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Harris JD, Hinojosa M, Williams JM, Stepke K, DuMont G. The Critical Importance of Recognition, Evaluation, and Management of Mental Health on Outcomes Following Hip Arthroscopy - A Synthetic Narrative Review: Current Concepts. J ISAKOS 2024:S2059-7754(24)00135-4. [PMID: 39059584 DOI: 10.1016/j.jisako.2024.07.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/12/2024] [Revised: 07/20/2024] [Accepted: 07/22/2024] [Indexed: 07/28/2024]
Abstract
Mental health and wellness influence patients with hip pain and dysfunction secondary to Femoroacetabular Impingement Syndrome, acetabular dysplasia, and labral injury. Disorders of mental wellness may impact hip preservation surgery patients both before and after surgery. Major depression and generalized anxiety are the two most common diagnoses that affect hip preservation surgery patients. There are dozens of unique questionnaires that can subjectively and objectively characterize the mental health of patients with hip pain. Pain threshold and pain tolerance are two issues that must be recognized to optimally predict treatment outcome in an informed consent shared decision-making discussion. Patient expectations may also significantly influence preoperative symptoms and postoperative outcome. Pain threshold, pain tolerance, and patient expectations are entities traditionally viewed as qualitative and unmeasurable. However, many valid and reliable methods exist to quantitatively assess these patient-specific variables. Recent original research and synthetic review publications have consistently concluded similar findings: patients with disorders of mental wellness generally have lower preoperative patient-reported outcome scores, do improve following surgery, albeit to a lesser magnitude than non-mental disorder patients, and ultimately have lower postoperative scores at their final follow. As with most Orthopedic Surgery literature, the investigation of mental health and hip preservation is primarily via retrospective level four evidence with small numbers of patients from a single-center and single-surgeon at short-term follow-up. Although hip preservation surgeons are Orthopedic Surgeons by training and practice, they must be able to recognize mental wellness disorders and either treat or refer when suspected or identified.
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Affiliation(s)
- Joshua D Harris
- Houston Methodist Hospital, Department of Sports Medicine and Orthopedics, 6565 Fannin Street, Houston, TX, 77030.
| | - Miriam Hinojosa
- Houston Methodist Hospital, Department of Sports Medicine and Orthopedics, 6565 Fannin Street, Houston, TX, 77030
| | - Julia M Williams
- Houston Methodist Hospital, Department of Sports Medicine and Orthopedics, 6565 Fannin Street, Houston, TX, 77030
| | - Katherine Stepke
- Houston Methodist Hospital, Department of Sports Medicine and Orthopedics, 6565 Fannin Street, Houston, TX, 77030
| | - Guillaume DuMont
- Lexington Orthopaedics and Sports Medicine, 3016 Longtown Commons Drive, Suite 200, Columbia, SC 29229
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2
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Phillips AE, Afghani E, Akshintala VS, Benos PY, Das R, Drewes AM, Easler J, Faghih M, Gabbert C, Halappa V, Khashab MA, Olesen SS, Saloman JL, Sholosh B, Slivka A, Wang T, Yadav D, Singh VK. Pancreatic quantitative sensory testing to predict treatment response of endoscopic therapy or surgery for painful chronic pancreatitis with pancreatic duct obstruction: study protocol for an observational clinical trial. BMJ Open 2024; 14:e081505. [PMID: 38514147 PMCID: PMC10961514 DOI: 10.1136/bmjopen-2023-081505] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/29/2023] [Accepted: 03/11/2024] [Indexed: 03/23/2024] Open
Abstract
INTRODUCTION Treatment for abdominal pain in patients with chronic pancreatitis (CP) remains challenging in the setting of central nervous system sensitisation, a phenomenon of remodelling and neuronal hyperexcitability resulting from persistent pain stimuli. This is suspected to render affected individuals less likely to respond to conventional therapies. Endotherapy or surgical decompression is offered to patients with pancreatic duct obstruction. However, the response to treatment is unpredictable. Pancreatic quantitative sensory testing (P-QST), an investigative technique of standardised stimulations to test the pain system in CP, has been used for phenotyping patients into three mutually exclusive groups: no central sensitisation, segmental sensitisation (pancreatic viscerotome) and widespread hyperalgesia suggestive of supraspinal central sensitisation. We will test the predictive capability of the pretreatment P-QST phenotype to predict the likelihood of pain improvement following invasive treatment for painful CP. METHODS AND ANALYSIS This observational clinical trial will enrol 150 patients from the University of Pittsburgh, Johns Hopkins and Indiana University. Participants will undergo pretreatment phenotyping with P-QST. Treatment will be pancreatic endotherapy or surgery for clearance of painful pancreatic duct obstruction. PRIMARY OUTCOME average pain score over the preceding 7 days measured by Numeric Rating Scale at 6 months postintervention. Secondary outcomes will include changes in opioid use during follow-up, and patient-reported outcomes in pain and quality of life at 3, 6 and 12 months after the intervention. Exploratory outcomes will include creation of a model for individualised prediction of response to invasive treatment. ETHICS AND DISSEMINATION The trial will evaluate the ability of P-QST to predict response to invasive treatment for painful CP and develop a predictive model for individualised prediction of treatment response for widespread use. This trial was approved by the University of Pittsburgh Institutional Review Board. Data and results will be reported and disseminated in conjunction with National Institutes of Health policies. TRIAL REGISTRATION NUMBER NCT04996628.
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Affiliation(s)
- Anna Evans Phillips
- Division of Gastroenterology, Hepatology, and Nutrition, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA
| | - Elham Afghani
- Division of Gastroenterology and Hepatology, Johns Hopkins Medical Institute, Baltimore, Maryland, USA
| | | | - Panayiotis Y Benos
- Department of Epidemiology, University of Florida, Gainesville, Florida, USA
| | - Rohit Das
- Division of Gastroenterology, Hepatology, and Nutrition, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA
| | - Asbjørn Mohr Drewes
- Centre for Pancreatic Diseases and Mech-Sense, Department of Gastroenterology and Hepatology, Aalborg University Hospital, Aalborg, Denmark
- Department of Clinical Medicine, Aalborg University, Aalborg, Denmark
| | - Jeffrey Easler
- Division of Gastroenterology and Hepatology, Indiana University School of Medicine, Indianapolis, Indiana, USA
| | - Mahya Faghih
- Division of Gastroenterology and Hepatology, Johns Hopkins Medical Institute, Baltimore, Maryland, USA
| | - Charles Gabbert
- Division of Gastroenterology, Hepatology, and Nutrition, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA
| | - Vivek Halappa
- Division of Radiology, Indiana University School of Medicine, Indianapolis, Indiana, USA
| | - Mouen A Khashab
- Division of Gastroenterology and Hepatology, Johns Hopkins Medical Institute, Baltimore, Maryland, USA
| | - Søren Schou Olesen
- Centre for Pancreatic Diseases and Mech-Sense, Department of Gastroenterology and Hepatology, Aalborg University Hospital, Aalborg, Denmark
- Department of Clinical Medicine, Aalborg University, Aalborg, Denmark
| | - Jami L Saloman
- Division of Gastroenterology, Hepatology, and Nutrition, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA
| | - Biatta Sholosh
- Division of Radiology, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA
| | - Adam Slivka
- Division of Gastroenterology, Hepatology, and Nutrition, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA
| | - Tianxiu Wang
- Center for Research on Healthcare Data, Department of Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA
| | - Dhiraj Yadav
- Division of Gastroenterology, Hepatology, and Nutrition, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA
| | - Vikesh K Singh
- Division of Gastroenterology and Hepatology, Johns Hopkins Medical Institute, Baltimore, Maryland, USA
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Ma K, Cheng Z, Jiang H, Lin Z, Liu C, Liu X, Lu L, Lu Y, Tao W, Wang S, Yang X, Yi Q, Zhang X, Zhang Y, Liu Y. Expert Consensus on Ion Channel Drugs for Chronic Pain Treatment in China. J Pain Res 2024; 17:953-963. [PMID: 38476873 PMCID: PMC10929561 DOI: 10.2147/jpr.s445171] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/17/2023] [Accepted: 01/22/2024] [Indexed: 03/14/2024] Open
Abstract
Ion channel drugs have been increasing used for chronic pain management with progress in the development of selective calcium channel modulators. Although ion channel drugs have been proven safe and effective in clinical practice, uncertainty remains regarding its use to treat chronic pain. To standardize the clinical practice of ion channel drug for the treatment of chronic pain, the National Health Commission Capacity Building and Continuing Education Center for Pain Diagnosis and Treatment Special Ability Training Project established an expert group to form an expert consensus on the use of ion channel drugs for the treatment of chronic pain after repeated discussions on existing medical evidence combined with the well clinical experience of experts. The consensus provided information on the mechanism of action of ion channel drugs and their recommendations, caution use, contraindications, and precautions for their use in special populations to support doctors in their clinical decision-making.
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Affiliation(s)
- Ke Ma
- Department of Algology, Xinhua Hospital Affiliated to Shanghai Jiao Tong University School of Medicine, Shanghai, People’s Republic of China
| | - Zhixiang Cheng
- Department of Algology, The Second Affiliated Hospital of Nanjing Medical University, Nanjing, People’s Republic of China
| | - Hao Jiang
- Department of Algology, The First Affiliated Hospital of Fujian Medical University, Fuzhou, People’s Republic of China
| | - Zhangya Lin
- Department of Neurosurgery, The First Affiliated Hospital of Fujian Medical University, Fuzhou, People’s Republic of China
| | - Chuansheng Liu
- Department of Algology, The Affiliated Hospital of Qingdao University, Qingdao, People’s Republic of China
| | - Xianguo Liu
- Pain Research Center, Zhongshan School of Medicine, Sun Yat-Sen University, Guangzhou, People’s Republic of China
| | - Lijuan Lu
- Department of Pain Medicine, Nanjing Drum Tower Hospital, The Affiliated Hospital of Nanjing University Medical School, Nanjing, People’s Republic of China
| | - Yan Lu
- Department of Algology, Xijing Hospital, The Fourth Military Medical University, Xian, People’s Republic of China
| | - Wei Tao
- Department of Neurosurgery, Shenzhen University General Hospital, Shenzhen, People’s Republic of China
| | - Suoliang Wang
- Department of Algology, The First Affiliated Hospital, Xi’an Jiaotong University, Xi’an, People’s Republic of China
| | - Xiaoqiu Yang
- Department of Algology, The First Affiliated Hospital of Chongqing Medical University, Chongqing, People’s Republic of China
| | - Qishan Yi
- Department of Algology, The Yibin First People’s Hospital Affiliated Chongqing Medical University, Yibin, People’s Republic of China
| | - Xiaomei Zhang
- Department of Algology, The First Affiliated Hospital of Kunming Medical University, Kunming, People’s Republic of China
| | - Ying Zhang
- Department of Algology. Hospital (T.C.M) Affiliated to Southwest Medical University, Luzhou, People’s Republic of China
| | - Yanqing Liu
- Department of Algology, Beijing Tiantan Hospital, Capital Medical University, Beijing, People’s Republic of China
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Walker J, Babyok OL, Saloman JL, Phillips AE. Recent advances in the understanding and management of chronic pancreatitis pain. JOURNAL OF PANCREATOLOGY 2024; 7:35-44. [PMID: 38524856 PMCID: PMC10959534 DOI: 10.1097/jp9.0000000000000163] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/14/2023] [Accepted: 12/09/2023] [Indexed: 03/26/2024] Open
Abstract
Abdominal pain is the most common symptom of chronic pancreatitis (CP) and is often debilitating for patients and very difficult to treat. To date, there exists no cure for the disease. Treatment strategies focus on symptom management and on mitigation of disease progression by reducing toxin exposure and avoiding recurrent inflammatory events. Traditional treatment protocols start with medical management followed by consideration of procedural or surgical intervention on selected patients with severe and persistent pain. The incorporation of adjuvant therapies to treat comorbidities including psychiatric disorders, exocrine pancreatic insufficiency, mineral bone disease, frailty, and malnutrition, are in its early stages. Recent clinical studies and animal models have been designed to improve investigation into the pathophysiology of CP pain, as well as to improve pain management. Despite the array of tools available, many therapeutic options for the management of CP pain provide incomplete relief. There still remains much to discover about the neural regulation of pancreas-related pain. In this review, we will discuss research from the last 5 years that has provided new insights into novel methods of pain phenotyping and the pathophysiology of CP pain. These discoveries have led to improvements in patient selection for optimization of outcomes for both medical and procedural management, and identification of potential future therapies.
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Affiliation(s)
- Jessica Walker
- Department of Internal Medicine, University of Pittsburgh Medical Center, Pittsburgh, PA, United States
| | - Olivia L. Babyok
- Division of Gastroenterology, Hepatology and Nutrition, Department of Medicine, School of Medicine, University of Pittsburgh, Pittsburgh, PA, United States
| | - Jami L. Saloman
- Division of Gastroenterology, Hepatology and Nutrition, Department of Medicine, School of Medicine, University of Pittsburgh, Pittsburgh, PA, United States
- Center for Pain Research, Center for Neuroscience, School of Medicine, University of Pittsburgh, Pittsburgh, PA, United States
| | - Anna Evans Phillips
- Division of Gastroenterology, Hepatology and Nutrition, Department of Medicine, School of Medicine, University of Pittsburgh, Pittsburgh, PA, United States
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Mangnus TJP, Dirckx M, Huygen FJPM. Different Types of Pain in Complex Regional Pain Syndrome Require a Personalized Treatment Strategy. J Pain Res 2023; 16:4379-4391. [PMID: 38162406 PMCID: PMC10757771 DOI: 10.2147/jpr.s432209] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/29/2023] [Accepted: 11/13/2023] [Indexed: 01/03/2024] Open
Abstract
Complex regional pain syndrome (CRPS) is a debilitating painful state of an extremity that can develop after trauma. CRPS is diagnosed by the new International Association for the Study of Pain (IASP) diagnostic criteria for CRPS. The syndrome is characterized by continuing regional pain with abnormal sensory, motor, sudomotor, vasomotor, edema, and/or trophic signs. The clinical presentation of CRPS can be very heterogeneous because CRPS is a multi-mechanism syndrome. Therefore, mechanism-based subgroups have been suggested to personalize treatment for CRPS. Additionally, the presentation of symptom pain may also be able to identify different subgroups of CRPS. In this review, the types of pain recognized by the IASP-nociceptive, neuropathic, and nociplastic pain-will be discussed as possible subgroups for CRPS. Each pain type should be identified in CRPS patients, with a thorough history taking, physical examination, and diagnostic tests or (novel) biomarkers to optimize treatment effectiveness. Over the course of the syndrome, patients with CRPS probably experience more than one distinct pain type. Therefore, pain specialists should be alert to not only adjust their treatment if underlying pathophysiologic mechanisms tend to change but also to personalize the treatment of the associated type of pain in the CRPS patient.
