Children with migraine: Provocation of headache via pressure to myofascial trigger points in the trapezius muscle? – A prospective controlled observational study

Abstract

Background

The objective was to evaluate a supposed clinical interdependency of myofascial trigger points and migraine in children. Such interdependency would support an interaction of spinal and trigeminal afferences in the trigemino-cervical complex as a contributing factor in migraine.

Methods

Children ≤18 years with the confirmed diagnosis of migraine were prospectively investigated. Comprehensive data on medical history, clinical neurological and psychological status were gathered. Trigger points in the trapezius muscle were identified by palpation and the threshold of pressure pain at these points was measured. Manual pressure was applied to the trigger points, and the occurrence and duration of induced headache were recorded. At a second consultation (4 weeks after the first), manual pressure with the detected pressure threshold was applied to non-trigger points within the same trapezius muscle (control). Headache and related parameters were again recorded and compared to the results of the first consultation.

Results

A total of 13 girls and 13 boys with migraine and a median age of 14.5 (Range 6.3–17.8) years took part in the study. Manual pressure to trigger points in the trapezius muscle led to lasting headache after termination of the manual pressure in 13 patients while no patient experienced headache when manual pressure was applied to non-trigger points at the control visit (p < 0.001). Headache was induced significantly more often in children ≥12 years and those with internalizing behavioural disorder.

Conclusion

We found an association between trapezius muscle myofascial trigger points and migraine, which might underline the concept of the trigemino-cervical complex, especially in adolescents.

Significance

In children with migraine headache can often be induced by pressure to myofascial trigger points, but not by pressure to non-trigger points in the trapezius muscle. This supports the hypothesis of a trigemino-cervical-complex in the pathophysiology of migraine, which might have implications for innovative therapies in children with migraine.

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Effects of duloxetine on pain and walking distance in neuropathic pain models via modulation of the spinal monoamine system

Abstract

Background

Approximately 40% of patients with chronic low back pain have a neuropathic component. In this study, we assessed the effects of analgesics on tactile hypersensitivity and walking distance in the rat cauda equina compression (CEC) model of neuropathic low back pain.

Methods

The effects of analgesics on tactile hypersensitivity were examined using the von Frey test in CEC and partial sciatic nerve ligation (pSNL) models. Effects on walking distance were assessed using a treadmill test. Levels of α2δ1 subunit and ATF-3 mRNA in dorsal-root ganglion (DRG) neurons and those of α2δ1 subunit protein in the spinal cord were determined using quantitative RT-PCR and western blotting, respectively. Histological features were assessed using immunohistological methods.

Results

Histological changes indicating nerve damage (increase in ATF-3 mRNA, decrease in NF-200 and an increase in CD68 immunoreactivity) were observed in the CEC model. Duloxetine had analgesic effects in both models and improved walking distance in the CEC model. Pregabalin had analgesic effects in both models; however, the effect was weaker in the CEC model than in the pSNL model. α2δ1 subunit expression in DRG neurons and in the spinal cord was unchanged in the CEC model, but significantly increased in the pSNL model. Indomethacin had no analgesic effect in either model. Intrathecal yohimbine inhibited the effects of duloxetine with significant effects on depression.

Conclusions

These findings suggest that the analgesic effects of duloxetine are mainly mediated by the spinal monoamine system, independent of the antidepressant effects of this agent.

Significance

The findings of this study suggest that duloxetine may be an effective treatment of broad neuropathic pain states, including neuropathic low back pain. The analgesic effects of duloxetine might be mediated by alterations of the descending pain modulatory pathways in the spinal cord, independent of the antidepressant effects.

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Sleep Mediates the Association between PTSD Symptoms and Chronic Pain in Youth

• Sleep quality partially mediated the association between post-traumatic stress symptoms (PTSS) and pain characteristics among a cohort of youth with chronic pain.• Higher PTSS was associated with higher levels of both pain intensity and pain interference and these PTSS-pain relationships were partially explained by poor sleep quality.• Findings provide empirical support for the pediatric model of mutual maintenance in PTSS and chronic pain, which posits that sleep disturbance is a key intrapersonal factor driving this co-occurrence.

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Attentional control and the competition between nonpain goals and the threat of pain

Abstract

Background

Fully understanding attention to pain requires taking into account the motivational context. Both pain- and (nonpain) goal-related information attracts attention. An intriguing question is which attentional bias prevails when pain- and goal-related information co-occurs? Reduced attentional bias towards pain- and goal-related information was predicted when the other competing information was presented simultaneously. Moreover, trait attentional control was predicted to be associated with stronger attentional bias towards goal-related information particularly in the presence of pain-related information.

Methods

Attentional competition between pain- and (nonpain) goal-related information was measured in ninety participants using a dot-probe task presenting two stimuli (pain-related, goal-related or neutral) simultaneously. Reaction time was the dependent variable. Dot-probe trials alternated with goal trials to induce a temporary goal. Trait attentional control was measured with the attentional control scale.

Results

For pain-related neutral stimulus pairs, participants responded fastest when probes appeared on the same, compared to the opposite, location as the pain-related stimulus. For pain-goal-related stimulus pairs, responses were fastest when probes appeared on the same, compared to the opposite, location as the goal-related stimulus. Higher trait attentional control was associated with faster responding when probes appeared on the same, compared to the opposite, location as the goal-related stimulus. Unpredicted, this effect was irrespective of the co-occurring stimulus (neutral vs. pain-related).

Conclusions

The findings suggest that the unintentional allocation of attention towards events related to a temporary (nonpain) goal prevails over attentional bias to events predicting pain. Trait attentional control predicts stronger attentional allocation towards events related to a temporary goal.

