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Jurth C, Lichtner G, Bienert T, von Dincklage F. The variability in nociceptive flexion reflex threshold measurement is mostly caused by probabilistic effects of the estimation algorithms: a simulation study. Int J Neurosci 2024:1-10. [PMID: 38315138 DOI: 10.1080/00207454.2024.2312991] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2022] [Accepted: 01/27/2024] [Indexed: 02/07/2024]
Abstract
OBJECTIVES The nociceptive flexion reflex (NFR) and its threshold are frequently used to investigate spinal nociception in humans. Since this threshold (NFRT) is a probabilistic measure, specific algorithms are used for NFRT estimation based on the stochastic occurrence of reflexes at different stimulus intensities. We used a validated simulation model of the NFR to investigate the amount of NFRT measurement variability induced by different estimation algorithms in a steady setting of reduced external influences. METHODS We simulated the behavior of different estimation algorithms in subjects with an artificially steady baseline NFRT variability (standard deviation: 0 mA) or low baseline NFRT variability (standard deviation: 0.156 mA), equaling a quiet experimental setting. The obtained data were analyzed for NFRT measurement variability caused by the algorithms compared to the baseline variability reflecting other physiological influences. RESULTS The standard deviation of the NFRT estimated by the different algorithms ranged between 0.381 and 3.464 mA with 96.8% to 99.6% of the measurement variability attributed to the algorithm used. Out of the investigated algorithms the dynamic staircase algorithm was most precise. CONCLUSION The NFRT measurement variability observed during quiet and steady experimental sessions is mostly caused by the properties of the estimation algorithms, due to the probabilistic nature of the reflex occurrence. Our results give reference for choosing the optimal estimation algorithm to improve measurement precision.
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Affiliation(s)
- Carlo Jurth
- Department of Anesthesiology and Intensive Care Medicine, Charité - Universitätsmedizin Berlin, Berlin, Germany
| | - Gregor Lichtner
- Department of Anesthesia, Intensive Care, Emergency and Pain Medicine, Universitätsmedizin Greifswald, Greifswald, Germany
| | - Thomas Bienert
- Department of Anesthesiology and Intensive Care Medicine, Charité - Universitätsmedizin Berlin, Berlin, Germany
| | - Falk von Dincklage
- Department of Anesthesia, Intensive Care, Emergency and Pain Medicine, Universitätsmedizin Greifswald, Greifswald, Germany
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2
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Fundaun J, Kolski M, Baskozos G, Dilley A, Sterling M, Schmid AB. Nerve pathology and neuropathic pain after whiplash injury: a systematic review and meta-analysis. Pain 2022; 163:e789-e811. [PMID: 35050963 PMCID: PMC7612893 DOI: 10.1097/j.pain.0000000000002509] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2021] [Accepted: 09/29/2021] [Indexed: 11/26/2022]
Abstract
ABSTRACT There is no clear understanding of the mechanisms causing persistent pain in patients with whiplash-associated disorder (WAD). The aim of this systematic review was to assess the evidence for nerve pathology and neuropathic pain in patients with WAD. EMBASE, PubMed, CINAHL (EBSCO), and MEDLINE were searched from inception to September 1, 2020. Study quality and risk of bias were assessed using the Newcastle-Ottawa Quality Assessment Scales. Fifty-four studies reporting on 390,644 patients and 918 controls were included. Clinical questionnaires suggested symptoms of predominant neuropathic characteristic in 34% of patients (range 25%-75%). The mean prevalence of nerve pathology detected with neurological examination was 13% (0%-100%) and 32% (10%-100%) with electrodiagnostic testing. Patients independent of WAD severity (Quebec Task Force grades I-IV) demonstrated significantly impaired sensory detection thresholds of the index finger compared with controls, including mechanical (SMD 0.65 [0.30; 1.00] P < 0.005), current (SMD 0.82 [0.25; 1.39] P = 0.0165), cold (SMD -0.43 [-0.73; -0.13] P = 0.0204), and warm detection (SMD 0.84 [0.25; 1.42] P = 0.0200). Patients with WAD had significantly heightened nerve mechanosensitivity compared with controls on median nerve pressure pain thresholds (SMD -1.10 [-1.50; -0.70], P < 0.0001) and neurodynamic tests (SMD 1.68 [0.92; 2.44], P = 0.0004). Similar sensory dysfunction and nerve mechanosensitivity was seen in WAD grade II, which contradicts its traditional definition of absent nerve involvement. Our findings strongly suggest a subset of patients with WAD demonstrate signs of peripheral nerve pathology and neuropathic pain. Although there was heterogeneity among some studies, typical WAD classifications may need to be reconsidered and include detailed clinical assessments for nerve integrity.
