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Wegeberg AM, Sejersgaard-Jacobsen TH, Brock C, Drewes AM. Prediction of pain using electrocardiographic-derived autonomic measures: A systematic review. Eur J Pain 2024; 28:199-213. [PMID: 37655709 DOI: 10.1002/ejp.2175] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/01/2023] [Revised: 08/08/2023] [Accepted: 08/18/2023] [Indexed: 09/02/2023]
Abstract
BACKGROUND AND OBJECTIVE Pain is a major clinical challenge, and understanding the pathophysiology is critical for optimal management. The autonomic nervous system reacts to pain stimuli, and autonomic dysfunction may predict pain sensation. The most used assessment of autonomic function is based on electrocardiographic measures, and the ability of such measures to predict pain was investigated. DATABASES AND DATA TREATMENT English articles indexed in PubMed and EMBASE were reviewed for eligibility and included when they reported electrocardiographic-derived measures' ability to predict pain response. The quality in prognostic studies (QUIPS) tool was used to assess the quality of the included articles. RESULTS The search revealed 15 publications, five on experimental pain, five on postoperative pain, and five on longitudinal clinical pain changes, investigating a total of 1069 patients. All studies used electrocardiographically derived parameters to predict pain assessed with pain thresholds using quantitative sensory testing or different scales. Across all study modalities, electrocardiographic measures were able to predict pain. Higher parasympathetic activity predicted decreased experimental, postoperative, and long-term pain in most cases while changes in sympathetic activity did not consistently predict pain. CONCLUSIONS Most studies demonstrated that parasympathetic activity could predict acute and chronic pain intensity. In the clinic, this may be used to identify which patients need more intensive care to prevent, for example postoperative pain and develop personalized chronic pain management. SIGNIFICANCE Pain is a debilitating problem, and the ability to predict occurrence and severity would be a useful clinical tool. Basal autonomic tone has been suggested to influence pain perception. This systematic review investigated electrocardiographic-derived autonomic tone and found that increased parasympathetic tone could predict pain reduction in different types of pain.
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Affiliation(s)
- Anne-Marie Wegeberg
- Thisted Research Unit, Aalborg University Hospital Thisted, Thisted, Denmark
- Department of Clinical Medicine, Aalborg University, Aalborg, Denmark
- Mech-Sense, Department of Gastroenterology and Hepatology, Aalborg University Hospital, Aalborg, Denmark
| | | | - Christina Brock
- Department of Clinical Medicine, Aalborg University, Aalborg, Denmark
- Mech-Sense, Department of Gastroenterology and Hepatology, Aalborg University Hospital, Aalborg, Denmark
- Steno Diabetes Center North Denmark, Aalborg, Denmark
| | - Asbjørn Mohr Drewes
- Thisted Research Unit, Aalborg University Hospital Thisted, Thisted, Denmark
- Mech-Sense, Department of Gastroenterology and Hepatology, Aalborg University Hospital, Aalborg, Denmark
- Steno Diabetes Center North Denmark, Aalborg, Denmark
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Cascella M, Schiavo D, Cuomo A, Ottaiano A, Perri F, Patrone R, Migliarelli S, Bignami EG, Vittori A, Cutugno F. Artificial Intelligence for Automatic Pain Assessment: Research Methods and Perspectives. Pain Res Manag 2023; 2023:6018736. [PMID: 37416623 PMCID: PMC10322534 DOI: 10.1155/2023/6018736] [Citation(s) in RCA: 7] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/22/2022] [Revised: 02/03/2023] [Accepted: 04/20/2023] [Indexed: 07/08/2023]
Abstract
Although proper pain evaluation is mandatory for establishing the appropriate therapy, self-reported pain level assessment has several limitations. Data-driven artificial intelligence (AI) methods can be employed for research on automatic pain assessment (APA). The goal is the development of objective, standardized, and generalizable instruments useful for pain assessment in different clinical contexts. The purpose of this article is to discuss the state of the art of research and perspectives on APA applications in both research and clinical scenarios. Principles of AI functioning will be addressed. For narrative purposes, AI-based methods are grouped into behavioral-based approaches and neurophysiology-based pain detection methods. Since pain is generally accompanied by spontaneous facial behaviors, several approaches for APA are based on image classification and feature extraction. Language features through natural language strategies, body postures, and respiratory-derived elements are other investigated behavioral-based approaches. Neurophysiology-based pain detection is obtained through electroencephalography, electromyography, electrodermal activity, and other biosignals. Recent approaches involve multimode strategies by combining behaviors with neurophysiological findings. Concerning methods, early studies were conducted by machine learning algorithms such as support vector machine, decision tree, and random forest classifiers. More recently, artificial neural networks such as convolutional and recurrent neural network algorithms are implemented, even in combination. Collaboration programs involving clinicians and computer scientists must be aimed at structuring and processing robust datasets that can be used in various settings, from acute to different chronic pain conditions. Finally, it is crucial to apply the concepts of explainability and ethics when examining AI applications for pain research and management.
