Hugh James Hoyland

bmj;370/jul31_6/m3011/FAF1faHugh James Hoyland (“Jim”) was a general practitioner of the old school. He started in rural Painswick in the Cotswolds in 1959, initially helping Dr Tinker, for whom four...

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Nuisance mediators and missing data in mediation analyses of pain trials

Abstract

This journal recently published a paper by O'Neill and colleagues, entitled "Examining what factors mediate treatment effect in chronic low back pain: a mediation analysis of a Cognitive Functional Therapy clinical trial” (O’Neill et al., 2020). Although the limitations in O'Neill et al. preclude robust conclusions about the mechanisms of Cognitive Functional Therapy (CFT), their study highlights wider issues for understanding treatment mechanisms for chronic pain. This commentary focuses on two issues: the need for mediation analyses to explain why treatments do not work, and the misreporting of missing data in mediation analyses.

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Injectable PLGA-coated ropivacaine produces a long-lasting analgesic effect on incisional pain and neuropathic pain

Despite great efforts in research on the control of persistent postsurgical pain during past decades, management of this disorder remains a challenge in a large number of patients59. Systemic administration of analgesic drugs (e.g., opioids) may cause severe side effects, especially when given repeatedly8. Local anesthetics (LA; e.g., ropivacaine (RVC)) have been used widely as simple and effective treatment for persistent pain with absent or reduced adverse effects 39. However, their analgesic effect lasts only several hours after single injection41.

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Activation of the descending pain modulatory system using cuff pressure algometry: Back translation from man to rat

Abstract

Background

Diffuse noxious inhibitory controls (DNIC) as measured in rat and conditioned pain modulation (CPM), the supposed psychophysical paradigm of DNIC measured in humans, are unique manifestations of an endogenous descending modulatory pathway that is activated by the application of a noxious conditioning stimulus. The predictive value of the human CPM processing is crucial when deliberating the translational worth of the two phenomena.

Methods

For CPM or DNIC measurement, test and conditioning stimuli were delivered using a computer‐controlled cuff algometry system or manual inflation of neonate blood pressure cuffs, respectively. In humans (n  = 20), cuff pain intensity (for pain detection and pain tolerance thresholds) was measured using an electronic visual analogue scale. In isoflurane‐anaesthetized naïve rats, nociception was measured by recording deep dorsal horn wide dynamic range (WDR) neuronal firing rates (n  = 7) using in vivo electrophysiology.

Results

A painful cuff‐pressure conditioning stimulus on the leg increased pain detection and pain tolerance thresholds recorded by cuff stimulation on the contralateral leg in humans by 32% ± 3% and 24% ± 2% (mean ± SEM ) of baseline responses, respectively (p  < .001). This finding was back‐translated by revealing that a comparable cuff‐pressure conditioning stimulus (40 kPa) on the hind paw inhibited the responses of WDR neurons to noxious contralateral cuff test stimulation to 42% ± 9% of the baseline neuronal response (p  = .003).

Conclusions

These data substantiate that the noxious cuff pressure paradigm activates the descending pain modulatory system in rodent (DNIC) and man (CPM), respectively. Future back and forward translational studies using cuff pressure algometry may reveal novel mechanisms in varied chronic pain states.

Significance

This study provides novel evidence that a comparable noxious cuff pressure paradigm activates a unique form of endogenous inhibitory control in healthy rat and man. This has important implications for the forward translation of bench and experimental pain research findings to the clinical domain. If translatable mechanisms underlying dysfunctional endogenous inhibitory descending pathway expression (previously evidenced in painful states in rat and man) were revealed using cuff pressure algometry, the identification of new analgesic targets could be expedited.

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Beyond pain intensity and catastrophizing: The association between self‐enhancing humour style and the adaptation of individuals with chronic pain

Abstract

Background

Many questions regarding the process by which self‐enhancing humour style has an effect on chronic pain individuals' adjustment remain unanswered. The aim of the present study was to analyse the association of self‐enhancing humour style with adjustment in a sample of individuals with chronic pain, over and above the role of catastrophizing and pain intensity. Adjustment was assessed using measures of depression, pain interference and flourishing. We also examined the indirect association between self‐enhancing humour style and adjustment via pain acceptance.

Methods

The study included 427 patients with heterogeneous chronic pain conditions. The study hypotheses were tested using three multiple linear regression analyses, one for each of the criterion variables.

Results

Consistent with the study hypothesis, both direct and indirect associations were found between self‐enhancing humour style and depressive symptoms, pain interference and flourishing via pain acceptance.

Conclusions

Self‐enhancing humour style could potentially help individuals with chronic pain to gain perspective and distance themselves from the situation through the acceptance of pain‐related negative emotions.

Significance

Very few studies have investigated the relationship between humour styles and adjustment in chronic pain samples. The results of the current study support the idea that adaptive dispositional traits, such as patient's self‐ enhancing humour style, play a role in the adaptation of individuals with chronic pain. Given that the association between self‐enhancing humour style and adjustment evidenced an indirect association through pain acceptance, training in the use of humour, as individuals with self‐enhancing humour style do, might be a useful addition to ACT treatment.

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A hidden mesencephalic variant of central pain

Abstract

Background

Central post‐stroke pain (CPSP) can arise after lesions anywhere in the central somatosensory pathways, essentially within the spinothalamic system (STS). Although the STS can be selectively injured in the mesencephalon, CPSP has not been described in pure midbrain infarcts.

Methods

Of more than 300 CPSP consecutive cases, we describe five patients who developed definite neuropathic pain following lesions circumscribed to the postero‐lateral mesencephalon.

Results

The mesencephalic lesion responsible for pain was always haemorrhagic and always involved the spinothalamic tract (STT), as demonstrated by suppressed laser‐evoked potentials in every case, with or without preserved lemniscal function. In three cases the midbrain injury could be ascribed to trauma, presumably from the cerebellar tentorium. As a result of the paucity of sensory symptoms, the pain was considered as ‘psychogenic’ in two of the patients until electrophysiological testing confirmed STT involvement.

Conclusion

Postero‐lateral midbrain lesions should be added to potential causes of CPSP. Because pain and spinothalamic deficits may be the only clinical sign, and because small lateral midbrain lesions may be difficult to trail with MRI, mesencephalic CPSP can be misdiagnosed as malingering or psychogenic pain for years.

Significance

Selective spinothalamic injury caused by small lateral midbrain lesions is a very rare cause of central post‐stroke pain that can remain undiagnosed for years. It appears to obey to haemorrhagic, sometimes post‐traumatic lesions. Sudden development of contralateral burning pain with isolated spinothalamic deficits may be the only localizing sign, which can be easily objectively detected with electrophysiological testing.

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Interpretation biases and visual attention in the processing of ambiguous information in chronic pain

Abstract

Background

Theories propose that interpretation biases and attentional biases might account for the maintenance of chronic pain symptoms, but the interactions between these two forms of biases in the context of chronic pain are understudied.

Methods

To fill this gap, 63 participants (40 females) with and without chronic pain completed an interpretation bias task that measures participants’ interpretation styles in ambiguous scenarios and a novel eye‐tracking task where participants freely viewed neutral faces that were given ambiguous pain/health‐related labels (i.e. ‘doctor’, ‘patient’ and ‘healthy people’). Eye movements were analysed with the Hidden Markov Models (EMHMM) approach, a machine‐learning data‐driven method that clusters people's eye movements into different strategy subgroups.