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Affiliation(s)
- Joel Fundaun
- Nuffield Department of Clinical Neurosciences, The University of Oxford, Oxford, United Kingdom
| | - Melissa Kolski
- Department of Physical Therapy and Human Movement Sciences, Northwestern University, Feinberg School of Medicine, Chicago, IL, United States
- Musculoskeletal Outpatient Department, Shirley Ryan AbilityLab, Chicago, IL, United States
| | - Georgios Baskozos
- Nuffield Department of Clinical Neurosciences, The University of Oxford, Oxford, United Kingdom
| | - Andrew Dilley
- Brighton and Sussex Medical School, University of Sussex, Brighton, United Kingdom
| | - Michele Sterling
- RECOVER Injury Research Centre, NHMRC Centre of Research Excellence in Recovery Following Road Traffic Injuries, The University of Queensland, Brisbane, Queensland, Australia
| | - Annina B Schmid
- Nuffield Department of Clinical Neurosciences, The University of Oxford, Oxford, United Kingdom
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3
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Tieppo Francio V, Barndt B, Eubanks J, Smith M. Third-degree full-thickness burns as a complication of cervical radiofrequency ablation. BMJ Case Rep 2021; 14:e245113. [PMID: 34848408 PMCID: PMC8634204 DOI: 10.1136/bcr-2021-245113] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/16/2021] [Indexed: 11/03/2022] Open
Abstract
A 46-year-old woman underwent a cervical radiofrequency ablation (RFA) for chronic neck pain. Following the procedure, two areas surrounding the grounding pad in the lumbar region developed full thickness third-degree burns. Burn injuries following cervical RFA are rarely reported and are most often associated with cardiac and solid tumour RFA. Only one other case has been reported in literature with a similar outcome following a thoracic facet RFA. In our case, the lesion was directly from the ground pad and not from the radiofrequency electrode, which is more often the culprit. This is the first case reported in the literature of a full-thickness skin burn from a cervical RFA. Physicians should be aware of the potential for severe burns around the RF probe and ground pad as sequelae of RFA, and we caution the use of sedation during the procedure, as patients will unlikely be able to report any unusual sensation.
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Affiliation(s)
| | - Brandon Barndt
- Physical Medicine and Rehabilitation, Temple University, Philadelphia, Pennsylvania, USA
| | - James Eubanks
- Physical Medicine and Rehabilitation, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
| | - McCasey Smith
- Rehabilitation Medicine, University of Kansas Medical Center, Kansas City, Kansas, USA
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4
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Linde LD, Bent LR, Dickey JP, Kumbhare DA, Srbely JZ. Exploring the effect of capsaicin-induced central sensitization on the upper limb nociceptive withdrawal reflex threshold. Exp Brain Res 2021; 239:3405-3415. [PMID: 34505162 DOI: 10.1007/s00221-021-06216-3] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/19/2020] [Accepted: 09/02/2021] [Indexed: 11/29/2022]
Abstract
The nociceptive withdrawal reflex (NWR) threshold is commonly employed in the lower limb to assess clinical and experimentally induced pain. However, no studies to date have investigated changes in spinal nociception in the upper limb, via the NWR threshold, following experimentally induced central sensitization (CS). We tested the hypothesis that experimentally induced CS of the C5-C6 spinal segment significantly reduces NWR thresholds in muscles of the upper limb. Upper limb NWR thresholds from 20 young, healthy adults were assessed by applying noxious electrical stimuli to the right index finger and recording muscle activity from the biceps brachii (BI), triceps brachii (TRI), flexor carpi ulnaris (WF), and extensor carpi radialis longus (WE) muscles via surface electromyography. Topical cream (either 0.075% capsaicin, or control) was applied to the C5-C6 dermatome of the lateral forearm (50 cm2). NWR thresholds were compared at baseline, and four 10-min intervals after topical application. WF muscle NWR thresholds were significantly reduced in the capsaicin session compared to control, while TRI muscle NWR thresholds were significantly reduced 40 min after capsaicin application only (p < 0.05). There were no significant differences for BI or WE muscle NWR thresholds. We observed poor to moderate test-retest reliability for all upper limb NWR thresholds, a key contributor to the selective reduction in NWR thresholds among muscles. Accordingly, while our findings demonstrate some comparability to previously reported lower limb NWR studies, we concurrently report limitations of the upper limb NWR technique. Further exploration of optimal parameters for upper limb NWR acquisition is needed.
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Affiliation(s)
- Lukas D Linde
- International Collaboration on Repair Discoveries (ICORD), University of British Columbia, Vancouver, BC, Canada. .,Department of Anesthesiology, Pharmacology & Therapeutics, Faculty of Medicine, University of British Columbia, Vancouver, BC, Canada. .,Djavad Mowafaghian Centre for Brain Health, University of British Columbia, Vancouver, BC, Canada.
| | - Leah R Bent
- Department of Human Health and Nutritional Sciences, University of Guelph, Guelph, ON, Canada
| | - James P Dickey
- School of Kinesiology, Western University, London, ON, Canada
| | - Dinesh A Kumbhare
- Department of Medicine, Division of Physical Medicine and Rehabilitation, University of Toronto, Toronto, ON, Canada
| | - John Z Srbely
- Department of Human Health and Nutritional Sciences, University of Guelph, Guelph, ON, Canada
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5
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Amiri M, Esmaili H, Hamad AH, Alavinia M, Masani K, Kumbhare D. Nociceptive Flexion Reflex Threshold in Chronic Pain Patients: A Needed Update for the Current Evidence. Am J Phys Med Rehabil 2021; 100:750-759. [PMID: 33065577 DOI: 10.1097/phm.0000000000001626] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
BACKGROUND The nociceptive flexion reflex is a physiological, polysynaptic reflex triggered by a nociceptive stimulus activating a withdrawal response. In chronic musculoskeletal-related pain conditions, a decreased nociceptive flexion reflex threshold has been suggested as a possible recognition evidence for central sensitization that may cause alteration of central nervous system processing. OBJECTIVE The aim of the study was to systematically review reported comparisons of the nociceptive flexion reflex threshold in chronic pain patients and healthy individuals. METHODS Electronic databases covering studies published between January 1990 and December 2019 were systematically searched. After application of exclusion criteria, 20 studies including 28 trials were included in this review. For meta-analysis, we used a random-effects model and funnel plot for publication bias. This research was registered at PROSPERO (CRD42019140354). RESULTS Compared with healthy controls, standardized mean differences in nociceptive flexion reflex threshold were significantly lower in the total sample of chronic pain patients. Subgroup analysis indicated a homogenous decreased nociceptive flexion reflex threshold in studies reporting fibromyalgia, chronic pain, and joint pain while heterogeneity existed in other included pain conditions. CONCLUSIONS A lower nociceptive flexion reflex threshold in patients experiencing chronic pain conditions may imply hyperexcitability in central nervous system processing. As a preliminary study, the findings would act as a basis for developing a methodology assisting current clinical practices.
