Psychophysical or spinal reflex measures when assessing conditioned pain modulation?

Abstract

Background

Assessing conditioning pain modulation (CPM) with spinal reflex measures may produce more objective and stable CPM effects than using psychophysical measures. The aim of the study was to compare the CPM effect and test‐retest reliability between a psychophysical protocol with thermal test‐stimulus and a spinal reflex protocol with electrical test‐stimulus.

Methods

Twenty‐five healthy volunteers participated in two identical experiments separated by minimum 1 week. The thermal test‐stimulus was a constant heat stimulation of 120 seconds on the subjects' forearm with continuous ratings of pain intensity on a 10 cm visual analogue scale. The electrical test‐stimulus was repeated electrical stimulation on the arch of the foot for 120 seconds, which elicited a nociceptive withdrawal reflex recorded from the anterior tibial muscle. Conditioning stimulus was a 7°C water bath. Differences in the magnitude and test–retest reliability were investigated with repeated‐measures analysis of variance and by relative and absolute reliability indices.

Results

The CPM effect was 46% and 4.5% during the thermal and electrical test‐stimulus (p<0.001), respectively. Intraclass correlation coefficient of 0.5 and 0.4 was found with the electrical and thermal test‐stimulus, respectively. Wide limits of agreement were found for both the electrical (‐3.4 to 3.8 mA) and the thermal test‐stimulus (‐3.2 to 3.6 cm).

Conclusions

More pronounced CPM effect was demonstrated when using a psychophysical protocol with thermal test‐stimulus compared to a spinal reflex protocol with electrical test‐stimulus. Fair relative reliability and poor absolute reliability (due to high intra‐individual variability) was found in both protocols.

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Technical and clinical performance of the thermo‐test device ‘Q‐sense' to assess small fiber function: A head to head comparison with the ‘Thermal Sensory Analyzer' TSA in diabetic patients and healthy volunteers

Abstract

Background

Thermo‐test devices are rarely used outside specialized pain centers because of high acquisition costs. Recently, a new, portable device (‘Q‐Sense') was introduced, which is less expensive but has reduced cooling capacity (20°C). We assessed the reliability/validity of the ‘Q‐Sense' by comparing it with the Thermal Sensory Analyzer (TSA).

Methods

Using a phantom‐skin model, the physical characteristics of both devices were compared. The clinical performance was assessed in a multi‐center study by performing Quantitative Sensory Testing (QST) in 121 healthy volunteers and 83 diabetic patients (Eudra‐Med‐No. CIV‐12‐05‐006501).

Results

Both device types showed ~ 40% slower temperature ramps for heating/cooling than nominal data. Cold/warm detection thresholds (CDT, WDT) and heat pain thresholds (HPT) of healthy subjects did not differ between device types. Cold pain thresholds (CPT) were biased for Q‐Sense by a floor effect (p<0.001). According to intraclass correlation coefficients (ICC), agreement between TSA and Q‐Sense was good/excellent for CDT (ICC= 0.894) and WDT (ICC = 0.898), moderate for HPT (ICC=0.525) and poor for CPT (ICC=0.305). In diabetic patients, the sensitivity of Q‐Sense to detect cold hypoesthesia was reduced in males > 60 years. Moderate correlations between thermal detection thresholds and morphological data from skin biopsies (n=51) were similar for both devices.

Conclusions

Physical characteristics of both thermo‐test devices are similarly limited by the poor temperature conduction of the skin. The Q‐sense is useful for thermal detection thresholds but of limited use for pain thresholds. For full clinical use, the lower cut‐off temperature should be set to ≤18 °C.

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Neuropsychological functions of verbal recall and psychomotor speed significantly affect pain tolerance

Abstract

Background

Effects from cognitive performance on pain tolerance have been documented, however, sample sizes are small and confounders often overlooked. We aimed to establish that performance on neuropsychological tests was associated with pain tolerance, controlling for salient confounders.

Methods

This was a cross‐sectional study nested within the Tromsø‐6 survey. Neuropsychological test performance and the cold pressor test were investigated in 4,623 participants. Due to significant interaction with age, participants were divided into three age groups (<60, ≥60 to <70 and ≥70 years). Cox proportional hazard models assessed the relationship between neuropsychological tests and cold pressure pain tolerance, using hand‐withdrawal as event. The fully adjusted models controlled for sex, education, BMI, smoking status, exercise, systolic blood pressure, sleep problems and mental distress.

Results

In the adjusted models, participants aged ≥70 years showed a decreased hazard of hand withdrawal of 18% (HR 0.82, 95% CI (0.73, 0.92) per standard deviation on immediate verbal recall, and a decreased hazard of 23% (HR 0.77, 95% CI (0.65, 0.08) per standard deviation on psychomotor speed. Participants aged ≥60 to <70 years had a significant decreased hazard of 11% (HR 0.89, 95% CI (0.80, 0.98) per standard deviation on immediate word recall. In participants aged <60 years, there was a decreased hazard of 14% (HR 0.86 95% CI: 0.76, 0.98), per standard deviation on psychomotor speed.

Conclusion

Better performance on neuropsychological tests increased pain tolerance on the cold pressor test. These exposure effects were present in all age groups.

Significance

This paper describes substantial associations between cognitive functioning and cold pressor tolerance in 4,623 participants. Reduced psychomotor speed and poor verbal recall gave greater odds for hand‐withdrawal on the cold pressor task. The associations were stronger in older participants, indicating an interaction with age.

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Assessment and treatment recommendations for pediatric pain: the influence of patient race, patient gender, and provider pain-related attitudes

Previous studies in adults have documented that racial minorities and women receive poorer pain care than their demographic counterparts.4,34,39,57,60 Suboptimal pain care negatively impacts patient functioning and quality of life,6,12,47,49,51,58 particularly for racial minorities and females who already face numerous barriers to maintaining a high quality of life [6,12,47,49,51,58,]. Biological, psychological, and social factors contribute to disparities in pain care. Providers contribute to these disparities when their pain-related decision-making systematically varies across patient groups.

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Self‐medication in pain management: the state of the art of pharmacists' role for optimal Over‐The‐Counter analgesic use

Abstract

Background and Objective

Self‐medication is associated with an important utilization of Over‐The‐Counter (OTC) analgesics. The medical outcome resulting from therapeutic options bypassing the physician prescription is a major issue. In that context, pharmacists are expected to play a crucial role. The main objective of this review was to analyse the state‐of‐the art of pharmacists' role in pain management self‐medication

Databases and Data Treatment

An expert multidisciplinary group dedicated to self‐medication in pain was established. Selection of publications was performed from PubMedand EMBASE databases which was based on the use of ‘pain' and/or ‘self‐medication' and/or ‘selfcare' and/or ‘analgesics' and/or ‘painkillers' keywords, restricted to the past 10‐years.

Results

A total of 480 papers were identified, 49 of which papers were considered relevant and finally kept for final discussion, on OTC pain management and pharmacist's role. Literature analysis demonstrates that OTC analgesics are generally safe when appropriately used. Risks associated with misuse or inappropriateness depend on patients' vulnerability (elderly, pregnancy) or behaviour. Social cognitive theory‐based intervention and multimedia applications improve self‐medication but do not replace healthcare professional advice Pharmacists' interventions may improve the benefits and safety of OTC analgesic medication, with a better management of pain.

Conclusions

Considering the heterogeneity of patients' knowledge and behaviour reported worldwide, inappropriate use of OTC pain medication should not be underestimated. Community pharmacists are ideally placed to guide self‐medication or recommend a medical advice when needed. Embedding pharmacists in primary care pain management is essential and pharmacist‐led medication coupled with an appropriate training of pharmacy staffs should be encouraged.

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Large treatment effect with extended home-based transcranial direct current stimulation over dorsolateral prefrontal cortex in fibromyalgia: A Proof of Concept Sham-Randomized Clinical Study

Fibromyalgia encompasses symptoms of central sensitization syndrome (CSS)26 such as increased levels of emotional distress, sleep disorders, depressed mood, catastrophizing thinking, cognitive deficits, and memory impairment58 However, according to systematic reviews, the pharmacologic treatments have a limited role in a substantial number of fibromyalgia patients.22,23 A new option with growing evidence for fibromyalgia treatment is the transcranial direct current stimulation (tDCS). Its effect is likely sensible to the neuroplastic state, as demonstrated in recent studies in the fibromyalgia serum brain-derived neurotropic factor (BDNF) predicted the tDCS effect on the short-term memory42 and improvement the disability due to pain after hallux valgus surgery.

