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Iuamoto LR, Ito FLK, Tomé TA, Hsing WT, Meyer A, Imamura M, Battistella LR. Effects of neuroplasticity in people with knee osteoarthritis: A systematic review of the literature. Medicine (Baltimore) 2022; 101:e28616. [PMID: 35060535 PMCID: PMC8772630 DOI: 10.1097/md.0000000000028616] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/31/2021] [Accepted: 01/03/2022] [Indexed: 01/05/2023] Open
Abstract
BACKGROUND Knee osteoarthritis (OA) is associated with chronic inflammation in somatic structures, which alters sensory afferents and leads to plastic changes in the nervous system. METHODS A systematic literature review was carried out, without language restrictions, period, or status of publication. The database used were Medline, EMBASE, Cochrane Library and clinicaltrials.gov. Extra bibliographic references were extracted through the discussion with specialists, and through scientific researches in conference papers. RESULTS The electronic search found 938 articles. When excluding duplicates and applying the inclusion/exclusion criteria, 5 studies were considered: 2 using EEG and 3 using TMS. Significant reduction of EEG activity in the cingulate medium cortex, reduction of conditioned pain modulation (CPM) in studies with EEG, as well as the occurrence of an association between pain and motor response threshold/intracortical pain facilitation in studies with TMS were observed. CONCLUSIONS The study contributes to a better understanding of the neurophysiological changes seen in the cingulate medium cortex, decrease in CPM and motor response threshold/intracortical pain facilitation. Advances in neuroplasticity studies may aid in the screening for early diagnosis of knee OA in the future. However, more studies are necessary.
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Affiliation(s)
- Leandro Ryuchi Iuamoto
- Centro de Pesquisa Clinica, Instituto de Medicina Fisica e Reabilitacao, Hospital das Clinicas HCFMUSP, University of Sao Paulo School of Medicine, Sao Paulo, SP, Brazil
| | | | | | - Wu Tu Hsing
- Center of Acupuncture, Department of Orthopaedics and Traumatology, University of Sao Paulo School of Medicine, Sao Paulo, SP, Brazil
| | - Alberto Meyer
- Department of Gastroenterology, Hospital das Clinicas, University of Sao Paulo School of Medicine, Sao Paulo, SP, Brazil
| | - Marta Imamura
- Faculdade de Medicina FMUSP, Department of Legal Medicine, Medical Ethics, Social and Work Medicine, Universidade de Sao Paulo, Sao Paulo, SP, Brazil
| | - Linamara Rizzo Battistella
- Faculdade de Medicina FMUSP, Department of Legal Medicine, Medical Ethics, Social and Work Medicine, Universidade de Sao Paulo, Sao Paulo, SP, Brazil
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2
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Lv ZT, Shen LL, Zhu B, Zhang ZQ, Ma CY, Huang GF, Yin J, Yu LL, Yu SY, Ding MQ, Li J, Yuan XC, He W, Jing XH, Li M. Effects of intensity of electroacupuncture on chronic pain in patients with knee osteoarthritis: a randomized controlled trial. Arthritis Res Ther 2019; 21:120. [PMID: 31088511 PMCID: PMC6518678 DOI: 10.1186/s13075-019-1899-6] [Citation(s) in RCA: 63] [Impact Index Per Article: 12.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/16/2018] [Accepted: 04/17/2019] [Indexed: 01/22/2023] Open
Abstract
