) administration in individuals with RYR1-RM. METHODS The study used a mixed-methods design applying methodological triangulation. Qualitative data were collected via semi-structured interviews at three visits to characterize symptoms in individuals with RYR1-RM and to analyze treatment effects. Qualitative data were then transformed into quantitative results to measure the frequency with which each symptom was mentioned by participants. RESULTS A total of 12 symptoms were identified as areas of interest to participants with RYR1-RM, highlighting fatigue and weakness as key symptoms. Data transformation categorized more than 1000 citations, reporting a greater number of positive comments for postintervention interviews than for baseline and preintervention visits and that NAC group participants stated more positive comments regarding treatment effect than did the placebo group. CONCLUSIONS We present a comprehensive characterization of symptoms in RYR1-RM and how those symptoms influence HRQoL. Furthermore, the introduction of mixed methods may be a valuable way to better understand patient-centered data in rare diseases to support affected individuals in coping with their symptoms.
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Affiliation(s)
- Carlos Capella-Peris
- Neuromuscular Symptoms Unit, Tissue Injury Branch, National Institute of Nursing Research, National Institutes of Health, Building 60, Room 254, Bethesda, MD, 20892, USA.
| | - Mary M Cosgrove
- Neuromuscular Symptoms Unit, Tissue Injury Branch, National Institute of Nursing Research, National Institutes of Health, Building 60, Room 254, Bethesda, MD, 20892, USA
| | - Irene C Chrismer
- Neuromuscular Symptoms Unit, Tissue Injury Branch, National Institute of Nursing Research, National Institutes of Health, Building 60, Room 254, Bethesda, MD, 20892, USA
| | - M Sonia Razaqyar
- Neuromuscular Symptoms Unit, Tissue Injury Branch, National Institute of Nursing Research, National Institutes of Health, Building 60, Room 254, Bethesda, MD, 20892, USA
| | - Jeffrey S Elliott
- Neuromuscular Symptoms Unit, Tissue Injury Branch, National Institute of Nursing Research, National Institutes of Health, Building 60, Room 254, Bethesda, MD, 20892, USA
| | - Anna Kuo
- Neuromuscular Symptoms Unit, Tissue Injury Branch, National Institute of Nursing Research, National Institutes of Health, Building 60, Room 254, Bethesda, MD, 20892, USA
| | - Magalie Emile-Backer
- Neuromuscular Symptoms Unit, Tissue Injury Branch, National Institute of Nursing Research, National Institutes of Health, Building 60, Room 254, Bethesda, MD, 20892, USA
| | - Katherine G Meilleur
- Neuromuscular Symptoms Unit, Tissue Injury Branch, National Institute of Nursing Research, National Institutes of Health, Building 60, Room 254, Bethesda, MD, 20892, USA
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111
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Flowers KM, Patton ME, Hruschak VJ, Fields KG, Schwartz E, Zeballos J, Kang JD, Edwards RR, Kaptchuk TJ, Schreiber KL. Conditioned open-label placebo for opioid reduction after spine surgery: a randomized controlled trial. Pain 2021; 162:1828-1839. [PMID: 33449503 PMCID: PMC8378225 DOI: 10.1097/j.pain.0000000000002185] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/05/2020] [Accepted: 12/31/2020] [Indexed: 12/19/2022]
Abstract
ABSTRACT Placebo effects have traditionally involved concealment or deception. However, recent evidence suggests that placebo effects can also be elicited when prescribed transparently as "open-label placebos" (OLPs), and that the pairing of an unconditioned stimulus (eg, opioid analgesic) with a conditioned stimulus (eg, placebo pill) can lead to the conditioned stimulus alone reducing pain. In this randomized control trial, we investigated whether combining conditioning with an OLP (COLP) in the immediate postoperative period could reduce daily opioid use and postsurgical pain among patients recovering from spine surgery. Patients were randomized to COLP or treatment as usual, with both groups receiving unrestricted access to a typical opioid-based postoperative analgesic regimen. The generalized estimating equations method was used to assess the treatment effect of COLP on daily opioid consumption and pain during postoperative period from postoperative day (POD) 1 to POD 17. Patients in the COLP group consumed approximately 30% less daily morphine milligram equivalents compared with patients in the treatment as usual group during POD 1 to 17 (-14.5 daily morphine milligram equivalents; 95% CI: [-26.8, -2.2]). Daily worst pain scores were also lower in the COLP group (-1.0 point on the 10-point scale; 95% CI: [-2.0, -0.1]), although a significant difference was not detected in average daily pain between the groups (-0.8 point; 95% CI: [-1.7, 0.2]). These findings suggest that COLP may serve as a potential adjuvant analgesic therapy to decrease opioid consumption in the early postoperative period, without increasing pain.
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Affiliation(s)
- Kelsey M. Flowers
- Departments of Anesthesiology, Perioperative, and Pain Medicine Orthopedic Surgery, Brigham and Women’s Hospital, Harvard Medical School, Boston, MA, United States
| | - Megan E. Patton
- Departments of Anesthesiology, Perioperative, and Pain Medicine Orthopedic Surgery, Brigham and Women’s Hospital, Harvard Medical School, Boston, MA, United States
| | - Valerie J. Hruschak
- Departments of Anesthesiology, Perioperative, and Pain Medicine Orthopedic Surgery, Brigham and Women’s Hospital, Harvard Medical School, Boston, MA, United States
| | - Kara G. Fields
- Departments of Anesthesiology, Perioperative, and Pain Medicine Orthopedic Surgery, Brigham and Women’s Hospital, Harvard Medical School, Boston, MA, United States
| | - Emily Schwartz
- Departments of Anesthesiology, Perioperative, and Pain Medicine Orthopedic Surgery, Brigham and Women’s Hospital, Harvard Medical School, Boston, MA, United States
| | - Jose Zeballos
- Departments of Anesthesiology, Perioperative, and Pain Medicine Orthopedic Surgery, Brigham and Women’s Hospital, Harvard Medical School, Boston, MA, United States
| | - James D. Kang
- Departments of Orthopedic Surgery, Brigham and Women’s Hospital, Harvard Medical School, Boston, MA, United States
| | - Rob R. Edwards
- Departments of Anesthesiology, Perioperative, and Pain Medicine Orthopedic Surgery, Brigham and Women’s Hospital, Harvard Medical School, Boston, MA, United States
| | - Ted J. Kaptchuk
- Program in Placebo Studies and Therapeutic Encounter, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, United States
| | - Kristin L. Schreiber
- Departments of Anesthesiology, Perioperative, and Pain Medicine Orthopedic Surgery, Brigham and Women’s Hospital, Harvard Medical School, Boston, MA, United States
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112
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Wilhelm M, Euteneuer F. Does Health Literacy Make a Difference? Comparing the Effect of Conventional Medicine Versus Homeopathic Prescribing on Treatment Credibility and Expectancy. Front Psychol 2021; 12:581255. [PMID: 34140910 PMCID: PMC8204743 DOI: 10.3389/fpsyg.2021.581255] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/08/2020] [Accepted: 04/27/2021] [Indexed: 11/13/2022] Open
Abstract
Objective While homeopathic remedies are often used to treat non-specific complaints such as headaches, empirical evidence suggests their treatment effect is due to the placebo effect. Low health literacy seems to be connected to higher use of complementary and alternative medicine (CAM). The aim of this study was to examine what people with occasional headaches expect from conventional medicine or homeopathic remedies and if health literacy interacts with this expectation. Methods In this experimental study, n = 582 participants with occasional headaches were randomized to read one of two vignettes, which described the prescription of either conventional medicine or a homeopathic remedy. Subsequently, the participants were asked to rate treatment credibility and expectancy with regard to their assigned vignette. Health literacy was assessed as a potential moderator. Results Participants in the conventional medicine group rated treatment credibility and expectancy higher than in the homeopathic remedy group. Moderation analysis revealed that when being offered conventional medicine, participant reports of treatment credibility and expectancy decreased with lower health literacy, while these outcomes increased with lower health literacy for homeopathic remedies. Discussion People with occasional headaches estimate the effectiveness of conventional medication properly. However, health care professionals should pay special attention to patients with low health literacy, as they might need more time and information to give their informed consent.
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Affiliation(s)
- Marcel Wilhelm
- Department of Clinical Psychology and Psychotherapy, Philipps University of Marburg, Marburg, Germany
| | - Frank Euteneuer
- Department of Clinical Psychology and Psychotherapy, Philipps University of Marburg, Marburg, Germany.,Department of Psychology, Clinical Psychology and Psychotherapy, Medical School Berlin, Berlin, Germany
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113
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Abstract
ABSTRACT Efficacy of treatment is heavily dependent on experience and expectations. Moreover, humans can generalize from one experience to a perceptually similar but novel situation. We investigated whether and how this applies to pain relief, using ecologically valid tonic pain stimuli treated by surreptitiously lowering the applied temperature. Using different face cues, participants experienced better treatment from one physician than another. Participants were then tested on 6 additional face cues perceptually lying between both faces. Our data from 2 independent samples (N = 18 and N = 39) show a treatment experience effect, ie, for physically identical treatments, the initially superior physician was reported to deliver stronger pain relief. More importantly, the other faces on the perceptual continuum showed a graded effect of pain relief, indicating placebo generalization. Introducing a paradigm feasible to induce placebo pain relief, we show that the generic learning principle of generalization can explain carryover effects between learned and novel treatment situations.
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114
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Manipulating placebo analgesia and nocebo hyperalgesia by changing brain excitability. Proc Natl Acad Sci U S A 2021; 118:2101273118. [PMID: 33941677 DOI: 10.1073/pnas.2101273118] [Citation(s) in RCA: 16] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
Abstract
Harnessing placebo and nocebo effects has significant implications for research and medical practice. Placebo analgesia and nocebo hyperalgesia, the most well-studied placebo and nocebo effects, are thought to initiate from the dorsal lateral prefrontal cortex (DLPFC) and then trigger the brain's descending pain modulatory system and other pain regulation pathways. Combining repeated transcranial direct current stimulation (tDCS), an expectancy manipulation model, and functional MRI, we investigated the modulatory effects of anodal and cathodal tDCS at the right DLPFC on placebo analgesia and nocebo hyperalgesia using a randomized, double-blind and sham-controlled design. We found that compared with sham tDCS, active tDCS could 1) boost placebo and blunt nocebo effects and 2) modulate brain activity and connectivity associated with placebo analgesia and nocebo hyperalgesia. These results provide a basis for mechanistic manipulation of placebo and nocebo effects and may lead to improved clinical outcomes in medical practice.