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Life as an anaesthetist

Anaesthetists are trained to provide pain relief services, to manage resuscitation problems, and to support and manage life functions while a patient is unconscious. They have been closely involved...

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Delayed effects of attention on pain sensitivity and Conditioned Pain Modulation

Abstract

Background

Efficacy of pain modulation is assessed as the difference in pain sensitivity during a painful conditioning, compared to before (conditioning pain modulation, CPM). Attention can be assessed with the Stroop‐task, in which participants report the number of words on a screen; either congruent or incongruent with the value of the words. Attention away from painful stimuli during CPM enhances the CPM‐effect. However, it is unknown if attention influences CPM‐effects when the two are done in sequence.

Methods

Healthy men (n=25) underwent cuff‐algometry CPM‐assessment where the pressure‐pain detection and tolerance thresholds (PTT) were recorded on one leg with and without contralateral conditioning. Two identical sessions of four test‐stimuli equal to PTT (5s, 1‐min interval, scored on a visual analogue scale, VAS) with a painful conditioning from the second to the last test‐stimulus were performed. Stroop‐sessions were followed by test‐stimuli with or without painful conditioning.

Results

The VAS scores in the first two sessions showed excellent reliability (ICC=0.92). VAS scores were lower in sessions with Stroop compared to sessions without Stroop (p=0.05) indicating an analgesic effect of Stroop. Participants were sub‐grouped into CPM‐responders and CPM‐non‐responders according to CPM‐effects in the first two sessions. CPM‐non‐responders (n=13) showed facilitation to repeated noxious stimuli in all sessions with no effect of conditioning or Stroop (p=0.02).

Conclusion

Attention and CPM both modulate pain in healthy men. Attention‐induced analgesia works in CPM‐non‐responders. Results indicate that attention and CPM are not the same and that they do not demonstrate additive effects when applied in sequence.

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PROMIS Correlates With Legacy Outcome Measures in Patients With Neck Pain and Improves Upon NDI When Assessing Disability in Cervical Deformity

Study Design. Retrospective cohort study. Objective. To evaluate the ability of patient reported outcome measurement information system (PROMIS) assessments to capture disability related to cervical sagittal alignment and secondarily to compare these findings to legacy outcome measures. Summary of Background Data. PROMIS is a validated patient-reported outcome metric that is increasing in popularity due to its speed of administration relative to legacy metrics. The ability of PROMIS to capture disability from sagittal alignment and baseline health status in patients with neck pain has not been investigated. Methods. Patients presenting with a chief complaint of neck pain from December 2016 to July 2017 were included. Demographics and comorbidities were retrospectively collected. All patients prospectively completed the neck disability index (NDI), EQ-5D, visual analog scale (VAS) neck, VAS arm, PROMIS physical function, PROMIS pain intensity, and PROMIS pain interference metrics. Cervical sagittal alignment parameters were measured on standing X-rays. The correlations between outcome measures, health status indexes, psychiatric diagnoses, and sagittal alignment were analyzed. Results. Two hundred twenty-six patients were included. The sample was 58.4% female with a mean age of 55.1 years. In patients with neck pain, PROMIS physical function correlated strongly with the NDI (r = −0.763, P < 0.01), EQ-5D (r = 0.616, P < 0.01), VAS neck pain (−0.466, P < 0.01), and VAS arm pain (r = −0.388, P < 0.01). One hundred seventy-seven patients (69.96%) were included in the radiographic analysis. 20.3% of the radiographic cohort had cervical deformity and in this group, less cervical lordosis correlated with PROMIS pain intensity and EQ-5D but not NDI. In patients without cervical deformity, no outcome metric was found to correlate significantly with cervical alignment parameters. Conclusion. PROMIS domains correlated strongly with legacy outcome metrics. For the whole cohort, sagittal alignment was not correlated with outcomes. In patients with sagittal cervical deformity, worsening alignment correlated with PROMIS pain intensity and EQ-5D but not NDI. Level of Evidence: 3

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Health-related Quality of Life and Postural Changes of Spinal Alignment in Female Adolescents Associated With Back Pain in Adolescent Idiopathic Scoliosis: A Prospective Cross-sectional Study

Study Design. A prospective cross-sectional study. Objective. To identify risk factors for chronic back pain and back pain at rest in adolescent idiopathic scoliosis (AIS) patients, particularly focusing on the psychological backgrounds of the patients and on postural changes of radiographical parameters for spinal alignment. Summary of Background Data. Back pain has been recognized as a relatively common condition in AIS. However, the effect of patients’ psychological backgrounds and dynamic changes of spinal alignment on back pain are unclear. Methods. One hundred two consecutive female AIS patients (mean age, 14.1 yrs [range, 10–18]) who first visited our outpatient clinic between July 2013 and December 2017 were included. Using SRS-22r questionnaire, the presence of chronic back pain and back pain at rest and the scores of self-image and mental health were evaluated. Using full-length standing and supine posteroanterior radiographs, parameters related to curve profiles and coronal global balance were measured, and postural changes of these parameters were calculated. From full-length standing lateral radiographs, sagittal spinal and spino-pelvic alignment parameters were also measured. Multivariate logistic regression analysis was performed to identify risk factors for back pain. Results. The prevalence of chronic back pain was 22.5% and that of back pain at rest was 25.5%. Poor self-image and mental health scores in SRS-22r were identified as risk factors for chronic back pain. Higher Risser grade, poor self-image score, large postural changes of apical vertebral translation at the main thoracic curve, and hyperlordosis in the lumbar spine were identified as risk factors for back pain at rest. Conclusion. Psychological distress and large postural changes of spinal alignment played an important role in the occurrence of back pain. Physicians should pay more attention to mental healthcare of AIS patients as well as to radiographical assessments of curve severity for better health-related quality of life. Level of Evidence: 4

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The Relationship Between Lumbar Lateral Listhesis and Radiculopathy in Adult Scoliosis

Study Design. Retrospective review and prospective validation study. Objective. To develop a classification system of lumbar lateral listhesis that suggests different likelihoods of having radiculopathy in adult scoliosis. Summary of Background Data. The association of lumbar lateral listhesis with radiculopathy remains uncertain. Methods. A retrospective cohort of patients with adult scoliosis enrolled from 2011 to 2015 was studied to develop a classification system of lateral listhesis that can stratify the likelihood of having radiculopathy. Four radiological aspects of lateral listhesis, including Nash and Moe vertebral rotation, L4–L5 lateral listhesis, the number of consecutive listheses, and the presence of a contralateral lateral listhesis at the thoracolumbar junction above a caudal listhesis, were evaluated on radiographs. Their associations with the presence of radicular leg pain were evaluated using multivariable logistic regression. The classification system of lateral listhesis was thus developed using the most influential radiological factors and then validated in a prospective cohort from 2016 to 2017. Results. The retrospective cohort included 189 patients. Vertebral rotation is more than or equal to grade 2 (odds ratio [OR] = 9.45, 95% confidence interval [CI]: 4.07–25.14) and L4–5 listhesis (OR = 4.56, 95%CI: 1.85–12.35) were the two most influential listhesis factors associated with radiculopathy. The classification system of lateral listhesis was thus built based on the combinations of their respective presence: Type 0, 1, 2, 3 were defined as not having listhesis at all, none of the two factors present, one of the two presents, and both present, respectively. This classification significantly stratified the probability of radiculopathy, in both the retrospective cohort (0%, 6.4%, 33.8%, and 68.4% in Type 0, 1, 2, and 3, respectively; P < 0.001) and a prospective cohort of 105 patients (0%, 16.7%, 46.9%, and 72.7%; P < 0.001). Conclusion. Lumbar lateral listhesis is associated with the presence of radiculopathy in adult scoliosis. Types 2 and 3 lateral listhesis on radiographs may alert surgeons treating patients with spinal deformity. Level of Evidence: 2

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The Relationship Between Endplate Pathology and Patient-reported Symptoms for Chronic Low Back Pain Depends on Lumbar Paraspinal Muscle Quality

