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Bedwell GJ, Chikezie PC, Siboza FT, Mqadi L, Rice ASC, Kamerman PR, Parker R, Madden VJ. A Systematic Review and Meta-analysis of Non-pharmacological Methods to Manipulate Experimentally Induced Secondary Hypersensitivity. THE JOURNAL OF PAIN 2023; 24:1759-1797. [PMID: 37356604 DOI: 10.1016/j.jpain.2023.06.013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/22/2022] [Revised: 06/13/2023] [Accepted: 06/18/2023] [Indexed: 06/27/2023]
Abstract
This systematic review and meta-analysis investigated the effects of non-pharmacological manipulations on experimentally induced secondary hypersensitivity in pain-free humans. We investigated the magnitude (change/difference in follow-up ratings from pre-manipulation ratings) of secondary hypersensitivity (primary outcome), and surface area of secondary hypersensitivity (secondary outcome), in 27 studies representing 847 participants. Risk of bias assessment concluded most studies (23 of 27) had an unclear or high risk of performance and detection bias. Further, 2 (of 27) studies had a high risk of measurement bias. Datasets were pooled by the method of manipulation and outcome. The magnitude of secondary hypersensitivity was decreased by diverting attention, anodal transcranial direct current stimulation, or emotional disclosure; increased by directing attention toward the induction site, nicotine deprivation, or negative suggestion; and unaffected by cathodal transcranial direct current stimulation or thermal change. Area of secondary hypersensitivity was decreased by anodal transcranial direct current stimulation, emotional disclosure, cognitive behavioral therapy, hyperbaric oxygen therapy, placebo analgesia, or spinal manipulation; increased by directing attention to the induction site, nicotine deprivation, or sleep disruption (in males only); and unaffected by cathodal transcranial direct current stimulation, thermal change, acupuncture, or electroacupuncture. Meta-analytical pooling was only appropriate for studies that used transcranial direct current stimulation or hyperbaric oxygen therapy, given the high clinical heterogeneity among the studies and unavailability of data. The evidence base for this question remains small. We discuss opportunities to improve methodological rigor including manipulation checks, structured blinding strategies, control conditions or time points, and public sharing of raw data. PERSPECTIVE: We described the effects of several non-pharmacological manipulations on experimentally induced secondary hypersensitivity in humans. By shedding light on the potential for non-pharmacological therapies to influence secondary hypersensitivity, it provides a foundation for the development and testing of targeted therapies for secondary hypersensitivity.
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Affiliation(s)
- Gillian J Bedwell
- Department of Health and Rehabilitation Sciences, University of Cape Town, Cape Town, South Africa; Department of Anaesthesia and Perioperative Medicine, University of Cape Town, Cape Town, South Africa
| | - Prince C Chikezie
- School of Physiology, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Felicia T Siboza
- School of Physiology, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Luyanduthando Mqadi
- Department of Anaesthesia and Perioperative Medicine, University of Cape Town, Cape Town, South Africa; HIV Mental Health Research Unit, Department of Psychiatry and Mental Health, University of Cape Town, Cape Town, South Africa
| | - Andrew S C Rice
- Pain Research Group, Department of Surgery and Cancer, Faculty of Medicine, Imperial College London, London, UK
| | - Peter R Kamerman
- School of Physiology, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Romy Parker
- Department of Anaesthesia and Perioperative Medicine, University of Cape Town, Cape Town, South Africa
| | - Victoria J Madden
- Department of Anaesthesia and Perioperative Medicine, University of Cape Town, Cape Town, South Africa; HIV Mental Health Research Unit, Department of Psychiatry and Mental Health, University of Cape Town, Cape Town, South Africa
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Madden VJ, Msolo N, Mqadi L, Lesosky M, Bedwell GJ, Hutchinson MR, Peter JG, Parker R, Schrepf A, Edwards RR, Joska JA. Study protocol: an observational study of distress, immune function and persistent pain in HIV. BMJ Open 2022; 12:e059723. [PMID: 36691234 PMCID: PMC9171212 DOI: 10.1136/bmjopen-2021-059723] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/15/2021] [Accepted: 04/28/2022] [Indexed: 01/27/2023] Open
Abstract
INTRODUCTION Many people with HIV report both distress and pain. The relationship between distress and pain is bidirectional, but the mechanisms by which distress exacerbates pain are unclear. The inflammatory response to challenge (inflammatory reactivity, IR) may be a partial mediator, given that neuroimmune interactions provide a substrate for IR to also influence neurological reactivity and, thus, pain-related neural signalling. This prospective, observational, case-control study will characterise the relationships between distress, IR, pain-related signalling as captured by induced secondary hyperalgesia (SH), and pain, in people with HIV who report persistent pain (PP) (cases) or no pain (controls). METHODS AND ANALYSIS One hundred people with suppressed HIV, reporting either PP or no pain, will be assessed two or four times over 6 months. The primary outcomes are distress (Hopkins 25-item symptom checklist), IR (multiplex assay after LPS challenge), and PP (Brief Pain Inventory), assessed at the baseline timepoint, although each will also be assessed at follow-up time points. Induced SH will be assessed in a subsample of 60 participants (baseline timepoint only). To test the hypothesis that IR partly mediates the relationship between distress and pain, mediation analysis will use the baseline data from the PP group to estimate direct and indirect contributions of distress and IR to pain. To test the hypothesis that IR is positively associated with SH, data from the subsample will be analysed with generalised mixed effects models to estimate the association between IR and group membership, with SH as the dependent variable. ETHICS AND DISSEMINATION Information obtained from this study will be published in peer-reviewed journals and presented at scientific meetings. The study has been approved by the Human Research Ethics Committee of the University of Cape Town (approval number: 764/2019) and the City of Cape Town (ref: 24699). TRIAL REGISTRATION NUMBER NCT04757987.