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Affiliation(s)
- Thomas J P Mangnus
- Department of Anesthesiology, Center for Pain Medicine, Erasmus MC University Medical Center, Rotterdam, the Netherlands
| | - Maaike Dirckx
- Department of Anesthesiology, Center for Pain Medicine, Erasmus MC University Medical Center, Rotterdam, the Netherlands
| | - Frank J P M Huygen
- Department of Anesthesiology, Center for Pain Medicine, Erasmus MC University Medical Center, Rotterdam, the Netherlands
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Knoph CS, Nedergaard RB, Olesen SS, Kuhlmann L, Drewes AM. Spinal Excitability in Patients with Painful Chronic Pancreatitis. J Pain Res 2023; 16:2287-2298. [PMID: 37431436 PMCID: PMC10329835 DOI: 10.2147/jpr.s408523] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/04/2023] [Accepted: 06/10/2023] [Indexed: 07/12/2023] Open
Abstract
Purpose Abdominal pain is common in patients with chronic pancreatitis (CP), but management is challenging - possibly due to altered pain processing within the central nervous system rendering conventional treatments ineffective. We hypothesized that many patients with painful CP have generalized hyperalgesia correlating with central neuronal hyperexcitability. Patients and Methods Seventeen CP patients with pain and 20 matched healthy controls underwent experimental pain testing, including repeated pain stimuli (temporal summation), pressure algometry performed in dermatomes with same spinal innervation as the pancreatic gland (pancreatic areas) and remote dermatomes (control areas), a cold pressor test and a conditioned pain modulation paradigm. To probe central neuronal excitability, the nociceptive withdrawal reflex was elicited by electrical stimulation of the plantar skin, and electromyography was obtained from the ipsilateral anterior tibial muscle together with somatosensory evoked brain potentials. Results Compared to healthy controls, patients with painful CP had generalized hyperalgesia as evidenced by 45% lower pressure pain detection thresholds (P<0.05) and decreased cold pressor endurance time (120 vs 180 seconds, P<0.001). In patients, reflex thresholds were lower (14 vs 23 mA, P=0.02), and electromyographic responses were increased (16.4 vs 9.7, P=0.04) during the withdrawal reflex, reflecting predominantly spinal hyperexcitability. Evoked brain potentials did not differ between groups. A positive correlation was found between reflex thresholds and cold pressor endurance time (ρ=0.71, P=0.004). Conclusion We demonstrated somatic hyperalgesia in patients with painful CP associated with spinal hyperexcitability. This highlights that management should be directed at central mechanisms using, eg, gabapentinoids or serotonin-noradrenaline reuptake inhibitors.
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Affiliation(s)
- Cecilie Siggaard Knoph
- Center for Pancreatic Diseases & Mech-Sense, Department of Gastroenterology and Hepatology, Aalborg University Hospital, Aalborg, Denmark
- Department of Clinical Medicine, Aalborg University, Aalborg, Denmark
| | - Rasmus Bach Nedergaard
- Center for Pancreatic Diseases & Mech-Sense, Department of Gastroenterology and Hepatology, Aalborg University Hospital, Aalborg, Denmark
| | - Søren Schou Olesen
- Center for Pancreatic Diseases & Mech-Sense, Department of Gastroenterology and Hepatology, Aalborg University Hospital, Aalborg, Denmark
- Department of Clinical Medicine, Aalborg University, Aalborg, Denmark
| | - Louise Kuhlmann
- Center for Pancreatic Diseases & Mech-Sense, Department of Gastroenterology and Hepatology, Aalborg University Hospital, Aalborg, Denmark
| | - Asbjørn Mohr Drewes
- Center for Pancreatic Diseases & Mech-Sense, Department of Gastroenterology and Hepatology, Aalborg University Hospital, Aalborg, Denmark
- Department of Clinical Medicine, Aalborg University, Aalborg, Denmark
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Jansen N, Berfelo T, Vonkeman HE, Ten Klooster PM, van Den Berg B, Krabbenbos IP, Buitenweg JR. The Relationship between Nociceptive Detection Thresholds and Pressure- and Electrical Pain Thresholds: An Explorative Study in Rheumatoid Arthritis Patients. ANNUAL INTERNATIONAL CONFERENCE OF THE IEEE ENGINEERING IN MEDICINE AND BIOLOGY SOCIETY. IEEE ENGINEERING IN MEDICINE AND BIOLOGY SOCIETY. ANNUAL INTERNATIONAL CONFERENCE 2023; 2023:1-4. [PMID: 38083185 DOI: 10.1109/embc40787.2023.10340755] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/18/2023]
Abstract
Recently, methods have been developed enabling the characterization of the nociceptive function at the detection threshold level by measuring nociceptive detection thresholds (NDTs), rather than at the level of the pain threshold via pain threshold (PT) measurements. Both NDT and PT measurements aim to characterize (parts of) the nociceptive system. To date it is unclear if, and if so to what extent, the two outcomes relate to one another. In this study, the primary aim is to explore the relationship between the two measures in patients with rheumatoid arthritis (RA). As secondary aim, we explore differences in NDT between these RA patients with age- and sex-matched healthy controls (HC) from a readily existing dataset. In total 46 RA patients have been recruited, whereby the pressure- (PPT; bilaterally at two locations) and electrical (EPT) pain threshold were evaluated, as well as the NDTs. Significant, positive correlations were found between the EPT and PPT (R=0.54-0.60), but not with the NDTs (R≤0.25). As compared to HC, higher NDTs were found in the RA group. As the presence of a statistically significant weak relationship can only be evaluated using a larger sample size, our results indicate that there is no moderate or stronger relation between PT and NDT outcomes. This implicates that the two outcomes are not strongly driven by the same (nociceptive) mechanism(s). Future research into NDTs and what factors and/or mechanisms affect the outcome, could yield relevant insights into how to use and interpret the results of this relatively new method.Clinical Relevance - The evaluation of nociceptive detection thresholds, in isolation or together with conventionally evaluated pain thresholds, might provide valuable and complementary insights into nociceptive (dis)function in man.
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Phillips AE, Faghih M, Singh VK, Bick B, Yadav D, Drewes AM, Olesen SS. Widespread Hyperalgesia by Pancreatic Quantitative Sensory Testing Is Associated With Reduced Pain Response in Chronic Pancreatitis. Pancreas 2023; 52:e257-e258. [PMID: 37967828 DOI: 10.1097/mpa.0000000000002247] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/17/2023]
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9
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Mangnus TJP, Dirckx M, Bharwani KD, Baart SJ, Siepman TAM, Redekop K, Dik WA, de Vos CC, Huygen FJPM. Intermittent versus continuous esketamine infusions for long-term pain modulation in complex regional pain syndrome: protocol of a randomized controlled non-inferiority study (KetCRPS-2). BMC Musculoskelet Disord 2023; 24:239. [PMID: 36991381 DOI: 10.1186/s12891-023-06258-4] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/31/2022] [Accepted: 02/20/2023] [Indexed: 03/31/2023] Open
Abstract
BACKGROUND Complex regional pain syndrome (CRPS) is a chronic pain condition of an extremity. While achieving pain relief in CRPS is challenging, esketamine infusions can accomplish pain relief for several weeks post-infusion in a subgroup of CRPS patients. Unfortunately, CRPS esketamine protocols are very heterogeneous in advice on dosage, administration and treatment setting. Currently, no trials are available that study differences between intermittent and continuous esketamine infusions for CRPS. With the current situation of bed shortages, it is difficult to admit patients for several consecutive days for inpatient esketamine treatments. In this study, we investigate whether 6 intermittent outpatient esketamine treatments are not inferior to a continuous 6-day inpatient esketamine treatment in establishing pain relief. In addition, several secondary study parameters will be assessed in order to investigate mechanisms responsible for pain relief by esketamine infusions. Furthermore, the cost-effectiveness will be analyzed. METHODS In this RCT, the primary objective is to demonstrate that an intermittent esketamine dosing regimen is non-inferior to a continuous esketamine dosing regimen at 3 months follow-up. We will include 60 adult CRPS patients. The inpatient treatment group receives a continuous intravenous esketamine infusion for 6 consecutive days. The outpatient treatment group receives a 6-hour intravenous esketamine infusion every 2 weeks for 3 months. Esketamine dose will be individually tailored and is started at 0.05 mg/kg/h and can be increased to a maximum of 0.2 mg/kg/h. Each patient will be followed for 6 months. The primary study parameter is perceived pain intensity, measured by an 11-point Numerical Rating Scale. Secondary study parameters are conditioned pain modulation, quantitative sensory testing, adverse events, thermography, blood inflammatory parameter, questionnaires about functionality, quality of life and mood and costs per patient. DISCUSSION If our study reveals non-inferiority between intermittent and continuous esketamine infusions, these findings can be beneficial to increase the availability and flexibility of esketamine infusions through outpatient treatments. Furthermore, the costs of outpatient esketamine infusions could be lower than inpatient esketamine infusions. In addition, secondary parameters may predict response to esketamine treatment. TRIAL REGISTRATION ClinicalTrials.gov Identifier NCT05212571 , date of registration 01-28-2022. PROTOCOL VERSION Version 3, February 2022.
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Affiliation(s)
- Thomas J P Mangnus
- Department of Anesthesiology, Center for Pain Medicine, Erasmus MC University Medical Center, Rotterdam, the Netherlands.
| | - Maaike Dirckx
- Department of Anesthesiology, Center for Pain Medicine, Erasmus MC University Medical Center, Rotterdam, the Netherlands
| | - Krishna D Bharwani
- Department of Anesthesiology, Center for Pain Medicine, Erasmus MC University Medical Center, Rotterdam, the Netherlands
| | - Sara J Baart
- Department of Biostatistics, Erasmus MC University Medical Center, Rotterdam, the Netherlands
| | - Theodora A M Siepman
- Department of Anesthesiology, Center for Pain Medicine, Erasmus MC University Medical Center, Rotterdam, the Netherlands
| | - Ken Redekop
- Institute of Health Policy & Management, Erasmus University, Rotterdam, the Netherlands
| | - Willem A Dik
- Laboratory Medical Immunology, Department of Immunology, Erasmus MC University Medical Center, Rotterdam, the Netherlands
| | - Cecile C de Vos
- Department of Anesthesiology, Center for Pain Medicine, Erasmus MC University Medical Center, Rotterdam, the Netherlands
| | - Frank J P M Huygen
- Department of Anesthesiology, Center for Pain Medicine, Erasmus MC University Medical Center, Rotterdam, the Netherlands
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Characterizing mechanism-based pain phenotypes in patients with chronic pancreatitis: a cross-sectional analysis of the PROspective Evaluation of Chronic Pancreatitis for EpidEmiologic and Translational StuDies. Pain 2023; 164:375-384. [PMID: 36149018 PMCID: PMC9726990 DOI: 10.1097/j.pain.0000000000002710] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/16/2022] [Accepted: 05/31/2022] [Indexed: 02/06/2023]
Abstract
ABSTRACT Pain is common in chronic pancreatitis (CP) and profoundly reduces quality of life (QoL). Multiple underlying mechanisms contribute to a heterogenous pain experience and reduce efficacy of pain management. This study was designed to characterize the distribution of mechanism-based pain phenotypes in painful CP. The data analyzed were collected as part of the PROspective Evaluation of Chronic Pancreatitis for EpidEmiologic and Translational StuDies, an NCI/NIDDK-funded longitudinal study of the natural history of CP. The PROspective Evaluation of Chronic pancreatitis for EpidEmiologic and translational stuDies includes patient-reported outcome (PRO) measures of pain, medication use, global health, and QoL. Of subjects (N = 681) with CP, 80% experienced abdominal pain within the year before enrollment. Subjects who experienced pain in the week before enrollment (N = 391) completed PROMIS Neuropathic and Nociceptive Pain Quality instruments which were then used to classify them by pain type: 40% had nociceptive, 5% had neuropathic-like, and 32% had both types of pain. The prevalence of having both types of pain was higher among women and subjects with diabetes mellitus, whereas nociceptive-only pain was more prevalent among men and those with pancreatic duct stricture. Other factors, including pain medication use and healthcare utilization, did not differ between groups based on pain type. Subjects in the Both group had significantly worse health and QoL scores relative to those with nociceptive-only pain, suggesting that using psychosocial pain surveys may be useful for understanding pain subtypes in patients with CP. Additional research is needed to identify biochemical and biophysical signatures that may associate with and predict responses to mechanism-specific interventions.
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Edwards RR, Schreiber KL, Dworkin RH, Turk DC, Baron R, Freeman R, Jensen TS, Latremoliere A, Markman JD, Rice ASC, Rowbotham M, Staud R, Tate S, Woolf CJ, Andrews NA, Carr DB, Colloca L, Cosma-Roman D, Cowan P, Diatchenko L, Farrar J, Gewandter JS, Gilron I, Kerns RD, Marchand S, Niebler G, Patel KV, Simon LS, Tockarshewsky T, Vanhove GF, Vardeh D, Walco GA, Wasan AD, Wesselmann U. Optimizing and Accelerating the Development of Precision Pain Treatments for Chronic Pain: IMMPACT Review and Recommendations. THE JOURNAL OF PAIN 2023; 24:204-225. [PMID: 36198371 PMCID: PMC10868532 DOI: 10.1016/j.jpain.2022.08.010] [Citation(s) in RCA: 20] [Impact Index Per Article: 20.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/11/2022] [Revised: 08/01/2022] [Accepted: 08/17/2022] [Indexed: 11/06/2022]
Abstract
Large variability in the individual response to even the most-efficacious pain treatments is observed clinically, which has led to calls for a more personalized, tailored approach to treating patients with pain (ie, "precision pain medicine"). Precision pain medicine, currently an aspirational goal, would consist of empirically based algorithms that determine the optimal treatments, or treatment combinations, for specific patients (ie, targeting the right treatment, in the right dose, to the right patient, at the right time). Answering this question of "what works for whom" will certainly improve the clinical care of patients with pain. It may also support the success of novel drug development in pain, making it easier to identify novel treatments that work for certain patients and more accurately identify the magnitude of the treatment effect for those subgroups. Significant preliminary work has been done in this area, and analgesic trials are beginning to utilize precision pain medicine approaches such as stratified allocation on the basis of prespecified patient phenotypes using assessment methodologies such as quantitative sensory testing. Current major challenges within the field include: 1) identifying optimal measurement approaches to assessing patient characteristics that are most robustly and consistently predictive of inter-patient variation in specific analgesic treatment outcomes, 2) designing clinical trials that can identify treatment-by-phenotype interactions, and 3) selecting the most promising therapeutics to be tested in this way. This review surveys the current state of precision pain medicine, with a focus on drug treatments (which have been most-studied in a precision pain medicine context). It further presents a set of evidence-based recommendations for accelerating the application of precision pain methods in chronic pain research. PERSPECTIVE: Given the considerable variability in treatment outcomes for chronic pain, progress in precision pain treatment is critical for the field. An array of phenotypes and mechanisms contribute to chronic pain; this review summarizes current knowledge regarding which treatments are most effective for patients with specific biopsychosocial characteristics.