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Affiliation(s)
- Mohammadreza Amiri
- From the Toronto Rehabilitation Institute, University Health Network, Toronto, Ontario, Canada (M. Amiri, AHH, M. Alavinia, DK); Isfahan University of Medical Sciences, Isfahan, Iran (HE); Institute of Biomaterials and Biomedical Engineering, University of Toronto, Toronto, Ontario, Canada (KM); and Division of Physical Medicine and Rehabilitation, Department of Medicine, University of Toronto, Toronto, Ontario, Canada (DK)
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6
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Engel A, King W, Schneider BJ, Duszynski B, Bogduk N. The Effectiveness of Cervical Medial Branch Thermal Radiofrequency Neurotomy Stratified by Selection Criteria: A Systematic Review of the Literature. PAIN MEDICINE 2020; 21:2726-2737. [DOI: 10.1093/pm/pnaa219] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
Abstract
Objective
To determine the effectiveness of cervical medial branch thermal radiofrequency neurotomy in the treatment of neck pain or cervicogenic headache based on different selection criteria.
Design
Comprehensive systematic review.
Methods
A comprehensive literature search was conducted, and the authors screened and evaluated the studies. The Grades of Recommendation, Assessment, Development, and Evaluation system was used to assess all eligible studies.
Outcome Measures
The primary outcome measure assessed was the success rate of the procedure, defined by varying degrees of pain relief following neurotomy. Data are stratified by number of diagnostic blocks and degree of pain relief.
Results
Results varied by selection criteria, which included triple placebo-controlled medial branch blocks, dual comparative medial branch blocks, single medial branch blocks, intra-articular blocks, physical examination findings, and symptoms alone. Outcome data showed a greater degree of pain relief more often when patients were selected by triple placebo-controlled medial branch blocks or dual comparative medial branch blocks, producing 100% relief of the index pain. The degree of pain relief was similar when triple or dual comparative blocks were used.
Conclusions
Higher degrees of relief from cervical medial branch thermal radiofrequency neurotomy are more often achieved, to a statistically significant extent, if patients are selected on the basis of complete relief of index pain following comparative diagnostic blocks. If selected based on lesser degrees of relief, patients are less likely to obtain complete relief.
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Affiliation(s)
- Andrew Engel
- Affordable Pain Management, Chicago, Illinois, USA
| | - Wade King
- Mayo Multidisciplinary Pain Clinic, Mayo Private Hospital, Taree, NSW, Australia
| | - Byron J Schneider
- Department of Physical Medicine and Rehabilitation, Vanderbilt University, Nashville, Tennessee
| | | | - Nikolai Bogduk
- University of Newcastle, Faculty of Health and Medicine, Newcastle, Australia
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7
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Smith AC, Albin SR, Abbott R, Crawford RJ, Hoggarth MA, Wasielewski M, Elliott JM. Confirming the geography of fatty infiltration in the deep cervical extensor muscles in whiplash recovery. Sci Rep 2020; 10:11471. [PMID: 32651447 PMCID: PMC7351986 DOI: 10.1038/s41598-020-68452-x] [Citation(s) in RCA: 17] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/27/2019] [Accepted: 06/22/2020] [Indexed: 02/08/2023] Open
Abstract
Previous preliminary work mapped the distribution of neck muscle fat infiltration (MFI) in the deep cervical extensor muscles (multifidus and semispinalis cervicis) in a small cohort of participants with chronic whiplash associated disorders (WAD), recovered, and healthy controls. While MFI was reported to be concentrated in the medial portion of the muscles in all participants, the magnitude was significantly greater in those with chronic WAD. This study aims to confirm these results in a prospective fashion with a larger cohort and compare the findings across a population of patients with varying levels of WAD-related disability one-year following the motor vehicle collision. Sixty-one participants enrolled in a longitudinal study: Recovered (n = 25), Mild (n = 26) and Severe WAD (n = 10) were studied using Fat/Water magnetic resonance imaging, 12-months post injury. Bilateral measures of MFI in four quartiles (Q1–Q4; medial to lateral) at cervical levels C4 through C7 were included. A linear mixed model was performed, controlling for covariates (age, sex, body mass index), examining interaction effects, and comparing MFI distribution between groups. The recovered group had significantly less MFI in Q1 compared to the two symptomatic groups. Group differences were not found in the more lateral quartiles. Results at 12 months are consistent with the preliminary study, indicating that MFI is spatially concentrated in the medial portions of the deep cervical extensors regardless of WAD recovery, but the magnitude of MFI in the medial portions of the muscles is significantly larger in those with severe chronic WAD.