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Affiliation(s)
- Victoria J Madden
- Pain Research Team, Department of Anaesthesia and Perioperative Medicine, Neuroscience Institute, University of Cape Town, Cape Town, South Africa
- HIV Mental Health Research Unit, Department of Psychiatry and Mental Health, Neuroscience Institute, University of Cape Town, Cape Town, South Africa
| | - Ncumisa Msolo
- Pain Research Team, Department of Anaesthesia and Perioperative Medicine, Neuroscience Institute, University of Cape Town, Cape Town, South Africa
| | - Luyanduthando Mqadi
- Pain Research Team, Department of Anaesthesia and Perioperative Medicine, Neuroscience Institute, University of Cape Town, Cape Town, South Africa
- HIV Mental Health Research Unit, Department of Psychiatry and Mental Health, Neuroscience Institute, University of Cape Town, Cape Town, South Africa
| | - Maia Lesosky
- Division of Epidemiology & Biostatistics, School of Public Health and Family Medicine, University of Cape Town, Cape Town, South Africa
| | - Gillian J Bedwell
- Pain Research Team, Department of Anaesthesia and Perioperative Medicine, Neuroscience Institute, University of Cape Town, Cape Town, South Africa
| | - Mark R Hutchinson
- Adelaide Medical School, The University of Adelaide, Adelaide, South Australia, Australia
| | - Jonathan Grant Peter
- Division of Allergy and Clinical Immunology, Department of Medicine, Groote Schuur Hospital, University of Cape Town, Rondebosch, South Africa
- Allergy and Immunology Unit, University of Cape Town Lung Institute, University of Cape Town, Cape Town, South Africa
| | - Romy Parker
- Pain Research Team, Department of Anaesthesia and Perioperative Medicine, Neuroscience Institute, University of Cape Town, Cape Town, South Africa
| | - Andrew Schrepf
- Chronic Pain and Fatigue Research Center, Department of Anesthesiology, Michigan Medicine, University of Michigan, Ann Arbor, Michigan, USA
| | - Robert R Edwards
- Department of Anesthesiology, Perioperative, and Pain Medicine, Harvard Medical School, Boston, Massachusetts, USA
| | - John A Joska
- HIV Mental Health Research Unit, Department of Psychiatry and Mental Health, Neuroscience Institute, University of Cape Town, Cape Town, South Africa
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Modality-specific facilitation of noninjurious sharp mechanical pain by topical capsaicin. Pain 2021; 162:275-286. [PMID: 32701656 DOI: 10.1097/j.pain.0000000000002020] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
We had previously shown that a "blunt blade" stimulator can mimic the noninjurious strain phase of incisional pain, but not its sustained duration. Here, we tested whether acute sensitization of the skin with topical capsaicin can add the sustained phase to this noninvasive surrogate model of intraoperative pain. Altogether, 110 healthy volunteers (55 male and 55 female; 26 ± 5 years) participated in several experiments using the "blunt blade" (0.25 × 4 mm) on normal skin (n = 36) and on skin pretreated by a high-concentration capsaicin patch (8%, Qutenza; n = 36). These data were compared with an experimental incision (n = 40) using quantitative and qualitative pain ratings by numerical rating scale and SES Pain Perception Scale descriptors. Capsaicin sensitization increased blade-induced pain magnitude and duration significantly (both P < 0.05), but it failed to fully match the sustained duration of incisional pain. In normal skin, the SES pattern of pain qualities elicited by the blade matched incision in pain magnitude and pattern of pain descriptors. In capsaicin-treated skin, the blade acquired a significant facilitation only of the perceived heat pain component (P < 0.001), but not of mechanical pain components. Thus, capsaicin morphed the descriptor pattern of the blade to become more capsaicin-like, which is probably explained best by peripheral sensitization of the TRPV1 receptor. Quantitative sensory testing in capsaicin-sensitized skin revealed hyperalgesia to heat and pressure stimuli, and loss of cold and cold pain sensitivity. These findings support our hypothesis that the blade models the early tissue-strain-related mechanical pain phase of surgical incisions.