Significance

These findings indicate that treatment interventions facilitating goal pursuit in patients with chronic pain are beneficial in reducing attentional biases towards pain-related events.

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New approach for the treatment of neuropathic pain: Fibroblast growth factor 1 gene-transfected adipose-derived mesenchymal stem cells

Abstract

Background

Neuropathic pain triggered by peripheral nerve lesion is extremely difficult to manage with current approaches, hence the importance of exploring therapeutic alternatives.

Methods

We have analysed adipose-derived mesenchymal stem cells (AD-MSCs) and fibroblast growth factor 1 gene-transfected adipose-derived mesenchymal stem cells (AD-MSCs ^FGF1) on chronic constriction injury (CCI). The mechanical and thermal hypersensitivity were assessed using the von Frey filament, radiant heat and acetone drop tests. Histopathological and apoptotic changes and the level of FGF1, GFAP and TNFα proteins were assessed in the lumbar portion (L4–L6). Moreover, AD-MSCs ^FGF1 were labelled with ^99mTc -HMPAO and isolated organ counting were performed upon AD-MSCs ^FGF1 administration.

Results

Administration of AD-MSCs ^FGF1 attenuated the CCI-induced mechanical and thermal hypersensitivity. Spinal structural alterations and apoptosis were decreased in the AD-MSCs ^FGF1 group. The injection of either phosphate-buffered saline or normal NIH3T3 fibroblasts could not attenuate the behavioural symptoms of neuropathic pain. Increased genetically engineered cells were counted in the injured sciatic nerve and the elevated levels of FGF1 were detected in the spinal tissue. Stem cell therapy lead to decrement the level of the CCI-induced TNF-α and GFAP expression.

Conclusion

The intravenous administration of AD-MSCs ^FGF1 could be considered as a potential remedy for the management of neuropathic pain.

Significance

AD-MSCs ^FGF1 attenuated the CCI-induced mechanical and thermal hypersensitivity. Spinal structural alterations and apoptosis were significantly decreased in the AD-MSCs ^FGF1 group. Elevated levels of FGF1 were detected in the spinal tissue.

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Effects of Scapular Stabilization Exercise Training on Scapular Kinematics, Disability, and Pain in Subacromial Impingement: A Randomized Controlled Trial

Immediate Effects of Mirror Therapy in Patients With Shoulder Pain and Decreased Range of Motion

Static and Dynamic Shoulder Imaging to Predict Initial Effectiveness and Recurrence After Ultrasound-Guided Subacromial Corticosteroid Injections

Association of Pectoralis Minor Muscle Extensibility, Shoulder Mobility, and Duration of Manual Wheelchair Use

Differential Impact of Patient Weight on Pain-Related Judgments About Male and Female Chronic Low Back Pain Patients.

• Pain was discounted for normal and overweight women and obese men.• Pain was treated less for normal and overweight women and obese men.• Across weight categories, women's pain was “psychologized” more than men's pain.• Results indicate disparate impact of weight on pain judgments about women and men.

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Daily Opioid Use Fluctuates as a Function of Pain, Catastrophizing, and Affect in Patients with Sickle Cell Disease: an Electronic Daily Diary Analysis

• A daily diary study of opioid use in patients with sickle cell disease is described• Daily pain and catastrophizing were associated with short-acting opioid use• Daily negative affect was associated with long-acting opioid use• Daily changes in pain, cognition, and affect help understand opioid use behavior

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Unravelling Fibromyalgia – Steps Towards Individualized Management

• Fibromyalgia is a heterogenous condition.• Individualized treatment can be based on subgrouping of patients according to associated conditions (mental health problems; other somatic diseases; chronic overlapping pain conditions) and on disease severity.• Categorizing FM as mild, moderate or severe can be based on clinical criteria (e.g. degree of daily functioning) or on questionnaires.• Shared decision making on treatment options can be based on patient preferences, comorbidities and availability of treatment options in various health care settings.

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Is gabapentin effective for women with unexplained chronic pelvic pain?

This article is linked with a commentary on “What to do in the light of this uncertainty” by James Duffy. What you need to knowUp to half of all women with chronic pelvic pain in secondary care have...

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Diversity in the emotional modulation of pain perception: An account of individual variability

Abstract

Background

While emotional state has been shown to modulate pain perception, there has been little consideration for the individual variability in this effect, or what factors may contribute to individual-level differences. The objective of this study was to characterize the variability in emotional modulation of pain in a healthy sample.

Methods

Twenty-five healthy, adult females participated in a heat pain-rating task. After calibration of the appropriate temperature for each participant, the pain-rating task was combined with viewing of positive, neutral, or negative valence images. Participants rated pain intensity and unpleasantness of the painful stimulus.

Results

The magnitude of the effect for emotional modulation of pain was markedly variable across individuals. Some participants exhibited greater pain relief from the positive emotional stimuli while others were more susceptible to pain amplification from the negative emotional stimuli. There were also significant correlations between emotional modulation of pain and specific psychological measures (depression and anxiety).

Conclusion

Overall, inducing a positive emotional state mitigates pain perception, while negative emotional state amplifies it. The magnitudes of these separate pain-modulating effects, however, vary across individuals, and are associated with individual levels of depressive and anxious feelings, even within a non-clinical population.

Significance

The opposite effects of valence on pain amplification and modulation revealed in this study are novel. This study shows that emotional modulation of pain varies markedly across individuals and is related to psychological factors including depression and anxiety. Examining this link in healthy individuals may inform our understanding of the comorbidity between pain and depression/anxiety.

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Prediction of persistent post-operative pain: Pain-specific psychological variables compared with acute post-operative pain and general psychological variables

Abstract

Background

Psychological variables and acute post-operative pain are of proven relevance for the prediction of persistent post-operative pain. We aimed at investigating whether pain-specific psychological variables like pain catastrophizing add to the predictive power of acute pain and more general psychological variables like depression.

