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Ang DC, Davuluri S, Kaplan S, Keefe F, Rini C, Miles C, Chen H. Duloxetine and cognitive behavioral therapy with phone-based support for the treatment of chronic musculoskeletal pain: study protocol of the PRECICE randomized control trial. Trials 2024; 25:330. [PMID: 38762720 PMCID: PMC11102257 DOI: 10.1186/s13063-024-08158-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2024] [Accepted: 05/07/2024] [Indexed: 05/20/2024] Open
Abstract
BACKGROUND Chronic musculoskeletal pain (CMP) is the most common, disabling, and costly of all pain conditions. While evidence exists for the efficacy of both duloxetine and web-based cognitive behavioral therapy (CBT) as monotherapy, there is a clear need to consider study of treatment components that may complement each other. In addition, given the reported association between patient's adherence and treatment outcomes, strategies are needed to enhance participant's motivation to adopt and maintain continued use of newly learned pain coping skills from CBT. METHODS Two hundred eighty participants will be recruited from the primary care clinics of a large academic health care system in North Carolina. Participants with CMP will be randomized to one of three treatment arms: (1) combination treatment (duloxetine + web-based self-guided CBT) with phone-based motivational interviewing (MI), (2) combination treatment without phone-based MI, and (3) duloxetine monotherapy. Participants will be in the study for 24 weeks and will be assessed at baseline, week 13, and week 25. The primary outcome is the Brief Pain Inventory (BPI)-Global Pain Severity score, which combines BPI pain severity and BPI pain interference. Secondary measures include between-group comparisons in mean BPI pain severity and BPI pain interference scores. Data collection and outcome assessment will be blinded to treatment group assignment. DISCUSSION This randomized controlled trial (RCT) will determine if combination treatment with duloxetine and web-based CBT is superior to duloxetine monotherapy for the management of CMP. Furthermore, this RCT will determine the effectiveness of phone-based motivational interviewing in promoting the continued practice of pain coping skills, thereby enhancing treatment outcomes. TRIAL REGISTRATION NCT04395001 ClinicalTrials.gov. Registered on May 15, 2020.
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Affiliation(s)
- Dennis C Ang
- Department of Medicine/Rheumatology, Wake Forest University School of Medicine, Winston Salem, NC, 27157, USA.
| | - Swetha Davuluri
- Department of Psychiatry and Behavioral Medicine, Wake Forest University School of Medicine, Winston Salem, NC, USA
| | - Sebastian Kaplan
- Department of Psychiatry and Behavioral Medicine, Wake Forest University School of Medicine, Winston Salem, NC, USA
| | - Francis Keefe
- Department of Psychiatry and Behavioral Sciences, Duke University, Durham, NC, USA
| | - Christine Rini
- Department of Medical Social Sciences, Northwestern University, Chicago, IL, USA
| | - Christopher Miles
- Department of Family Medicine, Wake Forest University School of Medicine, Winston Salem, NC, USA
| | - Haiying Chen
- Department of Biostatistical Sciences, Wake Forest University, Winston Salem, NC, USA
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Schliessbach J, Siegenthaler A, Graven-Nielsen T, Arendt-Nielsen L, Curatolo M. Effects of conditioned pain modulation on Capsaicin-induced spreading muscle hyperalgesia in humans. Scand J Pain 2023; 23:735-742. [PMID: 37293789 DOI: 10.1515/sjpain-2023-0020] [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: 03/01/2023] [Accepted: 05/23/2023] [Indexed: 06/10/2023]
Abstract
OBJECTIVES Muscle pain can be associated with hyperalgesia that may spread outside the area of primary injury due to both peripheral and central sensitization. However, the influence of endogenous pain inhibition is yet unknown. This study investigated how endogenous pain inhibition might influence spreading hyperalgesia in experimental muscle pain. METHODS Conditioned pain modulation (CPM) was assessed in 30 male volunteers by cold pressor test at the non-dominant hand as conditioning and pressure pain thresholds (PPT) at the dominant 2nd toe as test stimuli. Subjects were classified as having inhibitory or facilitating CPM based on published reference values. Subsequently, muscle pain and hyperalgesia were induced by capsaicin injection into the non-dominant supraspinatus muscle. Before and 5, 10, 15, 20, 30, 40, 50 and 60 min later, PPTs were recorded at the supraspinatus, infraspinatus and deltoid muscle, ring finger and toe. RESULTS Compared to baseline, PPTs decreased at the supraspinatus, infraspinatus and deltoid muscle (p≤0.03), and increased at the finger and toe (p<0.001). In facilitating CPM (n=10), hyperalgesia occurred at 5, 10, 15, 20 and 40 min (p≤0.026). In inhibitory CPM (n=20), hyperalgesia only occurred after 10 and 15 min (p≤0.03). At the infraspinatus muscle, groups differed after 5 and 40 min (p≤0.008). CONCLUSIONS The results suggest that facilitating CPM is associated with more spreading hyperalgesia than inhibitory CPM. This implies that poor endogenous pain modulation may predispose to muscle pain and spreading hyperalgesia after injury, and suggest that strategies to enhance endogenous pain modulation may provide clinical benefits.
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Affiliation(s)
- Jürg Schliessbach
- Institute of Interventional Pain Medicine Zurich, IISZ, Zurich, Switzerland
- Department of Anesthesiology and Pain Medicine, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Andreas Siegenthaler
- Chronic Pain Management, Lindenhof Hospital, Lindenhof Group Bern, Bern, Switzerland
| | - Thomas Graven-Nielsen
- Center for Neuroplasticity and Pain (CNAP), SMI, Aalborg University, Aalborg, Denmark
| | - Lars Arendt-Nielsen
- Center for Neuroplasticity and Pain (CNAP), SMI, Aalborg University, Aalborg, Denmark
| | - Michele Curatolo
- Center for Neuroplasticity and Pain (CNAP), SMI, Aalborg University, Aalborg, Denmark
- Department of Anesthesiology and Pain Medicine, University of Washington, SeattleWA, USA
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3
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Warfield AE, Prather JF, Todd WD. Systems and Circuits Linking Chronic Pain and Circadian Rhythms. Front Neurosci 2021; 15:705173. [PMID: 34276301 PMCID: PMC8284721 DOI: 10.3389/fnins.2021.705173] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2021] [Accepted: 06/10/2021] [Indexed: 12/15/2022] Open
Abstract
Research over the last 20 years regarding the link between circadian rhythms and chronic pain pathology has suggested interconnected mechanisms that are not fully understood. Strong evidence for a bidirectional relationship between circadian function and pain has been revealed through inflammatory and immune studies as well as neuropathic ones. However, one limitation of many of these studies is a focus on only a few molecules or cell types, often within only one region of the brain or spinal cord, rather than systems-level interactions. To address this, our review will examine the circadian system as a whole, from the intracellular genetic machinery that controls its timing mechanism to its input and output circuits, and how chronic pain, whether inflammatory or neuropathic, may mediate or be driven by changes in these processes. We will investigate how rhythms of circadian clock gene expression and behavior, immune cells, cytokines, chemokines, intracellular signaling, and glial cells affect and are affected by chronic pain in animal models and human pathologies. We will also discuss key areas in both circadian rhythms and chronic pain that are sexually dimorphic. Understanding the overlapping mechanisms and complex interplay between pain and circadian mediators, the various nuclei they affect, and how they differ between sexes, will be crucial to move forward in developing treatments for chronic pain and for determining how and when they will achieve their maximum efficacy.
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Affiliation(s)
| | | | - William D. Todd
- Program in Neuroscience, Department of Zoology and Physiology, University of Wyoming, Laramie, WY, United States
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Scales CD, Lai HH, Desai AC, Antonelli JA, Maalouf NM, Tasian GE, Reese PP, Curatolo M, Weinfurt K, Al-Khalidi HR, Wessells H, Kirkali Z, Harper JD. Study to Enhance Understanding of Stent-Associated Symptoms: Rationale and Study Design. J Endourol 2020; 35:761-768. [PMID: 33081503 DOI: 10.1089/end.2020.0776] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022] Open
Abstract
Background: Ureteral stents are commonly employed after ureteroscopy to treat urinary stone disease, but the devices impose a substantial burden of stent-associated symptoms (SAS), including pain and urinary side effects. The NIDDK (National Institute of Diabetes and Digestive and Kidney Diseases) Urinary Stone Disease Research Network sought to develop greater understanding of SAS causes and severity among individuals treated ureteroscopically for ureteral or renal stones. Materials and Methods: We designed a prospective, observational cohort study comprising adolescents and adults undergoing ureteroscopic intervention for ureteral or renal stones. Participants will undergo detailed symptom assessment using validated questionnaires, a psychosocial assessment, and detailed collection of clinical and operative data. Quantitative sensory testing will be utilized to assess pain sensitization. In addition, a small cohort (∼40 individuals) will participate in semi-structured interviews to develop more granular information regarding their stent symptoms and experience. Biospecimens (blood and urine) will be collected for future research. Results: The Study to Enhance Understanding of sTent-associated Symptoms (STENTS) enrolled its first participant in March 2019 and completed nested qualitative cohort follow-up in August 2019. After a planned pause, enrollment for the main study cohort resumed in September 2019 and is expected to be completed in 2021. Conclusion: STENTS is expected to provide important insights into the mechanisms and risk factors for severe ureteral SAS after ureteroscopy. These insights will generate future investigations to mitigate the burden of SAS among individuals with urinary stone disease.
