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Shaballout N, Aloumar A, Manuel J, May M, Beissner F. Lateralization and Bodily Patterns of Segmental Signs and Spontaneous Pain in Acute Visceral Disease: Observational Study. J Med Internet Res 2021; 23:e27247. [PMID: 34448718 PMCID: PMC8459716 DOI: 10.2196/27247] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/19/2021] [Revised: 05/02/2021] [Accepted: 06/14/2021] [Indexed: 01/23/2023] Open
Abstract
Background The differential diagnosis of acute visceral diseases is a challenging clinical problem. Older literature suggests that patients with acute visceral problems show segmental signs such as hyperalgesia, skin resistance, or muscular defense as manifestations of referred visceral pain in somatic or visceral tissues with overlapping segmental innervation. According to these sources, the lateralization and segmental distribution of such signs may be used for differential diagnosis. Segmental signs and symptoms may be accompanied by spontaneous (visceral) pain, which, however, shows a nonsegmental distribution. Objective This study aimed to investigate the lateralization (ie, localization on one side of the body, in preference to the other) and segmental distribution (ie, surface ratio of the affected segments) of spontaneous pain and (referred) segmental signs in acute visceral diseases using digital pain drawing technology. Methods We recruited 208 emergency room patients that were presenting for acute medical problems considered by triage as related to internal organ disease. All patients underwent a structured 10-minute bodily examination to test for various segmental signs and spontaneous visceral pain. They were further asked their segmental symptoms such as nausea, meteorism, and urinary retention. We collected spontaneous pain and segmental signs as digital drawings and segmental symptoms as binary values on a tablet PC. After the final diagnosis, patients were divided into groups according to the organ affected. Using statistical image analysis, we calculated mean distributions of pain and segmental signs for the heart, lungs, stomach, liver/gallbladder, and kidneys/ureters, analyzing the segmental distribution of these signs and the lateralization. Results Of the 208 recruited patients, 110 (52.9%) were later diagnosed with a single-organ problem. These recruited patients had a mean age of 57.3 (SD 17.2) years, and 40.9% (85/208) were female. Of these 110 patients, 85 (77.3%) reported spontaneous visceral pain. Of the 110, 81 (73.6%) had at least 1 segmental sign, and the most frequent signs were hyperalgesia (46/81, 57%), and muscle resistance (39/81, 48%). While pain was distributed along the body midline, segmental signs for the heart, stomach, and liver/gallbladder appeared mostly ipsilateral to the affected organ. An unexpectedly high number of patients (37/110, 33.6%) further showed ipsilateral mydriasis. Conclusions This study underlines the usefulness of including digitally recorded segmental signs in bodily examinations of patients with acute medical problems.
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Affiliation(s)
- Nour Shaballout
- Somatosensory and Autonomic Therapy Research, Institute for Neuroradiology, Hannover Medical School, Hannover, Germany
| | - Anas Aloumar
- Somatosensory and Autonomic Therapy Research, Institute for Neuroradiology, Hannover Medical School, Hannover, Germany.,Department of Internal Medicine, Klinikum Region Hannover, Großburgwedel, Hannover, Germany
| | - Jorge Manuel
- Somatosensory and Autonomic Therapy Research, Institute for Neuroradiology, Hannover Medical School, Hannover, Germany.,Institute of Aerospace Medicine, German Aerospace Centre, Cologne, Germany
| | - Marcus May
- Somatosensory and Autonomic Therapy Research, Institute for Neuroradiology, Hannover Medical School, Hannover, Germany
| | - Florian Beissner
- Somatosensory and Autonomic Therapy Research, Institute for Neuroradiology, Hannover Medical School, Hannover, Germany.,Insula Institute for Integrative Therapy Research, Hannover, Germany
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Postuma R, Vajcner G, Postuma RB, Keijzer R. Bedside pressure-pain threshold algometry to measure abdominal tenderness in childhood appendicitis: A retrospective cohort study. INTERNATIONAL JOURNAL OF SURGERY OPEN 2021. [DOI: 10.1016/j.ijso.2021.100338] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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3
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A splenic cyst causing a viscerosomatic reflex in the thoracic spine. A case report. INT J OSTEOPATH MED 2021. [DOI: 10.1016/j.ijosm.2020.10.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
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4
