Dexmedetomidine versus Clonidine Adjuvants to Levobupivacaine for Ultrasound‐Guided Transversus Abdominis Plane Block in Pediatric Laparoscopic Orchiopexy: Randomized, Double‐Blind Study

Abstract

Background

Laparoscopic surgeries are associated with less postoperative pain and adverse events compared to open procedures. But, it still reduces quality of life in children. Transversus abdominis plane (TAP) block is used to reduce pain. We hypothesized that dexmedetomidine or clonidine could improve the analgesic profile of levobupivacaine to the same extent during TAP block in children.

Methods

Ninety children were randomly allocated in a randomized double‐blind trial to receive bilateral TAP block with levobupivacaine plus normal saline (Group‐B, n=30), or dexmedetomidine (Group‐D, n=30), or clonidine (Group‐C, n=30). Primary outcome was the modified CHEOPS score. Secondary outcomes included time to initial analgesic request, number of analgesic claims, total analgesic consumption, parents' satisfaction, sedation score, and complications.

Results

Children of group‐D showed reduced pain scores compared to other groups. They represented the longest period of analgesia (565.00 ± 71.5 minutes) with p‐value < 0.001, and fewer patients required two doses of analgesia during the first postoperative day. The cumulative amount of backup analgesia was significantly different between these groups (p‐value = 0.026). Higher parents’ satisfaction scores were recorded in groups D and C compared to group‐B. Sedation among the study groups revealed significant differences (p‐value = 0.035), but no severe complications were recorded.

Conclusions

Adding dexmedetomidine to levobupivacaine can extend the time of analgesia, reduce the use of postoperative backup analgesics with minimal sedation effects when used in TAP block in pediatrics undergoing laparoscopic orchiopexy. Clonidine can be used as an alternative adjuvant to local anesthetics with good postoperative analgesic profiles.

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Thomas Kenneth Hardy

bmj;371/oct30_9/m4173/FAF1faIn 1962 Thomas Kenneth Hardy (“Ken”) was appointed consultant anaesthetist at Caernarfon and Anglesey General Hospital in Bangor, north Wales. With an interest in pain...

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Digital manikins to self‐report pain on a smartphone: a systematic review of mobile apps

Abstract

Background

Chronic pain is the leading cause of disability. Improving our understanding of pain occurrence and treatment effectiveness requires robust methods to measure pain at scale. Smartphone‐based pain manikins are human‐shaped figures to self‐report location‐specific aspects of pain on people’s personal mobile devices.

Methods

We searched the main app stores to explore the current state of smartphone‐based pain manikins and to formulate recommendations to guide their development in the future.

Results

The search yielded 3,938 apps. Twenty‐eight incorporated a pain manikin and were included in the analysis. For all apps, it was unclear whether they had been tested and had end‐user involvement in the development. Pain intensity and quality could be recorded in 28 and 13 apps, respectively, but this was location‐specific in only 11 and four. Most manikins had two or more views (n=21) and enabled users to shade or select body areas to record pain location (n=17). Seven apps allowed personalising the manikin appearance. Twelve apps calculated at least one metric to summarise manikin reports quantitatively. Twenty‐two apps had an archive of historical manikin reports; only eight offered feedback summarising manikin reports over time.

Conclusions

Several publically available apps incorporated a manikin for pain reporting, but only few enabled recording of location‐specific pain aspects, calculating manikin‐derived quantitative scores, or generating summary feedback. For smartphone‐based manikins to become adopted more widely, future developments should harness manikins’ digital nature and include robust validation studies. Involving end users in the development may increase manikins’ acceptability as a tool to self‐report pain.

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Parallel ascending spinal pathways for affective touch and pain

Nature, Published online: 28 October 2020; doi:10.1038/s41586-020-2860-1

Two populations of neurons with distinct anatomy and receptor expression that convey information from the spinal cord to the brain have different functional properties with respect to touch and pain.

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Thigh pain after a stroke

This axial view of an abdominal and pelvic computed tomogram shows warfarin induced left psoas (black arrow) and retroperitoneal (white arrow) haematomas (fig 1).bmj;371/oct28_2/m3697/F1F1f1Fig 1The...

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Identifying participants with knee osteoarthritis likely to benefit from physical therapy education and exercise: a hypothesis‐generating study

Abstract

Background

The purpose of this investigation was to undertake a hypothesis‐generating study to identify candidate variables that characterize people with knee osteoarthritis who are most likely to experience a positive response to exercise.

Methods

One hundred fifty participants with knee osteoarthritis participated in this observational, longitudinal study. All participants received a standard exercise intervention that consisted of 20‐minute sessions two to three times a week for three months. The classification and regression tree methodology (CART) was used to develop prediction of positive clinical outcome. Positive pain and disability outcomes (dependent variables) were defined as an improvement in pain intensity by >50% or an improvement of five or more on the Oxford knee score, respectively. The predictor variables considered included age, sex, body mass index, knee osteoarthritis severity (Kellgren/Lawrence grade), pain duration, use of medication, range of knee motion, pain catastrophising, self‐efficacy and knee self‐perception.

Results

Fifty‐five participants (36.6%) were classified as responders for pain intensity and 36.6% were classified as responders for disability. The CART model identified impairments in knee self‐perception and knee osteoarthritis severity as the discriminators for pain intensity reduction following exercise. No variables predicted reduction of disability level following exercise.

Conclusions

Such findings suggest that both body perception and osteoarthritis severity may play a role in treatment outcome with exercise. It also raises the possibility that those with higher levels of disrupted body perception may need additional treatment targeted at restoring body perception prior to undertaking exercise.

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Prior pain exposure and mere possession of a placebo analgesic predict placebo analgesia: Findings from a randomised, double-blinded, controlled trial

Placebo effects occur when an inert substance/treatment procedure induces beneficial psychological/physical change60,90. A significant amount of research investigating the placebo effect is in the realm of pain and analgesia. These researches provided evidence of placebo analgesic response18,75,97, and the magnitude of placebo analgesia varied across studies19,94,96. Researchers had identified several key variables that modulate the placebo responses. For example, researchers have surmised that positive expectancies, introduced through various strategies such as verbal suggestion4,78,96, conditioning67,80 and social observation,22 contributed to placebo analgesia.

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An Environmental Scan to Identify Current Chronic Pain Treatment Practices for Persons with Traumatic Brain Injury

Publication date: November 2020

Source: Archives of Physical Medicine and Rehabilitation, Volume 101, Issue 11

Author(s): Bridget Cotner, Deveney Ching, Risa Nakase-Richardson, Jennifer Murphy, Aaron Martin, S. Curtis Takagishi, Georgia Kane, Steven Scott, Jeanne Hoffman

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Association Between Life Satisfaction and Pain Severity in Veterans with Spinal Cord Injuries

Publication date: November 2020

Source: Archives of Physical Medicine and Rehabilitation, Volume 101, Issue 11

Author(s): Ana Lopez, Daniella Lopez Palacios, Alan Quintana, Douglas Gibson

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III. Detecting treatment effects in clinical trials with different indices of pain intensity derived from ecological momentary assessment

Pain intensity is the primary outcome in most clinical trials of pain disorders.14 Although a substantial body of research has been devoted to determining reliable and valid methods of self-reported pain assessment,25 an important question is whether and how the information obtained from pain intensity measures could be improved to enhance detection of treatment effects.23,24,47,48,53 The overall amount of pain (typically conceptualized as the average pain level over a day or week) has served as the most common pain intensity outcome in many clinical trials.

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II. Indices of pain intensity derived from ecological momentary assessments and their relationships with patient functioning: an individual patient data meta-analysis

Pain intensity is one of the core outcome measures in chronic pain research and practice. Even though the label “chronic pain” carries a notion of constancy, pain experiences in everyday life are not static, but rather dynamically changing within days and across days, even in patients with chronic pain9,31,52. Often the primary outcome variable in clinical settings has been the average of an individual's pain intensity over a specified period of time (e.g., the average pain over the course of one week).