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Affiliation(s)
- Charles D Scales
- Departments of Surgery and Population Health Sciences, Duke Surgical Center for Outcomes Research, Duke Clinical Research Institute, Duke University School of Medicine, Durham, North Carolina, USA
| | - H Henry Lai
- Division of Urologic Surgery, Department of Surgery, Washington University School of Medicine, St. Louis, Missouri, USA.,Department of Anesthesiology, Washington University School of Medicine, St. Louis, Missouri, USA
| | - Alana C Desai
- Division of Urologic Surgery, Department of Surgery, Washington University School of Medicine, St. Louis, Missouri, USA
| | - Jodi A Antonelli
- Department of Urology, University of Texas Southwestern Medical Center, Dallas, Texas, USA
| | - Naim M Maalouf
- Department of Internal Medicine and Charles, Jane Pak Center for Mineral Metabolism and Clinical Research, University of Texas Southwestern Medical Center, Dallas, Texas, USA
| | - Gregory E Tasian
- Department of Surgery, Division of Pediatric Urology, The Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA.,Department of Biostatistics, Epidemiology, and Informatics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Peter P Reese
- Department of Biostatistics, Epidemiology, and Informatics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA.,Renal-Electrolyte and Hypertension Division, Department of Medicine, The Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Michele Curatolo
- Department of Anesthesiology and Pain Medicine, University of Washington School of Medicine, Seattle, Washington, USA
| | - Kevin Weinfurt
- Department of Population Health Sciences, Duke University School of Medicine, Durham, North Carolina, USA
| | - Hussein R Al-Khalidi
- Department of Biostatistics and Bioinformatics, Duke Clinical Research Institute, Duke University School of Medicine, Durham, North Carolina, USA
| | - Hunter Wessells
- Department of Urology, University of Washington School of Medicine, Seattle, Washington, USA
| | - Ziya Kirkali
- National Institute of Diabetes and Digestive and Kidney Diseases, Bethesda, Maryland, USA
| | - Jonathan D Harper
- Department of Urology, University of Washington School of Medicine, Seattle, Washington, USA
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Lannon EW, Jure FA, Andersen OK, Rhudy JL. Does Threat Enlarge Nociceptive Reflex Receptive Fields? THE JOURNAL OF PAIN 2020; 22:487-497. [PMID: 33166655 DOI: 10.1016/j.jpain.2020.10.006] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/28/2020] [Revised: 10/26/2020] [Accepted: 10/27/2020] [Indexed: 10/23/2022]
Abstract
Threat-induced pain modulation can increase survival by amplifying physiological and behavioral reactions toward danger. Threat can also modulate spinal nociception, suggesting engagement of endogenous top-down circuitry. A unique method to assess spinal nociception is via reflex receptive fields (RRF) associated with the nociceptive withdrawal reflex (NWR, a protective spinally-mediated reflex). The size of nociceptive RRFs can be modulated by top-down circuitry with the enlargement of RRFs related to increased spinal nociception. Threat has been previously shown to enhance pain and spinal nociception, but the relationship between threat and RRFs has not been investigated. The present study investigated this issue in 25 healthy individuals. RRFs were determined from NWRs measured by electromyography of the tibialis anterior following electrocutaneous stimulations. RRFs and pain were assessed during periods in which participants were under threat of unpredictable painful abdominal stimulations and when they were not under threat. Results indicated that threat periods led to significantly higher pain, larger nociceptive RRFs and NWR magnitudes. These findings imply that threat produces changes in protective reflexes related to spinal nociceptive sensitivity and increased pain perception. This is likely mediated by top-down circuitry that enhances dorsal horn nociceptive neurons by enlarging RRFs and amplifying ascending pain signals. PERSPECTIVE: This article presents the enlargement of RRF during periods of threat. The results from this study may help clarify the mechanism underlining emotional modulation of spinal nociception.
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Affiliation(s)
- Edward W Lannon
- Department of Psychology, The University of Tulsa, Tulsa, OK; Center for Neuroplasticity and Pain (CNAP), Aalborg University, Aalborg Ø, Denmark.
| | - Fabricio A Jure
- Center for Neuroplasticity and Pain (CNAP), Aalborg University, Aalborg Ø, Denmark
| | - Ole Kæseler Andersen
- Center for Neuroplasticity and Pain (CNAP), Aalborg University, Aalborg Ø, Denmark
| | - Jamie L Rhudy
- Department of Psychology, The University of Tulsa, Tulsa, OK
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The Distributed Nociceptive System: A Framework for Understanding Pain. Trends Neurosci 2020; 43:780-794. [PMID: 32800534 DOI: 10.1016/j.tins.2020.07.004] [Citation(s) in RCA: 43] [Impact Index Per Article: 10.8] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/14/2020] [Revised: 06/30/2020] [Accepted: 07/12/2020] [Indexed: 12/31/2022]
Abstract
Chronic pain remains challenging to both diagnose and treat. These challenges, in part, arise from limited systems-level understanding of the basic mechanisms that process nociceptive information and ultimately instantiate a subjectively available experience of pain. Here, I provide a framework, the distributed nociceptive system, for understanding nociceptive mechanisms at a systems level by integrating the concepts of neural population coding with distributed processing. Within this framework, wide-spread engagement of populations of neurons produces representations of nociceptive information that are highly resilient to disruption. The distributed nociceptive system provides a foundation for understanding complex spatial aspects of chronic pain and provides an impetus for nonpharmacological cognitive and physical therapies that can effectively target the highly distributed system that gives rise to an experience of pain.
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Temporal Summation in Chronic Pelvic Pain. JOURNAL OF OBSTETRICS AND GYNAECOLOGY CANADA 2020; 42:556-560. [DOI: 10.1016/j.jogc.2019.09.012] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/30/2019] [Revised: 09/15/2019] [Accepted: 09/16/2019] [Indexed: 01/09/2023]
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Evaluation of pain and flexor reflex responses and their association with clinical parameters in patients with fibromyalgia. Turk J Phys Med Rehabil 2020; 66:1-9. [PMID: 32318668 DOI: 10.5606/tftrd.2020.3753] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/11/2018] [Accepted: 05/21/2019] [Indexed: 11/21/2022] Open
Abstract
Objectives In the present study, we aimed to evaluate electrophysiological outcomes of flexor reflexes (FR) emerging in response to painful stimuli in fibromyalgia (FM) patients. Patients and methods This study included a total of 21 female FM patients (mean age 36.8±8.0 years; range, 20 to 50 years) and 28 healthy female controls (mean age 37.3±8.8 years; range, 22 to 53 years). Clinical features of the patients, Fibromyalgia Impact Questionnaire (FIQ), Beck Depression Inventory (BDI), and Beck Anxiety Inventory (BAI) scores were recorded. Electrophysiological stimulation threshold, visual analog scale (VAS) scores of generated pain after each stimulation, current intensity, flexor responses obtained from muscles, and electrophysiological measurement of these responses were noted. Results The threshold for perception of electrical current was higher and resistance level to maximum electrical current was lower in FM patients (p<0.05). The VAS scores of FM patients under maximum electrical current were higher than the control group (p<0.05), while the lowest current value in which FR response obtained in FM patients was lower (p<0.05). The latency was lower, amplitude was higher, and response area was wider in FM patients (p<0.05). No significant relationship between the FIQ, BDI, BAI scores and stimulant perception threshold levels was found in FM patients (p>0.05). Conclusion Based on these findings, FR responses may be useful as an electrophysiological parameter in FM diagnosis.
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Orr NL, Wahl KJ, Noga H, Allaire C, Williams C, Bedaiwy MA, Albert A, Smith KB, Yong PJ. Phenotyping Sexual Pain in Endometriosis Using the Central Sensitization Inventory. J Sex Med 2020; 17:761-770. [PMID: 31983669 DOI: 10.1016/j.jsxm.2019.12.019] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2019] [Revised: 12/10/2019] [Accepted: 12/13/2019] [Indexed: 12/30/2022]
Abstract
INTRODUCTION Deep dyspareunia, a common symptom in endometriosis, has previously been associated with bladder and/or pelvic floor tenderness (BPFT), which suggests a role for central nervous system sensitization. The Central Sensitization Inventory (CSI, 0-100) is a validated self-reported scale for patients with central sensitization. AIM The objective of this study was to phenotype deep dyspareunia using BPFT and the CSI. METHODS The methods included cross-sectional analysis from a prospective registry from January 2018 to June 2018 at a tertiary center for endometriosis (ClinicalTrials.gov #NCT02911090). Included were women aged 18-50 years with endometriosis (previously surgically diagnosed, current visualized endometrioma on ultrasound, or current palpable or visualized nodule on ultrasound), who were newly or re-referred to the center. Severity of deep dyspareunia was self-reported using an 11-point numeric rating scale (0 = no pain; 10 = worst pain imaginable), categorized as no or low deep dyspareunia (0-4) and high deep dyspareunia (5-10). We identified the subgroup with high deep dyspareunia and presence of BPFT, where we hypothesized a central component of the sexual pain. This subgroup was compared with 2 other subgroups: no or low deep dyspareunia and high deep dyspareunia but no BPFT. The CSI was compared between the groups using analysis of variance, followed by post hoc testing (P < .05). MAIN OUTCOME MEASURE The main outcome measure was the CSI score ranging from 0 to 100. RESULTS Data from 163 women with endometriosis were analyzed. The mean age of this cohort was 36.4 ± 6.8 years, and the mean CSI score was 41.0 ± 18.6. 37 percent (61/163) had high deep dyspareunia and BPFT; 29% (47/163) had high deep dyspareunia and no BPFT; and 34% (55/163) had no or low deep dyspareunia. The CSI significantly differed between the 3 groups (analysis of variance: F = 22.4, P < .001). In post hoc testing, the CSI was higher in women with high deep dyspareunia and BPFT (51.3 ± 16.9), compared with women with no or low deep dyspareunia (30.9 ± 15.4, P < .001) and compared with women with high deep dyspareunia but no BPFT (39.4 ± 17.2, P = .001). CLINICAL IMPLICATIONS The CSI could be used to classify and phenotype patients with endometriosis-associated sexual pain. STRENGTH & LIMITATIONS Strengths include a prospective registry with integrated pain scores, validated questionnaires, and physical examination findings. Limitations include the lack of quantitative sensory testing for central sensitization. CONCLUSIONS In women with endometriosis, the subgroup with high deep dyspareunia and bladder and/or pelvic floor tenderness had a significantly higher score on the CSI than other subgroups, suggesting that this group may have a central component to their sexual pain. Orr NL, Wahl KJ,Noga H, et al. Phenotyping Sexual Pain in Endometriosis Using the Central Sensitization Inventory. J Sex Med 2020;17:761-770.
