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Slater H, Graven-Nielsen T, Wright A, Schug SA. Low-Dose Sublingual Ketamine Does Not Modulate Experimentally Induced Mechanical Hyperalgesia in Healthy Subjects. PAIN MEDICINE 2012; 13:1235-46. [DOI: 10.1111/j.1526-4637.2012.01444.x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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Abstract
UNLABELLED BACKGROUND The mechanisms subserving deep spinal pain have not been studied as well as those related to the skin and to deep pain in peripheral limb structures. The clinical phenomenology of deep spinal pain presents unique features which call for investigations which can explain these at a mechanistic level. METHODS Targeted searches of the literature were conducted and the relevant materials reviewed for applicability to the thesis that deep spinal pain is distinctive from deep pain in the peripheral limb structures. Topics related to the neuroanatomy and neurophysiology of deep spinal pain were organized in a hierarchical format for content review. RESULTS Since the 1980's the innervation characteristics of the spinal joints and deep muscles have been elucidated. Afferent connections subserving pain have been identified in a distinctive somatotopic organization within the spinal cord whereby afferents from deep spinal tissues terminate primarily in the lateral dorsal horn while those from deep peripheral tissues terminate primarily in the medial dorsal horn. Mechanisms underlying the clinical phenomena of referred pain from the spine, poor localization of spinal pain and chronicity of spine pain have emerged from the literature and are reviewed here, especially emphasizing the somatotopic organization and hyperconvergence of dorsal horn "low back (spinal) neurons". Taken together, these findings provide preliminary support for the hypothesis that deep spine pain is different from deep pain arising from peripheral limb structures. CONCLUSIONS This thesis addressed the question "what is different about spine pain?" Neuroanatomic and neurophysiologic findings from studies in the last twenty years provide preliminary support for the thesis that deep spine pain is different from deep pain arising from peripheral limb structures.
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Affiliation(s)
- Howard Vernon
- Canadian Memorial Chiropractic College, 6100 Leslie Street, Toronto, ON, M2H 3J1, Canada.
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103
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Davis CG. Mechanisms of chronic pain from whiplash injury. J Forensic Leg Med 2012; 20:74-85. [PMID: 23357391 DOI: 10.1016/j.jflm.2012.05.004] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2011] [Revised: 05/03/2012] [Accepted: 05/30/2012] [Indexed: 10/28/2022]
Abstract
This article is to provide insights into the mechanisms underlying chronic pain from whiplash injury. Studies show that injury produces plasticity changes of different neuronal structures that are responsible for amplification of nociception and exaggerated pain responses. There is consistent evidence for hypersensitivity of the central nervous system to sensory stimulation in chronic pain after whiplash injury. Tissue damage, detected or not by the available diagnostic methods, is probably the main determinant of central hypersensitivity. Different mechanisms underlie and co-exist in the chronic whiplash condition. Spinal cord hyperexcitability in patients with chronic pain after whiplash injury can cause exaggerated pain following low intensity nociceptive or innocuous peripheral stimulation. Spinal hypersensitivity may explain pain in the absence of detectable tissue damage. Whiplash is a heterogeneous condition with some individuals showing features suggestive of neuropathic pain. A predominantly neuropathic pain component is related to a higher pain/disability level.
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Daenen L, Nijs J, Roussel N, Wouters K, Van Loo M, Cras P. Sensorimotor incongruence exacerbates symptoms in patients with chronic whiplash associated disorders: an experimental study. Rheumatology (Oxford) 2012; 51:1492-9. [DOI: 10.1093/rheumatology/kes050] [Citation(s) in RCA: 41] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
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Trauma and work-related pain syndromes: risk factors, clinical picture, insurance and law interventions. Best Pract Res Clin Rheumatol 2012; 25:199-207. [PMID: 22094196 DOI: 10.1016/j.berh.2011.01.003] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/13/2010] [Indexed: 11/20/2022]
Abstract
In the past decade, major progress has been made in our understanding of fibromyalgia syndrome (FMS). Various triggers have been implicated as contributing to symptom development in FMS when genetically susceptible individuals are challenged. A substantial amount of data points towards the association between trauma and chronic widespread pain/fibromyalgia syndrome (CWP/FMS). There is abundant data suggesting that the pathogenesis of CWP/FMS might be related to cervical spine injury. Furthermore, several persistent local pain conditions may progress to CWP/FMS. These conditions may share a common pathogenic mechanism namely, central sensitisation. Physical trauma and emotional trauma co-exist in many traumatic events and may interact in the pathogenesis of CWP/FMS.