Methods

In all, 104 young male patients undergoing thoracic surgery for pectus excavatum correction were studied on the pre-operative day (T0) and 1 week (T1) and 3 months (T2) after surgery. They provided self-report ratings (pain-related: Pain Catastrophizing Scale, Pain Anxiety Symptoms Scale = PASS, Pain Vigilance and Awareness Questionnaire = PVAQ; general psychological: Screening for Somatoform Symptoms, State-Anxiety Inventory-X1, Center for Epidemiologic Studies Depression Scale = CES-D). Additional predictors (T1) as well as criterion variables (T2) were pain intensity (Numerical Rating Scale) and pain disability (Pain Disability Index).

Results

Three months after surgery, 25% of the patients still reported clinically relevant pain (pain intensity ≥3) and over 50% still reported pain-related disability. Acute post-operative pain as well as general psychological variables did not allow for a significant prediction of persistent post-operative pain; in contrast, pain-related psychological variables did. The best single predictors were PASS for pain intensity and PVAQ for pain disability.

Conclusions

Pain-related psychological variables derived from the fear-avoidance model contributed significantly to the prediction of persistent post-operative pain. The best possible compilation of these measures requires further research. More general psychological variables may become relevant predictors later in the medical history.

Significance

Our results suggest that pain-specific psychological variables such as pain anxiety and pain hypervigilance add significantly to the prediction of persistent post-operative pain and might even outperform established predictors such as acute pain and general psychological variables. Clinicians might benefit from the development of time-economic screening tools based on these variables.

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The Role of Self-Efficacy on the Prognosis of Chronic Musculoskeletal Pain: a Systematic Review

• High self-efficacy is associated with lower levels of pain and disability• Depressive symptoms are negatively associated with self-efficacy• Higher self-efficacy levels are associated with better physical functioning

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Novel Endomorphin Analogs are More Potent and Longer Lasting Analgesics in Neuropathic, Postoperative, Inflammatory, and Visceral Pain Relative to Morphine

• Novel endomorphin analogs with reduced adverse effects alleviate multiple forms of pain.• Neuropathic, inflammatory, postoperative and visceral pain are effectively relieved.• Intrathecal injection produces more potent and longer lasting relief than morphine.• Intravenous injection produces equal or greater potency and longer lasting relief than morphine.

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Morphology and Possible Clinical Significance of the Radiating Extraforaminal Ligaments at the L1-L5 Levels

Study Design. A dissection-based study of 10 fresh-frozen human cadavers. Objective. The objective of this study was to identify and describe the radiating extraforaminal ligaments in the exit regions of the L1-L5 intervertebral foramina and to research their possible clinical significance. Summary of Background Data. The transforaminal ligaments at the L1-L5 intervertebral foramina have been well studied. However, detailed descriptions of the radiating extraforaminal ligaments at L1-L5 are lacking. Methods. Eighty L1-L5 intervertebral foramina from 10 fresh cadavers were studied, and the extraforaminal ligaments were identified. The quantity, morphology, origin, insertion, and spatial orientation of the extraforaminal ligaments in the L1-L5 regions were examined. The length, width, diameter, and thickness of the ligaments were measured using a vernier caliper. Results. A total of 224 extraforaminal ligaments were identified in the 80 L1-L5 intervertebral foramina, and the occurrence rate of extraforaminal ligaments was 100%. One hundred and eighteen (52.68%) of the extraforaminal ligaments were radiating ligaments, and 106 (47.32%) of the extraforaminal ligaments were transforaminal ligaments. There were 97 (43.30%) ligaments at the superior aspect of the exit regions of the intervertebral foramina, 51 (22.77%) ligaments at the anterior aspect, 44 (19.64%) ligaments at the inferior aspect, and 32 (14.29%) ligaments at the posterior aspect. The morphologies of the extraforaminal ligaments were divided into two types: the strap type and the trabs type. Conclusion. Radiating extraforaminal ligaments exist between spinal nerves and nearby structures. Radiating extraforaminal ligaments may be of clinical importance to surgeons. Dissecting the radiating extraforaminal ligaments before percutaneous endoscopic lumbar discectomy may be an important step in reducing postoperative pain, which may result in significant benefits for patients. Level of Evidence: 3

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Predictors of Long-term Opioid Use Following Lumbar Fusion Surgery

Study Design. A population-based retrospective cohort study. Objective. The aim of this study was to examine risk factors for long-term opioid use following lumbar spinal fusion surgery in a nationally representative cohort of commercially insured adults. Summary of Background Data. Opioid prescription rates for the management of low back pain have more than doubled in the US over the past decade. Although opioids are commonly used for the management of pain following lumbar spinal fusion surgery, to date, no large-scale nationally representative studies have examined the risk factors for long-term opioid use following such surgical intervention. Methods. Using one of the nation's largest commercial insurance databases, we conducted a retrospective cohort study of 8377 adults, aged 21 to 63 years, who underwent lumbar spinal fusion surgery between January 1, 2009, and December 31, 2012. Long-term opioid use was defined as ≥365 days of filled opioid prescriptions in the 24 months following lumbar fusion. Multivariable logistic regression was used to calculate adjusted odds ratios (ORs) and 95% confidence intervals for the risk of long-term opioid use following lumbar fusion. Results. After adjusting for covariates, the following factors were associated with an increased risk of long-term opioid use following surgery: duration of opioid use in the year before lumbar surgery [Referent (0 days); Quartile 1 (1–22 days) OR = 2.27, 95% CI = 1.48–3.49; Quartile 2 (23–72 days): OR = 5.94, 95% CI = 4.00–8.83; Quartile 3: (73–250 days) OR = 25.31, 95% CI = 17.26–37.10; Quartile 4 (≥250 days) OR = 219.95, 95% CI = 148.53–325.71)], refusion surgery (OR = 1.32, 95% CI = 1.02–1.72), and diagnosis of depression (OR = 1.43, 95% CI = 1.18–1.74). Receipt of anterior fusion was associated with a modest decrease in the risk of long-term opioid use (OR = 0.79, 95% CI = 0.63–0.99). Conclusion. These findings may provide clinically relevant information to physicians, patients, and their families regarding the risk factors for opioid dependence following lumbar fusion surgery. Level of Evidence: 3

