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Umeda M, Okifuji A. Exploring the sex differences in conditioned pain modulation and its biobehavioral determinants in healthy adults. Musculoskelet Sci Pract 2023; 63:102710. [PMID: 36566112 DOI: 10.1016/j.msksp.2022.102710] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/21/2022] [Revised: 12/13/2022] [Accepted: 12/17/2022] [Indexed: 12/23/2022]
Abstract
BACKGROUND Females are at greater risk of chronic pain, and exhibit higher pain sensitivity compared to males. However, sex differences in conditioned pain modulation (CPM), a neurophysiological risk factor of chronic pain, are unclear. CPM is influenced by many factors, some of which are sex-dependent. This study explored the sex differences in CPM and its biobehavioral determinants, such as blood pressure responses, physical activity levels, pain catastrophizing scores, and conditioning stimulus intensity, in young, healthy, physically active males and females. METHODS Twenty-six males and 24 females completed the CPM test using an electrical pain stimulus and a cold pain stimulus induced via 2 min of cold pressor test. Blood pressure was assessed at baseline and during cold pressor test, whereas cold pain ratings were obtained during cold pressor test to monitor the conditioning stimulus intensity. Physical activity was evaluated via questionnaires and accelerometer, whereas pain catastrophizing was evaluated via a questionnaire. RESULTS Both males and females exhibited CPM, without sex differences in the magnitude of CPM. The males showed higher resting blood pressure, higher physical activity levels, and lower pain catastrophizing scores than the females, without sex differences observed in cold pain ratings and proportion of those who met the physical activity guidelines. No correlations were observed between CPM and its determinants. CONCLUSIONS The results suggest the complexity of mechanisms underlying the sex differences in CPM. The sex differences in CPM, along with its determinants, may need to be examined in individuals with some risk factors for chronic pain.
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Affiliation(s)
- Masataka Umeda
- Department of Kinesiology, University of Texas at San Antonio, San Antonio, TX, USA.
| | - Akiko Okifuji
- Division of Pain Medicine, Department of Anesthesiology, University of Utah, Salt Lake City, UT, USA
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Oono Y, Kubo H, Takagi S, Wang K, Arendt-Nielsen L, Kohase H. Conditioned pain modulation is not associated with thermal pain illusion. Scand J Pain 2023; 23:175-183. [PMID: 35607757 DOI: 10.1515/sjpain-2022-0037] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/16/2022] [Accepted: 04/25/2022] [Indexed: 01/17/2023]
Abstract
OBJECTIVES Paradoxical sensations, known as thermal pain illusions, can be evoked by painful cold-heat pulse stimulation. They may provide diagnostic value; however, the possible interaction between conditioned pain modulation and thermal pain illusions has not been explored. The present study examined: (1) whether conditioned pain modulation could be induced by alternating tonic painful cold-heat pulse stimulation; and (2) whether the presence of thermal pain illusions during the conditioning stimulus influences the degree of conditioned pain modulation. METHODS This study was approved by the Ethics Committee of Meikai University (A1507). Conditioned pain modulation was provoked using alternating painful cold-heat pulses delivered at 20-s intervals applied to the forearm. Thermal pain illusions were qualitatively evaluated, and conditioned pain modulation was assessed quantitatively using the pressure pain threshold as a test stimulus. Differences in the conditioned pain modulation effect between the participants who experienced thermal pain illusions and those who did not were analysed using Student's t-test. RESULTS A significant positive conditioned pain modulation effect (51.0 ± 4.7%, overall effect) was detected. There was no significant difference in conditioned pain modulation between the participants who experienced thermal pain illusions and those who did not (44.3 ± 6.0% and 55.5 ± 6.8%, respectively; p = 0.255). CONCLUSIONS Conditioned pain modulation induced by alternating painful conditioning cold-heat pulse stimulation was identical during the conditioning stimulation in volunteers with and without thermal pain illusions. Conditioning cold-heat pulse stimulation is useful to evaluate conditioned pain modulation. Moreover, conditioned pain modulation is not influenced by the presence of thermal pain illusions, indicating partially different underlying supraspinal, neuronal networks.