Results

Adults with chronic pain endorsed more negative interpretations for scenarios related to immediate bodily injury and long‐term illness than healthy controls, but they did not differ significantly in terms of their eye movements on ambiguous faces. Across groups, people who interpreted illness‐related scenarios in a more negative way also focused more on the nose region and less on the eye region when looking at patients’ and healthy people's faces and, to a lesser extent, doctors’ faces. This association between interpretive and attentional processing was particularly apparent in participants with chronic pain.

Conclusions

In summary, the present study provided evidence for the interplay between multiple forms of cognitive biases. Future studies should investigate whether this interaction might influence subsequent functioning in people with chronic pain.

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Stuck on pain? Assessing children’s vigilance and awareness of pain sensations

Abstract

Background

Attending towards pain is proposed as a key mechanism influencing the experience and chronification of pain. Persistent attention towards pain is proposed to drive poor outcomes in both adults and children with chronic pain. However, there are no validated self‐report measures of pain‐related attention for children.

Methods

The goals of this study were to adapt the Pain Vigilance and Awareness Questionnaire (PVAQ) for use in a child sample, to preliminary examine its psychometric properties, and to assess its utility over and above a measure of general attentional capacities. We adapted the language of the PVAQ to be more easily understood by children as young as 8 years. In a sample of 160 children (8–18 years) with chronic pain, we examined the factor structure, internal consistency and criterion validity of the PVAQ‐C.

Results

The PVAQ‐C demonstrated excellent internal consistency (α = 0.92) and moderate‐to‐strong criterion validity. A one‐factor structure best fit the data. Children who reported greater attention to pain also reported greater pain catastrophizing, fear of pain, avoidance of activities and poorer physical functioning. Pain‐related attention remained a significant predictor of functioning while controlling for demographics, catastrophizing and fear‐avoidance. Pain‐related attention also significantly predicted child outcomes independent of the child's general attention control capacities, indicating added value of a pain‐specific measure of attention.

Conclusions

The PVAQ‐C shows strong indices of internal reliability and criterion validity, and indicates unique predictive utility. It will be important to study the role of pain‐related attention in youth within developmental and functional–motivational frameworks.

Significance

Pain‐related attention is proposed as a key factor influencing fear‐avoidance outcomes in both adults and youth with chronic pain, yet no self‐report measures of pain‐related attention have been validated for children. This paper presents a child version of the Pain Vigilance and Awareness Questionnaire (PVAQ‐C), which indicates strong internal consistency, criterion validity and unique predictive validity, and provides evidence to support the Fear‐Avoidance Model in youth with chronic pain.

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Insomnia is a risk factor for spreading of chronic pain: A Swedish longitudinal population study (SwePain)

Abstract

Background

Recent evidence suggests that insomnia negatively influences the occurrence of generalized pain. This study examined whether insomnia is a risk factor for the transition from local pain (LP) to generalized pain (i.e. spreading of pain).

Methods

This longitudinal study, with a follow‐up of 24 months, included 959 participants (mean age: 55.8 years; SD : 13.9) with local or regional pain at baseline. Participants were grouped by insomnia symptoms as measured by the Insomnia Severity Index. Spreading of pain was measured by body manikins based on the spatial distribution of pain on the body. We defined two outcome categories; one with relatively localized pain (i.e. LP and moderate regional pain [MRP]), and one with relatively generalized pain (i.e. substantial regional pain and widespread pain [WSP]). Baseline age, sex, education, depressive symptoms, anxiety symptoms, catastrophizing, pain intensity and spread of pain were also included in the Generalized Linear Model analysis.

Results

The unadjusted model showed that the risk of spreading of pain increased with an increase in insomnia symptoms (no insomnia: 55.4%; subthreshold insomnia: 25.4% moderate insomnia: 16.5% and severe insomnia: 2.7%). The risk increased in a dose‐dependent manner; moderate insomnia risk ratio (RR) 2.34 (95% confidence interval [CI]: 1.34–4.09) and severe insomnia RR 4.13 (95% CI: 1.56–10.92). The results were maintained in the fully adjusted model although MRP was the strongest predictor RR 6.95 (95% CI: 3.11–15.54).

Conclusion

Our findings show a strong prospective relationship between insomnia symptoms and the transition from relatively localized to generalized pain.

Significance

This study shows that people with LP conditions are at much higher risk of developing WSP if they also have significant insomnia symptoms. The elevated risk is evident after 24 months and increases in a dose‐dependent manner regarding the degree of exposure to insomnia symptoms. Local pain conditions are quite common in primary care, and an evaluation of the insomnia symptoms is highly recommended since the most common sleep problems can be treated effectively if detected.

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Association of quantitative sensory testing parameters with clinical outcome in patients with lumbar radiculopathy undergoing microdiscectomy

Abstract

Background/Aim

This study aimed to establish the somatosensory profile of patients with lumbar radiculopathy at pre‐and post‐microdiscectomy and to explore any association between pre‐surgical quantitative sensory test (QST) parameters and post‐surgical clinical outcomes.

Methods

A standardized QST protocol was performed in 53 patients (mean age 38 ± 11 years, 26 females) with unilateral L5/S1 radiculopathy in the main pain area (MPA), affected dermatome and contralateral mirror sites and in age‐ and gender‐,and body site‐matched healthy controls. Repeat measures at 3 months included QST, the Oswestry Disability Index (ODI) and numerous other clinical measures; at 12 months, only clinical measures were repeated. A change <30% on the ODI was defined as ‘no clinically meaningful improvement’.

Results

Patients showed a significant loss of function in their symptomatic leg both in the dermatome (thermal, mechanical, vibration detection p  < .002), and MPA (thermal, mechanical, vibration detection, mechanical pain threshold, mechanical pain sensitivity p  < .041) and increased cold sensitivity in the MPA (p  < .001). Pre‐surgical altered QST parameters improved significantly post‐surgery in the dermatome (p  < .018) in the symptomatic leg and in the MPA (p  < .010), except for thermal detection thresholds and cold sensitivity. Clinical outcomes improved at 3 and 12 months (p  < .001). Seven patients demonstrated <30% change on the ODI at 12 months. Baseline loss of function in mechanical detection in the MPA was associated with <30% change on the ODI at 12 months (OR 2.63, 95% CI 1.09–6.37, p  = .032).

Conclusion

Microdiscectomy resulted in improvements in affected somatosensory parameters and clinical outcomes. Pre‐surgical mechanical detection thresholds may be predictive of clinical outcome.

Significance

This study documented quantitative sensory testing (QST) profiles in patients with lumbar radiculopathy in their main pain area (MPA) and dermatome pre‐ and post‐microdiscectomy and explored associations between QST parameters and clinical outcome. Lumbar radiculopathy was associated with loss of function in modalities mediated by large and small sensory fibres. Microdiscectomy resulted in significant improvements in loss of function and clinical outcomes in 85% of our cohort. Pre‐surgical mechanical detection thresholds in the MPA may be predictive of clinical outcome.

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Interplay between body schema, visuospatial perception and pain in patients with spinal cord injury

Abstract

Background

Changes in body representations (body image and/or body schema) have been reported in several chronic musculoskeletal pain syndromes, but rarely in patients with neuropathic pain and never in patients with spinal cord injury (SCI)‐related pain.

Methods

We used implicit motor imagery (the laterality judgement task and visuospatial body perception tests) in 56 patients with thoracic SCI with (n  = 32) or without (n  = 24) pain below the level of the injury, and in a group of matched healthy controls (n  = 37). We compared the participants' reaction time and the accuracy with which they identified the laterality of hands and feet presented in various orientations. Visuospatial body perception was assessed with a series of tests referred to as the 'horizontal subjective body midline', and the umbilicus‐reaching task (URT), in which participants were asked to estimate the location of the umbilicus under different experimental conditions.