Study Design. Cross-sectional cohort study of chronic low back pain (CLBP) patients and matched controls. Objective. To explore the interplay between vertebral endplate damage and adjacent paraspinal muscle (PSM) quality, and to test their association in a cohort of patients with CLBP and matched controls. Summary of Background Data. Nonspecific CLBP is challenging to diagnose, in part, due to uncertainty regarding the source of pain. Delineating interactions among potential CLBP mechanisms may enhance diagnosis and treatment customization. Methods. We collected advanced MRI imaging on 52 adult subjects, including 38 CLBP patients and 14 age- and sex-matched asymptomatic control subjects. Mean multifidus and erector spinae fat fraction (FF) was measured throughout the spine using an IDEAL MRI sequence. Presence of cartilage endplate (CEP) defects was determined at each disc level using UTE MRI. Logistic regression was used to test association of PSM FF, CEP defects, modic changes (MC), disc degeneration, and their interplay. Results. We observed that CEP defects were the strongest predictor of nonspecific CLBP (OR: 14.1, P < 0.01) even after adjusting for MC and disc degeneration (OR: 26.1, P = 0.04). PSM quality did not independently distinguish patient and control groups, except for patients with high self-reported disability. At specifically L4L5, CEP damage was most prevalent and CEP damage was significantly associated with CLBP (OR: 3.7, 95% CI: 1.2–21.5, P = 0.03). CEP damage at L4L5 was predictive of CLBP when adjacent to PSMs with greater FF (MF, OR 14.7, P = 0.04; ES, OR: 17.3, P = 0.03), but not when PSM FF was lower and comparable to values in control, asymptomatic subjects. Conclusion. These results demonstrate the clinically important reciprocity between passive and dynamic spinal stabilizers, and support the notion that therapies targeting the PSMs may provide clinical benefit even in the presence of other spinal pathologies. Level of Evidence: 4

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PROMIS Pain Interference Is Superior to the Likert Pain Scale for Pain Assessment in Spine Patients

Study Design. Cross-sectional cohort analysis. Objective. (1) To assess the correlation between Patient-Reported Outcomes Measurement Information System (PROMIS) physical function (PF) and pain interference (PI) in patients seeking spine care; (2) to assess the correlation between PROMIS PF and the Likert Pain Scale (LPS) in patients seeking spine care; (3) to determine which pain scale best correlates to physical function overall and by number of clinic visits. Summary of Background Data. An accurate understanding of a patient's pain level is beneficial in setting clinical and pain management expectations. There is limited work analyzing which instrument best captures pain and its impact on function in patients seeking spine care. Methods. Spine center patients from February 2015 to November 2017 were asked to complete PROMIS PF and PI domains, as well as to report their pain level on a 0 (no pain) to 10 (worst pain) LPS at each visit. Pearson correlation coefficients were calculated between PROMIS PF and PROMIS PI; PROMIS PI and LPS; and PROMIS PF and LPS. Fisher r–z transformation method was utilized for confidence intervals (CIs) and to determine significant correlation differences. Analyses were performed for all data, as well as by office visit. Significance was set at P < 0.01. Results. A total of 21,774 first visit, 11,130 second visit, 6575 third visit, 4202 fourth visit, and 2819 fifth visit patients’ data were recorded. PROMIS PF demonstrated a moderate correlation with the LPS over all visits (r = 0.46–0.49, P < 0.01). PROMIS PF demonstrated a strong correlation with PROMIS PI over all visits (r = 0.73–0.77, P < 0.01). Overall, PROMIS PI demonstrated significantly better correlation to self-reported physical function than the LPS (P < 0.01). Conclusion. While PROMIS PI and the LPS both demonstrated significant correlation with self-reported physical function, PROMIS PI had a significantly stronger correlation. Level of Evidence: 2

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Hide your Pain: Social Threat Increases Pain Reports and Aggression, but Reduces Facial Pain Expression and Empathy

Social context can profoundly alter the experience and communication of pain9,21,32 and it has been proposed to explicitly acknowledge the social dimension in the very definition of pain.73 Social context can be harnessed to alleviate pain and facilitate coping with pain, for instance via social support5,27 but much less is known about the effects of social contexts that are perceived as threatening,28 even though people with chronic pain frequently feel excluded,48 stigmatized,49,74 treated unfairly,38,51,56 and invalidated.

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Maintenance of quality of life improvement for patients with chronic pain and obesity after interdisciplinary multimodal pain rehabilitation – a study using the Swedish Quality Registry for Pain Rehabilitation (SQRP)

Abstract

Background

Throughout the world many people have both obesity and chronic pain, comorbidities that decrease Health‐Related Quality of Life (HRQoL). It is uncertain whether patients with comorbid obesity can maintain improved HRQoL after Interdisciplinary Multimodal Pain Rehabilitation (IMMPR).

Methods

Data from 2016, 2017, and 2018 were obtained from a national pain database for Swedish specialized pain clinics and collected at three time points: Pre‐IMMPR; Post‐ IMMPR; and 12‐month follow‐up (FU‐IMMPR). Participants (N=872) reported body weight, height, pain aspects, and HRQoL (RAND 36‐Item Health Survey). Severe obesity (Body Mass Index, BMI ≥35 kg/m²) was defined according to WHO classifications. We used linear mixed regression models to examine BMI group differences in HRQoL over time.

Results

More than 25% of patients (224/872) were obese and nearly 30% (63/224) of these were severely obese. All BMI groups improved significantly in both physical and mental composites of HRQoL after IMMPR (Pre‐ vs. Post‐IMMPR, P<0.001). The improvements were maintained at a 12‐month follow‐up (Post‐ vs. FU‐IMMPR, P>0.05). The severe obesity group had the lowest physical health score and least improvement (pre‐ vs. FU‐IMMPR, Cohen's d= 0.422, small effect size). Severe obesity had negative impact on physical health (β=‐4.39, P<0.05) after controlling for sociodemographic factors and pain aspects.

Conclusion

Improvements in HRQoL after IMMPR were achieved and maintained across all weights, including patients with comorbid obesity. Only severe obesity was negatively associated with physical health aspects of HRQoL.

Significance

Patients with chronic pain and comorbid obesity achieve sustained Health‐Related Quality of Life (HRQoL) improvements from Interdisciplinary Multimodal Pain Rehabilitation (IMMPR). This finding suggests that rehabilitation professionals should consider using IMMPR for patients with comorbid obesity even though their improvement may not reach the same level as for non‐obese patients.

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A Prospective Longitudinal Study of Trajectories of Depressive Symptoms After Dysvascular Amputation

Publication date: August 2019

Source: Archives of Physical Medicine and Rehabilitation, Volume 100, Issue 8

Author(s): Ann Marie Roepke, Aaron P. Turner, Alison W. Henderson, Simon B. Goldberg, Daniel C. Norvell, Joseph M. Czerniecki, Rhonda M. Williams

Abstract

Objectives

Characterize the course of depressive symptoms during the first year after dysvascular amputation and identify factors that predict symptom trajectories.

Design

Prospective cohort study of individuals undergoing lower extremity amputation (LEA), surveyed at 4 time points (perioperative period, 6 weeks, 4 months, and 12 months postamputation). Multilevel modeling was used to describe and predict trajectories.

Setting

Four Veterans Affairs medical centers, a university hospital, and a level I trauma center.

Participants

Participants (N=141; 74% retention) were a consecutive sample, eligible if they were undergoing their first unilateral LEA secondary to dysvascular disease.

Interventions

Not applicable.

Main Outcome Measure

Patient Health Questionnaire-9.

Results

Approximately 40% of participants endorsed at least moderate depressive symptoms at perioperative baseline. Individuals with greater depressive symptoms in the perioperative period concurrently reported greater pain, poorer self-rated health, and prior mental health treatment. In the first 6 weeks after amputation there was a substantial improvement in depressive symptoms, especially among individuals with greater symptoms at baseline. Depressive symptoms were generally stable after 6 weeks. None of the covariates assessed significantly predicted trajectories of depressive symptom improvement.

Conclusions

Watchful waiting may be the most appropriate course of action for many patients in the first 6 weeks after amputation. After 6 weeks, however, symptom levels tend to stabilize, suggesting that active intervention is called for if patients remain depressed at this point. Some patients may benefit from more proactive intervention, such as those with prior mental health treatment histories.

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Long-Term Specialized Physical Therapy in Cervical Dystonia: Outcomes of a Randomized Controlled Trial

Publication date: August 2019

Source: Archives of Physical Medicine and Rehabilitation, Volume 100, Issue 8

Author(s): Joost van den Dool, Bart Visser, Johannes H. Koelman, Raoul H. Engelbert, Marina A. Tijssen

Abstract

Objective

To evaluate the effectiveness of a specialized physical therapy (SPT) program on disability in cervical dystonia (CD) compared to regular physical therapy (RPT).

Design

A single-blinded randomized controlled trial.

Setting

This study was performed by a physical therapist in a primary health care setting. Measurements were performed at baseline, 6 and 12 months in the botulinum toxin (BoNT) outpatient clinic of the neurology department.