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Affiliation(s)
- Yuka Oono
- Department of Diagnostic and Therapeutic Sciences, Division of Dental Anesthesiology, Meikai University School of Dentistry, Sakado, Japan
| | - Hidenori Kubo
- Department of Diagnostic and Therapeutic Sciences, Division of Dental Anesthesiology, Meikai University School of Dentistry, Sakado, Japan
| | - Saori Takagi
- Department of Diagnostic and Therapeutic Sciences, Division of Dental Anesthesiology, Meikai University School of Dentistry, Sakado, Japan
| | - Kelun Wang
- Center for Sensory-Motor Interaction (SMI), Department of Health Science & Technology, Faculty of Medicine, Aalborg University, Aalborg, Denmark
| | - Lars Arendt-Nielsen
- Department of Health Science and Technology, Center for Neuroplasticity and Pain, SMI, School of Medicine, Aalborg University, Aalborg, Denmark
- Department of Medical Gastroenterology, Mech-Sense, Aalborg University Hospital, Aalborg, Denmark
| | - Hikaru Kohase
- Department of Diagnostic and Therapeutic Sciences, Division of Dental Anesthesiology, Meikai University School of Dentistry, Sakado, Japan
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Machida T, Katayama H, Yoshida O, Watanabe A. Successful Pain Relief With Duloxetine in a Patient With Chronic Postsurgical Pain After Open Reduction and Internal Fixation: A Case Report. Cureus 2021; 13:e20456. [PMID: 35070525 PMCID: PMC8760792 DOI: 10.7759/cureus.20456] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/15/2021] [Indexed: 11/17/2022] Open
Abstract
Chronic postsurgical pain (CPSP) is a common complication of surgery. We report that a patient with CPSP after open reduction and internal fixation (ORIF) had pain relief with duloxetine, and that the conditioned pain modulation (CPM) efficiency may predict the efficacy of duloxetine. A 54-year-old woman with CPSP after ORIF due to proximal humeral fracture was presented to our orthopedic clinic one month after surgery. Despite several analgesics, she still had pain three months after surgery, pain during activity was 74 on the visual analogue scale (VAS), 16 on the American Shoulder and Elbow Surgeons Standardized Shoulder Assessment Form (ASES), 18 on the PainDETECT questionnaire, and CPM efficiency was -5.7%. The patient was treated with duloxetine, starting at 20mg/day and increasing every week. Three months after starting duloxetine, pain on the VAS was 18, ASES was 61, PainDETECT questionnaire was 6, and CPM efficiency was -39.8%. The dose of duloxetine was decreased every week and then withdrawn. Neuropathic pain may be involved even in patients with CPSP after ORIF, and duloxetine may be efficacious in such cases. CPM testing may provide useful information for clinicians in selecting appropriate drugs and in determining when to withdraw drugs.
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Ibancos-Losada MDR, Osuna-Pérez MC, Castellote-Caballero MY, Díaz-Fernández Á. Conditioned Pain Modulation Effectiveness: An Experimental Study Comparing Test Paradigms and Analyzing Potential Predictors in a Healthy Population. Brain Sci 2020; 10:brainsci10090599. [PMID: 32872642 PMCID: PMC7565989 DOI: 10.3390/brainsci10090599] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/13/2020] [Revised: 08/26/2020] [Accepted: 08/28/2020] [Indexed: 11/16/2022] Open
Abstract
Conditioned pain modulation (CPM) is an endogenous pain inhibition phenomenon that can be summarized simply as one type of pain being able to inhibit another, which must be in a remote area in relation to the first pain. We aimed to compare the effectiveness of four CPM test paradigms as well as the association of the CPM effect with potential predictors in 72 healthy volunteers. Pressure pain from an algometer was used as the test stimulus, and pain provoked by cold water or ischemic pressure was used as the conditioning stimulus, applied either sequentially or in parallel. No significant differences were found between the test paradigms, although the cold-parallel test showed the most significant effect size (ηP2 = 0.614). No association was found between the CPM effect and sociodemographic variables (age or sex), nor anxiety, depression, catastrophizing, previous history of pain or self-perceived pain tolerance. Nevertheless, a strong association was found between the CPM effect and individual affinity for the stimulus in participants who underwent the cold water test paradigm; this explained around 45% of the total CPM effect when the paradigm (cold water) coincided with personal affinity for the stimulus (“I prefer cold to heat”, “cold is not unpleasant”).
