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Halverson CME, Doyle TA. Patients' strategies for numeric pain assessment: a qualitative interview study of individuals with hypermobile Ehlers-Danlos Syndrome. Disabil Rehabil 2024; 46:1527-1533. [PMID: 37067184 PMCID: PMC10579449 DOI: 10.1080/09638288.2023.2200039] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/18/2022] [Revised: 03/21/2023] [Accepted: 04/01/2023] [Indexed: 04/18/2023]
Abstract
PURPOSE Chronic pain is a common feature of hypermobile Ehlers-Danlos Syndrome (hEDS), yet how patients assess and communicate their pain remains poorly understood. The objective of the present study was to explore the use of numeric pain assessment in individuals with hEDS, from a patient-centered perspective. MATERIALS AND METHODS Our analysis is based on in-depth qualitative interviews. The interviews were conducted over the phone. Our participants were patients living with hEDS (N = 35). Interviews were recorded, transcribed, and analyzed to identify factors related to their use of these pain assessment instruments. RESULTS Three primary themes emerged from these data, namely, (1) confusion around the quantification of multidimensional pain, (2) the subjectivity of pain experience, and (3) a strategic use of assessments for practical purposes beyond the accurate representation of pain. These results demonstrate the need for caution in relying exclusively on numeric pain assessment instruments. We conclude with a brief proposal for a clinical communication strategy that may help to address the limitations of numeric pain assessment that were identified in our interviews.
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Affiliation(s)
- Colin M E Halverson
- Center for Bioethics, Indiana University School of Medicine, Indianapolis, IN, USA
- Department of Medicine, Indiana University School of Medicine, Indianapolis, IN, USA
- Department of Anthropology, Indiana University, Indianapolis, IN, USA
- Regenstrief Institute, Indianapolis, IN, USA
- Charles Warren Fairbanks Center for Medical Ethics, Indianapolis, IN, USA
| | - Tom A Doyle
- Center for Bioethics, Indiana University School of Medicine, Indianapolis, IN, USA
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Sirucek L, Jutzeler CR, Rosner J, Schweinhardt P, Curt A, Kramer JLK, Hubli M. The Effect of Conditioned Pain Modulation on Tonic Heat Pain Assessed Using Participant-Controlled Temperature. PAIN MEDICINE 2021; 21:2839-2849. [PMID: 32176283 DOI: 10.1093/pm/pnaa041] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
Abstract
OBJECTIVE Descending pain modulation can be experimentally assessed by way of testing conditioned pain modulation. The application of tonic heat as a test stimulus in such paradigms offers the possibility of observing dynamic pain responses, such as adaptation and temporal summation of pain. Here we investigated conditioned pain modulation effects on tonic heat employing participant-controlled temperature, an alternative tonic heat pain assessment. Changes in pain perception are thereby represented by temperature adjustments performed by the participant, uncoupling this approach from direct pain ratings. Participant-controlled temperature has emerged as a reliable and sex-independent measure of tonic heat. METHODS Thirty healthy subjects underwent a sequential conditioned pain modulation paradigm, in which a cold water bath was applied as the conditioning stimulus and tonic heat as a test stimulus. Subjects were instructed to change the temperature of the thermode in response to variations in perception to tonic heat in order to maintain their initial rating over a two-minute period. Two additional test stimuli (i.e., lower limb noxious withdrawal reflex and pressure pain threshold) were included as positive controls for conditioned pain modulation effects. RESULTS Participant-controlled temperature revealed conditioned pain modulation effects on temporal summation of pain (P = 0.01). Increased noxious withdrawal reflex thresholds (P = 0.004) and pressure pain thresholds (P < 0.001) in response to conditioning also confirmed inhibitory conditioned pain modulation effects. CONCLUSIONS The measured interaction between conditioned pain modulation and temporal summation of pain supports the participant-controlled temperature approach as a promising method to explore dynamic inhibitory and facilitatory pain processes previously undetected by rating-based approaches.