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Affiliation(s)
| | | | | | - Dennis C Turk
- Department of Anesthesiology and Pain Medicine, University of Washington, Seattle, Washington
| | - Ralf Baron
- Division of Neurological Pain Research and Therapy, Department of Neurology, University Hospital Schleswig-Holstein, Arnold-Heller-Straße 3, House D, 24105 Kiel, Germany
| | - Roy Freeman
- Harvard Medical School, Boston, Massachusetts
| | | | | | | | | | | | | | | | | | - Nick A Andrews
- Salk Institute for Biological Studies, San Diego, California
| | | | | | | | - Penney Cowan
- American Chronic Pain Association, Rocklin, California
| | - Luda Diatchenko
- Department of Anesthesia and Faculty of Dentistry, McGill University, Montreal, California
| | - John Farrar
- University of Pennsylvania, Philadelphia, Pennsylvania
| | | | | | - Robert D Kerns
- Yale University, Departments of Psychiatry, Neurology, and Psychology, New Haven, Connecticut
| | | | | | - Kushang V Patel
- Department of Anesthesiology and Pain Medicine, University of Washington, Seattle, Washington
| | | | | | | | | | - Gary A Walco
- Department of Anesthesiology and Pain Medicine, University of Washington, Seattle, Washington
| | - Ajay D Wasan
- University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Ursula Wesselmann
- Department of Anesthesiology/Division of Pain Medicine, Neurology and Psychology, The University of Alabama at Birmingham, Birmingham, Alabama
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12
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Petersen KKS. Predicting pain after standard pain therapy for knee osteoarthritis - the first steps towards personalized mechanistic-based pain medicine in osteoarthritis. Scand J Pain 2023; 23:40-48. [PMID: 35993966 DOI: 10.1515/sjpain-2022-0082] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/20/2022] [Accepted: 08/01/2022] [Indexed: 01/17/2023]
Abstract
OBJECTIVES The prevalence of osteoarthritis (OA) is rising, and pain is the hallmark symptom of OA. Pain in OA is complicated and can be influenced by multiple joint-related factors and factors related to, e.g., physiological, epigenetic, and pain sensory profiles. Increasing evidence suggests that a subset of patients with OA are pain sensitive. This can be assessed using quantitative sensory testing (QST). Common treatments of OA are total knee arthroplasty (TKA) and administration of 3-weeks of non-steroidal anti-inflammatory drugs (NSAIDs), which provide pain relief to many patients with OA. However, approx. 20% of patients experience chronic postoperative pain after TKA, whereas NSAIDs provide an average pain relief of approx. 25%. The current topical review focuses on the emerging evidence linking pretreatment QST to the treatment response of TKA and NSAID treatments. CONTENT MEDLINE was systematically searched for all studies from 2000 to 2022 on pretreatment QST, TKA, and NSAIDs. Pre-clinical studies, reviews, and meta-analyses were excluded. SUMMARY Currently, 14 studies on TKA and four studies on NSAIDs have been published with the aim to attempt prediction of the treatment response. The QST methodologies in the studies are inconsistent, but 11/14 (79%) studies on TKA and 4/4 (100%) studies on NSAIDs report statistically significant associations between pretreatment QST and chronic postoperative pain after TKA or analgesic effect after NSAID treatment. The strength of the associations remains low-to-moderate. The most consistent pretreatment QST predictors are pressure pain thresholds, temporal summation of pain, and conditioned pain modulation. OUTLOOK The use of QST as predictors of standard OA treatment is interesting, but the predictive strength remains low-to-moderate. A transition of QST from a research-based setting and into the clinic is not advised until the predictive strength has been improved and the methodology has been standardized.
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Affiliation(s)
- Kristian Kjær-Staal Petersen
- Center for Neuroplasticity and Pain, Department of Health Science and Technology, Faculty of Medicine, Aalborg University, Aalborg, Denmark
- Center for Mathematical Modelling of Knee Osteoarthritis, Department of Materials and Production, Aalborg University, Aalborg, Denmark
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13
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Kriek N, de Vos CC, Groeneweg JG, Baart SJ, Huygen FJPM. Allodynia, Hyperalgesia, (Quantitative) Sensory Testing and Conditioned Pain Modulation in Patients With Complex Regional Pain Syndrome Before and After Spinal Cord Stimulation Therapy. Neuromodulation 2023; 26:78-86. [PMID: 36050204 DOI: 10.1016/j.neurom.2022.06.009] [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: 02/12/2022] [Revised: 05/14/2022] [Accepted: 06/07/2022] [Indexed: 01/11/2023]
Abstract
OBJECTIVES Complex regional pain syndrome (CRPS) is a chronic debilitating disease characterized by sensory abnormalities. Spinal cord stimulation (SCS) is an effective therapy for CRPS, but few studies have investigated the effects of SCS therapy on sensory characteristics. Therefore, this study investigated the effect of SCS on allodynia, hyperalgesia, electrical quantitative sensory testing (QST) parameters, and conditioned pain modulation (CPM) effect. MATERIALS AND METHODS This study is part of a multicenter randomized controlled trial (ISRCTN 36655259). Patients with CRPS in one extremity and eligible for SCS were included. The outcome parameters allodynia (symptom and sign), hyperalgesia (symptom), sensory thresholds with QST, CPM effect, and pain scores were tested before and after three months of SCS (40-Hz tonic SCS). Both the CRPS-affected extremity and the contralateral, clinically unaffected extremity were used to test three sensory thresholds with electrical QST: current perception threshold (CPT), pain perception threshold (PPT), and pain tolerance threshold (PTT). The PTT also was used as a test stimulus for the CPM paradigm both before and after the conditioning ice-water test. Nonparametric testing was used for all statistical analyses. RESULTS In total, 31 patients were included for analysis. Pain, allodynia (sign and symptom), and hyperalgesia (symptom) were all significantly reduced after SCS therapy. On the unaffected side, none of the QST thresholds (CPT, PPT, and PTT) was significantly altered after SCS therapy. However, the CPT on the CRPS-affected side was significantly increased after SCS therapy. A CPM effect was present both before and after SCS. CONCLUSIONS Standard 40-Hz tonic SCS significantly reduces pain, hyperalgesia, and allodynia in patients with CRPS. These findings suggest that SCS therapy should not be withheld from patients who suffer from allodynia and hyperalgesia, which contradicts previous findings derived from retrospective analysis and animal research. ISRCTN Registry: The ISRCTN registration number for the study is ISRCTN 36655259.
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Affiliation(s)
- Nadia Kriek
- Center for Pain Medicine, Erasmus University Medical Center, Rotterdam, the Netherlands.
| | - Cecile C de Vos
- Center for Pain Medicine, Erasmus University Medical Center, Rotterdam, the Netherlands
| | - Johannes G Groeneweg
- Center for Pain Medicine, Erasmus University Medical Center, Rotterdam, the Netherlands
| | - Sara J Baart
- Department of Biostatistics, Erasmus University Medical Center, Rotterdam, the Netherlands
| | - Frank J P M Huygen
- Center for Pain Medicine, Erasmus University Medical Center, Rotterdam, the Netherlands
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14
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Kuhlmann L, Olesen SS, Drewes AM. Assessment of visceral pain with special reference to chronic pancreatitis. FRONTIERS IN PAIN RESEARCH (LAUSANNE, SWITZERLAND) 2022; 3:1067103. [PMID: 36606031 PMCID: PMC9807876 DOI: 10.3389/fpain.2022.1067103] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 10/11/2022] [Accepted: 12/06/2022] [Indexed: 12/24/2022]
Abstract
A thorough pain assessment is of utmost importance when managing pain in clinical practice as it is the foundation for defining pain in need of treatment, either interventional or pharmacological. Pain characteristics can also guide interventional strategies and help evaluate the effect of treatment. In research settings, standardized pain assessment is crucial to improve comparability across studies and facilitate meta-analysis. Due to the importance of thorough visceral pain assessment, this manuscript describes the key elements of pain evaluation focusing on chronic pancreatitis. Most studies in pain assessment have focused on somatic pain, and although chronic pain often shares characteristics between etiologies, some differences must be addressed when assessing visceral pain. Especially differences between somatic and visceral pain are apparent, where visceral pain is diffuse and difficult to localize, with referred pain aspects and often autonomic symptoms dominating the clinical picture. These aspects need to be incorporated into the pain assessment instrument. The manuscript will discuss the different ways of assessing pain, including unidimensional measurement scales, multidimensional questionnaires, and quantitative sensory testing. The advantages and challenges linked to the different methods will be evaluated.
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Affiliation(s)
- Louise Kuhlmann
- Mech-Sense, Department of Gastroenterology and Hepatology, Aalborg University Hospital, Aalborg, Denmark,Department of Clinical Medicine, Aalborg University, Aalborg, Denmark,Correspondence: Louise Kuhlmann
| | - Søren Schou Olesen
- Mech-Sense, Department of Gastroenterology and Hepatology, Aalborg University Hospital, Aalborg, Denmark,Department of Clinical Medicine, Aalborg University, Aalborg, Denmark
| | - Asbjørn Mohr Drewes
- Mech-Sense, Department of Gastroenterology and Hepatology, Aalborg University Hospital, Aalborg, Denmark,Department of Clinical Medicine, Aalborg University, Aalborg, Denmark
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15
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Hargreaves R, Akinsanya K, Ajit SK, Dhruv NT, Driscoll J, Farina P, Gavva N, Gill M, Houghton A, Iyengar S, Jones C, Kavelaars A, Kaykas A, Koroshetz WJ, Laeng P, Laird JM, Lo DC, Luthman J, Munro G, Oshinsky ML, Sittampalam GS, Woller SA, Tamiz AP. Preclinical target validation for non-addictive therapeutics development for pain. Expert Opin Ther Targets 2022; 26:811-822. [DOI: 10.1080/14728222.2022.2147063] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Affiliation(s)
| | | | - Seena K. Ajit
- Department of Pharmacology, Drexel University College of Medicine, Philadelphia, Pennsylvania, United States
| | - Neel T. Dhruv
- National Institute of Neurological Disorders and Stroke, Bethesda, Maryland, United States
| | - Jamie Driscoll
- National Institute of Mental Health, Bethesda, Maryland, United States
| | - Peter Farina
- Canaan Partners, Westport, Connecticut, United States
| | - Narender Gavva
- Drug Discovery Sciences, Takeda Pharmaceuticals, San Diego, California, United States
| | - Marie Gill
- National Institute of Neurological Disorders and Stroke, Bethesda, Maryland, United States
| | | | - Smriti Iyengar
- National Institute of Neurological Disorders and Stroke, Bethesda, Maryland, United States
| | - Carrie Jones
- Department of Pharmacology, Vanderbilt University, Nashville, Tennessee, United States
| | - Annemieke Kavelaars
- The University of Texas MD Anderson Cancer Center, Houston, Texas, United States
| | | | - Walter J. Koroshetz
- National Institute of Neurological Disorders and Stroke, Bethesda, Maryland, United States
| | - Pascal Laeng
- National Institute of Neurological Disorders and Stroke, Bethesda, Maryland, United States
| | - Jennifer M. Laird
- Eli Lilly and Company, Windlesham, United Kingdom of Great Britain and Northern Ireland
| | - Donald C. Lo
- National Center for Advancing Translational Sciences, Bethesda, Maryland, United States
| | | | | | - Michael L. Oshinsky
- National Institute of Neurological Disorders and Stroke, Bethesda, Maryland, United States
| | - G. Sitta Sittampalam
- National Center for Advancing Translational Sciences, Bethesda, Maryland, United States
| | - Sarah A. Woller
- National Institute of Neurological Disorders and Stroke, Bethesda, Maryland, United States
| | - Amir P. Tamiz
- National Institute of Neurological Disorders and Stroke, Bethesda, Maryland, United States
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16
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Association between the Use of Quantitative Sensory Testing and Conditioned Pain Modulation and the Prescription of Medication and Interventional Procedures in Children with Chronic Pain Conditions. CHILDREN (BASEL, SWITZERLAND) 2022; 9:children9081157. [PMID: 36010048 PMCID: PMC9406785 DOI: 10.3390/children9081157] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 06/20/2022] [Revised: 07/15/2022] [Accepted: 07/28/2022] [Indexed: 11/17/2022]
Abstract
The evidence supporting the use of pharmacological treatments in pediatric chronic pain is limited. Quantitative sensory testing (QST) and conditioned pain modulation evaluation (CPM) provide information on pain phenotype, which may help clinicians to tailor the treatment. This retrospective study aimed to evaluate the association between the use of QST/CPM phenotyping on the selection of the treatment for children with chronic pain conditions. We retrospectively analyzed the medical records of 208 female patients (mean age 15 ± 2 years) enrolled in an outpatient interdisciplinary pediatric complex pain center. Pain phenotype information (QST/CPM) of 106 patients was available to the prescribing physician. The records of 102 age- and sex-matched patients without QST/CPM were used as controls. The primary endpoint was the proportion of medications and interventions prescribed. The secondary endpoint was the duration of treatment. The QST/CPM group received less opioids (7% vs. 28%, respectively, p < 0.001), less anticonvulsants (6% vs. 25%, p < 0.001), and less interventional treatments (29% vs. 44%, p = 0.03) than controls. Patients with an optimal CPM result tended to be prescribed fewer antidepressants (2% vs. 18%, p = 0.01), and patients with signs of allodynia and/or temporal summation tended to be prescribed fewer NSAIDs (57% vs. 78%, p = 0.04). There was no difference in the duration of the treatments between the groups. QST/CPM testing appears to provide more targeted therapeutic options resulting in the overall drop in polypharmacy and reduced use of interventional treatments while remaining at least as effective as the standard of care.
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17
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Buscaglia JM, Chang L. Pain Phenotypes in Chronic Pancreatitis: Beginning to Fine-tune Our Approach to Treatment. Clin Gastroenterol Hepatol 2022; 20:28-30. [PMID: 33387669 DOI: 10.1016/j.cgh.2020.12.032] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/17/2020] [Accepted: 12/28/2020] [Indexed: 02/07/2023]
Affiliation(s)
- Jonathan M Buscaglia
- Division of Gastroenterology, Department of Medicine, Renaissance School of Medicine at Stony Brook University, Stony Brook, New York
| | - Lin Chang
- Vatche and Tamar Manoukian Division of Digestive Diseases, David Geffen School of Medicine at UCLA, Los Angeles, California
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18
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Faghih M, Phillips AE, Kuhlmann L, Afghani E, Drewes AM, Yadav D, Singh VK, Olesen SS. Pancreatic QST Differentiates Chronic Pancreatitis Patients into Distinct Pain Phenotypes Independent of Psychiatric Comorbidities. Clin Gastroenterol Hepatol 2022; 20:153-161.e2. [PMID: 34108130 PMCID: PMC8629107 DOI: 10.1016/j.cgh.2020.10.036] [Citation(s) in RCA: 17] [Impact Index Per Article: 8.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/29/2020] [Revised: 10/12/2020] [Accepted: 10/16/2020] [Indexed: 02/07/2023]
Abstract
BACKGROUND & AIMS Quantitative sensory testing (QST) has been previously used to study pain in chronic pancreatitis (CP) but included methods that are not suitable for clinical purposes. The aims of this study were to determine if pancreatic QST (P-QST) can differentiate patients into distinct pain phenotypes and to determine the association of these with their clinical pain and psychiatric comorbidities. METHODS A multicenter cross-sectional study was conducted where patients completed validated questionnaires assessing quality of life (QoL), depression and anxiety scores as well as clinical pain symptoms followed by P-QST which included a cold pressor test, repetitive pinprick stimuli and pressure stimulation of the upper abdominal (T10) and control dermatomes. P-QST categorized patients into pain phenotypes based on a previously established nomogram. QoL, clinical pain and psychiatric assessment scores were compared across these groups. RESULTS A total of 179 patients were enrolled with a mean age of 54.1±13.6 years among whom 59% were males and 42% had an alcoholic etiology. P-QST showed no hyperalgesia in 91 (51%), segmental hyperalgesia in 50 (28%) and widespread hyperalgesia in 38 (21%) patients. Patients with widespread hyperalgesia had significantly higher pain intensity scores (P = .03) and rates of constant pain (P = .002) as well as decreased QoL (P < .001) and physical functioning (P =.03) in comparison with the other two pain phenotypes. In contrast, psychiatric comorbidities were similar across all groups. CONCLUSIONS P-QST may serve as a novel unbiased pain assessment tool in CP as it categorizes patients into distinct pain phenotypes independent of their psychiatric comorbidities.