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115
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LaRowe LR, Maisto SA, Ditre JW. A measure of expectancies for alcohol analgesia: Preliminary factor analysis, reliability, and validity. Addict Behav 2021; 116:106822. [PMID: 33460990 DOI: 10.1016/j.addbeh.2021.106822] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/17/2020] [Revised: 12/13/2020] [Accepted: 01/05/2021] [Indexed: 02/08/2023]
Abstract
Rates of alcohol consumption are substantially higher among persons with pain, and recent research has focused on elucidating bidirectional pain-alcohol effects. Expectancies for alcohol analgesia could influence the degree to which alcohol confers acute pain-relieving effects, and may amplify the propensity to respond to pain with drinking behavior. However, no validated measures of expectancies for alcohol analgesia are available. Therefore, we developed a five-item measure of Expectancies for Alcohol Analgesia (EAA), which assesses the perceived likelihood that alcohol will reduce pain. The goal of this project was to examine psychometric properties of the EAA among a sample of 273 current alcohol users with chronic pain (Mage = 32.9; 34% female) who completed an online survey of pain and substance use. Confirmatory factor analysis (CFA) results indicated that the hypothesized single-factor structure of the EAA provided good model fit (Bollen-Stine bootstrap p = .13). The EAA also showed excellent internal consistency (α = 0.97), and scores were positively associated with quantity/frequency of alcohol use, alcohol outcome expectancies, coping-related drinking motives, and pain severity (ps < 0.01). These findings provide initial support regarding the single-factor structure, reliability, and validity of the EAA. Examination of predictive utility and further validation are important next steps.
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116
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Lawn T, Aman Y, Rukavina K, Sideris-Lampretsas G, Howard M, Ballard C, Ray Chaudhuri K, Malcangio M. Pain in the neurodegenerating brain: insights into pharmacotherapy for Alzheimer disease and Parkinson disease. Pain 2021; 162:999-1006. [PMID: 33239526 PMCID: PMC7977618 DOI: 10.1097/j.pain.0000000000002111] [Citation(s) in RCA: 21] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/04/2020] [Revised: 09/18/2020] [Accepted: 10/08/2020] [Indexed: 12/13/2022]
Affiliation(s)
- Timothy Lawn
- Centre for Neuroimaging Sciences, The Institute of Psychiatry, Psychology, and Neuroscience, King's College London, London, United Kingdom
| | - Yahyah Aman
- Department of Clinical Molecular Biology, University of Oslo and Akershus University Hospital, Lørenskog, Norway
| | - Katarina Rukavina
- The Maurice Wohl Clinical Neuroscience Institute, The Institute of Psychiatry, Psychology, and Neuroscience, King's College London, London, United Kingdom
- Parkinson Foundation Centre of Excellence, King's College Hospital, London, United Kingdom
| | - George Sideris-Lampretsas
- Wolfson Centre for Age Related Diseases, The Institute of Psychiatry, Psychology, and Neuroscience, King's College London, London, United Kingdom
| | - Matthew Howard
- Centre for Neuroimaging Sciences, The Institute of Psychiatry, Psychology, and Neuroscience, King's College London, London, United Kingdom
| | | | - Kallol Ray Chaudhuri
- The Maurice Wohl Clinical Neuroscience Institute, The Institute of Psychiatry, Psychology, and Neuroscience, King's College London, London, United Kingdom
- Parkinson Foundation Centre of Excellence, King's College Hospital, London, United Kingdom
| | - Marzia Malcangio
- Wolfson Centre for Age Related Diseases, The Institute of Psychiatry, Psychology, and Neuroscience, King's College London, London, United Kingdom
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117
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Munk A, Reme SE, Jacobsen HB. What Does CATS Have to Do With Cancer? The Cognitive Activation Theory of Stress (CATS) Forms the SURGE Model of Chronic Post-surgical Pain in Women With Breast Cancer. Front Psychol 2021; 12:630422. [PMID: 33833718 PMCID: PMC8023326 DOI: 10.3389/fpsyg.2021.630422] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/17/2020] [Accepted: 03/01/2021] [Indexed: 01/25/2023] Open
Abstract
Chronic post-surgical pain (CPSP) represents a highly prevalent and significant clinical problem. Both major and minor surgeries entail risks of developing CPSP, and cancer-related surgery is no exception. As an example, more than 40% of women undergoing breast cancer surgery struggle with CPSP years after surgery. While we do not fully understand the pathophysiology of CPSP, we know it is multifaceted with biological, social, and psychological factors contributing. The aim of this review is to advocate for the role of response outcome expectancies in the development of CPSP following breast cancer surgery. We propose the Cognitive Activation Theory of Stress (CATS) as an applicable theoretical framework detailing the potential role of cortisol regulation, inflammation, and inflammatory-induced sickness behavior in CPSP. Drawing on learning theory and activation theory, CATS offers psychobiological explanations for the relationship between stress and health, where acquired expectancies are crucial in determining the stress response and health outcomes. Based on existing knowledge about risk factors for CPSP, and in line with the CATS position, we propose the SURGEry outcome expectancy (SURGE) model of CPSP. According to SURGE, expectancies impact stress physiology, inflammation, and fear-based learning influencing the development and persistence of CPSP. SURGE further proposes that generalized response outcome expectancies drive adaptive or maladaptive stress responses in the time around surgery, where coping dampens the stress response, while helplessness and hopelessness sustains it. A sustained stress response may contribute to central sensitization, alterations in functional brain networks and excessive fear-based learning. This sets the stage for a prolonged state of inflammatory-induced sickness behavior - potentially driving and maintaining CPSP. Finally, as psychological factors are modifiable, robust and potent predictors of CPSP, we suggest hypnosis as an effective intervention strategy targeting response outcome expectancies. We here argue that presurgical clinical hypnosis has the potential of preventing CPSP in women with breast cancer.
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Affiliation(s)
- Alice Munk
- The Mind-Body Lab, Department of Psychology, Faculty of Social Sciences, University of Oslo, Oslo, Norway
| | - Silje Endresen Reme
- The Mind-Body Lab, Department of Psychology, Faculty of Social Sciences, University of Oslo, Oslo, Norway.,Department of Pain Management and Research, Oslo University Hospital, Oslo, Norway
| | - Henrik Børsting Jacobsen
- The Mind-Body Lab, Department of Psychology, Faculty of Social Sciences, University of Oslo, Oslo, Norway.,Department of Pain Management and Research, Oslo University Hospital, Oslo, Norway
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118
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Dunbar EK, Saloman JL, Phillips AE, Whitcomb DC. Severe Pain in Chronic Pancreatitis Patients: Considering Mental Health and Associated Genetic Factors. J Pain Res 2021; 14:773-784. [PMID: 33762844 PMCID: PMC7982558 DOI: 10.2147/jpr.s274276] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/29/2020] [Accepted: 02/20/2021] [Indexed: 12/24/2022] Open
Abstract
Pain is the most distressing and disruptive feature of recurrent acute pancreatitis (RAP) and chronic pancreatitis (CP) resulting in low quality of life (QOL) and disabilities. There is no single, characteristic pain pattern in patients with RAP and CP. Abdominal imaging features of CP accurately reflect morphologic features but they do not correlate with pain. Pain is the major driver of poor quality of life (QOL) and it is the constant pain, rather than intermittent pain that drives poor QOL. Furthermore, the most severe constant pain experience in CP is also a complex condition. The ability to target the etiopathogenesis of severe pain requires new methods to detect the exact pain mechanisms in an individual at cellular, tissue, system and psychiatric levels. In patients with complex and severe disease, it is likely that multiple overlapping mechanisms are simultaneously driving pain, anxiety and depression. Quantitative sensory testing (QST) shows promise in detecting alterations in central processing of pain signals and to classify patients for mechanistic and therapeutic studies. New genetic research suggests that genetic loci for severe pain in CP overlap with genetic loci for depression and other psychiatric disorders, providing additional insights and therapeutic targets for individual patients with severe CP pain. Well-designed clinical trials that integrate clinical features, QST, genetics and psychological assessments with targeted treatment and assessment of responses are required for a quantum leap forward. A better understanding of the context and mechanisms contributing to severe pain experiences in individual patients is predicted to lead to better therapies and quality of life.
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Affiliation(s)
- Ellyn K Dunbar
- Departments of Human Genetics and Medicine, Division of Gastroenterology, Hepatology and Nutrition, University of Pittsburgh, Pittsburgh, PA, USA
| | - Jami L Saloman
- Departments of Neurobiology and Medicine, Division of Gastroenterology, Hepatology and Nutrition, Pittsburgh Center for Pain Research, University of Pittsburgh, Pittsburgh, PA, USA
| | - Anna Evans Phillips
- Department of Medicine, Division of Gastroenterology, Hepatology and Nutrition, University of Pittsburgh, Pittsburgh, PA, USA
| | - David C Whitcomb
- Departments of Human Genetics, Cell Biology and Molecular Physiology, and Medicine, Division of Gastroenterology, Hepatology and Nutrition, Pittsburgh Center for Pain Research, University of Pittsburgh, Pittsburgh, PA, USA
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119
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Smits RM, Veldhuijzen DS, Olde Hartman T, Peerdeman KJ, Van Vliet LM, Van Middendorp H, Rippe RCA, Wulffraat NM, Evers AWM. Explaining placebo effects in an online survey study: Does 'Pavlov' ring a bell? PLoS One 2021; 16:e0247103. [PMID: 33705397 PMCID: PMC7951811 DOI: 10.1371/journal.pone.0247103] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/03/2020] [Accepted: 02/01/2021] [Indexed: 12/12/2022] Open
Abstract
OBJECTIVES Despite the increasing knowledge about placebo effects and their beneficial impact on treatment outcomes, strategies that explicitly employ these mechanisms remain scarce. To benefit from placebo effects, it is important to gain better understanding in how individuals want to be informed about placebo effects (for example about the underlying mechanisms that steer placebo effects). The main aim of this study was to investigate placebo information strategies in a general population sample by assessing current placebo knowledge, preferences for different placebo explanations (built around well-known mechanisms involved in placebo effects), and attitudes and acceptability towards the use of placebo effects in treatment. DESIGN Online survey. SETTING Leiden, The Netherlands. PARTICIPANTS 444 participants (377 completers), aged 16-78 years. MAIN OUTCOME MEASURES Current placebo knowledge, placebo explanation preferences, and placebo attitudes and acceptability. RESULTS Participants scored high on current placebo knowledge (correct answers: M = 81.15%, SD = 12.75). Comparisons of 8 different placebo explanations revealed that participants preferred explanations based on brain mechanisms and positive expectations more than all other explanations (F(7, 368) = 3.618, p = .001). Furthermore, attitudes and acceptability for placebos in treatment varied for the type of the condition (i.e. more acceptant for psychological complaints) and participants indicated that physicians do not always have to be honest while making use of placebo effects for therapeutic benefit. CONCLUSION Our results brought forth new evidence in placebo information strategies, and indicated that explanations based on brain mechanisms and positive expectations were most preferred. These results can be insightful to construct placebo information strategies for both clinical context and research practices.