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Affiliation(s)
- Andrew C Smith
- School of Physical Therapy, Regis University, Denver, CO, USA
| | | | - Rebecca Abbott
- Physical Therapy and Human Movement Sciences, Feinberg School of Medicine, Northwestern University, Chicago, IL, USA.,Department of Mechanical Engineering, Northwestern University, Evanston, IL, USA
| | | | - Mark A Hoggarth
- Physical Therapy and Human Movement Sciences, Feinberg School of Medicine, Northwestern University, Chicago, IL, USA.,Department of Biomedical Engineering, Northwestern University, Evanston, IL, USA
| | - Marie Wasielewski
- Physical Therapy and Human Movement Sciences, Feinberg School of Medicine, Northwestern University, Chicago, IL, USA
| | - James M Elliott
- Physical Therapy and Human Movement Sciences, Feinberg School of Medicine, Northwestern University, Chicago, IL, USA. .,Faculty of Medicine and Health, The Northern Sydney Local Health District, The Kolling Institute, The University of Sydney, St. Leonards, NSW, 2065, Australia.
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8
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Hambraeus J, Hambraeus KS, Sahlen KG. Patient perspectives on interventional pain management: thematic analysis of a qualitative interview study. BMC Health Serv Res 2020; 20:604. [PMID: 32611397 PMCID: PMC7329503 DOI: 10.1186/s12913-020-05452-7] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/17/2019] [Accepted: 06/19/2020] [Indexed: 11/10/2022] Open
Abstract
Background Chronic pain is a widespread problem that is usually approached by focusing on its psychological aspects or on trying to reduce the pain from the pain generator. Patients report that they feel responsible for their pain and that they are disempowered and stigmatized because of it. Here, we explored interventional pain management from the patient’s perspective to understand the process better. Methods A purposive sample of 19 subjects was interviewed by an independent interviewer. The interviews were transcribed into text and thematic analysis was performed. Results The subjects’ perceptions covered three key themes: themselves as objects; the caregivers, including the process of tests and retests, the encounters and interactions with professionals, and the availability of the caregivers; and finally the outcomes, including the results of the tests and treatments and how these inspired them to think of other people with pain. Linking these themes, the subjects reported something best described as “gained empowerment” during interventional pain management; they were feeling heard and seen, they gained knowledge that helped them understand their problem better, they could ask questions and receive answers, and they felt safe and listened to. Conclusions Many of the themes evolved in relation to the subjects’ contact with the healthcare services they received, but when the themes were merged and structured into the model, a cohesive pattern of empowerment appeared. If empowerment is a major factor in the positive effects of interventional pain management, it is important to facilitate and not hinder empowerment. Trial registration Clinicaltrials.gov 2013-04-24 (Protocol ID SE-Dnr-2012-446-31 M-3, ClinicalTrials ID NCT01838603).
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Affiliation(s)
- Johan Hambraeus
- Department of Epidemiology and Global Health, Umeå University, SE90185, Umeå, Sweden.
| | | | - Klas-Göran Sahlen
- Department of Epidemiology and Global Health, Umeå University, SE90185, Umeå, Sweden
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9
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Linde LD, Duarte FC, Esmaeili H, Hamad A, Masani K, Kumbhare DA. The nociceptive flexion reflex: a scoping review and proposed standardized methodology for acquisition in those affected by chronic pain. Br J Pain 2020; 15:102-113. [PMID: 33633857 DOI: 10.1177/2049463720913289] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022] Open
Abstract
The nociceptive flexion reflex (NFR) is used in neurophysiological research as an objective measure of nociception. NFR thresholds are reduced in numerous chronic pain pathologies, which are indicative of common central hyperexcitability within conditions. However, variation exists in both the NFR assessment and determinants of NFR threshold among research groups. Our purpose was to provide a review of the recent literature to (a) confirm the NFR threshold's efficacy in identifying those with chronic pain compared to controls and (b) provide a narrative synthesis on the current methodology used to assess the NFR in clinical populations. We conducted a review of multiple databases (MEDLINE, Cumulative Index to Nursing and Allied Health Literature (CINAHL), Google Scholar and Cochrane Library), including articles that reported controlled clinical studies of humans, in English, comparing NFR thresholds within chronic pain conditions to matched control subjects, published since the last NFR review in 2010. Our search resulted in nine studies included in our narrative synthesis and eight studies included in a meta-analysis. There was a significant pooled standardized mean difference in NFR threshold between chronic pain conditions and controls (-0.94, 95% confidence interval (CI) -1.33 to -0.55, p < 0.0001), with substantial heterogeneity of pooled estimates (I 2 = 87%, τ 2 = 0.41, Q = 76.13, the degrees of freedom (df) = 11, p < 0.0001). Significant variations in participant positioning, stimulation parameters and determinants of the NFR threshold were evident among included studies. We provided a narrative synthesis on the methodologies of included studies, as a recommendation for future studies in the assessment of the NFR in chronic pain.
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Affiliation(s)
- Lukas D Linde
- ICORD, University of British Columbia, Vancouver, British Columbia, Canada.,School of Kinesiology, University of British Columbia, Vancouver, British Columbia, Canada
| | - Felipe Ck Duarte
- Division of Research and Innovation, Canadian Memorial Chiropractic College, Toronto, Ontario, Canada
| | - Hamid Esmaeili
- Toronto Rehabilitation Institute, University Health Network, Toronto, Ontario, Canada
| | - Abdul Hamad
- Toronto Rehabilitation Institute, University Health Network, Toronto, Ontario, Canada.,Department of Medicine, Division of Physical Medicine and Rehabilitation, University of Toronto, Toronto, Ontario, Canada
| | - Kei Masani
- Institute of Biomaterials and Biomedical Engineering, University of Toronto, Ontario, Canada
| | - Dinesh A Kumbhare
- Toronto Rehabilitation Institute, University Health Network, Toronto, Ontario, Canada.,Department of Medicine, Division of Physical Medicine and Rehabilitation, University of Toronto, Toronto, Ontario, Canada
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10
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November 2019 Letter to the Editor-in-Chief. J Orthop Sports Phys Ther 2019; 49:866-867. [PMID: 31672118 DOI: 10.2519/jospt.2019.0202] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
Letter to the Editor-in-Chief of JOSPT as follows: "The Whole Pie? Maybe-But Let's Compare Apples With Apples" with Authors' Response J Orthop Sports Phys Ther 2019;49(11):866-867. doi:10.2519/jospt.2019.0202.