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106
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Arendt-Nielsen L, Graven-Nielsen T. Translational musculoskeletal pain research. Best Pract Res Clin Rheumatol 2012; 25:209-26. [PMID: 22094197 DOI: 10.1016/j.berh.2010.01.013] [Citation(s) in RCA: 111] [Impact Index Per Article: 9.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/13/2010] [Indexed: 01/25/2023]
Abstract
Diagnosis and management of musculoskeletal pain is a major clinical challenge. Fundamental knowledge of nociception from deep somatic structures and related mechanisms of sensitisation have been characterised in animals but the translation into clinical sciences is still lacking. Development and refinement of mechanism-based quantitative sensory testing in healthy volunteers and pain patients have provided new opportunities to assess pain and hyperalgesic reactions. The current technologies can provide information about, for example, peripheral and central sensitisation, descending pain control, central integration and structure specific sensitisation. Such a mechanistic approach can be used for differentiated diagnosis and for target validating new and existing analgesics. Mechanistic pain assessment of new compounds under development provides opportunities for target validation in proof-of-concept studies, which generate information to be used for selecting the most optimal patients for later clinical trials. New safe and efficient compounds are highly needed in the area of musculoskeletal pain management.
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Affiliation(s)
- Lars Arendt-Nielsen
- Center for Sensory-Motor Interaction (SMI), Department of Health Sciences and Technology, Faculty of Medicine, Aalborg University, Fredrik Bajers Vej 7, Aalborg, Denmark.
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Staud R. Peripheral pain mechanisms in chronic widespread pain. Best Pract Res Clin Rheumatol 2012; 25:155-64. [PMID: 22094192 DOI: 10.1016/j.berh.2010.01.010] [Citation(s) in RCA: 102] [Impact Index Per Article: 8.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/13/2010] [Indexed: 10/15/2022]
Abstract
UNLABELLED Clinical symptoms of chronic widespread pain (CWP) conditions like fibromyalgia (FM), include pain, stiffness, subjective weakness, and muscle fatigue. Muscle pain in CWP is usually described as fluctuating and often associated with local or generalised tenderness (hyperalgesia and/or allodynia). This tenderness related to muscle pain depends on increased peripheral and/or central nervous system responsiveness to peripheral stimuli, which can be either noxious (hyperalgesia) or non-noxious (allodynia). For example, patients with muscle hyperalgesia will rate painful muscle stimuli higher than normal controls, whereas patients with allodynia may perceive light touch as painful, something that a 'normal' individual will never describe as painful. The pathogenesis of such peripheral and/or central nervous system changes in CWP is unclear, but peripheral soft tissue changes have been implicated. Indirect evidence from interventions that attenuate tonic peripheral nociceptive impulses in patients with CWP syndromes like FM suggest that overall FM pain is dependent on peripheral input. More importantly, allodynia and hyperalgesia can be improved or abolished by removal of peripheral impulse input. Another potential mechanism for CWP pain is central disinhibition. However, this pain mechanism also depends on tonic impulse input, even if only inadequately inhibited. Thus, a promising approach to understanding CWP is to determine whether abnormal activity of receptors in deep tissues is fundamental to the development and maintenance of this chronic pain disorder. CONCLUSIONS Most CWP patients present with focal tissue abnormalities including myofascial trigger points, ligamentous trigger points or osteoarthritis of the joints and spine. While not predictive for the development of CWP, these changes nevertheless represent important pain generators that may initiate or perpetuate chronic pain. Local chemical mediators, including lactic acid, adenosine triphosphate (ATP) and cytokines, seem to play an important role in sensitising deep tissue nociceptors of CWP patients. Thus, the combination of peripheral impulse input and increased central pain sensitivity may be responsible for widespread chronic pain disorders including FM.
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Affiliation(s)
- Roland Staud
- Division of Rheumatology and Clinical Immunology, McKnight Brain Institute, University of Florida, Gainesville, FL 32610, USA.