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Affiliation(s)
- Natasha L Orr
- BC Women's Centre for Pelvic Pain and Endometriosis, Vancouver, BC, Canada; Department of Obstetrics and Gynecology, University of British Columbia, Vancouver, BC, Canada
| | - Kate J Wahl
- BC Women's Centre for Pelvic Pain and Endometriosis, Vancouver, BC, Canada; Department of Obstetrics and Gynecology, University of British Columbia, Vancouver, BC, Canada
| | - Heather Noga
- Women's Health Research Institute, Vancouver, BC, Canada
| | - Catherine Allaire
- BC Women's Centre for Pelvic Pain and Endometriosis, Vancouver, BC, Canada; Department of Obstetrics and Gynecology, University of British Columbia, Vancouver, BC, Canada; Women's Health Research Institute, Vancouver, BC, Canada
| | - Christina Williams
- BC Women's Centre for Pelvic Pain and Endometriosis, Vancouver, BC, Canada; Department of Obstetrics and Gynecology, University of British Columbia, Vancouver, BC, Canada
| | - Mohamed A Bedaiwy
- BC Women's Centre for Pelvic Pain and Endometriosis, Vancouver, BC, Canada; Department of Obstetrics and Gynecology, University of British Columbia, Vancouver, BC, Canada; Women's Health Research Institute, Vancouver, BC, Canada
| | - Arianne Albert
- Women's Health Research Institute, Vancouver, BC, Canada
| | - Kelly B Smith
- BC Centre for Vulvar Health, Gordon and Leslie Diamond Health Care Centre, Vancouver, BC, Canada
| | - Paul J Yong
- BC Women's Centre for Pelvic Pain and Endometriosis, Vancouver, BC, Canada; Department of Obstetrics and Gynecology, University of British Columbia, Vancouver, BC, Canada; Women's Health Research Institute, Vancouver, BC, Canada; BC Centre for Vulvar Health, Gordon and Leslie Diamond Health Care Centre, Vancouver, BC, Canada.
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Hollins M, Bryen CP, Taylor D. Effects of chronic pain history on perceptual and cognitive inhibition. Exp Brain Res 2020; 238:321-332. [PMID: 31907554 DOI: 10.1007/s00221-019-05715-8] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/22/2019] [Accepted: 12/18/2019] [Indexed: 01/01/2023]
Abstract
Measures of sensory and cognitive inhibition were obtained from university students with and without a history of chronic pain. The form of sensory inhibition measured was diffuse noxious inhibitory controls (DNIC), the capacity of a painful stimulus to reduce the subjective intensity of a second stimulus delivered to a remote body site. To measure cognitive inhibition, the Stroop effect was used. Participants with a history of chronic pain showed less DNIC (i.e., less sensory inhibition) than the healthy controls, but had a smaller Stroop effect (indicating greater cognitive inhibition). The fact that chronic pain history is associated with opposite changes in these two measures casts doubt on the view that the two inhibitory processes are related. Scores on each experimental measure were equivalent in pain-history subjects with ongoing chronic pain and those whose chronic pain had resolved. This equivalence suggests that chronic pain in childhood or adolescence may have lingering effects on sensory and cognitive inhibition.
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Affiliation(s)
- Mark Hollins
- Department of Psychology and Neuroscience, University of North Carolina at Chapel Hill, Chapel Hill, NC, 27599, USA.
| | - Chloe P Bryen
- Department of Psychology and Neuroscience, University of North Carolina at Chapel Hill, Chapel Hill, NC, 27599, USA
| | - Dillon Taylor
- Department of Psychology and Neuroscience, University of North Carolina at Chapel Hill, Chapel Hill, NC, 27599, USA
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Abstract
Abstract
Purpose of Review
Centralized pain syndromes (CPS), including chronic pelvic pain (CPP) syndrome, are significant public health problems with prevalence more than diabetes, cancer, or cardiovascular disease. A variety of pathologies are linked with CPP syndrome; however, pain often continues without the presence of pathology, or when an underlying pelvic disease is found, the extent and severity of pain are disproportionate. Although this is not a systematic review, we performed a detailed literature search to identify relevant papers and to provide the available evidence for central changes in association with CPP syndrome.
Recent Findings
Recent advances in brain imaging techniques have provided more accurate data on gray matter volume, functional connectivity, and metabolite levels in the pain-relevant areas of the brain. The present evidence shows that like other chronic pain conditions, the CPP syndrome is associated with central nervous system (CNS) alterations. In particular, these include changes in brain structure, in the activity of both the hypothalamic–pituitary–adrenal (HPA) axis and the autonomic nervous system, and in the behavioral and central response to noxious stimulation.
Summary
A growing body of evidence, mostly from neuroimaging, suggests that for many patients with CPP, the pain may be associated to changes in both structure and function of the CNS. The treatment of pain symptoms, even without the presence of identifiable pathology, may prevent the development or at least minimize the progression of long-term central changes. These findings support the use of new therapeutic strategies targeting the CNS for controlling of pain in CPP conditions.
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Leake HB, Heathcote LC, Simons LE, Stinson J, Kamper SJ, Williams CM, Burgoyne LL, Craigie M, Kammers M, Moen D, Pate JW, Szeto K, Moseley GL. Talking to Teens about Pain: A Modified Delphi Study of Adolescent Pain Science Education. CANADIAN JOURNAL OF PAIN-REVUE CANADIENNE DE LA DOULEUR 2019; 3:200-208. [PMID: 35005410 PMCID: PMC8730612 DOI: 10.1080/24740527.2019.1682934] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 12/02/2022]
Abstract
Background: Persistent pain is a prevalent condition that negatively influences physical, emotional, social and family functioning in adolescents. Pain science education is a promising therapy for adults, yet to be thoroughly investigated for persistent pain in adolescents. There is a need to develop suitable curricula for adolescent pain science education. Methods: An interdisciplinary meeting of 12 clinicians and researchers was held during March 2018 in Adelaide, South Australia. An a priori objective of the meeting was to identify and gain consensus on key learning objectives for adolescent pain science education using a modified-Delphi process. Results and Conclusion: Consensus was reached via a modified Delphi process for seven learning objectives to form the foundation of a curriculum: 1) Pain is a protector; 2) The pain system can become overprotective; 3) Pain is a brain output; 4) Pain is not an accurate marker of tissue state; 5) There are many potential contributors to anyone’s pain; 6) We are all bioplastic and; 7) Pain education is treatment. Recommendations are made for promising areas for future research in adolescent pain science education.
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Affiliation(s)
- Hayley B. Leake
- IIMPACT, University of South Australia, Adelaide, South Australia, Australia
| | - Lauren C. Heathcote
- Department of Anesthesiology, Perioperative and Pain Medicine, Stanford University School of Medicine, Palo Alto, California, USA
| | - Laura E. Simons
- Department of Anesthesiology, Perioperative and Pain Medicine, Stanford University School of Medicine, Palo Alto, California, USA
| | - Jennifer Stinson
- Child Health Evaluative Sciences, The Hospital for Sick Children, Toronto, Canada
- Lawrence S. Bloomberg Faculty of Nursing, University of Toronto, Toronto, Canada
| | - Steven J. Kamper
- Institute for Musculoskeletal Health, University of Sydney, Sydney, New South Wales, Australia
| | - Christopher M. Williams
- School of Medicine and Public Health, Hunter Medical Research Institute, University of Newcastle, New South Wales, Australia
| | - Laura L. Burgoyne
- Children’s Anaesthesia, Women’s and Children’s Hospital, Adelaide, South Australia, Australia
| | - Meredith Craigie
- College of Medicine and Public Health, Flinders University, Adelaide, South Australia, Australia
| | - Marjolein Kammers
- Melbourne School of Psychological Sciences, The University of Melbourne, Melbourne, Victoria, Australia
| | - David Moen
- Form Physiotherapy, Adelaide, South Australia, Australia
| | - Joshua W. Pate
- Faculty of Medicine and Health Sciences, Macquarie University, Sydney, New South Wales, Australia
| | - Kimberley Szeto
- IIMPACT, University of South Australia, Adelaide, South Australia, Australia
| | - G. Lorimer Moseley
- IIMPACT, University of South Australia, Adelaide, South Australia, Australia
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Linde LD, Srbely JZ. The Acute Effect of Skin Preheating on Capsaicin-Induced Central Sensitization in Humans. Pain Pract 2019; 19:811-820. [PMID: 31231923 DOI: 10.1111/papr.12811] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/16/2019] [Revised: 05/17/2019] [Accepted: 06/11/2019] [Indexed: 01/10/2023]
Abstract
INTRODUCTION Topical capsaicin is commonly employed to experimentally induce central sensitization (CS) in humans. While previous studies have investigated the effect of skin preheating on the sensitizing effect of capsaicin, no studies have compared the synergistic effect of skin preheating on the magnitude of sensitization via topical capsaicin within the first 30 minutes of application. We tested the hypothesis that skin preheating potentiates the sensitizing effect of topical capsaicin by evoking a larger region of secondary hyperalgesia vs. topical capsaicin alone. METHODS Twenty young, healthy subjects each received topical capsaicin (Zostrix HP 0.075%) only (CAP), topical capsaicin with preheating (CAP + HEAT), and topical nonsensitizing placebo cream (CON) in a crossover design. Capsaicin and placebo creams were applied to a 50 cm2 area of the dorsal forearm. The CAP + HEAT session also included a 10-minute preheating session. Regions of secondary hyperalgesia were assessed using mechanical brush allodynia testing, and skin temperature was assessed via infrared thermography. Outcomes were normalized to baseline and compared at 10, 20, and 30 minutes after cream application. RESULTS The CAP + HEAT session led to a significantly larger area of secondary hyperalgesia compared to the CAP session as measured by brush allodynia (CON: 0 ± 0 cm; CAP: 2.08 ± 0.45 cm; CAP + HEAT: 3.70 ± 0.46 cm; P < 0.05) and skin temperature (CON: -2.92% ± 0.03%; CAP: -0.63% ± 0.09%; CAP + HEAT: 2.50% ± 0.11%; ( of baseline) P < 0.05). CONCLUSION Preheating amplifies the sensitizing effect of topical capsaicin within 30 minutes of application. The heat-capsaicin technique may be employed to assess differing magnitudes of CS induction and enables future studies investigating the development and progression of CS in humans.