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Conduction velocity of the cold spinal pathway in healthy humans

Abstract

Objectives

We aimed to investigate the conduction velocity of the cold spinal pathway in healthy humans.

Methods

Using a cold stimulator consisting of micro‐Peltier elements that was able to produce steep cooling ramps up to −300°C/s, we recorded cold‐evoked potentials after stimulation of the dorsal midline at C5, T2, T6 and T10 vertebral levels and calculated the conduction velocity of the cold spinal pathway. In all participants, we used laser stimulation to deliver painful heat (Aδ‐fibres–mediated) and warm (C‐fibres–mediated) stimuli to the same sites in order to compare the conduction velocity of the cold spinal pathway with that of the nociceptive and warm spinal pathways.

Results

Cold stimulation evoked large‐amplitude vertex potentials from all stimulation sites. The mean conduction velocity of the cold spinal pathway was 12.0 m/s, which did not differ from that of the nociceptive spinal pathway (10.5 m/s). The mean conduction velocity of the warm spinal pathway was 2.0 m/s.

Discussion

This study provides previously unreported findings regarding cold spinal pathway conduction velocity in humans that may be useful in the assessment of spinal cord lesions as well as in intraoperative monitoring during spinal surgery.

Significance

This neurophysiological study provides previously unreported findings on cold spinal pathway conduction velocity in healthy humans. Cold‐evoked potentials may represent an alternative to laser‐evoked potential recording, useful to assess spinothalamic tract in patients with spinal cord lesions and monitor patients during spinal surgery.

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N‐docosahexaenoyl ethanolamine (synaptamide) has antinociceptive effects in male mice

Abstract

Background

N‐docosahexaenoyl ethanolamine (DHEA; also known as synaptamide) binds to both the cannabinoid‐1 and 2 (CB1 and CB2) cannabinoid receptors and has anti‐inflammatory properties in vitro. However, the in vivo effects of DHEA remain unknown. Therefore, this study was designed to understand the effects of DHEA in models of pain and inflammation in mice.

Methods

The intraplantar formaldehyde assay, hot water tail withdrawal assay and hotplate model were used to assess the antinociceptive properties of DHEA in mice. The mechanism of action was studied by antagonising the cannabinoid receptors, transient receptor potential vanilloid 1 (TRPV1) ion channel, peroxisome proliferator‐activated receptors (PPARs) and G‐protein receptor 55 (GPR55).

Results

N‐docosahexaenoyl ethanolamine (2–10 mg/kg) reduced the levels of nociceptive and inflammatory pain‐related behaviour over 60 min in the intraplantar formaldehyde assay via both intraperitoneal and local intraplantar administration. The area under the curve analysis showed the overall antinociceptive effects of DHEA (10 mg/kg) were not modulated by pre‐treatment with antagonists for the cannabinoid receptors, TRPV1ion channel, PPARα, PPARγ or GPR55. However, the time‐course analysis showed that within the early inflammatory phase, antagonism of the CB2 receptor, PPARα and PPARγ led to a partial reversal of the antinociceptive effects of DHEA. In the hot water tail withdrawal and hotplate models of thermal nociception, DHEA (2–10 mg/kg) did not have any antinociceptive effects.

Conclusions

N‐docosahexaenoyl ethanolamine reduced the level of formaldehyde‐induced nociceptive and inflammatory pain‐related behaviour; however, was not active in thermal nociceptive models. This study highlights the potential of DHEA for the treatment of acute inflammatory pain.

Significance

This study shows that both intraperitoneal and intraplantar administration of DHEA reduces the level of formaldehyde‐induced nociceptive and inflammatory pain.

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Mothers’ appraisals of injustice in the context of their child’s chronic pain: An interpretative phenomenological analysis

Abstract

Background

In line with research highlighting the role of observer appraisals in understanding individuals’ pain experience, recent work has demonstrated the effects of parental child‐ and self‐oriented injustice appraisals on child pain‐related outcomes. However, research on parental injustice appraisals is in its infancy and lacks a valid and context‐specific operationalization of what parental injustice appraisals of child pain precisely entail. The current study presents an in‐depth qualitative analysis of parental child‐ and self‐oriented appraisals of injustice in the context of their child's chronic pain.

Methods

Twenty‐one mothers of children living with chronic pain participated in one of five focus group interviews conducted in Ghent (Belgium), Glasgow (Scotland) and Indianapolis (USA).

Results

The interviews were subjected to interpretative phenomenological analysis, which revealed three key justice‐related themes, labelled ‘You shouldn't be in this much pain’, ‘The problem's probably with the mother’ and ‘At least it's not cancer’. Maternal injustice appraisals focused mainly on the child rather than the self and reflected various perceived barriers to their efforts to provide quality of life for their child. A fourth theme labelled ‘Not everybody gets a healthy child’ reflected maternal strategies to effectively cope with the child's condition and the associated appraisals of injustice.

Conclusions

The current findings attest to the relevance of (child‐ and self‐oriented) injustice in the parental experience of caring for a child with chronic pain and provides insight into the specific content and scope of these appraisals. As such, this study provides valuable insights to further research in this area.

Significance

The current study presents an in‐depth qualitative analysis of parental appraisals of injustice in the context of their child's chronic pain condition. The findings provide valuable insights into the phenomenology of this construct and may inform future research and assessment methods. Furthermore, the themes reported in this study may contribute to clinical practice, as they may raise awareness of parental concerns regarding their child's pain management.

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Fear of movement in children and adolescents undergoing major surgery: A psychometric evaluation of the Tampa Scale for Kinesiophobia

Abstract

Background

The objective of this study was to evaluate the psychometric properties of the 17‐item Tampa Scale for Kinesiophobia (TSK) in youth.

Methods

Participants were 264 children and adolescents (58.7% female, M _age = 14.1 years, SD _age = 2.51) scheduled for major surgery who were assessed before surgery, while in hospital postoperatively, and at 6 and 12 months after surgery. Exploratory factor analyses (EFA) were conducted to determine the factor structure of pre‐operative TSK scores. Reliability, and convergent, discriminant, and predictive validity were examined.

Results

EFA on the 17‐item TSK revealed a two‐factor model distinguishing the 13 positively scored items from the 4 reverse scored items, but the fit was poor. A second EFA was conducted on the 13 positively scored items (TSK‐13) revealing a three‐factor model: Fear of injury, bodily vulnerability, and activity avoidance. The TSK‐13 showed adequate internal consistency (Ω = 0.82) and weak convergent validity. The TSK‐13 was not correlated with postoperative, in‐hospital physical activity (actigraphy; r (179) = −0.10, p = 0.18) and showed adequate discriminant validity, that is correlations less than 0.70, with measures of depression (r (225) = 0.41, p < 0.001) and general anxiety (r (224)=0.35, p < 0.001). Predictive validity for pain‐related disability at 12 months (r (70) = 0.34, p < 0.001) was adequate.

Conclusions

The original TSK‐17 does not appear to be a meaningful measure of kinesiophobia in youth after surgery possibly because of the syntactic structure of the reverse scored items. In contrast, a modified TSK‐13, comprised of only the positively scored items, revealed a 3‐factor structure that is reliable and demonstrates adequate convergent, discriminant, and predictive validity.

Significance

Kinesiophobia is an important construct to evaluate in the transition from acute to chronic pain among children and adolescents. The 17 item Tampa Scale for Kinesiophobia (TSK) does not show adequate validity or reliability in youth undergoing major surgery, however, the psychometric properties of a 13‐item modified scale (TSK‐13) are promising.