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Affiliation(s)
- Rosanne M. Smits
- Health, Medical and Neuropsychology unit, Leiden University, Leiden, The Netherlands
- Leiden Institute for Brain and Cognition, Leiden, The Netherlands
- Pediatric Immunology and Rheumatology, Wilhelmina Children’s Hospital, Utrecht, The Netherlands
| | - Dieuwke S. Veldhuijzen
- Health, Medical and Neuropsychology unit, Leiden University, Leiden, The Netherlands
- Leiden Institute for Brain and Cognition, Leiden, The Netherlands
- Pediatric Immunology and Rheumatology, Wilhelmina Children’s Hospital, Utrecht, The Netherlands
| | - Tim Olde Hartman
- Department of Primary and Community Care, Radboud Institute for Health Sciences, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Kaya J. Peerdeman
- Health, Medical and Neuropsychology unit, Leiden University, Leiden, The Netherlands
- Leiden Institute for Brain and Cognition, Leiden, The Netherlands
| | - Liesbeth M. Van Vliet
- Health, Medical and Neuropsychology unit, Leiden University, Leiden, The Netherlands
- Leiden Institute for Brain and Cognition, Leiden, The Netherlands
| | - Henriët Van Middendorp
- Health, Medical and Neuropsychology unit, Leiden University, Leiden, The Netherlands
- Leiden Institute for Brain and Cognition, Leiden, The Netherlands
| | - Ralph C. A. Rippe
- Research Methods and Statistics, Institute of Education and Child Studies, Leiden University, Leiden, The Netherlands
| | - Nico M. Wulffraat
- Pediatric Immunology and Rheumatology, Wilhelmina Children’s Hospital, Utrecht, The Netherlands
| | - Andrea W. M. Evers
- Health, Medical and Neuropsychology unit, Leiden University, Leiden, The Netherlands
- Leiden Institute for Brain and Cognition, Leiden, The Netherlands
- Department of Psychiatry, Leiden University Medical Center, Leiden, The Netherlands
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120
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Schönenberg M, Weingärtner AL, Weimer K, Scheeff J. Believing is achieving - On the role of treatment expectation in neurofeedback applications. Prog Neuropsychopharmacol Biol Psychiatry 2021; 105:110129. [PMID: 33031860 DOI: 10.1016/j.pnpbp.2020.110129] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/02/2020] [Revised: 10/01/2020] [Accepted: 10/03/2020] [Indexed: 11/16/2022]
Abstract
In neurofeedback applications, neural activity is recorded, processed in real-time and fed back to the user in order to facilitate self-regulation of the putative neural mechanisms that underlie cognition and behavior. Numerous studies suggest that neurofeedback interventions are an efficacious treatment particularly for patients with attention-deficit/hyperactivity disorder (ADHD). In recent years, however, findings of several well-controlled studies raised doubts concerning the proposed mechanism of action behind the behavioral effect of neurofeedback. This study investigated the impact of expectation on the efficacy of a sensorimotor rhythm (SMR) training. In a within-subjects design 30 blinded volunteers with ADHD symptoms received a standard SMR training session after inducing no (no-expectancy condition), positive (placebo condition), and negative (nocebo condition) expectations regarding the effectiveness of neurofeedback (by telling them that they would train a specific frequency band that was previously shown to be either unrelated to attention, should improve attention, or interfere with attentional processes). After each training, participants were presented with a cognitive test and subsequently requested to rate their performance on it. We could show that participants were able to successfully modify their EEG signal during training. Further, we found an effect over trainings on objective attentional performance. Most importantly, we found that the expectancy of positive or negative treatment effects considerably changed participants' perception of neurofeedback's efficacy even in the absence of any objective evidence. This study presents strong first evidence for a substantial effect of self-confirming response expectancies as one factor underlying the efficacy of neurofeedback. Future research has to carefully consider the impact of such psychosocial mechanisms when evaluating the (specific) efficacy of neuromodulatory treatments.
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Affiliation(s)
| | | | - Katja Weimer
- Department of Psychosomatic Medicine and Psychotherapy, Ulm University Medical Center, Germany
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121
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Camerone EM, Wiech K, Benedetti F, Carlino E, Job M, Scafoglieri A, Testa M. 'External timing' of placebo analgesia in an experimental model of sustained pain. Eur J Pain 2021; 25:1303-1315. [PMID: 33619820 DOI: 10.1002/ejp.1752] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/04/2020] [Indexed: 12/29/2022]
Abstract
BACKGROUND Research on placebo analgesia commonly focuses on the impact of information about direction (i.e., increase or decrease of pain) and magnitude of the expected analgesic effect, whereas temporal aspects of expectations have received little attention so far. In a recent study, using short-lasting, low-intensity stimuli, we demonstrated that placebo analgesia onset is influenced by temporal information. Here, we investigate whether the same effect of temporal suggestions can be found in longer lasting, high-intensity pain in a Cold Pressor Test (CPT). METHODS Fifty-three healthy volunteers were allocated to one of three groups. Participants were informed that the application of an (inert-)cream would reduce pain after 5 min (P5) or 30 min (P30). The third group was informed that the cream only had hydrating properties (NE). All participants completed the CPT at baseline and 10 (Test 10) and 35 min (Test 35) following cream application. Percentage change in exposure time (pain tolerance) from baseline to Test 10 (Δ10) and to Test 35 (Δ35) and changes in heart rate (HR) during CPT were compared between the three groups. RESULTS Δ10 was greater in P5 than in NE and P30, indicating that analgesia was only present in the group that was expecting an early onset of analgesia. Δ35 was greater in P5 and P30 compared to NE, reflecting a delayed onset of analgesia in P30 and maintained analgesia in P5. HR differences between groups were not significant. CONCLUSIONS Our data suggest that 'externally timing' of placebo analgesia may be possible for prolonged types of pain. SIGNIFICANCE Research on placebo effects mainly focuses on the influence of information about direction (i.e., increase or decrease of pain) and magnitude (i.e., strong or weak) of the expected effect but ignores temporal aspects of expectations. In our study in healthy volunteers, the reported onset of placebo analgesia followed the temporal information provided. Such 'external timing' effects could not only aid the clinical use of placebo treatment (e.g., in open-label placebos) but also support the efficacy of active drugs.
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Affiliation(s)
- Eleonora Maria Camerone
- Department of Neuroscience, Rehabilitation, Ophthalmology, Genetics and Maternal and Child Science (DINOGMI), University of Genoa, Genoa, Italy
| | - Katja Wiech
- Nuffield Department of Clinical Neurosciences, University of Oxford, Oxford, UK
| | - Fabrizio Benedetti
- Department of Neuroscience, University of Turin Medical School, Turin, Italy.,Plateau Rosà Laboratories, Plateau Rosà, Italy
| | - Elisa Carlino
- Department of Neuroscience, University of Turin Medical School, Turin, Italy
| | - Mirko Job
- Department of Neuroscience, Rehabilitation, Ophthalmology, Genetics and Maternal and Child Science (DINOGMI), University of Genoa, Genoa, Italy
| | - Aldo Scafoglieri
- Department of Physiotherapy, Human Physiology and Anatomy, Vrije Universiteit Brussels, Brussels, Belgium
| | - Marco Testa
- Department of Neuroscience, Rehabilitation, Ophthalmology, Genetics and Maternal and Child Science (DINOGMI), University of Genoa, Genoa, Italy
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122
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Zunhammer M, Spisák T, Wager TD, Bingel U. Meta-analysis of neural systems underlying placebo analgesia from individual participant fMRI data. Nat Commun 2021; 12:1391. [PMID: 33654105 PMCID: PMC7925520 DOI: 10.1038/s41467-021-21179-3] [Citation(s) in RCA: 62] [Impact Index Per Article: 20.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/19/2020] [Accepted: 01/04/2021] [Indexed: 12/13/2022] Open
Abstract
The brain systems underlying placebo analgesia are insufficiently understood. Here we performed a systematic, participant-level meta-analysis of experimental functional neuroimaging studies of evoked pain under stimulus-intensity-matched placebo and control conditions, encompassing 603 healthy participants from 20 (out of 28 eligible) studies. We find that placebo vs. control treatments induce small, widespread reductions in pain-related activity, particularly in regions belonging to ventral attention (including mid-insula) and somatomotor networks (including posterior insula). Behavioral placebo analgesia correlates with reduced pain-related activity in these networks and the thalamus, habenula, mid-cingulate, and supplementary motor area. Placebo-associated activity increases occur mainly in frontoparietal regions, with high between-study heterogeneity. We conclude that placebo treatments affect pain-related activity in multiple brain areas, which may reflect changes in nociception and/or other affective and decision-making processes surrounding pain. Between-study heterogeneity suggests that placebo analgesia is a multi-faceted phenomenon involving multiple cerebral mechanisms that differ across studies.
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Affiliation(s)
- Matthias Zunhammer
- Center for Translational Neuro- and Behavioral Sciences, Dept. of Neurology, University Hospital Essen, Essen, Germany
| | - Tamás Spisák
- Center for Translational Neuro- and Behavioral Sciences, Dept. of Neurology, University Hospital Essen, Essen, Germany
| | - Tor D Wager
- Cognitive and Affective Neuroscience Laboratory, Department of Psychological and Brain Sciences, Dartmouth College, Hanover, NH, USA.
| | - Ulrike Bingel
- Center for Translational Neuro- and Behavioral Sciences, Dept. of Neurology, University Hospital Essen, Essen, Germany.