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Affiliation(s)
- Mahya Faghih
- Division of Gastroenterology, Department of Medicine, Johns Hopkins Medical Institutions, Baltimore, Maryland
| | - Anna E Phillips
- University of Pittsburgh School of Medicine, Department of Medicine, Division of Gastroenterology, Hepatology, and Nutrition, Pittsburgh, Pennsylvania
| | - Louise Kuhlmann
- Centre for Pancreatic Diseases and Mech-Sense, Department of Gastroenterology and Hepatology, Aalborg University, Aalborg, Denmark; Department of Clinical Medicine, Aalborg University, Aalborg, Denmark
| | - Elham Afghani
- Division of Gastroenterology, Department of Medicine, Johns Hopkins Medical Institutions, Baltimore, Maryland; Pancreatitis Center, Department of Medicine, Johns Hopkins Medical Institutions, Baltimore, Maryland
| | - Asbjørn M Drewes
- Centre for Pancreatic Diseases and Mech-Sense, Department of Gastroenterology and Hepatology, Aalborg University, Aalborg, Denmark; Department of Clinical Medicine, Aalborg University, Aalborg, Denmark
| | - Dhiraj Yadav
- University of Pittsburgh School of Medicine, Department of Medicine, Division of Gastroenterology, Hepatology, and Nutrition, Pittsburgh, Pennsylvania
| | - Vikesh K Singh
- Division of Gastroenterology, Department of Medicine, Johns Hopkins Medical Institutions, Baltimore, Maryland; Pancreatitis Center, Department of Medicine, Johns Hopkins Medical Institutions, Baltimore, Maryland.
| | - Søren S Olesen
- Centre for Pancreatic Diseases and Mech-Sense, Department of Gastroenterology and Hepatology, Aalborg University, Aalborg, Denmark; Department of Clinical Medicine, Aalborg University, Aalborg, Denmark
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19
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Ammitzbøll N, Arendt-Nielsen L, Bertoli D, Brock C, Olesen AE, Kappel A, Drewes AM, Petersen KK. A mechanism-based proof of concept study on the effects of duloxetine in patients with painful knee osteoarthritis. Trials 2021; 22:958. [PMID: 34961547 PMCID: PMC8710922 DOI: 10.1186/s13063-021-05941-y] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/07/2021] [Accepted: 12/15/2021] [Indexed: 12/27/2022] Open
Abstract
BACKGROUND The global burden of osteoarthritis (OA) is steadily increasing due to demographic and lifestyle changes. The nervous system can undergo peripheral and central neuroplastic changes (sensitization) in patients with OA impacting the options to manage the pain adequately. As a result of sensitization, patients with OA show lower pressure pain thresholds (PPTs), facilitated temporal summation of pain (TSP), and impaired conditioned pain modulation (CPM). As traditional analgesics (acetaminophen and non-steroidal anti-inflammatory drugs) are not recommended for long-term use in OA, more fundamental knowledge related to other possible management regimes are needed. Duloxetine is a serotonin-noradrenalin reuptake inhibitor, and analgesic effects are documented in patients with OA although the underlying fundamental mechanisms remain unclear. The descending pain inhibitory control system is believed to be dependent on serotonin and noradrenalin. We hypothesized that the analgesic effect of duloxetine could act through these pathways and consequently indirectly reduce pain and sensitization. The aim of this mechanistic study is to investigate if PPTs, TSP, CPM, and clinical pain parameters are modulated by duloxetine. METHODS This proof of concept study is a randomized, placebo-controlled, double-blinded, crossover trial, which compares PPTs, TSP, and CPM before and after 18 weeks of duloxetine and placebo in forty patients with knee OA. The intervention periods include a titration period (2 weeks), treatment period (60 mg daily for 14 weeks), and a discontinuation period (2 weeks). Intervention periods are separated by 2 weeks. DISCUSSION Duloxetine is recommended for the treatment of chronic pain, but the underlying mechanisms of the analgesic effects are currently unknown. This study will investigate if duloxetine can modify central pain mechanisms and thereby provide insights into the underlying mechanisms of the analgesic effect. TRIAL REGISTRATION ClinicalTrials.gov NCT04224584 . Registered on January 6, 2020. EudraCT 2019-003437-42 . Registered on October 22, 2019. The North Denmark Region Committee on Health Research Ethics N-20190055. Registered on October 31, 2019.
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Affiliation(s)
- Nadia Ammitzbøll
- Department of Gastroenterology and Hepatology, Aalborg University Hospital, Aalborg, Denmark
| | - Lars Arendt-Nielsen
- Center for Neuroplasticity and Pain, SMI, Department of Health Science and Technology, Faculty of Medicine, Aalborg University, Aalborg, Denmark.,Center for Neuroplasticity and Pain, Department of Health Science and Technology, Faculty of Medicine, Aalborg University, Aalborg, Denmark
| | - Davide Bertoli
- Department of Gastroenterology and Hepatology, Aalborg University Hospital, Aalborg, Denmark.,Department of Clinical Medicine, Faculty of Medicine, Aalborg University, Aalborg, Denmark
| | - Christina Brock
- Department of Gastroenterology and Hepatology, Aalborg University Hospital, Aalborg, Denmark.,Department of Clinical Medicine, Faculty of Medicine, Aalborg University, Aalborg, Denmark
| | - Anne Estrup Olesen
- Department of Clinical Medicine, Faculty of Medicine, Aalborg University, Aalborg, Denmark.,Department of Clinical Pharmacology, Aalborg University Hospital, Aalborg, Denmark
| | - Andreas Kappel
- Department of Clinical Medicine, Faculty of Medicine, Aalborg University, Aalborg, Denmark.,Department of Orthopaedics, Aalborg University Hospital, Aalborg, Denmark
| | - Asbjørn Mohr Drewes
- Department of Gastroenterology and Hepatology, Aalborg University Hospital, Aalborg, Denmark.,Department of Clinical Medicine, Faculty of Medicine, Aalborg University, Aalborg, Denmark
| | - Kristian Kjær Petersen
- Center for Neuroplasticity and Pain, SMI, Department of Health Science and Technology, Faculty of Medicine, Aalborg University, Aalborg, Denmark. .,Center for Neuroplasticity and Pain, Department of Health Science and Technology, Faculty of Medicine, Aalborg University, Aalborg, Denmark.
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20
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Machida T, Katayama H, Yoshida O, Watanabe A. Successful Pain Relief With Duloxetine in a Patient With Chronic Postsurgical Pain After Open Reduction and Internal Fixation: A Case Report. Cureus 2021; 13:e20456. [PMID: 35070525 PMCID: PMC8760792 DOI: 10.7759/cureus.20456] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/15/2021] [Indexed: 11/17/2022] Open
Abstract
Chronic postsurgical pain (CPSP) is a common complication of surgery. We report that a patient with CPSP after open reduction and internal fixation (ORIF) had pain relief with duloxetine, and that the conditioned pain modulation (CPM) efficiency may predict the efficacy of duloxetine. A 54-year-old woman with CPSP after ORIF due to proximal humeral fracture was presented to our orthopedic clinic one month after surgery. Despite several analgesics, she still had pain three months after surgery, pain during activity was 74 on the visual analogue scale (VAS), 16 on the American Shoulder and Elbow Surgeons Standardized Shoulder Assessment Form (ASES), 18 on the PainDETECT questionnaire, and CPM efficiency was -5.7%. The patient was treated with duloxetine, starting at 20mg/day and increasing every week. Three months after starting duloxetine, pain on the VAS was 18, ASES was 61, PainDETECT questionnaire was 6, and CPM efficiency was -39.8%. The dose of duloxetine was decreased every week and then withdrawn. Neuropathic pain may be involved even in patients with CPSP after ORIF, and duloxetine may be efficacious in such cases. CPM testing may provide useful information for clinicians in selecting appropriate drugs and in determining when to withdraw drugs.
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21
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Wilson SH, Hellman KM, James D, Adler AC, Chandrakantan A. Mechanisms, Diagnosis, and Medical Management of Hyperalgesia: an Educational Review. CURRENT ANESTHESIOLOGY REPORTS 2021. [DOI: 10.1007/s40140-021-00485-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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22
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Phillips AE, Faghih M, Singh VK, Olesen SS, Kuhlmann L, Novovic S, Bick B, Hart PA, Ramsey ML, Talukdar R, Garg PK, Yadav D, Drewes AM. Rationale for and Development of the Pancreatic Quantitative Sensory Testing Consortium to Study Pain in Chronic Pancreatitis. Pancreas 2021; 50:1298-1304. [PMID: 34860815 DOI: 10.1097/mpa.0000000000001912] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/26/2023]
Abstract
OBJECTIVES Abdominal pain is the primary symptom of chronic pancreatitis (CP), but pain is difficult to assess, and objective methods for pain assessment are lacking. The characterization of the sensory component of pain as a surrogate for nociception can be achieved by sensory testing using standardized stimuli. Herein, we describe the rationale for and development of an international consortium to better understand and characterize CP pain. METHODS A collaboration was initially formed between the University of Aalborg, Johns Hopkins University, and the University of Pittsburgh. This group refined the protocol for pancreatic quantitative sensory testing (P-QST) and then expanded the collaboration with plans for incorporating P-QST into prospective studies. RESULTS The collaboration has successfully developed a P-QST nomogram. Chronic pancreatitis patients identified with P-QST as having widespread hyperalgesia had higher pain intensity scores, higher prevalence of constant pain, and decreased quality of life. Psychiatric comorbidities were independent of pain phenotypes. Multiple studies are underway to validate these findings and evaluate their utility in clinical trials. CONCLUSIONS Development of the P-QST Consortium will facilitate collaborative efforts to use P-QST as a means for evaluation and characterization of pain in CP patients, and optimize methods to guide individualized pain management approaches.
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Affiliation(s)
- Anna Evans Phillips
- From the Division of Gastroenterology, Hepatology, and Nutrition, Department of Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA
| | - Mahya Faghih
- Division of Gastroenterology and Hepatology, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Vikesh K Singh
- Division of Gastroenterology and Hepatology, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD
| | | | | | - Srdan Novovic
- Pancreatitis Centre Copenhagen, Gastrounit, Hvidovre Hospital, Copenhagen, Denmark
| | - Benjamin Bick
- Division of Gastroenterology and Hepatology, Department of Medicine, Indiana University School of Medicine, Indianapolis, IN
| | - Philip A Hart
- Division of Gastroenterology, Hepatology, and Nutrition, Department of Medicine, The Ohio State University Wexner Medical Center, Columbus, OH
| | - Mitchell L Ramsey
- Division of Gastroenterology, Hepatology, and Nutrition, Department of Medicine, The Ohio State University Wexner Medical Center, Columbus, OH
| | - Rupjyoti Talukdar
- Department of Gastroenterology, Asian Institute of Gastroenterology, Hyderabad
| | - Pramod K Garg
- Department of Gastroenterology, All India Institute of Medical Sciences, New Delhi, India
| | - Dhiraj Yadav
- From the Division of Gastroenterology, Hepatology, and Nutrition, Department of Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA
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Assessment of pain associated with chronic pancreatitis: An international consensus guideline. Pancreatology 2021; 21:1256-1284. [PMID: 34391675 DOI: 10.1016/j.pan.2021.07.004] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/13/2021] [Revised: 07/16/2021] [Accepted: 07/16/2021] [Indexed: 12/11/2022]
Abstract
Pain is the most common symptom in chronic pancreatitis (CP) with a major impact on quality of life. Few validated questionnaires to assess pain in CP exist, and the lack of consensus negatively impacts clinical management, research and meta-analysis. This guideline aims to review generic pain questionnaires for their usability in CP, to outline how pain assessment can be modified by confounding factors and pain types, to assess the value of additional measures such as quality of life, mental health and quantitative sensory testing, and finally to review pain assessment questionnaires used specifically in CP. A systematic review was done to answer 27 questions that followed the PICO (Population; Intervention; Comparator; Outcome) template. Quality of evidence of the statements was judged by Grades of Recommendation, Assessment, Development and Evaluation (GRADE) criteria. The manuscript was sent for review to 36 experts from various disciplines and continents in a multi-stage Delphi process, and finally reviewed by patient representatives. Main findings were that generic pain instruments are valid in most settings, but aspects of pain are specific for CP (including in children), and instruments have to account for the wide phenotypic variability and development of sensitization of the central nervous system. Side effects to treatment and placebo effects shall also be considered. Some multidimensional questionnaires are validated for CP and are recommended together with assessment of quality of life and psychiatric co-morbidities. This guideline will result in more homogeneous and comprehensive pain assessment to potentially improve management of painful CP.
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Sean M, Coulombe-Lévêque A, Bordeleau M, Vincenot M, Gendron L, Marchand S, Léonard G. Comparison of Thermal and Electrical Modalities in the Assessment of Temporal Summation of Pain and Conditioned Pain Modulation. FRONTIERS IN PAIN RESEARCH 2021; 2:659563. [PMID: 35295416 PMCID: PMC8915752 DOI: 10.3389/fpain.2021.659563] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/27/2021] [Accepted: 08/16/2021] [Indexed: 11/29/2022] Open
Abstract
Temporal summation of pain (TSP) and conditioned pain modulation (CPM) can be measured using a thermode and a cold pressor test (CPT). Unfortunately, these tools are complex, expensive, and are ill-suited for routine clinical assessments. Building on the results from an exploratory study that attempted to use transcutaneous electrical nerve stimulation (TENS) to measure CPM and TSP, the present study assesses whether a “new” TENS protocol can be used instead of the thermode and CPT to measure CPM and TSP. The objective of this study was to compare the thermode/CPT protocol with the new TENS protocol, by (1) measuring the association between the TSP evoked by the two protocols; (2) measuring the association between the CPM evoked by the two protocols; and by (3) assessing whether the two protocols successfully trigger TSP and CPM in a similar number of participants. We assessed TSP and CPM in 50 healthy participants, using our new TENS protocol and a thermode/CPT protocol (repeated measures and randomized order). In the TENS protocol, both the test stimulus (TS) and the conditioning stimulus (CS) were delivered using TENS; in the thermode/CPT protocol, the TS was delivered using a thermode and the CS consisted of a CPT. There was no association between the response evoked by the two protocols, neither for TSP nor for CPM. The number of participants showing TSP [49 with TENS and 29 with thermode (p < 0.001)] and CPM [16 with TENS and 30 with thermode (p = 0.01)] was different in both protocols. Our results suggest that response to one modality does not predict response to the other; as such, TENS cannot be used instead of a thermode/CPT protocol to assess TSP and CPM without significantly affecting the results. Moreover, while at first glance it appears that TENS is more effective than the thermode/CPT protocol to induce TSP, but less so to induce CPM, these results should be interpreted carefully. Indeed, TSP and CPM response appear to be modality-dependent as opposed to an absolute phenomenon, and the two protocols may tap into entirely different mechanisms, especially in the case of TSP.