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Affiliation(s)
- Marco Cascella
- Division of Anesthesia and Pain Medicine, Istituto Nazionale Tumori IRCCS Fondazione G. Pascale, Naples 80131, Italy
| | - Daniela Schiavo
- Division of Anesthesia and Pain Medicine, Istituto Nazionale Tumori IRCCS Fondazione G. Pascale, Naples 80131, Italy
| | - Arturo Cuomo
- Division of Anesthesia and Pain Medicine, Istituto Nazionale Tumori IRCCS Fondazione G. Pascale, Naples 80131, Italy
| | - Alessandro Ottaiano
- SSD-Innovative Therapies for Abdominal Metastases, Istituto Nazionale Tumori di Napoli IRCCS “G. Pascale”, Via M. Semmola, Naples 80131, Italy
| | - Francesco Perri
- Head and Neck Oncology Unit, Istituto Nazionale Tumori IRCCS-Fondazione “G. Pascale”, Naples 80131, Italy
| | - Renato Patrone
- Dieti Department, University of Naples, Naples, Italy
- Division of Hepatobiliary Surgical Oncology, Istituto Nazionale Tumori IRCCS, Fondazione Pascale-IRCCS di Napoli, Naples, Italy
| | - Sara Migliarelli
- Department of Pharmacology, Faculty of Medicine and Psychology, University Sapienza of Rome, Rome, Italy
| | - Elena Giovanna Bignami
- Anesthesiology, Critical Care and Pain Medicine Division, Department of Medicine and Surgery, University of Parma, Parma, Italy
| | - Alessandro Vittori
- Department of Anesthesia and Critical Care, ARCO ROMA, Ospedale Pediatrico Bambino Gesù IRCCS, Rome 00165, Italy
| | - Francesco Cutugno
- Department of Electrical Engineering and Information Technologies, University of Naples “Federico II”, Naples 80100, Italy
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Kim DD, DeSnyder SM, Dougherty PM, Cata JP. Effect of neoadjuvant chemotherapy on intraoperative core temperature in patients with breast cancer: a retrospective cohort study. BJA OPEN 2023; 5:100119. [PMID: 37587989 PMCID: PMC10430839 DOI: 10.1016/j.bjao.2022.100119] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 08/16/2022] [Revised: 12/06/2022] [Accepted: 12/12/2022] [Indexed: 08/18/2023]
Abstract
Background Clinical evidence suggests that chemotherapeutic agents are associated with neuropathy and peripheral autonomic dysfunction. However, the possible effects of neoadjuvant chemotherapy on intraoperative temperature remain poorly characterised. Methods We evaluated patients who underwent a mastectomy for breast cancer between April 2016 and July 2020. Propensity scores were used to match patients who received neoadjuvant chemotherapy with those who did not, and intraoperative core temperature patterns were analysed in the matched cohort. The independent associations between vasopressor use and heart rate during general anaesthesia in the matched cohort were also analysed. Results Data from 1764 patients were analysed (882 patients in each group). Both groups presented a similar pattern of heat redistribution and subsequent rewarming; however, the neoadjuvant chemotherapy group did not reach the same intraoperative plateau temperature as the group that did not receive prior chemotherapy, with differences of up to 0.4°C (95% confidence interval: 0.11-0.63°C; P=0.005). In a subgroup analysis, neuropathy in patients who received neoadjuvant chemotherapy was associated with increased use of vasopressors and higher heart rate. Conclusions In patients with breast cancer, neoadjuvant chemotherapy is associated with lower plateau core temperatures, increased vasopressor use, and higher heart rates during general anaesthesia, which is more severe in the presence of neuropathy.
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Affiliation(s)
- Daniel D. Kim
- Department of Anesthesiology and Perioperative Medicine, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
- Anesthesiology and Surgical Oncology Research Group, Houston, TX, USA
| | - Sarah M. DeSnyder
- Department of Breast Surgical Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Patrick M. Dougherty
- Department of Pain Medicine, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Juan P. Cata
- Department of Anesthesiology and Perioperative Medicine, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
- Anesthesiology and Surgical Oncology Research Group, Houston, TX, USA
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Zinglersen AH, Drange IL, Myhr KA, Fuchs A, Pfeiffer-Jensen M, Brock C, Jacobsen S. Vagus nerve stimulation as a novel treatment for systemic lupus erythematous: study protocol for a randomised, parallel-group, sham-controlled investigator-initiated clinical trial, the SLE-VNS study. BMJ Open 2022; 12:e064552. [PMID: 36127117 PMCID: PMC9490576 DOI: 10.1136/bmjopen-2022-064552] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/03/2022] Open
Abstract
INTRODUCTION Systemic lupus erythematosus (SLE) is a chronic autoimmune disease. SLE is treated with immunosuppressants with suboptimal efficacy and high risk of serious side effects. Patients with SLE have increased risk of mortality, organ damage and debilitating treatment-resistant fatigue. Autonomic nervous system dysfunction (AD) is present in approximately half of the patients and may promote autoimmunity by weakening the vagally mediated anti-inflammatory reflex. Recent studies suggest that transcutaneous vagus nerve stimulation (tVNS) has few side effects and beneficial effects on fatigue, pain, disease activity and organ function. This study investigates whether adjuvant tVNS improves measures of fatigue (primary end point), AD, clinical disease activity, inflammation, pain, organ function and quality of life.Hence, this study will contribute to the understanding of AD as a potentially important precursor of fatigue, disease activity, progression and complications in SLE, and how tVNS mechanistically may attenuate this. As adjuvant tVNS use may reduce the need for traditional immunosuppressive therapy, this trial may prompt a shift in the treatment of SLE and potentially other autoimmune disorders. METHODS AND ANALYSIS Eighty-four patients with SLE with fatigue and AD will be randomised 1:1 to active or sham tVNS in this double-blinded parallel-group study. In period 1 (1 week), participants will receive a 4 min tVNS 4 times daily and report on fatigue daily. After a 2-week pause, period 2 (8 weeks) will entail tVNS twice daily and participants will report on fatigue, pain and disease activity weekly. Secondary end points will be assessed before and after each period and after 1 week in period 2. ETHICS AND DISSEMINATION The study is approved by the Danish Medical Research Ethical Committees (case no: 2120231) and results will be published in international peer-reviewed journals. TRIAL REGISTRATION NUMBER NCT05315739.