Results

Both groups of patients had longer reaction times for the identification of laterality for the feet than for the hands, but with no difference in accuracy. This longer reaction time was not correlated with spinal lesion severity, but was directly related to both average pain intensity and specific neuropathic pain components. The URT was affected in both groups of patients, with no effect of pain intensity. By contrast, the horizontal subjective body midline task was unaffected.

Conclusion

These results suggest an interplay between lower body scheme distortions and pain in patients with SCI.

Significance

Spinal cord injury is associated with alterations of lower body scheme as assessed with the laterality judgement task, which are directly related to pain intensity in patients with below‐level neuropathic pain.

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Mindfulness meditation is related to sensory‐affective uncoupling of pain in trained novice and expert practitioners

Abstract

Background

Mindfulness meditation can alleviate acute and chronic pain. It has been proposed that mindfulness meditation reduces pain by uncoupling sensory and affective pain dimensions. However, studies to date have reported mixed results, possibly due to a diversity of styles of and expertise in mindfulness meditation. Furthermore, the interrelations between mindfulness meditation and pain catastrophizing during acute pain remain little known.

Methods

This cross‐sectional study investigated the effect of a style of mindfulness meditation called Open Monitoring (OM) on sensory and affective pain experience by comparing novice (2‐day formal training; average ~20 hr practice) to expert practitioners (>10.000 hr practice). We implemented a paradigm that was designed to amplify the cognitive‐affective aspects of pain experience by the manipulation of pain anticipation and uncertainty of stimulus length (8 or 16 s thermal pain stimuli). We collected pain intensity and unpleasantness ratings and assessed trait pain catastrophizing with the Pain Catastrophizing Scale (PCS).

Results

Across groups, mindfulness meditation reduced unpleasantness, but not intensity ratings compared to attentional distraction. Experts reported a lower score on PCS, reduced amplification of unpleasantness by long painful stimuli, and larger sensory‐affective uncoupling than novices particularly during long painful stimuli. In experts, meditation‐induced uncoupling spilled over the control condition. Across groups and task conditions, a higher score on PCS predicted lower sensory‐affective uncoupling during long painful stimuli and higher ratings of pain intensity during short painful stimuli.

Conclusion

These findings suggest that mindfulness meditation specifically down‐regulates pain affect as opposed to pain intensity, and that pain catastrophizing undermines sensory‐affective uncoupling of pain.

Significance

In this study, we found that a style of mindfulness meditation referred to as OM reduced unpleasantness but not intensity ratings compared to attentional distraction in trained novice (state effect) and expert meditators (state and trait effects). We also observed that trait pain catastrophizing scores predicted this sensory‐affective uncoupling. These findings advance our understanding of the cognitive mechanisms underlying mindfulness meditation and can inform treatment strategies for chronic pain.

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Neuropathic pain after thoracotomy: Tracking signs and symptoms before and at monthly intervals following surgery

Abstract

Background

As the development of neuropathic symptoms contributes to pain severity and chronification after surgery, their early prediction is important to allow targeted treatment.

Objectives

We longitudinally investigated trajectories of signs and symptoms in patients undergoing thoracotomy and assessed whether and at which time they were related to the development of neuropathic pain symptoms 6 months after surgery.

Methods

Presurgical and 6 monthly postsurgical assessments included questionnaires for mental and physical well‐being (e.g., depression/anxiety, pain catastrophizing, sleep quality, neuropathic pain symptoms), and quantitative sensory testing (QST).

Results

QST trajectories indicated nerve impairment of the surgery site with predominant loss of function. Signs of recovery towards the end of the assessment period were observed for some tests. Unsupervised cluster analysis with NPSI scores 6 months after surgery as clustering variable identified one group with no/low levels of neuropathic symptoms and one with moderate levels. The two groups differed w.r.t. several signs and symptoms already at early time points. Notably, neuropathic pain anywhere in the body differed already preoperatively and sleep impairment differentiated the two groups at all time points. Regression analysis revealed three factors that seemed particularly suited to predicted 6 months NPSI scores, namely preoperative neuropathic pain symptoms, with contributions from sleep impairment 1 month after surgery and the presence of dynamic mechanical allodynia 3 months after surgery.

Conclusions

Clinical routine should focus on the individual's physiological state, including pre‐existing neuropathic pain and sleep quality to identify patients early who might be at risk to develop chronic post‐surgical neuropathic pain.

Significance

Development of neuropathies contributes to pain severity and pain chronification after surgery. Here we demonstrate trajectories of quantitative sensory tests (assessed at monthly intervals for 6 months after surgery) that reveal accurate time courses of gain/loss of nerve function following thoracotomy. Independent of the degree of neuropathic signs after surgery, the main predictors for post‐surgical neuropathic pain are self‐reported neuropathic pain before surgery and sleep quality shortly after surgery.

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The N2pc component as a neural index of early attention allocation among adults with chronic musculoskeletal pain

Abstract

Recent evidence from event‐related potentials (ERPs) has identified N2 posterior contralateral (pc) amplitudes as a neural marker of early attention allocation. The N2pc has been used to evaluate attention biases (ABs) in samples with anxiety‐based problems, but its utility has yet to be considered among persons with chronic pain, another group theorized to display ABs that perpetuate their difficulties. To address this gap, we assessed N2pc responses of adults with chronic pain (N  = 70) and pain‐free controls (N  = 70) during a dot‐probe task comprising painful‐neutral and happy‐neutral facial expression image pairs. Analyses indicated that (1) larger N2pc amplitudes were elicited by both painful and happy expressions compared to complementary neutral expressions in each sample, (2) the chronic pain sample displayed larger N2pc amplitudes during exposure to both painful and happy expressions than controls did and (3) no group differences were evident for N2pc latencies. Overall N2pc results reflected general biases in early allocation of attention towards affectively valenced expressions rather than pain‐specific ABs among chronic pain cohorts.

Significance

Although numerous researchers have examined pain‐related attention biases, these data are based exclusively upon behavioural measures of attention such as reaction times and eye movements. Drawing from relevant event‐related potentials research, this study is the first to evaluate and identify differences in orienting of attention between adults with chronic pain and pain‐free controls based on N2 posterior contralateral (pc) amplitudes which provide a neural index of early attention allocation.

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Treatment preferences in fibromyalgia patients: A cross‐sectional web‐based survey

Abstract

Background

Therapeutic approaches to fibromyalgia (FM) are shifting towards a combined multi‐treatment approach to tackle the variety of symptoms experienced in FM. Importantly, little is known about FM patients' attitude towards the available treatments.

Methods

A cross‐sectional web survey obtained responses from 464 individuals who satisfied diagnostic criteria for FM. Respondents were asked to report which treatments they adopted in their past, present and intend to adopt in the future. They also rated their level of well‐being, depression, anxiety and pain catastrophizing.

Results

Data revealed a predominantly combined multi‐treatment approach in a sample characterized by middle‐aged, Caucasian women. Respondents reported pervasive use of pharmacological therapy but had also adopted non‐pharmacological treatment in the past. Future intentions clustered on alternative treatment or no treatment. Regression analyses revealed that pharmacological treatment in the past was predictive of both pharmacological and non‐pharmacological treatments in the present. However, use of non‐pharmacological treatment in the past was uniquely predictive of its reuse in the present and future. This pattern was also accounted for by individual differences in pain magnification and well‐being in the past.