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11
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Histological Osteoarthritic Changes in the Human Cervical Spine Facet Joints Related to Age and Sex. Spine (Phila Pa 1976) 2018; 43:E689-E696. [PMID: 29135880 DOI: 10.1097/brs.0000000000002474] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
STUDY DESIGN Cross-sectional autopsy study. OBJECTIVE Quantify histological changes in the lower cervical spine facet joints with regard to age and sex using systematic random sampling of entire joints. SUMMARY OF BACKGROUND DATA Neck pain is a common debilitating musculoskeletal condition and one of the highest ranked causes of years lived with disability. The cause of neck pain is multifactorial and osteoarthritis is one potential cause. The cervical spine facet joints have been implicated in the etiology of chronic neck pain. Hence, a detailed description of their anatomy and age- and sex-related changes is needed. METHODS The lower four cervical spine segments (C4-C7 included) were obtained from 72 subjects during autopsy; 29 women (median age 53 years [22-77]) and 43 men (median age 38 years [20-78]). A total of 1132 articular facets were embedded in toto in hard plastic and sliced into 3-mm thick sections from where 10 μm thick histological sections were produced. Morphological variables were evaluated microscopically and histomorphometric variables were retrieved using random sampling methods. Data were analyzed with a linear regression model. RESULTS Significant associations were found between increasing age and in particular splitting, fissures, osteophytes, thickness of the calcified cartilage, and subchondral bone plate. The thickness of the calcified cartilage and subchondral bone plate increased with increasing age, whereas the hyaline cartilage thickness decreased. Males had more extensive degenerative changes in the cartilage. CONCLUSION Using semiquantitative histological methods, degenerative findings were observed at all spinal levels involving the articular cartilage and the osseous structures of the cervical spine facet joints similar to those observed in larger weight-bearing joints. In particular, the thickening of the calcified cartilage and the subchondral bone identified the osteocartilaginous junction as an important area in osteoarthritis. These findings may be relevant for the pathogenesis of osteoarthritis. LEVEL OF EVIDENCE 3.
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12
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Harris S, Sterling M, Farrell SF, Pedler A, Smith AD. The influence of isometric exercise on endogenous pain modulation: comparing exercise-induced hypoalgesia and offset analgesia in young, active adults. Scand J Pain 2018; 18:513-523. [DOI: 10.1515/sjpain-2017-0177] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/04/2017] [Accepted: 03/06/2018] [Indexed: 12/28/2022]
Abstract
Abstract
Background and aims
Impairment of endogenous analgesia has been associated with the development, maintenance and persistence of pain. Endogenous analgesia can be evaluated using exercise-induced hypoalgesia (EIH) and offset analgesia (OffA) paradigms, which measure temporal filtering of sensory information. It is not clear if these paradigms are underpinned by common mechanisms, as EIH and OffA have not previously been directly compared. A further understanding of the processes responsible for these clinically relevant phenomena may have future diagnostic and therapeutic utility in management of individuals with persistent pain conditions. The primary aim of this study was to investigate if there is a correlation between the magnitudes of EIH and OffA. The secondary aim of the study was to examine whether exercise influences OffA.
Methods
Thirty-six healthy, pain-free participants were recruited. EIH was evaluated using pressure pain thresholds (PPT) and pain ratings to suprathreshold pressure stimuli over tibialis anterior and the cervical spine. OffA evaluation utilised a three-step protocol, whereby individualised heat pain thermal stimuli [Numerical Rating Scale (NRS)=50/100] were applied (T1), before increasing 1 °C (T2), followed by 1 °C reduction (T3). The magnitude of OffA was calculated as the percentage reduction in the NRS from T2 to T3. PPT/suprathreshold pain ratings and OffA measures were recorded, before and after 5 min of isometric quadriceps exercise performed at 20–25% maximum voluntary contraction (MVC); and following a 15 min rest period. Data were analysed using repeated measures (RM) ANCOVA and correlational analyses.
Results
There was no correlation between EIH measures (PPTs or pain ratings to suprathreshold pressure stimuli over tibialis anterior or the cervical spine) and OffA (p>0.11 for all). OffA was induced and not modulated by exercise (p=0.28).
Conclusions
Five minutes of 20–25% MVC lower limb isometric exercise provided non-pharmacological pain modulation in young, active adults. Magnitude of EIH was not correlated with that of OffA, and exercise did not influence magnitude of OffA.
Implications
These results suggest that in young, pain-free individuals, separate testing of these two paradigms is required to comprehensively evaluate efficacy of endogenous analgesia. If these results are replicated in patient populations, alternative or complementary methods to exercise interventions may be required to modulate impaired OffA.