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Affiliation(s)
- Amanda Hempel Zinglersen
- Copenhagen Research Center for Autoimmune Connective Tissue Diseases (COPEACT), Department of Rheumatology, Rigshospitalet, Copenhagen, Denmark
- Department of Clinical Medicine, University of Copenhagen Faculty of Health and Medical Sciences, Copenhagen, Denmark
| | - Ida Lynghøj Drange
- Copenhagen Research Center for Autoimmune Connective Tissue Diseases (COPEACT), Department of Rheumatology, Rigshospitalet, Copenhagen, Denmark
| | - Katrine Aagaard Myhr
- Department of Clinical Medicine, University of Copenhagen Faculty of Health and Medical Sciences, Copenhagen, Denmark
- Department of Cardiology, Rigshospitalet, Copenhagen, Denmark
| | - Andreas Fuchs
- Department of Cardiology, Rigshospitalet, Copenhagen, Denmark
| | - Mogens Pfeiffer-Jensen
- Department of Clinical Medicine, University of Copenhagen Faculty of Health and Medical Sciences, Copenhagen, Denmark
- Copenhagen Center for Arthritis Research (COPECARE), Department of Rheumatology, Rigshospitalet, Glostrup, Denmark
| | - Christina Brock
- Mech-Sense, Aalborg University Hospital, Aalborg, Denmark
- Department of Clinical Medicine, Aalborg University Faculty of Medicine, Aalborg, Denmark
| | - Søren Jacobsen
- Copenhagen Research Center for Autoimmune Connective Tissue Diseases (COPEACT), Department of Rheumatology, Rigshospitalet, Copenhagen, Denmark
- Department of Clinical Medicine, University of Copenhagen Faculty of Health and Medical Sciences, Copenhagen, Denmark
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Moscato S, Cortelli P, Chiari L. Physiological responses to pain in cancer patients: A systematic review. COMPUTER METHODS AND PROGRAMS IN BIOMEDICINE 2022; 217:106682. [PMID: 35172252 DOI: 10.1016/j.cmpb.2022.106682] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/17/2021] [Revised: 01/23/2022] [Accepted: 02/04/2022] [Indexed: 06/14/2023]
Abstract
BACKGROUND AND OBJECTIVE Pain is one of the most debilitating symptoms in persons with cancer. Still, its assessment is often neglected both by patients and healthcare professionals. There is increasing interest in conducting pain assessment and monitoring via physiological signals that promise to overcome the limitations of state-of-the-art pain assessment tools. This systematic review aims to evaluate existing experimental studies to identify the most promising methods and results for objectively quantifying cancer patients' pain experience. METHODS Four electronic databases (Pubmed, Compendex, Scopus, Web of Science) were systematically searched for articles published up to October 2020. RESULTS Fourteen studies (528 participants) were included in the review. The selected studies analyzed seven physiological signals. Blood pressure and ECG were the most used signals. Sixteen physiological parameters showed significant changes in association with pain. The studies were fairly consistent in stating that heart rate, the low-frequency to high-frequency component ratio (LF/HF), and systolic blood pressure positively correlate with the pain. CONCLUSIONS Current evidence supports the hypothesis that physiological signals can help objectively quantify, at least in part, cancer patients' pain experience. While there is much more to be done to obtain a reliable pain assessment method, this review takes an essential first step by highlighting issues that should be taken into account in future research: use of a wearable device for pervasive recording in a real-world context, implementation of a big-data approach possibly supported by AI, including multiple stratification factors (e.g., cancer site and stage, source of pain, demographic and psychosocial data), and better-defined recording procedures. Improved methods and algorithms could then become valuable add-ons in taking charge of cancer patients.
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Affiliation(s)
- Serena Moscato
- Department of Electrical, Electronic, and Information Engineering "Guglielmo Marconi" - DEI, University of Bologna, Bologna, Italy.
| | - Pietro Cortelli
- IRCCS Istituto Delle Scienze Neurologiche Di Bologna, UOC Clinica Neurologica NeuroMet, Ospedale Bellaria, Bologna, Italy; Department of Biomedical and Neuromotor Sciences (DIBINEM), University of Bologna, Bologna, Italy
| | - Lorenzo Chiari
- Department of Electrical, Electronic, and Information Engineering "Guglielmo Marconi" - DEI, University of Bologna, Bologna, Italy; Health Sciences and Technologies, Interdepartmental Center for Industrial Research (CIRI-SDV), University of Bologna, Bologna, Italy
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Kong Y, Posada-Quintero HF, Chon KH. Sensitive Physiological Indices of Pain Based on Differential Characteristics of Electrodermal Activity. IEEE Trans Biomed Eng 2021; 68:3122-3130. [PMID: 33705307 DOI: 10.1109/tbme.2021.3065218] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
OBJECTIVE Electrodermal activity (EDA) has been widely used to assess human response to stressful stimuli, including pain. Recently, spectral analysis of EDA has been found to be more sensitive and reproducible for assessment of sympathetic arousal than traditional indices (e.g., tonic and phasic components). However, none of the aforementioned analyses incorporate the differential characteristics of EDA, which could be more sensitive to capturing fast-changing dynamics associated with pain responses. METHODS We have tested the feasibility of using the derivative of phasic EDA and the modified time-varying spectral analysis of EDA. Sixteen subjects underwent four levels of pain stimulation using electric stimulation. Five-second segments of EDA were used for each level of stimulation, and pre-stimulation segments were considered stimulation level 0. We used support vector machines with the radial basis function kernel and multi-layer perceptron for three different scenarios of stimulation-level classification tasks: five stimulation levels (four levels of stimulation plus no stimulation); low, medium, and high pain stimulation (stimulation levels 0-1, 2, and 3-4, respectively); and high stimulation levels (stimulation levels 3-4) vs. no stimulation. RESULTS The maximum balanced accuracies were 44% (five stimulation levels), 63% (for low, medium, and high pain stimulation), and 87% (sensitivity 83% and specificity 89%, for high stimulation vs. no stimulation). CONCLUSION The differential characteristics of EDA contributed highly to the accuracy of pain stimulation level detection of the classifiers. The external validity dataset was not considered in the study. SIGNIFICANCE Our approach has the potential for accurate pain quantification using EDA.