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Smell and taste dissociations in the modulation of tonic pain perception induced by a capsaicin cream application

Abstract

Background

Pain is a subjective experience characterized by sensory (intensity) and emotional (unpleasantness) aspects. Although literature reports behavioural effects on pain due to smell and taste influence, to our knowledge the relationship between tonic pain induced by a capsaicin cream and these chemosensory systems has never been explored before. The aim of this study was to investigate the modulation of olfactory and gustatory substances having different valence on tonic pain perception mediated by a capsaicin cream application.

Methods

Sixty healthy volunteers were included in two separated experiments (N = 30 smell; N = 30 taste) and underwent different valence smell and taste stimulations, while receiving painful stimuli. Perception of pain intensity (the sensory component) and unpleasantness (the affective component) was measured with a numerical rating scale, both during the two aforementioned experiments.

Results

Pain unpleasantness rating showed differences only in the smell experiment between the two odourous conditions. In particular, pleasant odour induced lower ratings of pain unpleasantness, while no significant results were found for intensity. Regarding taste, we could not observe significant effects nor for pain unpleasantness or intensity.

Conclusions

These findings highlight the potential role of pleasant odours in influencing the affective aspects of pain perception induced by this kind of tonic pain. Such evidence might provide new insight for using chemosensory substances as analgesics for modulating the cognitive aspects of neuropathic pain.

Significance

This work shows the effect of smell on the emotional component of tonic pain, experimentally induced by capsaicin cream application. Previous literature investigated tonic pain in interaction with smell and/or taste stimuli, but mainly with physical methods such as temperature. Our findings add new information in this field, contributing to a deeper insight on the role of olfaction on this particular kind of tonic pain perception. This approach could open to new investigations aimed to consider odours for pain management.

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Pain‐autonomic interaction: A surrogate marker of central sensitization

Abstract

Background

Central sensitization represents a key pathophysiological mechanism underlying the development of neuropathic pain, often manifested clinically as mechanical allodynia and hyperalgesia. Adopting a mechanism‐based treatment approach relies highly on the ability to assess the presence of central sensitization. The aim of the study was to investigate potential pain‐autonomic readouts to operationalize experimentally induced central sensitization in the area of secondary hyperalgesia.

Methods

Pinprick evoked potentials (PEPs) and sympathetic skin responses (SSRs) were recorded in 20 healthy individuals. Three blocks of PEP and SSR recordings were performed before and after heat‐induced secondary hyperalgesia. All measurements were also performed before and after a control condition. Multivariate analyses were performed using linear mixed‐effect regression models to examine the effect of experimentally induced central sensitization on PEP and SSR parameters (i.e. amplitudes, latencies and habituation) and on pinprick pain ratings.

Results

The noxious heat stimulation induced robust mechanical hyperalgesia with a significant increase in PEP and SSR amplitudes (p < 0.001) in the area of secondary hyperalgesia. Furthermore, PEP and SSR habituation were reduced (p < 0.001) after experimentally induced central sensitization.

Conclusions

The findings demonstrate that combined recordings of PEPs and SSRs are sensitive to objectify experimentally induced central sensitization and may have a great potential to reveal its presence in clinical pain conditions. Corroborating current pain phenotyping with pain‐autonomic markers has the potential to unravel central sensitization along the nociceptive neuraxis and might provide a framework for mechanistically founded therapies.

Significance

Our findings provide evidence that combined recordings of sympathetic skin responses (SSRs) and pinprick evoked potentials (PEPs) might be able to unmask central sensitization induced through a well‐established experimental pain model in healthy individuals. As such, these novel readouts of central sensitization might attain new insights towards complementing clinical pain phenotyping.

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The interrelation between interpretation biases, threat expectancies and pain‐related attentional processing

Abstract

Background

Few studies examining the effect of pain‐related threat on eye movements have incorporated a measure of interpretation bias. However, theories suggest that interpretation biases also play an important role in the anticipation of harm in situations where pain could be imminent. The current study investigates the association between interpretation biases and pain‐related threat expectancies and their associations with eye movements to pain‐related imagery.

Methods

Healthy adults’ (N = 91) fear of pain, emotional functioning and interpretation biases were assessed prior to a threat manipulation where they were given either threatening or reassuring information about an upcoming cold pressor task. Participants were then asked to freely view scene images that were either pain‐related or neutral.

Results

We used a data‐driven machine learning method to analyse eye movements. We identified an explorative (i.e. greater dispersal of eye fixations) and a focused eye movement pattern subgroup (i.e. mainly focusing on foreground information) for scene viewing in the sample. Participants with more negative interpretation biases expected that the cold pressor task would be more harmful, and those with higher levels of anticipated harm used a more explorative strategy when viewing injury scene images. Subsequent analysis confirmed an indirect effect of interpretation biases on eye movements through expected bodily harm. No difference in eye movements was found between participants given threatening and reassuring information.

Conclusions

Interpretation biases may play a prominent role in threat‐related attentional processing. By adopting a novel eye movement analysis approach, our results revealed interesting associations among interpretations, threat expectancies and eye movements.

Significance

Negative interpretation biases may be associated with greater threat expectancies for an upcoming experimental pain task. Anticipation of bodily harm may induce a stimulus non‐specific hypervigilant style of scanning of pain‐related scenes.

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The pathophysiological nature of sarcomeres in trigger points in patients with myofascial pain syndrome: A preliminary study

Abstract

Background

Myofascial pain syndrome (MPS) has a high global prevalence and is associated with myofascial trigger points (MTrPs) in taut bands or nodules. Little is known about the aetiology. The current study assessed the pathophysiological characteristics of MTrPs in MPS patients.

Methods

Biopsies of the trapezius muscle were collected from the MTrPs of MPS patients (MTrP group; n = 29) and from healthy controls (control group; n = 24), and their morphologies were analysed via haematoxylin‐eosin (H&E) and Masson staining. A protein microarray was used to detect the receptor tyrosine kinase (RTK) family proteins. mRNA and long non‐coding RNA (lncRNA) sequencing and analysis were conducted, and immunohistochemistry and Western blotting were used to examine the expression of EphB and Rho family proteins.

Results

Abnormally contracted sarcomeres showed enlarged, round fibres without inflammation or fibrosis. An lncRNA‐mRNA network analysis revealed activation of muscle contraction signalling pathways in MTrP regions. Among RTK family proteins, 15 exhibited increased phosphorylation, and two exhibited decreased phosphorylation in the MTrP regions relative to control levels. In particular, EphB1/EphB2 phosphorylation was increased on the muscle cell membranes of abnormal sarcomeres. RhoA and Rac1, but not cell division control protein 42 (Cdc42), were activated in the abnormal sarcomeres.

Conclusions

EphB1/EphB2 and RhoA/Rac1 might play roles in the aetiology of abnormally contracted sarcomeres in MTrPs without inflammatory cell infiltration and fibrotic adhesion.

Significance

Contracted sarcomeres were found in MTrP regions, which is consistent with the MTrP formation hypothesis. EphB1/EphB2 and RhoA/Rac1 might play roles in the sarcomere contractile sites of MTrPs, which may be promising therapeutic targets.

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Comment on a manuscript by Paramasivan et al. entitled ‘Intrathecal dexmedetomidine and postoperative pain: A systematic review and meta‐analysis of randomized controlled trials’

European Journal of Pain, Volume 24, Issue 10, Page 2037-2037, November 2020.

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Issue Information

European Journal of Pain, Volume 24, Issue 10, Page 1863-1864, November 2020.

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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.

Significance

Understanding which factors influence the effectiveness of cognitive engagement in distracting from pain could help to optimize its therapeutic application in patient care. This study shows that a complex interplay of cognitive inhibition abilities, specifically selective attention, and negative pain‐related cognitions, such as pain catastrophizing, modulate the magnitude of the distraction effect.