BACKGROUND Conditioned pain modulation (CPM) is impaired in people with chronic pain such as knee osteoarthritis (KOA). The purpose of this randomized, controlled clinical trial was to investigate whether strong electroacupuncture (EA) was more effective on chronic pain by strengthening the CPM function than weak EA or sham EA in patients with KOA. METHODS In this multicenter, three-arm parallel, single-blind randomized controlled trial, 301 patients with KOA were randomly assigned. Patients were randomized into three groups based on EA current intensity: strong EA (> 2 mA), weak EA (< 0.5 mA), and sham EA (non-acupoint). Treatments consisted of five sessions per week, for 2 weeks. Primary outcome measures were visual analog scale (VAS), CPM function, and Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC). RESULTS Three hundred one patients with KOA were randomly assigned, among which 271 (90.0%) completed the study (mean age 63.93 years old). One week of EA had a clinically important improvement in VAS and WOMAC but not in CPM function. After 2 weeks treatment, EA improved VAS, CPM, and WOMAC compared with baseline. Compared with sham EA, weak EA (3.8; 95% CI 3.45, 4.15; P < .01) and strong EA (13.54; 95% CI 13.23, 13.85; P < .01) were better in improving CPM function. Compared with weak EA, strong EA was better in enhancing CPM function (9.73; 95% CI 9.44, 10.02; P < .01), as well as in reducing VAS and total WOMAC score. CONCLUSION EA should be administered for at least 2 weeks to exert a clinically important effect on improving CPM function of KOA patients. Strong EA is better than weak or sham EA in alleviating pain intensity and inhibiting chronic pain. TRIAL REGISTRATION This study was registered with the Chinese Clinical Trial Registry ( ChiCTR-ICR-14005411 ), registered on 31 October 2014.
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Affiliation(s)
- Zheng-Tao Lv
- Department of Neurobiology, School of Basic Medicine, Tongji Medical College of Huazhong University of Science and Technology, Wuhan, 430030, China.,Department of Orthopedics, Tongji Hospital, Tongji Medical College of Huazhong University of Science and Technology, Wuhan, 430030, China
| | - Lin-Lin Shen
- Combined Traditional Chinese and Western Medicine Hospital affiliated to Tongji Medical College of Huazhong University of Science and Technology, Wuhan, 430030, China
| | - Bing Zhu
- Institute of Acupuncture and Moxibustion, China Academy of Chinese Medical Sciences, Beijing, 100700, China
| | | | | | - Guo-Fu Huang
- Combined Traditional Chinese and Western Medicine Hospital affiliated to Tongji Medical College of Huazhong University of Science and Technology, Wuhan, 430030, China
| | - Jing Yin
- The Third Hospital of Wuhan, Wuhan, 430060, China
| | - Ling-Ling Yu
- Department of Neurobiology, School of Basic Medicine, Tongji Medical College of Huazhong University of Science and Technology, Wuhan, 430030, China.,Combined Traditional Chinese and Western Medicine Hospital affiliated to Tongji Medical College of Huazhong University of Science and Technology, Wuhan, 430030, China
| | - Si-Yi Yu
- School of Acupuncture and Moxibustion, Chengdu University of Traditional Chinese Medicine, Chengdu, 610075, China
| | | | - Jing Li
- Union Hospital affiliated to Tongji Medical College of Huazhong University of Science and Technology, Wuhan, 430022, China
| | - Xiao-Cui Yuan
- Department of Neurobiology, School of Basic Medicine, Tongji Medical College of Huazhong University of Science and Technology, Wuhan, 430030, China
| | - Wei He
- Institute of Acupuncture and Moxibustion, China Academy of Chinese Medical Sciences, Beijing, 100700, China
| | - Xiang-Hong Jing
- Institute of Acupuncture and Moxibustion, China Academy of Chinese Medical Sciences, Beijing, 100700, China.
| | - Man Li
- Department of Neurobiology, School of Basic Medicine, Tongji Medical College of Huazhong University of Science and Technology, Wuhan, 430030, China.
