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Lazaridou A, Paschali M, Bernstein C, Curiel M, Moore S, Edwards RR. sEMG Biofeedback for Episodic Migraines: A Pilot Randomized Clinical Trial. Appl Psychophysiol Biofeedback 2024; 49:271-279. [PMID: 38280149 DOI: 10.1007/s10484-023-09615-0] [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] [Accepted: 12/18/2023] [Indexed: 01/29/2024]
Abstract
The aim of this study was to assess the feasibility and potential effectiveness of a 6-week virtual sEMG biofeedback intervention for patients with episodic migraines. Patients with episodic migraines were randomized to treatment with a novel surface EMG (sEMG) at-home biofeedback device or a treatment as usual control group; they completed validated baseline and post-intervention assessments of migraine related disability (migraine-specific quality of life, anxiety and depression). Participants also underwent a series of Quantitative Sensory Testing (QST) procedures referring to several different tests that quantitatively assess responses to mechanical stimuli during two separate visits (baseline and post intervention). No adverse events were reported during the study. Compared to the treatment as usual comparison group, patients in the sEMG biofeedback group reported lower migraine disability (p < 0.05). Compared to baseline, participants in the sEMG biofeedback group demonstrated statistically significant reductions in anxiety (p < 0.01), and significant increases in quality of life (p < 0.001), and significant decreases in temporal summation (p < 0.05) assessed by QST. No significant changes were observed in any of the outcomes in the control comparison group (p > 0.05). No significant changes were observed in migraine frequency in either of the two groups (p > 0.05). In addition, mediation analyses revealed that changes in migraine related quality of life mediated group effects on changes in migraine disability. Virtual sEMG biofeedback shows promise as a potential therapy for reducing disability, anxiety and depression and improving quality of life in individuals with episodic migraines. These results demonstrate the feasibility of a digital intervention for migraines and set the basis for conducting a future, larger scale randomized controlled trial to confirm these preliminary findings.
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Affiliation(s)
- Asimina Lazaridou
- Department of Anesthesiology, Perioperative & Pain Medicine, Harvard Medical School, Brigham & Women's Hospital, Boston, USA.
- Fielding Graduate University, Santa Barbara, CA, USA.
| | - Myrella Paschali
- Department of Anesthesiology, Perioperative & Pain Medicine, Harvard Medical School, Brigham & Women's Hospital, Boston, USA
| | - Carolyn Bernstein
- Department of Neurology, Harvard Medical School, Brigham & Women's Hospital, Boston, USA
| | - Marie Curiel
- Department of Anesthesiology, Perioperative & Pain Medicine, Harvard Medical School, Brigham & Women's Hospital, Boston, USA
| | - Sara Moore
- Department of Anesthesiology, Perioperative & Pain Medicine, Harvard Medical School, Brigham & Women's Hospital, Boston, USA
| | - Robert R Edwards
- Department of Anesthesiology, Perioperative & Pain Medicine, Harvard Medical School, Brigham & Women's Hospital, Boston, USA
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Bender C, Karstens S, Muth F, Baskozos G, Schmid AB. Reliability of a clinical sensory test battery in patients with spine-related leg and arm pain. Eur J Pain 2024. [PMID: 38525884 DOI: 10.1002/ejp.2267] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/08/2022] [Revised: 12/13/2023] [Accepted: 03/07/2024] [Indexed: 03/26/2024]
Abstract
BACKGROUND The current standard to evaluate the presence of somatosensory dysfunctions is quantitative sensory testing, but its clinical utility remains limited. Low-cost and time-efficient clinical sensory testing (CST) batteries have thus been developed. Recent studies show moderate to substantial reliability in populations with neuropathic pain. This study evaluates the inter- and intra-tester reliability of people with spine-related leg and arm pain, representing mixed pain mechanisms. METHODS Fifty-three patients with spine-related leg (n = 41) and arm pain (n = 12) attended three CST sessions. The CST battery consisted of eleven tests, determining loss and gain of sensory nerve function. CST was performed by the same investigator twice and by an additional investigator to determine inter- and intra-tester reliability. Fleiss' (inter-tester) and Cohen's (intra-tester) kappa were calculated for dichotomized and intraclass correlation coefficients (ICC) for continuous outcomes. RESULTS Fleiss' kappa varied among modalities from fair to substantial (κ = 0.23-0.66). Cold, warm, and vibration detection thresholds and cold and pressure pain thresholds reached kappa >0.4 (moderate to substantial reliability). Cohen's kappa ranged from moderate to substantial (κ = 0.45-0.66). The reliability of the windup ratio was poor (ICC <0.18). CONCLUSION CST modalities with moderate to substantial inter-tester reliability could be of benefit as a screening tool. The moderate to substantial intra-tester reliability for all sensory modalities (except windup ratio) supports their potential use in clinical practice and research to monitor somatosensory changes over time in patients with spine-related limb pain of mixed pain mechanisms. SIGNIFICANCE We already know that most modalities of clinical sensory test (CST) batteries achieve moderate to substantial inter- and intra-tester reliability in populations with neuropathic pain. This study evaluates the reliability of a CST battery in populations with mixed pain mechanisms. We found inter-tester reliability varied from poor to substantial for sensory modalities, questioning the value of some CST modalities. The CST battery showed moderate to substantial intra-tester reliability, suggesting its usefulness to monitor sensory changes over time in this cohort.