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Affiliation(s)
- Laura Sirucek
- Spinal Cord Injury Center, Balgrist University Hospital, University of Zurich, Zurich, Switzerland.,Integrative Spinal Research Group, Department of Chiropractic Medicine, Balgrist University Hospital, University of Zurich, Zurich, Switzerland
| | - Catherine Ruth Jutzeler
- Spinal Cord Injury Center, Balgrist University Hospital, University of Zurich, Zurich, Switzerland.,International Collaboration on Repair Discoveries (ICORD), University of British Columbia, Vancouver, British Columbia, Canada.,School of Kinesiology, University of British Columbia, Vancouver, British Columbia, Canada
| | - Jan Rosner
- Spinal Cord Injury Center, Balgrist University Hospital, University of Zurich, Zurich, Switzerland.,School of Kinesiology, University of British Columbia, Vancouver, British Columbia, Canada
| | - Petra Schweinhardt
- Integrative Spinal Research Group, Department of Chiropractic Medicine, Balgrist University Hospital, University of Zurich, Zurich, Switzerland
| | - Armin Curt
- Spinal Cord Injury Center, Balgrist University Hospital, University of Zurich, Zurich, Switzerland
| | - John Lawrence Kipling Kramer
- International Collaboration on Repair Discoveries (ICORD), University of British Columbia, Vancouver, British Columbia, Canada.,School of Kinesiology, University of British Columbia, Vancouver, British Columbia, Canada
| | - Michèle Hubli
- Spinal Cord Injury Center, Balgrist University Hospital, University of Zurich, Zurich, Switzerland
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Frangos E, Čeko M, Wang B, Richards EA, Gracely JL, Colloca L, Schweinhardt P, Bushnell MC. Neural effects of placebo analgesia in fibromyalgia patients and healthy individuals. Pain 2021; 162:641-652. [PMID: 32925593 PMCID: PMC7808362 DOI: 10.1097/j.pain.0000000000002064] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2020] [Accepted: 08/20/2020] [Indexed: 12/19/2022]
Abstract
ABSTRACT Placebo analgesia is hypothesized to involve top-down engagement of prefrontal regions that access endogenous pain inhibiting opioid pathways. Fibromyalgia (FM) patients have neuroanatomical and neurochemical alterations in pathways relevant to placebo analgesia. Thus, it remains unclear whether placebo analgesic mechanisms would differ in FM patients compared to healthy controls (HCs). Here, using placebo-analgesia-inducing paradigms that included verbal suggestions and conditioning manipulations, we examined whether behavioral and neural placebo analgesic responses differed between 32 FM patients and 46 age- and sex-matched HCs. Participants underwent a manipulation scan, where noxious high and low heat were paired with the control and placebo cream, respectively, and a placebo experimental scan with equal noxious heat temperatures. Before the experimental scan, each participant received saline or naloxone, an opioid receptor antagonist. Across all participants, the placebo condition decreased pain intensity and unpleasantness ratings, decreased activity within the right insula and bilateral secondary somatosensory cortex, and modulated the neurologic pain signature. There were no differences between HCs and FM patients in pain intensity ratings or neural responses during the placebo condition. Despite the perceptual and neural effects of the placebo manipulation, prefrontal circuitry was not activated during the expectation period and the placebo analgesia was unaltered by naloxone, suggesting placebo effects were driven more by conditioning than expectation. Together, these findings suggest that placebo analgesia can occur in both HCs and chronic pain FM patients, without the involvement of opioidergic prefrontal modulatory networks.