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Contralateral Spondylolysis and Fracture of the Lumbar Pedicle in a Young Athlete

Study Design. Clinical case report of unilateral pedicular stress fracture with a contralateral spondylolysis in a male high-school athlete presenting with low back pain. Objective. To report this uncommon cause of low back pain in an adolescent athlete, and review the relevant literature. Summary of Background Data. The incidence of spondylolysis in the Caucasian population was found to be about 3% to 6%. This number is probably higher in the athletic adolescent age group, with reports ranging from 8% to 15%. Spondylolysis may be associated with pedicle fracture, usually on the contralateral side. This is an uncommon phenomenon that is not well described in the adolescent age group. Methods. A 16-year-old male athlete presents with low back pain and limitation in sports as well as in daily activities. Clinical evaluation was suspicious for, and radiographic evaluation revealed left-sided L5 spondylolysis as well as contralateral L5 pedicle fracture. Conservative management included Boston Overlapping brace, external electrical stimulation, modification of activities, and a comprehensive physical therapy program. Results. Radiological evaluation revealed persistent left L5 pars defect and advanced healing of the contralateral pedicle fracture. The patient achieved complete pain relief and returned to varsity level sporting activity. Conclusion. Complete radiographic and clinical healing of the pedicle defect was observed, with return competitive varsity-level football without symptoms. Level of Evidence: 5

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Benefits of the Restorative Exercise and Strength Training for Operational Resilience and Excellence Yoga Program for Chronic Lower Back Pain in Service Members: A Pilot Randomized Control Trial

Physical pain increases interpersonal trust in females

Abstract

Background

People behave and interact with others differently when experiencing physical pain. Pain has dramatic effects on one's emotional responses, cognitive functions and social interaction. However, little has been known about whether and how physical pain influences interpersonal trust in social interaction. In the present study, we examined the influence of physical pain on trusting behaviour.

Methods

A total of 112 healthy participants were recruited and assigned to physical pain condition (induced by Capsaicin) and control condition (with hand cream), respectively. Thirty minutes after pain induction, three decision-making tasks were conducted to measure behaviours in social interaction, including trust and trustworthiness (trust game), non-social risk-taking (risk game) and altruism (dictator game).

Results

Results showed that physical pain increased interpersonal trust among females, but not among males. Pain did not influence non-social risk-taking, altruism or trustworthiness, as evaluated by monetary transfers in those tasks. Moreover, the effect of physical pain on interpersonal trust was fully mediated by expectation of monetary profit.

Conclusions

These findings demonstrate an effect of pain on interpersonal trust and suggest a reciprocity mechanism that the effect may be driven by self-interest rather than altruistic motivation. The pain effect on trust was evident only in females, implying distinct pain coping strategies used by both genders.

Significance

The present work highlights the social component of pain and extends our understanding of mutual interactions between pain and social cognition.

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Preoperative ultraviolet B inflammation in skin: Modelling individual differences in acute postoperative pain and neuro-immune interactions

Abstract

Background

Neuroimmune interactions play a vital role in many of the most common pain conditions, such as arthritis. There have been many attempts to derive clinically predictive information from an individual's inflammatory response in order to gauge subsequent pain perception.

Objectives

Here, we wanted to test whether this effort could be enhanced and complemented by the use of a model system which takes into account the function of not just circulating, but also tissue-resident immune cells: ultraviolet B (UVB) irradiation of the skin.

Methods

We conducted psychophysical and transcriptional analysis of hyperalgesia arising as a result of UVB-induced inflammation in patients before total knee arthroplasty (TKA, n = 23). Levels of acute postoperative pain were assessed and correlated with preoperative data.

Results

Cytokine and chemokine responses after UVB irradiation were found to be inversely correlated with the level of pain experienced after surgery (Spearman's ρ = −0.498).

Conclusion

It may be possible to use this simple model to study and predict the nature of neuro-immune responses at more remote, clinically relevant sites.

Significance

A simple model of UVB inflammation in the skin might predict the degree of a patient's neuro-immune response and the extent of their postoperative pain after total knee arthroplasty.

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Misdirected care in a misdirected world

Hurricanes and floods tell a story of planetary pain and distress. Many of us love our planet but don’t fully understand it. Our solutions are misdirected, ignoring what matters to the planet. Our...

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Painful red eyes in a contact lens wearer

A 21 year old woman from Singapore presented to the eye hospital with a two week history of painful red eyes, where the severity of the pain was continuing to worsen. She was short-sighted and wore...