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Affiliation(s)
- Cedric Bender
- School of Health Professions, Institute of Physiotherapy, Zurich University of Applied Sciences, Winterthur, Switzerland
- Nuffield Department of Clinical Neurosciences, University of Oxford, Oxford, UK
| | - Sven Karstens
- Division of Therapeutic Sciences, Department of Computer Science, Trier University of Applied Sciences, Trier, Germany
| | - Fabian Muth
- MEDIAN Vesalius-Klinik, Bad Rappenau, Germany
| | - Georgios Baskozos
- Nuffield Department of Clinical Neurosciences, University of Oxford, Oxford, UK
| | - Annina B Schmid
- Nuffield Department of Clinical Neurosciences, University of Oxford, Oxford, UK
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Coxon L, Vollert J, Perro D, Lunde CE, Ferreira-Gomes J, Charrua A, Abreu-Mendes P, Krassowski M, Birch J, Meijlink J, Hummelshoj L, Hoffmann A, Aziz Q, Arendt-Nielsen L, Pogatzki-Zahn E, Evans E, Demetriou L, McMahon SB, Missmer SA, Becker CM, Zondervan KT, Horne AW, Cruz F, Sieberg CB, Treede RD, Nagel J, Vincent K. Comprehensive quantitative sensory testing shows altered sensory function in women with chronic pelvic pain: results from the Translational Research in Pelvic Pain (TRiPP) Study. Pain 2023; 164:2528-2539. [PMID: 37289573 PMCID: PMC10578421 DOI: 10.1097/j.pain.0000000000002955] [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: 10/21/2022] [Revised: 04/26/2023] [Accepted: 04/27/2023] [Indexed: 06/10/2023]
Abstract
ABSTRACT Chronic pelvic pain (CPP), despite its high prevalence, is still relatively poorly understood mechanistically. This study, as part of the Translational Research in Pelvic Pain (TRiPP) project, has used a full quantitative sensory testing (QST) paradigm to profile n = 85 women with and without CPP (endometriosis or bladder pain specifically). We used the foot as a control site and abdomen as the test site. Across 5 diagnostically determined subgroups, we found features which are common across different aetiologies, eg, gain of function in pressure pain threshold (PPT) when assessing responses from the lower abdomen or pelvis (referred pain site). However, disease-specific phenotypes were also identified, eg, greater mechanical allodynia in endometriosis, despite there being large heterogeneities within diagnostic groups. The most common QST sensory phenotype was mechanical hyperalgesia (>50% across all the groups). A "healthy' sensory phenotype was seen in <7% of CPP participants. Specific QST measures correlated with sensory symptoms assessed by the painDETECT questionnaire (pressure-evoked pain [painDETECT] and PPT [QST] [ r = 0.47, P < 0.001]; mechanical hyperalgesia (painDETECT) and mechanical pain sensitivity [MPS from QST] [ r = 0.38, P = 0.009]). The data suggest that participants with CPP are sensitive to both deep tissue and cutaneous inputs, suggesting that central mechanisms may be important in this cohort. We also see phenotypes such as thermal hyperalgesia, which may be the result of peripheral mechanisms, such as irritable nociceptors. This highlights the importance of stratifying patients into clinically meaningful phenotypes, which may have implications for the development of better therapeutic strategies for CPP.
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Affiliation(s)
- Lydia Coxon
- Nuffield Department of Women's and Reproductive Health, University of Oxford, Oxford, United Kingdom
| | - Jan Vollert
- University Hospital Muenster, Muenster, Germany
- Heidelberg University, Mannheim, Germany
- Pain Research, Department of Surgery and Cancer, Imperial College London, London, United Kingdom
- Division of Neurological Pain Research and Therapy, Department of Neurology, University Hospital of Schleswig-Holstein, Campus Kiel, Germany
| | - Danielle Perro
- Nuffield Department of Women's and Reproductive Health, University of Oxford, Oxford, United Kingdom
| | - Claire E. Lunde
- Nuffield Department of Women's and Reproductive Health, University of Oxford, Oxford, United Kingdom
- Biobehavioral Pain Innovations Lab, Department of Psychiatry & Behavioral Sciences, Boston Children's Hospital, Boston, MA, United States
- Pain and Affective Neuroscience Center, Department of Anesthesiology, Critical Care, and Pain Medicine, Boston Children's Hospital, Boston, MA, United States
| | | | - Ana Charrua
- IBMC/I3S, Faculty of Medicine of Porto & Hospital São João, Porto, Portugal
| | - Pedro Abreu-Mendes
- IBMC/I3S, Faculty of Medicine of Porto & Hospital São João, Porto, Portugal
| | - Michal Krassowski
- Nuffield Department of Women's and Reproductive Health, University of Oxford, Oxford, United Kingdom
| | - Judy Birch
- Pelvic Pain Support Network, Poole, United Kingdom
| | - Jane Meijlink
- International Painful Bladder Foundation, Naarden, the Netherlands
| | | | - Anja Hoffmann
- Bayer AG, Research & Development, Pharmaceuticals, Berlin, Germany
| | - Qasim Aziz
- Queen Mary University of London, London, United Kingdom
| | - Lars Arendt-Nielsen
- Center for Neuroplasticity and Pain (CNAP), SMI, Department of Health Science and Technology, Aalborg University, Aalborg, Denmark
- Department of Medical Gastroenterology, Mech-Sense, Aalborg University Hospital, Aalborg, Denmark
| | | | - Emma Evans
- Nuffield Department of Women's and Reproductive Health, University of Oxford, Oxford, United Kingdom