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Damien J, Colloca L, Bellei-Rodriguez CÉ, Marchand S. Pain Modulation: From Conditioned Pain Modulation to Placebo and Nocebo Effects in Experimental and Clinical Pain. INTERNATIONAL REVIEW OF NEUROBIOLOGY 2018; 139:255-296. [PMID: 30146050 DOI: 10.1016/bs.irn.2018.07.024] [Citation(s) in RCA: 73] [Impact Index Per Article: 12.2] [Reference Citation Analysis] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
Accumulating evidence reveal important applications of endogenous pain modulation assessment in healthy controls and in patients in clinical settings, as dysregulations in the balance of pain modulatory circuits may facilitate pain and promote chronification of pain. This article reviews data on pain modulation, focusing on the mechanisms and translational aspects of pain modulation from conditioned pain modulation (CPM) to placebo and nocebo effects in experimental and clinical pain. The specific roles of expectations, learning, neural and neurophysiological mechanisms of the central nervous system are briefly reviewed herein. The interaction between CPM and placebo systems in pain inhibitory pathways is highly relevant in the clinic and in randomized controlled trials yet remains to be clarified. Examples of clinical implications of CPM and its relationship to placebo and nocebo effects are provided. A greater understanding of the role of pain modulation in various pain states can help characterize the manifestation and development of chronic pain and assist in predicting the response to pain-relieving treatments. Placebo and nocebo effects, intrinsic to every treatment, can be used to develop personalized therapeutic approaches that improve clinical outcomes while limiting unwanted effects.
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Affiliation(s)
- Janie Damien
- Research Center of the Centre hospitalier universitaire de Sherbrooke (CHUS), Department of Surgery, Faculty of Medicine and Health Sciences, Université de Sherbrooke, Sherbrooke, QC, Canada
| | - Luana Colloca
- Department of Pain Translational Symptom Science, School of Nursing, University of Maryland, Baltimore, MD, United States; Departments of Psychiatry and Anesthesiology, School of Medicine, University of Maryland, Baltimore, MD, United States
| | - Carmen-Édith Bellei-Rodriguez
- Research Center of the Centre hospitalier universitaire de Sherbrooke (CHUS), Department of Surgery, Faculty of Medicine and Health Sciences, Université de Sherbrooke, Sherbrooke, QC, Canada
| | - Serge Marchand
- Research Center of the Centre hospitalier universitaire de Sherbrooke (CHUS), Department of Surgery, Faculty of Medicine and Health Sciences, Université de Sherbrooke, Sherbrooke, QC, Canada; Fonds de Recherche du Québec-Santé (FRQS), Montréal, QC, Canada.
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4
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Yuan XC, Zhu B, Jing XH, Xiong LZ, Wu CH, Gao F, Li HP, Xiang HC, Zhu H, Zhou B, He W, Lin CY, Pan HL, Wang Q, Li M. Electroacupuncture Potentiates Cannabinoid Receptor-Mediated Descending Inhibitory Control in a Mouse Model of Knee Osteoarthritis. Front Mol Neurosci 2018; 11:112. [PMID: 29681797 PMCID: PMC5897736 DOI: 10.3389/fnmol.2018.00112] [Citation(s) in RCA: 33] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/09/2018] [Accepted: 03/20/2018] [Indexed: 11/13/2022] Open
Abstract
Knee osteoarthritis (KOA) is a highly prevalent, chronic joint disorder, which can lead to chronic pain. Although electroacupuncture (EA) is effective in relieving chronic pain in the clinic, the involved mechanisms remain unclear. Reduced diffuse noxius inhibitory controls (DNIC) function is associated with chronic pain and may be related to the action of endocannabinoids. In the present study, we determined whether EA may potentiate cannabinoid receptor-mediated descending inhibitory control and inhibit chronic pain in a mouse model of KOA. We found that the optimized parameters of EA inhibiting chronic pain were the low frequency and high intensity (2 Hz + 1 mA). EA reversed the reduced expression of CB1 receptors and the 2-arachidonoylglycerol (2-AG) level in the midbrain in chronic pain. Microinjection of the CB1 receptor antagonist AM251 into the ventrolateral periaqueductal gray (vlPAG) can reversed the EA effect on pain hypersensitivity and DNIC function. In addition, CB1 receptors on GABAergic but not glutamatergic neurons are involved in the EA effect on DNIC function and descending inhibitory control of 5-HT in the medulla, thus inhibiting chronic pain. Our data suggest that endocannabinoid (2-AG)-CB1R-GABA-5-HT may be a novel signaling pathway involved in the effect of EA improving DNIC function and inhibiting chronic pain.