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Magerl W, Thalacker E, Vogel S, Schleip R, Klein T, Treede RD, Schilder A. Tenderness of the Skin after Chemical Stimulation of Underlying Temporal and Thoracolumbar Fasciae Reveals Somatosensory Crosstalk between Superficial and Deep Tissues. Life (Basel) 2021; 11:life11050370. [PMID: 33919303 PMCID: PMC8143345 DOI: 10.3390/life11050370] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2021] [Revised: 04/17/2021] [Accepted: 04/17/2021] [Indexed: 01/14/2023] Open
Abstract
Musculoskeletal pain is often associated with pain referred to adjacent areas or skin. So far, no study has analyzed the somatosensory changes of the skin after the stimulation of different underlying fasciae. The current study aimed to investigate heterotopic somatosensory crosstalk between deep tissue (muscle or fascia) and superficial tissue (skin) using two established models of deep tissue pain (namely focal high frequency electrical stimulation (HFS) (100 pulses of constant current electrical stimulation at 10× detection threshold) or the injection of hypertonic saline in stimulus locations as verified using ultrasound). In a methodological pilot experiment in the TLF, different injection volumes of hypertonic saline (50–800 µL) revealed that small injection volumes were most suitable, as they elicited sufficient pain but avoided the complication of the numbing pinprick sensitivity encountered after the injection of a very large volume (800 µL), particularly following muscle injections. The testing of fascia at different body sites revealed that 100 µL of hypertonic saline in the temporal fascia and TLF elicited significant pinprick hyperalgesia in the overlying skin (–26.2% and –23.5% adjusted threshold reduction, p < 0.001 and p < 0.05, respectively), but not the trapezius fascia or iliotibial band. Notably, both estimates of hyperalgesia were significantly correlated (r = 0.61, p < 0.005). Comprehensive somatosensory testing (DFNS standard) revealed that no test parameter was changed significantly following electrical HFS. The experiments demonstrated that fascia stimulation at a sufficient stimulus intensity elicited significant across-tissue facilitation to pinprick stimulation (referred hyperalgesia), a hallmark sign of nociceptive central sensitization.
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Affiliation(s)
- Walter Magerl
- Department of Neurophysiology, Mannheim Center for Translational Neuroscience (MCTN), Medical Faculty Mannheim, Heidelberg University, 68167 Mannheim, Germany; (W.M.); (E.T.); (S.V.); (T.K.); (R.-D.T.)
| | - Emanuela Thalacker
- Department of Neurophysiology, Mannheim Center for Translational Neuroscience (MCTN), Medical Faculty Mannheim, Heidelberg University, 68167 Mannheim, Germany; (W.M.); (E.T.); (S.V.); (T.K.); (R.-D.T.)
| | - Simon Vogel
- Department of Neurophysiology, Mannheim Center for Translational Neuroscience (MCTN), Medical Faculty Mannheim, Heidelberg University, 68167 Mannheim, Germany; (W.M.); (E.T.); (S.V.); (T.K.); (R.-D.T.)
| | - Robert Schleip
- Conservative and Rehabilitative Orthopedics, Department of Sport and Health Sciences, Health Sciences, Technical University of Munich, 80333 Munich, Germany;
- DIPLOMA Hochschule, 37242 Bad Sooden-Allendorf, Germany
| | - Thomas Klein
- Department of Neurophysiology, Mannheim Center for Translational Neuroscience (MCTN), Medical Faculty Mannheim, Heidelberg University, 68167 Mannheim, Germany; (W.M.); (E.T.); (S.V.); (T.K.); (R.-D.T.)
| | - Rolf-Detlef Treede
- Department of Neurophysiology, Mannheim Center for Translational Neuroscience (MCTN), Medical Faculty Mannheim, Heidelberg University, 68167 Mannheim, Germany; (W.M.); (E.T.); (S.V.); (T.K.); (R.-D.T.)
| | - Andreas Schilder
- Department of Neurophysiology, Mannheim Center for Translational Neuroscience (MCTN), Medical Faculty Mannheim, Heidelberg University, 68167 Mannheim, Germany; (W.M.); (E.T.); (S.V.); (T.K.); (R.-D.T.)