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Affiliation(s)
- Lukas D Linde
- Department of Human Health and Nutritional Sciences, University of Guelph, Guelph, Ontario, Canada
| | - John Z Srbely
- Department of Human Health and Nutritional Sciences, University of Guelph, Guelph, Ontario, Canada
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Vuilleumier PH, Fritsche R, Schliessbach J, Schmitt B, Arendt-Nielsen L, Zeilhofer HU, Curatolo M. Mutations affecting glycinergic neurotransmission in hyperekplexia increase pain sensitivity. Brain 2019; 141:63-71. [PMID: 29149236 DOI: 10.1093/brain/awx289] [Citation(s) in RCA: 20] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2017] [Accepted: 09/19/2017] [Indexed: 11/14/2022] Open
Abstract
See Dickenson (doi:10.1093/brain/awx334) for a scientific commentary on this article.Inhibitory interneurons in the spinal cord use glycine and GABA for fast inhibitory neurotransmission. While there is abundant research on these inhibitory pain pathways in animal models, their relevance in humans remains unclear, largely due to the limited possibility to manipulate selectively these pathways in humans. Hyperekplexia is a rare human disease that is caused by loss-of-function mutations in genes encoding for glycine receptors and glycine transporters. In the present study, we tested whether hyperekplexia patients display altered pain perception or central pain modulation compared with healthy subjects. Seven patients with genetically and clinically confirmed hyperekplexia were compared to 14 healthy age- and sex-matched controls. The following quantitative sensory tests were performed: pressure pain detection threshold (primary outcome), ice water tolerance, single and repeated electrical pain detection thresholds, nociceptive withdrawal reflex threshold, and conditioned pain modulation. Statistical analysis was performed using linear mixed models. Hyperekplexia patients displayed lower pain thresholds than healthy controls for all of the quantitative sensory tests [mean (standard deviation)]: pressure pain detection threshold [273 (170) versus 475 (115) kPa, P = 0.003], ice water tolerance [49.2 (36.5) versus 85.7 (35.0) s, P = 0.015], electrical single pain detection threshold [5.42 (2.64) versus 7.47 (2.62) mA, P = 0.012], electrical repeated pain detection threshold [3.76 (1.41) versus 5.8 (1.73) mA, P = 0.003], and nociceptive withdrawal reflex [7.42 (3.63) versus 14.1 (6.9) mA, P = 0.015]. Conditioned pain modulation was significantly reduced in hyperekplexia [increase to baseline: 53.2 (63.7) versus 105 (57) kPa, P = 0.030]. Our data demonstrate increased pain sensitivity and impaired central pain modulation in hyperekplexia patients, supporting the importance of glycinergic neurotransmission for central pain modulation in humans.
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Affiliation(s)
- Pascal Henri Vuilleumier
- Department of Anaesthesiology and Pain Medicine, Bern University Hospital, University of Bern, Switzerland
| | - Raphael Fritsche
- Department of Ophthalmology, Canton Hospital of Lucerne, Switzerland
| | - Jürg Schliessbach
- Department of Anaesthesiology and Pain Medicine, Bern University Hospital, University of Bern, Switzerland
| | - Bernhard Schmitt
- Department of Child Neurology, Children's Hospital, University of Zurich, Switzerland
| | - Lars Arendt-Nielsen
- Center for Sensory-Motor Interaction, School of Medicine, University of Aalborg, Denmark
| | - Hanns Ulrich Zeilhofer
- Institute of Pharmacology and Toxicology, University of Zurich, and Institute of Pharmaceutical Sciences, Swiss Federal Institute of Technology (ETH) Zurich, Switzerland
| | - Michele Curatolo
- Center for Sensory-Motor Interaction, School of Medicine, University of Aalborg, Denmark.,Department of Anaesthesiology and Pain Medicine, University of Washington, Seattle, USA
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Liu Z, Chen S, Qiu C, Sun Y, Li W, Jiang J, Zhang JM. Fractalkine/CX3CR1 Contributes to Endometriosis-Induced Neuropathic Pain and Mechanical Hypersensitivity in Rats. Front Cell Neurosci 2018; 12:495. [PMID: 30622457 PMCID: PMC6309014 DOI: 10.3389/fncel.2018.00495] [Citation(s) in RCA: 26] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/01/2018] [Accepted: 12/03/2018] [Indexed: 11/13/2022] Open
Abstract
Pain is the most severe and common symptom of endometriosis. Its underlying pathogenetic mechanism is poorly understood. Nerve sensitization is a particular research challenge, due to the limitations of general endometriosis models and sampling nerve tissue from patients. The chemokine fractalkine (FKN) has been demonstrated to play a key role in various forms of neuropathic pain, while its role in endometriotic pain is unknown. Our study was designed to explore the function of FKN in the development and maintenance of peripheral hyperalgesia and central sensitization in endometriosis using a novel endometriosis animal model developed in our laboratory. After modeling, behavioral tests were carried out and the optimal time for molecular changes was obtained. We extracted ectopic tissues and L4-6 spinal cords to detect peripheral and central roles for FKN, respectively. To assess morphologic characteristics of endometriosis-like lesions-as well as expression and location of FKN/CX3CR1-we performed H&E staining, immunostaining, and western blotting analyses. Furthermore, inhibition of FKN expression in the spinal cord was achieved by intrathecal administration of an FKN-neutralizing antibody to demonstrate its function. Our results showed that implanted autologous uterine tissue around the sciatic nerve induced endometriosis-like lesions and produced mechanical hyperalgesia and allodynia. FKN was highly expressed on macrophages, whereas its receptor CX3CR1 was overexpressed in the myelin sheath of sciatic nerve fibers. Overexpressed FKN was also observed in neurons. CX3CR1/pp38-MAPK was upregulated in activated microglia in the spinal dorsal horn. Intrathecal administration of FKN-neutralizing antibody not only reversed the established mechanical hyperalgesia and allodynia, but also inhibited the expression of CX3CR1/pp38-MAPK in activated microglia, which was essential for the persistence of central sensitization. We concluded that the FKN/CX3CR1 signaling pathway might be one of the mechanisms of peripheral hyperalgesia in endometriosis, which requires further studies. Spinal FKN is important for the development and maintenance of central sensitization in endometriosis, and it may further serve as a novel therapeutic target to relieve persistent pain associated with endometriosis.
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Affiliation(s)
- Zhiming Liu
- Department of Obstetrics and Gynecology, Qilu Hospital of Shandong University, Jinan, China.,Key Laboratory of Gynecologic Oncology of Shandong Province, Qilu Hospital of Shandong University, Jinan, China
| | - Sisi Chen
- Pain Research Center, Department of Anesthesiology, University of Cincinnati College of Medicine, Cincinnati, OH, United States
| | - Chunping Qiu
- Department of Obstetrics and Gynecology, Qilu Hospital of Shandong University, Jinan, China.,Key Laboratory of Gynecologic Oncology of Shandong Province, Qilu Hospital of Shandong University, Jinan, China
| | - Yaqiong Sun
- Department of Obstetrics and Gynecology, Shandong Obstetrics and Gynecology Hospital, Jinan, China
| | - Wenzhi Li
- Department of Obstetrics and Gynecology, Qilu Hospital of Shandong University, Jinan, China.,Key Laboratory of Gynecologic Oncology of Shandong Province, Qilu Hospital of Shandong University, Jinan, China
| | - Jie Jiang
- Department of Obstetrics and Gynecology, Qilu Hospital of Shandong University, Jinan, China
| | - Jun-Ming Zhang
- Pain Research Center, Department of Anesthesiology, University of Cincinnati College of Medicine, Cincinnati, OH, United States
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van Aken M, Oosterman J, van Rijn T, Woudsma K, Ferdek M, Ruigt G, Kozicz T, Braat D, Peeters A, Nap A. Experimental pain tolerance is decreased and independent of clinical pain intensity in patients with endometriosis. Fertil Steril 2018; 110:1118-1128. [DOI: 10.1016/j.fertnstert.2018.06.040] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/05/2018] [Revised: 06/26/2018] [Accepted: 06/27/2018] [Indexed: 02/06/2023]
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17
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Levitt AE, Galor A, Chowdhury AR, Felix ER, Sarantopoulos CD, Zhuang GY, Patin D, Maixner W, Smith SB, Martin ER, Levitt RC. Evidence that Dry Eye Represents a Chronic Overlapping Pain Condition. Mol Pain 2018; 13:1744806917729306. [PMID: 28814146 PMCID: PMC5584655 DOI: 10.1177/1744806917729306] [Citation(s) in RCA: 30] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022] Open
Abstract
Recent data suggest that corneal somatosensory dysfunction may be the underlying cause of
severe dry eye symptoms in the absence of ocular surface pathology seen in a subset of
patients diagnosed with “dry eye syndrome.” This subset of patients tends to demonstrate a
unique constellation of symptoms that are persistent, more severe, and generally respond
poorly to current dry eye therapies targeting inadequate or dysfunctional tears. A growing
body of literature suggests that symptoms in these patients may be better characterized as
neuropathic ocular pain rather than dry eye. In these patients, dry eye symptoms are often
associated with numerous comorbid pain conditions and evidence of central pain processing
abnormalities, where eye pain is just one of multiple overlapping peripheral
manifestations. In this review, we discuss the concept and potential mechanisms of chronic
overlapping pain conditions as well as evidence for considering neuropathic ocular pain as
one of these overlapping pain conditions.