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Theodosis-Nobelos P, Filotheidou A, Triantis C. The placebo phenomenon and the underlying mechanisms. Hormones (Athens) 2021; 20:61-71. [PMID: 32940864 DOI: 10.1007/s42000-020-00243-5] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/28/2020] [Accepted: 09/02/2020] [Indexed: 12/17/2022]
Abstract
The clinical role of the placebo effect is a topic of increasing interest for the scientific community. Focus is shifting from the inert role of placebos in randomized controlled trials (RCTs) to potential effects in clinical applications, since the phenomenon is thought to be inherent in routine clinical practice, affecting therapy success rates. Mediation of the mind-brain-body relationship involves both psychosocial and neurobiological factors, the interaction of which comprises the placebo mechanisms. Psychosocial factors include environmentally induced expectations, reward expectations, and even conditioned responses to certain stimuli. Expectations also depend on previous experience of the patient with a similar procedure and can affect future responses. Moreover, the supportive bedside behavior of the clinician and the positive framing of information provided to the patient have proven to be of great importance, setting the foundations for reconsideration of standardized practices. Neurobiological mechanisms mediate these effects through neurotransmitter and neuromodulator pathways. The best understood mechanisms are those regulating non-opioid- and opioid-mediated analgesic responses that implicate specific brain regions of pain control and activation of endogenous opioids. Other responses concern, among others, hormonal control, motor performance, and antidepressant responses. Although mechanisms underlying placebo responses are not as yet completely elucidated, there is substantial evidence suggesting that placebo effects are indicative of healthy functioning of intact brain structures and occur through actual functional changes, and are not simply subjective symptom reports. These effects can be utilized in treatment optimization while maintaining an ethical and respectful manner toward the patient and the standardized disclosure procedures.
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Affiliation(s)
| | - A Filotheidou
- Department of Pharmacy, Frederick University, Nicosia, Cyprus
| | - C Triantis
- Department of Pharmacy, Frederick University, Nicosia, Cyprus.
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Puntillo F, Giglio M, Paladini A, Perchiazzi G, Viswanath O, Urits I, Sabbà C, Varrassi G, Brienza N. Pathophysiology of musculoskeletal pain: a narrative review. Ther Adv Musculoskelet Dis 2021; 13:1759720X21995067. [PMID: 33737965 PMCID: PMC7934019 DOI: 10.1177/1759720x21995067] [Citation(s) in RCA: 28] [Impact Index Per Article: 9.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/13/2020] [Accepted: 01/27/2021] [Indexed: 02/06/2023] Open
Abstract
Musculoskeletal pain (excluding bone cancer pain) affects more than 30% of the global population and imposes an enormous burden on patients, families, and caregivers related to functional limitation, emotional distress, effects on mood, loss of independence, and reduced quality of life. The pathogenic mechanisms of musculoskeletal pain relate to the differential sensory innervation of bones, joints, and muscles as opposed to skin and involve a number of peripheral and central nervous system cells and mediators. The interplay of neurons and non-neural cells (e.g. glial, mesenchymal, and immune cells) amplifies and sensitizes pain signals in a manner that leads to cortical remodeling. Moreover, sex, age, mood, and social factors, together with beliefs, thoughts, and pain behaviors influence the way in which musculoskeletal pain manifests and is understood and assessed. The aim of this narrative review is to summarize the different pathogenic mechanisms underlying musculoskeletal pain and how these mechanisms interact to promote the transition from acute to chronic pain.
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Affiliation(s)
- Filomena Puntillo
- Department of Interdisciplinary Medicine, 'Aldo Moro' University of Bari, Piazza G. Cesare 11, Bari 70124, Italy
| | - Mariateresa Giglio
- Anesthesia, Intensive Care and Pain Unit, Policlinico Hospital, Bari, Italy
| | | | - Gaetano Perchiazzi
- Department of Surgical Science, Hedenstierna Laboratory, Uppsala University, Uppsala, Sweden
| | - Omar Viswanath
- Department of Anesthesiology, Creighton University School of Medicine, Omaha, NE, USA
| | - Ivan Urits
- Department of Anesthesia, Beth Israel Deaconess Med Center, Harvard Medical School, Boston, MA, USA
| | - Carlo Sabbà
- Department of Interdisciplinary Medicine, 'Aldo Moro' University of Bari, Bari, Italy
| | | | - Nicola Brienza
- Department of Interdisciplinary Medicine, 'Aldo Moro' University of Bari, Bari, Italy
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Mouraux A, Bannister K, Becker S, Finn DP, Pickering G, Pogatzki-Zahn E, Graven-Nielsen T. Challenges and opportunities in translational pain research - An opinion paper of the working group on translational pain research of the European pain federation (EFIC). Eur J Pain 2021; 25:731-756. [PMID: 33625769 PMCID: PMC9290702 DOI: 10.1002/ejp.1730] [Citation(s) in RCA: 19] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
For decades, basic research on the underlying mechanisms of nociception has held promise to translate into efficacious treatments for patients with pain. Despite great improvement in the understanding of pain physiology and pathophysiology, translation to novel, effective treatments for acute and chronic pain has however been limited, and they remain an unmet medical need. In this opinion paper bringing together pain researchers from very different disciplines, the opportunities and challenges of translational pain research are discussed. The many factors that may prevent the successful translation of bench observations into useful and effective clinical applications are reviewed, including interspecies differences, limited validity of currently available preclinical disease models of pain, and limitations of currently used methods to assess nociception and pain in non-human and human models of pain. Many paths are explored to address these issues, including the backward translation of observations made in patients and human volunteers into new disease models that are more clinically relevant, improved generalization by taking into account age and sex differences, and the integration of psychobiology into translational pain research. Finally, it is argued that preclinical and clinical stages of developing new treatments for pain can be improved by better preclinical models of pathological pain conditions alongside revised methods to assess treatment-induced effects on nociception in human and non-human animals. Significance: For decades, basic research of the underlying mechanisms of nociception has held promise to translate into efficacious treatments for patients with pain. Despite great improvement in the understanding of pain physiology and pathophysiology, translation to novel, effective treatments for acute and chronic pain has however been limited, and they remain an unmet medical need.
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Affiliation(s)
- André Mouraux
- Institute of Neuroscience (IONS), UCLouvain, Brussels, Belgium
| | - Kirsty Bannister
- Institute of Psychiatry, Psychology and Neuroscience, King's College London, London, UK
| | - Susanne Becker
- Department of Cognitive and Clinical Neuroscience, Central Institute of Mental Health, Medical Faculty Mannheim, Heidelberg University, Mannheim, Germany.,Integrative Spinal Research, Department of Chiropractic Medicine, Balgrist University Hospital, University of Zurich, Zurich, Switzerland
| | - David P Finn
- Pharmacology and Therapeutics, Centre for Pain Research, School of Medicine, National University of Ireland Galway, Galway, Ireland
| | - Gisèle Pickering
- Department of Clinical Pharmacology, Inserm CIC 1405, University Hospital, CHU Clermont-Ferrand, France.,Fundamental and Clinical Pharmacology of Pain, University Clermont Auvergne, Clermont-Ferrand, France
| | - Esther Pogatzki-Zahn
- Department of Anesthesiology, Critical Care Medicine and Pain Therapy, University Hospital Muenster, Muenster, Germany
| | - Thomas Graven-Nielsen
- Center for Neuroplasticity and Pain (CNAP), Department of Health Science and Technology, Faculty of Medicine, Aalborg University, Aalborg, Denmark
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127
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Selective modulation of tonic aversive qualities of neuropathic pain by morphine in the central nucleus of the amygdala requires endogenous opioid signaling in the anterior cingulate cortex. Pain 2021; 161:609-618. [PMID: 31725062 DOI: 10.1097/j.pain.0000000000001748] [Citation(s) in RCA: 33] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
The amygdala is a key subcortical region believed to contribute to emotional components of pain. As opioid receptors are found in both the central (CeA) and basolateral (BLA) nuclei of the amygdala, we investigated the effects of morphine microinjection on evoked pain responses, pain-motivated behaviors, dopamine release in the nucleus accumbens (NAc), and descending modulation in rats with left-side spinal nerve ligation (SNL). Morphine administered into the right or left CeA had no effect on nerve injury-induced tactile allodynia or mechanical hyperalgesia. Right, but not left, CeA morphine produced conditioned place preference (CPP) and increased extracellular dopamine in the NAc selectively in SNL rats, suggesting relief of aversive qualities of ongoing pain. In SNL rats, CPP and NAc dopamine release following right CeA morphine was abolished by blocking mu opioid receptor signaling in the rostral anterior cingulate cortex (rACC). Right CeA morphine also significantly restored SNL-induced loss of the diffuse noxious inhibitory controls, a spino-bulbo-spinal pain modulatory mechanism, termed conditioned pain modulation in humans. Microinjection of morphine into the BLA had no effects on evoked behaviors and did not produce CPP in nerve-injured rats. These findings demonstrate that the amygdalar action of morphine is specific to the right CeA contralateral to the side of injury and results in enhancement of net descending inhibition. In addition, engagement of mu opioid receptors in the right CeA modulates affective qualities of ongoing pain through endogenous opioid neurotransmission within the rACC, revealing opioid-dependent functional connections from the CeA to the rACC.
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128
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Distinct neural networks subserve placebo analgesia and nocebo hyperalgesia. Neuroimage 2021; 231:117833. [PMID: 33549749 DOI: 10.1016/j.neuroimage.2021.117833] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/13/2020] [Revised: 01/20/2021] [Accepted: 01/30/2021] [Indexed: 12/19/2022] Open
Abstract
Neural networks involved in placebo analgesia and nocebo hyperalgesia processes have been widely investigated with neuroimaging methods. However, few studies have directly compared these two processes and it remains unclear whether common or distinct neural circuits are involved. To address this issue, we implemented a coordinate-based meta-analysis and compared neural representations of placebo analgesia (30 studies; 205 foci; 677 subjects) and nocebo hyperalgesia (22 studies; 301 foci; 401 subjects). Contrast analyses confirmed placebo-specific concordance in the right ventral striatum, and nocebo-specific concordance in the dorsal anterior cingulate cortex (dACC), left posterior insula and left parietal operculum during combined pain anticipation and administration stages. Importantly, no overlapping regions were found for these two processes in conjunction analyses, even when the threshold was low. Meta-analytic connectivity modeling (MACM) and resting-state functional connectivity (RSFC) analyses on key regions further confirmed the distinct brain networks underlying placebo analgesia and nocebo hyperalgesia. Together, these findings indicate that the placebo analgesia and nocebo hyperalgesia processes involve distinct neural circuits, which supports the view that the two phenomena may operate via different neuropsychological processes.