| | - Lysia Demetriou
- Nuffield Department of Women's and Reproductive Health, University of Oxford, Oxford, United Kingdom
| | - Stephen B. McMahon
- Formerly of Neurorestoration Group, Wolfson Centre for Age-Related Diseases, King's College London, London, United Kingdom
| | - Stacey A. Missmer
- Department of Obstetrics, Gynecology, and Reproductive Biology, College of Human Medicine, Michigan State University, Grand Rapids, MI, United States
- Department of Epidemiology, Harvard T.H. Chan School of Public Health, Boston, MA, United States
- Division of Adolescent and Young Adult Medicine, Department of Pediatrics, Boston Children's Hospital and Harvard Medical School, Boston, MA, United States
| | - Christian M. Becker
- Nuffield Department of Women's and Reproductive Health, University of Oxford, Oxford, United Kingdom
| | - Krina T. Zondervan
- Nuffield Department of Women's and Reproductive Health, University of Oxford, Oxford, United Kingdom
| | | | - Francisco Cruz
- IBMC/I3S, Faculty of Medicine of Porto & Hospital São João, Porto, Portugal
| | - Christine B. Sieberg
- Biobehavioral Pain Innovations Lab, Department of Psychiatry & Behavioral Sciences, Boston Children's Hospital, Boston, MA, United States
- Pain and Affective Neuroscience Center, Department of Anesthesiology, Critical Care, and Pain Medicine, Boston Children's Hospital, Boston, MA, United States
- Department of Psychiatry, Harvard Medical School, Boston, MA, United States
| | | | - Jens Nagel
- Bayer AG, Research & Development, Pharmaceuticals, Wuppertal, Germany
| | - Katy Vincent
- Nuffield Department of Women's and Reproductive Health, University of Oxford, Oxford, United Kingdom
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Bouhassira D, Attal N. Personalized treatment of neuropathic pain: Where are we now? Eur J Pain 2023; 27:1084-1098. [PMID: 37114461 DOI: 10.1002/ejp.2120] [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: 02/16/2023] [Revised: 04/07/2023] [Accepted: 04/15/2023] [Indexed: 04/29/2023]
Abstract
BACKGROUND The treatment of neuropathic pain remains a major unmet need that the development of personalized and refined treatment strategies may contribute to address. DATABASE In this narrative review, we summarize the various approaches based on objective biomarkers or clinical markers that could be used. RESULTS In principle, the validation of objective biomarkers would be the most robust approach. However, although promising results have been reported demonstrating a potential value of genomics, anatomical or functional markers, the clinical validation of these markers has only just begun. Thus, most of the strategies documented to date have been based on the development of clinical markers. In particular, many studies have suggested that the identification of specific subgroups of patients presenting with specific combinations of symptoms and signs would be a relevant approach. Two main approaches have been used to identify relevant sensory profiles: quantitative sensory testing and specific patients reported outcomes based on description of pain qualities. CONCLUSION We discuss here the advantages and limitations of these approaches, which are not mutually exclusive. SIGNIFICANCE Recent data indicate that various new treatment strategies based on predictive biological and/or clinical markers could be helpful to better personalized and therefore improve the management of neuropathic pain.
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Affiliation(s)
- Didier Bouhassira
- Inserm U987, UVSQ-Paris-Saclay University, Ambroise Pare Hospital, Boulogne-Billancourt, France
| | - Nadine Attal
- Inserm U987, UVSQ-Paris-Saclay University, Ambroise Pare Hospital, Boulogne-Billancourt, France
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Greco CM, Wasan AD, Schneider MJ, Mehling W, Williams DA, Darwin J, Harte SE. Biobehavioral Assessments in BACPAC: Recommendations, Rationale, and Methods. PAIN MEDICINE (MALDEN, MASS.) 2023; 24:S61-S70. [PMID: 36370080 PMCID: PMC10403301 DOI: 10.1093/pm/pnac175] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/31/2022] [Revised: 10/06/2022] [Accepted: 11/02/2022] [Indexed: 08/06/2023]
Abstract
The Biobehavioral Working Group of BACPAC was charged to evaluate a range of psychosocial, psychophysical, and behavioral domains relevant to chronic low back pain, and recommend specific assessment tools and procedures to harmonize biobehavioral data collection across the consortium. Primary references and sources for measure selection were the Initiative on Methods, Measurement, and Pain Assessment in Clinical Trials, the Minimum Data Set from the National Institutes of Health (NIH) Research Task Force on Standards for Chronic Low Back Pain, the Patient-Reported Outcomes Measurement Information System, and NeuroQOL. The questionnaire's recommendations supplemented the NIH HEAL Common Data Elements and BACPAC Minimum Data Set. Five domains were identified for inclusion: Pain Characteristics and Qualities; Pain-Related Psychosocial/Behavioral Factors; General Psychosocial Factors; Lifestyle Choices; and Social Determinants of Health/Social Factors. The Working Group identified best practices for required and optional Quantitative Sensory Testing of psychophysical pain processing for use in BACPAC projects.