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Affiliation(s)
| | - María C. Osuna-Pérez
- Department of Health Sciences, University of Jaén, Jaén-23071, Spain; (M.Y.C.-C.); (Á.D.-F.)
- Correspondence: ; Tel.: +34-953213020
| | | | - Ángeles Díaz-Fernández
- Department of Health Sciences, University of Jaén, Jaén-23071, Spain; (M.Y.C.-C.); (Á.D.-F.)
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Lie MU, Petriu E, Matre D, Hansson P, Andersen OK, Zwart JA, Nilsen KB. Psychophysical or spinal reflex measures when assessing conditioned pain modulation? Eur J Pain 2019; 23:1879-1889. [PMID: 31359580 DOI: 10.1002/ejp.1462] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/02/2018] [Revised: 07/05/2019] [Accepted: 07/23/2019] [Indexed: 01/31/2023]
Abstract
BACKGROUND Assessing conditioning pain modulation (CPM) with spinal reflex measures may produce more objective and stable CPM effects than using psychophysical measures. The aim of the study was to compare the CPM effect and test-retest reliability between a psychophysical protocol with thermal test-stimulus and a spinal reflex protocol with electrical test-stimulus. METHODS Twenty-five healthy volunteers participated in two identical experiments separated by minimum 1 week. The thermal test-stimulus was a constant heat stimulation of 120 s on the subjects' forearm with continuous ratings of pain intensity on a 10 cm visual analogue scale. The electrical test-stimulus was repeated electrical stimulation on the arch of the foot for 120 s, which elicited a nociceptive withdrawal reflex recorded from the anterior tibial muscle. Conditioning stimulus was a 7°C water bath. Differences in the magnitude and test-retest reliability were investigated with repeated-measures analysis of variance and by relative and absolute reliability indices. RESULTS The CPM effect was -46% and 4.5% during the thermal and electrical test-stimulus (p < 0.001) respectively. Intraclass correlation coefficient of 0.5 and 0.4 was found with the electrical and thermal test-stimulus respectively. Wide limits of agreement were found for both the electrical (-3.4 to 3.8 mA) and the thermal test-stimulus (-3.2 to 3.6 cm). CONCLUSIONS More pronounced CPM effect was demonstrated when using a psychophysical protocol with thermal test-stimulus compared to a spinal reflex protocol with electrical test-stimulus. Fair relative reliability and poor absolute reliability (due to high intraindividual variability) was found in both protocols. SIGNIFICANCE The large difference in CPM effect between the two protocols suggests that the CPM effect relates to pain perception rather than nociception on the spinal level. Due to poor absolute intrarater reliability, we recommend caution and further research before using any of the investigated CPM protocols in clinical decision making on an individual level.