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Affiliation(s)
- Monica Sean
- Research Centre on Aging, School of Rehabilitation, Faculty of Medicine and Health Sciences, Université de Sherbrooke, Sherbrooke, QC, Canada
| | - Alexia Coulombe-Lévêque
- Research Centre on Aging, School of Rehabilitation, Faculty of Medicine and Health Sciences, Université de Sherbrooke, Sherbrooke, QC, Canada
| | - Martine Bordeleau
- Research Centre on Aging, School of Rehabilitation, Faculty of Medicine and Health Sciences, Université de Sherbrooke, Sherbrooke, QC, Canada
| | - Matthieu Vincenot
- Research Centre on Aging, School of Rehabilitation, Faculty of Medicine and Health Sciences, Université de Sherbrooke, Sherbrooke, QC, Canada
| | - Louis Gendron
- Department of Pharmacology-Physiology, Faculty of Medicine and Health Sciences, Université de Sherbrooke, Sherbrooke, QC, Canada
| | - Serge Marchand
- Department of Neurosurgery, Faculty of Medicine and Health Sciences, Université de Sherbrooke, Sherbrooke, QC, Canada
| | - Guillaume Léonard
- Research Centre on Aging, School of Rehabilitation, Faculty of Medicine and Health Sciences, Université de Sherbrooke, Sherbrooke, QC, Canada
- *Correspondence: Guillaume Léonard
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Yadav D, Palermo TM, Phillips AE, Bellin MD, Conwell DL. Painful chronic pancreatitis - new approaches for evaluation and management. Curr Opin Gastroenterol 2021; 37:504-511. [PMID: 34172622 PMCID: PMC8826115 DOI: 10.1097/mog.0000000000000769] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
PURPOSE OF REVIEW Management of abdominal pain in patients with chronic pancreatitis is often suboptimal. We review recent data on the epidemiology and new approaches for managing pain in chronic pancreatitis. RECENT FINDINGS Chronic pancreatitis duration does not appear to affect the pain experience. Pain pattern in chronic pancreatitis patients frequently changes and is not related to traditional patient and disease-related factors. Psychologic comorbidities, i.e. anxiety and depression, are frequent in patients with chronic pancreatitis, and are associated with more severe pain and pain interference. Adjunctive treatments, such as cognitive behavioral therapy, may positively influence pain management in chronic pancreatitis. Total pancreatectomy with islet autotransplantation (TPIAT) is an increasingly adopted treatment option in painful chronic pancreatitis. Ongoing multicenter studies will help define optimal candidates, predictors of successful pain remission and diabetes outcomes after TPIAT. Pancreatic quantitative sensory testing, a promising technique to interrogate nociception and sensory response, holds promise to identify patients with central sensitization. Initial studies show feasibility to stratify patients into defined pain profiles, and future studies will explore if these can help in prognostication of pain therapy. SUMMARY Several lines of investigations currently under evaluation are likely to have a positive impact on the management of pain in chronic pancreatitis.
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Affiliation(s)
- Dhiraj Yadav
- Division of Gastroenterology, Hepatology and Nutrition, Department of Medicine, University of Pittsburgh Medical Center, Pittsburgh, PA
| | - Tonya M. Palermo
- Department of Anesthesiology & Pain Medicine, University of Washington, Seattle, WA
| | - Anna E. Phillips
- Division of Gastroenterology, Hepatology and Nutrition, Department of Medicine, University of Pittsburgh Medical Center, Pittsburgh, PA
| | - Melena D. Bellin
- Division of Endocrinology and Metabolism, University of Minnesota Medical Center, Minneapolis, MN
| | - Darwin L. Conwell
- Division of Gastroenterology, Hepatology, and Nutrition, The Ohio State University Wexner Medical Center, Columbus, OH
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26
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Han SY, Papachristou GI, Shah RJ, Conwell DL. Effect of pancreatic endotherapy on quality of life in chronic pancreatitis patients: A systematic review. World J Gastrointest Endosc 2021; 13:336-355. [PMID: 34512881 PMCID: PMC8394180 DOI: 10.4253/wjge.v13.i8.336] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/12/2021] [Revised: 06/11/2021] [Accepted: 07/13/2021] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND Pancreatic endotherapy provides treatment options for the management of chronic pancreatitis-related structural complications such as pancreatic duct stones, strictures, and pancreatic fluid collections. Most studies detailing endotherapy, however, have focused on technical success outcomes such as stone clearance or stricture resolution. AIM To review the effect of pancreatic endotherapy on patient-centered outcomes. METHODS Systematic review of studies examining pancreatic endotherapy. RESULTS A total of 13 studies including 3 randomized clinical trials were included. The majority of studies found an improvement in quality of life with pancreatic endotherapy. CONCLUSION While pancreatic endotherapy does appear to improve quality of life, there are clear gaps in knowledge regarding many pancreatic endotherapy modalities. Furthermore, qualitative analysis is lacking in these studies and further work is needed to elucidate the patient experience with pancreatic endotherapy.
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Affiliation(s)
- Samuel Y Han
- Division of Gastroenterology, Hepatology and Nutrition, The Ohio State University Wexner Medical Center, Columbus, OH 43210, United States
| | - Georgios I Papachristou
- Division of Gastroenterology, Hepatology and Nutrition, The Ohio State University Wexner Medical Center, Columbus, OH 43210, United States
| | - Raj J Shah
- Division of Gastroenterology and Hepatology, University of Colorado Anschutz Medical Campus, Aurora, CO 80045, United States
| | - Darwin L Conwell
- Division of Gastroenterology, Hepatology and Nutrition, The Ohio State University Wexner Medical Center, Columbus, OH 43210, United States
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27
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Uc A, Andersen DK, Apkarian AV, Bellin MD, Colloca L, Drewes AM, Dunbar EK, Forsmark CE, Goodman MT, Kapural L, Koob GF, Palermo TM, Pandol SJ, Pasricha P, Phillips AE, Piomelli D, Saloman JL, Schwarzenberg SJ, Singh VK, Sowa G, Strouse T, Treisman GJ, Windsor JA, Yadav D. Pancreatic Pain-Knowledge Gaps and Research Opportunities in Children and Adults: Summary of a National Institute of Diabetes and Digestive and Kidney Diseases Workshop. Pancreas 2021; 50:906-915. [PMID: 34643606 PMCID: PMC10273134 DOI: 10.1097/mpa.0000000000001899] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
ABSTRACT A workshop was sponsored by the National Institute of Diabetes and Digestive and Kidney Diseases to focus on research gaps and opportunities in pancreatic pain. The event was held on July 21, 2021, and structured into 4 sessions: (1) pathophysiology; (2) biomarkers, mediators, and pharmacology of pain; (3) pain assessment; and (4) pain treatment challenges and opportunities. The current state of knowledge was reviewed; many knowledge gaps and research needs were identified that require further investigation. Common themes included the need to better understand the underlying mechanisms of pain in pancreatic diseases, the relationship of visceral neural pathways and central pain centers, the role of behavioral factors and disorders on the perception of pain, and differences in pain perception and processes in children when compared with adults. In addition, the role of genetic risk factors for pain and the mechanisms and role of placebos in pain treatment were discussed. Methods of pain assessment including quantitative sensory testing were examined, as well as the process of central sensitization of pain. Finally, newer approaches to pain management including cognitive behavioral therapy, nerve stimulation, experimental (nonopioid) drugs, and cannabinoid compounds were covered.
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Affiliation(s)
- Aliye Uc
- From the Division of Gastroenterology, Hepatology, Pancreatology and Nutrition, Stead Family Department of Pediatrics, The University of Iowa, Iowa City, IA
| | - Dana K Andersen
- Division of Digestive Diseases and Nutrition, National Institute of Diabetes and Digestive and Kidney Diseases, National Institutes of Health, Bethesda, MD
| | - A Vania Apkarian
- Departments of Physiology, Anesthesiology, Physical Medicine and Rehabilitation, and Center for Translational Pain Research, Northwestern University, Feinberg School of Medicine, Chicago, IL
| | - Melena D Bellin
- Departments of Pediatrics and Surgery, University of Minnesota Masonic Children's Hospital, Minneapolis, MN
| | | | - Asbjørn M Drewes
- Department of Gastroenterology and Hepatology, Aalborg University Hospital, Aalborg, Denmark
| | | | - Christopher E Forsmark
- Division of Gastroenterology, Hepatology and Nutrition, Department of Medicine, University of Florida, Gainesville, FL
| | - Marc T Goodman
- Cancer Prevention and Control Program, Samuel Oschin Cancer Center, Cedars-Sinai Medical Center, Los Angeles, CA
| | | | - George F Koob
- National Institute on Alcohol Abuse and Alcoholism and Intramural Research Program, National Institute on Drug, National Institutes of Health, Bethesda, MD
| | | | - Stephen J Pandol
- Division of Gastroenterology, Department of Medicine, Cedars Sinai Medical Center, Los Angeles, CA
| | - Pankaj Pasricha
- Division of Gastroenterology and Hepatology, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Anna E Phillips
- Division of Gastroenterology, Hepatology and Nutrition, Department of Medicine
| | - Daniele Piomelli
- Departments of Anatomy and Neurobiology, Biological Chemistry, and Pharmacology, University of California, Irvine School of Medicine, Irvine, CA
| | - Jami L Saloman
- Division of Gastroenterology, Hepatology and Nutrition, Department of Medicine
| | - Sarah Jane Schwarzenberg
- Division of Pediatric Gastroenterology, Hepatology and Nutrition, University of Minnesota Masonic Children's Hospital, Minneapolis, MN
| | - Vikesh K Singh
- Division of Gastroenterology and Hepatology, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Gwendolyn Sowa
- Department of Physical Medicine and Rehabilitation, University of Pittsburgh School of Medicine, Pittsburgh, PA
| | - Thomas Strouse
- Department of Psychiatry and Biobehavioral Sciences, David Geffen School of Medicine at UCLA, Los Angeles, CA
| | - Glenn J Treisman
- Department of Psychiatry and Behavioral Sciences, Department of Internal Medicine, The Johns Hopkins University School of Medicine, Baltimore, MD
| | - John A Windsor
- Surgical and Translational Research Centre, Faculty of Medical and Health Sciences, The University of Auckland, Auckland, New Zealand
| | - Dhiraj Yadav
- Division of Gastroenterology, Hepatology and Nutrition, Department of Medicine
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28
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Molero X, Ayuso JR, Balsells J, Boadas J, Busquets J, Casteràs A, Concepción M, Cuatrecasas M, Fernàndez Esparrach G, Fort E, Garcia Borobia F, Ginès À, Ilzarbe L, Loras C, Masachs M, Merino X, Olsina JJ, Puig-Diví V, Salord S, Serrano T, Vaquero EC. Chronic pancreatitis for the clinician. Part 2: Treatment and follow-up. Interdisciplinary Position Paper of the Societat Catalana de Digestologia and the Societat Catalana de Pàncrees. GASTROENTEROLOGIA Y HEPATOLOGIA 2021; 45:304-314. [PMID: 34171422 DOI: 10.1016/j.gastrohep.2021.05.016] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/14/2021] [Revised: 05/11/2021] [Accepted: 05/25/2021] [Indexed: 02/07/2023]
Abstract
Chronic pancreatitis is associated with impaired quality of life, high incidence of comorbidities, serious complications and mortality. Healthcare costs are exorbitant. Some medical societies have developed guidelines for treatment based on scientific evidence, but the gathered level of evidence for any individual topic is usually low and, therefore, recommendations tend to be vague or weak. In the present position papers on chronic pancreatitis from the Societat Catalana de Digestologia and the Societat Catalana de Pàncrees we aimed at providing defined position statements for the clinician based on updated review of published literature and on multidisciplinary expert agreement. The final goal is to propose the use of common terminology and rational diagnostic/therapeutic circuits based on current knowledge. To this end 51 sections related to chronic pancreatitis were reviewed by 21 specialists from 6 different fields to generate 88 statements altogether. Statements were designed to harmonize concepts or delineate recommendations. Part 2 of these paper series discuss topics on treatment and follow-up. The therapeutic approach should include assessment of etiological factors, clinical manifestations and complications. The complexity of these patients advocates for detailed evaluation in multidisciplinary committees where conservative, endoscopic, interventional radiology or surgical options are weighed. Specialized multidisciplinary units of Pancreatology should be constituted. Indications for surgery are refractory pain, local complications, and suspicion of malignancy. Enzyme replacement therapy is indicated if evidence of exocrine insufficiency or after pancreatic surgery. Response should be evaluated by nutritional parameters and assessment of symptoms. A follow-up program should be planned for every patient with chronic pancreatitis.
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Affiliation(s)
- Xavier Molero
- Servei d'Aparell Digestiu, Hospital Universitari Vall d'Hebron, Barcelona, España; Exocrine Pancreas Research Unit, Vall d'Hebron Institut de Recerca (VHIR), Barcelona, España; Campus de la UAB, Universitat Autònoma de Barcelona, Bellaterra, Barcelona, España; CIBERehd, Instituto de Salud Carlos III, Madrid, España.
| | - Juan Ramon Ayuso
- Servei de Radiologia, Centre de Diagnòstic per la Imatge Clínic, Hospital Clínic, Barcelona, España; Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Barcelona, España
| | - Joaquim Balsells
- Campus de la UAB, Universitat Autònoma de Barcelona, Bellaterra, Barcelona, España; Servei de Cirurgia Hepato-Bilio-Pancreàtica, Hospital Universitari Vall d'Hebron, Barcelona, España
| | - Jaume Boadas
- Servei de Digestologia, Hospital de Terrassa, Consorci Sanitari de Terrassa, Terrassa, Barcelona, España
| | - Juli Busquets
- Unitat de Cirurgia Hepatobiliar i Pancreàtica, Hospital Universitari de Bellvitge, L'Hospitalet de Llobregat, Barcelona, España
| | - Anna Casteràs
- Servei d'Endocrinologia, Hospital Universitari Vall d'Hebron, Barcelona, España
| | - Mar Concepción
- Campus de la UAB, Universitat Autònoma de Barcelona, Bellaterra, Barcelona, España; Servei de Gastroenterologia, Hospital de la Santa Creu i Sant Pau, Barcelona, España
| | - Míriam Cuatrecasas
- CIBERehd, Instituto de Salud Carlos III, Madrid, España; Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Barcelona, España; Servei d'Anatomia Patològica, Hospital Clínic, Barcelona, España
| | - Gloria Fernàndez Esparrach
- CIBERehd, Instituto de Salud Carlos III, Madrid, España; Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Barcelona, España; Unitat d'Endoscòpia, Servei de Gastroenterologia, ICMDiM, Hospital Clínic, Universitat de Barcelona, Barcelona, España
| | - Esther Fort
- Servei de Gastroenterologia, Hospital Universitari Doctor Josep Trueta, Girona, España; Universitat de Girona (UdG), Girona, España
| | - Francisco Garcia Borobia
- Unitat de Cirurgia Hepatobiliopancreàtica, Servei de Cirurgia General i de l'Aparell Digestiu, Hospital Universitari Parc Taulí, Sabadell, Barcelona, España
| | - Àngels Ginès
- CIBERehd, Instituto de Salud Carlos III, Madrid, España; Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Barcelona, España; Servei de Gastroenterologia, Hospital Universitari Doctor Josep Trueta, Girona, España
| | - Lucas Ilzarbe
- Servei de Digestiu, Hospital del Mar Parc Salut Mar, Barcelona, España
| | - Carme Loras
- CIBERehd, Instituto de Salud Carlos III, Madrid, España; Servei de Gastroenterologia, Unitat d'Endoscòpia, Hospital Universitari Mútua de Terrassa, Terrassa, Barcelona, España
| | - Miquel Masachs
- Servei d'Endoscòpia Digestiva, Hospital Universitari Vall d'Hebron, Barcelona, España
| | - Xavier Merino
- Unitat d'Imatge Abdominal, Servei de Radiologia, Hospital Universitari Vall d'Hebron, Barcelona, España
| | - Jorge J Olsina
- Servei de Cirurgia Gerenal i Aparell Digestiu, Hospital Universitari Arnau de Vilanova, Lleida, España
| | - Valentí Puig-Diví
- Campus de la UAB, Universitat Autònoma de Barcelona, Bellaterra, Barcelona, España; Servei de Digestiu, Corporació Sanitària Universitaria Parc Taulí, Sabadell, Barcelona, España
| | - Sílvia Salord
- Servei de Gastroenterologia, Hospital Universitari de Bellvitge-IDIBELL, L'Hospitalet de Llobregat, Barcelona, España
| | - Teresa Serrano
- CIBERehd, Instituto de Salud Carlos III, Madrid, España; Servei d'Anatomia Patològica, Hospital Universitari de Bellvitge, L'Hospitalet de Llobregat, Barcelona, España
| | - Eva Cristina Vaquero
- CIBERehd, Instituto de Salud Carlos III, Madrid, España; Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Barcelona, España; Servei de Gastroenterologia, ICMDiM, Hospital Clínic, Barcelona, España; Gastrointestinal and Pancreatic Oncology Research Group, Hospital Clínic, Barcelona, España
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29
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The predictive value of quantitative sensory testing: a systematic review on chronic postoperative pain and the analgesic effect of pharmacological therapies in patients with chronic pain. Pain 2021; 162:31-44. [PMID: 32701654 DOI: 10.1097/j.pain.0000000000002019] [Citation(s) in RCA: 82] [Impact Index Per Article: 27.3] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
Studies have suggested that quantitative sensory testing (QST) might hold a predictive value for the development of chronic postoperative pain and the response to pharmacological interventions. This review systematically summarizes the current evidence on the predictive value of QST for chronic postoperative pain and the effect of pharmacological interventions. The main outcome measures were posttreatment pain intensity, pain relief, presence of moderate-to-severe postoperative pain, responders of 30% and 50% pain relief, or validated questionnaires on pain and disability. A systematic search of MEDLINE and EMBASE yielded 25 studies on surgical interventions and 11 on pharmacological interventions. Seventeen surgical and 11 pharmacological studies reported an association between preoperative or pretreatment QST and chronic postoperative pain or analgesic effect. The most commonly assessed QST modalities were pressure stimuli (17 studies), temporal summation of pain (TSP, 14 studies), and conditioned pain modulation (CPM, 16 studies). Of those, the dynamic QST parameters TSP (50%) and CPM (44%) were most frequently associated with chronic postoperative pain and analgesic effects. A large heterogeneity in methods for assessing TSP (n = 4) and CPM (n = 7) was found. Overall, most studies demonstrated low-to-moderate levels of risk of bias in study design, attrition, prognostic factors, outcome, and statistical analyses. This systematic review demonstrates that TSP and CPM show the most consistent predictive values for chronic postoperative pain and analgesic effect, but the heterogeneous methodologies reduce the generalizability and hence call for methodological guidelines.