Conclusions

Treatment preferences of FM individuals reveal an ambivalent combination of heavy reliance on pharmacological treatment with lower but consistent reliance on non‐pharmacological treatment for those individuals who used it in the past and present. This finding may inform longitudinal research into the relationship between pharmacological and non‐pharmacological treatment preference in FM patients, which could in turn inform guidelines for individualized therapeutic plans for clinicians.

Significance

Individuals with fibromyalgia reported the use of non‐pharmacological and pharmacological treatments in the past but a predominant use of a pharmacological approach overall. Patterns of treatment experienced in the past were differentially related to future preferences. Pharmacological treatment in the past was likely to lead to both pharmacological and non‐pharmacological choices in the present. However, non‐pharmacological treatment in the past was more likely to be chosen again in the present and future, but unlikely to lead to a pharmacological choice.

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Peripheral input and phantom limb pain: A somatosensory event‐related potential study

Abstract

Background

Following amputation, nearly all amputees report nonpainful phantom phenomena and many of them suffer from chronic phantom limb pain (PLP) and residual limb pain (RLP). The aetiology of PLP remains elusive and there is an ongoing debate on the role of peripheral and central mechanisms. Few studies have examined the entire somatosensory pathway from the truncated nerves to the cortex in amputees with PLP compared to those without PLP. The relationship among afferent input, somatosensory responses and the change in PLP remains unclear.

Methods

Transcutaneous electrical nerve stimulation was applied on the truncated median nerve, the skin of the residual limb and the contralateral homologous nerve in 22 traumatic upper‐limb amputees (12 with and 10 without PLP). Using somatosensory event‐related potentials, the ascending volley was monitored from the brachial plexus, the spinal cord, the brainstem and the thalamus to the primary somatosensory cortex.

Results

Peripheral input could evoke PLP in amputees with chronic PLP (7/12), but not in amputees without a history of PLP (0/10). The amplitudes of the somatosensory components were comparable between amputees with and without PLP. In addition, evoked potentials from the periphery through the spinal, subcortical and cortical segments were not significantly associated with PLP.

Conclusions

Peripheral input can modulate PLP but seems insufficient to cause PLP. These findings suggest the multifactorial complexity of PLP and different mechanisms for PLP and RLP.

Significance

Peripheral afferent input plays a role in PLP and has been assumed to be sufficient to generate PLP. In this study we found no significant differences in the electrical potentials generated by peripheral stimulation from the truncated nerve and the skin of the residual limb in amputees with and without PLP. Peripheral input could enhance existing PLP but could not cause it. These findings indicate the multifactorial complexity of PLP and an important role of central processes in PLP.

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Dissociation proneness and pain hyposensitivity in current and remitted borderline personality disorder

Abstract

Background

Stress‐related dissociation has been shown to negatively co‐vary with pain perception in current borderline personality disorder (cBPD). While remission of the disorder (rBPD) is associated with normalized pain perception, it remains unclear whether dissociation proneness is still enhanced in this group and how this feature interacts with pain sensitivity.

Methods

Twenty‐five cBPD patients, 20 rBPD patients and 24 healthy controls (HC) participated in an experiment using the script‐driven imagery approach. We presented a personalized stressful and neutral narrative. After listening to the scripts, dissociation and heat pain thresholds (HPT) were assessed.

Results

Compared to HC, cBPD patients showed enhanced dissociation and exhibited significantly enhanced HPT in the neutral condition, whereas rBPD participants were in between. After listening to the stress script, both clinical groups exhibited enhanced dissociation scores. Current BPD participants responded with significantly higher HPT, whereas rBPD only showed a trend in the same direction. However, both BPD groups showed significantly increased HPT compared to the HC in the stress condition, but did not differ from each other. Dissociation proneness correlated significantly positively with pain hyposensitivity only in cBPD.

Conclusion

Dissociation proneness is enhanced in both BPD groups. This feature is clearly positively related to pain hyposensitivity in cBPD, but not in rBPD. However, the data indicate that stress causes the pain perception in rBPD to drift away from that obtained in HC. These results highlight the volatile state of BPD remission and might have important implications for the care of BPD patients in the remitted stage.

Significance

Both current (cBPD) and remitted borderline personality disorder (rBPD) patients show enhanced proneness to dissociation. This feature is significantly linked with pain hyposensitivity in cBPD in a paradigm that induces stress using a script‐driven imagery approach, whereas this connection cannot be observed in rBPD. However, in the stress compared to the neutral condition, rBPD participants also show pain hyposensitivity compared to healthy controls. This study provides new insights into the pain processing mechanisms of BPD and its remission.

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Issue Information

European Journal of Pain, Volume 24, Issue 7, Page 1213-1214, August 2020.

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Erratum

European Journal of Pain, Volume 24, Issue 7, Page 1419-1419, August 2020.

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Erratum

European Journal of Pain, Volume 24, Issue 7, Page 1420-1420, August 2020.

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A systematic review of cross‐cultural validation of the pain catastrophizing scale

Abstract

Background

Although it has been suggested that the different cultural and social environments between countries contribute to variations in pain catastrophizing (PC), an international comparison of PC in patients with chronic pain has not yet been reported. Prior to undertaking this comparison, a cross‐cultural assessment of the pain catastrophizing scale (PCS) was undertaken to explore the different factor structures among each translated version of the PCS.

Methods

The protocol for this systematic review was prospectively registered on International Prospective Register of Systematic Reviews 2018 (CRD 42018086719). Electronic searches were conducted in the following databases: Ovid/Embase, Ovid/MEDLINE and Ovid/PsycINFO, and then 19 articles (16 language versions) were included in this review. Based on the COSMIN check list, we investigated language translation followed by five domains of cross‐cultural validation: structural validity, internal consistency, test–retest reliability and hypotheses testing for construct validity in each study.

Results

We found that (a) there were inconsistent structural models among each translated version, leading to variant subdomain structures for rumination, magnification and helplessness; (b) all languages versions showed sufficient internal consistency when assessing whole items and (c) the correlation coefficients between pain intensities and total scores of the PCS among each sample of chronic pain varied across the studies.

Conclusions

These results indicate that the total score of the PCS could be compared across each translated version, however, caution is warranted when each subdomain of the PCS is compared between countries.

Significance

Although the pain catastrophizing scale has been translated into approximately 20 languages, methodological quality during their translation process has not been systematically assessed. We found that all languages versions showed sufficient internal consistency when assessing whole items, however, there were inconsistent structural models among each translated version, leading to variant subdomain structures for rumination, magnification and helplessness.

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Intrathecal dexmedetomidine and postoperative pain: A systematic review and meta‐analysis of randomized controlled trials

Abstract

Background and Objective

A systematic review and meta‐analysis of randomized controlled trials (RCTs) was undertaken to evaluate the effect of intrathecal dexmedetomidine (DEX) on the duration of postoperative analgesia, postoperative pain scores and incidences of adverse effects.

Databases and Data Treatment

Database search was performed from inception until January 2019. All RCTs analysing acute postoperative pain characteristics after intrathecal DEX administration in adults undergoing spinal anaesthesia for elective surgery were included. The primary outcome was postoperative analgesic duration, defined as the time to first analgesic request. The secondary outcomes included pain scores at 6, 12 and 24 postoperative hours and rates of hypotension, bradycardia, shivering and postoperative nausea and vomiting.