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Affiliation(s)
- Marie Udnesseter Lie
- Research and Communication Unit for Musculoskeletal Health (FORMI), Oslo University Hospital, Oslo, Norway.,Faculty of Medicine, University of Oslo, Oslo, Norway
| | - Elena Petriu
- Faculty of Health Science, Oslo Metropolitan University, Oslo, Norway.,Department of Neurology, Oslo University Hospital, Oslo, Norway
| | - Dagfinn Matre
- Department of Work Psychology and Physiology, National Institute of Occupational Health, Oslo, Norway
| | - Per Hansson
- Department of Molecular Medicine and Surgery, Karolinska Institutet, Stockholm, Sweden.,Department of Pain Management and Research, Division of Emergencies and Critical Care, Oslo University Hospital, Oslo, Norway
| | - Ole Kaeseler Andersen
- Center for Neuroplasticity and Pain (CNAP), SMI®, Department of Health Science and Technology, Aalborg University, Aalborg, Denmark
| | - John-Anker Zwart
- Research and Communication Unit for Musculoskeletal Health (FORMI), Oslo University Hospital, Oslo, Norway.,Faculty of Medicine, University of Oslo, Oslo, Norway.,Department of Neurology, Oslo University Hospital, Oslo, Norway
| | - Kristian Bernhard Nilsen
- Research and Communication Unit for Musculoskeletal Health (FORMI), Oslo University Hospital, Oslo, Norway.,Department of Neurology, Oslo University Hospital, Oslo, Norway.,Department of Neuromedicine and Movement Science, Norwegian University of Science and Technology, Trondheim, Norway
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Not just a matter of pain intensity: Effects of three different conditioning stimuli on conditioned pain modulation effects. Neurophysiol Clin 2018; 48:287-293. [DOI: 10.1016/j.neucli.2018.06.078] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/10/2018] [Revised: 06/06/2018] [Accepted: 06/06/2018] [Indexed: 12/11/2022] Open
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Damien J, Colloca L, Bellei-Rodriguez CÉ, Marchand S. Pain Modulation: From Conditioned Pain Modulation to Placebo and Nocebo Effects in Experimental and Clinical Pain. INTERNATIONAL REVIEW OF NEUROBIOLOGY 2018; 139:255-296. [PMID: 30146050 DOI: 10.1016/bs.irn.2018.07.024] [Citation(s) in RCA: 73] [Impact Index Per Article: 12.2] [Reference Citation Analysis] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
Accumulating evidence reveal important applications of endogenous pain modulation assessment in healthy controls and in patients in clinical settings, as dysregulations in the balance of pain modulatory circuits may facilitate pain and promote chronification of pain. This article reviews data on pain modulation, focusing on the mechanisms and translational aspects of pain modulation from conditioned pain modulation (CPM) to placebo and nocebo effects in experimental and clinical pain. The specific roles of expectations, learning, neural and neurophysiological mechanisms of the central nervous system are briefly reviewed herein. The interaction between CPM and placebo systems in pain inhibitory pathways is highly relevant in the clinic and in randomized controlled trials yet remains to be clarified. Examples of clinical implications of CPM and its relationship to placebo and nocebo effects are provided. A greater understanding of the role of pain modulation in various pain states can help characterize the manifestation and development of chronic pain and assist in predicting the response to pain-relieving treatments. Placebo and nocebo effects, intrinsic to every treatment, can be used to develop personalized therapeutic approaches that improve clinical outcomes while limiting unwanted effects.
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Affiliation(s)
- Janie Damien
- Research Center of the Centre hospitalier universitaire de Sherbrooke (CHUS), Department of Surgery, Faculty of Medicine and Health Sciences, Université de Sherbrooke, Sherbrooke, QC, Canada
| | - Luana Colloca
- Department of Pain Translational Symptom Science, School of Nursing, University of Maryland, Baltimore, MD, United States; Departments of Psychiatry and Anesthesiology, School of Medicine, University of Maryland, Baltimore, MD, United States
| | - Carmen-Édith Bellei-Rodriguez
- Research Center of the Centre hospitalier universitaire de Sherbrooke (CHUS), Department of Surgery, Faculty of Medicine and Health Sciences, Université de Sherbrooke, Sherbrooke, QC, Canada
| | - Serge Marchand
- Research Center of the Centre hospitalier universitaire de Sherbrooke (CHUS), Department of Surgery, Faculty of Medicine and Health Sciences, Université de Sherbrooke, Sherbrooke, QC, Canada; Fonds de Recherche du Québec-Santé (FRQS), Montréal, QC, Canada.