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Affiliation(s)
- Carol M Greco
- Department of Psychiatry, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA
- Department of Physical Therapy, School of Health and Rehabilitation Science, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Ajay D Wasan
- Department of Anesthesiology and Perioperative Medicine, School of Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Michael J Schneider
- Department of Physical Therapy, School of Health and Rehabilitation Science, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
- Clinical and Translational Science Institute, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Wolf Mehling
- Department of Family and Community Medicine, University of California San Francisco, San Francisco, California, USA
| | - David A Williams
- Chronic Pain and Fatigue Research Center, Department of Anesthesiology, University of Michigan Medical School, Ann Arbor, Michigan, USA
- Department of Psychiatry, University of Michigan Medical School, Ann Arbor, Michigan, USA
- Department of Internal Medicine-Rheumatology, University of Michigan Medical School, Ann Arbor, Michigan, USA
| | - Jessa Darwin
- Department of Physical Medicine and Rehabilitation, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA
| | - Steven E Harte
- Chronic Pain and Fatigue Research Center, Department of Anesthesiology, University of Michigan Medical School, Ann Arbor, Michigan, USA
- Department of Internal Medicine-Rheumatology, University of Michigan Medical School, Ann Arbor, Michigan, USA
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McWilliams DF, Walsh DA. Inflammatory and Noninflammatory Disease Activity in Rheumatoid Arthritis: The Effect of Pain on Personalized Medicine. J Rheumatol 2023; 50:721-723. [PMID: 37003607 DOI: 10.3899/jrheum.230158] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/03/2023]
Affiliation(s)
- Daniel F McWilliams
- D.F. McWilliams, PhD, Research Fellow, Pain Centre Versus Arthritis, and NIHR Nottingham Biomedical Research Centre & Department of Academic Rheumatology, Academic Unit of Injury, Recovery and Inflammation Sciences, University of Nottingham, Nottingham
| | - David A Walsh
- D.A. Walsh, PhD, Professor, Co-Director, Pain Centre Versus Arthritis and Programme Director, Nottingham, UKRI/Versus Arthritis Advanced Pain Discovery Platform, and Department of Academic Rheumatology, Academic Unit of Injury, Recovery and Inflammation Sciences, University of Nottingham, Nottingham, and Honorary Consultant Rheumatologist, Sherwood Forest Hospitals NHS Foundation Trust, Sutton-in-Ashfield, UK.
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Bender C, Dove L, Schmid AB. Does Your Bedside Neurological Examination for Suspected Peripheral Neuropathies Measure Up? J Orthop Sports Phys Ther 2023; 53:107-112. [PMID: 36306170 DOI: 10.2519/jospt.2022.11281] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
SYNOPSIS: Neurological testing is essential for screening and diagnosing suspected peripheral neuropathies. Detecting changes in somatosensory and motor nerve function can also have direct implications for management decisions. Nevertheless, there is considerable variation in what is included in a bedside neurological examination and how it is performed. Neurological examinations are often used as screening tools to detect neurological deficits but not used to their full potential for monitoring progress or deterioration. Here, we advocate for better use of the neurological examination within a clinical reasoning framework. Constrained by the lack of research in this field, our Viewpoint is based on neuroscientific principles. We highlight 6 challenges for clinicians when conducting neurological examinations and propose ways to overcome these challenges in clinical practice. We challenge widely held ideas about how the results of neurological examinations for peripheral neuropathies are interpreted and how the examinations are performed in practice. J Orthop Sports Phys Ther 2023;53(3):107-112. Epub: 28 October 2022. doi:10.2519/jospt.2022.11281.
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Lazaridou A, Paschali M, Vilsmark ES, Sadora J, Burton D, Bashara A, Edwards RR. Biofeedback EMG alternative therapy for chronic low back pain (the BEAT-pain study). Digit Health 2023; 9:20552076231154386. [PMID: 36776410 PMCID: PMC9909059 DOI: 10.1177/20552076231154386] [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: 04/17/2022] [Accepted: 01/16/2023] [Indexed: 02/11/2023] Open
Abstract
Objective The aim of this study was to assess the feasibility and potential effectiveness of an 8-week virtual EMG biofeedback intervention for patients with CLBP. Methods Patients with CLBP completed validated baseline and post-intervention assessments of pain intensity and interference (Brief Pain Inventory), back pain-related disability (Oswestry Disability Index), anxiety and depression (Hospital Anxiety and Depression Scale). Participants underwent a series of Quantitative Sensory Testing (QST) procedures assessing responses to mechanical stimuli during two separate visits (baseline and post-intervention). In addition, we assessed, using surface EMG, the muscle tension in the trapezius, latissimus, and low back muscles at each session. Patients were randomized into the EMG biofeedback intervention or usual care group. Factorial analysis of variance including the interaction between treatment group and time was used to analyze the changes in pain intensity (primary outcome), pain interference, disability (secondary outcomes), anxiety, and depression (secondary outcomes). Results Compared to the treatment as usual comparison group, patients in the EMG biofeedback group reported lower pain intensity after completing the intervention (mean group difference 0.9, 95% CI -1.07, -0.32; p≤0.01). Compared to baseline, participants in the EMG biofeedback group demonstrated statistically significant reductions in pain interference (mean difference 1.3, 95% CI 0.42, 2.1; p≤0.01), disability (mean difference 4.32, 95% CI 1.2, 7.3; p≤0.01), and significant increases in low back pain thresholds (mean difference 0.5, 95% CI -0.87, -0.05; p≤0.01), assessed by QST. However, no significant group by time effects were observed for secondary outcomes: pain interference, disability, and low back pain thresholds. In addition, significant changes were observed in muscle tension for the trapezius, latissimus, and low back muscles in the EMG biofeedback group (p<0.001). Conclusions Virtual EMG biofeedback shows promise as a potential therapy for reducing pain and disability in individuals with chronic nonspecific low back pain.
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Affiliation(s)
- Asimina Lazaridou
- Department of Anesthesiology, Perioperative & Pain Medicine, Harvard Medical School, Brigham & Women's Hospital, Boston, MA, USA,Fielding Graduate University, Santa Barbara, CA, USA,Asimina Lazaridou, Department of Anesthesiology, Perioperative & Pain Medicine, Harvard Medical School, Brigham & Women's Hospital, Pain Management Center, 850 Boylston St, Chestnut Hill, MA 02467, USA.