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Affiliation(s)
- Samuel Harris
- School of Allied Health Sciences , Griffith University , Gold Coast, QLD , Australia
| | - Michele Sterling
- RECOVER Injury Research Centre, NHMRC Centre for Research Excellence in Recovery Following Road Traffic Injuries , The University of Queensland , Brisbane , Australia
- Menzies Health Institute Queensland , Griffith University , Gold Coast , Australia
| | - Scott F. Farrell
- RECOVER Injury Research Centre, NHMRC Centre for Research Excellence in Recovery Following Road Traffic Injuries , The University of Queensland , Brisbane , Australia
- Menzies Health Institute Queensland , Griffith University , Gold Coast , Australia
| | - Ashley Pedler
- RECOVER Injury Research Centre, NHMRC Centre for Research Excellence in Recovery Following Road Traffic Injuries , The University of Queensland , Brisbane , Australia
| | - Ashley D. Smith
- School of Allied Health Sciences , Griffith University, 58 Parklands Dr , Southport, Gold Coast, QLD 4215 , Australia , Phone: +1 403 281 7264
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13
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Abstract
Rapid advances in the basic, clinical, and behavioral sciences are molding developments in conservative management of musculoskeletal disorders. Curiously, there seems to be discord developing between approaches to the assessment and management of patients, depending on whether they present with an extremity or spinal disorder. This viewpoint will comment on examples of differences emerging in some current practices. The aim is not to present a scientific treatise about underpinning sciences and evidence-based practice or to comment on what is correct or incorrect. Rather, the aim is to stimulate thought on the seeming discord in clinical practice, with respect to both the clinical evaluation of, as well as management approaches to, extremity and spinal disorders. J Orthop Sports Phys Ther 2016;46(11):938-941. doi:10.2519/jospt.2016.0610.
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14
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Watson DH, Drummond PD. The Role of the Trigemino Cervical Complex in Chronic Whiplash Associated Headache: A Cross Sectional Study. Headache 2016; 56:961-75. [PMID: 27091393 DOI: 10.1111/head.12805] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/11/2015] [Revised: 01/05/2016] [Accepted: 02/15/2016] [Indexed: 12/18/2022]
Abstract
OBJECTIVE To investigate signs of central sensitization in a cohort of patients with chronic whiplash associated headache (CWAH). BACKGROUND Central sensitization is one of the mechanisms leading to chronicity of primary headache, and thus might contribute to CWAH. However, the pathophysiological mechanism of CWAH is poorly understood and whether it is simply an expression of the primary headache or has a distinct pathogenesis remains unclear. Thus, the factors involved in the genesis of CWAH require further investigation. METHODS Twenty-two patients with CWAH (20 females, 2 males; age 25-50 years, mean age 36.3 years) and 25 asymptomatic participants (13 females, 12 males; age 18-50 years, mean age 35.6 years) rated glare and light-induced discomfort in response to light from an ophthalmoscope. Hyperalgesia evoked by a pressure algometer was assessed bilaterally on the forehead, temples, occipital base, and the middle phalanx of the third finger. The number, latency, area under the curve, and recovery cycle of nociceptive blink reflexes elicited by a supraorbital electrical stimulus were also recorded. RESULTS Eight and 6 CWAH patients had migrainous and tension-type headache (TTH) profiles, respectively; the remainder had features attributable to both migraine and TTH. Patients in the whiplash group reported significantly greater light-induced pain than controls (8.48 ± .35 vs 6.66 ± .43 on a 0-10 scale; P = .001). The CWAH patients reported significantly lower pressure pain thresholds at all sites. For stimuli delivered at 20 second intervals, whiplash patients were more responsive than controls (4.8 ± .6 blinks vs 3.0 ± .6 blinks in a block of 10 stimuli; P = .036). While R2 latencies and the area under the curve for the 20 second interval trials were comparable in both groups, there was a significant reduction of the area under the curve from the first to the second of the 2-second interval trials only in controls (99 ± 8% of baseline in whiplash patients vs 68 ± 7% in controls; P = .009). The recovery cycle was comparable for both groups. CONCLUSIONS Our results corroborate previous findings of mechanical hypersensitivity and photophobia in CWAH patients. The neurophysiological data provide further evidence for hyperexcitability in central nociceptive pathways, and endorse the hypothesis that CWAH may be driven by central sensitization.
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Affiliation(s)
- Dean H Watson
- School of Psychology and Exercise Science, Murdoch University, Murdoch, Western Australia, Australia
| | - Peter D Drummond
- School of Psychology and Exercise Science, Murdoch University, Murdoch, Western Australia, Australia
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Sterling M, Head J, Cabot PJ, Farrell M. Serum C-reactive protein levels predict regional brain responses to noxious cold stimulation of the hand in chronic whiplash associated disorders. Scand J Pain 2016; 11:19-26. [PMID: 28850464 DOI: 10.1016/j.sjpain.2015.11.003] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/08/2015] [Revised: 10/25/2015] [Accepted: 11/01/2015] [Indexed: 01/23/2023]
Abstract
BACKGROUND AND AIMS Whiplash Associated Disorders (WAD) are a costly health burden. The condition is characterised by sensory disturbances such as widespread hyperalgesia likely indicative of central hyperexcitability. Recently elevated levels of pro-inflammatory biomarkers have also found in acute and chronic WAD. The aim of this cross-sectional study was to investigate the relationship between inflammatory biomarkers and pain processing in people with persistent whiplash associated disorders (WAD). METHODS Twenty one participants with chronic whiplash (>3 months) were recruited. Venous blood samples were collected and assays performed for C-reactive protein (CRP) and TNF-α. Blood oxygen level-dependent (BOLD) contrast images of the brain were acquired with a Siemens 1.5T MRI scanner during repeated 24s stimulus blocks of innocuous or painful stimuli (thumbnail pressure and cold stimulation of dorsum of hand) separated by 36s inter-stimulus intervals. Stimulus intensities used during scanning were at the level of participants' thresholds for moderate pain. Parameter estimates representing BOLD signal increases during painful events from each participant were tested for associations with inflammatory biomarkers. RESULTS Clinically relevant levels of CRP and TNF-α were found in 33% and 38% of participants. Levels of CRP showed a positive correlation with levels of cold pain activation in brain regions including the anterior insula, posterior parietal cortex, caudate and thalamus (pcorrected<0.05). Levels of TNF-α were not related to activation levels during either noxious pressure or cold. Pressure pain activations also did not show a relationship with CRP levels. CONCLUSIONS Shared variance between inflammation and increased levels of regional pain-related activation in people with persistent whiplash symptoms is apparent for cold, but not pressure stimuli. IMPLICATIONS The results highlight cold pain processing as an important aspect of whiplash chronicity, although the implications of this modality-specific effect are not readily apparent.