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A tonic heat test stimulus yields a larger and more reliable conditioned pain modulation effect compared to a phasic heat test stimulus. Pain Rep 2017; 2:e626. [PMID: 29392240 PMCID: PMC5741326 DOI: 10.1097/pr9.0000000000000626] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2017] [Revised: 08/15/2017] [Accepted: 09/13/2017] [Indexed: 11/26/2022] Open
Abstract
Introduction The interest in conditioned pain modulation (CPM) as a clinical tool for measuring endogenously induced analgesia is increasing. There is, however, large variation in the CPM methodology, hindering comparison of results across studies. Research comparing different CPM protocols is needed in order to obtain a standardized test paradigm. Objectives The aim of the study was to assess whether a protocol with phasic heat stimuli as test-stimulus is preferable to a protocol with tonic heat stimulus as test-stimulus. Methods In this experimental crossover study, we compared 2 CPM protocols with different test-stimulus; one with tonic test-stimulus (constant heat stimulus of 120-second duration) and one with phasic test-stimuli (3 heat stimulations of 5 seconds duration separated by 10 seconds). Conditioning stimulus was a 7°C water bath in parallel with the test-stimulus. Twenty-four healthy volunteers were assessed on 2 occasions with minimum 1 week apart. Differences in the magnitude and test-retest reliability of the CPM effect in the 2 protocols were investigated with repeated-measures analysis of variance and by relative and absolute reliability indices. Results The protocol with tonic test-stimulus induced a significantly larger CPM effect compared to the protocol with phasic test-stimuli (P < 0.001). Fair and good relative reliability was found with the phasic and tonic test-stimuli, respectively. Absolute reliability indices showed large intraindividual variability from session to session in both protocols. Conclusion The present study shows that a CPM protocol with a tonic test-stimulus is preferable to a protocol with phasic test-stimuli. However, we emphasize that one should be cautious to use the CPM effect as biomarker or in clinical decision making on an individual level due to large intraindividual variability.
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Imai Y, Petersen KK, Mørch CD, Arendt Nielsen L. Comparing test-retest reliability and magnitude of conditioned pain modulation using different combinations of test and conditioning stimuli. Somatosens Mot Res 2016; 33:169-177. [PMID: 27650216 DOI: 10.1080/08990220.2016.1229178] [Citation(s) in RCA: 82] [Impact Index Per Article: 10.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
Abstract
This study aimed to compare the reliability and magnitude of conditioned pain modulation (CPM) by applying different test stimuli (TS) and conditioning stimuli (CS). Twenty-six healthy male participants were recruited in the study of two identical sessions. In each session, four TS (electrical, heat, handheld, and cuff pressure algometry) were applied before and during CS (cold pressor test (CPT) or cuff algometry). The same procedure was repeated with 45-min intervals, but with the other CS. Five thresholds were measured including four pain detection thresholds from four TS and pain tolerance threshold from cuff TS (cuff PTT). Intraclass correlation coefficient (ICC (3,1)) and coefficient of variation (CV) were calculated as measures of reliability. The reliability of TS before and during CS was good for all combinations (ICC: 0.60-0.96, CV: 2.2-22.9%), but the reliability of the CPM effect varied (ICC: 0.04-0.53, CV: 63.6-503.9%). The most reliable combinations were considered to be the handheld pressure pain threshold with CPT (ICC: 0.49, CV: 63.6%) and the cuff pressure pain threshold with CPT (ICC: 0.44, CV: 107.6%). Significant CPM effects were found for all combinations, except the combinations of electrical and heat pain thresholds with cuff CS, which indicates the novel classification of the CPM mechanism. The combinations of handheld pressure and heat pain threshold with CPT would provide the minimum sample size to detect the significant CPM changes in further studies. It is beneficial to provide and compare both ICC and CV to design further clinical trials.