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Chronic Pain and Telomere Length in Community-Dwelling Adults: Findings From the 1999-2002 National Health and Nutrition Examination Survey

• Biopsychosocial stress associated with chronic pain may accelerate the aging process• Leukocyte telomere length (LTL) is a recognized biomarker of cellular aging• In this nationally representative study, chronic pain was not associated with LTL• There were no significant interactive effects of pain and emotional distress on LTL• Further investigation of LTL with more comprehensive assessment of pain is needed

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Skin denervation does not alter cortical potentials to surface concentric electrode stimulation: A comparison with laser evoked potentials and contact heat evoked potentials

Abstract

Background

In the neurophysiological assessment of patients with neuropathic pain, laser evoked potentials (LEPs), contact heat evoked potentials (CHEPs) and the evoked potentials by the intraepidermal electrical stimulation via concentric needle electrode are widely agreed as nociceptive specific responses; conversely, the nociceptive specificity of evoked potentials by surface concentric electrode (SE-PREPs) is still debated.

Methods

In this neurophysiological study we aimed at verifying the nociceptive specificity of SE-PREPs. We recorded LEPs, CHEPs and SE-PREPs in eleven healthy participants, before and after epidermal denervation produced by prolonged capsaicin application. We also used skin biopsy to verify the capsaicin-induced nociceptive nerve fibre loss in the epidermis.

Results

We found that whereas LEPs and CHEPs were suppressed after capsaicin-induced epidermal denervation, the surface concentric electrode stimulation of the same denervated skin area yielded unchanged SE-PREPs.

Conclusion

The suppression of LEPs and CHEPs after nociceptive nerve fibre loss in the epidermis indicates that these techniques are selectively mediated by nociceptive system. Conversely, the lack of SE-PREP changes suggests that SE-PREPs do not provide selective information on nociceptive system function.

Significance

Capsaicin-induced epidermal denervation abolishes laser evoked potentials (LEPs) and contact heat evoked potentials (CHEPs), but leaves unaffected pain-related evoked potentials by surface concentric electrode (SE-PREPs). These findings suggest that unlike LEPs and CHEPs, SE-PREPs are not selectively mediated by nociceptive system.

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Offset analgesia: The role of peripheral and central mechanisms

Abstract

Background

Offset Analgesia (OA) can be evoked by a three-heat-stimulus train (T1-T2-T3), with T1 (5 s) and T3 (20 s) having the same temperature (e.g. 48 °C) and T2 (5 s) being slightly higher (1–3 °C). OA is defined as a disproportional pain reduction caused by the slight temperature decrease from T2 to T3. As the pain modulatory mechanisms behind OA are still poorly understood, the current study aimed to investigate the role of peripheral and central mechanisms by applying heat stimuli to the same location and to different unilateral and bilateral locations.

Method

Young healthy volunteers participated in the study. A ‘standard-OA’ paradigm (48–49–48 °C) was applied to the non-dominant volar forearm (T1–T2–T3 applied on the same location). ‘Unilateral-OA’ trials were applied on three different locations of the non-dominant volar forearm (the same dermatome). ‘Bilateral-OA’ trials were applied by shifting T1–T2–T3 between dominant and non-dominant volar forearms. A constant stimulus of 48 °C was applied as control for the evoked pain. The pain intensities were continuously recorded using an electronic visual analogue scale.

Results

The largest pain intensity reduction was reported for the ‘standard-OA’ paradigm (p < 0.001) compared with the control stimulus. Both ‘Unilateral-OA’ and ‘Bilateral-OA’ trials caused a significant pain reduction (p < 0.05) compared with the control; however, the pain reduction was less than that evoked by ‘standard-OA’ (p < 0.05).

Conclusion

This study showed that OA could be elicited when the stimuli were applied both to the same and to different locations (ipsi- and contralateral) indicating that peripheral as well as central mechanisms are involved in mediating OA.

Significance

This study investigated offset analgesia by applying thermal painful stimuli to the ipsi- and bilateral forearms in healthy subjects and found that both peripheral and central mechanisms seem to mediate offset analgesia.

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Reliability of surface electromyography activity of gluteal and hamstring muscles during sub-maximal and maximal voluntary isometric contractions

Normalizing to a reference signal is essential when analysing and comparing electromyography signals across or within individuals. However, studies have shown that MVC testing may not be as reliable in persons with acute and chronic pain.

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Comparative efficacy of intra-articular steroid injection and distension in patients with frozen shoulder: a systematic review and network meta-analysis

Effects of Exergames on Quality of Life, Pain, and Disease Effect in Women With Fibromyalgia: A Randomized Controlled Trial

Communication Skills Training for Practitioners to Increase Patient Adherence to Home-Based Rehabilitation for Chronic Low Back Pain: Results of a Cluster Randomized Controlled Trial

Shoe Orthotics for the Treatment of Chronic Low Back Pain: A Randomized Controlled Trial

Issue Information

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The development of the Dutch version of the Fremantle Back Awareness Questionnaire

Disturbed body perception may play a role in the aetiology of chronic low back pain (LBP). The Fremantle Back Awareness Questionnaire (FreBAQ) is currently the only self-report questionnaire to assess back-specific body perception in individuals with LBP.

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[Comment] Surgical trials for chronic pancreatitis

Chronic pancreatitis is associated with a heavy burden for patients and substantial economic costs.1,2 Patients with chronic pancreatitis might have debilitating pain, opioid dependence, and reduced quality of life; be recurrently admitted to hospital; and be unable to work.3,4 Yet, for patients and physicians, chronic pancreatitis remains a difficult disease to manage, with few medical options and little consensus on the optimum timing or type of surgical intervention. Reports5,6 suggest potential superiority of surgical intervention over endoscopic drainage for long-term pain relief.

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Contraction of the transverse abdominal muscle in pelvic girdle pain is enhanced by pain provocation during the task

Understanding of the pathogenesis of pain in the lumbopelvic region remains a challenge. It is suggested that lumbopelvic pain is related to decreased contraction of the transverse abdominal muscles (TrA).