- Correspondence: ; Tel.: +49-621-383-71400; Fax: +49-621-383-71401
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Kinfe T, von Willebrand N, Stadlbauer A, Buchfelder M, Yearwood TL, Muhammad S, Chaudhry SR, Gravius S, Randau T, Winder K, Maihöfner C, Gravius N, Magerl W. Quantitative sensory phenotyping in chronic neuropathic pain patients treated with unilateral L4-dorsal root ganglion stimulation. J Transl Med 2020; 18:403. [PMID: 33087129 PMCID: PMC7579938 DOI: 10.1186/s12967-020-02566-8] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/12/2020] [Accepted: 10/12/2020] [Indexed: 11/22/2022] Open
Abstract
Background In a previous study, we reported that selective dorsal root ganglion stimulation (DRGSTIM) at DRG level L4 promoted a favorable outcome for complex regional pain syndrome (CRPS) patients along with DRGSTIM-related changes of inflammatory biomarkers in blood and saliva. The impact on somatosensation is largely unknown. Herein, we assessed the quantitative sensory profile to quantify L4-DRGSTIM effects in CRPS patients. Methods Twelve refractory CRPS patients (4 female; 8 male; mean age 69 ± 9 years) received standardized quantitative sensory testing (QST) protocol at baseline and after 3 months of unilateral L4-DRGSTIM assessing nociceptive and non-nociceptive thermal and mechanical sensitivity of the knee affected by CRPS and the contralateral non-painful knee area. Results At baseline, CRPS subjects showed significantly increased thresholds for warmth, tactile and vibration detection (WDT, MDT and VDT) and exaggerated pain summation (WUR). After 3 months of unilateral L4-DRGSTIM all pain parameters exhibited trends towards normalization of sensitivity accumulating to a significant overall normalization for pain sensitivity (effect size: 0.91, p < 0.01), while with the one exception of WDT all non-nociceptive QST parameters remained unchanged. Overall change of non-nociceptive detection was negligible (effect size: 0.25, p > 0.40). Notably, reduction of pain summation (WUR) correlated significantly with pain reduction after 3 months of L4-DRGSTIM. Conclusions Selective L4-DRGSTIM lowered ongoing pain in CRPS patients and evoked significant normalization in the pain domain of the somatosensory profile. Thermoreception and mechanoreception remained unchanged. However, larger randomized, sham-controlled trials are highly warranted to shed more light on effects and mechanisms of dorsal root ganglion stimulation on quantitative sensory characteristics. The study protocol was registered at the 15.11.2016 on German Register for Clinical Trials (DRKS ID 00011267). https://www.drks.de/drks_web/navigate.do?navigationId=trial.HTML&TRIAL_ID=DRKS00011267
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Affiliation(s)
- Thomas Kinfe
- Division of Functional Neurosurgery and Stereotaxy, Department of Neurosurgery, Friedrich-Alexander University (FAU) Erlangen-Nürnberg, Schwabachanlage 6, 91054, Erlangen, Germany.