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Affiliation(s)
- Y Imai
- a Department of Health Science and Technology , Aalborg University , Aalborg , Denmark.,b Clinical Development Department , Asahi Kasei Pharma Corporation , Tokyo , Japan
| | - K K Petersen
- a Department of Health Science and Technology , Aalborg University , Aalborg , Denmark
| | - C D Mørch
- a Department of Health Science and Technology , Aalborg University , Aalborg , Denmark
| | - L Arendt Nielsen
- a Department of Health Science and Technology , Aalborg University , Aalborg , Denmark
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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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Devoize L, Chalaye P, Lafrenaye S, Marchand S, Dallel R. Relationship between adaptation and cardiovascular response to tonic cold and heat pain Adaptability to tonic pain and cardiovascular responses. Eur J Pain 2015; 20:731-41. [PMID: 26491836 DOI: 10.1002/ejp.799] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/27/2015] [Indexed: 11/11/2022]
Abstract
BACKGROUND The mechanisms of adaptation to tonic pain are not elucidated. We hypothesized that the adaptability to tonic pain is related to the cardiovascular system. METHODS Twenty-six subjects received over two sessions in a random order: tonic cold (7 ± 0.2 °C) and heat pain (47.5 ± 0.5 °C) on the hand for 5 min. Pain intensity, blood pressure (BP), and heart rate (HR) were continuously monitored. RESULTS Pain experience during the heat (HIT) and cold (CIT) immersion tests exhibited different average time courses, being approximated with a linear and cubic function, respectively. In each test, two groups of participants could be identified based on the time course of their tonic thermal pain: one-third of participants were pain adaptive and two-thirds non adaptive. The adaptive group exhibited higher initial pain, lower last pain, and shorter latency to peak pain than the non-adaptive one. Interestingly, some participants were adaptive to both pain stimuli, most were not. HIT as well as CIT produced a stable elevation of BP. However, BP was higher during CIT than HIT (p = 0.034). HR was also increased during CIT and HIT, but the two tests differed with respect to the time course of responses. Finally, the intensity and time course of pain rating to both HIT and CIT correlated with neither BP nor HR responses. CONCLUSIONS These results suggest that individual sensitivity and adaptability to tonic thermal pain is related to the intensity of initial pain rating and the latency to peak pain but not to cardiovascular responses.
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Affiliation(s)
- L Devoize
- Clermont Université, Université d'Auvergne, Neuro-Dol, France.,Clermont-Ferrand & Inserm U1107, France.,CHU Clermont-Ferrand, Service d'Odontologie, France
| | - P Chalaye
- Université de Sherbrooke, Departement de Chirurgie, Canada
| | - S Lafrenaye
- Centre Hospitalier Universitaire de Sherbrooke, Département de Pédiatrie, Canada
| | - S Marchand
- Université de Sherbrooke, Departement de Chirurgie, Canada
| | - R Dallel
- Clermont Université, Université d'Auvergne, Neuro-Dol, France.,Clermont-Ferrand & Inserm U1107, France.,CHU Clermont-Ferrand, Service d'Odontologie, France
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Matre D, Andersen M, Knardahl S, Nilsen K. Conditioned pain modulation is not decreased after partial sleep restriction. Eur J Pain 2015; 20:408-16. [DOI: 10.1002/ejp.741] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/10/2015] [Indexed: 01/08/2023]
Affiliation(s)
- D. Matre
- Department of Work Psychology and Physiology; National Institute of Occupational Health; Oslo Norway
| | - M.R. Andersen
- Department of Work Psychology and Physiology; National Institute of Occupational Health; Oslo Norway
| | - S. Knardahl
- Department of Work Psychology and Physiology; National Institute of Occupational Health; Oslo Norway
| | - K.B. Nilsen
- Department of Work Psychology and Physiology; National Institute of Occupational Health; Oslo Norway
- Department of Neuroscience; Norwegian University of Science and Technology; Trondheim Norway
- Section for Clinical Neurophysiology; Department of Neurology; Oslo University Hospital - Ullevål; Norway
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