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Effects of S 38093, an antagonist/inverse agonist of histamine H3 receptors, in models of neuropathic pain in rats

Abstract

Background

Histamine H3 receptors are mainly expressed on CNS neurons, particularly along the nociceptive pathways. The potential involvement of these receptors in pain processing has been suggested using H3 receptor inverse agonists.

Methods

The antinociceptive effect of S 38093, a novel inverse agonist of H3 receptors, has been evaluated in several neuropathic pain models in rat and compared with those of gabapentin and pregabalin.

Results

While S 38093 did not change vocalization thresholds to paw pressure in healthy rats, it exhibited a significant antihyperalgesic effect in the Streptozocin-induced diabetic (STZ) neuropathy model after acute and chronic administration and, in the chronic constriction injury (CCI) model only after chronic administration, submitted to the paw-pressure test. Acute S 38093 administration at all doses tested displayed a significant cold antiallodynic effect in a model of acute or repeated administration of oxaliplatin-induced neuropathy submitted to cold tail immersion, cold allodynia being the main side effect of oxaliplatin in patients. The effect of S 38093 increased following chronic administration (i.e. twice a day during 5 days) in the CCI and STZ models except in the oxaliplatin models where its effect was already maximal from the first administration The kinetics and size of effect of S 38093 were similar to gabapentin and/or pregabalin. Finally, the antinociceptive effect of S 38093 could be partially mediated by α2 adrenoreceptors desensitization in the locus coeruleus.

Conclusions

These results highlight the interest of S 38093 to relieve neuropathic pain and warrant clinical trials especially in chemotherapeutic agent-induced neuropathic pain.

Significance

S 38093, a new H3 antagonist/inverse agonist, displays antiallodynic and antihyperalgesic effect in neuropathic pain, especially in oxaliplatin-induced neuropathy after chronic administration. This effect of S 38093 in neuropathic pain could be partly mediated by α2 receptors desensitization in the locus coeruleus.

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Multidisciplinary Evaluation Leads to the Decreased Utilization of Lumbar Spine Fusion: An Observational Cohort Pilot Study

Study Design. Observational cohort pilot study. Objective. To determine the impact of a multidisciplinary conference on treatment decisions for lumbar degenerative spine disease. Summary of Background Data. Multidisciplinary decision making improves outcomes in many disciplines. The lack of integrated systems for comprehensive care for spinal disorders has contributed to the inappropriate overutilization of spine surgery in the United States. Methods. We implemented a multidisciplinary conference involving physiatrists, anesthesiologists, pain specialists, neurosurgeons, orthopaedic spine surgeons, physical therapists, and nursing staff. Over 10 months, we presented patients being considered for spinal fusion or who had a complex history of prior spinal surgery. We compared the decision to proceed with surgery and the proposed surgical approach proposed by outside surgeons with the consensus of our multidisciplinary conference. We also assessed comprehensive demographics and comorbidities for the patients and examined outcomes for surgical patients. Results. A total of 137 consecutive patients were reviewed at our multidisciplinary conference during the 10-month period. Of these, 100 patients had been recommended for lumbar spine fusion by an outside surgeon. Consensus opinion of the multidisciplinary conference advocated for nonoperative management in 58 patients (58%) who had been previously recommended for spinal fusion at another institution (χ 2  = 26.6; P < 0.01). Furthermore, the surgical treatment plan was revised as a product of the conference in 28% (16 patients) of the patients who ultimately underwent surgery (χ 2  = 43.6; P < 0.01). We had zero 30-day complications in surgical patients. Conclusion. Isolated surgical decision making may result in suboptimal treatment recommendations. Multidisciplinary conferences can reduce the utilization of lumbar spinal fusion, possibly resulting in more appropriate use of surgical interventions with better candidate selection while providing patients with more diverse nonoperative treatment options. Although long-term patient outcomes remain to be determined, such multidisciplinary care will likely be essential to improving the quality and value of spine care. Level of Evidence: 3

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Is the Number of Different MRI Findings More Strongly Associated With Low Back Pain Than Single MRI Findings?

Study design. A cross-sectional and longitudinal analysis using two different datasets. Objective. To investigate if the number of different magnetic resonance imaging (MRI) findings present is more strongly associated with low back pain (LBP) than single MRI findings. Summary of Background Data. Most previous studies have investigated the associations between single MRI findings and back pain rather than investigating combinations of MRI findings. If different individuals have different pathoanatomic sources contributing to their pain, then combinations of MRI findings may be more strongly associated with LBP. Methods. This study used data from two previous studies that investigated the association between single MRI findings and LBP. One study was a cross-sectional population cohort of 412 people of 40 years; the second was a longitudinal cohort of 76 people recently recovered from LBP who were followed for 12 months. The outcome for the cross-sectional study was presence of LBP during the last year. The outcome for the longitudinal study was days to recurrence of activity limiting LBP. In both datasets, we created an aggregate score of the number of different MRI findings present in each individual and assessed the relationship between this aggregate score and LBP. Results. The risk of LBP outcome increased with increasing numbers of different MRI findings. Compared with those with no MRI findings, those with three MRI findings were at substantially greater risk of LBP in the last year (odd ratio = 14.1; 95% confidence interval, 4.32–49.47) in the cross-sectional study, or of future recurrence of LBP (hazard ratio = 12.2; 95% confidence interval 1.26–118.21) in the longitudinal study. Conclusion. The aggregate MRI score was more strongly associated with LBP outcomes than single MRI findings in both datasets. Further investigation of this approach is indicated. Level of Evidence: 2

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Does Familial Aggregation of Chronic Low Back Pain Affect Recovery?: A Population-Based Twin Study