Participants

Patients with primary CD and stable on BoNT treatment for 1 year (N=96).

Main Outcome Measures

The primary outcome was disability assessed with the Toronto Western Spasmodic Torticollis Rating Scale (TWSTRS). Secondary outcomes were pain, anxiety, depression, quality of life (QOL), and health related costs over 12 months.

Results

A total of 72 participants (30 men, 42 women) finished the study: 40 received SPT, 32 RPT. No significant between group differences were found after 12 months of treatment (P=.326). Over these 12 months both groups improved significantly (P<.001) on the TWSTRS disability scale compared to baseline (SPT 1.7 points, RPT 1.0 points). Short Form 36 (SF-36) General Health Perceptions (P=.046) and self-perceived improvement (P=.007) showed significantly larger improvements after 12 months in favor of SPT. Total health related costs after 12 months were $1373±556 for SPT compared to $1614±917 for RPT.

Conclusion

SPT revealed no significant differences compared to RPT after 12 months of treatment on the TWSTRS disability scale. Both groups showed similar improvements compared to baseline. Positive results in the SPT group were higher patient perceived effects and general health perception. Treatment costs were lower in the SPT group. With lower costs and similar effects, the SPT program seems to be the preferred program to treat CD.

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Neck swelling and enlarged tonsils

An 18 year old man presented with a seven day history of gradually worsening throat pain, malaise, vomiting, neck swelling, odynophagia, and pyrexia. He had no history of weight loss, foreign travel,...

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Remembering the pain of surgery 1 year later: a longitudinal examination of anxiety in children's pain memory development

Children who develop greater negatively-biased recall of pain (ie, recalled pain is higher than the initial pain report) following surgery are at risk for developing chronic pain; therefore, identifying risk factors for the development of biased pain memories is important. Higher anxiety has been implicated in the development of greater negatively-biased recall of pain; however, studies have not examined anxiety at multiple time points before and after a surgery and its relationship to children's postsurgical pain memories after 1 year. This prospective study examined a cohort of 237 children and adolescents undergoing major surgery. Anxiety sensitivity, pain catastrophizing, and pain anxiety were assessed at baseline, 48 to 72 hours after surgery, and at 6- and 12-month follow-ups. Pain intensity at rest, movement-evoked pain intensity, and pain unpleasantness were assessed daily in hospital. Memories for pain were elicited via telephone 1-year post surgery. Findings revealed that children who had higher levels of anxiety at baseline and 48 to 72 hours after surgery developed greater negatively-biased recall of pain intensity 12 months after surgery. Specifically, higher anxiety sensitivity at baseline and greater tendencies to catastrophize about pain at baseline and in the immediate acute recovery phase were most strongly linked to greater negatively-biased recall of pain. Greater negatively-biased recall of pain was related to higher pain intensity at 6 and 12 months post surgery. Findings support conceptual models of anxiety and pain memory biases and can inform intervention efforts to reduce anxiety in the pre- and post-op periods to minimize negative biases in pain memories.

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The role of narrative in the development of children's pain memories: influences of father– and mother–child reminiscing on children's recall of pain

Negatively biased memories for pain (ie, recalled pain is higher than initial report) robustly predict future pain experiences. During early childhood, parent–child reminiscing has been posited as playing a critical role in how children's memories are constructed and reconstructed; however, this has not been empirically demonstrated. This study examined the role of parent–child reminiscing about a recent painful surgery in young children's pain memory development. Participants included 112 children (Mage = 5.3 years; 60% boys) who underwent a tonsillectomy and one of their parents (34% fathers). Pain was assessed in hospital and during the recovery phase at home. Two weeks after surgery, parents and children attended a laboratory visit to participate in a structured narrative elicitation task wherein they reminisced about the surgery. Four weeks after surgery, children completed an established pain memory interview using the same previously administered scales through telephone. Narratives were coded for style (elaboration) and content (pain and emotion) based on coding schemes drawn from the developmental psychology literature. Findings revealed that a more elaborative parental reminiscing style in addition to greater use of emotional words predicted more accurate/positively biased pain memories. Greater parental use of pain words predicted more negatively biased pain memories. Although there were no sex and parent-role differences in pain memory biases, mothers and fathers differed in how they reminisced with their boys vs girls. This research underscores the importance of parent–child reminiscing in children's pain memory development and may be used to inform the development of a parent-led memory reframing intervention to improve pediatric pain management.

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Endogenous pain modulation in children with functional abdominal pain disorders

Functional abdominal pain disorders (FAPDs) are common among young individuals. To date, relatively little is known regarding the function of the endogenous analgesic mechanisms in this vulnerable group. Therefore, this case–control study aimed to compare conditioned pain modulation (CPM), pressure algometry, and psychosocial variables in 39 young children (aged 6-12 years) with FAPD and 36 age- and sex-matched pain-free controls. Pressure algometry was used to assess pressure pain thresholds (PPTs) at both symptomatic (umbilicus) as remote (trapezius and tibia) test sites. Conditioned pain modulation was recorded as an increase in the PPT at the trapezius test site in response to experimental conditioning pain imposed by the cold pressor task (12 ± 1°C). The assessors were blinded to the diagnoses. Parent-proxy and/or self-reported questionnaires were used to assess child's pain intensity, functional disability, pain-related fear, and parental pain catastrophizing. Compared with pain-free controls, young children with FAPD showed lower PPTs at all test sites (P < 0.05), a lower CPM response (P = 0.02), more functional disability (P < 0.001), and pain-related fear (P < 0.001). Parents of children with FAPD catastrophized more about their child's pain than parents of healthy children (P < 0.001). No sex differences were found for the experimental pain measurements (P > 0.05), nor was there a significant correlation between the child- and parent-reported questionnaires and the CPM effect (P > 0.05). In summary, young children with FAPD demonstrated secondary hyperalgesia and decreased functioning of endogenous analgesia.

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Patients find GP online services “cumbersome,” survey finds

Patients are deterred from using online services offered by general practices, such as booking appointments online, because they find the registration process “a pain” and the range of services...

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Concurrent validity of a low‐cost and time‐efficient clinical sensory test battery to evaluate somatosensory dysfunction

Abstract

Background

This study describes a low‐cost and time‐efficient clinical sensory test battery (CST), and evaluates its concurrent validity as a screening tool to detect somatosensory dysfunction as determined by quantitative sensory testing (QST).

Method

Three patient cohorts with carpal tunnel syndrome (CTS, n=76), non‐specific neck and arm pain (NSNAP, n=40) and lumbar radicular pain/radiculopathy (LR, n=26) were included. The CST consisted of 13 tests, each corresponding to a QST parameter and evaluating a broad spectrum of sensory functions using thermal (coins, ice cube, hot test tube) and mechanical (cotton wool, von Frey hairs, tuning fork, toothpicks, thumb and eraser pressure) detection and pain thresholds testing both loss and gain of function. Agreement rate, statistical significance and strength of correlation (phi coefficient) between CST and QST parameters were calculated.

Results

Several CST parameters (cold, warm and mechanical detection thresholds as well as cold and pressure pain thresholds) were significantly correlated with QST, with a majority demonstrating >60% agreement rates and moderate to relatively strong correlations. However, agreement varied among cohorts. Gain of function parameters showed stronger agreement in the CTS and LR cohorts, whereas loss of function parameters performed better in the NSNAP cohort. Other CST parameters (16mN von Frey tests, vibration detection, heat and mechanical pain thresholds, windup ratio) did not significantly correlate with QST.

Conclusion

Some of the tests in the CST can detect somatosensory dysfunction as determined with QST. Parts of the CST could therefore be used as a low‐cost screening tool in a clinical setting.

This article is protected by copyright. All rights reserved.

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Assessment of experimental orofacial pain, pleasantness and unpleasantness via standardized psychophysical testing

Abstract

Background

Somatosensory assessment within the orofacial region may be performed using highly standardized quantitative sensory testing (QST). However, the function of the C‐tactile (CT) afferent, a nerve fibre linked to the perception of pleasant touch, is usually not evaluated. Furthermore, the perception of unpleasantness is also rarely assessed, a dimension not only limited to a painful experience. Therefore, the primary aim was to apply standardized QST stimuli as well as standardized pleasant stimuli and evaluate their potential capacity for evocation of perceived pain, pleasant and unpleasant sensations in the facial region.

Methods

Twenty‐one female participants underwent QST as per the protocol derived from the German Research Network on Neuropathic Pain. For the first time, two modified protocols were used to investigate stimuli for perceived pleasantness and unpleasantness.