| | - Nico von Willebrand
- Department of Neurosurgery, Rheinische Friedrich-Wilhelms University, Bonn, Germany
| | - Andreas Stadlbauer
- Department of Neurosurgery, Friedrich-Alexander University (FAU) Erlangen-Nürnberg, Erlangen, Germany
| | - Michael Buchfelder
- Department of Neurosurgery, Friedrich-Alexander University (FAU) Erlangen-Nürnberg, Erlangen, Germany
| | - Thomas L Yearwood
- Department of Pain Management, Guy's and St Thomas' Hospitals, London, UK
| | - Sajjad Muhammad
- Department of Neurosurgery, Heinrich-Heine University Düsseldorf, Düsseldorf, Germany
| | - Shafqat R Chaudhry
- Department of Basic Medical Sciences Shifa College of Pharmaceutical Sciences, Shifa Tameer-E-Millat University, Islamabad, Pakistan
| | - Sascha Gravius
- Department of Orthopedics and Trauma Surgery, University Hospital Mannheim, University Heidelberg, Heidelberg, Germany
| | - Thomas Randau
- Department of Orthopedics and Trauma Surgery, Rheinische Friedrich-Wilhelms University Bonn, Bonn, Germany
| | - Klemens Winder
- Department of Neurology, Friedrich-Alexander University (FAU) Erlangen-Nürnberg, Erlangen, Germany
| | | | - Nadine Gravius
- Department of Orthopedics and Trauma Surgery, University Hospital Mannheim, University Heidelberg, Heidelberg, Germany
| | - Walter Magerl
- Institute of Neurophysiology, Medical Faculty Mannheim, University Heidelberg, Heidelberg, Germany
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Vaughan S, McGlone F, Poole H, Moore DJ. A Quantitative Sensory Testing Approach to Pain in Autism Spectrum Disorders. J Autism Dev Disord 2020; 50:1607-1620. [PMID: 30771132 PMCID: PMC7211210 DOI: 10.1007/s10803-019-03918-0] [Citation(s) in RCA: 24] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/02/2023]
Abstract
Sensory abnormalities in autism has been noted clinically, with pain insensitivity as a specified diagnostic criterion. However, there is limited research using psychophysically robust techniques. Thirteen adults with ASD and 13 matched controls completed an established quantitative sensory testing (QST) battery, supplemented with measures of pain tolerance and central modulation. The ASD group showed higher thresholds for light touch detection and mechanical pain. Notably, the ASD group had a greater range of extreme scores (the number of z-scores outside of the 95% CI > 2), dynamic mechanical allodynia and paradoxical heat sensation; phenomena not typically seen in neurotypical individuals. These data support the need for research examining central mechanisms for pain in ASD and greater consideration of individual difference.
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Affiliation(s)
- Sarah Vaughan
- School of Natural Sciences and Psychology, Psychology Department, Liverpool John Moores University, Liverpool, L3 3AF, UK.,Faculty of Social Sciences, School of Psychology, Chester University, Chester, CH1 4BJ, UK
| | - Francis McGlone
- School of Natural Sciences and Psychology, Psychology Department, Liverpool John Moores University, Liverpool, L3 3AF, UK.,Institute of Psychology, Health and Society, University of Liverpool, Liverpool, L69 3GL, UK
| | - Helen Poole
- School of Natural Sciences and Psychology, Psychology Department, Liverpool John Moores University, Liverpool, L3 3AF, UK
| | - David J Moore
- School of Natural Sciences and Psychology, Psychology Department, Liverpool John Moores University, Liverpool, L3 3AF, UK. .,Department of Natural Sciences and Psychology, Liverpool John Moores University, Liverpool, L3 3AF, UK.
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Madden VJ, Bedwell GJ, Chikezie PC, Rice ASC, Kamerman PR. A systematic review of experimental methods to manipulate secondary hyperalgesia in humans: protocol. Syst Rev 2019; 8:208. [PMID: 31426841 PMCID: PMC6700765 DOI: 10.1186/s13643-019-1120-7] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/24/2019] [Accepted: 07/26/2019] [Indexed: 12/17/2022] Open
Abstract
BACKGROUND Neuropathic pain affects 7-10% of people, but responds poorly to pharmacotherapy, indicating a need for better treatments. Mechanistic research on neuropathic pain frequently uses human surrogate models of the secondary hyperalgesia that is a common feature of neuropathic pain. Experimentally induced secondary hyperalgesia has been manipulated with pharmacological and non-pharmacological methods to clarify the relative contributions of different mechanisms to secondary hyperalgesia. However, this literature has not been systematically synthesised. The aim of this systematic review is to identify, describe, and compare methods that have been used to manipulate experimentally induced secondary hyperalgesia in healthy humans. METHODS A systematic search strategy will be supplemented by reference list checks and direct contact with identified laboratories to maximise the identification of data reporting the experimental manipulation of experimentally induced secondary hyperalgesia in healthy humans. Duplicated screening, risk of bias assessment, and data extraction procedures will be used. Authors will be asked to provide data as necessary. Data will be pooled and meta-analyses conducted where possible, with subgrouping according to manipulation method. Manipulation methods will be ranked for potency and risk. DISCUSSION The results of this review will provide a useful reference for researchers interested in using experimental methods to manipulate secondary hyperalgesia in humans and will help to clarify the relative contributions of different mechanisms to secondary hyperalgesia. SYSTEMATIC REVIEW REGISTRATION This protocol will be registered on PROSPERO before the review begins. Review records will be updated on PROSPERO once the review is complete. This review is intended for publication in a peer-reviewed journal. Analyses and scripts will be made publicly available.