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7
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Omran M, Belcher EK, Mohile NA, Kesler SR, Janelsins MC, Hohmann AG, Kleckner IR. Review of the Role of the Brain in Chemotherapy-Induced Peripheral Neuropathy. Front Mol Biosci 2021; 8:693133. [PMID: 34179101 PMCID: PMC8226121 DOI: 10.3389/fmolb.2021.693133] [Citation(s) in RCA: 24] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/09/2021] [Accepted: 05/24/2021] [Indexed: 12/18/2022] Open
Abstract
Chemotherapy-induced peripheral neuropathy (CIPN) is a common, debilitating, and dose-limiting side effect of many chemotherapy regimens yet has limited treatments due to incomplete knowledge of its pathophysiology. Research on the pathophysiology of CIPN has focused on peripheral nerves because CIPN symptoms are felt in the hands and feet. However, better understanding the role of the brain in CIPN may accelerate understanding, diagnosing, and treating CIPN. The goals of this review are to (1) investigate the role of the brain in CIPN, and (2) use this knowledge to inform future research and treatment of CIPN. We identified 16 papers using brain interventions in animal models of CIPN and five papers using brain imaging in humans or monkeys with CIPN. These studies suggest that CIPN is partly caused by (1) brain hyperactivity, (2) reduced GABAergic inhibition, (3) neuroinflammation, and (4) overactivation of GPCR/MAPK pathways. These four features were observed in several brain regions including the thalamus, periaqueductal gray, anterior cingulate cortex, somatosensory cortex, and insula. We discuss how to leverage this knowledge for future preclinical research, clinical research, and brain-based treatments for CIPN.
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Affiliation(s)
- Maryam Omran
- University of Rochester Medical Center, Rochester, NY, United States
| | | | - Nimish A Mohile
- University of Rochester Medical Center, Rochester, NY, United States
| | - Shelli R Kesler
- The University of Texas at Austin, Austin, TX, United States
| | | | - Andrea G Hohmann
- Psychological and Brain Sciences, Program in Neuroscience and Gill Center for Biomolecular Science, Indiana University Bloomington, Bloomington, IN, United States
| | - Ian R Kleckner
- University of Rochester Medical Center, Rochester, NY, United States
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Abstract
Chemotherapy-induced peripheral neuropathy (CIPN) is an unsolved and potentially life-compromising problem for most patients receiving neurotoxic chemotherapy. It manifests with numbness, tingling, and possibly neuropathic pain and motor and autonomic symptoms. This review aims to provide an evidence synthesis that prepares nurses to comprehensively assess, provide supportive care for, and critically evaluate the literature on CIPN. The prevalence, significance, characteristics, mechanisms, and risk factors of CIPN will be discussed, as well as nursing-relevant evidence on the assessment, prevention, and management of CIPN. The importance of critical literature evaluation before clinical implementation to reduce physical and financial harms to patients will also be highlighted.
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Posada-Quintero HF, Kong Y, Nguyen K, Tran C, Beardslee L, Chen L, Guo T, Cong X, Feng B, Chon KH. Using electrodermal activity to validate multilevel pain stimulation in healthy volunteers evoked by thermal grills. Am J Physiol Regul Integr Comp Physiol 2020; 319:R366-R375. [PMID: 32726157 DOI: 10.1152/ajpregu.00102.2020] [Citation(s) in RCA: 18] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
We have tested the feasibility of thermal grills, a harmless method to induce pain. The thermal grills consist of interlaced tubes that are set at cool or warm temperatures, creating a painful "illusion" (no tissue injury is caused) in the brain when the cool and warm stimuli are presented collectively. Advancement in objective pain assessment research is limited because the gold standard, the self-reporting pain scale, is highly subjective and only works for alert and cooperative patients. However, the main difficulty for pain studies is the potential harm caused to participants. We have recruited 23 subjects in whom we induced electric pulses and thermal grill (TG) stimulation. The TG effectively induced three different levels of pain, as evidenced by the visual analog scale (VAS) provided by the subjects after each stimulus. Furthermore, objective physiological measurements based on electrodermal activity showed a significant increase in levels as stimulation level increased. We found that VAS was highly correlated with the TG stimulation level. The TG stimulation safely elicited pain levels up to 9 out of 10. The TG stimulation allows for extending studies of pain to ranges of pain in which other stimuli are harmful.
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Affiliation(s)
| | | | | | - Cara Tran
- University of Connecticut, Storrs, Connecticut
| | - Luke Beardslee
- Emory University School of Medicine Department of Surgery, Atlanta, Georgia
| | - Longtu Chen
- University of Connecticut, Storrs, Connecticut
| | | | | | - Bin Feng
- University of Connecticut, Storrs, Connecticut
| | - Ki H Chon
- University of Connecticut, Storrs, Connecticut
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de Matos NMP, Pach D, Xing JJ, Barth J, Beyer LE, Shi X, Kern A, Lukic N, Ettlin DA, Brügger M, Witt CM. Evaluating the Effects of Acupuncture Using a Dental Pain Model in Healthy Subjects - A Randomized, Cross-Over Trial. THE JOURNAL OF PAIN 2019; 21:440-454. [PMID: 31521794 DOI: 10.1016/j.jpain.2019.08.013] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/12/2019] [Revised: 08/20/2019] [Accepted: 08/25/2019] [Indexed: 10/26/2022]
Abstract
Acupuncture is a complementary and nonpharmacological intervention that can be effective for the management of chronic pain in addition to or instead of medication. Various animal models for neuropathic pain, inflammatory pain, cancer-related pain, and visceral pain already exist in acupuncture research. We used a newly validated human pain model and examined whether acupuncture can influence experimentally induced dental pain. For this study, we compared the impact of manual acupuncture (real acupuncture), manual stimulation of a needle inserted at nonacupuncture points (sham acupuncture) and no acupuncture on experimentally induced dental pain in 35 healthy men who were randomized to different sequences of all 3 interventions in a within-subject design. BORG CR10 pain ratings and autonomic responses (electrodermal activity and heart rate variability) were investigated. An initial mixed model with repeated measures included preintervention pain ratings and the trial sequence as covariates. The results showed that acupuncture was effective in reducing pain intensity when compared to no acupuncture (β = -.708, P = .002), corresponding to a medium Cohen's d effect size of .56. The comparison to the sham acupuncture revealed no statistically significant difference. No differences in autonomic responses between real and sham acupuncture were found during the intervention procedures. PERSPECTIVE: This study established a dental pain model for acupuncture research and provided evidence that experimentally induced dental pain can be influenced by either real acupuncture or manual stimulation of needles at nonacupuncture points. The data do not support that acupoint specificity is a significant factor in reducing experimental pain.