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Affiliation(s)
- Michele Sterling
- Centre of National Research on Disability and Rehabilitation Medicine (CONROD), CRE in Road Traffic Injury, Menzies Health Institute Queensland, Griffith University, Parklands, Australia.
| | - Jessica Head
- School of Health and Rehabilitation Sciences, The University of Queensland, St Lucia, Australia
| | - Peter J Cabot
- The School of Pharmacy, Pharmacy Australia Centre of Excellence, The University of Queensland, St Lucia, Australia
| | - Michael Farrell
- Department of Medical Imaging and Radiation Sciences, Monash University, Melbourne, Australia
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Kotlyar A, Brener R, Lis M. Use of Dr. Tan's Chinese Balance Acupuncture for Treatment of Chronic Neck–Shoulder Pain. Med Acupunct 2016. [DOI: 10.1089/acu.2015.1156] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Affiliation(s)
- Arkady Kotlyar
- Outpatient Pain Clinic, Kaplan Medical Center, Rehovot, Israel
| | - Rina Brener
- Outpatient Pain Clinic, Kaplan Medical Center, Rehovot, Israel
| | - Michael Lis
- Outpatient Pain Clinic, Kaplan Medical Center, Rehovot, Israel
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Engel A, Rappard G, King W, Kennedy DJ. The Effectiveness and Risks of Fluoroscopically-Guided Cervical Medial Branch Thermal Radiofrequency Neurotomy: A Systematic Review with Comprehensive Analysis of the Published Data. PAIN MEDICINE 2016; 17:658-69. [PMID: 26359589 DOI: 10.1111/pme.12928] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/15/2015] [Accepted: 08/17/2015] [Indexed: 12/21/2022]
Abstract
OBJECTIVE To determine the effectiveness and risks of fluoroscopically-guided cervical medial branch thermal radiofrequency neurotomy (CMBTRFN) for treating chronic neck pain of zygapophysial joint origin. DESIGN Systematic review of the literature with comprehensive analysis of the published data. INTERVENTIONS Four reviewers formally trained in evidence-based medicine searched the literature on CMBTRFN. Each assessed the methodologies of studies found and appraised the quality of evidence presented. OUTCOME MEASURES The primary outcomes assessed were 100% relief of pain 6 and 12 months after treatment. Other outcomes were noted if reported. The evidence was evaluated in accordance with the Grades of Recommendation, Assessment, Development, and Evaluation (GRADE) system. RESULTS The searches yielded eight primary publications on the effectiveness of the procedure. The evidence shows a majority of patients were pain free at 6 months and over a third were pain free at 1 year. The number needed to treat for complete pain relief at 6 months is 2. The evidence of effectiveness is of high quality according to the GRADE system. Twelve papers were found reporting unwanted effects, most of which are minor and temporary. No serious complications have ever been reported from procedures performed according to the published guidelines. The evidence of risks is of low quality according to the GRADE system. CONCLUSIONS If performed as described in the International Spine Intervention Society Guidelines, fluoroscopically-guided CMBTRFN is effective for abolishing zygapophysial joint pain and carries only minor risks.