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30
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Lyng KD, Thorsen JBB, Boye Larsen D, Kjær Petersen K. The Modulatory Effect of QST in Shoulder Pain: A Systematic Review and Meta-Analysis. PAIN MEDICINE 2021; 23:733-744. [PMID: 33905508 DOI: 10.1093/pm/pnab155] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
BACKGROUND The underlying mechanisms for shoulder pain (SP) are still widely unknown. Previous reviews report signs of altered pain processing in SP measured using quantitative sensory testing (QST). Evidence suggests that QST might hold predictive value for SP after intervention, yet it is not known whether QST profiles can be modulated in response to different treatments. Therefore, this systematic review and meta-analysis aimed to assess if QST-parameters can be modified by interventions for patients with SP. METHODS Three databases were searched to identify eligible studies. Eligible studies had a prospective design, with at least one QST variable as an outcome in conjunction with an intervention measured before and after intervention. Studies that involved SP caused by spinal or brain injury and studies looking at combined chronic neck/shoulder pain were excluded. RESULTS 19 studies investigating SP were eligible for inclusion for this review. Pressure pain threshold (PPT) was the most frequently used QST-parameter investigating local and widespread hyperalgesia. A meta-analysis was performed with data from 10 studies with a total of 16 interventions. Results demonstrated an overall acute effect (<24 hours after intervention) of interventions in favour of local decreased pain sensitivity and of remote decreased pain sensitivity comparing PPTs before and after interventions. CONCLUSIONS This study demonstrates that interventions such as exercise and manual therapy can modulate PPTs acutely both locally and remotely in patients with shoulder pain. Further research investigating the acute and long-term modulatory ability of these interventions on other QST-parameters is needed in patients with shoulder pain.
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Affiliation(s)
- Kristian Damgaard Lyng
- SMI, Department of Health Science and Technology, Faculty of Medicine, Aalborg University, Aalborg, Denmark
| | | | - Dennis Boye Larsen
- SMI, Department of Health Science and Technology, Faculty of Medicine, Aalborg University, Aalborg, Denmark.,Center for Neuroplasticity and Pain, Department of Health Science and Technology, Faculty of Medicine, Aalborg University, Aalborg, Denmark
| | - Kristian Kjær Petersen
- SMI, Department of Health Science and Technology, Faculty of Medicine, Aalborg University, Aalborg, Denmark.,Center for Neuroplasticity and Pain, Department of Health Science and Technology, Faculty of Medicine, Aalborg University, Aalborg, Denmark
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31
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Sean M, Coulombe-Lévêque A, Vincenot M, Martel M, Gendron L, Marchand S, Léonard G. Transcutaneous electrical nerve stimulation (TENS): towards the development of a clinic-friendly method for the evaluation of excitatory and inhibitory pain mechanisms. CANADIAN JOURNAL OF PAIN-REVUE CANADIENNE DE LA DOULEUR 2021; 5:56-65. [PMID: 34189390 PMCID: PMC8210867 DOI: 10.1080/24740527.2020.1862624] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 12/02/2022]
Abstract
Background: Temporal summation and conditioned pain modulation (CPM) can be measured using a thermode and cold pressor test (CPTest). Unfortunately, these complex and expensive tools are ill-suited for routine clinical assessments. Aims: We aimed to compare the temporal summation and CPM obtained with the thermode + CPTest paradigm to those obtained with a novel paradigm using transcutaneous electrical nerve stimulation (TENS). Methods: We assessed temporal summation and CPM in 29 healthy participants, using two paradigms (random order): TENS, and thermode + CPTest. In the TENS paradigm, both the conditioning stimulus (CS) and the test stimulus (TS) were delivered using TENS; in the thermode + CPTest paradigm, the CS consisted of a CPTest and the TS was delivered using a thermode. We compared the average temporal summation and CPM evoked by the two paradigms. Results: Average temporal summation was similar for both modalities (P = 0.90), and the number of participants showing temporal summation was similar in both paradigms (19 with thermode vs. 18 with TENS; P = 1.00). Average CPM response was larger following the thermode + CPTest than following the TENS (P = 0.005), and more participants showed CPM with the thermode + CPTest paradigm compared to the TENS paradigm (24 vs. 14; P = 0.01). Conclusions: Both paradigms were roughly equivalent in the ability to evoke temporal summation (although response to one modality did not predict response to the other), but the TENS paradigm appeared to be less apt to induce a CPM response than the thermode + CPTest paradigm.
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Affiliation(s)
- Monica Sean
- Research Centre on Aging, Sherbrooke, Quebec, Canada.,School of Rehabilitation, Faculty of Medicine and Health Sciences, Université de Sherbrooke, Sherbrooke, Quebec, Canada
| | - Alexia Coulombe-Lévêque
- Research Centre on Aging, Sherbrooke, Quebec, Canada.,School of Rehabilitation, Faculty of Medicine and Health Sciences, Université de Sherbrooke, Sherbrooke, Quebec, Canada
| | - Matthieu Vincenot
- Research Centre on Aging, Sherbrooke, Quebec, Canada.,School of Rehabilitation, Faculty of Medicine and Health Sciences, Université de Sherbrooke, Sherbrooke, Quebec, Canada
| | - Marylie Martel
- Research Centre on Aging, Sherbrooke, Quebec, Canada.,School of Rehabilitation, Faculty of Medicine and Health Sciences, Université de Sherbrooke, Sherbrooke, Quebec, Canada
| | - Louis Gendron
- Centre de recherche du CHUS, Sherbrooke, Quebec, Canada.,Department of Pharmacology-Physiology, Faculty of Medicine and Health Sciences, Université de Sherbrooke, Sherbrooke, Quebec, Canada
| | - Serge Marchand
- Centre de recherche du CHUS, Sherbrooke, Quebec, Canada.,Department of Neurosurgery, Faculty of Medicine and Health Sciences, Université de Sherbrooke, Sherbrooke, Quebec, Canada
| | - Guillaume Léonard
- Research Centre on Aging, Sherbrooke, Quebec, Canada.,School of Rehabilitation, Faculty of Medicine and Health Sciences, Université de Sherbrooke, Sherbrooke, Quebec, Canada
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Schneider A, Hirth M. Pain Management in Chronic Pancreatitis: Summary of Clinical Practice, Current Challenges and Potential Contribution of the M-ANNHEIM Classification. Drugs 2021; 81:533-546. [PMID: 33587287 DOI: 10.1007/s40265-021-01472-7] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/23/2021] [Indexed: 01/06/2023]
Abstract
Abdominal pain, diarrhea with weight loss, and endocrine insufficiency represent the dominant symptoms of chronic pancreatitis (CP). High intensity of pain and constant pain have been shown to reduce quality of life in CP and may result in disability and increased health resource utilization. Various basic challenges and unanswered questions still exist regarding the treatment of pain in CP. Recently, limited evidence has been gained that early surgery for painful disease might be associated with better treatment results. Thus, timing of pancreatic surgery in painful disease represents a major issue that needs to be clarified in future studies. In this context, surveillance of patients is necessary in clinical practice. It appears that a generally accepted classification of the disease represents a major requirement for inter-institutional comparison of data with future progress in clinical research. Among recently proposed classification systems, the M-ANNHEIM classification system of CP with its recently presented M-ANNHEIM Surgery Score might be a useful tool to picture the course of the disease and to monitor treatment results. Future research is required to clarify the possible role of this system in the management of pain in CP. In the present article, we provide an overview of current status, challenges, and unanswered questions in the treatment of pain in CP, and we demonstrate the potential benefits of the M-ANNHEIM classification system in the management of painful CP.
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Affiliation(s)
- Alexander Schneider
- Department of Gastroenterology and Hepatology, Medical Center Bad Hersfeld-Rotenburg, Bad Hersfeld, Germany. .,Department of Medicine II, University Medical Center Mannheim, Medical Faculty Mannheim, University of Heidelberg, Mannheim, Germany.
| | - Michael Hirth
- Department of Medicine II, University Medical Center Mannheim, Medical Faculty Mannheim, University of Heidelberg, Mannheim, Germany
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Vincenot M, Coulombe-Lévêque A, Sean M, Camirand Lemyre F, Gendron L, Marchand S, Léonard G. Development and Validation of a Predictive Model of Pain Modulation Profile to Guide Chronic Pain Treatment: A Study Protocol. FRONTIERS IN PAIN RESEARCH 2021; 2:606422. [PMID: 35295452 PMCID: PMC8915565 DOI: 10.3389/fpain.2021.606422] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/14/2020] [Accepted: 01/13/2021] [Indexed: 11/27/2022] Open
Abstract
Introduction: Quantitative sensory testing is frequently used in research to assess endogenous pain modulation mechanisms, such as Temporal Summation (TS) and Conditioned Pain Modulation (CPM), reflecting excitatory and inhibitory mechanisms, respectively. Numerous studies found that a dysregulation of these mechanisms is associated with chronic pain conditions. In turn, such a patient's “profile” (increased TS and/or weakened CPM) could be used to recommend different pharmacological treatments. However, the procedure to evaluate these mechanisms is time-consuming and requires expensive equipment that is not available in the clinical setting. In this study, we aim to identify psychological, physiological and socio-demographic markers that could serve as proxies to allow healthcare professionals to identify these pain phenotypes in clinic, and consequently optimize pharmacological treatments. Method: We aim to recruit a healthy participant cohort (n = 360) and a chronic pain patient cohort (n = 108). Independent variables will include psychological questionnaires, pain measurements, physiological measures and sociodemographic characteristics. Dependent variables will include TS and CPM, which will be measured using quantitative sensory testing in a single session. We will evaluate one prediction model and two validation models (for healthy and chronic pain participants) using multiple regression analysis between TS/CPM and our independent variables. The significance thresholds will be set at p = 0.05, respectively. Perspectives: This study will allow us to develop a predictive model to compute the pain modulation profile of individual patients based on their biopsychosocial characteristics. The development of the predictive model is the first step toward the overarching goal of providing clinicians with a set of quick and cheap tests, easily applicable in clinical practice to orient pharmacological treatments.
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Affiliation(s)
- Matthieu Vincenot
- Research Center on Aging, Université de Sherbrooke, Sherbrooke, QC, Canada
- Faculty of Medicine and Health Sciences, Université de Sherbrooke, Sherbrooke, QC, Canada
| | - Alexia Coulombe-Lévêque
- Research Center on Aging, Université de Sherbrooke, Sherbrooke, QC, Canada
- Faculty of Medicine and Health Sciences, Université de Sherbrooke, Sherbrooke, QC, Canada
| | - Monica Sean
- Research Center on Aging, Université de Sherbrooke, Sherbrooke, QC, Canada
- Department of Pharmacology-Physiology, Faculty of Medicine and Health Sciences, Université de Sherbrooke, Sherbrooke, QC, Canada
| | - Félix Camirand Lemyre
- Centre de Recherche du Centre Hospitaliser Universitaire de Sherbrooke, Sherbrooke, QC, Canada
- Département de Mathématiques, Faculté des Sciences, Université de Sherbrooke, Sherbrooke, QC, Canada
| | - Louis Gendron
- Department of Pharmacology-Physiology, Faculty of Medicine and Health Sciences, Université de Sherbrooke, Sherbrooke, QC, Canada
- Centre de Recherche du Centre Hospitaliser Universitaire de Sherbrooke, Sherbrooke, QC, Canada
| | - Serge Marchand
- Faculty of Medicine and Health Sciences, Université de Sherbrooke, Sherbrooke, QC, Canada
| | - Guillaume Léonard
- Research Center on Aging, Université de Sherbrooke, Sherbrooke, QC, Canada
- Faculty of Medicine and Health Sciences, School of Rehabilitation, Université de Sherbrooke, Sherbrooke, QC, Canada
- *Correspondence: Guillaume Léonard
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Abstract
There is tremendous interpatient variability in the response to analgesic therapy
(even for efficacious treatments), which can be the source of great frustration
in clinical practice. This has led to calls for “precision
medicine” or personalized pain therapeutics (ie, empirically based
algorithms that determine the optimal treatments, or treatment combinations, for
individual patients) that would presumably improve both the clinical care of
patients with pain and the success rates for putative analgesic drugs in phase 2
and 3 clinical trials. However, before implementing this approach, the
characteristics of individual patients or subgroups of patients that increase or
decrease the response to a specific treatment need to be identified. The
challenge is to identify the measurable phenotypic characteristics of patients
that are most predictive of individual variation in analgesic treatment
outcomes, and the measurement tools that are best suited to evaluate these
characteristics. In this article, we present evidence on the most promising of
these phenotypic characteristics for use in future research, including
psychosocial factors, symptom characteristics, sleep patterns, responses to
noxious stimulation, endogenous pain-modulatory processes, and response to
pharmacologic challenge. We provide evidence-based recommendations for core
phenotyping domains and recommend measures of each domain.