Results

Thermal stimuli provided separate thresholds for each sensation. From certain mechanical stimuli (e.g., vibration), overlap between the perceived sensations of pleasantness and unpleasantness was identified. It was not possible to evoke only an unpleasant sensation without a painful contribution, and both these sensations increased significantly when utilizing an increasing pinprick force (p < 0.011). Between dynamic stimuli, the brush was rated as significantly more pleasant than the cotton wool tip (p = 0.015). A quadratic model provided the best fit for velocity against mean pleasantness ratings (R ² = 0.62 ± 0.08), supporting previous CT afferent literature to some extent.

Conclusion

Stimuli were generally not isolated to one sensation, highlighting the multidimensional construct of stimulus perception and the need for scales to capture this.

Significance

The battery of QST tests from the DFNS protocol has been modified to investigate pleasant and unpleasant sensations. This allows the evaluation of psychophysical properties across standardized dimensions to provide a thorough view of somatosensory function and to better understand the affective spectrum of somatosensory function.

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The relationships between worry, happiness and pain catastrophizing in the experience of acute pain

Abstract

Background

The current study aimed to (a) evaluate the effects of an experimental manipulation of worry and happiness on pain perception and measures of worry about pain and pain catastrophizing and (b) determine if changes in situation‐specific worry about pain and pain catastrophizing would be related to changes in acute pain.

Methods

The study included 120 healthy, pain‐free volunteers. Participants were exposed to four levels of noxious stimulation and asked to report on the pain intensity, worry about pain and pain catastrophizing they experienced during the stimulation procedures. They were then randomly assigned to either a Happy or a Worry condition, where they were exposed to emotion induction procedures. The noxious exposure procedures and measures of pain, pain‐related worry and pain catastrophizing were then repeated.

Results

Participants in the Worry condition reported significant increases in pain intensity, and those in the Happy condition reported significant decreases in pain intensity. Further, the Worry condition participants reported significant increases in both pain‐related worry and pain catastrophizing, while the Happy condition showed the opposite effects. Finally, changes in worry about pain and pain catastrophizing were found to mediate the impact of the affect induction procedure on pain intensity.

Conclusions

The findings demonstrate that pain intensity, worry about pain and pain catastrophizing are all sensitive to changes in mood. The results have potential clinical implications.

Significance

The current study shows that manipulation‐induced changes in pain‐related worry, pain catastrophizing, and affect have direct effects on the experience of acute pain. More broadly, the overlap of these three variables provides with anxiety and mood disorders offers the promise of new vistas for research and treatment of pain conditions by assessing and targeting the cognitions and behaviors that are common to worry and catastrophizing.

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Conditioning pain modulation reduces pain only during the first stimulation of the temporal summation of pain paradigm in healthy participants

Abstract

Background

Pro‐nociceptive and anti‐nociceptive mechanisms are commonly assessed in clinical and experimental pain studies, but their potential interaction is not well understood.

Objectives

Investigate the effect of conditioning pain modulation (CPM) on temporal summation of pain (TSP).

Methods

Twenty healthy participants underwent cuff algometry assessment on the lower legs to establish the pressure pain tolerance threshold (PTT). For the TSP assessment, ten stimuli at the level of the PTT were delivered by computerised cuff inflations (1‐s stimulation, 1‐s break) while participants rated pain intensity on a 10‐cm electronic visual analogue scale (VAS). This TSP paradigm was then repeated with a simultaneous conditioning stimulus induced by a cuff on the contralateral leg, inflated to a constant pressure corresponding to 30% (mild), 70% (moderate) or 100% (severe) of the PTT. These were assessed in a randomised order, with a fifteen‐minute break between tests. A final TSP test without conditioning was reassessed at the end (post‐recording).

Results

An interaction between stimuli (1–10) and repetition (p < 0.05) was found for VAS scores. VAS scores for the first stimulus were decreased during 30%, 70%, and 100% conditioning intensities, compared to baseline and post‐recordings (p < 0.05). There was a significant increase in TSP during conditioning (p < 0.05). There were no significant differences between baseline and post‐recordings for any stimuli (p > 0.05).

Conclusions

The current study indicates that mild to severe stimuli administered by cuff algometry does not modulate summation effect of temporal summation of pain, which could indicate that pain facilitatory mechanisms are more potent compared with pain inhibitory mechanisms.

Significance

Current knowledge on the interaction effect of pro and anti‐nociceptive paradigms are the lacking. The current study indicates that conditioning pain modulation does not modulate the summation effect of temporal summation of pain, when evaluated by computerized pressure algometry. This finding was independent of the mild, moderate and severe painful conditioning intensities.

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Does my pain affect your disgust? Cross‐modal influence of first‐hand aversive experiences in the appraisal of others’ facial expressions

Abstract

Background

Embodied models of social cognition argue that others’ affective states are processed by re‐enacting a sensory‐specific representation of the same state in the observer. However, neuroimaging studies suggest that a reliable part of the representation shared between self and others is supramodal and relates to dimensions such as Unpleasantness or arousal, common to qualitatively different experiences. Here we investigated whether representations of first‐hand pain and disgust influenced the subsequent evaluation of facial expressions in Modality‐specific fashion, or in terms of Unpleasantness or arousal.

Methods

Thirty volunteers were subjected to thermal painful and olfactory disgusting events, and subsequently were asked to classify computer‐generated faces expressing pain (characterized by high Unpleasantness and arousal), disgust (high Unpleasantness and low arousal), surprise (low Unpleasantness and high arousal) and hybrid combinations thereof.

Results

Thermal and olfactory events were associated with comparable Unpleasantness ratings and heart rate (but stronger galvanic response was found for painful temperatures). Furthermore, we found that the appraisal of facial expressions was biased by the prior stimulus, with more frequent pain classifications following thermal stimuli, and more frequent disgust classifications following olfactory stimuli. Critically, this modulation was cross‐modal in nature, as each first‐hand stimulation influenced in comparable fashion facial traits diagnostic of both pain and disgust, without instead generalizing to features of surprise.

Conclusion

Overall, these data support the presence of shared coding between one's aversive experiences and the appraisal of others’ facial responses, which is best describable as supramodal representation of the Unpleasantness of the experience.

Significance

These results extend previous findings about common representational coding between the experience of first‐hand and others’ pain. In particular, they highlight that reliable part of the information shared is supramodal in nature and relates to a broad dimension of Unpleasantness common also to painless aversive states such as disgust.

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Opioid use after hip fracture surgery: A Danish nationwide cohort study from 2005 to 2015

Abstract

Background

There is currently a knowledge gap regarding persistent opioid use after hip fracture surgery. Thus, opioid use within a year after hip fracture surgery in patients with/without opioid use before surgery was examined.

Methods

This population‐based cohort study included all patients (aged ≥ 65) undergoing primary hip fracture surgery in Denmark (2005–2015) identified from the Danish Multidisciplinary Hip Fracture Database. Opioid use was assessed from The Danish National Health Service Prescription Database as redeemed prescriptions. The proportion of patients with ≥1 opioid prescription was computed within 6 months before surgery and each of four 3‐month periods (quarters) after surgery, among patients alive first day in each period. Proportion differences (95% CI) were calculated for each quarter compared to before surgery. Proportions were calculated for users and nonusers before surgery, including initiators after first quarter.

Results

This study included 69,456 patients. Proportion differences of opioid users were 35.0 (95% CI 34.5–35.5), 7.0 (95% CI 6.5–7.5), 2.9 (95% CI 2.4–3.4) and 1.4 percentage‐points (95% CI 0.9–1.9) the four quarters after surgery compared to before. Among opioid nonusers before surgery, 54.7% (95% CI 54.3–55.1), 21.8% (95% CI 21.4–22.2), 17.8% (95% CI 17.4–18.2) and 16.8% (95% CI 16.4–17.2) were opioid users in 1st‐4th quarter after surgery. However, 8.5% (95% CI 8.2–8.7) of the nonusers before surgery in 4th quarter initiated opioid use more than a quarter after surgery.

Conclusions

The proportion of opioid users increased after hip fracture surgery and was 1.4 percentage‐points increased in fourth quarter compared to before. Of opioid nonusers before surgery, 16.8% were opioid users fourth quarter after surgery.

Significance

Opioid use 1 year after hip fracture surgery is common, both in patients who were opioid users and nonusers before the surgery. These significant findings point out the need for indication of benefits and risks of opioid use in the acute and long‐term management of patients undergoing hip fracture surgery.