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Affiliation(s)
- Victoria J. Madden
- Pain Unit, Department of Anaesthesia and Perioperative Medicine, Neuroscience Institute, University of Cape Town, D23.30 Groote Schuur Hospital, Observatory, Cape Town, 7925 South Africa
- Department of Psychiatry and Mental Health, University of Cape Town, Cape Town, South Africa
| | - Gillian J. Bedwell
- Pain Unit, Department of Anaesthesia and Perioperative Medicine, Neuroscience Institute, University of Cape Town, D23.30 Groote Schuur Hospital, Observatory, Cape Town, 7925 South Africa
- Department of Health and Rehabilitation Sciences, University of Cape Town, Cape Town, South Africa
| | - Prince C. Chikezie
- School of Physiology, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Andrew S. C. Rice
- Pain Research Group, Department of Surgery and Cancer, Faculty of Medicine, Imperial College London, London, UK
| | - Peter R. Kamerman
- School of Physiology, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
- School of Pharmacy and Biomedical Sciences, Faculty of Health Sciences, Curtin University, Perth, Australia
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Pogatzki-Zahn EM, Segelcke D, Schug SA. Postoperative pain-from mechanisms to treatment. Pain Rep 2017; 2:e588. [PMID: 29392204 PMCID: PMC5770176 DOI: 10.1097/pr9.0000000000000588] [Citation(s) in RCA: 182] [Impact Index Per Article: 26.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/09/2016] [Revised: 02/04/2017] [Accepted: 02/06/2017] [Indexed: 12/12/2022] Open
Abstract
INTRODUCTION Pain management after surgery continues to be suboptimal; there are several reasons including lack of translation of results from basic science studies and scientific clinical evidence into clinical praxis. OBJECTIVES This review presents and discusses basic science findings and scientific evidence generated within the last 2 decades in the field of acute postoperative pain. METHODS In the first part of the review, we give an overview about studies that have investigated the pathophysiology of postoperative pain by using rodent models of incisional pain up to July 2016. The second focus of the review lies on treatment recommendations based on guidelines and clinical evidence, eg, by using the fourth edition of the "Acute Pain Management: Scientific Evidence" of the Australian and New Zealand College of Anaesthetists and Faculty of Pain Medicine. RESULTS Preclinical studies in rodent models characterized responses of primary afferent nociceptors and dorsal horn neurons as one neural basis for pain behavior including resting pain, hyperalgesia, movement-evoked pain or anxiety- and depression-like behaviors after surgery. Furthermore, the role of certain receptors, mediators, and neurotransmitters involved in peripheral and central sensitization after incision were identified; many of these are very specific, relate to some modalities only, and are unique for incisional pain. Future treatment should focus on these targets to develop therapeutic agents that are effective for the treatment of postoperative pain as well as have few side effects. Furthermore, basic science findings translate well into results from clinical studies. Scientific evidence is able to point towards useful (and less useful) elements of multimodal analgesia able to reduce opioid consumption, improve pain management, and enhance recovery. CONCLUSION Understanding basic mechanisms of postoperative pain to identify effective treatment strategies may improve patients' outcome after surgery.