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129
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Halicka M, Vittersø AD, McCullough H, Goebel A, Heelas L, Proulx MJ, Bultitude JH. Prism adaptation treatment for upper-limb complex regional pain syndrome: a double-blind randomized controlled trial. Pain 2021; 162:471-489. [PMID: 32833791 PMCID: PMC7808368 DOI: 10.1097/j.pain.0000000000002053] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2020] [Revised: 07/14/2020] [Accepted: 08/03/2020] [Indexed: 12/17/2022]
Abstract
ABSTRACT Initial evidence suggested that people with complex regional pain syndrome (CRPS) have reduced attention to the affected side of their body and the surrounding space, which might be related to pain and other clinical symptoms. Three previous unblinded, uncontrolled studies showed pain relief after treatment with prism adaptation, an intervention that has been used to counter lateralised attention bias in brain-lesioned patients. To provide a robust test of its effectiveness for CRPS, we conducted a double-blind randomized controlled trial of prism adaptation for unilateral upper-limb CRPS-I. Forty-nine eligible adults with CRPS were randomized to undergo 2 weeks of twice-daily home-based prism adaptation treatment (n = 23) or sham treatment (n = 26). Outcomes were assessed in person 4 weeks before and immediately before treatment, and immediately after and 4 weeks after treatment. Long-term postal follow-ups were conducted 3 and 6 months after treatment. We examined the effects of prism adaptation vs sham treatment on current pain intensity and the CRPS symptom severity score (primary outcomes), as well as sensory, motor, and autonomic functions, self-reported psychological functioning, and experimentally tested neuropsychological functions (secondary outcomes). We found no evidence that primary or secondary outcomes differed between the prism adaptation and sham treatment groups when tested at either time point after treatment. Overall, CRPS severity significantly decreased over time for both groups, but we found no benefits of prism adaptation beyond sham treatment. Our findings do not support the efficacy of prism adaptation treatment for relieving upper-limb CRPS-I. This trial was prospectively registered (ISRCTN46828292).
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Affiliation(s)
- Monika Halicka
- Centre for Pain Research, University of Bath, Bath, United Kingdom
- Department of Psychology, University of Bath, Bath, United Kingdom
| | - Axel D. Vittersø
- Centre for Pain Research, University of Bath, Bath, United Kingdom
- Department of Psychology, University of Bath, Bath, United Kingdom
- Department of Sport and Health Sciences, University of Exeter, Exeter, United Kingdom
| | - Hayley McCullough
- Department of Translational Medicine, Pain Research Institute, University of Liverpool, Liverpool, United Kingdom
| | - Andreas Goebel
- Department of Translational Medicine, Pain Research Institute, University of Liverpool, Liverpool, United Kingdom
- Department of Pain Medicine, Walton Centre NHS Foundation Trust, Liverpool, United Kingdom
| | - Leila Heelas
- Optimise Pain Rehabilitation Unit, Oxford University Hospitals NHS Trust, Oxford, United Kingdom
| | - Michael J. Proulx
- Department of Psychology, University of Bath, Bath, United Kingdom
- Department of Computer Science, Centre for Real & Virtual Environments Augmentation Labs, University of Bath, Bath, United Kingdom
| | - Janet H. Bultitude
- Centre for Pain Research, University of Bath, Bath, United Kingdom
- Department of Psychology, University of Bath, Bath, United Kingdom
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Sondermann W, Reinboldt-Jockenhöfer F, Dissemond J, Pfaar O, Bingel U, Schedlowski M. Effects of Patients' Expectation in Dermatology: Evidence from Experimental and Clinical Placebo Studies and Implications for Dermatologic Practice and Research. Dermatology 2021; 237:857-871. [PMID: 33498052 DOI: 10.1159/000513445] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/02/2020] [Accepted: 11/28/2020] [Indexed: 11/19/2022] Open
Abstract
Patients' expectations towards the benefit of a treatment are key determinants of placebo responses and can affect the development and course of medical conditions and the efficacy and tolerability of active medical treatment. The mechanisms mediating these placebo and nocebo effects have been best described in the field of experimental pain and placebo analgesia. However, also in dermatology experimental and clinical studies demonstrate that various skin diseases such as inflammatory dermatoses and allergic reactions can be modulated by patients' expectations. Dermatologists should consider the important modulatory role of patients' expectations on the efficacy and tolerability of specific treatments and the key role of verbal information, patients' prior treatment experiences (associative learning), and the quality and quantity of doctor-patient communication in shaping treatment expectation. As a consequence, techniques aiming at maximizing patients' expectation effects should be implemented into daily clinical routine. By contrast, in clinical studies expectation effects should be maximally controlled and harmonized to improve the "assay sensitivity" to detect new compounds. Further translational studies, also in dermatoses that have not been investigated yet, are needed to better characterize the mechanisms underlying patients' expectation and to gain further insights into potential clinical implications of these effects in dermatologic conditions. Therefore, in this review, we provide a brief overview on the concept of expectation effects on treatment outcome in general, summarize what is already known about this topic for dermatologic diseases, and finally present the relevance of this topic in clinical dermatology.
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Affiliation(s)
- Wiebke Sondermann
- Department of Dermatology, Venereology, and Allergology, University Hospital Essen, University of Duisburg-Essen, Essen, Germany,
| | - Finja Reinboldt-Jockenhöfer
- Department of Dermatology, Venereology, and Allergology, University Hospital Essen, University of Duisburg-Essen, Essen, Germany
| | - Joachim Dissemond
- Department of Dermatology, Venereology, and Allergology, University Hospital Essen, University of Duisburg-Essen, Essen, Germany
| | - Oliver Pfaar
- Section of Rhinology and Allergy, Department of Otorhinolaryngology, Head and Neck Surgery, University Hospital Marburg, Philipps University Marburg, Marburg, Germany
| | - Ulrike Bingel
- Department of Neurology, University Hospital Essen, University of Duisburg-Essen, Essen, Germany
| | - Manfred Schedlowski
- Institute of Medical Psychology and Behavioral Immunobiology, University Hospital Essen, University of Duisburg-Essen, Essen, Germany.,Department of Clinical Neuroscience, Osher Center for Integrative Medicine, Karolinska Institutet, Stockholm, Sweden
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131
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Effects of open-label placebos on test performance and psychological well-being in healthy medical students: a randomized controlled trial. Sci Rep 2021; 11:2130. [PMID: 33483552 PMCID: PMC7822842 DOI: 10.1038/s41598-021-81502-2] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/20/2020] [Accepted: 01/07/2021] [Indexed: 01/30/2023] Open
Abstract
Psychological distress is prevalent in students and can predispose to psychiatric disorders. Recent findings indicate that distress might be linked to impaired cognitive performance in students. Experimental findings in healthy participants suggest that placebo interventions can improve cognition. However, whether non-deceptive (i.e., open-label, OLP) placebos can enhance cognitive function and emotional well-being is unclear. Using a randomized-controlled design we demonstrate a positive impact of OLP on subjective well-being (i.e., stress, fatigue, and confusion) after a 21-day OLP application in healthy students during midterm exams. OLP did not improve test performance, but, within the OLP group, test performance was positively correlated with measures of general belief in the benefit of medication. These results show that OLP can counteract negative effects of acute stress on psychological well-being and might improve cognitive performance if supported by positive treatment expectations. Additionally, our findings in healthy volunteers warrant further investigation in exploring the potential of OLP in reducing stress-related psychological effects in patients. The trial was preregistered at the German Clinical Trials Register on December 20, 2017 (DRKS00013557).
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132
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Association of nocebo hyperalgesia and basic somatosensory characteristics in a large cohort. Sci Rep 2021; 11:762. [PMID: 33436821 PMCID: PMC7804006 DOI: 10.1038/s41598-020-80386-y] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/13/2020] [Accepted: 12/18/2020] [Indexed: 02/06/2023] Open
Abstract
Medical outcomes are strongly affected by placebo and nocebo effects. Prediction of who responds to such expectation effects has proven to be challenging. Most recent approaches to prediction have focused on placebo effects in the context of previous treatment experiences and expectancies, or personality traits. However, a recent model has suggested that basic somatosensory characteristics play an important role in expectation responses. Consequently, this study investigated not only the role of psychological variables, but also of basic somatosensory characteristics. In this study, 624 participants underwent a placebo and nocebo heat pain paradigm. Additionally, individual psychological and somatosensory characteristics were assessed. While no associations were identified for placebo responses, nocebo responses were associated with personality traits (e.g. neuroticism) and somatosensory characteristics (e.g. thermal pain threshold). Importantly, the associations between somatosensory characteristics and nocebo responses were among the strongest. This study shows that apart from personality traits, basic somatosensory characteristics play an important role in individual nocebo responses, in agreement with the novel idea that nocebo responses result from the integration of top-down expectation and bottom-up sensory information.