Results

Twenty‐four studies comprising a total of 1,460 patients were included. Postoperative analgesic duration was prolonged with intrathecal DEX compared to placebo, with a pooled mean difference (MD) of 191.3 min (95% CI 168.8–213.8). Patients who received intrathecal DEX reported lower Visual Analogue Scale scores at 24 postoperative hours compared with those patients receiving placebo, with a MD (95% CI) of −1.05 (−1.89 to −0.20, p  = 0.02). There were no differences in the incidence of adverse effects, except for a lower rate of postoperative shivering in the intrathecal DEX group (pooled relative risk 0.58, 95% CI 0.34–0.98, p  = 0.04).

Conclusions

Compared to placebo, intrathecal DEX prolonged postoperative analgesic duration, reduced 24‐hr pain intensity and reduced the incidence of shivering without an increase in other adverse effects.

Significance

The analgesic role of intrathecal DEX is promising due to its ability to significantly increase postoperative analgesic duration when compared with placebo. Its usage can be considered for patients undergoing surgeries with significant postoperative pain, particularly those intolerant of systemic analgesia. However, the optimal dose for various surgeries as well as its long‐term neurological effects warrants further studies.

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Heterogeneous presentation of caspr2 antibody‐associated peripheral neuropathy – A case series

Abstract

Contactin‐associated protein 2–like (caspr2) antibodies have been discovered recently. Since then a multitude of patients with caspr2 antibodies presenting with different neurological symptoms have been reported. Here, we describe three patients with caspr2 antibodies with different types of pain/no pain in combination with peripheral neuropathy. The first patient, a 33‐year‐old woman, presented with erythromelalgia‐like pain and autonomic symptoms; the second patient, a 58‐year‐old man, with paresthesia and pain while walking together with signs of peripheral motor neuron hyperexcitability in combination with optic neuritis, and the third patient, a 74‐year‐old man, without any pain but with polyneuropathy and encephalopathy. These cases illustrate the spectrum of symptoms in anti‐caspr2 diseases. The pain in such cases can be treated causally.

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Dinosaur retraction, Neanderthal pain and EU budget woe

Nature, Published online: 29 July 2020; doi:10.1038/d41586-020-02204-9

The latest science news, in brief.

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DACC Resting State Functional Connectivity as a Predictor of Pain Symptoms Following Motor Vehicle Crash: A Preliminary Investigation

Motor vehicle crashes (MVCs) are a leading cause of traumatic injuries in the United States – second only to falls – and account for over 20% of all severe injuries that require hospital care.21 While a host of negative outcomes accompany MVCs, chief among these is the experience of severe pain symptoms, which affect up to 80% of MVC survivors immediately after injury.9 In terms of the long-term prognosis of pain outcomes, there is considerable variability. Large-scale and population-based studies demonstrate that anywhere from 12-40% of MVC survivors continue to suffer from pain months after injury.

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Daily briefing: Quantum tunnelling takes time

Nature, Published online: 24 July 2020; doi:10.1038/d41586-020-02229-0

The quantum effect that underlies everything from photosynthesis to nuclear fusion is not instantaneous. Plus, a Neanderthal gene linked to increased pain sensitivity and how ancient DNA is rewriting our long history with infectious disease.

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Efficacy of Extracorporeal Shockwave Therapy on Pain and Function in Myofascial Pain Syndrome of the Trapezius: A Systematic Review and Meta-Analysis

Publication date: August 2020

Source: Archives of Physical Medicine and Rehabilitation, Volume 101, Issue 8

Author(s): Qing Zhang, Chenying Fu, Liyi Huang, Feng Xiong, Lihong Peng, Zejun Liang, Li Chen, Chengqi He, Quan Wei

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Association of Initial Provider Type on Opioid Fills for Individuals With Neck Pain

Publication date: August 2020

Source: Archives of Physical Medicine and Rehabilitation, Volume 101, Issue 8

Author(s): Christopher J. Louis, Carolina-Nicole S. Herrera, Brigid M. Garrity, Christine M. McDonough, Howard Cabral, Robert B. Saper, Lewis E. Kazis

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Family History Influences the Effectiveness of Home Exercise in Older People With Chronic Low Back Pain: A Secondary Analysis of a Randomized Controlled Trial

Publication date: August 2020

Source: Archives of Physical Medicine and Rehabilitation, Volume 101, Issue 8

Author(s): Joshua R. Zadro, Debra Shirley, Tom I.L. Nilsen, Paul J. Mork, Paulo H. Ferreira

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Effects of an Individualized Comprehensive Rehabilitation Program on Impaired Postural Control in Women With Chronic Pelvic Pain: A Randomized Controlled Trial

Publication date: August 2020

Source: Archives of Physical Medicine and Rehabilitation, Volume 101, Issue 8

Author(s): Janet Rodríguez-Torres, Laura López-López, Irene Cabrera-Martos, Esther Prados-Román, María Granados-Santiago, Marie C. Valenza

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Aquatic Cycling Improves Knee Pain and Physical Functioning in Patients With Knee Osteoarthritis: A Randomized Controlled Trial

Publication date: August 2020

Source: Archives of Physical Medicine and Rehabilitation, Volume 101, Issue 8

Author(s): Stefanie Rewald, A.F. Ton Lenssen, Pieter J. Emans, Rob A. de Bie, Gerard van Breukelen, Ilse Mesters

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A gene helps women in labour to skip the painkillers

Nature, Published online: 23 July 2020; doi:10.1038/d41586-020-02201-y

Uncommon genetic variant dampens the response of uterine neurons that sense pain.

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Neanderthal gene linked to increased pain sensitivity

Nature, Published online: 23 July 2020; doi:10.1038/d41586-020-02202-x

People who have inherited nerve-altering mutations from the ancient hominins tend to experience more pain.

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Characterization of pain syndromes in patients with neuromyelitis optica

Abstract

Background

Pain is common and refractory in spinal cord injury (SCI). Currently, most studies evaluated pain in male‐predominant traumatic‐SCI. Also, concomitant secondary pain syndromes and its temporal evolution were seldom reported.

Methods

We aimed to prospectively describe the main and secondary pain and its associated factors in inflammatory‐SCI evaluating neuromyelitis optica (NMO) patients. In‐remission NMO patients underwent neurological, imaging and autoantibody evaluations. Questionnaires detailing main and secondary pains, functional state, mood, catastrophizing, quality of life (QoL) and “non‐motor symptoms" were used at two time points.

Results

Pain was present in 53 (73.6%) of the 72 patients included. At‐level neuropathic pain was the most common main pain syndrome, affecting 32 subjects (60.4% of those with pain). Over 70% (n  = 38) of this cohort reported two pain syndromes. Those without pain were significantly younger (26.1 ± 12.7 y.o. in those without pain and 40.1 ± 12.5, 37.2 ± 11.4 y.o. in those whose main pain was neuropathic and non‐neuropathic, respectively, p  = .001), and no differences in the inflammatory status were observed between groups. On follow‐up, one‐fifth (n  = 11) had a different main pain syndrome from the first visit. Pain impacted QoL as much as disability and motor strength.

Conclusion

Pain is a prevalent and disabling non‐motor symptom in NMO‐SCI. Most patients experience more than one pain syndrome which can change in time even in the absence of clinical relapse. Age of the inflammatory‐SCI was a major determinant of pain. Acknowledging temporal changes and multiplicity of pain syndromes in NMO‐SCI may give insights into more precise designs of clinical trials and general management of pain in SCI.

Significance

In this longitudinal study with NMO‐related SCI, pain affected almost three‐quarters of patients with NMO. Over 70% have more than one pain syndrome and at‐level neuropathic pain is the most common type of pain syndrome. Patients without pain were significantly younger but had the same burden of inflammatory lesions than those with pain. During follow‐up, up to one fifth of patients presented with changes in the main pain syndromes, which can occur even in the absence of clinical activity of the inflammatory disease. In this cohort, Pain affected quality of life as much as disability or motor strength.