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Affiliation(s)
- Nuno M P de Matos
- Institute for Complementary and Integrative Medicine, University of Zurich and University Hospital Zurich, Zurich, Switzerland; Clinic of Cranio-Maxillofacial and Oral Surgery, Center of Dental Medicine, University of Zurich, Zurich, Switzerland
| | - Daniel Pach
- Institute for Complementary and Integrative Medicine, University of Zurich and University Hospital Zurich, Zurich, Switzerland; Charité - Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Institute for Social Medicine, Epidemiology and Health Economics, Berlin, Germany.
| | - Jing Jing Xing
- First Teaching Hospital of Tianjin University of Traditional Chinese Medicine, Tianjin, China
| | - Jürgen Barth
- Institute for Complementary and Integrative Medicine, University of Zurich and University Hospital Zurich, Zurich, Switzerland
| | - Lara Elena Beyer
- Institute for Complementary and Integrative Medicine, University of Zurich and University Hospital Zurich, Zurich, Switzerland
| | - Xuemin Shi
- Institute for Complementary and Integrative Medicine, University of Zurich and University Hospital Zurich, Zurich, Switzerland
| | - Alexandra Kern
- Institute for Complementary and Integrative Medicine, University of Zurich and University Hospital Zurich, Zurich, Switzerland
| | - Nenad Lukic
- Clinic of Cranio-Maxillofacial and Oral Surgery, Center of Dental Medicine, University of Zurich, Zurich, Switzerland
| | - Dominik A Ettlin
- Clinic of Cranio-Maxillofacial and Oral Surgery, Center of Dental Medicine, University of Zurich, Zurich, Switzerland
| | - Mike Brügger
- Clinic of Cranio-Maxillofacial and Oral Surgery, Center of Dental Medicine, University of Zurich, Zurich, Switzerland; Institute for Biomedical Engineering, ETH Zurich and University of Zurich, Zurich, Switzerland
| | - Claudia M Witt
- Institute for Complementary and Integrative Medicine, University of Zurich and University Hospital Zurich, Zurich, Switzerland; Charité - Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Institute for Social Medicine, Epidemiology and Health Economics, Berlin, Germany; Center for Integrative Medicine, University of Maryland School of Medicine Baltimore, Baltimore, Maryland
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Kano M, Yoshizawa M, Kono K, Muratsubaki T, Morishita J, Van Oudenhove L, Yagihashi M, Mugikura S, Dupont P, Takase K, Kanazawa M, Fukudo S. Parasympathetic activity correlates with subjective and brain responses to rectal distension in healthy subjects but not in non-constipated patients with irritable bowel syndrome. Sci Rep 2019; 9:7358. [PMID: 31089154 PMCID: PMC6517375 DOI: 10.1038/s41598-019-43455-5] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/24/2018] [Accepted: 04/18/2019] [Indexed: 12/15/2022] Open
Abstract
The nociceptive and autonomic nervous systems (ANS) are significantly intertwined. Decoupling of these systems may occur in pathological pain conditions, including irritable bowel syndrome (IBS). We investigated ANS activity and its association with visceral perception and brain activity during rectal distention in 27 patients with non-constipated IBS and 33 controls by assessing heart rate variability (HRV) using electrocardiography at rest, before, and during colorectal distention. Brain responses to colorectal distention were measured using functional magnetic resonance imaging and correlated with individual ANS function parameters. The IBS group displayed blunted sympathovagal balance [low/high-frequency ratio (LF:HF) of HRV] in response to colorectal distention compared with controls (P = 0.003). In controls, basal parasympathetic tone (HF component of HRV) was significantly negatively correlated with toleration threshold to the rectal distention, but not in patients with IBS (group comparison P = 0.04). Further, a positive correlation between baseline HF values and neural responses to rectal distension was found in the right caudate, bilateral dorsolateral anterior cingulate cortex, and pregenual anterior cingulate cortex in the control group but not in the IBS group. The results indicate abnormal interactions between ANS activity and the brain mechanisms underlying visceral perception in patients with IBS.