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133
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Kim S, Bae DW, Park SG, Park JW. The impact of Pain-related emotions on migraine. Sci Rep 2021; 11:577. [PMID: 33436778 PMCID: PMC7804193 DOI: 10.1038/s41598-020-80094-7] [Citation(s) in RCA: 18] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/15/2020] [Accepted: 12/14/2020] [Indexed: 02/07/2023] Open
Abstract
The response to pain is highly individual and can be influenced by complex emotional perception. This study aims to investigate the status of the pain-related emotional response, and the influence on headache characteristics and disability in migraine. We studied the pain-related emotional response in 145 consecutive migraine patients using the Pain Anxiety Symptoms Scale (PASS), the Pain Catastrophizing Scale (PCS), and the Pain Sensitivity Questionnaire (PSQ) and compared them with 106 healthy controls. We investigated the relationship between emotional factors and migraine characteristics. The effect of pain-related emotion on migraine-related disability assessed with the Headache Impact Test-6 (HIT-6) and the Migraine Disability Assessment (MIDAS). Migraine patients showed significantly higher scores on total PASS (p < 0.001), PCS (p < 0.001) and PSQ (p = 0.002) compared to the healthy controls. The HIT-6 was weakly correlated with PASS (r = 0.390, p < 0.001) and PCS (r = 0.354, p < 0.001). PASS-Total (p = 0.001), headache frequency (p = 0.003), and HADS-Anxiety (p = 0.028) were independent variables associated with HIT-6. Headache frequency (p < 0.001) was an independent variable associated with MIDAS. The structural equation model indicated that headache severity has direct loading on emotion and subsequently influenced migraine-related disability. Disability has a significant effect on the frequency of abortive medication use. Migraine patients have altered emotional responses to pain perception. Pain-related anxiety made an important contribution to headache-related disability. The present results suggest that the management of disability by considering various pain-related emotional factors may be necessary for the therapeutic aspects of migraine.
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Affiliation(s)
- Seonghoon Kim
- Department of Neurology, Uijeongbu St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Republic of Korea
| | - Dae-Woong Bae
- Department of Neurology, St. Vincent's hospital, College of Medicine, The Catholic University of Korea, Seoul, Republic of Korea
| | - Sang-Gue Park
- Department of Applied Statistics, Chung-Ang University, Seoul, Republic of Korea
| | - Jeong-Wook Park
- Department of Neurology, Uijeongbu St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Republic of Korea.
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134
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Abstract
There is tremendous interpatient variability in the response to analgesic therapy
(even for efficacious treatments), which can be the source of great frustration
in clinical practice. This has led to calls for “precision
medicine” or personalized pain therapeutics (ie, empirically based
algorithms that determine the optimal treatments, or treatment combinations, for
individual patients) that would presumably improve both the clinical care of
patients with pain and the success rates for putative analgesic drugs in phase 2
and 3 clinical trials. However, before implementing this approach, the
characteristics of individual patients or subgroups of patients that increase or
decrease the response to a specific treatment need to be identified. The
challenge is to identify the measurable phenotypic characteristics of patients
that are most predictive of individual variation in analgesic treatment
outcomes, and the measurement tools that are best suited to evaluate these
characteristics. In this article, we present evidence on the most promising of
these phenotypic characteristics for use in future research, including
psychosocial factors, symptom characteristics, sleep patterns, responses to
noxious stimulation, endogenous pain-modulatory processes, and response to
pharmacologic challenge. We provide evidence-based recommendations for core
phenotyping domains and recommend measures of each domain.
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135
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Abstract
Background: Healing is a complicated process that can have several components including the self-healing properties of the body, the nonspecific effects of treatment (e.g., the power of the mind), and the specific effects of an intervention. This article first discusses the brain imaging studies on placebo acupuncture analgesia and the modulation effects of expectancy on real acupuncture in healthy subjects. Then, it introduces some attempts to translate findings from healthy subjects to patient population using power of the mind as a way to enhance acupuncture's treatment effects on chronic pain. After that, a new alternative method which merges acupuncture and imagery, while also drawing on power of the mind, is presented. Finally, the specific effects of acupuncture are discussed. Conclusions: Elucidating the mechanism underlying power of the mind would provide new opportunities for boosting the therapeutic effect of acupuncture treatment and furthering the development of new alternative interventions.
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Affiliation(s)
- Jian Kong
- Department of Psychiatry, Massachusetts General Hospital, Harvard Medical School, MA, USA
| | - Maya Nicole Eshel
- Department of Psychiatry, Massachusetts General Hospital, Harvard Medical School, MA, USA
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136
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Horing B, Beadle SC, Inks Z, Robb A, Muth ER, Babu SV. A virtual experimenter does not increase placebo hypoalgesia when delivering an interactive expectancy manipulation. Sci Rep 2020; 10:20353. [PMID: 33230290 PMCID: PMC7684301 DOI: 10.1038/s41598-020-77453-9] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/04/2020] [Accepted: 11/10/2020] [Indexed: 12/18/2022] Open
Abstract
Lack of standardization and unblinding threaten the research of mechanisms involved in expectancy effects on pain. We evaluated a computer-controlled virtual experimenter (VEx) to avoid these issues. Fifty-four subjects underwent a baseline-retest heat pain protocol. Between sessions, they received an expectancy manipulation (placebo or no-treatment) delivered by VEx or text-only control condition. The VEx provided standardized "social" interaction with the subjects. Pain ratings and psychological state/trait measures were recorded. We found an interaction of expectancy and delivery on pain improvement following the intervention. In the text conditions, placebo was followed by lower pain, whereas in the VEx conditions, placebo and no-treatment were followed by a comparable pain decrease. Secondary analyses indicated that this interaction was mirrored by decreases of negative mood and anxiety. Furthermore, changes in continuous pain were moderated by expectation of pain relief. However, retrospective pain ratings show an effect of expectancy but not of delivery. We conclude that we successfully applied an automated protocol for inducing expectancy effects on pain. The effect of the VEx regardless of treatment may be due to interactions of attention allocation and locus of control. This points to the diversity of expectancy mechanisms, and has implications for research and computer-based treatment applications.
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Affiliation(s)
- Bjoern Horing
- Affective Neuroscience Group, Department of Systems Neuroscience, University Medical Center Hamburg-Eppendorf, Martinistr. 52, 20246, Hamburg, Germany.
| | - Sarah C Beadle
- Department of Psychology, Clemson University, Clemson, SC, USA
| | - Zachariah Inks
- Division of Human Centered Computing, School of Computing, Clemson University, Clemson, SC, USA
| | - Andrew Robb
- Division of Human Centered Computing, School of Computing, Clemson University, Clemson, SC, USA
| | - Eric R Muth
- Department of Psychology, Clemson University, Clemson, SC, USA
- Division of Research and Economic Development, North Carolina Agricultural and Technical State University, Greensboro, NC, USA
| | - Sabarish V Babu
- Division of Human Centered Computing, School of Computing, Clemson University, Clemson, SC, USA
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137
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Geers AL, Faasse K, Guevarra DA, Clemens KS, Helfer SG, Colagiuri B. Affect and emotions in placebo and nocebo effects: What do we know so far? SOCIAL AND PERSONALITY PSYCHOLOGY COMPASS 2020. [DOI: 10.1111/spc3.12575] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Affiliation(s)
- Andrew L. Geers
- Department of Psychology University of Toledo Toledo Ohio USA
| | - Kate Faasse
- School of Psychology University of New South Wales Sydney New South Wales Australia
| | - Darwin A. Guevarra
- Department of Psychology Michigan State University East Lansing Michigan USA
| | | | | | - Ben Colagiuri
- School of Psychology University of Sydney Sydney New South Wales Australia
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138
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Affiliation(s)
- Kate Faasse
- School of Psychology, University of New South Wales, Sydney, New South Wales, Australia
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139
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Hansen E, Zech N, Benson S. [Nocebo, informed consent and doctor-patient communication]. DER NERVENARZT 2020; 91:691-699. [PMID: 32728796 DOI: 10.1007/s00115-020-00963-4] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
Negative previous experiences (conditioning), observational learning and expectations can trigger nocebo effects. They are responsible for a substantial proportion of the side effects of medical treatment, and are induced primarily by risk information for informed consent. This has been demonstrated in studies on patient groups with or without modified medical information. Drug trials in the field of neurology and psychiatry have regularly revealed side effects and drop-out also in placebo groups. The underlying neurobiological mechanisms were experimentally investigated especially for nocebo-induced hyperalgesia, whereby the specifically involved regions of the brain could be identified by functional imaging as well as changes in the dopamine, endorphin and cholecystokinin systems. Nocebo effects are specific, i.e. they are closely related to patient information and can induce or aggravate exactly the symptoms addressed. Nevertheless, informed consent is an essential part of doctor-patient communication; however, information on risks can be markedly less damaging when unnecessary repetitions are avoided, misunderstandings are recognized or resolved and several different options are given. In addition, risks should always be named together with positive aspects, such as the advantages of the appropriate treatment, the prophylactic measures applied or the early detection and treatment of developing side effects. The best protection against harm caused by information on risks is a trustful doctor-patient relationship. Poor knowledge of nocebo effects or lack of countermeasures constitute a serious threat to patients and according to the current state of knowledge could be rated as medical malpractice.
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Affiliation(s)
- E Hansen
- Klinik für Anästhesiologie, Universitätsklinikum Regensburg, Franz-Josef-Strauß-Allee 11, 93053, Regensburg, Deutschland.
| | - N Zech
- Klinik für Anästhesiologie, Universitätsklinikum Regensburg, Franz-Josef-Strauß-Allee 11, 93053, Regensburg, Deutschland
| | - S Benson
- Institut für Medizinische Psychologie und Verhaltensbiologie, Universitätsklinikum Essen, Essen, 45122, Deutschland
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140
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Affiliation(s)
- Tobias Bertsch
- Földi Clinic, Hinterzarten-European Center of Lymphology, Germany
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141
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Rossettini G, Geri T, Palese A, Marzaro C, Mirandola M, Colloca L, Fiorio M, Turolla A, Manoni M, Testa M. What Physiotherapists Specialized in Orthopedic Manual Therapy Know About Nocebo-Related Effects and Contextual Factors: Findings From a National Survey. Front Psychol 2020; 11:582174. [PMID: 33192904 PMCID: PMC7606996 DOI: 10.3389/fpsyg.2020.582174] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/10/2020] [Accepted: 09/25/2020] [Indexed: 12/11/2022] Open
Abstract
Objective The aim of this study was to investigate the knowledge of orthopedic manual therapists (OMTs) regarding context factors (CFs) capable of triggering nocebo effects during the treatment and how this knowledge is related to their socio-demographic features. Design A cross-sectional online survey. Setting National. Main Outcome Measures A 20 items questionnaire composed by open-ended and closed single-choice questions was administered to explore: (a) socio-demographic variables (10 questions); (b) the relation between different CFs and nocebo-related effects (2 questions); and (c) the knowledge of participants about nocebo-related effects and how they managed them in the clinical practice (8 questions). Participants 1288 OMTs were recruited from the database of the Master in Rehabilitation of Musculoskeletal Disorders (MRDM) of the University of Genova from March to May 2019. Inclusion criteria were: (a) to possess a valid email account; (b) to understand and use as a native language the Italian; (c) to be graduated as OMTs; and (d) to be employed as physiotherapists specialized-OMTs during the survey. Results 791 responses were received (61.4%); 473 of them were male (59.8%), with an average age of 31.0 ± 7.1 years. OMTs defined nocebo-related effects as the psychosocial context effects around therapy and patient with specific biological bases (72.2%). OMTs know that their clinical practice is pervaded by nocebo-related effects (42.5%), triggered by CFs. Participants communicated nocebo-related effects balancing the positive features of the therapy with the negative ones (50.9%), during the decision of the therapeutic plan (42.7%). They reported associative learning as the main mechanism involved in nocebo-related effects (28.8%). OMTs taught and trained patient’s strategies to manage nocebo-related effects (39.6%) through an evaluation and correction of patient’s anxieties, doubts and expectations (37.7%). OMTs most frequently considered themselves to have a “medium” education about nocebo-related effects (48.2%) and that their management should be taught during bachelor (78.6%). Conclusion OMTs believed that nocebo-related effects were present in their clinical practice and that they can be triggered by CFs.