| | - Myrella Paschali
- Department of Anesthesiology, Perioperative & Pain Medicine, Harvard Medical School, Brigham & Women's Hospital, Boston, MA, USA
| | - Eric S Vilsmark
- Department of Anesthesiology, Perioperative & Pain Medicine, Harvard Medical School, Brigham & Women's Hospital, Boston, MA, USA
| | - Jason Sadora
- Fielding Graduate University, Santa Barbara, CA, USA
| | - Dustin Burton
- Fielding Graduate University, Santa Barbara, CA, USA
| | - Annie Bashara
- Fielding Graduate University, Santa Barbara, CA, USA
| | - Robert R Edwards
- Department of Anesthesiology, Perioperative & Pain Medicine, Harvard Medical School, Brigham & Women's Hospital, Boston, MA, USA
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Test-retest reliability of a simple bedside-quantitative sensory testing battery for chronic neuropathic pain. Pain Rep 2023; 8:e1049. [PMID: 36660554 PMCID: PMC9842225 DOI: 10.1097/pr9.0000000000001049] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2022] [Revised: 09/08/2022] [Accepted: 10/04/2022] [Indexed: 01/21/2023] Open
Abstract
Introduction The sensory phenotype is believed to provide information about the underlying pathophysiological mechanisms and to be used in the diagnosis and treatment of chronic neuropathic pain. However, the use of standardized quantitative sensory testing (QST) protocols is limited due to high expenditures of time and costs. Thus, a simple bedside-QST battery was recently developed showing good agreement when compared with laboratory QST. The aim of this study was to preliminary validate this bedside-QST protocol. Methods Patients experiencing chronic pain with neuropathic features (n = 60) attended 3 visits. During the first visit, laboratory QST and bedside-QST were performed by the same trained investigator. Three hours and 3 weeks later, bedside-QST was repeated. Patients completed questionnaires regarding their pain (intensity, quality), depression/anxiety, and quality of life. Test-retest reliability and convergent/divergent validity were investigated. Results Most of the bedside-QST parameters, including also those recommended in our first study as being indicative for sensory phenotypes, revealed a moderate to excellent test-retest reliability. Overall, results for short-term reliability and interval-scaled parameters were slightly better. Most of the bedside-QST parameters did not correlate with the depression and anxiety score, suggesting a good divergent validity. Conclusions Bedside-QST has good criterion and divergent validity as well as reliability. This battery consists of 5 low-cost devices that can be quickly and easily used to characterize the sensory phenotype of patients with neuropathic pain. A combination of bedside-QST parameters can be used to investigate patients' subgroups with specific pathophysiological mechanisms and to identify treatment responders.
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Sachau J, Baron R. Precision Medicine in Neuropathic Pain. Handb Exp Pharmacol 2023; 280:187-210. [PMID: 37439846 DOI: 10.1007/164_2023_662] [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] [Indexed: 07/14/2023]
Abstract
Neuropathic pain is a common chronic pain condition that is caused by a lesion or disease of the somatosensory nervous system. The multitude of sensory negative and positive sensations and associated comorbidities have a major impact on quality of life of affected patients. Current treatment options often only lead to a partial pain relief or are even completely ineffective. In addition, many clinical trials for the development of new drugs have not met the primary endpoint. Therefore, there is still an unmet clinical need in neuropathic pain syndromes. One reason for this therapeutic dilemma could be the heterogeneity of neuropathic pain with a variety of pathophysiological pain mechanisms that are expressed differently in each patient regardless of the underlying disease etiology. Reclassification of neuropathic pain syndromes therefore focuses on the underlying mechanisms of pain development rather than the disease etiology. A priori stratification of patients based on these individual mechanisms could allow the identification of potential treatment responders and thus realize the concept of a mechanism-based treatment. As no biomarkers for pain mechanisms have been discovered yet, one has to rely on surrogate markers that are thought to be closely related to these mechanisms. In this chapter, we present promising predictive biomarkers, focusing in particular on sensory symptoms and signs assessed by patient-reported outcome measures and sensory testing, and discuss how these tools might be used in clinical trials in the future.
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Affiliation(s)
- Juliane Sachau
- Division of Neurological Pain Research and Therapy, Department of Neurology, University Hospital Schleswig-Holstein Campus Kiel, Kiel, Germany
| | - Ralf Baron
- Division of Neurological Pain Research and Therapy, Department of Neurology, University Hospital Schleswig-Holstein Campus Kiel, Kiel, Germany.
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Small-Fiber-Neuropathien. DGNEUROLOGIE 2022; 5. [PMCID: PMC9559077 DOI: 10.1007/s42451-022-00488-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
Die Small-Fiber-Neuropathie (SFN) ist eine Erkrankung des peripheren Nervensystems aufgrund einer isolierten oder vorwiegenden Schädigung dünn myelinisierter Aδ-Fasern und/oder unmyelinisierter C‑Fasern. Für die sichere Diagnose einer SFN ist neben der klinischen Symptomatik mit Schmerzen und Sensibilitätsstörungen, typischerweise mit distal betonter Ausbreitung, der apparative Nachweis einer Rarefizierung oder einer Funktionsstörung der dünn myelinisierten Aδ-Fasern und/oder der unmyelinisierten C‑Fasern gefordert. Im vorliegenden Beitrag wird eine Übersicht über die diagnostischen Verfahren zum Nachweis einer SFN sowie über mögliche Ursachen und Behandlungsoptionen gegeben.