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Affiliation(s)
- Esther M. Pogatzki-Zahn
- Department of Anaesthesiology, Intensive Care Medicine and Pain Therapy, University Hospital of Muenster, Muenster, Germany
| | - Daniel Segelcke
- Department of Anaesthesiology, Intensive Care Medicine and Pain Therapy, University Hospital of Muenster, Muenster, Germany
| | - Stephan A. Schug
- Pharmacology, Pharmacy and Anaesthesiology Unit, School of Medicine and Pharmacology, University of Western Australia, Perth, Western Australia, Australia
- Department of Anaesthesia and Pain Medicine, Royal Perth Hospital, Perth, Western Australia, Australia
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Xia W, Mørch CD, Andersen OK. Test-Retest Reliability of 10 Hz Conditioning Electrical Stimulation Inducing Long-Term Potentiation (LTP)-Like Pain Amplification in Humans. PLoS One 2016; 11:e0161117. [PMID: 27529175 PMCID: PMC4986952 DOI: 10.1371/journal.pone.0161117] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/19/2016] [Accepted: 07/29/2016] [Indexed: 11/19/2022] Open
Abstract
Background 10 Hz conditioning electrical stimulation (CES) has been shown to induce long-term potentiation (LTP)-like pain amplification similar to traditional 100 Hz CES in healthy humans. The aim of this study was to assess the test-retest reliability and to estimate sample sizes required for future crossover and parallel study designs. Methods The 10 Hz paradigm (500 rectangular pulses lasting 50 s) was repeated on two separate days with one week interval in twenty volunteers. Perceptual intensities to single electrical stimulation (SES) at the conditioned skin site and to mechanical stimuli (pinprick and light stroking) in immediate vicinity to the conditioned skin site were recorded. Superficial blood flow (SBF) was assessed as indicator of neurogenic inflammation. All outcome measures were assessed with 10 min interval three times before and six times after the CES. The coefficient of variation and intra-class correlation coefficient were calculated within session and between sessions. Sample sizes were estimated for future crossover (Ncr) and parallel (Np) drug testing studies expected to detect a 30% decrease for the individual outcome measure following 10 Hz CES. Results Perceptual intensity ratings to light stroking (Ncr = 2, Np = 33) and pinprick stimulation (491 mN) (Ncr = 6, Np = 54) increased after CES and showed better reliability in crossover than parallel design. The SBF increased after CES, and then declined until reaching a plateau 20 minutes postCES. SBF showed acceptable reliability both in crossover and parallel designs (Ncr = 3, Np = 13). Pain ratings to SES were reliable, but with large estimated sample sizes (Ncr = 634, Np = 11310) due to the minor pain amplification. Conclusions The reliability of 10 Hz CES was acceptable in inducing LTP-like effects in the assessments of superficial blood flow, heterotopic mechanical hyperalgesia, and dysesthesia in terms of sample sizes for future crossover study designs.
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Affiliation(s)
- Weiwei Xia
- Center for Neuroplasticity and Pain (CNAP), SMI ®, Department of Health Science and Technology, Aalborg University, Aalborg, Denmark
- China-Japan Union Hospital, Jilin University, Changchun, Jilin Province, China
- * E-mail:
| | - Carsten Dahl Mørch
- Center for Neuroplasticity and Pain (CNAP), SMI ®, Department of Health Science and Technology, Aalborg University, Aalborg, Denmark
| | - Ole Kæseler Andersen
- Center for Neuroplasticity and Pain (CNAP), SMI ®, Department of Health Science and Technology, Aalborg University, Aalborg, Denmark
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An improved model of heat-induced hyperalgesia--repetitive phasic heat pain causing primary hyperalgesia to heat and secondary hyperalgesia to pinprick and light touch. PLoS One 2014; 9:e99507. [PMID: 24911787 PMCID: PMC4050052 DOI: 10.1371/journal.pone.0099507] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/14/2014] [Accepted: 05/02/2014] [Indexed: 01/31/2023] Open
Abstract
This study tested a modified experimental model of heat-induced hyperalgesia, which improves the efficacy to induce primary and secondary hyperalgesia and the efficacy-to-safety ratio reducing the risk of tissue damage seen in other heat pain models. Quantitative sensory testing was done in eighteen healthy volunteers before and after repetitive heat pain stimuli (60 stimuli of 48°C for 6 s) to assess the impact of repetitive heat on somatosensory function in conditioned skin (primary hyperalgesia area) and in adjacent skin (secondary hyperalgesia area) as compared to an unconditioned mirror image control site. Additionally, areas of flare and secondary hyperalgesia were mapped, and time course of hyperalgesia determined. After repetitive heat pain conditioning we found significant primary hyperalgesia to heat, and primary and secondary hyperalgesia to pinprick and to light touch (dynamic mechanical allodynia). Acetaminophen (800 mg) reduced pain to heat or pinpricks only marginally by 11% and 8%, respectively (n.s.), and had no effect on heat hyperalgesia. In contrast, the areas of flare (−31%) and in particular of secondary hyperalgesia (−59%) as well as the magnitude of hyperalgesia (−59%) were significantly reduced (all p<0.001). Thus, repetitive heat pain induces significant peripheral sensitization (primary hyperalgesia to heat) and central sensitization (punctate hyperalgesia and dynamic mechanical allodynia). These findings are relevant to further studies using this model of experimental heat pain as it combines pronounced peripheral and central sensitization, which makes a convenient model for combined pharmacological testing of analgesia and anti-hyperalgesia mechanisms related to thermal and mechanical input.