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Affiliation(s)
- Michiko Kano
- Sukawa Clinic, Kirari Health Coop, Fukushima, Japan. .,Behavioral Medicine, Graduate School of Medicine, Tohoku University, Sendai, Japan.
| | - Makoto Yoshizawa
- Research Division on Advanced Information Technology, Cyberscience Center, Tohoku University, Sendai, Japan
| | - Keiji Kono
- Behavioral Medicine, Graduate School of Medicine, Tohoku University, Sendai, Japan
| | - Tomohiko Muratsubaki
- Behavioral Medicine, Graduate School of Medicine, Tohoku University, Sendai, Japan
| | - Joe Morishita
- Behavioral Medicine, Graduate School of Medicine, Tohoku University, Sendai, Japan
| | - Lukas Van Oudenhove
- Laboratory for Brain-Gut Axis Studies (LaBGAS), Translational Research Center for Gastrointestinal Disorders (TARGID), KU Leuven, Leuven, Belgium
| | - Mao Yagihashi
- Dept. Biodesign, Clinical Research, Innovation and Education Center (CRIETO), Tohoku University Hospital, Sendai, Japan
| | - Shunji Mugikura
- Diagnostic Radiology, Tohoku University Hospital, Sendai, Japan
| | - Patrick Dupont
- Laboratory for Cognitive Neurology, KU Leuven, Leuven, Belgium
| | - Kei Takase
- Diagnostic Radiology, Tohoku University Hospital, Sendai, Japan
| | - Motoyori Kanazawa
- Behavioral Medicine, Graduate School of Medicine, Tohoku University, Sendai, Japan
| | - Shin Fukudo
- Behavioral Medicine, Graduate School of Medicine, Tohoku University, Sendai, Japan
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The effects of propranolol on heart rate variability and quantitative, mechanistic, pain profiling: a randomized placebo-controlled crossover study. Scand J Pain 2018; 18:479-489. [DOI: 10.1515/sjpain-2018-0054] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/12/2018] [Accepted: 04/23/2018] [Indexed: 12/20/2022]
Abstract
Abstract
Background and aims
The autonomic nervous system (ANS) is capable of modulating pain. Aberrations in heart rate variability (HRV), reflective of ANS activity, are associated with experimental pain sensitivity, chronic pain, and more recently, pain modulatory mechanisms but the underlying mechanisms are still unclear. HRV is lowered during experimental pain as well as in chronic pain conditions and HRV can be increased by propranolol, which is a non-selective β-blocker. Sensitization of central pain pathways have been observed in several chronic pain conditions and human mechanistic pain biomarkers for these central pain pathways include temporal summation of pain (TSP) and conditioned pain modulation (CPM). The current study aimed to investigate the effect of the β-blocker propranolol, and subsequently assessing the response to standardized, quantitative, mechanistic pain biomarkers.
Methods
In this placebo-controlled, double-blinded, randomized crossover study, 25 healthy male volunteers (mean age 25.6 years) were randomized to receive 40 mg propranolol and 40 mg placebo. Heart rate, blood pressure, and HRV were assessed before and during experimental pain tests. Cuff pressure pain stimulation was used for assessment of pain detection (cPDTs) and pain tolerance (cPTTs) thresholds, TSP, and CPM. Offset analgesia (OA) was assessed using heat stimulation.
Results
Propranolol significantly reduced heart rate (p<0.001), blood pressure (p<0.02) and increased HRV (p<0.01) compared with placebo. No significant differences were found comparing cPDT (p>0.70), cPTT (p>0.93), TSP (p>0.70), OA-effect (p>0.87) or CPM (p>0.65) between propranolol and placebo.
Conclusions
The current study demonstrated that propranolol increased HRV, but did not affect pressure pain sensitivity or any pain facilitatory or modulatory outcomes.
Implications
Analgesic effects of propranolol have been reported in clinical pain populations and the results from the current study could indicate that increased HRV from propranolol is not associated with peripheral and central pain pathways in healthy male subjects.
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Dayan L, Hochberg U, Nahman-Averbuch H, Brill S, Ablin JN, Jacob G. Increased Sympathetic Outflow Induces Adaptation to Acute Experimental Pain. Pain Pract 2017. [PMID: 28627793 DOI: 10.1111/papr.12606] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/22/2023]
Abstract
BACKGROUND There are interrelationships between the autonomic nervous system and pain. This study aims to explore the effect of different autonomic manipulations on pain perception and modulation. METHODS Twenty healthy subjects (10 men and 10 women, mean age 25 ± 3 years) participated in this single-blinded, semi-randomized, controlled study, which included 2 study visits. Warm detection thresholds, heat pain thresholds, conditioned pain modulation (CPM), and pain adaptation were tested before and after administration of phenylephrine, clonidine, yohimbine, and saline. RESULTS Changes in heart rate and blood pressure were found after all the pharmacological interventions. The only effect on pain measures was that yohimbine enhanced pain adaptation capacity while phenylephrine reduced it (P = 0.032). Several significant correlations were found between autonomic and pain parameters; greater decreases in heart rate after phenylephrine were associated with reduced pain ratings (r2 = 0.288, P = 0.018). In addition, enhanced pain adaptation was associated with higher total vascular resistance (r2 = 0.442, P = 0.01). CONCLUSIONS Different effects of acute autonomic manipulations on experimental pain were found: an increase in sympathetic tone induced by yohimbine led to reduced pain sensitivity; a decrease in sympathetic tone with no effect on vagal-parasympathetic tone induced by phenylephrine led to reduction in pain adaptation capacity; and a decrease in sympathetic tone and increase in vagal parasympathetic tone by clonidine led to no change in pain adaptation capacity. While increased sympathetic outflow does facilitate pain adaptation, activation of either the sympathetic or parasympathetic limbs of the autonomic nervous system does not affect pain thresholds or CPM. Finally, a correlation exists between nociception and cardiovascular parameters only due to baroreflex activation.