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Crofton E, Meredith P, Gray P, Strong J. Compression garment wear and sensory variables after burn: a single-site study. Burns 2020; 46:1903-1913. [DOI: 10.1016/j.burns.2020.06.004] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/12/2020] [Revised: 05/13/2020] [Accepted: 06/06/2020] [Indexed: 11/28/2022]
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Patient and Disease Characteristics Associate With Sensory Testing Results in Chronic Pancreatitis. Clin J Pain 2020; 35:786-793. [PMID: 31268890 PMCID: PMC6693925 DOI: 10.1097/ajp.0000000000000740] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
BACKGROUND Abdominal pain is the most common symptom in chronic pancreatitis (CP) and has an extensive impact on patients' lives. Quantitative sensory testing (QST) provides information on sensitivity to pain and mechanisms that can help quantify pain and guide treatment. The aims of this study were (1) to explore sensitivity to pain in patients with CP using QST and (2) to associate patient and disease characteristics with QST results. METHODS Ninety-one patients with painful CP and 28 healthy control participants completed a QST paradigm using static tests (muscle pressure stimulation and electrical skin stimulations) to unravel segmental and widespread hyperalgesia as a consequence of visceral pain. A dynamic conditioned pain modulation (CPM) paradigm was used as a proxy of pain modulation from the brainstem to inhibit incoming nociceptive barrage, and questionnaires were used to gather information on pain experience and quality of life. RESULTS Patients had impaired CPM compared with controls (18.0±29.3% vs. 30.9±29.3%, P=0.04) and were hypersensitive to pressure stimulation, specifically in the pancreatic (Th10) dermatome (P<0.001). The capacity of CPM was associated with clinical pain intensity (P=0.01) and (in the univariate analysis only) the use of opioids was associated with hyperalgesia to pressure stimulation (P<0.05). CONCLUSIONS Sensitivity to pain in CP patients can be characterized by a simple bedside QST. Severe clinical pain in CP was associated with reduced CPM function and should be targeted in management.
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Quantitative assessment of nonpelvic pressure pain sensitivity in urologic chronic pelvic pain syndrome: a MAPP Research Network study. Pain 2020; 160:1270-1280. [PMID: 31050659 DOI: 10.1097/j.pain.0000000000001505] [Citation(s) in RCA: 24] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
Abstract
Experimental pain sensitivity was assessed in individuals with urologic chronic pelvic pain syndrome (UCPPS) as part of the Multidisciplinary Approach to the Study of Chronic Pelvic Pain (MAPP) Research Network. A series of computer-controlled pressure stimuli were delivered to the thumbnail bed, an asymptomatic site distant from the area of UCPPS pain that is considered to be indicative of overall body pain threshold. Stimuli were rated according to a standardized magnitude estimation protocol. Pain sensitivity in participants with UCPPS was compared with healthy controls and a mixed pain group composed of individuals with other chronic overlapping pain conditions, including fibromyalgia, chronic fatigue, and irritable bowel syndromes. Data from 6 participating MAPP testing sites were pooled for analysis. Participants with UCPPS (n = 153) exhibited an intermediate pain sensitivity phenotype: they were less sensitive relative to the mixed pain group (n = 35) but significantly more sensitive than healthy controls (n = 100). Increased pain sensitivity in patients with UCPPS was associated with both higher levels of clinical pain severity and more painful body areas outside the pelvic region. Exploratory analyses in participants with UCPPS revealed that pain sensitivity increased during periods of urologic symptom flare and that less pressure pain sensitivity at baseline was associated with a greater likelihood of subsequent genitourinary pain improvement 1 year later. The finding that individuals with UCPPS demonstrate nonpelvic pain hypersensitivity that is related to clinical symptoms suggests that central nervous system mechanisms of pain amplification contribute to UCPPS.
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Olesen SS, Drewes AM, Gaud R, Tandan M, Lakhtakia S, Ramchandani M, Rao GV, Reddy DN, Talukdar R. Combined extracorporeal shock wave lithotripsy and endoscopic treatment for pain in chronic pancreatitis (SCHOKE trial): study protocol for a randomized, sham-controlled trial. Trials 2020; 21:338. [PMID: 32299454 PMCID: PMC7164272 DOI: 10.1186/s13063-020-04296-0] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/13/2019] [Accepted: 03/30/2020] [Indexed: 02/08/2023] Open
Abstract
Background Pain is the primary symptom of chronic pancreatitis (CP) and remains a considerable therapeutic challenge. In patients with obstruction of the pancreatic duct, including stones and strictures, endoscopic treatment with or without preceding extracorporeal shock wave lithotripsy (ESWL) has been used for pancreatic duct decompression. The rationale for these procedures is based on the assumption that obstruction of the pancreatic duct leads to ductal hypertension and pain. However, clinical pain symptoms correlate poorly with pancreatic duct morphology, and the evidence for pancreatic duct decompression as an effective treatment for pain is based on case series and comparison between different procedures. No randomized, prospective, sham-controlled trials are currently available. The SCHOKE (Extracorporeal Shock Wave Lithotripsy and Endotherapy for Pain in Chronic Pancreatitis) trial is a randomized, sham-controlled trial designed to determine if pancreatic duct decompression is an effective treatment for pain in patients with CP. Methods The SCHOKE trial is a randomized, single-blind, parallel-group, sham-controlled trial designed to evaluate the effect of combined ESWL and endoscopic treatment for pain in patients with CP. In total, 106 adult patients with painful CP and pancreatic duct obstruction will be randomized to combined ESWL and subsequent endoscopic treatment or corresponding sham procedures. The primary outcome is pain relief during the 3-month postrandomization period as documented in a pain diary. Secondary outcomes include quality of life and functional scores, patient global impression of change, change in use of analgesics, frequency of hospitalization, and complications. Standard follow-up is at 3 and 6 months after randomization. In an experimental substudy, quantitative sensory testing obtained before and after intervention will be used to obtain information on central pain processing and to develop models for prediction of treatment outcome. Discussion The SCHOKE trial investigates if pancreatic duct decompression, obtained by combined ESWL and endoscopic treatment, is effective for pain treatment in patients with CP. Trial registration ClinicalTrials.gov, NCT03966781. Registered on May 25, 2019. Protocol date and version identifier: March 1, 2020; version 3.0. Sponsor: Rupjyoti Talukdar, Department of Medical Gastroenterology, Asian Institute of Gastroenterology, Hyderabad, Telangana, India.
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Affiliation(s)
- Søren S Olesen
- Department of Gastroenterology and Hepatology, Centre for Pancreatic Diseases, Aalborg University Hospital, Aalborg, Denmark.
| | - Asbjørn M Drewes
- Department of Gastroenterology and Hepatology, Centre for Pancreatic Diseases, Aalborg University Hospital, Aalborg, Denmark
| | - Rajesh Gaud
- Department of Medical Gastroenterology, Asian Institute of Gastroenterology, Hyderabad, Telangana, India
| | - Manu Tandan
- Department of Medical Gastroenterology, Asian Institute of Gastroenterology, Hyderabad, Telangana, India
| | - Sundeep Lakhtakia
- Department of Medical Gastroenterology, Asian Institute of Gastroenterology, Hyderabad, Telangana, India
| | - Mohan Ramchandani
- Department of Medical Gastroenterology, Asian Institute of Gastroenterology, Hyderabad, Telangana, India
| | - G V Rao
- Department of Surgical Gastroenterology, Asian Institute of Gastroenterology, Hyderabad, Telangana, India
| | - D Nageshwar Reddy
- Department of Medical Gastroenterology, Asian Institute of Gastroenterology, Hyderabad, Telangana, India
| | - Rupjyoti Talukdar
- Department of Medical Gastroenterology, Asian Institute of Gastroenterology, Hyderabad, Telangana, India.,Pancreas Research Group, Wellcome DBT Labs, Asian Healthcare Foundation, Hyderabad, Telangana, India
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Abstract
In this article, I review the concept of personalized pain management and consider how brain imaging and quantitative sensory testing can be used to derive biomarkers of chronic pain treatment outcome. I review how different modalities of brain imaging can be used to acquire information about brain structure and function and how this information can be linked to individual measures of pain.
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Abstract
Gastrointestinal (GI) pain - a form of visceral pain - is common in some disorders, such as irritable bowel syndrome, Crohn's disease and pancreatitis. However, identifying the cause of GI pain frequently represents a diagnostic challenge as the clinical presentation is often blurred by concomitant autonomic and somatic symptoms. In addition, GI pain can be nociceptive, neuropathic and associated with cancer, but in many cases multiple aetiologies coexist in an individual patient. Mechanisms of GI pain are complex and include both peripheral and central sensitization and the involvement of the autonomic nervous system, which has a role in generating the symptoms that frequently accompany pain. Treatment of GI pain depends on the precise type of pain and the primary disorder in the patient but can include, for example, pharmacological therapy, cognitive behavioural therapies, invasive surgical procedures, endoscopic procedures and lifestyle alterations. Owing to the major differences between organ involvement, disease mechanisms and individual factors, treatment always needs to be personalized and some data suggest that phenotyping and subsequent individual management of GI pain might be options in the future.
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Tsedinova Y, Churuykanov M, Medvedeva L, Zagorulko O. Neurophysiological methods in examination of patients with chronic postoperative pain. ACTA ACUST UNITED AC 2020. [DOI: 10.17116/pain20201804160] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
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A clinically feasible method for the assessment and characterization of pain in patients with chronic pancreatitis. Pancreatology 2020; 20:25-34. [PMID: 31787527 DOI: 10.1016/j.pan.2019.11.007] [Citation(s) in RCA: 25] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/24/2019] [Revised: 11/14/2019] [Accepted: 11/18/2019] [Indexed: 12/11/2022]
Abstract
BACKGROUND AND AIMS Pain is the primary symptom of chronic pancreatitis (CP), but methods for sensory testing and pain characterization have not previously been validated for clinical use. We present a clinically feasible method for the assessment and characterization of pain mechanisms in patients with CP based on quantitative sensory testing (QST). METHODS This was a cross-sectional, multicenter study of 122 control subjects without pancreatic disease and another 60 patients with painful CP. All subjects underwent standardized QST assessments including a cold pressor test, a conditioned pain modulation paradigm, repetitive pin-prick stimuli (temporal summation) and pressure stimulation of the upper abdominal (pancreatic) and control dermatomes. The effects of age and gender on QST assessment parameters were investigated and normative reference values based on quartile regression were derived and implemented in algorithms to categorize patients according to their patterns of central pain processing (normal vs. segmental sensitization vs. widespread sensitization). RESULTS Absolute pressure thresholds were subject to clinically relevant gender effects (all p < 0.001), while the remainder of QST parameters were unaffected by age and gender. The algorithm with the best discriminatory capacity showed good separation between patients and controls (p < 0.001); 50% of patients had normal central pain processing, 23% had evidence of segmental sensitization and 27% had evidence of widespread sensitization. CONCLUSION We show normative reference values for a clinically feasible method for assessment and characterization of pain mechanisms in patients with CP. Application of this method streamlines the evaluation of pancreatic pain and may be used to inform treatment. CLINICALTRIALS. GOV ID NCT03434392.
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Georgopoulos V, Akin-Akinyosoye K, Zhang W, McWilliams DF, Hendrick P, Walsh DA. Quantitative sensory testing and predicting outcomes for musculoskeletal pain, disability, and negative affect: a systematic review and meta-analysis. Pain 2019; 160:1920-1932. [PMID: 31045746 PMCID: PMC6701980 DOI: 10.1097/j.pain.0000000000001590] [Citation(s) in RCA: 122] [Impact Index Per Article: 24.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
Hypersensitivity due to central pain mechanisms can influence recovery and lead to worse clinical outcomes, but the ability of quantitative sensory testing (QST), an index of sensitisation, to predict outcomes in chronic musculoskeletal disorders remains unclear. We systematically reviewed the evidence for ability of QST to predict pain, disability, and negative affect using searches of CENTRAL, MEDLINE, EMBASE, AMED, CINAHL, and PubMed databases up to April 2018. Title screening, data extraction, and methodological quality assessments were performed independently by 2 reviewers. Associations were reported between baseline QST and outcomes using adjusted (β) and unadjusted (r) correlations. Of the 37 eligible studies (n = 3860 participants), 32 were prospective cohort studies and 5 randomised controlled trials. Pain was an outcome in 30 studies, disability in 11, and negative affect in 3. Meta-analysis revealed that baseline QST predicted musculoskeletal pain (mean r = 0.31, 95% confidence interval [CI]: 0.23-0.38, n = 1057 participants) and disability (mean r = 0.30, 95% CI: 0.19-0.40, n = 290 participants). Baseline modalities quantifying central mechanisms such as temporal summation and conditioned pain modulation were associated with follow-up pain (temporal summation: mean r = 0.37, 95% CI: 0.17-0.54; conditioned pain modulation: mean r = 0.36, 95% CI: 0.20-0.50), whereas baseline mechanical threshold modalities were predictive of follow-up disability (mean r = 0.25, 95% CI: 0.03-0.45). Quantitative sensory testing indices of pain hypersensitivity might help develop targeted interventions aiming to improve outcomes across a range of musculoskeletal conditions.
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Affiliation(s)
- Vasileios Georgopoulos
- Department of Academic Rheumatology, Faculty of Medicine and Health
Sciences, University of Nottingham
| | - Kehinde Akin-Akinyosoye
- Department of Academic Rheumatology, Faculty of Medicine and Health
Sciences, University of Nottingham
| | - Weiya Zhang
- Department of Academic Rheumatology, Faculty of Medicine and Health
Sciences, University of Nottingham
| | - Daniel F. McWilliams
- Department of Academic Rheumatology, Faculty of Medicine and Health
Sciences, University of Nottingham
| | - Paul Hendrick
- Department of Physiotherapy, Faculty of Medicine and Health
Sciences, University of Nottingham
| | - David A. Walsh
- Department of Academic Rheumatology, Faculty of Medicine and Health
Sciences, University of Nottingham
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45
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Novovic S, Borch A, Werge M, Karran D, Gluud L, Schmidt PN, Hansen EF, Nøjgaard C, Jensen AB, Jensen FK, Frøkjær JB, Hansen MB, Jørgensen LN, Drewes AM, Olesen SS. Characterisation of the fibroinflammatory process involved in progression from acute to chronic pancreatitis: study protocol for a multicentre, prospective cohort study. BMJ Open 2019; 9:e028999. [PMID: 31439604 PMCID: PMC6707691 DOI: 10.1136/bmjopen-2019-028999] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
INTRODUCTION Chronic pancreatitis (CP) is thought to present the end stage of a continuous disease process evolving from acute pancreatitis (AP), over recurrent AP, to early and end-stage CP. Due to the irreversible nature of CP, early detection and prevention is key. Prospective assessment based on advanced imaging modalities as well as biochemical markers of inflammation, fibrosis and oxidative stress may provide a better understanding of the underlying pathological processes and help identify novel biomarkers of disease with the ultimate goal of early diagnosis, intervention and prevention of disease progression. This paper describes the protocol of a prospective multicentre cohort study investigating the fibroinflammatory process involved in progression from acute to CP using state-of-the-art diagnostic imaging modalities and circulating biomarkers of inflammation, fibrosis and oxidative stress. METHODS AND ANALYSIS Adult control subjects and patients at different stages of CP according to the M-ANNHEIM system will be recruited from outpatient clinics at the participating sites and form three cohorts: controls (n=40), suspected CP (n=60) and definitive CP (n=60). Included patients will be followed prospectively for 15 years with advanced MRI and contrast-enhanced endoscopic ultrasound with elastography, assessment of endocrine and exocrine pancreatic function, biochemical and nutritional assessment, and evaluation of pain processing using quantitative sensory testing. Blood samples for a biobank will be obtained. The purpose of the biobank is to allow analyses of potential circulating biomarkers of disease progression, including markers of inflammation, fibrosis and oxidative stress. ETHICS AND DISSEMINATION Permissions from the Regional Science Ethics committee and the Regional Data Protection Agency have been obtained. We will submit the results of the study for publication in peer-reviewed journals regardless of whether the results are positive, negative or inconclusive.