Study Design. Longitudinal twin-cohort study. Objective. To investigate the effect familial aggregation of chronic low back pain (LBP) has on the recovery from chronic LBP. Summary of Background Data. LBP is a worldwide problem, with pain and disability often becoming chronic. Genetics and familial behaviors could significantly affect the recovery from chronic LBP but have not been extensively investigated. Methods. A total of 624 Spanish twins from the Murcia Twin Registry reported experiencing chronic LBP within the past 2 years during the 2009/11 data collection wave and were followed up in 2013. Familial aggregation of chronic LBP was determined by the co-twin experiencing chronic LBP within the past 2 years at baseline. Twins reporting LBP “within the past 4 weeks” at follow-up were considered to have not recovered. Results. There were 455 twins with available data on LBP at follow-up and available data on LBP from their co-twin at baseline. Twins with an affected co-twin at baseline were significantly more likely to have not recovered from chronic LBP at follow-up (odds ratio [OR] = 1.6, 95% confidence interval [CI]: 1.0–2.4, P = 0.046). This relationship was stronger for monozygotic twins (OR = 2.5, 95% CI: 1.3–4.8, P = 0.006) (n = 172) but disappeared when considering only dizygotic twins (OR = 1.1, 95% CI: 0.6–2.0, P = 0.668) (n = 283). Sibling-relative recurrence risk (λs) was 1.2 for the total sample, 1.5 for monozygotic twins, and 1.1 for dizygotic twins. Conclusion. Having a sibling with chronic LBP at baseline increased the likelihood of LBP at follow-up by 20%, with this likelihood increasing to 50% if the sibling was an identical twin. These results are novel and highlight the important influence genetics have on people's recovery from chronic LBP. Information regarding the presence of chronic LBP within a family is easy to obtain and has the potential to inform clinicians on which patients are less likely to recover when treatment implementation is not considered. Level of Evidence: 3

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A Profile of Low Back Pain: Treatment and Costs Associated With Patients Referred to Orthopedic Specialists in Sweden

Study Design. Analysis of Swedish national and regional register data. Objectives. The aim of this study was to characterize healthcare resource utilization, productivity loss, and costs of patients with low back pain (LBP) with or without leg pain, who have been referred from primary care settings to orthopedic specialist care. Summary of Background Data. Register data on outpatient and inpatient care, work absence, drug prescriptions, socioeconomics, and mortality were extracted for patients visiting orthopedic specialists for LBP in the Swedish region Västra Götaland (1.6 million inhabitants in 2015) in 2008 to 2011 (4 years). Methods. Patients were followed with regard to resource use and costs during “LBP episodes,” defined as the time period from the first visit to an orthopedic specialist (“index-point”) until the last observed resource use registered with an LBP diagnosis. Patients were also followed during fixed time periods of 2 years before and 2 years after the index-point. Results. In total, 16,329 LBP episodes were identified (13,931 unique patients), in six diagnosis groups. Mean societal cost per LBP episode was estimated at €6466 (SD 21,884), where indirect cost constituted 74% and half of the 26% remaining direct costs were owing to hospital inpatient care. Patients underwent surgery in 10% of the episodes (n = 1583). Cost per LBP episode varied between diagnosis groups, with a range of €18,668 to €40,774 in episodes with surgery and €978 to €10,379 in episodes without surgery. Assessment of the fixed time period of 2 years before and after index-point showed that costs increased gradually during the year before in all groups and declined the year after in all groups. Conclusion. The marked decline in total costs the year after referral to an orthopaedic specialist indicates that the treatment provided, regardless of treatment, has an effect and also likely improves the quality of life for the patient. Level of Evidence: 4

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Measurement Properties of the Scoliosis Research Society Outcomes Questionnaire in Adolescent Patients With Spondylolisthesis

Study Design. Prospective validation of the Scoliosis Research Society Outcomes Questionnaire French-Canadian version (SRS-22fv) in adolescent patients with spondylolisthesis. Objective. To determine the measurement properties of the SRS-22fv. Summary of Background Data. The SRS-22 is widely used for the assessment of health-related quality of life in adolescent idiopathic scoliosis (AIS) and other spinal deformities. Spondylolisthesis has an important effect on quality of life. The instrument was previously used in this population, although its measurement properties remained unknown. We aim to determine its reliability, factorial, concurrent validity, and its discriminant capacity in an adolescent spondylolisthesis population. Methods. The SRS-22fv was tested in 479 subjects (272 patients with spondylolisthesis, 143 with AIS, and 64 controls) at a single institution. Its reliability was measured using the coefficient of internal consistency, concurrent validity by the short form-12 (SF-12v2 French version) and discriminant validity using multivariate analysis of variance, analysis of covariance, and multivariate linear regression. Results. The SRS-22fv showed a good global internal consistency (spondylolisthesis: Cronbach α = 0.91, AIS: 0.86, and controls: 0.78) in all its domains for spondylolisthesis patients. It showed a factorial structure consistent with the original questionnaire, with 60% of explained variance under four factors. Moderate to high correlation coefficients were found for specifically corresponding domains between SRS-22fv and SF-12v2. Boys had higher scores than do girls, scores worsened with increasing age and body mass index. Analysis of covariance showed statistically significant differences between patients with spondylolisthesis, patients with AIS, and controls when controlling for age, sex, body mass index, pain, function, and self-image scores. In the spondylolisthesis group, scores on all domains and mean total scores were significantly lower in surgical candidates and in patients with high-grade spondylolisthesis. Low to moderate ceiling effects were shown in function (1.1%), self-image (10.7%), and pain (13.6%). Conclusion. The SRS-22fv can discriminate between healthy and spondylolisthesis subjects. It can be used in spondylolisthesis patients to assess health-related quality of life. Level of Evidence: 4

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Explaining How Cognitive Behavioral Approaches Work for Low Back Pain: Mediation Analysis of the Back Skills Training Trial