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Affiliation(s)
| | - Anat Galor
- Miami Veterans Administration Medical Center, Miami, FL
| | - Aneesa R Chowdhury
- Department of Anesthesiology, Perioperative Medicine and Pain Management, University of Miami, Miller School of Medicine, Miami, FL
| | | | | | - Gerald Y Zhuang
- Department of Anesthesiology, Perioperative Medicine and Pain Management, University of Miami, Miller School of Medicine, Miami, FL
| | - Dennis Patin
- Department of Anesthesiology, Perioperative Medicine and Pain Management, University of Miami, Miller School of Medicine, Miami, FL
| | | | | | - Eden R Martin
- John P. Hussman Institute for Human Genomics, University of Miami, Miller School of Medicine, Miami, FL 7John T. Macdonald Foundation
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A common pronociceptive pain modulation profile typifying subgroups of chronic pelvic pain syndromes is interrelated with enhanced clinical pain. Pain 2018; 158:1021-1029. [PMID: 28178074 DOI: 10.1097/j.pain.0000000000000869] [Citation(s) in RCA: 30] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/13/2023]
Abstract
Provoked vestibulodynia (PVD) and painful bladder syndrome (PBS), subgroups of chronic pelvic pain syndromes (CPPS), are considered to share common biophysiological peripheral mechanisms. In addition, indications of a pronociceptive pain profile coexisting with psychological vulnerability suggest common dysfunctional pain processing and pain modulation in these 2 subgroups of CPPS. We therefore aimed at comparing the pain profile and psychological traits of patients with PVD and PBS to see whether the pain profile contributes to intersubject variability of clinical pain symptoms. Patients with PVD (n = 18) and PBS (n = 21) were compared with healthy controls (n = 20) in their responses to (1) pain psychophysical tests applied to both referred (suprapubis) and remote (hand) body areas and (2) pain-related psychological factors (pain catastrophizing, depression, anxiety, and somatization). We found a similar pronociceptive pain profile in the 2 subgroups of CPPS-enhanced facilitation (ie, hyperalgesia in the referred body area [P < 0.001]) and inefficient inhibition (ie, reduced conditioned pain modulation [P < 0.001] that were associated with both enhanced pain ratings evoked during trigger point examination [P < 0.037]) and higher Brief Pain Inventory ratings (P = 0.002). The latter was also correlated with pain catastrophizing (r = 0.504, P = 0.001) and depression symptoms (r = 0.361, P = 0.024). The findings suggest common mechanisms underlying a dysfunctional nociceptive system in both PVD and PBS. The intersubject variability in the level of dysfunction and its association with disease severity recommends a personalized pain treatment that may alleviate daily pain and dysfunction in patients with CPPS.
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Psychophysical and Electrophysiological Evidence for Enhanced Pain Facilitation and Unaltered Pain Inhibition in Acute Low Back Pain Patients. THE JOURNAL OF PAIN 2017. [DOI: 10.1016/j.jpain.2017.05.008] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
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Wallwork SB, Grabherr L, O’Connell NE, Catley MJ, Moseley GL. Defensive reflexes in people with pain – a biomarker of the need to protect? A meta-analytical systematic review. Rev Neurosci 2017; 28:381-396. [DOI: 10.1515/revneuro-2016-0057] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/12/2016] [Accepted: 12/21/2016] [Indexed: 12/25/2022]
Abstract
AbstractUpregulation of defensive reflexes such as the nociceptive flexion reflex (NFR) has been attributed to sensitisation of peripheral and spinal nociceptors and is often considered biomarkers of pain. Experimental modulation of defensive reflexes raises the possibility that they might be better conceptualised as markers of descending cognitive control. Despite strongly held views on both sides and several narrative reviews, there has been no attempt to evaluate the evidence in a systematic manner. We undertook a meta-analytical systematic review of the extant English-language literature from inception. Thirty-six studies satisfied our a priori criteria. Seventeen were included in the meta-analysis. Reflexive threshold was lower in people with clinical pain than it was in pain-free controls, but reflex size, latency, and duration were unaffected. The pattern of difference was not consistent with sensitisation of nociceptive neurones, as these changes were not isolated to the affected body part but was more consistent with top-down cognitive control reflective of heightened protection of body tissue. The pattern of modulation is dependent on potentially complex evaluative mechanisms. We offer recommendations for future investigations and suggest that defensive reflex threshold may reflect a biomarker of a broader psychological construct related to bodily protection, rather than sensitisation of primary nociceptors, spinal nociceptors, or pain.
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Affiliation(s)
- Sarah B. Wallwork
- Sansom Institute for Health Research, University of South Australia, Adelaide 5001, SA, Australia
| | - Luzia Grabherr
- Sansom Institute for Health Research, University of South Australia, Adelaide 5001, SA, Australia
| | - Neil E. O’Connell
- Health Economics Research Group, Institute of Environment, Health and Societies, Department of Clinical Sciences, Brunel University London, Uxbridge UB8 3PN, UK
| | - Mark J. Catley
- Sansom Institute for Health Research, University of South Australia, Adelaide 5001, SA, Australia
| | - G. Lorimer Moseley
- Sansom Institute for Health Research, University of South Australia, Adelaide 5001, SA, Australia
- Neuroscience Research Australia, Sydney 2031, NSW, Australia
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Dynamic Changes in Nociception and Pain Perception After Spinal Cord Stimulation in Chronic Neuropathic Pain Patients. Clin J Pain 2016; 31:1046-53. [PMID: 25789414 DOI: 10.1097/ajp.0000000000000209] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
OBJECTIVES Patients with an implanted spinal cord stimulation (SCS) system for pain management present an opportunity to study dynamic changes in the pain system in a situation where patients are not stimulated (ie, experiencing severe pain) compared with a situation in which patients have just been stimulated (ie, pain free or greatly reduced pain). The aims of this study were (1) to determine if there are differences in nociceptive withdrawal reflex thresholds (NWR-T) and electrical pain thresholds (EP-T) before and after SCS; and (2) to establish if these differences are related to psychological factors associated with chronic pain. METHODS Seventeen volunteers with chronic neuropathic pain participated in the experiment. Electrical stimuli were applied to assess the NWR-T and the EP-T. In addition, psychological factors (ie, pain characteristics, depression, anxiety, and disability indexes) were also recorded. The NWR-T and EP-T were assessed with the SCS system off (at least 8 h before the experiment), and then reassessed 1 hour after the SCS system was turned on. RESULTS Ongoing pain intensity ratings decreased (P=0.018), whereas the NWR-T increased (P=0.028) after the SCS was turned on, whereas no significant difference was found for EP-T (P=0.324). Psychological factors were significant predictors for EP-T but not for NWR-T. DISCUSSION The results of this study suggest that pain relief after SCS is partially mediated by a decrease in the excitability of dorsal horn neurons in the spinal cord.
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22
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Discriminative ability of reflex receptive fields to distinguish patients with acute and chronic low back pain. Pain 2016; 157:2664-2671. [PMID: 27479866 DOI: 10.1097/j.pain.0000000000000683] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Low back pain has a life time prevalence of 70% to 85%. Approximately 10% to 20% of all patients experience recurrent episodes or develop chronic low back pain. Sociodemographic, clinical, and psychological characteristics explain the transition from acute to chronic low back pain only to a limited extent. Altered central pain processing may be a contributing mechanism. The measurement of reflex receptive fields (RRF) is a novel method to assess altered central pain processing. The RRF area denotes the area of the foot sole from which spinal nociceptive reflexes can be elicited. It was shown to be enlarged in patients with acute and chronic low back pain compared with pain-free individuals. The aim of the study was to explore the discriminative ability of the RRF to distinguish patients with acute and chronic low back pain with the hypothesis that enlarged RRF are associated with chronic low back pain. We included 214 patients with either acute or chronic low back pain and compared RRF between groups in both univariable and multivariable analyses adjusted for different sociodemographic and clinical characteristics possibly associated with the transition to chronic pain. We found a mean difference between patients with acute and chronic low back pain of -0.01 (95% confidence interval [CI], -0.06 to 0.04) in the crude, -0.02 (95% CI, -0.08 to 0.04) in the age and sex adjusted, and -0.02 (95% CI, -0.09 to 0.05) in the fully adjusted model. Our results suggest that the enlargement of RRF area may not be associated with the transition from acute to chronic low back pain.
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Serrao M, Cortese F, Andersen OK, Conte C, Spaich EG, Fragiotta G, Ranavolo A, Coppola G, Perrotta A, Pierelli F. Modular organization of the head retraction responses elicited by electrical painful stimulation of the facial skin in humans. Clin Neurophysiol 2015; 126:2306-13. [PMID: 25769929 DOI: 10.1016/j.clinph.2015.01.029] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/26/2014] [Revised: 01/07/2015] [Accepted: 01/28/2015] [Indexed: 11/25/2022]
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Reliable estimation of nociceptive withdrawal reflex thresholds. J Neurosci Methods 2015; 253:110-5. [DOI: 10.1016/j.jneumeth.2015.06.014] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/06/2015] [Revised: 06/15/2015] [Accepted: 06/15/2015] [Indexed: 11/19/2022]
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25
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Curatolo M, Arendt-Nielsen L. Central Hypersensitivity in Chronic Musculoskeletal Pain. Phys Med Rehabil Clin N Am 2015; 26:175-84. [DOI: 10.1016/j.pmr.2014.12.002] [Citation(s) in RCA: 32] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
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On the use of information theory for the analysis of synchronous nociceptive withdrawal reflexes and somatosensory evoked potentials elicited by graded electrical stimulation. J Neurosci Methods 2015; 240:1-12. [DOI: 10.1016/j.jneumeth.2014.10.011] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/22/2014] [Revised: 10/13/2014] [Accepted: 10/14/2014] [Indexed: 12/30/2022]
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McKinnon BD, Bertschi D, Bersinger NA, Mueller MD. Inflammation and nerve fiber interaction in endometriotic pain. Trends Endocrinol Metab 2015; 26:1-10. [PMID: 25465987 DOI: 10.1016/j.tem.2014.10.003] [Citation(s) in RCA: 129] [Impact Index Per Article: 14.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/31/2014] [Revised: 10/03/2014] [Accepted: 10/21/2014] [Indexed: 11/20/2022]
Abstract
Endometriosis is an extremely prevalent estrogen-dependent condition characterized by the growth of ectopic endometrial tissue outside the uterine cavity, and is often presented with severe pain. Although the relationship between lesion and pain remains unclear, nerve fibers found in close proximity to endometriotic lesions may be related to pain. Also, women with endometriosis pain develop central sensitization. Endometriosis creates an inflammatory environment and recent research is beginning to elucidate the role of inflammation in stimulating peripheral nerve sensitization. In this review, we discuss endometriosis-associated inflammation, peripheral nerve fibers, and assess their potential mechanism of interaction. We propose that an interaction between lesions and nerve fibers, mediated by inflammation, may be important in endometriosis-associated pain.