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Affiliation(s)
- Eleni Frangos
- National Center for Complementary and Integrative Health, National Institutes of Health, Bethesda, MD, United States
| | - Marta Čeko
- National Center for Complementary and Integrative Health, National Institutes of Health, Bethesda, MD, United States
- Institute of Cognitive Science, University of Colorado, Boulder, CO, United States
| | - Binquan Wang
- National Center for Complementary and Integrative Health, National Institutes of Health, Bethesda, MD, United States
| | - Emily A. Richards
- National Center for Complementary and Integrative Health, National Institutes of Health, Bethesda, MD, United States
| | - John L. Gracely
- National Center for Complementary and Integrative Health, National Institutes of Health, Bethesda, MD, United States
| | - Luana Colloca
- Department of Pain Translational Symptom Science, School of Nursing, University of Maryland, Baltimore, MA, United States
- Department of Anesthesiology, School of Medicine, University of Maryland, Baltimore, MA, United States
| | - Petra Schweinhardt
- The Alan Edwards Centre for Research on Pain, Neurology and Neurosurgery, McGill University, Montreal, QC, Canada
- Department of Chiropractic Medicine, Balgrist University Hospital and University of Zurich, Zurich, Switzerland
| | - M. Catherine Bushnell
- National Center for Complementary and Integrative Health, National Institutes of Health, Bethesda, MD, United States
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Pujol J, Ramos-López D, Blanco-Hinojo L, Pujol G, Ortiz H, Martínez-Vilavella G, Blanch J, Monfort J, Deus J. Testing the effects of gentle vibrotactile stimulation on symptom relief in fibromyalgia. Arthritis Res Ther 2019; 21:148. [PMID: 31200775 PMCID: PMC6570892 DOI: 10.1186/s13075-019-1932-9] [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: 12/19/2018] [Accepted: 06/06/2019] [Indexed: 01/01/2023] Open
Abstract
Background Sensory disturbances in fibromyalgia extend beyond nociception. It has been proposed that imbalance in the mutual competition between painful input and non-painful sensory activity may, to a significant extent, account for the augmented subjective perception of pain. In this context, non-nociceptive somatosensory stimulation could arguably attenuate fibromyalgia symptoms by restoring the sensory balance. We specifically tested the effect of vibrotactile stimulation on symptom relief in fibromyalgia patients with a randomized, double-blind, sham-controlled, crossover clinical trial. Methods Seventy-seven female patients were randomized and data from 63 valid cases were analyzed. Active intervention involved extensive body stimulation with gentle mechanical vibrations administered during 3 h at night for 3 weeks, and the placebo effect was controlled using identical instruments to simulate an alternative treatment option. The primary outcome measure combined pain, fatigue, and complaints of poor cognition. Results Vibrotactile stimulation was significantly superior to sham in alleviating fibromyalgia symptoms globally. However, univariate analyses showed that the effect was not universal. Benefits were perceived on unpleasant somatic sensations such as generalized pain and fatigue, but not on poor cognition, anxiety, and depression. Vibrotactile stimulation was notably well tolerated and sleep quality significantly improved despite the fact that vibrations were administered at night. Conclusions Results thus provide new evidence that non-nociceptive somatosensory stimulation may favorably act upon altered somatosensory balance in fibromyalgia. From a clinical perspective, both the degree of improvement and the easy application of our proposal would seem to support a potential role for vibrotactile stimulation in the symptomatic treatment of fibromyalgia. Trial registration ClinicalTrials.gov registration number NCT03227952. Registered 24 July, 2017.
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Affiliation(s)
- Jesus Pujol
- MRI Research Unit, Department of Radiology, Hospital del Mar, Passeig Marítim 25-29, 08003, Barcelona, Spain. .,Centro Investigación Biomédica en Red de Salud Mental, CIBERSAM G21, Barcelona, Spain.
| | - Daniel Ramos-López
- MRI Research Unit, Department of Radiology, Hospital del Mar, Passeig Marítim 25-29, 08003, Barcelona, Spain
| | - Laura Blanco-Hinojo
- MRI Research Unit, Department of Radiology, Hospital del Mar, Passeig Marítim 25-29, 08003, Barcelona, Spain.,Centro Investigación Biomédica en Red de Salud Mental, CIBERSAM G21, Barcelona, Spain
| | - Guillem Pujol
- MRI Research Unit, Department of Radiology, Hospital del Mar, Passeig Marítim 25-29, 08003, Barcelona, Spain
| | - Héctor Ortiz
- Department of Project and Construction Engineering, Universitat Politècnica de Catalunya (UPC), Barcelona, Spain
| | - Gerard Martínez-Vilavella
- MRI Research Unit, Department of Radiology, Hospital del Mar, Passeig Marítim 25-29, 08003, Barcelona, Spain
| | - Josep Blanch
- Rheumatology Department, Hospital del Mar, Barcelona, Spain
| | - Jordi Monfort
- Rheumatology Department, Hospital del Mar, Barcelona, Spain
| | - Joan Deus
- MRI Research Unit, Department of Radiology, Hospital del Mar, Passeig Marítim 25-29, 08003, Barcelona, Spain.,Department of Clinical and Health Psychology, Autonomous University of Barcelona, Barcelona, Spain
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