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Affiliation(s)
- Andrew Engel
- *Affordable Pain Management, Chicago, Illinois, USA
| | - George Rappard
- Los Angeles Minimally Invasive Spine Institute, Los Angeles, California, USA
| | - Wade King
- Mayo Private Hospital, Manning Pain Management, Taree, New South Wales, Australia
| | - David J Kennedy
- Department of Orthopaedics, Stanford University, Redwood City, California, USA
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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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The geography of fatty infiltrates within the cervical multifidus and semispinalis cervicis in individuals with chronic whiplash-associated disorders. J Orthop Sports Phys Ther 2015; 45:281-8. [PMID: 25739843 PMCID: PMC7223031 DOI: 10.2519/jospt.2015.5719] [Citation(s) in RCA: 42] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
STUDY DESIGN Cross-sectional. OBJECTIVES To quantify the magnitude and distribution of muscle fat infiltration (MFI) within the cervical multifidus and semispinalis cervicis muscles in participants with chronic whiplash-associated disorders (WADs) compared to those who have fully recovered from a whiplash injury and healthy controls. BACKGROUND Previous research has established the presence of increased MFI throughout the cervical extensor muscles of individuals with WAD when compared to healthy controls. These changes appear to be greater in the deepest muscles (eg, multifidus and semispinalis cervicis) than in the more superficial muscles. A detailed analysis of the distribution of MFI within these deep extensor muscles in chronic WAD, recovered, and control groups would provide a foundation for further investigation of specific mechanisms, etiologies, and targets for treatments. METHODS Fifteen participants (WAD, n = 5; recovered, n = 5; and control, n = 5) were studied using a 3-D fat-water separation magnetic resonance imaging sequence. Bilateral measures of cervical multifidus and semispinalis cervicis MFI in 4 quartiles (1 [medial] to 4 [lateral]) at cervical levels C3 through C7 were included in the analysis. Intrarater and interrater reliability were established. A mixed-model analysis was performed to control for covariates, identify interaction effects, and compare MFI distribution between groups. RESULTS The limits of agreement confirmed strong intrarater and interrater agreement at all levels (C3-C7). Sex, age, and body mass index were identified as significant covariates for MFI. Significant interactions were found between group and muscle quartile (P<.001) and between muscle quartile and cervical level (P<.001). Pairwise comparisons for intraquartile MFI between groups revealed significantly greater MFI in the WAD group when compared to the recovered group in the first quartile (P<.001), second quartile (P<.001), and third quartile (P = .03). When compared to the control group, the WAD group had significantly greater MFI in the first quartile (P = .002) and the second quartile (P = .045). The control group had significantly higher MFI in comparison to the recovered group in the first quartile (P = .048). CONCLUSION This study provides preliminary data mapping the spatial distribution of MFI in the cervical multifidus and semispinalis cervicis muscles in individuals with chronic WAD, those who have recovered from a whiplash injury, and healthy controls. Muscle fat infiltration is more concentrated in the medial portion of the muscles in all participants. However, the magnitude of MFI in the medial quartiles (1 and 2) is greatest in the chronic WAD group.
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Modulation of Cervical Facet Joint Nociception and Pain Attenuates Physical and Psychological Features of Chronic Whiplash: A Prospective Study. PM R 2015; 7:913-921. [PMID: 25805617 DOI: 10.1016/j.pmrj.2015.03.014] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/15/2014] [Revised: 03/11/2015] [Accepted: 03/13/2015] [Indexed: 11/23/2022]
Abstract
OBJECTIVE To investigate changes in clinical (physical and psychological) features of individuals with chronic whiplash-associated disorder who had previously undergone cervical radiofrequency neurotomy at the time point when the effects of radiofrequency neurotomy had dissipated and pain returned. DESIGN Prospective cohort observational trial of consecutive patients. SETTING Tertiary spinal intervention centre in Calgary, Alberta, Canada. PATIENTS A total of 53 consecutive individuals with chronic whiplash-associated disorder. METHODS Individuals underwent radiofrequency neurotomy and were assessed before radiofrequency neurotomy, at 1 and 3 months postprocedure, and then after the return of pain (approximately 10 months postprocedure). MAIN OUTCOME MEASUREMENTS Quantitative sensory tests (pressure; thermal pain thresholds; brachial plexus provocation test), nociceptive flexion reflex, and motor function (cervical range of movement; craniocervical flexion test) were measured. Self-reported disability, psychological distress, pain catastrophization, and posttraumatic stress disorder symptoms also were measured. RESULTS Upon the return of pain after radiofrequency neurotomy, levels of disability increased (P < .0001), and were no different to those before radiofrequency neurotomy (P = .99). There also was a significant deterioration in quantitative sensory testing measures and reduced cervical range of motion after the return of pain (all P < .05); all approaching values were recorded before radiofrequency neurotomy (P > .22). There were no significant changes in pressure hyperalgesia (P > .054) or craniocervical flexion test performance (P > .07) after the return of pain. Psychological distress and pain catastrophizing increased significantly after the return of pain (P < .01), and again were no different than measures taken prior to radiofrequency neurotomy (P > .13). However, there was no difference in number or severity of posttraumatic stress symptoms after the return of pain (P > .30). CONCLUSIONS Physical and psychological features of chronic whiplash-associated disorder are modulated dynamically with cervical radiofrequency neurotomy. These findings indicate that peripheral nociception is involved in the manifestations of chronic whiplash-associated disorder in this cohort of individuals.
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Smith AD, Jull GA, Schneider GM, Frizzell B, Hooper RA, Sterling MM. Low Pain Catastrophization and Disability Predict Successful Outcome to Radiofrequency Neurotomy in Individuals with Chronic Whiplash. Pain Pract 2015; 16:311-9. [DOI: 10.1111/papr.12282] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2014] [Revised: 10/14/2014] [Accepted: 11/02/2014] [Indexed: 10/24/2022]
Affiliation(s)
- Ashley D. Smith
- Division of Physiotherapy; Centre of Clinical Excellence Spinal Pain, Injury and Health; University of Queensland; Brisbane Queensland Australia
| | - Gwendolen A. Jull
- Division of Physiotherapy; Centre of Clinical Excellence Spinal Pain, Injury and Health; University of Queensland; Brisbane Queensland Australia
| | | | | | | | - Michele M. Sterling
- Griffith Health Institute; Centre of National Research on Disability and Rehabilitation Medicine; Griffith University; Gold Coast Queensland Australia
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International Spine Intervention Society – 2014 22nd Annual Scientific Meeting Research Abstracts. PAIN MEDICINE 2014. [DOI: 10.1111/pme.12540] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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Nijs J, Malfliet A, Ickmans K, Baert I, Meeus M. Treatment of central sensitization in patients with ‘unexplained’ chronic pain: an update. Expert Opin Pharmacother 2014; 15:1671-83. [DOI: 10.1517/14656566.2014.925446] [Citation(s) in RCA: 111] [Impact Index Per Article: 11.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
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