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Affiliation(s)
- Srdan Novovic
- Department of Gastroenterology and Gastrointestinal Surgery, Hvidovre Hospital, Hvidovre, Denmark
| | - Anders Borch
- Abdominal Center K, Bispebjerg Hospital, Kobenhavn, Denmark
| | - Mikkel Werge
- Department of Gastroenterology and Gastrointestinal Surgery, Hvidovre Hospital, Hvidovre, Denmark
| | - David Karran
- Abdominal Center K, Bispebjerg Hospital, Kobenhavn, Denmark
| | - Lise Gluud
- Department of Gastroenterology and Gastrointestinal Surgery, Hvidovre Hospital, Hvidovre, Denmark
| | - Palle Nordblad Schmidt
- Department of Gastroenterology and Gastrointestinal Surgery, Hvidovre Hospital, Hvidovre, Denmark
| | - Erik Feldager Hansen
- Department of Gastroenterology and Gastrointestinal Surgery, Hvidovre Hospital, Hvidovre, Denmark
| | - Camilla Nøjgaard
- Department of Gastroenterology and Gastrointestinal Surgery, Hvidovre Hospital, Hvidovre, Denmark
| | | | | | - Jens Brøndum Frøkjær
- Mech-Sense, Department of Radiology, Aalborg University Hospital, Aalborg, Denmark
| | | | | | - Asbjørn Mohr Drewes
- Mech-Sense, Department of Gastroenterology and Hepatology, Aalborg University Hospital, Aalborg, Denmark
| | - Søren Schou Olesen
- Mech-Sense, Department of Gastroenterology and Hepatology, Aalborg University Hospital, Aalborg, Denmark
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Drewes AM, Kempeneers MA, Andersen DK, Arendt-Nielsen L, Besselink MG, Boermeester MA, Bouwense S, Bruno M, Freeman M, Gress TM, van Hooft JE, Morlion B, Olesen SS, van Santvoort H, Singh V, Windsor J. Controversies on the endoscopic and surgical management of pain in patients with chronic pancreatitis: pros and cons! Gut 2019; 68:1343-1351. [PMID: 31129569 PMCID: PMC6691929 DOI: 10.1136/gutjnl-2019-318742] [Citation(s) in RCA: 40] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/20/2019] [Revised: 05/01/2019] [Accepted: 05/07/2019] [Indexed: 01/09/2023]
Affiliation(s)
- Asbjørn Mohr Drewes
- Centre for Pancreatic Diseases, Department of Gastroenterology, Aalborg University Hospital & Clinical Institute, Aalborg University, Aalborg, Denmark
| | - Marinus A Kempeneers
- Department of Surgery, Amsterdam Gastroenterology and Metabolism, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
| | - Dana K Andersen
- Division of Digestive Diseases and Nutrition, National Institute of Diabetes and Digestive and Kidney Diseases, National Institutes of Health, Bethesda, Maryland, USA
| | - Lars Arendt-Nielsen
- Center for Sensory-Motor Interactions (SMI), Faculty of Medicine, Aalborg University, Aalborg, Denmark
| | - Marc G Besselink
- Department of Surgery, Amsterdam Gastroenterology and Metabolism, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
| | - Marja A Boermeester
- Department of Surgery, Amsterdam Gastroenterology and Metabolism, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
| | - Stefan Bouwense
- Department of Surgery, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Marco Bruno
- Department of Gastroenterology and Hepatology, Erasmus MC, University Medical Center, Rotterdam, The Netherlands
| | - Martin Freeman
- Division of Gastroenterology, Hepatology and Nutrition, University of Minnessota Medical School, Minneapolis, Minnesota, USA
| | - Thomas M Gress
- Department of Gastroenterology, Philipps University & University Hospital of Marburg, Marburg, Germany
| | - Jeanin E van Hooft
- Department of Gastroenterology and Hepatology, Amsterdam Gastroenterology and Metabolism, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
| | - Bart Morlion
- The Leuven Centre for Algology & Pain Management, University Hospitals Leuven, Leuven, Belgium
| | - Søren Schou Olesen
- Centre for Pancreatic Diseases, Department of Gastroenterology, Aalborg University Hospital & Clinical Institute, Aalborg University, Aalborg, Denmark
| | - Hjalmar van Santvoort
- Department of Surgery, St Antonius Hospital, Nieuwegein, The Netherlands,Department of Surgery, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Vikesh Singh
- Division of Gastroenterology, Johns Hopkins Medical Institutions, Baltimore, Maryland, USA
| | - John Windsor
- Surgical and Translational Research Centre, Faculty of Medical and Health Sciences, University of Auckland, Auckland, New Zealand
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Baeumler PI, Conzen P, Irnich D. High Temporal Summation of Pain Predicts Immediate Analgesic Effect of Acupuncture in Chronic Pain Patients-A Prospective Cohort Study. Front Neurosci 2019; 13:498. [PMID: 31354400 PMCID: PMC6637793 DOI: 10.3389/fnins.2019.00498] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2018] [Accepted: 04/30/2019] [Indexed: 11/22/2022] Open
Abstract
Objectives: This prospective cohort study explored whether two distinguished sensory parameters predicted acupuncture effects in chronic pain patients; namely high temporal summation of pain (TS) indicating spinal synaptic facilitation as well as a low vibration detection threshold (VDT) indicating a loss of Aβ-fiber function. Methods: Pinprick induced TS and VDT were assessed by standardized, validated methods at the most painful body site and a pain free control site in 100 chronic pain patients receiving six acupuncture sessions as part of an interdisciplinary multimodal pain treatment (IMPT). Immediate change in pain intensity after the first acupuncture session (first treatment on the first day of IMPT) was assessed by the verbal rating scale (VRS, 0-100). After 4 weeks of treatment, patients indicated in a questionnaire whether acupuncture had relieved pain immediately and whether it had contributed to overall pain reduction and well-being after IMPT. Results: Logistic regression analysis revealed an association between high TS at the control site and a reduction in pain intensity of at least 30% (VRS) after the first acupuncture (OR [95%-CI] 4.3 [1.6-11.8]). Questionnaire ratings of immediate pain relief after acupuncture were associated with high TS at the control site (OR [95%-CI] 3.8 [1.4-10.2] any pain relief, OR [95%-CI] 5.5 [1.7-17.1] over 50% pain reduction) and at the pain site (OR [95%-CI] 3.2 [1.2-8.9] any pain relief). Appraisals of the contribution of acupuncture to overall pain reduction and well-being after IMPT were not associated with TS. The VDT was not associated with any outcome. Conclusion: This explorative study provides first-time evidence that high TS, especially at a pain free control site, but not VDT, might predict immediate analgesic response to acupuncture in chronic pain patients. Thus, highly centrally sensitized chronic pain patients might respond particularly well to acupuncture.
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Affiliation(s)
- Petra Iris Baeumler
- Multidisciplinary Pain Center, Department of Anaesthesiology, University Hospital Ludwig-Maximilians-University, Munich, Germany
| | - Peter Conzen
- Department of Anaesthesiology, University Hospital Ludwig-Maximilians-University, Munich, Germany
| | - Dominik Irnich
- Multidisciplinary Pain Center, Department of Anaesthesiology, University Hospital Ludwig-Maximilians-University, Munich, Germany
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van de Donk T, van Velzen M, Dahan A, Niesters M. Cornea nerve fibre state determines analgesic response to tapentadol in fibromyalgia patients without effective endogenous pain modulation. Eur J Pain 2019; 23:1586-1595. [PMID: 31162787 PMCID: PMC6790686 DOI: 10.1002/ejp.1435] [Citation(s) in RCA: 17] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2019] [Revised: 05/22/2019] [Accepted: 05/27/2019] [Indexed: 12/20/2022]
Abstract
BACKGROUND Tapentadol is a centrally acting analgesic with μ-agonistic activity combined with noradrenaline reuptake inhibition. Its mechanism of action relies on improvement of descending pain inhibition. In the current study, tapentadol's ability to enhance conditioned pain modulation (CPM, an experimental measure of descending pain inhibition) was evaluated in fibromyalgia patients with absent or reduced CPM responses. METHODS A total of 34 fibromyalgia patients completed this double-blind trial. Patients were randomized to receive treatment with tapentadol sustained-release or placebo for a 3-month period with 1-month follow-up. At baseline, the cornea nerve fibre state (CNFS) was quantified to determine the presence of nerve fibre pathology and assess its value in the prediction of the analgesic response. RESULTS Tapentadol significantly increased CPM responses during treatment with an average increase from baseline of 20.5 ± 12.5% (tapentadol) versus 3.0 ± 11.2% (placebo; p = 0.042). No treatment effect was observed for the absolute pain scores, however, analgesia responder rate analyses demonstrated a treatment effect in favour of tapentadol. Pain relief (a reduction in pain score ≥ 30%) was predicted by the presence of a normal CNFS (p = 0.035). Patients with an abnormal CNFS had no analgesic effect from tapentadol despite an increase in CPM. CONCLUSIONS In chronic pain patients with fibromyalgia, the increase in endogenous pain inhibition by tapentadol was translated into analgesia in patients with a normal CNFS. In those with abnormal CNFS, tapentadol treatment was without analgesic effect. SIGNIFICANCE In this double-blind randomized placebo-controlled trial, we showed that tapentadol significantly enhanced the descending pain inhibition in fibromyalgia patients. Tapentadol-induced pain relief was only present in patients with a normal CNFS.
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Affiliation(s)
- Tine van de Donk
- Department of Anesthesiology, Leiden University Medical Center, Leiden, the Netherlands
| | - Monique van Velzen
- Department of Anesthesiology, Leiden University Medical Center, Leiden, the Netherlands
| | - Albert Dahan
- Department of Anesthesiology, Leiden University Medical Center, Leiden, the Netherlands
| | - Marieke Niesters
- Department of Anesthesiology, Leiden University Medical Center, Leiden, the Netherlands
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Kilgallon E, Vasant DH, Green D, Shields PL, Hamdy S, Lal S, Paine P. Chronic continuous abdominal pain: evaluation of diagnostic features, iatrogenesis and drug treatments in a cohort of 103 patients. Aliment Pharmacol Ther 2019; 49:1282-1292. [PMID: 30950110 DOI: 10.1111/apt.15241] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/06/2018] [Revised: 11/23/2018] [Accepted: 03/11/2019] [Indexed: 02/06/2023]
Abstract
BACKGROUND Chronic continuous abdominal pain (CCAP) is characteristic of centrally mediated gastrointestinal pain disorders. It consumes significant healthcare resources yet is poorly understood, with minimal cohort-specific data in the literature. AIMS To examine in a large cohort of CCAP patients, (a) diagnostic features, (b) iatrogenic impact of opioids and surgery, (c) drug treatment effects and tolerance. METHODS Consecutive tertiary CCAP referrals to a neurogastroenterology clinic (2009-2016) were reviewed for Rome IV and neuropathic pain criteria. Medical, surgical and drug histories, interventions and outcomes were correlated with clinical diagnosis and associated opioid use. RESULTS Of 103 CCAP patients (mean age 40 ± 14, 85% female), 50% had physiological exacerbations precluding full Rome IV Centrally Mediated Abdominal Pain Syndrome criteria. However, there were no significant differences between patients who satisfied Rome IV criteria and those who did not. Overall, 81% had allodynia (a nonpainful stimulus evoking pain sensation). Opioid use was associated with allodynia (P = 0.003). Prior surgery was associated with further operations post CCAP onset (P < 0.001). Although 68% had undergone surgical interventions, surgery did not resolve pain in any patient and worsened pain in 35%. Whilst duloxetine was the most effective neuromodulator (P = 0.003), combination therapy was superior to monotherapy (P = 0.007). CONCLUSIONS This is currently the largest cohort CCAP dataset that supports eliciting neuropathic features, including allodynia, for a positive clinical diagnosis, to guide treatment. Physiological exacerbation of CCAP may represent visceral allodynia, and need not preclude central origin. Use of centrally acting neuromodulators, and avoidance of detrimental opioids and surgical interventions appear to predict favourable outcomes.
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Affiliation(s)
| | - Dipesh H Vasant
- Division of Diabetes, Endocrinology and Gastroenterology, University of Manchester, Manchester, UK.,Manchester University Foundation Trust, Wythenshawe Hospital, Manchester, UK
| | - Darren Green
- Division of Cardiovascular Sciences, University of Manchester, Manchester, UK
| | | | - Shaheen Hamdy
- Gastroenterology, Salford Royal NHS Foundation Trust, Salford, UK.,Division of Diabetes, Endocrinology and Gastroenterology, University of Manchester, Manchester, UK
| | - Simon Lal
- Gastroenterology, Salford Royal NHS Foundation Trust, Salford, UK.,Division of Diabetes, Endocrinology and Gastroenterology, University of Manchester, Manchester, UK
| | - Peter Paine
- Gastroenterology, Salford Royal NHS Foundation Trust, Salford, UK.,Division of Diabetes, Endocrinology and Gastroenterology, University of Manchester, Manchester, UK
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Castaldo M, Catena A, Fernández-de-las-Peñas C, Arendt-Nielsen L. Widespread Pressure Pain Hypersensitivity, Health History, and Trigger Points in Patients with Chronic Neck Pain: A Preliminary Study. PAIN MEDICINE 2019; 20:2516-2527. [DOI: 10.1093/pm/pnz035] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/12/2023]
Abstract
Abstract
Background
Pain sensitivity in chronic neck pain patients may be influenced by health conditions related to higher levels of widespread pressure pain hypersensitivity (sensitization). Trigger points have also been reported to play a role in the sensitization process.
Objectives
To investigate the association between pressure pain thresholds, trigger points, and health conditions in patients with chronic neck pain.
Design
Original research, preliminary study.
Setting
A private clinic.
Subjects
Thirty-four chronic mechanical neck pain patients and 34 chronic whiplash-associated neck pain patients, giving a final sample of 68 chronic neck pain patients.
Methods
Patients underwent an assessment of pressure pain thresholds over the upper trapezius, extensor carpi radialis longus, and tibialis anterior muscles and were screened for the presence of trigger points in the upper trapezius muscle. Further, information about health history conditions was obtained and collected in a form.
Results
Significantly negative correlations between all pressure pain thresholds and duration of health history conditions were found (all P < 0.02). Significantly lower pressure pain thresholds (all P < 0.01) were found in patients with active trigger points as compared with those with latent trigger points.
Conclusion
Widespread pressure pain hypersensitivity was associated with duration of health history conditions, suggesting that long-lasting health complaints may act as a triggering/perpetuating factor, driving sensitization in individuals with chronic neck pain. Active trigger points may be associated with higher widespread pressure hypersensitivity.
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Affiliation(s)
- Matteo Castaldo
- Center for Neuroplasticity and Pain (CNAP), SMI, Department of Health Science and Technology, Faculty of Medicine, Aalborg University, Aalborg, Denmark
- Poliambulatorio FisioCenter, Private Practice, Collecchio, Parma, Italy
- Physiotherapy department, University of Siena, Siena, Italy
| | - Antonella Catena
- Poliambulatorio FisioCenter, Private Practice, Collecchio, Parma, Italy
| | - César Fernández-de-las-Peñas
- Center for Neuroplasticity and Pain (CNAP), SMI, Department of Health Science and Technology, Faculty of Medicine, Aalborg University, Aalborg, Denmark
- Department of Physical Therapy, Occupational Therapy, Physical Medicine and Rehabilitation, Universidad Rey Juan Carlos, Alcorcón, Spain
| | - Lars Arendt-Nielsen
- Center for Neuroplasticity and Pain (CNAP), SMI, Department of Health Science and Technology, Faculty of Medicine, Aalborg University, Aalborg, Denmark
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