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Affiliation(s)
- Xiao-Cui Yuan
- Department of Neurobiology and Key Laboratory of Neurological Diseases of Ministry of Education, The Institute of Brain Research, School of Basic Medicine, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Bing Zhu
- Institute of Acupuncture and Moxibustion, China Academy of Chinese Medical Sciences, Beijing, China
| | - Xiang-Hong Jing
- Institute of Acupuncture and Moxibustion, China Academy of Chinese Medical Sciences, Beijing, China
| | - Li-Ze Xiong
- Department of Anesthesiology, Xijing Hospital, Fourth Military Medical University, Xi'an, China
| | - Cai-Hua Wu
- Department of Neurobiology and Key Laboratory of Neurological Diseases of Ministry of Education, The Institute of Brain Research, School of Basic Medicine, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Fang Gao
- Department of Neurobiology and Key Laboratory of Neurological Diseases of Ministry of Education, The Institute of Brain Research, School of Basic Medicine, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Hong-Ping Li
- Department of Neurobiology and Key Laboratory of Neurological Diseases of Ministry of Education, The Institute of Brain Research, School of Basic Medicine, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Hong-Chun Xiang
- Department of Neurobiology and Key Laboratory of Neurological Diseases of Ministry of Education, The Institute of Brain Research, School of Basic Medicine, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - He Zhu
- Department of Neurobiology and Key Laboratory of Neurological Diseases of Ministry of Education, The Institute of Brain Research, School of Basic Medicine, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Bin Zhou
- Department of Neurobiology and Key Laboratory of Neurological Diseases of Ministry of Education, The Institute of Brain Research, School of Basic Medicine, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Wei He
- Institute of Acupuncture and Moxibustion, China Academy of Chinese Medical Sciences, Beijing, China
| | - Chuan-You Lin
- Department of Neurobiology and Key Laboratory of Neurological Diseases of Ministry of Education, The Institute of Brain Research, School of Basic Medicine, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Hui-Lin Pan
- Department of Anesthesiology and Perioperative Medicine, The University of Texas MD Anderson Cancer Center, Houston, TX, United States
| | - Qiang Wang
- Department of Anesthesiology, First Affiliated Hospital of Xi'an JiaoTong University, Xi'an, China
| | - Man Li
- Department of Neurobiology and Key Laboratory of Neurological Diseases of Ministry of Education, The Institute of Brain Research, School of Basic Medicine, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
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Shen LL, Huang GF, Tian W, Yu LL, Yuan XC, Zhang ZQ, Yin J, Ma CY, Cai GW, Li JW, Ding MQ, He W, Gao XY, Zhu B, Jing XH, Li M. Electroacupuncture inhibits chronification of the acute pain of knee osteoarthritis: study protocol for a randomized controlled trial. Trials 2015; 16:131. [PMID: 25873092 PMCID: PMC4411929 DOI: 10.1186/s13063-015-0636-y] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/06/2014] [Accepted: 03/05/2015] [Indexed: 11/28/2022] Open
Abstract