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Switters JM, Podar S, Perraton L, Machotka Z. Is visceral manipulation beneficial for patients with low back pain? A systematic review of the literature. INT J OSTEOPATH MED 2019. [DOI: 10.1016/j.ijosm.2019.09.002] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
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5
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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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6
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Hambrecht-Wiedbusch VS, Gabel M, Liu LJ, Imperial JP, Colmenero AV, Vanini G. Preemptive Caffeine Administration Blocks the Increase in Postoperative Pain Caused by Previous Sleep Loss in the Rat: A Potential Role for Preoptic Adenosine A2A Receptors in Sleep-Pain Interactions. Sleep 2018; 40:4037126. [PMID: 28934532 DOI: 10.1093/sleep/zsx116] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022] Open
Abstract
Sleep and pain are reciprocally related, but the precise mechanisms underlying this relationship are poorly understood. This study used a rat model of surgical pain to examine the effect of previous sleep loss on postoperative pain and tested the hypothesis that preoptic adenosinergic mechanisms regulate sleep-pain interactions. Relative to ad libitum sleep, 6 hours of total sleep deprivation prior to a surgical incision significantly enhanced postoperative mechanical hypersensitivity in the affected paw and prolonged the time to recovery from surgery. There were no sex-specific differences in these measures. There were also no changes in adrenocorticotropic hormone and corticosterone levels after sleep deprivation, suggesting that this effect was not mediated by the stress associated with the sleep perturbation. Systemic administration of the nonselective adenosine receptor antagonist caffeine at the onset of sleep deprivation prevented the sleep deprivation-induced increase in postoperative hypersensitivity. Microinjection of the adenosine A2A receptor antagonist ZM 241385 into the median preoptic nucleus (MnPO) blocked the increase in surgical pain levels and duration caused by prior sleep deprivation and eliminated the thermal hyperalgesia induced by sleep deprivation in a group of nonoperated (i.e., without surgical incision) rats. These data show that even a brief sleep disturbance prior to surgery worsens postoperative pain and are consistent with our hypothesis that adenosine A2A receptors in the MnPO contribute to regulate these sleep-pain interactions.
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Affiliation(s)
| | - Maya Gabel
- Department of Anesthesiology, University of Michigan, Ann Arbor, MI
| | - Linda J Liu
- Department of Anesthesiology, University of Michigan, Ann Arbor, MI
| | - John P Imperial
- Department of Anesthesiology, University of Michigan, Ann Arbor, MI
| | | | - Giancarlo Vanini
- Department of Anesthesiology, University of Michigan, Ann Arbor, MI
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van Rijckevorsel DC, Boelens OB, Roumen RM, Wilder-Smith OH, van Goor H. Treatment response and central pain processing in Anterior Cutaneous Nerve Entrapment Syndrome: An explorative study. Scand J Pain 2017; 14:53-59. [PMID: 28850430 DOI: 10.1016/j.sjpain.2016.09.014] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/07/2016] [Revised: 08/21/2016] [Accepted: 09/30/2016] [Indexed: 12/28/2022]
Abstract
BACKGROUND 10-30% of chronic abdominal pain originates in the abdominal wall. A common cause for chronic abdominal wall pain is the Anterior Cutaneous Nerve Entrapment Syndrome (ACNES), in which an intercostal nerve branch is entrapped in the abdominal rectus sheath. Treatment consists of local anaesthetics and neurectomy, and is ineffective in 25% of cases for yet unknown reasons. In some conditions, chronic pain is the result of altered pain processing. This so-called sensitization can manifest as segmental or even generalized hyperalgesia, and is generally difficult to treat. OBJECTIVE The aim of this study was to assess pain processing in ACNES patients responsive and refractory to treatment by using Quantitative Sensory Testing, in order to explore whether signs of altered central pain processing are present in ACNES and are a possible explanation for poor treatment outcomes. METHODS 50 patients treated for ACNES with locally orientated treatment were included. They were allocated to a responsive or refractory group based on their response to treatment. Patients showing an improvement of the Visual Analogue Scale (VAS) pain score combined with a current absolute VAS of <40mm were scored as responsive. Sensation and pain thresholds to pressure and electric skin stimulation