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Affiliation(s)
- Giacomo Rossettini
- Department of Neuroscience, Rehabilitation, Ophthalmology, Genetics, Maternal and Child Health, University of Genova, Genova, Italy.,School of Physiotherapy, University of Verona, Verona, Italy
| | - Tommaso Geri
- Department of Neuroscience, Rehabilitation, Ophthalmology, Genetics, Maternal and Child Health, University of Genova, Genova, Italy
| | - Alvisa Palese
- Department of Medical Sciences, University of Udine, Udine, Italy
| | - Chiara Marzaro
- Department of Neuroscience, Rehabilitation, Ophthalmology, Genetics, Maternal and Child Health, University of Genova, Genova, Italy
| | - Mattia Mirandola
- Department of Neuroscience, Rehabilitation, Ophthalmology, Genetics, Maternal and Child Health, University of Genova, Genova, Italy
| | - Luana Colloca
- Department of Pain and Translational Symptom Science, School of Nursing, University of Maryland, Baltimore, Baltimore, MD, United States.,Department of Anesthesiology and Psychiatry, School of Medicine, Center to Advance Chronic Pain Research, University of Maryland, Baltimore, Baltimore, MD, United States
| | - Mirta Fiorio
- Department of Neurosciences, Biomedicine and Movement Sciences, University of Verona, Verona, Italy
| | - Andrea Turolla
- Department of Neurorehabilitation Technologies, San Camillo IRCCS srl, Venezia, Italy
| | - Mattia Manoni
- Department of Neuroscience, Rehabilitation, Ophthalmology, Genetics, Maternal and Child Health, University of Genova, Genova, Italy
| | - Marco Testa
- Department of Neuroscience, Rehabilitation, Ophthalmology, Genetics, Maternal and Child Health, University of Genova, Genova, Italy
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142
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Stilwell P, Stilwell C, Sabo B, Harman K. Painful metaphors: enactivism and art in qualitative research. MEDICAL HUMANITIES 2020; 47:medhum-2020-011874. [PMID: 33077504 DOI: 10.1136/medhum-2020-011874] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Accepted: 06/11/2020] [Indexed: 06/11/2023]
Abstract
Enactivism is an emerging theory for sense-making (cognition) with increasing applications to research and medicine. Enactivists reject the idea that sense-making is simply in the head or can be reduced to neural processes. Instead, enactivists argue that cognisers (people) are embodied and action-oriented, and that sense-making emerges from relational processes distributed across the brain-body-environment. We start this paper with an overview of a recently proposed enactive approach to pain. With rich theoretical and empirical roots in phenomenology and cognitive science, conceptualising pain as an enactive process is appealing as it overcomes the problematic dualist and reductionist nature of current pain theories and healthcare practices. Second, we discuss metaphor in the context of pain and enactivism, including a pain-related metaphor classification system. Third, we present and discuss five paintings created alongside an enactive study of clinical communication and the co-construction of pain-related meanings. Each painting represents pain-related metaphors delivered by clinicians during audio-recorded clinical appointments or discussed by clinicians and patients during interviews. We classify these metaphors, connecting them to enactive theory and relevant literature. The art, metaphors and associated narratives draw attention to the intertwined nature of language, meaning and pain. Of clinical relevance to primary and allied healthcare, we explore how clinicians' taken-for-granted pain-related metaphors can act as scaffolding for patients' pain and agency, for better or worse. We visually depict and give examples of clinical situations where metaphors became enactive, in that they were clinically reinforced and embodied through assessment and treatment. We conclude with research and clinical considerations, suggesting that enactive metaphor is a widely overlooked learning mechanism that clinicians could consider employing and intentionally shape.
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Affiliation(s)
- Peter Stilwell
- Faculty of Health, Dalhousie University, Halifax, Nova Scotia, Canada
| | - Christie Stilwell
- Faculty of Health, Dalhousie University, Halifax, Nova Scotia, Canada
| | - Brenda Sabo
- School of Nursing, Faculty of Health, Dalhousie University, Halifax, Nova Scotia, Canada
| | - Katherine Harman
- School of Physiotherapy, Faculty of Health, Dalhousie University, Halifax, Nova Scotia, Canada
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143
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Shi Y, Huang S, Zhan H, Wang Y, Zeng Y, Cai G, Yang J, Wu W. Personality Differences of Brain Networks in Placebo Analgesia and Nocebo Hyperalgesia: A Psychophysiological Interaction (PPI) Approach in fMRI. Neural Plast 2020; 2020:8820443. [PMID: 33133178 PMCID: PMC7591942 DOI: 10.1155/2020/8820443] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/28/2020] [Revised: 09/28/2020] [Accepted: 09/30/2020] [Indexed: 11/18/2022] Open
Abstract
It is generally believed that the placebo response can elicit an analgesic effect, whilst the nocebo response can elicit a hyperalgesia effect in pain. Placebo analgesia and nocebo hyperalgesia effects are increasing concerns for researchers. Growing evidence suggests personality differences have an impact on both placebo and nocebo effects. However, previous studies have not reached a unified conclusion. We designed this study to explore the personality differences of functional magnetic resonance imaging (fMRI) signals in placebo response and nocebo response by using psychophysiological interaction (PPI) analysis. 30 healthy subjects underwent conditioning induction training to establish expectations of placebo effect and nocebo effect, and then, all subjects completed the following experimental procedures: (1) baseline scanning, (2) acute pain model establishment, (3) pain status scanning, and (4) pseudorandom scanning of block design of placebo response or nocebo response. Behavioral data were collected after each scan. The results of this study showed that (1) there were significant differences of VAS placebo intervention between the extrovert group and the introvert group (p = 0.004); (2) there were significant differences of VAS nocebo intervention between the extrovert group and the introvert group (p = 0.011); (3) there were significant differences between the VAS placebo intervention and VAS pain status (baseline) in both the extrovert group (p < 0.001) and the introvert group (p = 0.001); (4) there were significant differences between the VAS nocebo intervention and VAS pain status (baseline) in both the extrovert group (p = 0.008) and the introvert group (p < 0.001). Moreover, there were significant differences in the brain network for placebo and nocebo responses between different personalities. We found that (1) deactivation differences of the pain-related network and limbic system play an important role in personality differences associated with placebo analgesia and (2) differences of control of anxiety and activation of dorsolateral prefrontal cortex may cause the personality differences observed in nocebo hyperalgesia.
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Affiliation(s)
- Yu Shi
- Department of Rehabilitation, Zhujiang Hospital, Southern Medical University, Guangzhou 510282, China
| | - Shimin Huang
- Department of Rehabilitation, Zhujiang Hospital, Southern Medical University, Guangzhou 510282, China
| | - Hongrui Zhan
- Department of Rehabilitation, Zhujiang Hospital, Southern Medical University, Guangzhou 510282, China
- Department of Physical Medicine and Rehabilitation, The Fifth Affiliated Hospital of Sun Yat-sen University, Zhuhai 519000, China
| | - Yaping Wang
- Department of Rehabilitation, Zhujiang Hospital, Southern Medical University, Guangzhou 510282, China
| | - Yanyan Zeng
- Department of Rehabilitation, Zhujiang Hospital, Southern Medical University, Guangzhou 510282, China
| | - Guiyuan Cai
- Department of Rehabilitation, Zhujiang Hospital, Southern Medical University, Guangzhou 510282, China
| | - Jianming Yang
- Department of Radiology, Zhujiang Hospital, Southern Medical University, Guangzhou 510282, China
| | - Wen Wu
- Department of Rehabilitation, Zhujiang Hospital, Southern Medical University, Guangzhou 510282, China
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144
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Abstract
PURPOSE OF REVIEW To review the current state of preoperative psychological preparation to improve outcomes after cardiac surgery. RECENT FINDINGS Preoperative psychosocial factors are associated with short- and long-term outcomes after cardiac surgery. There are several approaches to optimize patients' preoperative psychological status with promising effects on postoperative outcomes (e.g., less complications, improved quality of life). Preoperative psychological preparation often aims to improve patients' knowledge or social support and to modify and optimize expectations and illness beliefs. Preoperative psychological preparation is gaining importance for cardiac surgery. However, patients' psychological status still does not get as much attention as it deserves. Preoperative psychological preparation seems to have positive effects on postoperative outcomes. Since overall evidence is still weak, further studies are warranted to understand which intervention works best for whom and why.