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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.

Significance

A common genetic liability seems to be of importance in the comorbidity of sick leave due to back pain and common mental disorders and the transition to disability pension, both among women and men. However, the proportion in each trait that was explained by genetic factors was somewhat higher for men than for women in all traits. This may be of importance to consider in intervention or prevention efforts.

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Pelvic floor muscle training for women with lumbopelvic pain: A systematic review and meta‐analysis

Abstract

Background and Objective

It has been suggested that pelvic floor dysfunction may contribute to the development of lumbopelvic pain as a result of changes in trunk muscle control. However, there is limited evidence that pelvic floor muscle training (PFMT) can improve clinical outcomes in women with lumbopelvic pain.

Databases and Data Treatment

Six databases were searched for randomized controlled trials (RCTs) comparing the effectiveness of PFMT to other conservative interventions (usual physiotherapy care or minimal intervention), no treatment or placebo interventions on pain and disability in women with lumbopelvic pain.

Results

We included eight RCTs totalling 469 participants. PFMT was more effective than minimal intervention for lumbopelvic pain [mean difference (MD) 15.9/100 (95% confidential interval (CI), 8.2 to 23.6; p = 0.00; I² = 3.92%)] and disability [standardized mean difference (SMD) 0.5 (95% CI 0.1–0.9; p = 0.00; I² = 0%)] during pregnancy. PFMT was more effective than usual physiotherapy care for pain (MD 11.7/100 [95% CI 7.5–15.9; p = 0.00; I² = 94.14%]) and disability (SMD 0.3 (95% CI 0.0–0.6; p = 0.01; I² = 82.54%]) in non‐pregnant women. Effect sizes were in general of arguable clinical relevance.

Conclusions

Overall, the certainty of the evidence was very low to low. There is no conclusive evidence that the addition of PFMT to usual physiotherapy care or minimal intervention is superior to minimal intervention and usual care alone given the small number of studies and high levels of heterogeneity of included studies. Further well‐designed trials are needed to establish the effectiveness of PFMT for lumbopelvic pain in women.

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Self‐compassion predicting pain, depression and anger in people suffering from chronic pain: A prospective study

Abstract

Self‐compassion is associated with disability, pain‐related anxiety as well as depression and anger in patients with chronic pain. However, the unique value of self‐compassion versus other concepts such as psychological flexibility and self‐esteem is unknown. The present study therefore aimed to clarify these relationships. Individuals with chronic pain (N_CP  = 872) and without chronic pain (N_NP  = 356) took part in a longitudinal study. Participants completed self‐report instruments: Pain Disability Index (PDI), Pain Catastrophizing Scale (PCS), Pain Anxiety Symptom Scale (PASS‐20), Patient Health Questionnaire (PHQ‐9), State Trait Anger Expression Inventory (STAXI), Self‐Compassion Scale (SCS), Psychological Inflexibility in Pain Scale (PIPS) and Rosenberg Self‐Esteem Scale (RSES). Assessments were repeated after 8 weeks. We found differences in baseline levels of all relevant variables except for anger‐out and anger‐control between people with and without chronic pain. Subsequently, we computed a path model analysis regarding individuals suffering from chronic pain (N _CP), addressing the predictive value of reduced uncompassionate self‐responding (RUS), compassionate self‐responding (CS), avoidance (PIPS), cognitive fusion (PIPS) and self‐esteem (RSES) regarding pain‐related (PDI, PCS, PASS) and emotional variables (PHQ‐9, STAXI). Avoidance predicted disability, catastrophizing, anxiety and depression. RUS predicted catastrophizing and pain‐related anxiety. Self‐esteem predicted depression. CS and cognitive fusion had no unique predictive value. The model explained 65.4%‐72.1% of the variance in pain‐related variables, 68.7% of the variance in depression and 38.7%‐60.7% in the variance of anger‐related variables. In conclusion, psychological flexibility, in terms of avoidance, seems to be more relevant for chronic pain than self‐compassion. Future research should focus on subgroups and tailored‐treatment approaches.

Significance

Applying a longitudinal design, this study examined the predictive value of self‐compassion regarding pain, depression and anger. The relevance of self‐compassion was compared to psychological flexibility and self‐esteem. We can conclude that psychological flexibility, in terms of avoidance behaviour, is the most relevant predictor concerning pain.

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Individuals with back and neck pain on medical forums: What do they mention? What do they fear?

Abstract

Background

The use of online medical forums is on the rise globally. Data scraping is a method of extracting website content using an automated computer program. We scraped users’ questions regarding back and neck pain (BNP) from popular Israeli online medical forums. We aimed to identify the sort of questions being asked about BNP, and to analyse explicit themes that characterize their questions.

Methods

Six leading Israeli BNP forums were identified. In phase 1, Python scripts scraped 12,418 questions into a data set. In phase 2 – five themes were identified: Surgery (n = 2,957); health care professions (n = 2,361); Sports (n = 2,304); drugs (n = 1,419) and interpretation of imaging (n = 845). Phase 3 – included the categorization of explicit fear‐related words by the authors. Phase 4 – analysis of explicit fear‐related themes yielded 402 questions.

Results

Gender was identified for 394 users, and age was identified for 181 users. A total of 248 users (61.6%) were women and 146 men (36.3%). Mean age 36.3 ± 16.15 for women and 35.5 ± 16.1 for men. The most commonly expressed fears were related to: invasive procedures, 30.9% (131 questions); fear of serious condition or misdiagnosis, 17.0% (72 questions); General concerns, 13.7% (58 questions); fear of worsening or relapse, 12.3% (52 questions); adverse effects of oral drugs or radiation, 10.8% (46 questions) and concerns related to lifestyle, 9.7% (41 questions).

Conclusions

Web scraping is a feasible strategy with which to explore medical forums and the above‐mentioned themes, all of which are of potential clinical significance.

Significance

Using automated algorithms, a total of 12,369 questions from online back and neck medical forums were scraped and analysed. Secondary analysis categorized fear‐related themes that were mentioned by users. Identifying and addressing patients' fear has potential to improve communication and therapeutic outcome. For example, questions regarding surgery were typically asked after the option was mentioned by a physician. This insight should encourage physicians to devote extra time explaining the possible implications of surgery, should they consider it as an option.

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Initial evaluation of the Chronic Pain Acceptance Questionnaire – 2

Abstract

Greater acceptance of chronic pain is associated with lesser levels of pain‐related distress and disability and better overall functioning. Pain acceptance is most often assessed using the Chronic Pain Acceptance Questionnaire (CPAQ), which includes both an eight‐item short form (CPAQ‐8) and a twenty item parent measure (CPAQ‐20). This study derived a two‐item CPAQ for use in busy clinical settings and for repeated measurement during treatment, the CPAQ‐2. An Item Response Theory (IRT) approach was used to identify the strongest items from the CPAQ‐20, one from each of its two subscales. Next, regression analyses were conducted to evaluate the utility of the CPAQ‐2 by examining variance accounted for in the CPAQ‐8, CPAQ‐20, and in measures of depression, pain‐related fear, physical disability, and psychosocial disability. Four clinical databases were combined (N = 1,776) for the analyses. Items 9 and 14 were identified as the strongest CPAQ‐20 items in the IRT analyses. The sum score of these two items accounted for over 60% of the variance in the CPAQ‐8 and CPAQ‐20. Furthermore, this score accounted for significant variance in measures of depression, pain‐related fear, physical disability, and psychosocial disability after controlling for data collection method (i.e. in clinic or online), participant age, education, pain duration and usual pain. Finally, the amount of variance accounted for by the CPAQ‐2 was comparable to that accounted for by both the CPAQ‐8 and CPAQ‐20. These results provide initial support for the CPAQ‐2 and suggest that it is well‐suited as a brief assessment of chronic pain acceptance.