were determined in the paravertebral bilateral ACNES dermatomes and at four control areas on the non-dominant side of the body, i.e. the musculus trapezius pars medialis, musculus rectus femoris, musculus abductor hallucis and the thenar. The ACNES dermatomes were chosen to signal segmental hyperalgesia and the sum of the control areas together as a reflection of generalized hyperalgesia. Lower thresholds were interpreted as signs of sensitized pain processing. To test for alterations in endogenous pain inhibition, a conditioned pain modulation (CPM) response to a cold pressor task was determined. Also, patients filled in three pain-related questionnaires, to evaluate possible influence of psychological characteristics on the experienced pain. RESULTS Patients refractory to treatment showed significantly lower pressure pain thresholds in the ACNES dermatomes and for the sum of as well as in two individual control areas. No differences were found between groups for electric thresholds or CPM response. Duration of complaints before diagnosis and treatment was significantly longer in the refractory compared to the responsive group, and refractory patients scored higher on the pain-related psychological surveys. CONCLUSION AND IMPLICATIONS In this hypothesis-generating exploratory study, ACNES patients refractory to treatment showed more signs of sensitized segmental and central pain processing. A longer duration of complaints before diagnosis and treatment may be related to these alterations in pain processing, and both findings could be associated with less effective locally orientated treatment. In order to validate these hypotheses further research is needed. REGISTRATION NUMBER NCT01920880 (Clinical Trials Register; http://www.clinicaltrials.gov).
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Affiliation(s)
- Dagmar C van Rijckevorsel
- Pain and Nociception Neuroscience Research Group, Department of Surgery, Radboud university medical center, Nijmegen, The Netherlands
| | - Oliver B Boelens
- Pain and Nociception Neuroscience Research Group, Department of Surgery, Maasziekenhuis Pantein, Boxmeer, Boxmeer, The Netherlands
| | - Rudi M Roumen
- Pain and Nociception Neuroscience Research Group, SolviMáx, Center of Excellence for Abdominal Wall and Groin Pain, Department of Surgery, Máxima Medical Centre, Veldhoven, The Netherlands
| | - Oliver H Wilder-Smith
- Pain and Nociception Neuroscience Research Group, Department of Anesthesiology, Pain and Palliative Medicine, Radboud university medical center, Nijmegen, The Netherlands.,Pain and Nociception Neuroscience Research Group, Centre for Sensory-Motor Interaction, Aalborg University, Aalborg, Denmark
| | - Harry van Goor
- Pain and Nociception Neuroscience Research Group, Department of Surgery, Radboud university medical center, Nijmegen, The Netherlands
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Beyaz SG, Özocak H, Ergönenç T, Palabıyık O, Tuna AT, Kaya B, Erkorkmaz Ü, Akdemir N. Chronic postsurgical pain and neuropathic symptoms after abdominal hysterectomy: A silent epidemic. Medicine (Baltimore) 2016; 95:e4484. [PMID: 27537570 PMCID: PMC5370797 DOI: 10.1097/md.0000000000004484] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/06/2016] [Revised: 07/11/2016] [Accepted: 07/11/2016] [Indexed: 11/25/2022] Open
Abstract
Chronic postsurgical pain (CPSP) is an important clinic problem. It is assessed that prevalence of chronic pain extends to 30% but it is contended that there are various risk factors. We aimed to evaluate the prevalence of chronic pain after hysterectomy, risk factors of chronicity, neuropathic features of pain, and sensorial alterations at surgery area.Between years 2012 and 2015, 16 to 65 ages old patients that electively undergone total abdominal hysterectomy bilateral salpingo-oophorectomy and passed minimum 3 months after surgery were included to study. Visual analog scale (VAS) and Douleur Neuropathique 4-questionnaire (DN-4) surveys were used to evaluate pain symptoms, algometry device was used for evaluating abdominal pressure threshold and Von Frey Filament was used for sensorial alterations.Ninety-three of 165 eligible patients were included to study. As the groups were compared by demographic data, no difference was obtained (P > 0.05). There was no difference between groups regarding patient and surgery attributes (P > 0.05). Most frequently performed incision type was Pfannenstiel. Neuropathic symptoms were observed in 90 patients (96.8%). Sensorial alterations as hypoesthesia and hyperesthesia were detected around abdominal scar in 18 patients (19.4%) with pinprick test.Neuropathic symptoms should not be ignored in studies evaluating CPSP and a standard methodology should be designed for studies in this topic.