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En pointe: dancers report their pain less variably than do controls

The perception of pain derives from complex processes modulated at both spinal and super-spinal levels of the central nervous system. Its subjective nature and lack of a gold standard for objective markers impede accurate assessment and diagnosis, communication between patients and healthcare providers, and clinical care. Identifying factors affecting the variability of pain, and how the latter could be modulated, is of importance.

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Placebos in chronic pain: evidence, theory, ethics, and use in clinical practice

ABSTRACTDespite their ubiquitous presence, placebos and placebo effects retain an ambiguous and unsettling presence in biomedicine. Specifically focused on chronic pain, this review examines the...

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Distraction from pain: The role of selective attention and pain catastrophizing

Abstract

Background

Previous research has demonstrated the efficacy of cognitive engagement in reducing concurrent pain. However, little is known about the role of individual differences in inhibitory control abilities and negative pain‐related cognitions in modulating the magnitude of this type of distraction from pain.

Methods

In a pain distraction paradigm, 41 participants completed a working memory task with both a demanding high load condition (2‐back) and an easy low load condition (0‐back), while receiving warm or painful thermal stimuli to their left forearm. To control for individual differences in sensitivity to pain and perceived task difficulty, nociceptive stimulus intensity and task speed were individually calibrated. Additionally, participants completed a set of cognitive inhibition tasks (flanker, go/nogo, Stroop) and questionnaires about negative pain‐related cognitions (fear of pain, pain catastrophizing) prior to the distraction paradigm.

Results

As expected, engaging in the high load condition significantly reduced perceived intensity and unpleasantness of nociceptive stimuli, compared to the low load condition. The size of the distraction effect correlated significantly with better cognitive inhibition and selective attention abilities, as measured by the flanker task. A moderation analysis revealed a significant interaction between pain catastrophizing and performance in the flanker task in predicting the distraction effect size: Participants who performed well on the flanker task showed more pain reduction, but only when they were average to high pain catastrophizers.

Conclusions

Selective attention abilities and pain catastrophizing seem to be important factors in explaining individual differences in the size of the analgesic response to a distractive task.

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Psychometric Properties of the Multidimensional Impression of Change in a Cohort of Pediatric Pain Patients

Publication date: Available online 16 July 2020

Source: Archives of Physical Medicine and Rehabilitation

Author(s): Christine M. Gagnon, Paul Scholten, Diane Amstutz, Lauren Henderson, Gadi Revivo

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Sick leave due to back pain, common mental disorders, and disability pension: Common genetic liability

Abstract

Background

Back pain and common mental disorders are often comorbid and known risk factors for future disability pension. However, the reason for the covariation is not known. The aim was to investigate the common genetic and environmental influences on the covariation between sick leave due to back pain, sick leave due to common mental disorders and disability pension.

Methods

Register data from the Swedish Social Insurance Agency on sick leave due to back pain, common mental disorders and disability pension between 2005 and 2018, in a population‐based sample of 56 686 working age twins was used to construct biometric twin models to calculate if the covariation between the traits were due to Additive (A) or Dominant (D) genetic factors, Common environmental factors (C) or unique Environmental factors (E), for women and men.

Results

The phenotypic correlations ranged between 0.17 and 0.25. A common factor common pathway AE model fitted best for both women and men. The latent underlying common factor, that explained the covariation was mostly explained by genetic factors (87% for women and 90% for men). Each trait was also influenced by its own unique genetic and unique environment factors. A higher heritability was found for disability pension than for sick leave.

Conclusions

The covariation between sick leave due to back pain and common mental disorders, and disability pension were mostly explained by common genetic factors, while the unique variation in each trait was influenced by both genetic and environmental factors not shared within the twin pairs.

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[Clinical Picture] Androgen-receptor-positive hepatocellular carcinoma in a transgender teenager taking exogenous testosterone

A 17-year-old transgender man attended our hospital with a 2-month history of intermittent right-sided abdominal pain, nausea, early satiety, profuse night sweats, and 14 kg weight loss.

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Acceptance and Commitment Therapy for Primary Headache Sufferers: A Randomized Controlled Trial of Efficacy

Despite the efficacy of behavioral therapies (e.g., relaxation, biofeedback, cognitive-behavioral stress-management) and pharmacotherapy for headache management, only about half of patients present benefits that decline within several weeks after treatment [25]. These treatments focus on teaching patients to prevent headache mostly via avoidance of external and internal triggers (things or situations associated with headache emergence: e.g., foods, noises, lights, stress). Though these lead to increased awareness of risk factors and triggers associated with headaches [44], they contribute to the propagation that triggers should be avoided for headache alleviation to occur.

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Matt Morgan: Patients’ notes should be addressed to them

Working in intensive care, I’m spared the pain (or joy) of writing clinic letters. In fact, most of the writing I do in my work is communication between healthcare professionals rather than directly...

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Opioid use trajectories after thoracic surgery among veterans in the United States

Abstract

Background

Opioid use has increased to epidemic levels over the past decade within the United States, particularly among vulnerable populations. This retrospective study aimed to evaluate rates of prolonged opioid use in the Veteran population after thoracic surgery and identify specific risk clusters.

Methods

Veterans Administration data on patients who underwent thoracic surgery between January 1, 2006 and September 30, 2015 included preoperative opioid use information for stratification of patients to preoperative chronic opioid use (PCOU; n_PCOU = 16,612) versus patients without preoperative chronic opioid use (WPCOU; n_WPCOU = 2,328). A Poisson regression model and prior literature were used to identify variables for use in a Latent Class Analysis (LCA) model for each stratum. Three‐cluster models were selected, and identified as ‘low‐’, ‘intermediate‐’ and ‘high‐’ risk groups.

Results

Cluster interpretations included: (a) Low risk: no psychiatric diagnoses, preoperative medication use, or preoperative chronic pain, (b) Intermediate risk: no psychiatric diagnoses, but had preoperative medication use and some preoperative chronic pain and (c) High risk: psychiatric diagnoses, preoperative medication use and preoperative chronic pain. For the PCOU stratum, rates of prolonged opioid use 1 year after surgery were as follows: 46.3%, 61.9% and 66.0%. For the WPCOU stratum, the observed rates were 4.7%, 8.3% and 9.2%.

Conclusions

Prolonged opioid use trajectories obviously differ by PCOU status, as well as preoperative psychosocial diagnoses, medication use and chronic pain. This is a first step in population‐level research to curb the rate of prolonged opioid use in Veterans following thoracic surgery.

Significance

This article presents population‐level chronic opioid use trajectories after thoracic surgery, using latent class structures. Demographics, preoperative psychological diagnoses, medication usage and chronic pain variables were utilized to identify population‐level clusters. The cluster identified as highest risk had preoperative chronic opioid use, psychological diagnoses, other medication prescriptions and chronic pain.

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Predictors of Mucosal and Muscle Pain in Vulvodynia: A Cross-Sectional Analysis from the National Vulvodynia Registry

Provoked vestibulodynia (PVD) is defined as pain of at least three months’ duration localized to the vulvar vestibule and provoked by touch and/or vaginal penetration. The etiology of PVD is unknown. Its prevalence is estimated at 8.3% of adult women.33 PVD is associated with significant psychosocial distress, impaired sexual functioning and diminished quality of life.4 Currently, no large randomized placebo-controlled trials support an effective pharmacologic treatment for this disorder.24 Few non-controlled studies support interventions such as pelvic floor physical therapy, cognitive behavioral therapy, and, for selected patients, vestibulectomy.