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Effect of tens on pain in relation to central sensitization in patients with osteoarthritis of the knee: study protocol of a randomized controlled trial. Trials 2012; 13:21. [PMID: 22353582 PMCID: PMC3307484 DOI: 10.1186/1745-6215-13-21] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/09/2011] [Accepted: 02/21/2012] [Indexed: 11/10/2022] Open
Abstract
Background Central sensitization has recently been documented in patients with knee osteoarthritis (OAk). So far, the presence of central sensitization has not been considered as a confounding factor in studies assessing the pain inhibitory effect of tens on osteoarthritis of the knee. The purpose of this study is to explore the pain inhibitory effect of burst tens in OAk patients and to explore the prognostic value of central sensitization on the pain inhibitory effect of tens in OAk patients. Methods Patients with knee pain due to OAk will be recruited through advertisements in local media. Temporal summation, before and after a heterotopic noxious conditioning stimulation, will be measured. In addition, pain on a numeric rating score, WOMAC subscores for pain and function and global perceived effect will be assessed. Patients will be randomly allocated to one of two treatment groups (tens, sham tens). Follow-up measurements will be scheduled after a period of 6 and 12 weeks. Discussion Tens influences pain through the electrical stimulation of low-threshold A-beta cutaneous fibers. The responsiveness of central pain-signaling neurons of centrally sensitized OAk patients may be augmented to the input of these electrical stimuli. This would encompass an adverse therapy effect of tens. To increase treatment effectiveness it might be interesting to identify a subgroup of symptomatic OAk patients, i.e., non-sensitized patients, who are likely to benefit from burst tens. Trial Registration ClinicalTrials.gov: NCT01390285
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Nijs J, Meeus M, Van Oosterwijck J, Ickmans K, Moorkens G, Hans G, De Clerck LS. In the mind or in the brain? Scientific evidence for central sensitisation in chronic fatigue syndrome. Eur J Clin Invest 2012; 42:203-12. [PMID: 21793823 DOI: 10.1111/j.1365-2362.2011.02575.x] [Citation(s) in RCA: 127] [Impact Index Per Article: 10.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/04/2023]
Abstract
BACKGROUND Central sensitisation entails several top-down and bottom-up mechanisms, all contributing to the hyperresponsiveness of the central nervous system to a variety of inputs. In the late nineties, it was first hypothesised that chronic fatigue syndrome (CFS) is characterised by hypersensitivity of the central nervous system (i.e. central sensitisation). Since then, several studies have examined central sensitisation in patients with CFS. This study provides an overview of such studies. MATERIALS AND METHODS Narrative review. RESULTS Various studies showed generalised hyperalgesia in CFS for a variety of sensory stimuli, including electrical stimulation, mechanical pressure, heat and histamine. Various tissues are affected by generalised hyperalgesia: the skin, muscle tissue and the lungs. Generalised hyperalgesia in CFS is augmented, rather than decreased, following various types of stressors like exercise and noxious heat pain. Endogenous inhibition is not activated in response to exercise and activation of diffuse noxious inhibitory controls following noxious heat application to the skin is delayed. CONCLUSIONS The observation of central sensitisation in CFS is in line with our current understanding of CFS. The presence of central sensitisation in CFS corroborates with the presence of several psychological influences on the illness, the presence of infectious agents and immune dysfunctions and the dysfunctional hypothalamus-pituitary-adrenal axis as seen in these severely debilitated patients.
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Affiliation(s)
- Jo Nijs
- Department of Human Physiology, Vrije Universiteit Brussel (VUB), Brussels, Belgium.
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Bakhtadze MA, Vernon H, Karalkin AV, Pasha SP, Tomashevskiy IO, Soave D. Cerebral Perfusion in Patients With Chronic Neck and Upper Back Pain: Preliminary Observations. J Manipulative Physiol Ther 2012; 35:76-85. [DOI: 10.1016/j.jmpt.2011.12.006] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2011] [Revised: 10/18/2011] [Accepted: 10/27/2011] [Indexed: 11/26/2022]
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111
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Neziri AY, Andersen OK, Petersen-Felix S, Radanov B, Dickenson AH, Scaramozzino P, Arendt-Nielsen L, Curatolo M. The nociceptive withdrawal reflex: Normative values of thresholds and reflex receptive fields. Eur J Pain 2012; 14:134-41. [DOI: 10.1016/j.ejpain.2009.04.010] [Citation(s) in RCA: 58] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/12/2009] [Revised: 04/08/2009] [Accepted: 04/28/2009] [Indexed: 11/15/2022]
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Neziril AY, Scaramozzinol P, Andersenl OK, Dickensonl AH, Arendt-Nielsenl L, Curatolol M. Reference values of mechanical and thermal pain tests in a pain-free population. Eur J Pain 2012; 15:376-83. [DOI: 10.1016/j.ejpain.2010.08.011] [Citation(s) in RCA: 116] [Impact Index Per Article: 9.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/14/2010] [Revised: 08/27/2010] [Accepted: 08/30/2010] [Indexed: 01/15/2023]