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Waller R, Smith AJ, Graven-Nielsen T, Arendt-Nielsen L, Sterling M, Karppinen JI, O'Sullivan PB, Straker LM, Slater H. Role of population-based cohorts in understanding the emergence and progression of musculoskeletal pain. Pain 2022; 163:58-63. [PMID: 33883537 DOI: 10.1097/j.pain.0000000000002316] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2020] [Accepted: 04/13/2021] [Indexed: 11/25/2022]
Affiliation(s)
- Robert Waller
- Curtin School of Allied Health, Curtin University, Perth, Western Australia, Australia
| | - Anne Julia Smith
- Curtin School of Allied Health, Curtin University, Perth, Western Australia, Australia
| | - Thomas Graven-Nielsen
- Department of Health Science and Technology, Faculty of Medicine, Center for Neuroplasticity and Pain (CNAP), SMI, Aalborg University, Aalborg DK, Denmark
| | - Lars Arendt-Nielsen
- Department of Health Science and Technology, Faculty of Medicine, Center for Neuroplasticity and Pain (CNAP), SMI, Aalborg University, Aalborg DK, Denmark
| | - Michele Sterling
- RECOVER Injury Research Centre, NHMRC Centre of Research Excellence in Road Traffic Injury, The University of Queensland, Herston, Australia
| | - Jaro Ilari Karppinen
- Medical Research Center Oulu, University of Oulu and Oulu University Hospital, Oulu, Finland
- Finnish Institute of Occupational Health, Oulu, Finland
| | | | - Leon Melville Straker
- Curtin School of Allied Health, Curtin University, Perth, Western Australia, Australia
| | - Helen Slater
- Curtin School of Allied Health, Curtin University, Perth, Western Australia, Australia
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13
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Realigning the role of quantitative sensory testing in sensory profiling of patients with and without neuropathic pain. Pain 2021; 162:2780. [PMID: 34652323 DOI: 10.1097/j.pain.0000000000002378] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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14
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Chadwick A, Frazier A, Khan TW, Young E. Understanding the Psychological, Physiological, and Genetic Factors Affecting Precision Pain Medicine: A Narrative Review. J Pain Res 2021; 14:3145-3161. [PMID: 34675643 PMCID: PMC8517910 DOI: 10.2147/jpr.s320863] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/19/2021] [Accepted: 08/11/2021] [Indexed: 12/11/2022] Open
Abstract
PURPOSE Precision pain medicine focuses on employing methods to assess each patient individually, identify their risk profile for disproportionate pain and/or the development of chronic pain, and optimize therapeutic strategies to target specific pathological processes underlying chronic pain. This review aims to provide a concise summary of the current body of knowledge regarding psychological, physiological, and genetic determinants of chronic pain related to precision pain medicine. METHODS Following the Scale for the Assessment of Narrative Review Articles (SANRA) criteria, we employed PubMed/Medline to identify relevant articles using primary database search terms to query articles such as: precision medicine, non-modifiable factors, pain, anesthesiology, quantitative sensory testing, genetics, pain medicine, and psychological. RESULTS Precision pain medicine provides an opportunity to identify populations at risk, develop personalized treatment strategies, and reduce side effects and cost through elimination of ineffective treatment strategies. As in other complex chronic health conditions, there are two broad categories that contribute to chronic pain risk: modifiable and non-modifiable patient factors. This review focuses on three primary determinants of health, representing both modifiable and non-modifiable factors, that may contribute to a patient's profile for risk of developing pain and most effective management strategies: psychological, physiological, and genetic factors. CONCLUSION Consideration of these three domains is already being integrated into patient care in other specialties, but by understanding the role they play in development and maintenance of chronic pain, we can begin to implement both precision and personalized treatment regimens.
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Affiliation(s)
- Andrea Chadwick
- Department of Anesthesiology, University of Kansas Medical Center, Kansas City, KS, USA
| | - Andrew Frazier
- Department of Anesthesiology, University of Kansas Medical Center, Kansas City, KS, USA
| | - Talal W Khan
- Department of Anesthesiology, University of Kansas Medical Center, Kansas City, KS, USA
| | - Erin Young
- Department of Anesthesiology, University of Kansas Medical Center, Kansas City, KS, USA
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15
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Alter BJ, Anderson NP, Gillman AG, Yin Q, Jeong JH, Wasan AD. Hierarchical clustering by patient-reported pain distribution alone identifies distinct chronic pain subgroups differing by pain intensity, quality, and clinical outcomes. PLoS One 2021; 16:e0254862. [PMID: 34347793 PMCID: PMC8336800 DOI: 10.1371/journal.pone.0254862] [Citation(s) in RCA: 17] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/25/2021] [Accepted: 07/06/2021] [Indexed: 11/18/2022] Open
Abstract
Background In clinical practice, the bodily distribution of chronic pain is often used in conjunction with other signs and symptoms to support a diagnosis or treatment plan. For example, the diagnosis of fibromyalgia involves tallying the areas of pain that a patient reports using a drawn body map. It remains unclear whether patterns of pain distribution independently inform aspects of the pain experience and influence patient outcomes. The objective of the current study was to evaluate the clinical relevance of patterns of pain distribution using an algorithmic approach agnostic to diagnosis or patient-reported facets of the pain experience. Methods and findings A large cohort of patients (N = 21,658) completed pain body maps and a multi-dimensional pain assessment. Using hierarchical clustering of patients by body map selection alone, nine distinct subgroups emerged with different patterns of body region selection. Clinician review of cluster body maps recapitulated some clinically-relevant patterns of pain distribution, such as low back pain with radiation below the knee and widespread pain, as well as some unique patterns. Demographic and medical characteristics, pain intensity, pain impact, and neuropathic pain quality all varied significantly across cluster subgroups. Multivariate modeling demonstrated that cluster membership independently predicted pain intensity and neuropathic pain quality. In a subset of patients who completed 3-month follow-up questionnaires (N = 7,138), cluster membership independently predicted the likelihood of improvement in pain, physical function, and a positive overall impression of change related to multidisciplinary pain care. Conclusions This study reports a novel method of grouping patients by pain distribution using an algorithmic approach. Pain distribution subgroup was significantly associated with differences in pain intensity, impact, and clinically relevant outcomes. In the future, algorithmic clustering by pain distribution may be an important facet in chronic pain biosignatures developed for the personalization of pain management.