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Affiliation(s)
- Stefan Salzmann
- Division of Clinical Psychology and Psychotherapy, Philipps University of Marburg, Gutenbergstraße 18, 35032 Marburg, Germany
| | | | - Marcel Wilhelm
- Division of Clinical Psychology and Psychotherapy, Philipps University of Marburg, Gutenbergstraße 18, 35032 Marburg, Germany
| | - Frank Euteneuer
- Division of Clinical Psychology and Psychotherapy, Philipps University of Marburg, Gutenbergstraße 18, 35032 Marburg, Germany
- Department of Psychology, Clinical Psychology and Psychotherapy, Medical School Berlin, Berlin, Germany
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145
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Tinnermann A, Büchel C, Cohen-Adad J. Cortico-spinal imaging to study pain. Neuroimage 2020; 224:117439. [PMID: 33039624 DOI: 10.1016/j.neuroimage.2020.117439] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/08/2020] [Revised: 09/21/2020] [Accepted: 10/01/2020] [Indexed: 12/15/2022] Open
Abstract
Functional magnetic resonance imaging of the brain has helped to reveal mechanisms of pain perception in health and disease. Recently, imaging approaches have been developed that allow recording neural activity simultaneously in the brain and in the spinal cord. These approaches offer the possibility to examine pain perception in the entire central pain system and in addition, to investigate cortico-spinal interactions during pain processing. Although cortico-spinal imaging is a promising technique, it bears challenges concerning data acquisition and data analysis strategies. In this review, we discuss studies that applied simultaneous imaging of the brain and spinal cord to explore central pain processing. Furthermore, we describe different MR-related acquisition techniques, summarize advantages and disadvantages of approaches that have been implemented so far and present software that has been specifically developed for the analysis of spinal fMRI data to address challenges of spinal data analysis.
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Affiliation(s)
- Alexandra Tinnermann
- Department for Systems Neuroscience, University Medical Center Hamburg-Eppendorf, Hamburg, Germany; Max Planck School of Cognition, Leipzig, Germany.
| | - Christian Büchel
- Department for Systems Neuroscience, University Medical Center Hamburg-Eppendorf, Hamburg, Germany; Max Planck School of Cognition, Leipzig, Germany
| | - Julien Cohen-Adad
- NeuroPoly Lab, Institute of Biomedical Engineering, Polytechnique Montreal, Montreal, Quebec, Canada; Functional Neuroimaging Unit, CRIUGM, Université de Montréal, Montreal, Quebec, Canada.
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146
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Weber A, Busbridge S, Governo R. Evaluation of the Efficacy of Musical Vibroacupuncture in Pain Relief: A Randomized Controlled Pilot Study. Neuromodulation 2020; 24:1475-1482. [PMID: 33029913 DOI: 10.1111/ner.13281] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/27/2020] [Revised: 08/05/2020] [Accepted: 08/24/2020] [Indexed: 12/17/2022]
Abstract
OBJECTIVES To investigate if skin vibration employing consonant frequencies emitted by skin transducers attached to a combination of acupuncture points and according to musical harmony (musical chord) produces more significant pain relief compared to just a single frequency. MATERIALS AND METHODS Skin vibrostimulation produced by five electromagnet transducers was applied at five acupoints traditionally used to pain relief and anxiety in 13 pain-free healthy volunteers using the cold pressor test (CPT). The study consisted of three randomized sessions conducted on alternate days, with participants receiving either simultaneous frequencies of 32, 48, and 64 Hz that equate those used in a musical chord, hereby defined as musical vibroacupuncture (MVA), a single frequency of 32 Hz, set as vibroacupuncture (VA) and sham procedure (SP). CPT scores for pain thresholds and pain tolerance were assessed using repeated-measures ANOVAs. Pain intensity was evaluated using a numerical rating scale (NRS), while sensory and affective aspects of pain were rated using the short-form McGill Pain Questionnaire (SF-MPQ) and State-Trait Anxiety Inventory (STAI) Y-Form. RESULTS Pain thresholds did not vary significantly between trials. Pain tolerance scores were markedly higher in MVA compared to baseline (p = 0.0043) or SP (p = 0.006) but not for VA. Pain intensity for MVA also differed significantly from the baseline (p = 0.007) or SP (p = 0.027), but not for VA. No significant differences were found in SF-MPQ and STAI questionnaires. CONCLUSIONS These results suggest that MVA effectively increased pain tolerance and reduced pain intensity when compared with all groups, although not significant to the VA group.
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Affiliation(s)
- Augusto Weber
- School of Computing, Engineering and Mathematics, University of Brighton, Brighton, East Sussex, UK
| | - Simon Busbridge
- School of Computing, Engineering and Mathematics, University of Brighton, Brighton, East Sussex, UK
| | - Ricardo Governo
- Brighton and Sussex Medical School (BSMS), University of Sussex, Brighton, East Sussex, UK
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147
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Wagner IC, Rütgen M, Hummer A, Windischberger C, Lamm C. Placebo-induced pain reduction is associated with negative coupling between brain networks at rest. Neuroimage 2020; 219:117024. [DOI: 10.1016/j.neuroimage.2020.117024] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/03/2019] [Revised: 04/10/2020] [Accepted: 06/03/2020] [Indexed: 10/24/2022] Open
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148
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Lee SO, Huang LP, Wong CS. Preoperative Administration of Extended-Release Dinalbuphine Sebacate Compares with Morphine for Post-Laparoscopic Cholecystectomy Pain Management: A Randomized Study. J Pain Res 2020; 13:2247-2253. [PMID: 32982387 PMCID: PMC7490073 DOI: 10.2147/jpr.s263315] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/28/2020] [Accepted: 08/20/2020] [Indexed: 12/22/2022] Open
Abstract
Purpose Perioperative pain management plays a critical role in the effort to promote enhanced recovery after surgery (ERAS). Pain is also the most concern for patients after laparoscopic cholecystectomy (LC). Naldebain (extended-release dinalbuphine sebacate, DS) is an oil-based formulation for intramuscular injection that has been designed for extended release and can be used for preoperative analgesia over a 7-day period. This study was aimed to compare the efficacy of DS injection with that of regular postoperative morphine administered when necessary for the management of post-laparoscopic cholecystectomy pain. Patients and Methods Forty-four patients scheduled for elective laparoscopic cholecystectomy were included in this prospective study. The patients were allocated randomly into two groups, with equal numbers receiving preoperative DS versus post-operative morphine. A total of 21 and 22 patients completed the study within the preoperative DS and post-operative morphine group, respectively. Results There were no statistically significant differences between two treatment groups with respect to length of surgery, anesthetics used during operation, or the average visual analog scale pain score in the post-operative anesthesia care unit (PACU), and at 4, 24, 48, and 72 hours post-procedure. Morphine was required only during the first postoperative day among those in the DS group. Safety was comparable in both DS and morphine groups. Conclusion A single preoperative dose of DS provides sufficient analgesia along with a manageable safety profile and no interference with surgical anesthetics when compared to control cases that underwent surgery without preoperative DS treatment. This pilot study suggests that preoperative administration of DS is safe and may decrease the need for postoperative opioid use after laparoscopic cholecystectomy. Registration ClinicalTrials.gov Identifier: NCT03713216.
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Affiliation(s)
- Sing-Ong Lee
- Department of Anesthesiology, Cathay General Hospital, Taipei, Taiwan
| | - Li-Ping Huang
- Department of Anesthesiology, Cathay General Hospital, Taipei, Taiwan
| | - Chih-Shung Wong
- Department of Anesthesiology, Cathay General Hospital, Taipei, Taiwan.,Graduate Institute of Medical Science, National Defense Medical Center, Taipei, Taiwan.,School of Medicine, Fu-Jen Catholic University, New Taipei, Taiwan
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149
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150
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Hendrickson RC, Thomas RG, Schork NJ, Raskind MA. Optimizing Aggregated N-Of-1 Trial Designs for Predictive Biomarker Validation: Statistical Methods and Theoretical Findings. Front Digit Health 2020; 2:13. [PMID: 34713026 PMCID: PMC8521797 DOI: 10.3389/fdgth.2020.00013] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2020] [Accepted: 07/06/2020] [Indexed: 12/12/2022] Open
Abstract
Background and Significance: Parallel-group randomized controlled trials (PG-RCTs) are the gold standard for detecting differences in mean improvement across treatment conditions. However, PG-RCTs provide limited information about individuals, making them poorly optimized for quantifying the relationship of a biomarker measured at baseline with treatment response. In N-of-1 trials, an individual subject moves between treatment conditions to determine their specific response to each treatment. Aggregated N-of-1 trials analyze a cohort of such participants, and can be designed to optimize both statistical power and clinical or logistical constraints, such as allowing all participants to begin with an open-label stabilization phase to facilitate the enrollment of more acutely symptomatic participants. Here, we describe a set of statistical simulation studies comparing the power of four different trial designs to detect a relationship between a predictive biomarker measured at baseline and subjects' specific response to the PTSD pharmacotherapeutic agent prazosin. Methods: Data was simulated from 4 trial designs: (1) open-label; (2) open-label + blinded discontinuation; (3) traditional crossover; and (4) open label + blinded discontinuation + brief crossover (the N-of-1 design). Designs were matched in length and assessments. The primary outcome, analyzed with a linear mixed effects model, was whether a statistically significant association between biomarker value and response to prazosin was detected with 5% Type I error. Simulations were repeated 1,000 times to determine power and bias, with varied parameters. Results: Trial designs 2 & 4 had substantially higher power with fewer subjects than open label design. Trial design 4 also had higher power than trial design 2. Trial design 4 had slightly lower power than the traditional crossover design, although power declined much more rapidly as carryover was introduced. Conclusions: These results suggest that an aggregated N-of-1 trial design beginning with an open label titration phase may provide superior power over open label or open label and blinded discontinuation designs, and similar power to a traditional crossover design, in detecting an association between a predictive biomarker and the clinical response to the PTSD pharmacotherapeutic prazosin. This is achieved while allowing all participants to spend the first 8 weeks of the trial on open-label active treatment.
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Affiliation(s)
- Rebecca C Hendrickson
- VISN 20 Northwest Network Mental Illness Research, Education and Clinical Center (MIRECC), VA Puget Sound Health Care System, Seattle, WA, United States.,Department of Psychiatry and Behavioral Sciences, University of Washington School of Medicine, Seattle, WA, United States
| | - Ronald G Thomas
- Department of Biostatistics, University of California, San Diego, San Diego, CA, United States
| | - Nicholas J Schork
- Quantitative Medicine and Systems Biology, The Translational Genomics Research Institute (TGen), Phoenix, AZ, United States.,The Joint City of Hope/TGen IMPACT Center (NJS), City of Hope National Medical Center, Duarte, CA, United States
| | - Murray A Raskind
- VISN 20 Northwest Network Mental Illness Research, Education and Clinical Center (MIRECC), VA Puget Sound Health Care System, Seattle, WA, United States.,Department of Psychiatry and Behavioral Sciences, University of Washington School of Medicine, Seattle, WA, United States
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