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Trajectories of post‐surgical pain in infants admitted to neonatal intensive care

Abstract

Background

The aim of this study was 1) to statistically identify distinct trajectories of pain following surgery in infants less than six months of age, and 2) to compare these trajectories to descriptions of chronic pain in infants in the neonatal intensive care unit (NICU).

Methods

This was a retrospective medical record review of infants admitted to a NICU between 2008 and 2018 following surgery. All infants who underwent one major procedure to the abdomen or thorax and returned to the NICU following surgery were included. Pain was assessed regularly using a validated pain assessment tool. Group based trajectory analysis was used to determine the trajectory of recovery from pain following surgery.

Results

A total of 726 infants were included in the study. A two‐group trajectory model, defined as typical and atypical pain trajectories, was selected. The typical group (n=467) consisted of infants who had significantly fewer days (1.5±2.3 versus 5.3±5.5, p < 0.001) and recorded instances of pain (2.0±3.4 versus 9.7±10.5, p < 0.001) compared to infants in the atypical group (n=259). The incidence of iatrogenic neonatal abstinence syndrome was greater in the atypical than the typical group (11% versus 5%, p =0.001).

Conclusions

This study has revealed two distinct pain trajectories in infants after surgery. While recovery from pain occurs within days in the typical group, the atypical group demonstrates pain for a significantly longer period, often weeks and months following surgery. This latter group adheres closely to current descriptions of chronic pain in infants.

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Sustained perturbation in functional connectivity induced by cold pain

Abstract

Background

Functional connectivity (FC) perturbations have been reported in multiple chronic pain phenotypes, but the nature of reported changes varies between cohorts and may relate to the consequences of living with chronic‐pain related comorbidities, such as anxiety, and depression. Healthy volunteer studies provide opportunities to study the effects of tonic noxious stimulation independently of these sequelae. Connectivity changes in task negative and positive networks, for example, the default mode and salience networks (DMN/SN), respectively, have been described, but how these and other connectivity networks, for example, those governing descending pain control are affected by the presence of tonic, noxious stimulation in healthy, pain‐free individuals remains unknown.

Method

In 20 healthy volunteers, we assessed FC prior to, during, and following tonic cold painful stimulation in the ventromedial prefrontal cortex (vmPFC), rostral anterior insula (rAI), subgenual anterior cingulate cortex (ACC) and periaqueductal grey (PAG). We also recorded subjectively reported pain using a computerised visual analogue scale. Results: We saw DMN FC changes during painful stimulation and that inter‐network connectivity between the rAI with the vmPFC increased during pain, whereas PAG‐precuneus FC decreased. Pain‐induced FC alterations persisted following noxious stimulation. FC changes related to the magnitude of individuals’ subjectively reported pain.

Conclusions

We demonstrate FC changes during and following tonic cold‐pain in healthy participants. Similarities between our findings and reports of patients with chronic pain suggest that some FC changes observed in these patients may relate to the presence of an ongoing afferent nociceptive drive.

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Movement, posture and low back pain. How do they relate? A replicated single‐case design in 12 people with persistent, disabling low back pain

Abstract

Background

Movement and posture are commonly believed to relate to non‐specific low back pain (NSLBP). While people with NSLBP appear to move and posture themselves differently from those without NSLBP, changes in movement and posture infrequently relate to improvements in NSLBP when analysed at a group‐level. Additionally, little is known about how movement or posture change when clinical outcome improves.

Methods

Within‐person relationships were investigated using a replicated, repeated measures, single‐case design in 12 people with persistent, disabling NSLBP. Individually relevant movement and posture were captured using wearable sensors on up to 20 occasions over a 22‐week period (5‐week baseline, 12‐week physiotherapy‐led intervention, 5‐week follow‐up), while pain and activity limitation were collected concomitantly. A series of cross‐correlation analyses estimated the presence, strength, and direction of relationships.

Results

Many participants (n=10/12) had strong (e.g. r=0.91, p=<0.001) relationships between changes in movement or posture and changes in pain and activity limitation, while some showed no strong association. Where relationships were observed, clinical improvement predominantly (93% or 57/61 relationships) related to increased spinal movement range and velocity during forward bending and lifting, reduced lumbar muscle EMG activity at maximum voluntary flexion, and increased posterior‐pelvic‐tilt during sitting and standing.

Conclusion

Within‐person changes to individually relevant movement and posture appear to often relate to clinical outcome, but not always. When changes were related, movement and posture appear to return towards being ‘less protective’, however causal directions remain unknown. Important activities, movements, and postural parameters varied across the participants, highlighting the potential importance of individualised management.

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Spinal manipulation for the management of cervicogenic headache: a systematic review and meta‐analysis

Abstract

Background

Spinal manipulative therapy (SMT) is frequently used to manage cervicogenic headache (CGHA). No meta‐analysis has investigated the effectiveness of SMT exclusively for CGHA.

Objective

Evaluate the effectiveness of SMT for CGHA.

Databases and Data Treatment

Five databases identified randomized controlled trials comparing SMT with other manual therapies. The PEDro scale assessed the risk‐of‐bias. Pain and disability data were extracted and converted to a common scale. A random effects model was used for several follow‐up periods. GRADE described the quality of evidence.

Results

Seven trials were eligible. At short‐term follow‐up, there was a significant, small effect favouring SMT for pain intensity (mean difference [MD] ‐10.88 [95% CI, ‐17.94, ‐3.82]) and small effects for pain frequency (standardized mean difference [SMD] ‐0.35 [95%CI, ‐0.66, ‐0.04]). There was no effect for pain duration (SMD ‐0.08 [95%CI, ‐0.47, 0.32]). There was a significant, small effect favoring SMT for disability (MD ‐13.31 [95% CI, ‐18.07, ‐8.56]). At intermediate follow‐up, there was no significant effects for pain intensity (MD ‐9.77 [‐24.21 to 4.68]) and a significant, small effect favoring SMT for pain frequency (SMD ‐0.32 [‐0.63 to ‐0.00]). At long‐term follow‐up, there was no significant effects for pain intensity (MD ‐0.76 [‐5.89 to 4.37]) and for pain frequency (SMD ‐0.37 [‐0.84 to 0.10]).

Conclusion

For CGHA, SMT provides small, superior short‐term benefits for pain intensity, frequency and disability but not pain duration, however, high‐quality evidence in this field is lacking. The long‐term impact is not significant.

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Systemic inflammatory markers in neck pain: a systematic review with meta‐analysis

Abstract

Background and Objective

Mechanisms underpinning symptoms in non‐traumatic neck pain (NTNP) and whiplash‐associated disorder (WAD) are not comprehensively understood. There is emerging evidence of systemic inflammation in musculoskeletal pain conditions, including neck and back pain. The aim of this systematic review was to determine if raised blood inflammatory markers are associated with neck pain.

Databases and Data Treatment

MEDLINE, EMBASE, Cochrane Library, CINAHL and Web of Science databases were searched. Two independent reviewers identified studies for inclusion and extracted data. Meta‐analysis was performed by random‐effects model to calculate standard mean differences (SMDs). Risk of bias of individual studies was assessed using the Newcastle‐Ottawa Scale. Overall quality of evidence from meta‐analysis was assessed by Grades of Recommendation, Assessment, Development, and Evaluation approach.