Background Previous studies have shown that electroacupuncture (EA) has a significant effect on acute pain, but it has not solved the clinical problem of the chronification of acute pain. Diffuse noxious inhibitory controls (DNIC) function as a reliable indicator to predict the risk of chronic pain events. DNIC function in knee osteoarthritis (KOA) patients has been demonstrated to gradually decrease during the development of chronic pain. The purpose of this study is to conduct a randomized, controlled clinical trial to determine if EA can repair impaired DNIC function and thus prevent chronification of the acute pain of KOA. Methods/Design This is a multicenter, single blind, randomized, controlled, three-arm, large-scale clinical trial. A total of 450 KOA patients will be randomly assigned to three groups. The strong EA group will receive EA with high-intensity current (2 mA < current < 5 mA) at the ipsilateral ‘Neixiyan’ (EX-LE5), ‘Dubi’(ST35), ‘Liangqiu’(ST34) and ‘Xuehai’ (SP10). The weak EA group will receive EA with low-intensity current (0 mA < current < 0.5 mA) on the same acupoints. The sham EA group will receive EA with low-intensity current (0 mA < current < 0.5 mA) with fine needles inserted superficially into the sites 2 cm lateral to the above acupoints. The patients will be treated with EA once a day, 30 minutes per session, in 5 sessions per week, for 2 weeks. In order to determine the best stage of KOA for effective EA intervention, patients within the treatment groups also will be divided into four stages. The primary outcomes are Visual Analog Scale (VAS), DNIC function and the Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC). Clinical assessments will be evaluated at baseline (before treatment) and after 5 to 10 sessions of treatment. Discussion This trial will be helpful in identifying whether strong EA is more effective than weak EA in reversing chronification of acute pain through repairing the impaired DNIC function and in screening for the best stage of KOA for effective EA intervention. Trial registration Chinese Clinical Trial Registry Number: ChiCTR-ICR-14005411. The date of registration is 31 October 2014.
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Affiliation(s)
- Lin-lin Shen
- Department of Neurobiology, School of Basic Medicine, Tongji Medical College of Huazhong University of Science and Technology, No.13 Hang Kong Road, Wuhan, 430030, P. R. China. .,Combined Traditional Chinese and Western Medicine Hospital affiliated to Hubei University of Traditional Chinese Medicine, No.215 Zhong Shan Road, Wuhan, 430022, P. R. China.
| | - Guo-fu Huang
- Department of Neurobiology, School of Basic Medicine, Tongji Medical College of Huazhong University of Science and Technology, No.13 Hang Kong Road, Wuhan, 430030, P. R. China. .,Combined Traditional Chinese and Western Medicine Hospital affiliated to Hubei University of Traditional Chinese Medicine, No.215 Zhong Shan Road, Wuhan, 430022, P. R. China.
| | - Wen Tian
- Department of Neurobiology, School of Basic Medicine, Tongji Medical College of Huazhong University of Science and Technology, No.13 Hang Kong Road, Wuhan, 430030, P. R. China. .,Combined Traditional Chinese and Western Medicine Hospital affiliated to Hubei University of Traditional Chinese Medicine, No.215 Zhong Shan Road, Wuhan, 430022, P. R. China.
| | - Ling-ling Yu
- Department of Neurobiology, School of Basic Medicine, Tongji Medical College of Huazhong University of Science and Technology, No.13 Hang Kong Road, Wuhan, 430030, P. R. China. .,Combined Traditional Chinese and Western Medicine Hospital affiliated to Hubei University of Traditional Chinese Medicine, No.215 Zhong Shan Road, Wuhan, 430022, P. R. China.
| | - Xiao-cui Yuan
- Department of Neurobiology, School of Basic Medicine, Tongji Medical College of Huazhong University of Science and Technology, No.13 Hang Kong Road, Wuhan, 430030, P. R. China.
| | - Zhao-qing Zhang
- The Third Hospital of Wuhan, No.241 Peng Liuyang Road, Wuhan, 430060, P. R. China.
| | - Jing Yin
- The Third Hospital of Wuhan, No.241 Peng Liuyang Road, Wuhan, 430060, P. R. China.
| | - Chao-yang Ma
- Central Hospital of Wuhan, No.26 Sheng Li Road, Wuhan, 430014, P. R. China.
| | - Guo-wei Cai
- Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, No.1277 Jiefang Ave, Wuhan, 430022, P. R. China.
| | - Jian-wu Li
- Wuhan Hospital of Traditional Chinese Medicine, No.49 Li Huangpi Road, Wuhan, 430014, P. R. China.