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Affiliation(s)
- Benedict J. Alter
- Department of Anesthesiology and Perioperative Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania, United States of America
- * E-mail:
| | - Nathan P. Anderson
- Department of Anesthesiology and Perioperative Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania, United States of America
| | - Andrea G. Gillman
- Department of Anesthesiology and Perioperative Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania, United States of America
| | - Qing Yin
- Department of Biostatistics, University of Pittsburgh, Pittsburgh, Pennsylvania, United States of America
| | - Jong-Hyeon Jeong
- Department of Biostatistics, University of Pittsburgh, Pittsburgh, Pennsylvania, United States of America
| | - Ajay D. Wasan
- Department of Anesthesiology and Perioperative Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania, United States of America
- Department of Psychiatry, University of Pittsburgh, Pittsburgh, Pennsylvania, United States of America
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16
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Reimer M, Sachau J, Forstenpointner J, Baron R. Bedside testing for precision pain medicine. Curr Opin Support Palliat Care 2021; 15:116-124. [PMID: 33905383 DOI: 10.1097/spc.0000000000000556] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
PURPOSE OF REVIEW In recent years, the identification of therapy responders has become an increasing focus of pain research. On the basis of laboratory quantitative sensory testing, subgroups of patients were identified, which have been shown to predict treatment response. However, the high cost and time expenditure limits the use of these lab-QST protocols in clinical practice and large clinical trials. RECENT FINDINGS Recently, different bedside testing protocols were developed as easy-to-use alternative for lab-QST. In addition, patients can be subgrouped based on their symptoms by use of patient-reported outcome measures. First results suggest that these approaches can be used to stratify patients into pathophysiological-plausible subgroups predictive for treatment response. SUMMARY This review presents recently developed bedside approaches that can be implemented as stratification tools in future clinical trials to realize individualized pain medicine. Being complementary rather than replaceable, future studies should combine questionnaires and sensory testing and apply them prospectively in large clinical trials.
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Affiliation(s)
- Maren Reimer
- Division of Neurological Pain Research and Therapy, Department of Neurology, University Hospital of Schleswig-Holstein, Campus Kiel, Kiel, Germany
| | - Juliane Sachau
- Division of Neurological Pain Research and Therapy, Department of Neurology, University Hospital of Schleswig-Holstein, Campus Kiel, Kiel, Germany
| | - Julia Forstenpointner
- Division of Neurological Pain Research and Therapy, Department of Neurology, University Hospital of Schleswig-Holstein, Campus Kiel, Kiel, Germany
- Center for Pain and the Brain, Boston Children's Hospital, Department of Anesthesia, Critical Care and Pain Medicine, Harvard Medical School, Boston, Massachusetts, USA
| | - Ralf Baron
- Division of Neurological Pain Research and Therapy, Department of Neurology, University Hospital of Schleswig-Holstein, Campus Kiel, Kiel, Germany
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Overstreet DS, Michl AN, Penn TM, Rumble DD, Aroke EN, Sims AM, King AL, Hasan FN, Quinn TL, Long DL, Sorge RE, Goodin BR. Temporal summation of mechanical pain prospectively predicts movement-evoked pain severity in adults with chronic low back pain. BMC Musculoskelet Disord 2021; 22:429. [PMID: 33971876 PMCID: PMC8111750 DOI: 10.1186/s12891-021-04306-5] [Citation(s) in RCA: 23] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/14/2020] [Accepted: 04/27/2021] [Indexed: 12/19/2022] Open
Abstract
BACKGROUND Biopsychosocial factors above and beyond pathoanatomical changes likely contribute to the severity of chronic low back pain. A pro-nociceptive endogenous pain modulatory balance (↓inhibition and ↑facilitation) may be an important contributor to chronic low back pain severity and physical function; however, additional research is needed to address this possibility. The objective of this study was to determine whether quantitative sensory tests of endogenous pain inhibition and facilitation prospectively predict movement-evoked pain and cLBP severity self-reported on a validated questionnaire. METHODS One hundred thirty-four individuals with chronic low back pain were enrolled in this two-session study. During the first study session, temporal summation of mechanical pain and conditioned pain modulation were assessed at the lumbar spine to determine endogenous pain facilitation and inhibition, respectively. One week later, participants returned for a second study session whereby they reported their pain severity and pain interference using the Brief Pain Inventory-Short Form. Movement-evoked pain and physical function capacity were assessed upon completion of the balance, walking, and transition from sit to stand tests of the Short Physical Performance Battery. RESULTS Temporal summation of mechanical pain, but not conditioned pain modulation, significantly and prospectively predicted greater movement-evoked pain and poorer physical function on the Short Physical Performance Battery. Neither temporal summation nor conditioned pain modulation were significantly related to self-reported pain severity or pain interference on the Brief Pain Inventory-Short Form. CONCLUSIONS Findings suggest that a pro-nociceptive pain modulatory balance characterized by enhanced pain facilitation may be an important driver of movement-evoked pain severity and poor physical function in individuals with chronic low back pain.