Results

In total, ten studies were included comprising 706 participants. Three studies provided data for acute WAD, two for chronic WAD, four for chronic NTNP, and one for chronic mixed WAD and NTNP. Meta‐analysis indicated increased interleukin 1β (SMD: 0.84 [95% CI 0.24, 1.44], p = 0.01, I² = 59%) and tumour necrosis factor α (SMD: 0.59 [0.09, 1.09], p = 0.02, I² = 45%) in chronic neck pain compared to controls, but no increase in monocyte chemoattractant protein‐1. Some inflammatory markers were associated with clinical variables (including pain intensity and disability). Quality of evidence was mostly low due to small samples and high heterogeneity.

Conclusions

Findings imply that raised blood inflammatory markers are present in chronic neck pain, which may represent an ongoing inflammatory process in this population.

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Parental (non‐)pain attending verbalizations moderate the relationship between child attention and memory bias for pain

Abstract

Background

Children’s negatively biased pain‐related memories (i.e., recalling pain as being more intense or fearful than initially reported) have been recognized as a key factor in explaining child pain development. While mechanisms underlying children’s pain memory development remain poorly understood, attention biases and parent language have been implicated in conceptual models. The current study examined the association between child pain‐related attention and memory biases and the moderating role of parental pain and non‐pain attending verbalizations.

Methods

Participants were 51 school children and one of their parents. Probability of initial fixation and gaze duration to pain were assessed using eye tracking methodology. Children performed a cold pressor task (CPT) and reported on experienced pain intensity and pain‐related fear. A 3‐minute parent‐child interaction upon CPT completion allowed measurement of parental pain and non‐pain attending verbalizations. Children’s pain‐related memories were elicited two weeks later.

Results

Findings indicated that the relationship between maintained attention to pain and fear memory bias was moderated by parental non‐pain attending verbalizations such that higher gaze duration bias was positively associated with fear memory bias but only among children whose parents demonstrated low levels of non‐pain attending verbalizations. The opposite pattern was observed for children whose parents showed high levels of non‐pain attending verbalizations. No such effects were observed for child initial attention bias to pain, memory bias for pain and parental pain attending verbalizations.

Conclusions

Findings highlight the importance of parental and child pain‐related variables as well as their interaction in understanding negatively biased pain‐related memories.

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Transcranial direct current stimulation and visual illusion effect according to sensory phenotypes in patients with spinal cord injury and neuropathic pain

Neuropathic pain (NP) is a common chronic complication present in around 45% of spinal cord injury (SCI) patients7,38. SCI patients with NP present a variety of pain-related sensory symptoms determined by multiple mechanisms46. Some patients may experience spontaneous pain like burning, dysesthesia and electric shocks, whereas in others the affected body area is numb6. These sensory symptoms sometimes coexist with an increased cutaneous sensibility to mechanical stimuli. All these symptoms perhaps contribute moderate to severe constant pain in the majority of affected subjects, which has a major negative impact on sleep, mood, and quality of life1,15,35.

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Characterising pain flares in adolescent inflammatory and non‐inflammatory musculoskeletal disorders: A qualitative study using an interpretative phenomenological approach

Abstract

Background

Adolescents with musculoskeletal disorders experience acute exacerbations in pain, colloquially called ‘pain flares’ in adult literature. This study aimed to explore adolescents’ lived experience of pain flares, including what pain flares are, why they occur, how they are managed and what lasting effects they have on adolescents.

Methods

A sample of 10 adolescents diagnosed with juvenile idiopathic arthritis or chronic idiopathic pain syndrome were recruited from a tertiary hospital in the UK. Data were collected using semi‐structured interviews and visual aids, and analysed using interpretative phenomenological analysis.

Results

Four broad themes were identified which describe as a journey of change from participants: 1) daily life with pain, where adolescents report a level of pain that is ‘normal’ for them which they can tolerate and continue their daily routines around; 2) pre‐flare period, where adolescents begin to notice pain increasing beyond normal levels and employ preventative strategies to reduce the risk of symptoms developing into a flare; 3) flare period, where adolescents describe the symptoms, frequency, duration, impact and their attempts to manage flares; to their 4) post‐flare period, where symptoms begin to return to baseline levels and adolescents take actions to regain the level of normality experienced in daily life.

Conclusion

This study has identified a number of components of the pain flare experience. Findings show that pain flares are more than an increase in pain intensity; they are multi‐layered and require other features to change. These findings help to differentiate pain flares from typical fluctuations in pain.

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Second Brazilian museum fire in two years reignites calls for reform

Nature, Published online: 01 July 2020; doi:10.1038/d41586-020-01990-6

A recent fire at a natural history museum in Minas Gerais is forcing some researchers to relive the pain of losing priceless specimens and artefacts.

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Assessing thermal sensitivity using transient heat and cold stimuli combined with a Bayesian adaptive method in a clinical setting: a proof of concept study

Abstract

Background

Quantitative sensory testing of thermal detection abilities is used as a clinical tool to assess the function of pain pathways. The most common procedure to assess thermal sensitivity, the “method of limits”, provides a quick but rough estimate of detection thresholds. Here, we investigate the potential of evaluating not only the threshold but also the slope of the psychometric functions for cold and warm detection.

Method

A convenience sample of 15 patients with diabetes mellitus (DM) and 15 age‐matched healthy controls (HC) was tested. Thirty brief (100 ms) stimuli of each modality were applied to the volar wrist and foot dorsum. Cold and warm stimuli were delivered with a Peltier thermode and a temperature‐controlled CO₂ laser, respectively. Stimulus intensities were dynamically selected using an adaptive Bayesian algorithm (psi method) maximizing information gain for threshold and slope estimation. ROC analyses were used to assess the ability of slopes, thresholds and the combination of both to discriminate between groups.

Results

Assessment of the slope and threshold of the psychometric function for thermal detection took about 10 minutes. The ability to detect warmth was not reduced in DM patients as compared to HC. Cold detection performance assessed using slope or threshold parameters separated DM from HC with good discriminative power. Discrimination was further increased when both parameters were used together (93% sensitivity and 87% specificity), indicating that they provide complementary information on patient status.

Conclusion

The psi method may be an interesting alternative to the classical method of limits for thermal QST.

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Emotions Matter: The Role of Emotional Approach Coping in Chronic Pain

Abstract

Background

Emotional approach coping (EAC) is a potentially adaptive emotion‐focused coping style that involves understanding or processing one’s emotions and expressing them appropriately. Although EAC has been studied in various populations, little is known about this construct among people with chronic pain, including potential mediators such as negative affect, which might link EAC to pain‐related variables, and moderators of these relationships.

Methods

Participants (N = 670; 76% women; 30% older adults—age 60 or over) with chronic pain completed online the Emotional Approach Coping Scale and measures of pain severity, pain interference, and negative affect. Analyses correlated EAC to pain severity and interference and tested whether gender and age group (older adults vs. young/middle‐age adults) moderated the mediated relationships of EAC with pain‐related variables through negative affect.

Results

Findings reveal that higher EAC was associated with lower pain intensity through lower negative affect in the young/middle‐age portion of the sample, but not older adults. Also, higher EAC was associated with lower pain interference through lower negative affect among women in the sample, but not men. The associations of EAC to pain intensity and interference are small in magnitude, however, and should be considered preliminary.

Conclusion

EAC is associated with lower pain intensity in young/middle‐age adults and lower pain interference in women, and lower negative affect mediates these relationships. These results suggest the potential value of assessing and bolstering emotional approach coping processes in some people with chronic pain.

from Wiley: European Journal of Pain: Table of Contents https://ift.tt/2NM7hms
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