Significance

The most frequently used measure of pain acceptance is the CPAQ, which includes both an eight‐item short form, the CPAQ‐8, and a longer twenty item parent measure, the CPAQ‐20. The present study sought to derive a two‐item measure of the CPAQ for use in busy clinical settings and for repeated measurement during treatment, the CPAQ‐2. An IRT approach was used to identify the strongest items from the CPAQ‐20, one from each of its two subscales in a large sample of 1,776 individuals with chronic pain. The two item measure accounted for significant variance in measures of depression, pain‐related fear, physical disability, and psychosocial disability. The brief measure will be useful in assessing pain acceptance in busy clinical setting and longitudinal designs.

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The burden of pain in rheumatoid arthritis: Impact of disease activity and psychological factors

Abstract

Background

Pain remains a prevalent symptom for rheumatoid arthritis (RA) patients despite a wide therapeutic choice. The objective of this study was to provide a multidimensional evaluation of pain.

Methods

A total of 295 RA patients from 7 French rheumatology centres were enrolled in a cross‐sectional study. Patients completed a chronic pain assessment questionnaire approved by the French National Authority for Health, the health assessment questionnaire (HAQ) as well as depression and anxiety scales (HAD, Beck Depression Inventory, STAI). Disease activity (DAS28) and ESR were recorded. A multivariate descriptive analysis was undertaken using principal component analysis (PCA).

Results

38.4% of patients had a pain score > 40 mm/100, although 83% were on biological treatment and 38.7% were in remission based on the RA activity score. The PCA analysis found four axes representing 70% of total variance. The axes, per cent of variance and variables represented were as follows: (a) axis 1, 41% variance, anxiety and depression scores, sensory and affective qualifier score, HAQ and pain impact on daily life; (b) axis 2, 13% variance, disease activity score (DAS28) and pain relief with current treatment; (c) axis 3, 9% of variance, RA duration and radiographic score and (d) axis 4, 6% of variance, DAS28 and ESR. Moderate to severe pain was significantly associated with axes 1 and 2.

Conclusions

Despite a high proportion of patients on biological treatments, 38.4% of patients continue to experience moderate to severe pain. Pain is associated with the RA activity score, but also with the depression and anxiety scores.

Significance

Substantial proportion of rheumatoid arthritis (RA) patients still experiences relevant pain, although more than 80% on biological treatment. Pain is primarily associated with anxiety and depression scores and with disease activity score. These findings highlight the need to assess patients’ mental well‐being alongside. Clinical measures of disease activity to better manage pain and guide treatment decisions.

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The effectiveness of parental distraction during children’s acute pain: The moderating effect of socioeconomic status

Abstract

Background

Parental responses to children's pain shape how children interpret and cope with pain symptoms through parental modelling and operant conditioning. Evidence suggests that parental distraction is effective in reducing children's acute pain responses, but findings are inconsistent across pain tolerance, intensity and unpleasantness, and are limited to samples of primarily middle and upper‐middle class families. Although socioeconomically disadvantaged families may have fewer psychological resources to cope with pain, no studies have examined whether the utility of parent distraction varies by family socioeconomic status (SES). The current study tested the hypothesis that relations between parental distraction and acute pain responses in children vary by family SES, with children from higher versus lower SES families experiencing more substantial benefits.

Methods

Children's pain symptoms and parents’ use of verbal distraction during a cold pressor task were examined in a community sample of 530 twin children aged 7–12 years old and their primary caregivers.

Results

Parental distraction was positively associated with children‘s pain tolerance and unrelated to intensity and unpleasantness, but these associations are qualified by significant moderation. In families with higher SES, parental distraction was an effective technique in children's pain management, associated with more pain tolerance and less pain intensity and unpleasantness. However, for families with lower SES, these same benefits were not present.

Conclusions

Findings suggest that the effectiveness of parental distraction for children's acute pain may depend on family SES.

Significance

Study findings suggest that the effects of parental distraction on children's responses to an acute pain task vary by family SES. Although parental distraction may be effective for higher SES children, further research is needed to identify whether and why distraction may not be beneficial for lower SES families.

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[Correspondence] Accelerated surgery for hip fractures—the HIP ATTACK results discussed

The HIP ATTACK investigators1 found that accelerated surgery (median 6 h) did not lower the risk of mortality or a composite of major complications compared with standard care (median 24 h) but reduced the risk of delirium, urinary tract infection, pain, and length of hospital stay. We have two concerns.

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[Department of Error] Department of Error

Horne AW, Vincent K, Hewitt CA, et al. Gabapentin for chronic pelvic pain in women (GaPP2): a multicentre, randomised, double-blind, placebo-controlled trial. Lancet 2020; 396: 909–17—In this Article, the final three references were omitted from the reference list. This correction has been made to the online version as of Oct 22, 2020.

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Some like it hot: preference for temperature and pungency consumption is associated with sensitivity to noxious heat

Abstract

Background

Individuals vary in their temperature and pungency preferences; whereas some individuals prefer to bath in, or consume food and beverages at very high temperatures, others prefer lukewarm temperatures. Similarly, pungent food may be preferred by some, but not by others. The aim was to investigate, for the first time whether temperature and pungency preferences are associated with variations in thermal sensitivity or ethnic origin related to pungency consumption.

Methods

115 healthy volunteers participated. The thresholds for warm (WST) and heat‐pain (HPT) sensations were measured over the tongue and dorsal hand, and the participants’ preferred drinking and bath temperatures were measured. In addition, data on the participants’ ethnic background as well as temperature and pungency preferences and household habits regarding eating, drinking, and bathing were collected.

Results

The reported drinking and bathing preferences correlated significantly with the measured drinking and bath temperatures, respectively, validating subjects’ reports. Tongue and hand HPT, but not WST, correlated with both the reported and the measured drinking and bathing preferences, as well as with pungency preferences. Neither ethnic origin nor sex affected HPT or temperature preferences; however, males preferred a greater level of spiciness than females.

Conclusions

The association of the reported and measured preferences with noxious heat sensitivity in both relevant and irrelevant body regions, and lack of an ethnicity effect may suggest that these qualities are innate. The association of HPT and spiciness preferences correspond with the mutual activation of the tongue vanilloid receptors by noxious heat and capsaicin.

Significance

People vary with regard to their temperature and spiciness preferences for reasons yet unknown. The study revealed that these preferences correlate with one another and were associated with the sensitivity to noxious heat but not with age, gender and cultural background, which suggests that they may be innate.

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A rapidly enlarging neck swelling

A man in his mid 50s with type 2 diabetes and hypertension presented with four days of fever and worsening neck pain and swelling, initially left sided but subsequently spreading to the right. The...

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Investigating the true effect of psychological variables measured prior to arthroplastic surgery on post-surgical outcomes: a p-curve analysis

Osteoarthritis (OA) is a chronic pain condition that affects roughly 8.75 million people in the UK, with the knee and hip being the most commonly affected sites 2. Although arthroplasty is considered an effective treatment and, in many cases, a cure for chronic OA-pain, almost 30% of patients undergoing knee or hip replacement surgery develop increased pain and disability, despite objective indicators of surgical success 7,17,51. Patients’ pre-surgical psychological profiles may play a major role in determining the long-term efficacy of surgery by affecting the recovery process 13,32,40,45,59,60,68,78–80.

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Algomania by Henry Lemesle

Abstract

Henry Lemesle (1871‐1947), French psychiatrist, graduated from both Angers Medical School (1891) and Caen Law School (1894). He then worked for two years at the Salpêtrière Hospital in Paris. He became a lawyer at Paris Court of Appeals (1894) and promoted the role of the psychiatrist as an expert in criminal cases.