| | - Ming-qiao Ding
- The Fifth Hospital of Wuhan, No.122 Xian Zheng Road, Wuhan, 430050, P. R. China.
| | - Wei He
- Institute of Acupuncture and Moxibustion, China Academy of Chinese Medical Sciences, No. 16 Nanxiaojie of Dongzhimennei, Beijing, 100700, P. R. China.
| | - Xin-yan Gao
- Institute of Acupuncture and Moxibustion, China Academy of Chinese Medical Sciences, No. 16 Nanxiaojie of Dongzhimennei, Beijing, 100700, P. R. China.
| | - Bing Zhu
- Institute of Acupuncture and Moxibustion, China Academy of Chinese Medical Sciences, No. 16 Nanxiaojie of Dongzhimennei, Beijing, 100700, P. R. China.
| | - Xiang-hong Jing
- Institute of Acupuncture and Moxibustion, China Academy of Chinese Medical Sciences, No. 16 Nanxiaojie of Dongzhimennei, Beijing, 100700, P. R. China.
| | - Man Li
- Department of Neurobiology, School of Basic Medicine, Tongji Medical College of Huazhong University of Science and Technology, No.13 Hang Kong Road, Wuhan, 430030, P. R. China.
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Røe C. Amplification of osteoarthritis pain by peripheral and central nervous systems pain mechanisms. Scand J Pain 2013; 4:109-110. [PMID: 29913897 DOI: 10.1016/j.sjpain.2012.10.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
Affiliation(s)
- Cecilie Røe
- Department of Physical Medicine and Rehabilitation, Oslo University Hospital, Ulleval, Oslo, Norway
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Granovsky Y, Yarnitsky D. Personalized pain medicine: the clinical value of psychophysical assessment of pain modulation profile. Rambam Maimonides Med J 2013; 4:e0024. [PMID: 24228167 PMCID: PMC3820297 DOI: 10.5041/rmmj.10131] [Citation(s) in RCA: 46] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/18/2022] Open
Abstract
Experimental pain stimuli can be used to simulate patients' pain experience. We review recent developments in psychophysical pain testing, focusing on the application of the dynamic tests-conditioned pain modulation (CPM) and temporal summation (TS). Typically, patients with clinical pain of various types express either less efficient CPM or enhanced TS, or both. These tests can be used in prediction of incidence of acquiring pain and of its intensity, as well as in assisting the correct choice of analgesic agents for individual patients. This can help to shorten the commonly occurring long and frustrating process of adjusting analgesic agents to the individual patients. We propose that evaluating pain modulation can serve as a step forward in individualizing pain medicine.
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Affiliation(s)
- Yelena Granovsky
- Department of Neurology, Rambam Medical Center, and Clinical Neurophysiology Lab, Faculty of Medicine, Technion - Israel Institute of Technology, Haifa, Israel
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The prevalence of fibromyalgia in other chronic pain conditions. PAIN RESEARCH AND TREATMENT 2011; 2012:584573. [PMID: 22191024 PMCID: PMC3236313 DOI: 10.1155/2012/584573] [Citation(s) in RCA: 69] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 05/03/2011] [Accepted: 08/15/2011] [Indexed: 12/12/2022]
Abstract
Central sensitivity syndromes (CSS) include fibromyalgia syndrome (FMS), irritable bowel syndrome, temporomandibular disorder, restless legs syndrome, chronic fatigue syndrome, and other similar chronic painful conditions that are based on central sensitization (CS). CSS are mutually associated. In this paper, prevalence of FMS among other members of CSS has been described. An important recent recognition is an increased prevalence of FMS in other chronic pain conditions with structural pathology, for example, rheumatoid arthritis, systemic lupus, ankylosing spondylitis, osteoarthritis, diabetes mellitus, and inflammatory bowel disease. Diagnosis and proper management of FMS among these diseases are of crucial importance so that unwarranted use of such medications as corticosteroids can be avoided, since FMS often occurs when RA or SLE is relatively mild.
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