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Puta C, Schulz B, Schoeler S, Magerl W, Gabriel B, Gabriel HHW, Miltner WHR, Weiss T. Enhanced sensitivity to punctate painful stimuli in female patients with chronic low back pain. BMC Neurol 2012; 12:98. [PMID: 22998460 PMCID: PMC3488472 DOI: 10.1186/1471-2377-12-98] [Citation(s) in RCA: 37] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/22/2012] [Accepted: 09/19/2012] [Indexed: 01/31/2023] Open
Abstract
Background Chronic low back pain (CLBP) has been shown to be associated with various pathophysiological changes at several level of the sensorimotor system, pointing to a general hypersensitivity in CLBP patients. The aim of the present study was to investigate signs of generalized mechanical pain hypersensitivity in CLBP patients on the hand and on the painful site of the back. Methods Pinprick stimulation according to a validated standardized quantitative sensory testing protocol was used in 14 female CLBP patients and 14 healthy controls (HC) matched for sex and age. Stimulus response functions to pinprick stimulation on the skin were examined at the affected back and reference sites (hand palmar and hand dorsum). Data from CLBP patients were compared with HC and with reference data from the German Research Network on Neuropathic Pain. Results We found significant differences in the stimulus response functions between CLBP patients and HC. Pain ratings to the pinpricks were increased for low and moderate pinprick stimuli in CLBP patients. Importantly, this kind of specific pinprick hyperalgesia was found not only for the affected body site (back), but also for the remote reference sites (hand dorsum and hand palmar). Conclusions We interpret our results as pointing to changes in the nociceptive processing in CLBP at higher levels of the neuraxis, possibly thalamus and/or attentional control, rather than changes of spinal processing. Alternatively, there might be a higher vulnerability to noxious stimulation in CLBP patients.
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Affiliation(s)
- Christian Puta
- Department of Sports Medicine and Health Promotion, Friedrich Schiller University, Wöllnitzer Strasse 42, Jena D-07749, Germany.
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Pfau DB, Klein T, Putzer D, Pogatzki-Zahn EM, Treede RD, Magerl W. Analysis of hyperalgesia time courses in humans after painful electrical high-frequency stimulation identifies a possible transition from early to late LTP-like pain plasticity. Pain 2011; 152:1532-1539. [PMID: 21440369 DOI: 10.1016/j.pain.2011.02.037] [Citation(s) in RCA: 72] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/07/2010] [Revised: 02/08/2011] [Accepted: 02/16/2011] [Indexed: 11/30/2022]
Abstract
Electrical high-frequency stimulation (HFS) of skin afferents elicits long-term potentiation (LTP)-like hyperalgesia in humans. Time courses were evaluated in the facilitating (homotopic) or facilitated (heterotopic) pathways to delineate the relative contributions of early or late LTP-like pain plasticity. HFS in healthy subjects (n=55) elicited highly significant pain increases to electrical stimuli via the conditioning electrode (to 145% of control, homotopic pain LTP) and to pinprick stimuli in adjacent skin (to 190% of control, secondary hyperalgesia). Individual time courses in subjects expressing a sufficient magnitude of hyperalgesia (>20% pain increase, n=28) revealed similar half-lives of homotopic pain LTP and secondary hyperalgesia of 6.9 h and 4.9 h (log(10) mean 0.839±0.395 and 0.687±0.306) and times to full recovery of 48 h and 24 h (log(10) mean 1.679±0.790 and 1.373±0.611). Time course and peak magnitudes were not correlated between (r=-0.19to+0.21, NS), nor within both readout (r=0.29 and 0.31, NS). In most subjects, time courses were consistent with early LTP1. Notably, in some subjects (10 of 28), estimated times to full recovery were much longer (>10 days), possibly indicating development of late LTP2-like pain plasticity. Dynamic mechanical allodynia (only present in 16 of 55 subjects) lasted for a shorter time than secondary hyperalgesia. Three different readouts of nociceptive central sensitization suggest that brief intense nociceptive input elicits early LTP1 of pain sensation (based on posttranslational modifications), but susceptible subjects may already develop longer-lasting late LTP2 (based on transcriptional modifications). These findings support the hypothesis that LTP may contribute to the development of persistent pain disorders.
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Affiliation(s)
- Doreen B Pfau
- Department of Neurophysiology, Center of Biomedicine and Medical Technology Mannheim (CBTM), Medical Faculty Mannheim, Ruprecht-Karls-University Heidelberg, Ludolf Krehl-Str. 13-17, 68167 Mannheim, Germany Department of Anaesthesiology and Intensive Care Medicine, University Hospital of Muenster, Albert-Schweitzer-Str. 33, 48129 Muenster, Germany
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