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How do patients with Alzheimer’s disease imagine their pain?

Abstract

Introduction

Pain is underdiagnosed and undertreated in patients with Alzheimer’s disease (AD). Pain management is of major importance in this population to limit behavioral and functional consequences. Our study aimed to assess the capacity of AD patients to represent pain using a questionnaire exploring daily painful situations and to determine the most appropriate pain scale assessment.

Methods

Twenty‐eight patients with mild AD, 21 with moderate AD and 28 matched controls underwent the Situation Pain Questionnaire (SP‐Q) and assessed imaginary pain with 4 pain scales. Two scores were compared between the 3 groups: the P(A) discrimination score and the response bias β score. P(A) reflects the degree of discrimination between high‐pain and low‐pain events, whereas the β score means the degree to which situations are considered as painful.

Results

Our results showed that AD patients hardly discriminated the high from low‐pain events. Compared to controls, the mean P(A) score was significantly lower for Mild AD (p<.03) and Moderate AD (p<.004). In addition, the β score indicated that the response bias is higher for AD patients (p<.01) in that they overestimated the level of pain.

Conclusion

The present results suggest that patients with Mild and Moderate AD are able to recognize and assess an imagined painful situation even though their pain tolerance is lower than that of controls. The pain scales used should be chosen according to the cognitive, sensorial and personal profiles of the patients.

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The impact of paradigm and stringent analysis parameters on measuring a net conditioned pain modulation effect: A test, re‐test, control study

Abstract

Background

Reporting in conditioned pain modulation (CPM) studies is not standardised. Here, two CPM protocols were performed in populations of healthy human subjects in order to investigate the influence of CPM paradigm and stringent analyses parameters on identification of a net CPM effect.

Methods

A standard thermal or mechanical CPM protocol was carried out on 25 and 17 subjects, respectively. The standard error of measurement (SEM) of the CPM effect was calculated in order to determine a change in pain thresholds greater than that due to measurement error or ‘real’ change in test scores. In addition, each individual underwent a minimum of two control CPM sessions, which were paired with the CPM test sessions. To quantify a net CPM effect, the intrasession difference between baseline and conditioning was subtracted from the difference calculated at the same timepoints during the control session.

Results

For both protocols excellent reliability for intrasession repeats of the test stimulus at baseline was demonstrated for thermal and mechanical stimulation (ICC >0.9). Test‐retest subject responses (in terms of experimental Session 1 versus Session 2) showed excellent reliability for mechanical (ICC >0.8), compared to thermal stimulation, which ranged from poor to moderate (ICC <0.4‐>0.75). However calculating the net CPM effect using control session data demonstrated poor‐fair reliability for both protocols (ICC <0.4‐0.59).

Conclusion

Calculating the net CPM effect should be optimised and standardised for comparison of CPM data collected from global research groups. Recommendation is made for the performance of a multi‐centre, test‐retest study.

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Metabolomics in Chronic Pain Research

Abstract

Background and Objective

Metabolomics deals with the identification and quantification of small molecules (metabolites) in biological samples. As metabolite levels can reflect normal or altered metabolic pathways, their measurement provides information to improve the understanding, diagnosis and management of diseases. Despite its immense potential, metabolomics applications to pain research have been sparse. This paper describes current metabolomics techniques, reviews published human metabolomics pain research, and compares successful metabolomics research in other areas of medicine with the goal of highlighting opportunities offered by metabolomics to advance pain medicine.

Databases and Data Treatment

Non‐systematic review.

Results

Our search identified 19 studies that adopted a metabolomics approach in: fibromyalgia (7), chronic widespread pain (4), other musculoskeletal pain conditions (5), neuropathic pain (1), complex regional pain syndrome (1) and pelvic pain (1). The studies used either mass spectrometry or nuclear magnetic resonance. Most are characterized by small sample sizes. Some consistency has been found for alterations in glutamate and testosterone metabolism, and metabolic imbalances caused by the gut microbiome.

Conclusions

Metabolomics research in chronic pain is at its infancy. Most studies are at the pilot stage. Metabolomics research has been successful in other areas of medicine. These achievements should motivate investigators to expand metabolomics research to improve understanding of the basic mechanisms of human pain, as well as provide tools to diagnose, predict and monitor chronic pain conditions. Metabolomics research can lead to the identification of biomarkers to support the development and testing of treatments, thereby facilitating personalized pain medicine.

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Medical Cannabis Treatment for Chronic Pain: Outcomes and Prediction of Response

Abstract

Background

Although studied in a few randomized controlled trials (RCTs), the efficacy of medical cannabis (MC) for chronic pain remains controversial. Using an alternative approach, this multicenter, questionnaire‐based prospective cohort was aimed to assess the long‐term effects of MC on chronic pain of various etiologies and to identify predictors for MC treatment success.

Methods

Patients with chronic pain, licensed to use MC in Israel reported weekly average pain intensity (primary outcome) and related symptoms before and at 1, 3, 6, 9 and 12 months following MC treatment initiation. A general linear model was used to assess outcomes and identify predictors for treatment success ( ≥30% reduction of pain intensity).

Results

1045 patients completed the baseline questionnaires and initiated MC treatment, and 551 completed the 12 month follow‐up. At one year, average pain intensity declined from baseline by 20% [‐1.97 points (95%CI= ‐2.13 to ‐1.81; p<0.001)]. All other parameters improved by 10‐30% (p<0.001). A significant decrease of 42% [reduction of 27mg; (95%CI= ‐34.89 to ‐18.56, p<0.001)] from baseline in morphine equivalent daily dosage of opioids was also observed. Reported adverse effects were common but mostly non‐serious. Presence of normal to long sleep duration, lower body mass index (BMI) and lower depression score predicted relatively higher treatment success, whereas presence of neuropathic pain predicted the opposite.

Conclusions

This prospective study provides further evidence for the effects of MC on chronic pain and related symptoms, demonstrating an overall mild to modest long‐term improvement of the tested measures and identifying possible predictors for treatment success.

Significance

This "real world" paper shows that MC mildly to modestly attenuates chronic pain and related symptoms. MC treatment can also cause frequent, but mostly non‐serious adverse effects, although central nervous system (CNS)‐related AEs that can impair the ability to drive vehicles are not uncommon. This study is novel in identifying possible predictors for treatment success, including normal to long sleep duration, lower BMI and lower depression scores. In contrast to current beliefs the diagnosis of neuropathic pain predicts a less favorable outcome. These findings provide physicians with new data to support decision making on recommendations for MC treatment.

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Evidence‐based treatment recommendations for neck and low back pain across Europe: a systematic review of guidelines

Abstract

Background and objective

This systematic review synthesised evidence from European neck and low back pain (NLBP) clinical practice guidelines (CPGs) to identify recommended treatment options for use across Europe.

Databases and Data Treatment

Comprehensive searches of thirteen databases were conducted, from 1^st January 2013 to 4^th May 2020 to identify up‐to‐date evidence‐based European CPGs for primary care management of NLBP, issued by professional bodies/organisations. Data extracted included; aim and target population, methods for development and implementation, and treatment recommendations. The AGREE II checklist was used to critically appraise guidelines. Criteria were devised to summarise and synthesise the direction and strength of recommendations across guidelines.

Results

Seventeen CPGs (11 low back; 5 neck; 1 both) from eight European countries were identified, of which seven were high‐quality. For neck pain , there was consistent weak or moderate strength recommendations for: reassurance, advice and education, manual therapy, referral for exercise therapy/programme, oral analgesics and topical medications, plus psychological therapies or multidisciplinary treatment for specific subgroups. Notable recommendation differences between back and neck pain included, i) analgesics for neck pain (not for back pain); ii) options for back pain specific subgroups ‐ work‐based interventions, return to work advice/programmes, and surgical interventions (but not for neck pain), and iii) a greater strength of recommendations (generally moderate or strong) for back pain than those for neck pain.