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Affiliation(s)
- Brett D McKinnon
- Department of Obstetrics and Gynaecology, Inselspital, Berne University Hospital, Effingerstrasse 102, Berne CH-3010, Switzerland; Department of Clinical Research, University of Berne, Murtenstrasse 35, Berne CH-3010, Switzerland.
| | - Dominic Bertschi
- Department of Obstetrics and Gynaecology, Inselspital, Berne University Hospital, Effingerstrasse 102, Berne CH-3010, Switzerland
| | - Nick A Bersinger
- Department of Obstetrics and Gynaecology, Inselspital, Berne University Hospital, Effingerstrasse 102, Berne CH-3010, Switzerland; Department of Clinical Research, University of Berne, Murtenstrasse 35, Berne CH-3010, Switzerland
| | - Michael D Mueller
- Department of Obstetrics and Gynaecology, Inselspital, Berne University Hospital, Effingerstrasse 102, Berne CH-3010, Switzerland; Department of Clinical Research, University of Berne, Murtenstrasse 35, Berne CH-3010, Switzerland
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Abstract
It is evident that chronic pain can modify the excitability of central nervous system which imposes a specific challenge for the management and for the development of new analgesics. The central manifestations can be difficult to quantify using standard clinical examination procedures, but quantitative sensory testing (QST) may help to quantify the degree and extend of the central reorganization and effect of pharmacological interventions. Furthermore, QST may help in optimizing the development programs for new drugs.Specific translational mechanistic QST tools have been developed to quantify different aspects of central sensitization in pain patients such as threshold ratios, provoked hyperalgesia/allodynia, temporal summation (wind-up like pain), after sensation, spatial summation, reflex receptive fields, descending pain modulation, offset analgesia, and referred pain areas. As most of the drug development programs in the area of pain management have not been very successful, the pharmaceutical industry has started to utilize the complementary knowledge obtained from QST profiling. Linking patients QST profile with drug efficacy profile may provide the fundamentals for developing individualized, targeted pain management programs in the future. Linking QST-assessed pain mechanisms with treatment outcome provides new valuable information in drug development and for optimizing the management regimes for chronic pain.
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Affiliation(s)
- Lars Arendt-Nielsen
- Center for Sensory-Motor Interaction (SMI), Department of Health Science and Technology, School of Medicine, Aalborg University, Fredrik Bajers Vej 7-D3, 9220, Aalborg, Denmark,
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30
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The interactions between cutaneous and deep pain. Scand J Pain 2014; 5:256-257. [DOI: 10.1016/j.sjpain.2014.08.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
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Brawn J, Morotti M, Zondervan KT, Becker CM, Vincent K. Central changes associated with chronic pelvic pain and endometriosis. Hum Reprod Update 2014; 20:737-47. [PMID: 24920437 DOI: 10.1093/humupd/dmu025] [Citation(s) in RCA: 161] [Impact Index Per Article: 16.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
Abstract
BACKGROUND Chronic pelvic pain (CPP) is a significant public health problem with 1 million affected women in the UK. Although many pathologies are associated with CPP, the pain experienced is often disproportionate to the extent of disease identified and frequently no pathology is found (chronic pelvic pain syndrome). The central nervous system (CNS) is central to the experience of pain and chronic pain conditions in general are associated with alterations in both the structure and function of the CNS. This review describes the available evidence for central changes in association with conditions presenting with CPP. METHODS A detailed literature search was performed to identify relevant papers, however, this is not a systematic review. RESULTS CPP is associated with central changes similar to those identified in other pain conditions. Specifically these include, alterations in the behavioural and central response to noxious stimulation, changes in brain structure (both increases and decreases in the volume of specific brain regions), altered activity of both the hypothalamic-pituitary-adrenal axis and the autonomic nervous system (ANS) and psychological distress. CONCLUSIONS The evidence reviewed in this paper demonstrates that CPP is associated with significant central changes when compared with healthy pain-free women. Moreover, the presence of these changes has the potential to both exacerbate symptoms and to predispose these women to the development of additional chronic conditions. These findings support the use of adjunctive medication targeting the CNS in these women.
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Affiliation(s)
- Jennifer Brawn
- Nuffield Department of Clinical Neurosciences, University of Oxford, Oxford, UK
| | - Matteo Morotti
- Nuffield Department of Obstetrics and Gynaecology, University of Oxford, Women's Centre, John Radcliffe Hospital, Oxford, UK Department of Obstetrics and Gynaecology, University of Genoa, Genoa 16100, Italy
| | - Krina T Zondervan
- Nuffield Department of Obstetrics and Gynaecology, University of Oxford, Women's Centre, John Radcliffe Hospital, Oxford, UK
| | - Christian M Becker
- Nuffield Department of Obstetrics and Gynaecology, University of Oxford, Women's Centre, John Radcliffe Hospital, Oxford, UK
| | - Katy Vincent
- Nuffield Department of Obstetrics and Gynaecology, University of Oxford, Women's Centre, John Radcliffe Hospital, Oxford, UK
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Activation of peripheral nerve fibers by electrical stimulation in the sole of the foot. BMC Neurosci 2013; 14:116. [PMID: 24103294 PMCID: PMC3851563 DOI: 10.1186/1471-2202-14-116] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/04/2013] [Accepted: 10/02/2013] [Indexed: 01/20/2023] Open
Abstract
Background Human nociceptive withdrawal reflexes (NWR) can be evoked by electrical stimulation applied to the sole of the foot. However, elicitation of NWRs is highly site dependent, and NWRs are especially difficult to elicit at the heel. The aim of the present study was to investigate potential peripheral mechanisms for any site dependent differences in reflex thresholds. Results The first part of the study investigated the neural innervation in different sites of the sole of the foot using two different staining techniques. 1) Staining for the Nav1.7 antigen (small nociceptive fibers) and 2) the Sihler whole nerve technique (myelinated part of the nerve). No differences in innervation densities were found across the sole of the foot using the two staining techniques: Nav1.7 immunochemistry (small nociceptive fibers (1-way ANOVA, NS)) and the Sihler’s method (myelinated nerve fibers (1-way ANOVA, NS)). However, the results indicate that there are no nociceptive intraepidermal nerve fibers (IENFs) innervating the heel. Secondly, mathematical modeling was used to investigate to what degree differences in skin thicknesses affect the activation thresholds of Aδ and Aβ fibers in the sole of the foot. The modeling comprised finite element analysis of the volume conduction combined with a passive model of the activation of branching cutaneous nerve fibers. The model included three different sites in the sole of the foot (forefoot, arch and heel) and three different electrode sizes (diameters: 9.1, 12.9, and 18.3 mm). For each of the 9 combinations of site and electrode size, a total of 3000 Aβ fibers and 300 Aδ fibers was modeled. The computer simulation of the effects of skin thicknesses and innervation densities on thresholds of modeled Aδ and Aβ fibers did not reveal differences in pain and perception thresholds across the foot sole as have been observed experimentally. Instead a lack of IENFs at the heel decreased the electrical activation thresholds compared to models including IENFs. Conclusions The nerve staining and modeling results do not explain differences in NWR thresholds across the sole of the foot which may suggest that central mechanisms contribute to variation in NWR excitability across the sole of the foot.
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Cornelissen L, Fabrizi L, Patten D, Worley A, Meek J, Boyd S, Slater R, Fitzgerald M. Postnatal temporal, spatial and modality tuning of nociceptive cutaneous flexion reflexes in human infants. PLoS One 2013; 8:e76470. [PMID: 24124564 PMCID: PMC3790695 DOI: 10.1371/journal.pone.0076470] [Citation(s) in RCA: 52] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/03/2013] [Accepted: 08/28/2013] [Indexed: 12/22/2022] Open
Abstract
Cutaneous flexion reflexes are amongst the first behavioural responses to develop and are essential for the protection and survival of the newborn organism. Despite this, there has been no detailed, quantitative study of their maturation in human neonates. Here we use surface electromyographic (EMG) recording of biceps femoris activity in preterm (<37 weeks gestation, GA) and term (≥ 37 weeks GA) human infants, less than 14 days old, in response to tactile, punctate and clinically required skin-breaking lance stimulation of the heel. We show that all infants display a robust and long duration flexion reflex (>4 seconds) to a single noxious skin lance which decreases significantly with gestational age. This reflex is not restricted to the stimulated limb: heel lance evokes equal ipsilateral and contralateral reflexes in preterm and term infants. We further show that infant flexion withdrawal reflexes are not always nociceptive specific: in 29% of preterm infants, tactile stimulation evokes EMG activity that is indistinguishable from noxious stimulation. In 40% of term infants, tactile responses are also present but significantly smaller than nociceptive reflexes. Infant flexion reflexes are also evoked by application of calibrated punctate von Frey hairs (vFh), 0.8-17.2 g, to the heel. Von Frey hair thresholds increase significantly with gestational age and the magnitude of vFh evoked reflexes are significantly greater in preterm than term infants. Furthermore flexion reflexes in both groups are sensitized by repeated vFh stimulation. Thus human infant flexion reflexes differ in temporal, modality and spatial characteristics from those in adults. Reflex magnitude and tactile sensitivity decreases and nociceptive specificity and spatial organisation increases with gestational age. Strong, relatively non-specific, reflex sensitivity in early life may be important for driving postnatal activity dependent maturation of targeted spinal cord sensory circuits.