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Affiliation(s)
| | - Hande Özocak
- Department of Anesthesiology, Sakarya University Training Research Hospital
| | - Tolga Ergönenç
- Department of Anesthesiology, Sakarya University Training Research Hospital
| | - Onur Palabıyık
- Department of Anesthesiology, Sakarya University Training Research Hospital
| | - Ayça Taş Tuna
- Department of Anesthesiology and Pain Medicine, Sakarya University Faculty of Medicine
| | - Burak Kaya
- Department of Anesthesiology and Pain Medicine, Sakarya University Faculty of Medicine
| | - Ünal Erkorkmaz
- Department of Biostatistics, Sakarya University Faculty of Medicine
| | - Nermin Akdemir
- Department of Obstetrics and Gynecology, Sakarya University Faculty of Medicine, Sakarya, Republic of Turkey
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9
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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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10
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Werner M, Kongsgaard U. I. Defining persistent post-surgical pain: is an update required? Br J Anaesth 2014; 113:1-4. [DOI: 10.1093/bja/aeu012] [Citation(s) in RCA: 206] [Impact Index Per Article: 20.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022] Open
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11
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Pedersen KV, Drewes AM, Graumann O, Osther SS, Olesen AE, Arendt-Nielsen L, Sloth Osther PJ. Somatosensory and trophic findings in the referred pain area in patients with kidney stone disease. Scand J Pain 2013; 4:165-170. [DOI: 10.1016/j.sjpain.2013.03.001] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/15/2013] [Accepted: 03/26/2013] [Indexed: 12/26/2022]
Abstract
Abstract
Background and purpose
Visceral and somatic afferents activate the same neuronal structures in the central nervous system. Assessing somatosensory function and trophic changes in the referred pain area may therefore indirectly increase information on mechanisms involved in painful visceral diseases. The aim of this study was to evaluate the sensory and trophic changes in the flank corresponding to the referred pain area in patients with kidney stone disease.
Methods
A total of 24 patients with unilateral pain-causing kidney stone disease were studied before and after endoscopic percutaneous kidney stone surgery. Trophic changes and sensitivity on the affected and on the contra-lateral side in the pain free period were investigated. For this purpose we used standardized experimental sensory testing including pressure stimulation and electrical (single and repeated) skin stimulation. Five repeated stimuli were used to investigate temporal summation (increased responses to repeated stimuli). To investigate trophic changes ultrasound as well as CT-scan was used, since the latter is considered more precise for exact tissue layer measurements.
Results
The pain tolerance thresholds to pressure and pain thresholds to electrical stimulation were not significantly different on the two sides (all P>0.1). After surgery no significant alterations in sensitivity were detected, but there was a tendency to higher pain thresholds to electrical stimuli on the affected side (single stimuli P=0.06; repeated stimuli P=0.09). No trophic changes were observed (all P>0.3), and there were no relations between the pain thresholds or trophic findings and the number of colics (all P >0.08).
Conclusion
In patients with unilateral pain-causing kidney stone disease the pain to experimental pressure and electrical stimuli were comparable on the affected and contra-lateral side. For the first time a CT-scan was used to evaluate tissue thickness in the referred pain area. No trophic changes were seen in the muscle or subcutaneous tissue at the affected side, and there were no correlations between the pain thresholds or trophic findings and the patients history of number of colics. After the operation no significant alterations in sensitivity were detected.
Implications
This study could not confirm previous studies showing referred hyperalgesia in the skin and trophic changes in the referred pain area to painful visceral disease. Differences in the pain intensity/duration between different diseases and hence the corresponding central neuronal changes may explain the negative findings in the present study.