Conclusions

This review of European CPGs identified a range of mainly non‐pharmacological recommended treatment options for NLBP that have broad consensus for use across Europe.

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Interpretation of cluster structures in pain‐related phenotype data using explainable artificial intelligence (XAI)

Abstract

Background

In pain research and clinics, it is common practice to subgroup subjects according to shared pain characteristics. This is often achieved by computer‐aided clustering. In response to a recent EU recommendation that computer‐aided decision‐making should be transparent, we propose an approach that uses machine learning to provide (i) an understandable interpretation of a cluster structure to (ii) enable a transparent decision process about why a person concerned is placed in a particular cluster.

Methods

Comprehensibility was achieved by transforming the interpretation problem into a classification problem: A sub‐symbolic algorithm was used to estimate the importance of each pain measure for cluster assignment, followed by an item categorization technique to select the relevant variables. Subsequently, a symbolic algorithm as explainable artificial intelligence (XAI) provided understandable rules of cluster assignment. The approach was tested using 100‐fold cross‐validation.

Results

The importance of the variables of the data set (6 pain‐related characteristics of 82 healthy subjects) changed with the clustering scenarios. The highest median accuracy was achieved by sub‐symbolic classifiers. A generalized post‐hoc interpretation of clustering strategies of the model led to a loss of median accuracy. XAI models were able to interpret the cluster structure almost as correctly, but with a slight loss of accuracy.

Conclusions

Assessing the variable importance in clustering is important for understanding any cluster structure. XAI models are able to provide a human‐understandable interpretation of the cluster structure. Model selection must be adapted individually to the clustering problem. The advantage of comprehensibility comes at an expense of accuracy.

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Nerve growth factor sensitizes nociceptors to C‐fiber selective

Abstract

Background

Intradermal injection of 1 µg nerve growth factor (NGF) causes sustained nociceptor sensitization. Slowly depolarizing electrical current preferentially activates C‐nociceptors.

Methods

We explored the differential contribution of A‐delta and C‐nociceptors in NGF sensitized skin using slowly depolarizing transcutaneous electrical current stimuli, CO2 laser heat, mechanical impact, and A‐fiber compression block. In 14 healthy volunteers pain rating was recorded on a numeric scale at days 1 – 14 after NGF treatment. Ratings during A‐ fiber conduction block were investigated at days 3 and 7 post NGF.

Results

Pain ratings to electrical, CO2 heat and mechanical impact stimuli were enhanced (> 30%, p < 0.0005, ANOVA) at NGF‐injection sites. Axon reflex erythema evoked by electrical stimulation was also larger at NGF‐injection sites (p < 0.02, ANOVA). Diminution of pain during continuous (1 min) sinusoidal current stimulation at 4 Hz was less pronounced after NGF (p < 0.05, ANOVA). Pain ratings to electrical sinusoidal and mechanical impact stimuli during A‐fiber conduction block were significantly elevated at the NGF sites compared to NaCl‐treated skin (p < 0.05, ANOVA).

Conclusions

NGF‐induced sensitization of human skin to electrical and mechanical stimuli is primarily driven by C‐nociceptors with little contribution from A‐delta fibers. Less pronounced accommodation during ongoing sinusoidal stimulation suggests that NGF could facilitate axonal spike generation and conduction in primary afferent nociceptors in humans. Further studies using this sinusoidal electrical stimulation profile to investigate patients with chronic inflammatory pain may allow localized assessment of skin C‐nociceptors and their putative excitability changes under pathologic conditions.

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Polymorphisms of the μ‐opioid receptor gene influence cerebral pain processing in fibromyalgia

Abstract

Background

Dysregulation of the μ‐opioid receptor has been reported in fibromyalgia (FM) and was linked to pain severity. Here we investigated the effect of the functional genetic polymorphism of the μ‐opioid receptor gene (OPRM1) (rs1799971) on symptom severity, pain sensitivity and cerebral pain processing in FM subjects and healthy controls.

Methods

Symptom severity and pressure pain sensitivity was assessed in FM subjects (n = 70) and healthy controls (n=35). Cerebral pain‐related activation was assessed by functional magnetic resonance imaging during individually calibrated painful pressure stimuli.

Results

FM subjects were more pain sensitive but no significant differences in pain sensitivity or pain ratings were observed between OPRM1 genotypes. A significant difference was found in cerebral pain processing, with carriers of at least one G‐allele showing increased activation in posterior cingulate cortex (PCC) extending to precentral gyrus, compared to AA homozygotes. This effect was significant in FM subjects but not in healthy participants, however, between‐group comparisons did not yield significant results. Seed‐based functional connectivity analysis was performed with the seed based on differences in PCC/precentral gyrus activation between OPRM1 genotypes during evoked pain across groups. G‐allele carriers displayed decreased functional connectivity between PCC/precentral gyrus and prefrontal cortex.

Conclusions

G‐allele carriers showed increased activation in PCC/precentral gyrus but decreased functional connectivity with the frontal control network during pressure stimulation, suggesting different pain modulatory processes between OPRM1 genotypes involving altered fronto‐parietal network involvement. Furthermore, our results suggest that the overall effects of the OPRM1 G‐allele may be driven by FM subjects.

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‘Drawing a line in the sand’: Physician diagnostic uncertainty in pediatric chronic pain

Abstract

Many patients with chronic pain do not receive a diagnosis that precisely explains a pathological cause of their pain (Butow & Sharpe, 2013; Serbic & Pincus, 2013). Over 40% of adults with chronic pain experience diagnostic uncertainty (DU), the perception that a label or explanation for a patient’s health problem is missing or inaccurate (Serbic & Pincus, 2013), which is associated with elevated levels of anxiety, depression, pain intensity (Serbic et al., 2016), and disability (Geisser & Roth, 1998).

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Which passengers are on your bus? A taxonomy of the barriers adolescents with chronic pain face in achieving functional recovery

Abstract

Background

Despite evidence that intensive interdisciplinary pain treatment (IIPT) is effective in facilitating functional recovery in adolescents with chronic pain, engagement with IIPT is suboptimal amongst adolescents. A key aspect of IIPT is to support functional recovery via (re)engagement with age‐appropriate daily activities. The aim of this study was to gain a comprehensive insight into adolescents’ perceptions of the barriers they need to overcome to engage with age‐appropriate activities in order to achieve functional recovery.

Methods

Forty‐one adolescents who were starting an IIPT program completed the ‘passenger‐on‐the‐bus metaphor’, an exercise in which they identify and describe their perceived barriers (i.e., ‘passengers’ on their bus) that prevent them from engaging with age‐appropriate activities. The responses were analysed using inductive thematic analyses to generate a taxonomy of perceived barriers to functional recovery.

Results

We generated a taxonomy of seven different barriers that participants described facing on their road to functional recovery: physical constraints, being ‘fed up’, low self‐confidence and self‐esteem, perfectionism, avoidance of engagement with pain, feelings (such as sadness, anger, guilt, anxiety), and social barriers (received from a range of sources such as parents, friends, school, and wider society).

Conclusion

The findings reveal a variety of barriers that were perceived to hinder functional recovery through reduced engagement with age‐appropriate activities and thereby hamper progress within IIPT. The passenger‐on‐the‐bus metaphor can be used to identify similar barriers faced by adolescents in an individualized treatment approach, thereby making it possible for clinicians to target their IIPT more precisely.