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Affiliation(s)
- Laura Cornelissen
- Department of Neuroscience, Physiology & Pharmacology, University College London, London, United Kingdom
| | - Lorenzo Fabrizi
- Department of Neuroscience, Physiology & Pharmacology, University College London, London, United Kingdom
| | - Deborah Patten
- Department of Neuroscience, Physiology & Pharmacology, University College London, London, United Kingdom
| | - Alan Worley
- Department of Clinical Neurophysiology, Great Ormond Street Hospital for Children, London, United Kingdom
| | - Judith Meek
- Elizabeth Garrett Anderson Obstetric Wing, University College Hospital, London, United Kingdom
| | - Stewart Boyd
- Department of Clinical Neurophysiology, Great Ormond Street Hospital for Children, London, United Kingdom
| | - Rebeccah Slater
- Department of Neuroscience, Physiology & Pharmacology, University College London, London, United Kingdom
| | - Maria Fitzgerald
- Department of Neuroscience, Physiology & Pharmacology, University College London, London, United Kingdom
- * E-mail:
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Biurrun Manresa JA, Nguyen GP, Curatolo M, Moeslund TB, Andersen OK. Probabilistic model for individual assessment of central hyperexcitability using the nociceptive withdrawal reflex: a biomarker for chronic low back and neck pain. BMC Neurosci 2013; 14:110. [PMID: 24088299 PMCID: PMC3850924 DOI: 10.1186/1471-2202-14-110] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/15/2013] [Accepted: 10/01/2013] [Indexed: 11/25/2022] Open
Abstract
Background The nociceptive withdrawal reflex (NWR) has been proven to be a valuable tool in the objective assessment of central hyperexcitability in the nociceptive system at spinal level that is present in some chronic pain disorders, particularly chronic low back and neck pain. However, most of the studies on objective assessment of central hyperexcitability focus on population differences between patients and healthy individuals and do not provide tools for individual assessment. In this study, a prediction model was developed to objectively assess central hyperexcitability in individuals. The method is based on statistical properties of the EMG signals associated with the nociceptive withdrawal reflex. The model also supports individualized assessment of patients, including an estimation of the confidence of the predicted result. Results up to 80% classification rates were achieved when differentiating between healthy volunteers and chronic low back and neck pain patients. EMG signals recorded after stimulation of the anterolateral and heel regions and of the sole of the foot presented the best prediction rates. Conclusions A prediction model was proposed and successfully tested as a new approach for objective assessment of central hyperexcitability in the nociceptive system, based on statistical properties of EMG signals recorded after eliciting the NWR. Therefore, the present statistical prediction model constitutes a first step towards potential applications in clinical practice.
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Affiliation(s)
- José A Biurrun Manresa
- Center for Sensory-Motor Interaction, Department of Health Science and Technology, Aalborg University, Fredrik Bajers Vej 7, Aalborg, Øst 9220, Denmark.
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Reflex receptive fields are enlarged in patients with musculoskeletal low back and neck pain. Pain 2013; 154:1318-24. [DOI: 10.1016/j.pain.2013.04.013] [Citation(s) in RCA: 36] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/13/2012] [Revised: 03/12/2013] [Accepted: 04/03/2013] [Indexed: 11/18/2022]
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Biurrun Manresa JA, Finnerup NSB, Johannesen IL, Biering-Sørensen F, Jensen TS, Arendt-Nielsen L, Andersen OK. Central sensitization in spinal cord injured humans assessed by reflex receptive fields. Clin Neurophysiol 2013; 125:352-62. [PMID: 23886548 DOI: 10.1016/j.clinph.2013.06.186] [Citation(s) in RCA: 27] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/03/2013] [Revised: 05/31/2013] [Accepted: 06/30/2013] [Indexed: 12/30/2022]
Abstract
OBJECTIVE To investigate the effects of central sensitization, elicited by intramuscular injection of capsaicin, by comparing the reflex receptive fields (RRF) of spinally-intact volunteers and spinal cord injured volunteers that present presensitized spinal nociceptive mechanisms. METHODS Fifteen volunteers with complete spinal cord injury (SCI) and fourteen non-injured (NI) volunteers participated in the experiment. Repeated electrical stimulation was applied on eight sites on the foot sole to elicit the nociceptive withdrawal reflex (NWR). RRF were assessed before, 1min after and 60min after an intramuscular injection of capsaicin in the foot sole in order to induce central sensitization. RESULTS Both groups presented RRF expansion and lowered NWR thresholds immediately after capsaicin injection, reflected by the enlargement of RRF sensitivity areas and RRF probability areas. Moreover, the topography of the RRF sensitivity and probability areas were significantly different in SCI volunteers compared to NI volunteers in terms of size and shape. CONCLUSIONS SCI volunteers can develop central sensitization, despite adaptive/maladaptive changes in synaptic plasticity and lack of supraspinal control. SIGNIFICANCE Protective plastic mechanisms may still be functional in SCI volunteers.
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Affiliation(s)
| | | | | | - Fin Biering-Sørensen
- Clinic for Spinal Cord Injuries, The Neuroscience Centre, Rigshospitalet and Faculty of Health Sciences, University of Copenhagen, Denmark
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Kong JT, Johnson KA, Balise RR, Mackey S. Test-retest reliability of thermal temporal summation using an individualized protocol. THE JOURNAL OF PAIN 2013; 14:79-88. [PMID: 23273835 DOI: 10.1016/j.jpain.2012.10.010] [Citation(s) in RCA: 44] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/19/2012] [Revised: 09/28/2012] [Accepted: 10/08/2012] [Indexed: 02/04/2023]
Abstract
UNLABELLED Temporal summation (TS) refers to the increased perception of pain with repetitive noxious stimuli. It is a behavioral correlate of wind-up, the spinal facilitation of recurring C-fiber stimulation. In order to utilize TS in clinical pain research, it is important to characterize TS in a wide range of individuals and to establish its test-retest reliability. Building on a fixed-parameter protocol, we developed an individually adjusted protocol to broadly capture thermally generated TS. We then examined the test-retest reliability of TS within-day (intertrial intervals ranging from 2 to 30 minutes) and between-days (intersession interval of 7 days). We generated TS-like effects in 19 of the 21 participants. Strong correlations were observed across all trials over both days (intraclass correlation [ICC] [A, 10] = .97, 95% confidence level [CL] = .94-.99) and across the initial trials between days (ICC [A, 1] = .83, 95% CL = .58-.93). Repeated measures mixed-effects modeling demonstrated no significant within-day variation and only a small (5 out of 100 points) between-day variation. Finally, a Bland-Altman analysis suggested that TS is reliable across the range of observed scores. Without intervention, thermally-generated TS is generally stable within day and between days. PERSPECTIVE Our study introduces a new strategy to generate thermal TS in a high proportion of individuals. This study confirms the test-retest reliability of thermal TS, supporting its use as a consistent behavioral correlate of central nociceptive facilitation.
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Affiliation(s)
- Jiang-Ti Kong
- Department of Anesthesia, Division of Pain Medicine, Stanford Neuroscience and Pain Laboratory, Stanford University, Palo Alto, California 94304, USA
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Scaramozzino P, Neziri AY, Andersen OK, Arendt-Nielsen L, Curatolo M. Percentile normative values of parameters of electrical pain and reflex thresholds. Scand J Pain 2013; 4:120-124. [DOI: 10.1016/j.sjpain.2012.09.002] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2012] [Accepted: 09/01/2012] [Indexed: 11/16/2022]
Abstract
Aabstract
Background and purpose
Central hypersensitivity, defined as an increased excitability of the central nervous system, is considered as the main factor behind facilitation of central pain processes and is probably a very important factor in the induction and maintenance of chronic pain. Widespread hyposensitivity is less studied than hypersensitivity states, but recent work indicates that hypoesthesia may be present in chronic non-neuropathic pain conditions and could have negative prognostic value. Electrical pain and reflex thresholds are well established measures of central pain sensitivity in human pain research. One potential application of these assessments in clinical practice is the detection of central hyper- or hyposensitivity in individual patients. In order to identify these disturbances in the central pain processing of individual patients, knowledge of reference values is essential. We computed percentile normative values of nociceptive withdrawal reflex (NWR) and pain thresholds to different electrical stimulation paradigms. The aim was to provide reference values for the assessment of widespread central hyper- and hyposensitivity in individual patients.
Methods
300 pain-free subjects (150 males and 150 females, 18-80 years) were studied. Pain and reflex thresholds to single and repeated electrical stimulation (applied on the innervations area of the sural nerve), and the area of reflex receptive fields (RRF) were recorded. The RRF area was defined as the skin area of the sole of the foot from which a NWR could be evoked in the tibialis anterior muscle, expressed as proportion of the foot sole. For the threshold assessments, quantile regressions were performed to compute critical normative values for widespread central hypersensitivity (5th, 10th and 25th percentiles) and hyposensitivity (75th, 90th and 95th percentiles). For the RRF the opposite applied, computing normative values for widespread central hypersensitivity as 75th, 90th and 95th percentiles, and normative values for hyposensitivity as 5th, 10th and 25th percentiles. The following covariates were included in the regression analyses: gender, age, height, weight, body mass index, body side of testing, depression (Beck Depression Inventory), anxiety (State-Trait-Anxiety-Inventory), catastrophizing (Catastrophizing Scale of the Coping Strategies Questionnaire) and Short-Form 36.
Results
Age had a significant impact on the subjective pain threshold to single electrical stimuli. The reflex threshold to single electrical stimuli was lower on the dominant compared to the non-dominant side. Therefore, the percentiles for single stimulus pain threshold have been stratified by age and the percentiles for single stimulus reflex threshold by body side (dominant vs. non-dominant). Critical normative values of all tests were computed for widespread central hypersensitivity (5th, 10th and 25th percentiles) and hyposensitivity (75th, 90th and 95th percentiles). The values are provided in the table of the manuscript.
Conclusions and implications
The computed estimates of critical normative values for the electrical pain test can be used in clinical practice for the assessment of widespread central hypersensitivity and hyposensitivity in individual patients, and in future research on mechanism-based treatment of chronic pain.