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Affiliation(s)
- Katja Venborg Pedersen
- Urological Research Centre, Department of Urology, Hospital Littlebelt , University of Southern Denmark , Dronningensgade 97, 7000 Frederica , Denmark
| | - Asbjørn Mohr Drewes
- Mech-Sense, Department of Gastroenterology and Hepatology , Aalborg University Hospital , Mølleparkvej 4, 4. sal, 9000 Aalborg , Denmark
- Center for Sensory-Motor Interactions (SMI), Department of Health Science and Technology , Aalborg University , Fredrik Bajers Vej 7-D3, 9220 Aalborg , Denmark
| | - Ole Graumann
- Urological Research Centre, Department of Urology, Hospital Littlebelt , University of Southern Denmark , Dronningensgade 97, 7000 Frederica , Denmark
| | - Susanne Sloth Osther
- Urological Research Centre, Department of Urology, Hospital Littlebelt , University of Southern Denmark , Dronningensgade 97, 7000 Frederica , Denmark
| | - Anne Estrup Olesen
- Mech-Sense, Department of Gastroenterology and Hepatology , Aalborg University Hospital , Mølleparkvej 4, 4. sal, 9000 Aalborg , Denmark
| | - Lars Arendt-Nielsen
- Center for Sensory-Motor Interactions (SMI), Department of Health Science and Technology , Aalborg University , Fredrik Bajers Vej 7-D3, 9220 Aalborg , Denmark
| | - Palle Jørn Sloth Osther
- Urological Research Centre, Department of Urology, Hospital Littlebelt , University of Southern Denmark , Dronningensgade 97, 7000 Frederica , Denmark
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Szczesniak MM, Fuentealba SE, Zhang T, Cook IJ. Modulation of esophageal afferent pathways by 5-HT3 receptor inhibition. Neurogastroenterol Motil 2013; 25:383-8, e293. [PMID: 23360084 DOI: 10.1111/nmo.12074] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
BACKGROUND The study aims were to investigate whether neural pathways involving 5-HT3 receptors mediate: (i) distension-induced upper esophageal sphincter (UES) relaxation reflex, (ii) esophageal sensitivity to acid and electrical stimuli, and (iii) viserosomatic sensitization following acid exposure. METHODS In Study I, in a double-blind crossover trial (n = 9) esophageal sensory and pain thresholds to electrical stimulation were measured in the esophagus, midsternum, and the foot, before subjects were randomized to receive either Ondansetron (8 mg i.v.) or NaCl (0.9% w/v). HCl (0.15 mol L(-1)) was then infused into distal esophagus and electrical thresholds were reassessed. Following electrical sensory threshold testing, subjects received a second esophageal infusion of HCl to evaluate esophageal sensitivity to acid. In Study II (N = 10), frequencies of distension-induced UES relaxation responses were scored before and after treatment with Ondansetron and NaCl in a double-blind crossover trial. KEY RESULTS In Study I, ondansetron had no effect on esophageal sensitivity to HCl or acid-induced sensitization. However, blockade of 5-HT3 receptors did reduce midsternum somatic pain thresholds. Sixty minutes after esophageal acid exposure, pain thresholds were significantly lower in the ondansetron arm (mean Δ-1.36 ± 0.4 mA) when compared with NaCl (mean Δ-0.14 ± 0.58 mA) (P < 0.05). In Study II, 5-HT3 receptor blockade had no significant effect on UES relaxation reflex. CONCLUSIONS & INFERENCES This study does not support the hypothesis that in health, 5-HT3 receptors play a significant role in esophago-UES distention-induced relaxation reflex and esophageal sensitivity to acid or electrical stimulation. It does provide new evidence for involvement of 5-HT3 receptors in viscerosomatic sensitization.
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Affiliation(s)
- M M Szczesniak
- Department of Gastroenterology, St George Hospital, University of New South Wales, Sydney, NSW, Australia.