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Health‐related quality of life change in patients treated at a multidisciplinary pain clinic

Abstract

Background

Multidisciplinary pain management (MPM) is a generally accepted method for treating chronic pain, but heterogeneous outcome measures provide only limited conclusions concerning its effectiveness. Therefore, further studies on the effectiveness of MPM are needed to identify subgroups of patients who benefit, or do not benefit, from these interventions. Our aim was to analyse health‐related quality of life (HRQoL) changes after MPM and to identify factors associated with treatment outcomes.

Methods

We carried out a real world observational follow‐up study of chronic pain patients referred to a tertiary multidisciplinary outpatient pain clinic to describe, using the validated HRQoL instrument 15D, the HRQoL change after MPM and to identify factors associated with this change. 1,043 patients responded to the 15D HRQoL questionnaire at baseline and 12 months after the start of treatment. Background data were collected from the pre‐admission questionnaire of the pain clinic.

Results

Fifty‐three percent of the patients reported a clinically important improvement and, of these, 81% had a major improvement. Thirty‐five percent reported a clinically important deterioration, and 12% had no change in HRQoL. Binary logistic regression analysis revealed that major improvement was positively associated with shorter duration of pain (<3 years), worse baseline HRQoL, higher education levels and being employed.

Conclusions

The majority of the patients reported significant HRQoL improvement after multidisciplinary pain management. Better understanding of the factors associated with treatment outcomes is needed to meet the needs of those who had unfavourable outcomes.

Significance

Multidisciplinary pain management (MPM) increases the health‐related quality of life (HRQoL) in most patients. More research into factors associated with HRQoL change is needed to understand why not all patients benefit from MPM and how MPM approaches could be improved to meet the needs of these patients.

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Exercise‐induced hypoalgesia is present in people with Parkinson’s disease: Two observational cross‐sectional studies

Abstract

Background

Exercise is prescribed for people with Parkinson’s disease to address motor and non‐motor impairments, including pain. Exercise‐induced hypoalgesia (i.e., an immediate reduction in pain sensitivity following exercise) is reported in the general population; however, the immediate response of pain sensitivity to exercise in people with Parkinson’s disease is unknown. The purpose of this study was to investigate if exercise‐induced hypoalgesia is present following isometric and aerobic exercise in people with Parkinson’s disease, and if so, if it varies with the dose of aerobic exercise.

Methods

Thirty people with idiopathic Parkinson’s disease and pain‐free age‐matched controls completed two observational studies evaluating the response to: (a) right arm isometric exercise; and (b) treadmill walking at low and moderate intensities. Pressure pain thresholds were measured over biceps brachii and quadriceps muscles immediately before and after exercise, with increased thresholds after exercise indicating exercise‐induced hypoalgesia.

Results

Pressure pain thresholds increased in the Parkinson’s disease group at all tested sites following all exercise bouts (e.g., isometric exercise, right bicep 29%; aerobic exercise, quadriceps, moderate intensity 8.9%, low intensity 7.1% (p ≤ 0.008)), with no effect of aerobic exercise dose (p = 0.159). Similar results were found in the control group.

Conclusions

Overall, people with Parkinson’s disease experienced an exercise‐induced hypoalgesia response similar to that of the control group, the extent of which did not vary between mild and moderate doses of aerobic exercise. Further research is warranted to investigate potential longer term benefits from exercise in the management of pain in this population.

Significance

Isometric and aerobic exercise reduces pain sensitivity in people with Parkinson’s disease. As exercise is important for people with Parkinson’s disease, these results provide assurance that people with Parkinson’s disease and pain can exercise without an immediate increase in pain sensitivity. The reduction in pain sensitivity with both modes and with low and moderate intensities of aerobic exercise suggests that people with Parkinson’s disease can safely choose the mode and intensity of exercise that best suits their needs.

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An internet‐delivered cognitive behavioural therapy pain management programme for spinal cord injury pain: A randomized controlled trial

Abstract

Background

Chronic pain is common after spinal cord injury (SCI) and dedicated SCI cognitive behavioural therapy pain management programmes (CBT‐PMPs) have a growing evidence base to support their uptake clinically. The development of internet‐delivered treatment options may overcome barriers to the access and uptake of centre‐based programmes. This study examines such an approach on quality of lie (QoL), pain, mood and sleep.

Methods

Adults with SCI pain (>3 months) were recruited and randomly assigned to the intervention or control group. The intervention comprised a six module CBT‐PMP delivered once weekly. A blinded assessor determined changes in self‐reported outcome measures post‐intervention and at 3 months. Linear mixed models and effect sizes based on changes between groups were reported. Significance was set p < 0.05.

Results

The recruitment rate was 32% (intervention n = 35, control n = 34), and the drop‐out rate at 3 months was 26%. On average, participants accessed three (SD 2.1) of six modules. While no difference in QoL was reported, a significant group*time interaction was found for NRS of current pain (χ² = 8.22, p = 0.016), worst pain (χ² = 11.20, p = 0.004), and Brief Pain Inventory (interference) (χ² = 6.924, p = 0.031). Moderate to large effect sizes favouring the intervention were demonstrated at each time point for the pain metrics (Cohen's d: 0.38–0.84). At 3‐month follow‐up, 48% of the intervention group rated themselves improved or very much improved (p < 0.05).

Conclusions

This study demonstrates the potential of an internet‐delivered SCI specific CBT‐PMP in reporting significant statistical and clinical benefit in pain intensity and interference. Strategies to improve engagement are needed.

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Parent psychological flexibility in the context of pediatric pain: Brief assessment and associations with parent behaviour and child functioning

Abstract

Background

The parent's role in the context of pediatric chronic pain is essential. There is growing evidence that parent psychological flexibility positively impacts child functioning. To assess parents’ abilities to respond with psychological flexibility to their child's pain, the Parent Psychological Flexibility Questionnaire (PPFQ) was developed. Here, we aim to validate the 10‐item version of the questionnaire in an English‐speaking population and to evaluate associations with parent behaviour, child pain acceptance and functioning.

Methods

Five hundred and seventy‐eight parent‐child dyads presenting at a pediatric pain clinic were included (92% mothers, average child age 15.2 ± 1.6 years). The PPFQ was completed by the parent. Parent and child also completed other standardized questionnaires. In addition to confirmatory factor analysis and assessments of reliability and validity of the PPFQ‐10, a mediation analysis was performed to examine the direct and indirect effects of parent psychological flexibility on child functioning.

Results

Confirmatory factor analysis supported the three‐factor model with subscales for Values‐Based Action, Pain Willingness and Emotional Acceptance, and the PPFQ‐10 demonstrated strong psychometric properties. After controlling for child pain, parent psychological flexibility indirectly affected child functioning through its association with both parent behaviour (i.e., protectiveness) and child pain acceptance.

Conclusions

Our findings provide further support for use of the PPFQ‐10 and the importance of assessing and addressing parent psychological flexibility in the context of child chronic pain. Our data show that parent psychological flexibility has an important adaptive role and can impact child functioning through two different routes, both of which can be actively targeted in treatment.

Significance

Our findings demonstrate that the PPFQ‐10 is an efficient measure of parent psychological flexibility, demonstrating strong psychometric properties. Furthermore, our analyses showed that parent psychological flexibility indirectly affects child functioning through associations with both adaptive parent behaviour and child functioning. Taken together, this study furthers the understanding of how parent psychological flexibility operates and affects children with chronic pain, and may inform and optimize treatments aimed at improving functioning by addressing child and parent coping.

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Splinting for the carpometacarpal joint relieves experimental basal thumb pain and loss of pinch strength

Abstract

Background

Splinting is a quite common intervention for the first carpometacarpal (CMC) osteoarthritis, however, underlying mechanisms of biomechanical and analgesic effects has not been fully investigated. The aim of this study was to develop an experimental basal thumb pain model and to elucidate the effects of CMC splinting on the pain profile and motor function.

Methods

In 14 healthy subjects, experimental basal thumb pain was induced by hypertonic saline injection into the dorsal radial ligament located on base of the first metacarpal bone. Isotonic saline was injected contralaterally as a control. Two experimental sessions with or without CMC splinting were conducted. Before, during and after injections, tip pinch strength was measured and surface electromyography of the abductor pollicis brevis (APB), first dorsal interosseous (FDI) and extensor pollicis longus (EPL) during tip pinch were evaluated in each session.

Results

Hypertonic saline induced significantly greater pain compared with baseline and isotonic saline (p < 0.01). Following hypertonic saline injection, the tip pinch strength decreased compared with baseline, concomitant with reduction of electromyographical activity of APB and FDI, but not of EPL (p < 0.05). The CMC splinting significantly improved the experimental pain, loss of pinch strength and inhibited intrinsic muscle activity compared with bare hand (p < 0.05).