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Affiliation(s)
- Pasquale Scaramozzino
- DeFiMS, SOAS , University of London , London , UK
- DEDI , University of Rome Tor Vergata , Rome , Italy
| | - Alban Y. Neziri
- University Department of Anesthesiology and Pain Therapy , University Hospital of Bern , 3010 Bern , Switzerland
| | - Ole K. Andersen
- Center for Sensory-Motor Interaction , Department of Health Science and Technology , Aalborg University , Aalborg , Denmark
| | - Lars Arendt-Nielsen
- Center for Sensory-Motor Interaction , Department of Health Science and Technology , Aalborg University , Aalborg , Denmark
| | - Michele Curatolo
- University Department of Anesthesiology and Pain Therapy , University Hospital of Bern , 3010 Bern , Switzerland
- Center for Sensory-Motor Interaction , Department of Health Science and Technology , Aalborg University , Aalborg , Denmark
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Ranking of parameters of pain hypersensitivity according to their discriminative ability in chronic low back pain. Pain 2012; 153:2083-2091. [DOI: 10.1016/j.pain.2012.06.025] [Citation(s) in RCA: 62] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/31/2011] [Revised: 06/13/2012] [Accepted: 06/25/2012] [Indexed: 11/19/2022]
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Courtney CA, O’Hearn MA, Hornby TG. Neuromuscular Function in Painful Knee Osteoarthritis. Curr Pain Headache Rep 2012; 16:518-24. [DOI: 10.1007/s11916-012-0299-2] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
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Napadow V, Edwards RR, Cahalan CM, Mensing G, Greenbaum S, Valovska A, Li A, Kim J, Maeda Y, Park K, Wasan AD. Evoked pain analgesia in chronic pelvic pain patients using respiratory-gated auricular vagal afferent nerve stimulation. PAIN MEDICINE 2012; 13:777-89. [PMID: 22568773 DOI: 10.1111/j.1526-4637.2012.01385.x] [Citation(s) in RCA: 124] [Impact Index Per Article: 10.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
OBJECTIVE Previous vagus nerve stimulation (VNS) studies have demonstrated antinociceptive effects, and recent noninvasive approaches, termed transcutaneous-vagus nerve stimulation (t-VNS), have utilized stimulation of the auricular branch of the vagus nerve in the ear. The dorsal medullary vagal system operates in tune with respiration, and we propose that supplying vagal afferent stimulation gated to the exhalation phase of respiration can optimize t-VNS. DESIGN Counterbalanced, crossover study. PATIENTS Patients with chronic pelvic pain (CPP) due to endometriosis in a specialty pain clinic. INTERVENTIONS/OUTCOMES: We evaluated evoked pain analgesia for respiratory-gated auricular vagal afferent nerve stimulation (RAVANS) compared with nonvagal auricular stimulation (NVAS). RAVANS and NVAS were evaluated in separate sessions spaced at least 1 week apart. Outcome measures included deep-tissue pain intensity, temporal summation of pain, and anxiety ratings, which were assessed at baseline, during active stimulation, immediately following stimulation, and 15 minutes after stimulus cessation. RESULTS RAVANS demonstrated a trend for reduced evoked pain intensity and temporal summation of mechanical pain, and significantly reduced anxiety in N = 15 CPP patients, compared with NVAS, with moderate to large effect sizes (η(2) > 0.2). CONCLUSION Chronic pain disorders such as CPP are in great need of effective, nonpharmacological options for treatment. RAVANS produced promising antinociceptive effects for quantitative sensory testing (QST) outcomes reflective of the noted hyperalgesia and central sensitization in this patient population. Future studies should evaluate longer-term application of RAVANS to examine its effects on both QST outcomes and clinical pain.
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Affiliation(s)
- Vitaly Napadow
- Martinos Center for Biomedical Imaging, Department of Radiology, Massachusetts General Hospital, Charlestown, MA, USA.
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Arendt-Nielsen L, Graven-Nielsen T. Translational musculoskeletal pain research. Best Pract Res Clin Rheumatol 2012; 25:209-26. [PMID: 22094197 DOI: 10.1016/j.berh.2010.01.013] [Citation(s) in RCA: 113] [Impact Index Per Article: 9.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/13/2010] [Indexed: 01/25/2023]
Abstract
Diagnosis and management of musculoskeletal pain is a major clinical challenge. Fundamental knowledge of nociception from deep somatic structures and related mechanisms of sensitisation have been characterised in animals but the translation into clinical sciences is still lacking. Development and refinement of mechanism-based quantitative sensory testing in healthy volunteers and pain patients have provided new opportunities to assess pain and hyperalgesic reactions. The current technologies can provide information about, for example, peripheral and central sensitisation, descending pain control, central integration and structure specific sensitisation. Such a mechanistic approach can be used for differentiated diagnosis and for target validating new and existing analgesics. Mechanistic pain assessment of new compounds under development provides opportunities for target validation in proof-of-concept studies, which generate information to be used for selecting the most optimal patients for later clinical trials. New safe and efficient compounds are highly needed in the area of musculoskeletal pain management.
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Affiliation(s)
- Lars Arendt-Nielsen
- Center for Sensory-Motor Interaction (SMI), Department of Health Sciences and Technology, Faculty of Medicine, Aalborg University, Fredrik Bajers Vej 7, Aalborg, Denmark.
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Neziri AY, Dickenmann M, Scaramozzino P, Andersen OK, Arendt-Nielsen L, Dickenson AH, Curatolo M. Effect of intravenous tropisetron on modulation of pain and central hypersensitivity in chronic low back pain patients. Pain 2011; 153:311-318. [PMID: 22100357 DOI: 10.1016/j.pain.2011.10.008] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/14/2011] [Revised: 10/04/2011] [Accepted: 10/05/2011] [Indexed: 10/15/2022]
Abstract
The activation of 5-hydroxytryptamine-3 (5-HT-3) receptors in spinal cord can enhance intrinsic spinal mechanisms of central hypersensitivity, possibly leading to exaggerated pain responses. Clinical studies suggest that 5-HT-3 receptor antagonists may have an analgesic effect. This randomized, double-blind, placebo-controlled crossover study tested the hypothesis that the 5-HT-3 receptor antagonist tropisetron attenuates pain and central hypersensitivity in patients with chronic low back pain. Thirty patients with chronic low back pain, 15 of whom were women (aged 53 ± 14 years) and 15 men (aged 48 ± 14 years), were studied. A single intravenous injection of 0.9% saline solution, tropisetron 2mg, and tropisetron 5mg was administrated in 3 different sessions, in a double-blind crossover manner. The main outcome was the visual analogue scale (VAS) score of spontaneous low back pain before, and 15, 30, 60, and 90 minutes after drug administration. Secondary outcomes were nociceptive withdrawal reflexes to single and repeated electrical stimulation, area of reflex receptive fields, pressure pain detection and tolerance thresholds, conditioned pain modulation, and area of clinical pain. The data were analyzed by analysis of variance and panel multiple regressions. All 3 treatments reduced VAS scores. However, there was no statistically significant difference between tropisetron and placebo in VAS scores. Compared to placebo, tropisetron produced a statistically significant increase in pain threshold after single electrical stimulation, but no difference in all other secondary outcomes was found. A single-dose intravenous administration of tropisetron in patients with chronic low back pain had no significant specific effect on intensity of pain and most parameters of central hypersensitivity.
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Affiliation(s)
- Alban Y Neziri
- University Department of Anaesthesiology and Pain Therapy, Bern University Hospital, Inselspital, Bern 3010, Switzerland Department of Financial and Management Studies, School of Oriental and African Studies, University of London, London, UK Department of Economics and Institutions, University of Rome Tor Vergata, Rome, Italy Center for Sensory-Motor Interaction, Department of Health Science and Technology, Aalborg University, Aalborg, Denmark Department of Pharmacology, University College London, London, UK
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Arendt-Nielsen L, Hoeck HC. Optimizing the early phase development of new analgesics by human pain biomarkers. Expert Rev Neurother 2011; 11:1631-1651. [DOI: 10.1586/ern.11.147] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/30/2023]
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The Puzzle of Pelvic Pain—A Rehabilitation Framework for Balancing Tissue Dysfunction and Central Sensitization, I. ACTA ACUST UNITED AC 2011. [DOI: 10.1097/jwh.0b013e31823b0750] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
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Nnoaham KE, Hummelshoj L, Webster P, d'Hooghe T, de Cicco Nardone F, de Cicco Nardone C, Jenkinson C, Kennedy SH, Zondervan KT. Impact of endometriosis on quality of life and work productivity: a multicenter study across ten countries. Fertil Steril 2011; 96:366-373.e8. [PMID: 21718982 PMCID: PMC3679489 DOI: 10.1016/j.fertnstert.2011.05.090] [Citation(s) in RCA: 867] [Impact Index Per Article: 66.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2011] [Revised: 05/06/2011] [Accepted: 05/25/2011] [Indexed: 12/24/2022]
Abstract
OBJECTIVE To assess the impact of endometriosis on health-related quality of life (HRQoL) and work productivity. DESIGN Multicenter cross-sectional study with prospective recruitment. SETTING Sixteen clinical centers in ten countries. PATIENT(S) A total of 1,418 premenopausal women, aged 18-45 years, without a previous surgical diagnosis of endometriosis, having laparoscopy to investigate symptoms or to be sterilized. INTERVENTION(S) None. MAIN OUTCOME MEASURE(S) Diagnostic delay, HRQoL, and work productivity. RESULT(S) There was a delay of 6.7 years, principally in primary care, between onset of symptoms and a surgical diagnosis of endometriosis, which was longer in centers where women received predominantly state-funded health care (8.3 vs. 5.5 years). Delay was positively associated with the number of pelvic symptoms (chronic pelvic pain, dysmenorrhoea, dyspareunia, and heavy periods) and a higher body mass index. Physical HRQoL was significantly reduced in affected women compared with those with similar symptoms and no endometriosis. Each affected woman lost on average 10.8 hours (SD 12.2) of work weekly, mainly owing to reduced effectiveness while working. Loss of work productivity translated into significant costs per woman/week, from US$4 in Nigeria to US$456 in Italy. CONCLUSION(S) Endometriosis impairs HRQoL and work productivity across countries and ethnicities, yet women continue to experience diagnostic delays in primary care. A higher index of suspicion is needed to expedite specialist assessment of symptomatic women. Future research should seek to clarify pain mechanisms in relation to endometriosis severity.
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