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Aasvang EK, Hansen JB, Kehlet H. Pre-operative pain and sensory function in groin hernia. Eur J Pain 2012; 13:1018-22. [DOI: 10.1016/j.ejpain.2008.11.015] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2008] [Revised: 09/12/2008] [Accepted: 11/23/2008] [Indexed: 10/21/2022]
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Viscero-somatic reflexes in referred pain areas evoked by capsaicin stimulation of the human gut. Eur J Pain 2012; 12:544-51. [DOI: 10.1016/j.ejpain.2007.08.010] [Citation(s) in RCA: 41] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/30/2006] [Revised: 08/15/2007] [Accepted: 08/30/2007] [Indexed: 01/26/2023]
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Mechanosensitivity before and after hysterectomy: a prospective study on the prediction of acute and chronic postoperative pain. Br J Anaesth 2011; 107:940-7. [DOI: 10.1093/bja/aer264] [Citation(s) in RCA: 47] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
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Arendt-Nielsen L, Yarnitsky D. Experimental and Clinical Applications of Quantitative Sensory Testing Applied to Skin, Muscles and Viscera. THE JOURNAL OF PAIN 2009; 10:556-72. [DOI: 10.1016/j.jpain.2009.02.002] [Citation(s) in RCA: 383] [Impact Index Per Article: 25.5] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/28/2008] [Revised: 01/12/2009] [Indexed: 01/23/2023]
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Graven-Nielsen T. Fundamentals of muscle pain, referred pain, and deep tissue hyperalgesia. Scand J Rheumatol 2007; 122:1-43. [PMID: 16997767 DOI: 10.1080/03009740600865980] [Citation(s) in RCA: 127] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/17/2023]
Affiliation(s)
- T Graven-Nielsen
- Center for Sensory-Motor Interaction (SMI), Laboratory for Experimental Pain Research, Aalborg University, Denmark.
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Kjaer DW, Stawowy M, Arendt-Nielsen L, Drewes AM, Funch-Jensen P. Reversibility of central neuronal changes in patients recovering from gallbladder stones or acute cholecystitis. World J Gastroenterol 2006; 12:7522-6. [PMID: 17167844 PMCID: PMC4087601 DOI: 10.3748/wjg.v12.i46.7522] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
AIM: To investigate the referred pain area in patients 2-7 years after cholecystectomy in order to test the hypothesis that neuroplastic changes could give rise to post cholecystectomy pain.
METHODS: Forty patients were tested. Twenty five were cholecystectomized due to uncomplicated gallbladder stones and 15 because of acute cholecystitis. Sensitivity to pinprick, heat, cold, pressure and single and repeated electrical stimulation was studied both in the referred pain area and in the control area on the contra lateral side of the abdomen.
RESULTS: Five patients still intermittently suffered from pain. But in the objective test of the 40 patients, no statistical significant difference was found between the referred pain area and the control area.
CONCLUSION: This study does not support the hypothesis that de novo neuroplastic changes could develop several years after cholecys-tectomy.
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Affiliation(s)
- Daniel-W Kjaer
- Surgical Gastroenterology Department L, Aarhus University Hospital, Aarhus, Denmark.
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Bielefeldt K, Lamb K, Gebhart GF. Convergence of sensory pathways in the development of somatic and visceral hypersensitivity. Am J Physiol Gastrointest Liver Physiol 2006; 291:G658-65. [PMID: 16500917 DOI: 10.1152/ajpgi.00585.2005] [Citation(s) in RCA: 85] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
Sensory neurons innervating different tissues converge onto second-order neurons in the spinal cord. We examined whether inflammation or transient overexpression of nerve growth factor (NGF) in one tissue triggers hypersensitivity in referral sites. Thresholds to mechanical and thermal stimulation of the hindpaw, visceromotor responses to colorectal distension, and cystometrograms were performed in appropriate controls and mice with experimentally induced cystitis, inflammation of the hindpaw or front paw, or injection of viral vectors encoding NGF or green fluorescent protein (GFP). Cystitis and NGF but not GFP overexpression in the bladder triggered bladder hyperactivity associated with mechanical and thermal hypersensitivity in cutaneous referral sites and enhanced responses to colorectal distension. Hindpaw inflammation and injection of the NGF- but not GFP-encoding viral vector or front paw inflammation induced mechanical and thermal hyperalgesia in the affected hindpaw and increased responses to colorectal distension without altering the micturition reflex. In conclusion, sensitization of sensory pathways by inflammation or NGF contributes to the development of hypersensitivity in neighboring organs and cutaneous referral sites and provides a potential mechanism underlying the coexistence of pain syndromes in patients with functional diseases.
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Affiliation(s)
- Klaus Bielefeldt
- Div. of Gastroenterology, Dept. of Medicine, Univ. of Pittsburgh, 200 Lothrop St., Pittsburgh, PA 15213, USA.