Conclusions

A novel experimental model mimicking the first CMC joint pain was developed. The CMC splinting relieved the basal thumb pain and augmented pinch strength as well as intrinsic muscle activity. This study provides new insights into the pain relief and pinch strength improvement by splinting for painful CMC joint disorders.

Significance

Newly developed experimental basal thumb pain model decreased tip pinch strength approximately 50%, concomitant with the reduction of intrinsic muscle activities. Splinting for the first carpometacarpal joint significantly improved experimental pain, loss of pinch strength and inhibited intrinsic muscle activity compared with bare hand.

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Implementation of Patient‐Reported Outcomes (PROMs) from specialist pain clinics in England and Wales: Experience from a nationwide study

Abstract

Introduction

Evaluating outcomes in routine clinical practice is a significant challenge for specialist pain clinics due to the complexity of interventions provided and the subjective nature of pain. This study reports findings from implementation of Patient Reported Outcomes (PROMs) in pain clinics in England and Wales between 2011 and 2013.

Methods

A paper‐based questionnaire was administered at a first appointment in participating centres. This assessed quality of life, experience of health care and health care usage with postal follow‐up at 6 and 12 months by the research team. Feasibility was assessed in terms of response rates, completion rates and outcomes.

Results

Ninety‐one (56%) clinics participated, entering 9,588 patients (19% of those eligible). For responders, there was a 92% item completion rate. The dropout rate was high, 46% and 19% returned questions at 6 and 12 months, respectively. Quality of life at baseline was low, with a mean EQ5D‐3L Time Trade Off value of 0.32. Amongst responders at 12 months, 92% continued to experience significant pain. For those with planned discharges 30% achieved the Minimal Important Change for quality of life. Nonetheless, 70% reported positive experiences of care.

Conclusions

Patients attending UK pain clinics report an extraordinarily poor quality of life and difficulty with understanding their condition. Problems with PROMs implementation included initial recruitment, follow‐up response rates, classification systems and benchmarking. Successful implementation should include use of electronic data capture, feedback and focus on gradual improvement. To achieve this would require extended periods of funding.

Significance

No nationwide evaluation of the effectiveness of specialist pain clinics had previously been attempted. Comparison of patient outcomes from services enables improvement. This work provides a platform to improve methods of routine PROMs capture in pain clinics, measure clinical effectiveness and identify areas for potential research.

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Expectations influence treatment outcomes in patients with low back pain. A secondary analysis of data from a randomized clinical trial

Abstract

Background

Low back pain (LBP) is a global public health challenge, which causes high healthcare costs and the highest burden on society in terms of years lived with disability. While patients’ expectations for improvement may have effects on LBP treatment outcomes, it remains unclear if psychological profiles modify this relationship. Therefore, the objectives of this study were to investigate if (a) patients’ expectations predicted short‐term outcome, and (b) psychological profile, pain intensity and self‐rated health modified the relationship between expectations and outcome.

Methods

Data were collected between April 2012 and January 2016 during the inclusion into a randomized controlled trial. Potentially eligible participants were identified through 40 chiropractic clinics located across Sweden. Patients’ expectations, psychological profile, pain intensity, activity limitation and self‐rated health were collected from patients with recurrent persistent LBP during their first chiropractic visit (n = 593). Subjective improvement was measured at the fourth visit.

Results

Patients with a high expectation of improvement had 58% higher risk to report an improvement at the fourth visit (RR = 1.58, 95% CI: 1.28, 1.95). Controlling for potential confounders only slightly decreased the strength of this association (RR = 1.49, 95% CI: 1.20, 1.86). Baseline pain intensity, psychological profile and self‐rated health did not modify the effect of expectation on outcome.

Conclusions

Baseline patients’ expectations play an important role when predicting LBP treatment outcomes. Clinicians should consider and address patients’ expectations at the first visit to best inform prognosis.

Significance

This study confirms the importance of patients’ expectations in a clinical setting. Patients’ expectations predict the short‐term outcome of chiropractic care for LBP. Pain intensity, psychological profile and self‐rated health did not modify this relationship.

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Issue Information

European Journal of Pain, Volume 23, Issue 7, Page 1223-1224, August 2019.

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Corrigendum

European Journal of Pain, Volume 23, Issue 7, Page 1397-1397, August 2019.

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Exposure to cannabinoids can lead to persistent cognitive and psychiatric disorders

Abstract

Background

Cannabinoids are proposed in a wide array of medical indications. Yet, the evaluation of adverse effects in controlled clinical studies, following the evidence‐based model, has partly been bypassed. On the other hand, studies on the consequences of recreational use of cannabis and experimental studies bring some insights on the potential long‐term consequences of cannabinoids use.

Results

Epidemiological studies have consistently demonstrated that cannabis use is associated with a risk of persistent cognitive deficits and increased risk of schizophrenia‐like psychoses. These risks are modulated by the dose and duration of use, on top of age of use and genetic factors, including partially shared genetic predisposition with schizophrenia. Experimental studies in healthy humans showed that cannabis and its principal psychoactive component, the delta‐9‐tetrahydrocannabinol (THC), could produce transient, dose‐dependent, psychotic symptoms as well as cognitive effects, which can be attenuated by cannabidiol (CBD). Studies in rodents have confirmed these effects and shown that adolescent exposure results in structural changes and impaired synaptic plasticity, impacting fronto‐limbic systems that are critically involved in higher brain functions. The endocannabinoid system plays an important role in brain maturation. Its over‐activation by cannabinoid receptor type 1 agonists (e.g., THC) during adolescence and the resulting changes in neuroplasticity could alter brain maturation and cause long‐lasting changes that persist in the adult brain.

Conclusions

Exposure to cannabinoids can have long‐term impact on the brain, with an inter‐individual variability that could be conveyed by personal and family history of psychiatric disorders and genetic background. Adolescence and early adulthood are critical periods of vulnerability.

Significance

The assessment of benefice–risk balance of medical use of cannabis and cannabinoids needs to carefully explore populations that could be more at‐risk of psychiatric and cognitive complications.

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A systematic review and meta‐analysis of memantine for the prevention or treatment of chronic pain

Abstract

Background and Objective

N‐methyl‐D‐aspartate (NMDA) receptors are involved in pain signalling and neuroplasticity. Memantine has been shown to have analgesic properties in pre‐clinical and small clinical studies. We conducted a systematic review and meta‐analysis to assess the efficacy of memantine to prevent or reduce chronic pain.

Databases and data treatment

MEDLINE, EMBASE and CENTRAL databases were searched for comparative trials using memantine, either against placebo or active medications, for chronic pain in adults. Pain relief was considered our primary outcome. Meta‐analyses were conducted if outcomes were reported in two or more studies. Outcomes were reported as mean differences (MD) or risk ratios (RR) with 95% confidence intervals (CI). Quality was assessed using the GRADE approach.

Results

Among 454 citations, 15 studies were included with populations predominantly consisting of neuropathic conditions and fibromyalgia. Overall, we observed unclear reporting of randomization and allocation methods, apart from potential for publication bias. Among the 11 studies looking at chronic pain treatment, the difference in end pain score with memantine was not significant: MD = −0.58 units (95% CI −1.31, 0.14); I² = 82% (low quality). In two surgical studies using memantine for pain prevention, memantine decreased pain intensity: MD = −1.02 units (95% CI −1.38, −0.66); I² = 0%. Dizziness was significantly more common with memantine: RR = 4.90 (95% CI 1.26, 18.99); I² = 52% (moderate quality).

Conclusion

The current evidence regarding the use of memantine for chronic pain is limited and uncertain. Despite its potential, pain relief achieved in clinical studies is small and is associated with an increase in dizziness.

Significance

Despite a sound rationale, the benefit of using memantine for chronic pain is unclear. Our systematic review and meta‐analysis show that memantine may have the potential to decrease pain. However, it can also increase common adverse effects. Considering the small number of studies with potential for bias and inconclusive evidence, there was low to very low certainty. Hence, no clear recommendations can be made about its routine clinical use until larger and more definitive studies are conducted.

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Physical activity as a prognostic factor of pain intensity and disability in patients with low back pain: A systematic review

Abstract

Background and objective

Identifying factors that influence the course of low back pain (LBP) is important to help clinicians to identify those patients at higher risk of non‐recovery. The objective of this systematic review was to investigate the prognostic role of physical activity in the course of LBP.