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Time course of DNA methylation in pain conditions: from experimental models to humans

Abstract

Background and Objective

Throughout the last decade, research has uncovered associations between pain and epigenetic alterations caused by environmental factors. Specifically, studies have demonstrated correlations between pain conditions and altered DNA methylation patterns. Thus, DNA methylation has been revealed as a possible modulator or contributor to pain conditions, providing a potential therapeutic target for treatment by DNA methylation modification. To develop such treatments, it is necessary to clarify a wide number of aspects on how DNA methylation affects pain perception; first and foremost, the temporal dynamics. The objective of the present review is to provide an overview of current knowledge on temporal dynamics of DNA methylation in response to pain, and to investigate if a time frame can be established based on the data of currently published studies.

Databases and Data Treatment

PubMed, MEDLINE, Google Scholar and Embase were searched comprehensively for studies of DNA methylation in neuropathic, inflammatory and alternative animal pain models, and in chronic pain patients including Complex Regional Pain Syndrome, chronic postsurgical pain, chronic widespread pain, fibromyalgia and Crohn’s disease.

Results

We identified 34 articles highlighting variations in temporal dynamics of DNA methylation across species and between different types of pain. These studies represent a starting point to uncover new insights in the DNA methylation time course in pain.

Conclusions

No time frame can currently be made for the DNA methylation response to pain in any of the reviewed conditions, highlighting an important focus area for future research.

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Differential effects of visually induced analgesia and attention depending on the pain stimulation site

Abstract

Background

The term ‘visually induced analgesia’ describes a reduced pain perception induced by watching the painful body part as opposed to watching a neutral object. In chronic back pain patients, experimental pain, movement‐induced pain and habitual pain can be reduced with visual feedback. Visual feedback can also enhance the effects of both massage treatment and manual therapy. The impact of somatosensory attentional processes remains unclear.

Methods

In the current study, participants received painful electrical stimuli to their thumb and back while being presented with either a real‐time video of their thumb or back (factor feedback). In addition, using an oddball paradigm, they had to count the number of deviant stimuli, applied to either their back or thumb (factor attention) and rate the pain intensity.

Results

We found a significant main effect for attention with decreased pain ratings during attention. There was no main effect for visual feedback and no significant interaction between visual feedback and attention. Post hoc tests revealed that the lowest pain intensity ratings were achieved during visual feedback of the back / thumb and counting at the back / thumb.

Conclusion

These data suggest that the modulation of perceived acute pain by visually induced analgesia may be influenced by a simultaneous somatosensory attention task.

Significance

Somatosensory attention reduced experimental pain intensity in the thumb and back in the presence of both congruent and incongruent visual feedback. We found no significant visual feedback effect on the complex interplay between visual feedback and somatosensory attention.

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Pain Intensity as a Lagging Indicator of Patient Improvement: Longitudinal Relationships with Sleep, Psychiatric Distress, and Function in Multidisciplinary Care

Traditional biomedical treatment models for chronic pain have conceptualized pain intensity as the primary target for intervention based on the belief that pain arises primarily from a specific medical pathology that must be addressed as a first step before co-occurring problems such as insomnia, depression and functional impairment may improve. That reduction of pain intensity must precede improvement in these other problems is a common belief for both clinicians13 and patients.2, 6, 24, 27 However, there is robust evidence that pain reduction may be accompanied or even preceded by changes in sleep disturbance, function, or affective distress.

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Median nerve stimulation as a non-pharmacological approach to bypass analgesic tolerance to morphine: a proof-of-concept study in mice

Opioids are commonly prescribed for postoperative pain77 or severe neuropathic pain.75 However, many patients continue to consume opioids well after surgery21 due to continued pain18 or postsurgical opioid over-prescription.5, 40 Analgesic tolerance developing after repeated opioid consumption7 further increases the risk of developing opioid dependence, withdrawal and/or overdose.38, 68 Therefore, unresolved severe chronic pain or opioid over-prescription may lead to opioid use disorder,22, 23 contributing to the ongoing opioid crisis.

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Acceptance is not acceptance, but acceptance!

Abstract

This journal recently published a paper by Vowles et al., entitled "Initial Evaluation of the Chronic Pain Acceptance Questionnaire – 2. The authors discuss the development of a two‐item measure to assess chronic pain acceptance. Items for this tool were derived from the Chronic Pain Acceptance Questionnaire (CPAQ) 20, and aim to map two key features of acceptance: (1) Activity Engagement, which entails participating in important or meaningful activities with continued pain and (2) Pain Willingness, which entails a willingness to experience pain without the need to reduce, avoid, or otherwise change it.

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Measures of central sensitisation and their measurement properties in musculoskeletal trauma: A systematic review

ABSTRACT

Background and Objective

Chronic pain following musculoskeletal trauma is common, which may partially be attributed to the early presence of central sensitisation (CS). Multiple measures are suggested to assess clinical features of CS, yet no systematic review has evaluated the measurement properties of these measures in a musculoskeletal trauma population.

Databases and Data Treatment

This systematic review, which followed a published and PROSPERO registered protocol (CRD42018091531), aimed to establish the scope of CS measures used within a musculoskeletal trauma population and evaluate their measurement properties. Searches were conducted in two stages by two independent reviewers. The Consensus‐based Standards for the selection of Health Measurement instruments (COSMIN) checklist was used to evaluate risk of bias and overall quality was assessed using the modified Grading of Recommendations Assessment, Development and Evaluation.

Results

From 86 studies, 30 different CS outcome measures were identified. Nine studies evaluated measurement properties of nine outcome measures; eight evaluated reliability and one evaluated construct validity. Measures included seven quantitative sensory testing methods (pressure, cold and electrical pain thresholds; warm, cold and vibration detection thresholds; vibration perception thresholds), pain drawings and a pinwheel. Risk of bias was assessed as doubtful/inadequate for all but one study, overall quality of evidence was low/very low for all measures. Reliability of measures ranged from poor to excellent.

Conclusions

Many measures are used to evaluate CS but with limited established measurement properties in musculoskeletal trauma. High quality research to establish measurement properties of CS outcome measures is required.

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Forefoot pain

What you need to knowTenderness on palpation of the metatarsal spaces with a positive Mulder’s test suggests Morton’s neuromaA key diagnostic test for plantar plate tears is the drawer testSuspect...

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Pain catastrophizing as a treatment process variable in cognitive behavioral therapy for adults with chronic pain

Abstract

Background

Interdisciplinary cognitive behavioral therapy (CBT) for chronic pain is effective at improving function, mood, and pain interference among individuals with disabling chronic pain. Traditionally, CBT assumes cognitive change is an active therapeutic ingredient in the determination of treatment outcome. Pain catastrophizing, a cognitive response style that views the experience of pain as uncontrollable, permanent, and destructive, has been identified as an important maladaptive cognition which contributes to difficulties with the management of chronic pain. Consequently, pain catastrophizing is commonly targeted in CBT for chronic pain.

Objectives

To examine change trajectories in pain catastrophizing during treatment and assess the relevance of these trajectories to outcomes at post‐treatment.

Methods

Participants included individuals with chronic pain (N = 463) who completed a three‐week program of interdisciplinary CBT. Pain catastrophizing was assessed weekly over the three weeks of treatment and latent growth curve modeling was used to identify trajectories of change.

Results

Findings indicated the presence of two classes of linear change, one with a significant negative slope in pain catastrophizing (i.e., improved class) and the other with a non‐significant slope (i.e., unchanged class). Next, latent growth mixture modeling examined treatment outcome in relation to class membership. These results indicated that individuals in the “improved” PCS class had significantly greater improvement in pain interference and mood, as well as physical and mental quality of life compared to the “unchanged” class.

Conclusions

Implications for our findings, in relation to the CBT model, are discussed.

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Reframing my chronic pain

Two years after my chronic leg pain started, I had gone through lots of investigations but still did not have a clear cause. My health professional asked, ‘Why do you think you’re in pain still?” I...

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