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21
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Stawowy M, Drewes AM, Arendt-Nielsen L, Funch-Jensen P. Somatosensory changes in the referred pain area before and after cholecystectomy in patients with uncomplicated gallstone disease. Scand J Gastroenterol 2006; 41:833-7. [PMID: 16785197 DOI: 10.1080/00365520500463332] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
OBJECTIVE It is estimated that 25-40% of patients have continuing symptoms after cholecystectomy and that 5-10% have pain. The pain may be related to central neuroplastic changes of sensory pathways induced by the gallstone disease. Such neuronal hyperexcitability can be reflected in the somatic referred pain area sharing central pathways with the gallbladder. The aim of this study was to examine somatosensory changes in the referred pain area evoked by painful gallstone attacks before and after cholecystectomy in patients with uncomplicated gallstone disease. MATERIAL AND METHODS Thirty-seven patients with uncomplicated gallstone disease were included in the study. The sensations and pain thresholds to pinprick, pinching, pressure, thermal and electrical stimulation were studied before and 4-12 weeks after surgery in the area where the pain was referred to during the previous gallstone attacks. An area on the contralateral side of the abdomen served as the control. RESULTS Somatosensory hyperalgesia in the referred pain area was observed in 84% of the patients before surgery. After elective cholecystectomy, none of the patients had pain complaints, and the sensibility in the referred area was normalized. CONCLUSIONS Uncomplicated gallstone disease leads to significant hyperalgesia in the somatic referred pain area. At the time of the postoperative investigation none of the patients suffered from pain, which was reflected in the normal sensory findings in the previous referred pain area.
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Affiliation(s)
- Marek Stawowy
- Department of Surgical Gastroenterology L, Aarhus University Hospital, Nørrebrogade 44, DK-8000 Aarhus C, Denmark
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Lamb K, Zhong F, Gebhart GF, Bielefeldt K. Experimental colitis in mice and sensitization of converging visceral and somatic afferent pathways. Am J Physiol Gastrointest Liver Physiol 2006; 290:G451-7. [PMID: 16195421 DOI: 10.1152/ajpgi.00353.2005] [Citation(s) in RCA: 77] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
Chronic pain syndromes affecting different organs often coexist. We hypothesized that sensitization of one afferent pathway may affect converging input from other areas of the body. We induced colitis in mice with 2,4,6-trinitrobenzenesulfonic acid (TNBS); control animals were treated with equal volumes of vehicle (50% ethanol) only. Visceromotor responses to graded colorectal distension, cystometrograms, and response thresholds to mechanical and thermal stimulation of both hind paws were determined on days 7 and 14. Inflammation of colon and bladder was assessed with validated histological markers and scores. TNBS caused significant colitis on day 7 that resolved by day 14; there was no evidence of bladder inflammation. There was a significant hypersensitivity to colorectal distension on day 7, which returned to normal on day 14. This was associated with bladder overactivity, as demonstrated by early onset of micturition and more frequent micturition on day 7 after TNBS administration. Colitis also significantly altered responses to mechanical and thermal stimulation of both hind paws on day 7 but not day 14. We conclude that cross talk between afferent visceral and somatic pathways may contribute to the coexistence of pain syndromes.
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Affiliation(s)
- Kenneth Lamb
- Department of Pharmacology, University of Iowa, Iowa City, Iowa, USA
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Buscher HCJL, Wilder-Smith OHG, van Goor H. Chronic pancreatitis patients show hyperalgesia of central origin: a pilot study. Eur J Pain 2005; 10:363-70. [PMID: 16087373 DOI: 10.1016/j.ejpain.2005.06.006] [Citation(s) in RCA: 87] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/18/2005] [Revised: 05/27/2005] [Accepted: 06/16/2005] [Indexed: 02/08/2023]
Abstract
BACKGROUND The pain of chronic pancreatitis remains challenging to manage, with treatment all too often being unsuccessful. A main reason for this is lacking understanding of underlying mechanisms of chronic pain in these patients. AIM To document, using somatic quantitative sensory testing, changes in central nervous system processing (neuroplasticity) associated with chronic pancreatitis pain and thus gain insight into underlying pain mechanisms. PATIENTS AND METHODS We studied 10 chronic pancreatitis patients on stable opioid analgesic medication. Ten matched surgical patients without pain served as controls. Pain verbal numeric rating scores (NRS) and thresholds to electric skin stimulation and pressure pain were measured in dermatomes T10 (pancreatic area), C5, T4, L1 and L4. RESULTS The pancreatitis patients had a median NRS pain score of 5 (range 3-8). Electric sensation and pain thresholds were significantly increased in the pancreatic region, tending to be more so in female pancreatitis patients. Pressure pain thresholds were significantly lower in pancreatitis patients than in controls, with men tending towards greater generalised relative hyperalgesia than women. CONCLUSIONS Chronic pancreatitis patients show pronounced generalised deep hyperalgesia that is present despite opioid therapy. These signs, consistent with central sensitisation, appear relatively more prominent in men than women. There is also evidence suggesting that women may have a better segmental inhibitory response than men, possibly explaining their relatively less prominent generalised deep tissue hyperalgesia compared to men.