Databases and data treatment

Literature searches were conducted in five electronic databases from their inception to February 2018. Prospective cohort studies investigating the influence of any type of physical activity in people with LBP were considered eligible. The primary outcomes were pain intensity and disability. Two independent reviewers extracted the data and assessed the methodological quality of the included studies. Results were stratified according to participants’ symptoms duration at baseline.

Results

Twelve studies were considered eligible for this review. Of these, six included patients with chronic LBP, four studies did not specify the patients’ duration of symptoms, one study included patients with acute LBP, and one study included patients with subacute LBP. Included studies were heterogeneous in terms of physical activity assessment, outcomes, follow‐up duration, and statistical methods, therefore, pooling of results was not performed. We found limited evidence to support the prognostic role of physical activity in the course of LBP.

Conclusions

Our review identified limited evidence supporting physical activity as a prognostic factor in LBP. Future cohort studies are needed to clarify the strength and importance of this association.

Significance

Despite recent research in the area, this systematic review shows that there is low quality evidence that physical activity may not be a prognostic factor for predicting pain and disability in patients with LBP.

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Liver and spleen pneumatosis

This is an abdominal computed tomography scan showing hepatic (red arrows) and splenic (blue arrow) pneumatosis (fig 1).The patient was a 64 year old man with four days of abdominal pain and...

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[Editorial] Oral health at a tipping point

What comes to mind when you think of dentistry? A luxury, a pain, excessive costs, the quest for straight, white teeth? Any way that dentistry is thought of, it's rarely as a mainstream part of health-care practice and policy, despite the centrality of the mouth and oral cavity to people's wellbeing and identity. The inattention to dental and oral health is concerning given the fact that oral diseases—tooth decay, gum disease, and oral cancers—are exceedingly common, affecting an estimated 3·5 billion people across the world.

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Nerve growth factor‐induced muscle hyperalgesia facilitates ischemic contraction‐evoked pain

Abstract

Background

Intramuscular injection of Nerve Growth Factor (NGF) may influence the responsiveness of active chemo‐sensitive channels affecting muscle pain sensitivity. This double‐blinded crossover study in healthy humans assessed contraction‐evoked pain responses and pain sensitivity during acute ischemia in the tibialis anterior (TA) muscle before and 24h after five distributed NGF injections (1μg, 4 cm interval) compared with control injections (isotonic‐saline).

Methods

Twenty‐one subjects participated in two experimental phases, each including 5 sessions over 7 days, with a gap of 4 weeks in‐between. Muscle pain intensity evoked with daily functional tasks (Likert scale score) was collected using a paper diary. Pain intensity evoked by ischemic and non‐ischemic contractions (numerical rating scale, NRS) was collected at Day0 and Day1. Pressure pain thresholds (PPTs) on the TA were recorded before (Day0), 3 hours, 1, 3, and 7 days post‐injection, and after the ischemic‐contractions and post‐cuff deflation at Day0 and Day1.

Results

Increased Likert scores of pain were present for 7 days after NGF compared to control injections (P<0.05). Higher NRS pain scores of ischemic‐contractions were seen when contracting the muscle injected with NGF compared to baseline (P=0.003) and control (P=0.012). Pain during non‐ischemic contractions was not significantly affected by NGF injections. Decreased PPTs were found at 3 hours, Day1 and Day3 post‐injection (P<0.05) in both conditions. Compared with pre‐contractions, PPTs were increased following ischemic contractions at Day0 (P<0.05) and Day1 (P<0.05) in both conditions.

Conclusion

This study showed that ischemic contraction‐evoked pain was facilitated in an NGF‐sensitized muscle.

This article is protected by copyright. All rights reserved.

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The effect of intradermal microdosing of a transient receptor potential cation channel subfamily V member 1 antagonist on heat evoked pain and thermal thresholds in normal and ultraviolet‐C exposed skin in healthy volunteers

Abstract

Background

Three TRPV1 (Transient Receptor Potential Vanilloid Receptor 1) antagonists were developed for testing in situ in human skin (Sjögren et al., 2016; Sjögren et al., 2018; Sjogren et al., 2018). The first human study using these compounds and capsaicin, was done to determine the required local antagonist concentrations needed for target engagement (Proof of Mechanism, PoM) (Sjogren et al., 2018). For this paper, the aim was to address a TRPV1 antagonist's ability to inhibit a more complex pain signal, and to define translational endpoints that could be used in further drug development, when progressing orally bioavailable TRPV1 antagonists as novel analgesic medications.

Method

This was a single center, placebo controlled, clinical proof of principle (PoP) study in 25 healthy volunteers. The subjects were exposed to UV irradiation, causing a local tissue inflammation. Three different doses of AZ12048189 were administered to assess pain perception through quantitative sensory testing (QST) and erythema by Laser Doppler scanning.

Results

AZ12048189 increased the warmth detection threshold (WDT) and the heat pain threshold (HPT), as well as decreased the intensity of supra threshold heat pain (STHP). AZ12048189 did not, however, have any significant effects as assessed by mechanical stimulation, or by Laser Doppler.

Conclusions

This study validated translational tools to confirm target engagement for TRPV1 antagonists; WDT, HPT and STHP have utility in this respect, after oral administration of a TRPV1 antagonist. This study also proved that TRPV1 antagonists can inhibit a more complex, non‐capsaicin dependent thermally induced pain signal.

This article is protected by copyright. All rights reserved.

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Thin‐fibre receptors expressing acid‐sensing ion channel 3 contribute to muscular mechanical hypersensitivity after exercise

Abstract

Background

Delayed onset muscle soreness (DOMS) is characterised by mechanical hyperalgesia after lengthening contractions (LC). It is relatively common and causes disturbance for many people who require continuous exercise, yet its molecular and peripheral neural mechanisms are poorly understood.

Methods

We examined whether muscular myelinated Aδ‐fibres, in addition to unmyelinated C‐fibres, are involved in LC‐induced mechanical hypersensitivity, and whether acid‐sensing ion channel (ASIC)‐3 expressed in thin‐fibre afferents contributes to this type of pain using a rat model of DOMS. The peripheral contribution of ASIC3 was investigated using single‐fibre electrophysiological recordings in extensor digitorum longus muscle‐peroneal nerve preparations in vitro.

Results

Behavioural tests demonstrated a significant decrease of the muscular mechanical withdrawal threshold following LC to ankle extensor muscles, and it was improved by intramuscular injection of APETx2 (2.2 μM), a selective blocker of ASIC3. The lower concentration of APETx2 (0.22 μM) and its vehicle had no effect on the threshold. Intramuscular injection of APETx2 (2.2 μM) in naïve rats without LC did not affect the withdrawal threshold. In the ankle extensor muscles that underwent LC one day before the electrophysiological recordings, the mechanical response of Aδ‐ and C‐fibres was significantly facilitated (i.e., decreased response threshold and increased magnitude of the response). The facilitated mechanical response of the Aδ‐ and C‐fibres was significantly suppressed by selective blockade of ASIC3 with APETx2, but not by its vehicle.

Conclusions

These results clearly indicate that ASIC3 contributes to the augmented mechanical response of muscle thin‐fibre receptors in delayed onset muscular mechanical hypersensitivity after LC.

This article is protected by copyright. All rights reserved.

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Parental injustice appraisals in the context of child pain: Examining the construct and criterion validity of the IEQ-Pc and IEQ-Ps

Research among adult and pediatric samples suggests that pain-related injustice appraisal - an appraisal comprising elements of severity and irreparability of pain-related loss, as well as perceived blame and unfairness50 – contribute significantly and uniquely to adverse pain outcomes.34,47,50,51,53,54 However, despite continuing advances, research has been largely restricted to an intrapersonal perspective, utilizing the Injustice Experience Questionnaire (IEQ49) to examine individuals’ (in)justice appraisals regarding personal pain.

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Quantification of Small Fiber Neuropathy in Chemotherapy Treated Patients

Chemotherapy-induced peripheral neuropathy (CIPN) is a major, dose-limiting side effect of treatment with neurotoxic cancer treatments, including platinum compounds, taxanes, vinca alkaloids, thalidomide, and bortezomib.79 Symptoms of CIPN include paraesthesia, numbness and weakness in the extremities, typically resulting from damage to large sensory as well as motor nerve fibers. However, small fiber components of the peripheral nervous system can also be affected, resulting in autonomic dysfunction and pain.

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A middle aged man with back pain and heavy legs

A 50 year old man presented with a two day history of “heavy legs,” reduced sensation bilaterally in his lower limbs, and five days of constipation. He had also experienced right upper quadrant pain...

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