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Affiliation(s)
- Lior Dayan
- Department of Anesthesia and Critical Care Medicine, Institute of Pain Medicine, Tel Aviv Sourasky Medical Center, Tel Aviv, Israel.,Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Uri Hochberg
- Department of Anesthesia and Critical Care Medicine, Institute of Pain Medicine, Tel Aviv Sourasky Medical Center, Tel Aviv, Israel.,Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel
| | | | - Silviu Brill
- Department of Anesthesia and Critical Care Medicine, Institute of Pain Medicine, Tel Aviv Sourasky Medical Center, Tel Aviv, Israel.,Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Jacob N Ablin
- Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel.,Department of Internal Medicine, Tel Aviv Sourasky Medical Center, Tel Aviv, Israel
| | - Giris Jacob
- Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel.,Department of Internal Medicine, Tel Aviv Sourasky Medical Center, Tel Aviv, Israel
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Pain-autonomic relationships: implications for experimental design and the search for an “objective marker” for pain. Pain 2017; 158:2064-2065. [DOI: 10.1097/j.pain.0000000000001035] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
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Efficient conditioned pain modulation despite pain persistence in painful diabetic neuropathy. Pain Rep 2017; 2:e592. [PMID: 29392208 PMCID: PMC5741298 DOI: 10.1097/pr9.0000000000000592] [Citation(s) in RCA: 26] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/26/2016] [Revised: 02/10/2017] [Accepted: 03/09/2017] [Indexed: 01/23/2023] Open
Abstract
Despite persistent clinical pain in patients with painful diabetic neuropathy, longer pain duration was associated with more efficient CPM. Introduction: Alleviation of pain, by either medical or surgical therapy, is accompanied by transition from less efficient, or pro-nociceptive, to efficient conditioned pain modulation (CPM). Spontaneous decrease or resolution of pain with disease progression is reported for some patients with painful diabetic neuropathy (PDN). Objectives: To explore whether CPM changes similarly in parallel to spontaneous resolution of pain in PDN patients. Methods: In this cross-sectional study, thirty-three patients with PDN underwent psychophysical assessment of pain modulation on the forearm, remote from the clinical pain. Results: Pain duration was not correlated with neuropathic pain intensity, yet, it correlated with CPM efficiency; patients with longer pain duration had same pain level, but more efficient CPM than those with short-pain duration (ρ = −0.417; P = 0.025, Spearman correlation). Patients with pain more than 2 years (median split) expressed efficient CPM that was not different from that of healthy controls. These patients also had lower temporal summation of pain than the short-pain duration patients group (P < 0.05). The 2 patient groups did not differ in clinical pain characteristics or use of analgesics. Conclusion: Pro-nociception, expressed by less efficient CPM and high temporal summation that usually accompanies clinical painful conditions, seems to “normalize” with chronicity of the pain syndrome. This is despite continuing pain, suggesting that pro-nociceptivity in pain syndromes is multifactorial. Because the pain modulation profile affects success of therapy, this suggests that different drugs might express different efficacy pending on duration of the pain in patients with PDN.
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Abstract
Compression therapy, a well-recognized treatment for lymphoedema and venous disorders, pressurizes limbs and generates massive non-noxious afferent sensory barrages. The aim of this study was to study whether such afferent activity has an analgesic effect when applied on the lower limbs, hypothesizing that larger compression areas will induce stronger analgesic effects, and whether this effect correlates with conditioned pain modulation (CPM). Thirty young healthy subjects received painful heat and pressure stimuli (47°C for 30 seconds, forearm; 300 kPa for 15 seconds, wrist) before and during 3 compression protocols of either SMALL (up to ankles), MEDIUM (up to knees), or LARGE (up to hips) compression areas. Conditioned pain modulation (heat pain conditioned by noxious cold water) was tested before and after each compression protocol. The LARGE protocol induced more analgesia for heat than the SMALL protocol (P < 0.001). The analgesic effect interacted with gender (P = 0.015). The LARGE protocol was more efficient for females, whereas the MEDIUM protocol was more efficient for males. Pressure pain was reduced by all protocols (P < 0.001) with no differences between protocols and no gender effect. Conditioned pain modulation was more efficient than the compression-induced analgesia. For the LARGE protocol, precompression CPM efficiency positively correlated with compression-induced analgesia. Large body area compression exerts an area-dependent analgesic effect on experimental pain stimuli. The observed correlation with pain inhibition in response to robust non-noxious sensory stimulation may suggest that compression therapy shares similar mechanisms with inhibitory pain modulation assessed through CPM.
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Nahman-Averbuch H, Dayan L, Sprecher E, Hochberg U, Brill S, Yarnitsky D, Jacob G. Pain Modulation and Autonomic Function: The Effect of Clonidine. PAIN MEDICINE 2016; 17:1292-1301. [PMID: 26893118 DOI: 10.1093/pm/pnv102] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/04/2015] [Revised: 12/01/2015] [Accepted: 12/11/2015] [Indexed: 01/17/2023]
Abstract
OBJECTIVE The α2-agonist clonidine is an analgesic agent, whose yet uncertain action may involve either increase in pain modulation efficiency, change in autonomic function, and/or decrease in anxiety level. The present study aimed to examine the effect of oral clonidine on pain perception in healthy subjects in order to reveal its mode of action. DESIGN Randomized, double-blind, placebo-controlled study. SUBJECTS Forty healthy subjects. METHODS Subjects received either 0.15 mg oral clonidine or placebo. We measured pain parameters of heat pain thresholds, tonic heat stimulus, mechanical temporal summation, offset analgesia (OA) and conditioned pain modulation (CPM); autonomic parameters of deep breathing ratio and heart rate variability indices obtained before, during, and after tonic heat stimulus; and psychological parameters of anxiety and pain catastrophizing. RESULTS Clonidine decreased systolic blood pressure (P = 0.022) and heart rate (P = 0.004) and increased rMSSD (P = 0.020), though no effect was observed on pain perception, pain modulation, and psychological parameters. Autonomic changes were correlated with pain modulation capacity; for OA, the separate slope model was significant (P = 0.008); in the clonidine group, more efficient OA was associated with lower heart rate (r = 0.633, P = 0.005), unlike in the placebo group. CONCLUSIONS The change in autonomic function that was related to the increase in pain modulation capacity, and the lack of change in anxiety, suggest a combined modulatory-autonomic mode of analgesic action for clonidine.