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Stawowy M, Funch-Jensen P, Arendt-Nielsen L, Drewes AM. Somatosensory changes in the referred pain area in patients with cholecystolithiasis. Eur J Gastroenterol Hepatol 2005; 17:865-70. [PMID: 16003137 DOI: 10.1097/00042737-200508000-00014] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
BACKGROUND AND AIMS Patients with abdominal pain provoked by acute cholecystitis increase the somatic sensitivity in the referred somatic pain area. Our aim in the present paper was to examine somatosensory changes in the referred pain area (previously evoked by painful attacks) in patients with uncomplicated gallstone disease and to evaluate the possible relation between referred pain patterns and clinical findings. Somatosensory changes in these areas may be important in the persistent pain after treatment and may help to develop treatment strategies for abdominal pain in the post-cholecystectomy syndrome. SUBJECTS Forty-two patients with symptomatic cholecystolithiasis, confirmed ultrasonographically, were studied in the pain-free period. METHODS Sensitivity and pain thresholds for standardized experimental sensory testing including different modalities: pinprick, pinching, heat, cold, pressure, and single and repeated electrical stimulation were studied in the area where the pain was referred to during the acute attacks, and in a control area on the contralateral side of the abdomen. RESULTS Patients with verified cholecystolithiasis showed hyperalgesia to pinprick (26% of subjects, P < 0.05) and cold stimuli (21% of subjects, P < 0.05) in the referred pain area. There was also a significant reduction in sensation/pain thresholds (indicating hyperalgesia) in the referred pain area to single (P = 0.007/P = 0.002) and repeated electrical (P = 0.017/P = 0.043) stimuli, as well as in pain threshold to pinching and mechanical stimuli (P = 0.049/P < 0.001). There were no significant relations between the hyperalgesia and the clinical findings. CONCLUSION Cholecystolithiasis leads to significant hyperalgesia in the somatic area, where pain was referred to during the acute attacks. This is explained by viscero-somatic convergence mechanisms in the central nervous system. Therefore, central neuroplastic changes may be significant in diseases related to the gallbladder such as the post-cholecystectomy syndrome.
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Affiliation(s)
- Marek Stawowy
- Department of Surgical Gastroenterology, Aarhus University Hospital, Denmark.
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Bielefeldt K, Christianson JA, Davis BM. Basic and clinical aspects of visceral sensation: transmission in the CNS. Neurogastroenterol Motil 2005; 17:488-99. [PMID: 16078937 DOI: 10.1111/j.1365-2982.2005.00671.x] [Citation(s) in RCA: 50] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
Pain and discomfort are the leading cause for consultative visits to gastroenterologists. Acute pain should be considered a symptom of an underlying disease, thereby serving a physiologically important function. However, many patients experience chronic pain in the absence of potentially harmful stimuli or disorders, turning pain into the primary problem rather than a symptom. Vagal and spinal afferents both contribute to the sensory component of the gut-brain axis. Current evidence suggests that they convey different elements of the complex sensory experience. Spinal afferents play a key role in the discriminatory dimension, while vagal input primarily affects the strong emotional and autonomic reactions to noxious visceral stimuli. Drugs, surgical and non-pharmacological treatments can target these pathways and provide therapeutic options for patients with chronic visceral pain syndromes.
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Affiliation(s)
- K Bielefeldt
- Department of Medicine, University of Pittsburgh, Pittsburgh, PA 15213, USA.
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