Study Design. This is secondary research examining the longitudinal mediation effect within a structural equation model. Objective. To identify possible mechanisms that mediate the effects of a cognitive behavioral approach upon disability and pain in low back pain patients. Summary of Background Data. Cognitive behavioral interventions (CBIs) can improve pain and disability in low back pain (LBP) but the mechanisms of action are unclear. We used data from a large randomized controlled trial to investigate mediators of the treatment effect of CBI. Methods. Pain self-efficacy, fear avoidance, and physical and mental functioning were selected as candidate mediators based on the theoretical rationale of the intervention. The primary treatment outcomes were the Roland Morris Questionnaire (RMDQ) and the modified Von Korff scale (MVK pain and disability) at 12 months. We used structural equation models to estimate the contribution of mediators. All models were tested for goodness-of-fit using χ 2 , Root Mean Square Error of Approximation, Adjusted Goodness of Fit Index, and Bentler Comparative Fit Index. Results. We included 701 adults with LBP. The average RMDQ score at baseline for those on the intervention arm was 8.8 (Standard Deviation 5.0). The intervention was effective in reducing disability and pain at 12 months. Change in mental functioning was not a significant mediator. Changes to pain self-efficacy, fear avoidance, and physical functioning were causal mediators of the treatment effect at 12 months (RMDQ b= –0.149, P < 0.001; MVK-pain b = –0.181, P < 0.001 and MVK-disability b = –0.180, P < 0.001). Overall, the SEM model exceeded the threshold for acceptable goodness-of-fit. Conclusion. Fear avoidance and self-efficacy were important causal mediators of the cognitive behavioral treatment effect. Self-assessed change in physical function was a causal mediator but mental functioning was not. This suggests people need to experience meaningful change in physical function and beliefs but not in mental functioning associated with LBP, to achieve a treatment benefit. Level of Evidence: 2

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Long-term trajectories of patients with neck pain and low back pain presenting to chiropractic care: A latent class growth analysis

Abstract

Background

Information on the course of neck pain (NP) and low back pain (LBP) typically relies on data collected at few time intervals during a period of up to 1 year.

Methods

In this prospective, multicentre practice-based cohort study, patients consulting a chiropractor responded weekly for 52 weeks to text messages on their cell phones. Data from 448 patients (153 NP, 295 LBP) who had returned at least one set of answers in the first 26 weeks were used. Outcome measures were pain intensity (VAS) and functional outcome, assessed using four different questions: pain intensity, limitation in activities of daily living (ADL), number of days with pain in the previous week and number of days limited in ADL. Distinct patterns of pain were analysed with quadratic latent class growth analysis.

Results

The final model was a 4-class model for NP and LBP. The ‘recovering from mild baseline pain’ is most common (76.3% of NP patients/58.3% of LBP patients) followed by the ‘recovering from severe baseline pain’ class (16.3% NP/29.8% LBP). They follow similar trajectories when considered over a period of 6 months. Pain at baseline, duration of complaints, functional status, limitations in ADL and the score on psychosocial scales were the variables that most contributed to distinguish between groups.

Conclusions

Most patients with NP or LBP presenting in chiropractic care show a trajectory of symptoms characterized by persistent or fluctuating pain of low or medium intensity. Only a minority either experience a rapid complete recovery or develop chronic severe pain.

Significance

Ninety percentage of patients with neck pain or low back pain presenting to chiropractors have a 30% improvement within 6 weeks and then show a trajectory of symptoms characterized by persistent or fluctuating pain of low or medium intensity. Only a minority either experience a rapid complete recovery or develop chronic severe pain.

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Clinical benefits of joint mobilisation on ankle sprains: a systematic review and meta-analysis

Exercise for the prevention of low back and pelvic girdle pain in pregnancy: A meta-analysis of randomized controlled trials

Abstract

Background and objective

The effect of exercise in prevention of low back and pelvic girdle pain during pregnancy is uncertain. This study aimed to assess the effect of exercise on low back pain, pelvic girdle pain and associated sick leave.

Databases and data treatment

Literature searches were conducted in PubMed, EMBASE, Cochrane Library, Google Scholar, ResearchGate and ClinicalTrials.gov databases from their inception through May 2017. Randomized controlled trials (RCTs) were eligible for inclusion in the review if they compared an exercise intervention with usual daily activities and at least some of the participants were free from low back pain and/or pelvic girdle pain at baseline. Methodological quality of included studies was evaluated using the Cochrane Collaboration's tool. A random-effects meta-analysis was performed, and heterogeneity and publication bias were assessed.

Results

Eleven randomized controlled trials (2347 pregnant women) qualified for meta-analyses. Exercise reduced the risk of low back pain in pregnancy by 9% (pooled risk ratio (RR) = 0.91, 95% CI 0.83–0.99, I² = 0%, seven trials, N = 1175), whereas it had no protective effect on pelvic girdle pain (RR = 0.99, CI 0.81–1.21, I² = 0%, four RCTs, N = 565) or lumbopelvic pain (RR = 0.96, CI 0.90–1.02, I² = 0%, eight RCTs, N = 1737). Furthermore, exercise prevented new episodes of sick leave due to lumbopelvic pain (RR = 0.79, CI 0.64–0.99, I² = 0%, three RCTs, N = 1168). There was no evidence of publication bias.

Conclusion

Exercise appears to reduce the risk of low back pain in pregnant women, and sick leave because of lumbopelvic pain, but there is no clear evidence for an effect on pelvic girdle pain.

Significance

Exercise has a small protective effect against low back pain during pregnancy.

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What is the longitudinal profile of impairments and can we predict difficulty caring for the profoundly-affected arm in the first year post-stroke?