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Affiliation(s)
- Demario S Overstreet
- Department of Psychology, University of Alabama at Birmingham, 1300 University Boulevard, Campbell Hall, Suite 237, Birmingham, AL, 35294, USA
| | - Ava N Michl
- Department of Psychology, University of Alabama at Birmingham, 1300 University Boulevard, Campbell Hall, Suite 237, Birmingham, AL, 35294, USA
| | - Terence M Penn
- Department of Psychology, University of Alabama at Birmingham, 1300 University Boulevard, Campbell Hall, Suite 237, Birmingham, AL, 35294, USA
| | - Deanna D Rumble
- Department of Psychology, University of Alabama at Birmingham, 1300 University Boulevard, Campbell Hall, Suite 237, Birmingham, AL, 35294, USA
| | - Edwin N Aroke
- School of Nursing, Nurse Anesthesia Program, Department of Acute, Chronic, & Continuing Care, University of Alabama at Birmingham, Birmingham, USA
| | - Andrew M Sims
- School of Public Health, Department of Biostatistics, University of Alabama at Birmingham, Birmingham, USA
| | - Annabel L King
- Department of Psychology, University of Alabama at Birmingham, 1300 University Boulevard, Campbell Hall, Suite 237, Birmingham, AL, 35294, USA
| | - Fariha N Hasan
- Department of Psychology, University of Alabama at Birmingham, 1300 University Boulevard, Campbell Hall, Suite 237, Birmingham, AL, 35294, USA
| | - Tammie L Quinn
- Department of Psychology, University of Alabama at Birmingham, 1300 University Boulevard, Campbell Hall, Suite 237, Birmingham, AL, 35294, USA
| | - D Leann Long
- School of Public Health, Department of Biostatistics, University of Alabama at Birmingham, Birmingham, USA
| | - Robert E Sorge
- Department of Psychology, University of Alabama at Birmingham, 1300 University Boulevard, Campbell Hall, Suite 237, Birmingham, AL, 35294, USA
| | - Burel R Goodin
- Department of Psychology, University of Alabama at Birmingham, 1300 University Boulevard, Campbell Hall, Suite 237, Birmingham, AL, 35294, USA.
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Hasvik E, Haugen AJ, Grøvle L. Pinprick and Light Touch Are Adequate to Establish Sensory Dysfunction in Patients with Lumbar Radicular Pain and Disc Herniation. Clin Orthop Relat Res 2021; 479:651-663. [PMID: 33394605 PMCID: PMC8083833 DOI: 10.1097/corr.0000000000001605] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/05/2020] [Accepted: 11/18/2020] [Indexed: 01/31/2023]
Abstract
BACKGROUND The frequency with which sensory disturbances occur in patients with radicular leg pain and disc herniation is not well known, and the efficacy of tests to identify such changes are not firmly established. The presence of sensory disturbances is a key sign of nerve root involvement and may contribute to the diagnosis of a lumbar disc herniation, identify patients for referral to spinal imaging and surgery, and improve disease classification. QUESTIONS/PURPOSES In this study, we sought: (1) to determine the frequency with which abnormal sensory findings occur in patients with lumbar disc herniation-related radicular pain, using a standard neurological sensory examination; (2) to determine what particular standard sensory test or combination of tests is most effective in establishing sensory dysfunction; and (3) to determine whether a more detailed in-depth sensory examination results in more patients being identified as having abnormal sensory findings. METHODS Between October 2013 and April 2016, 115 patients aged 18 to 65 years referred to secondary health care with radicular leg pain and disc herniation were considered potentially eligible for inclusion in the study. Based on these inclusion criteria, 79% (91) were found eligible. Ten percent (11) were excluded because of other illness that interfered with the study purpose, 3% (3) because of cauda equina syndrome, 2% (2) because of spinal stenosis, 2% (2) because of prior surgery at the same disc level, and 2% (2) because of poor Norwegian language skills. Three percent (4) of the patients did not want to participate in the study. Of the 91 eligible patients, 56% (51) consented to undergo a comprehensive clinical examination and were used for analysis here. The sample for the purposes of the present study was predetermined at 50. These patients were first examined by a standard procedure, including sensory assessment of light touch, pinprick, vibration, and warmth and cold over the back and legs. Second, an in-depth semiquantitative sensory testing procedure was performed in the main pain area to assess sensory dysfunction and improve the detection of potential positive sensory signs, or sensory gain of function more precisely. Sensory loss was defined as sensations experienced as distinctly reduced in the painful side compared with the contralateral reference side. In contrast, sensory gain was defined as sensations experienced as abnormally strong, unpleasant, or painful and distinctly stronger than the contralateral side. Ambiguous test results were coded as a normal response to avoid inflating the findings. The proportions of abnormal findings were calculated for each sensory modality and for all combinations of the standard examination tests. RESULTS The standard examination identified at least one abnormal finding in 88% (45 of 51) of patients. Sensory loss was present in 80% (41), while sensory gain was present in 35% (18). The combination of pinprick and light touch identified all patients who were classified as having abnormal findings by the full standard examination. The semiquantitative procedure identified an additional three patients with an abnormal finding. CONCLUSION We suggest that the combination of pinprick and light touch assessment is an adequate minimal approach for diagnostic and classification purposes in patients with lumbar radicular pain. LEVEL OF EVIDENCE Level I, diagnostic study.
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Affiliation(s)
- Eivind Hasvik
- E. Hasvik, Department of Physical Medicine and Rehabilitation, Østfold Hospital Trust, Norway
- A. J. Haugen, L. Grøvle, Department of Rheumatology, Østfold Hospital Trust, Norway
| | - Anne Julsrud Haugen
- E. Hasvik, Department of Physical Medicine and Rehabilitation, Østfold Hospital Trust, Norway
- A. J. Haugen, L. Grøvle, Department of Rheumatology, Østfold Hospital Trust, Norway
| | - Lars Grøvle
- E. Hasvik, Department of Physical Medicine and Rehabilitation, Østfold Hospital Trust, Norway
- A. J. Haugen, L. Grøvle, Department of Rheumatology, Østfold Hospital Trust, Norway
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Yaksh TL. Frontiers in Pain Research: A Scope of Its Focus and Content. FRONTIERS IN PAIN RESEARCH 2020; 1:601528. [PMID: 35295691 PMCID: PMC8915630 DOI: 10.3389/fpain.2020.601528] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/01/2020] [Accepted: 09/30/2020] [Indexed: 11/24/2022] Open
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