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Affiliation(s)
- Hadas Nahman-Averbuch
- *The Laboratory of Clinical Neurophysiology, the Rappaport Faculty of Medicine, Technion - Israel Institute of Technology, Haifa, Israel
| | - Lior Dayan
- Institute of Pain Medicine, Department of Anesthesia and Critical Care Medicine, Tel Aviv Sourasky Medical Center, Tel-Aviv, Israel
| | - Elliot Sprecher
- *The Laboratory of Clinical Neurophysiology, the Rappaport Faculty of Medicine, Technion - Israel Institute of Technology, Haifa, Israel
| | - Uri Hochberg
- Institute of Pain Medicine, Department of Anesthesia and Critical Care Medicine, Tel Aviv Sourasky Medical Center, Tel-Aviv, Israel
| | - Silviu Brill
- Institute of Pain Medicine, Department of Anesthesia and Critical Care Medicine, Tel Aviv Sourasky Medical Center, Tel-Aviv, Israel
| | - David Yarnitsky
- *The Laboratory of Clinical Neurophysiology, the Rappaport Faculty of Medicine, Technion - Israel Institute of Technology, Haifa, Israel.,Department of Neurology, Rambam Medical Center, Haifa, Israel
| | - Giris Jacob
- Department of Internal Medicine, Tel Aviv Sourasky Medical Center, Tel Aviv, Israel
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Nahman-Averbuch H, Sprecher E, Jacob G, Yarnitsky D. The Relationships Between Parasympathetic Function and Pain Perception: The Role of Anxiety. Pain Pract 2016; 16:1064-1072. [PMID: 26878998 DOI: 10.1111/papr.12407] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/18/2015] [Accepted: 10/09/2015] [Indexed: 11/28/2022]
Abstract
BACKGROUND Previous studies have identified relationships between autonomic function and pain perception. Anxiety was found to influence both autonomic and pain responses. We examined the effect of anxiety level on parasympathetic function and pain perception as well as on the relationships between these 2 systems. METHODS Thirty healthy females were divided into high- and low-anxiety groups according to their trait anxiety levels. Parasympathetic function was obtained using heart rate variability, deep breathing, and Valsalva ratios. Pain perception parameters of heat pain thresholds, pain rating of supra-thresholds stimulus, mechanical temporal summation, and conditioned pain modulation response were examined. RESULTS The low-anxiety and high-anxiety groups exhibited no significant differences in the parasympathetic function and pain perception parameters. Assessment of the associations revealed that in the high-anxiety group, higher mean ratings of the tonic heat pain stimulus were significantly correlated with higher rMSSD (r2 = 0.358, P = 0.019), but this was not found for the low-anxiety group (P = 0.282). In addition, in the high-anxiety group, efficient conditioned pain modulation response was correlated with higher deep breathing ratio (r2 = 0.363, P = 0.023); however, in the low-anxiety group, the correlation did not reach significance (P = 0.109). CONCLUSIONS This study demonstrates the role of anxiety level on the relationships between parasympathetic function and pain perception. We suggest that a situation of high anxiety leads to higher norepinephrine levels that can influence both parasympathetic function and pain perception, thus explaining the significant relationships found between these 2 systems only in subjects with high anxiety.
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Affiliation(s)
- Hadas Nahman-Averbuch
- The Laboratory of Clinical Neurophysiology, the Rappaport Faculty of Medicine, Technion - Israel Institute of Technology, Haifa, Israel
| | - Elliot Sprecher
- The Laboratory of Clinical Neurophysiology, the Rappaport Faculty of Medicine, Technion - Israel Institute of Technology, Haifa, Israel
| | - Giris Jacob
- Department of Internal Medicine, Tel Aviv Sourasky Medical Center, Tel Aviv, Israel
| | - David Yarnitsky
- The Laboratory of Clinical Neurophysiology, the Rappaport Faculty of Medicine, Technion - Israel Institute of Technology, Haifa, Israel.,Department of Neurology, Rambam Medical Center, Haifa, Israel
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Sex differences in the relationships between parasympathetic activity and pain modulation. Physiol Behav 2016; 154:40-8. [DOI: 10.1016/j.physbeh.2015.11.004] [Citation(s) in RCA: 37] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/16/2015] [Revised: 10/20/2015] [Accepted: 11/05/2015] [Indexed: 12/23/2022]
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Howard E. Cancer survivorship: An insider's perspective. PROGRESS IN PEDIATRIC CARDIOLOGY 2015. [DOI: 10.1016/j.ppedcard.2015.10.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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Yuan H, Silberstein SD. Vagus Nerve and Vagus Nerve Stimulation, a Comprehensive Review: Part III. Headache 2015; 56:479-90. [PMID: 26364805 DOI: 10.1111/head.12649] [Citation(s) in RCA: 78] [Impact Index Per Article: 8.7] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/08/2015] [Indexed: 12/23/2022]
Abstract
Vagus nerve stimulation (VNS) is currently undergoing multiple trials to explore its potential for various clinical disorders. To date, VNS has been approved for the treatment of refractory epilepsy and depression. It exerts antiepileptic or antiepileptogenic effect possibly through neuromodulation of certain monoamine pathways. Beyond epilepsy, VNS is also under investigation for the treatment of inflammation, asthma, and pain. VNS influences the production of inflammatory cytokines to dampen the inflammatory response. It triggers the systemic release of catecholamines that alleviates the asthma attack. VNS induces antinociception by modulating multiple pain-associated structures in the brain and spinal cord affecting peripheral/central nociception, opioid response, inflammation process, autonomic activity, and pain-related behavior. Progression in VNS clinical efficacy over time suggests an underlying disease-modifying neuromodulation, which is an emerging field in neurology. With multiple potential clinical applications, further development of VNS is encouraging.
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Affiliation(s)
- Hsiangkuo Yuan
- Jefferson Headache Center, Thomas Jefferson University, Philadelphia, PA, USA
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