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Lemming D, Sörensen J, Graven-Nielsen T, Lauber R, Arendt-Nielsen L, Gerdle B. Managing chronic whiplash associated pain with a combination of low-dose opioid (remifentanil) and NMDA-antagonist (ketamine). Eur J Pain 2012; 11:719-32. [PMID: 17197214 DOI: 10.1016/j.ejpain.2006.11.002] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/07/2006] [Revised: 08/27/2006] [Accepted: 11/03/2006] [Indexed: 10/23/2022]
Abstract
The aim was to investigate the efficacy of a combination of low-dose remifentanil (REMI) and ketamine (KET) compared to the single drugs and placebo (P) on whiplash associated pain (WAD) in a double-blind, randomized, placebo-controlled, cross-over study. Twenty patients with chronic (>1 year) WAD were included. Four different drug combinations were tested in four sessions: placebo/placebo (P/P), placebo/remifentanil (P/REMI), ketamine/placebo (KET/P) and ketamine/remifentanil (KET/REMI). Target concentrations were 1 and 2ng/ml (stepwise) for remifentanil and 100ng/ml for ketamine. Habitual pain intensity was assessed on a visual analogue scale (VAS). Experimental pain was assessed with electrical stimulation (single and repeated) of tibialis anterior (TA) muscle, pressure pain algometry applied over infraspinatus (IS) and TA muscles and VAS scores after intramuscular hypertonic saline infusion in TA. KET/REMI significantly reduced habitual pain. KET/REMI infused at low REMI target concentration (1ng/ml) significantly elevated electrical intramuscular pain thresholds (single and repeated). Pain thresholds to electrical stimulation were similarly increased by both P/REMI and KET/REMI at 2ng/ml target concentration. Pressure pain thresholds were increased by both KET/REMI and P/REMI. VAS-scores after intramuscular saline were also similarly decreased by both REMI combinations. Seven out of 20 subjects were non-responders (<50% pain relief). No correlation was found between effects on spontaneous pain and experimental pain. KET/REMI showed an analgesic effect on habitual pain. Experimental pain was attenuated by both combinations containing the opioid, however, KET seemed to enhance the effect of REMI on electrical pain thresholds when a low REMI target concentration was used.
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Affiliation(s)
- Dag Lemming
- Pain and Rehabilitation Centre, University Hospital, Linköping, Sweden
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114
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O'Neill S, Manniche C, Graven-Nielsen T, Arendt-Nielsen L. Generalized deep-tissue hyperalgesia in patients with chronic low-back pain. Eur J Pain 2012; 11:415-20. [PMID: 16815054 DOI: 10.1016/j.ejpain.2006.05.009] [Citation(s) in RCA: 216] [Impact Index Per Article: 18.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2005] [Revised: 04/24/2006] [Accepted: 05/23/2006] [Indexed: 11/16/2022]
Abstract
Some chronic painful conditions including e.g. fibromyalgia, whiplash associated disorders, endometriosis, and irritable bowel syndrome are associated with generalized musculoskeletal hyperalgesia. The aim of the present study was to determine whether generalized deep-tissue hyperalgesia could be demonstrated in a group of patients with chronic low-back pain with intervertebral disc herniation. Twelve patients with MRI confirmed lumbar intervertebral disc herniation and 12 age and sex matched controls were included. Subjects were exposed to quantitative nociceptive stimuli to the infraspinatus and anterior tibialis muscles. Mechanical pressure (thresholds and supra-threshold) and injection of hypertonic saline (pain intensity, duration, distribution) were used. Pain intensity to experimental stimuli was assessed on a visual analogue scale (VAS). Patients demonstrated significantly higher pain intensity (VAS), duration, and larger areas of pain referral following saline injection in both infraspinatus and tibialis anterior. The patients rated significantly higher pain intensity to supra-threshold mechanical pressure stimulation in both muscles. In patients, the pressure pain-threshold was lower in the anterior tibialis muscle compared to controls. In conclusion, generalized deep-tissue hyperalgesia was demonstrated in chronic low-back pain patients with radiating pain and MRI confirmed intervertebral disc herniation, suggesting that this central sensitization should also be addressed in the pain management regimes.
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Affiliation(s)
- Søren O'Neill
- Human Locomotion Science, University of Southern Denmark, Odense, Denmark
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115
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Kosek E, Januszewska A. Mechanisms of pain referral in patients with whiplash associated disorder. Eur J Pain 2012; 12:650-60. [DOI: 10.1016/j.ejpain.2007.10.006] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/21/2007] [Revised: 09/21/2007] [Accepted: 10/21/2007] [Indexed: 10/22/2022]
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Linnman C, Appel L, Söderlund A, Frans Ö, Engler H, Furmark T, Gordh T, Långström B, Fredrikson M. Chronic whiplash symptoms are related to altered regional cerebral blood flow in the resting state. Eur J Pain 2012; 13:65-70. [DOI: 10.1016/j.ejpain.2008.03.001] [Citation(s) in RCA: 31] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/04/2007] [Revised: 03/04/2008] [Accepted: 03/04/2008] [Indexed: 11/16/2022]
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Potential processes involved in the initiation and maintenance of whiplash-associated disorders: discussion paper 3. Spine (Phila Pa 1976) 2011; 36:S322-9. [PMID: 22101752 DOI: 10.1097/brs.0b013e318238853f] [Citation(s) in RCA: 37] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
STUDY DESIGN Nonsystematic review and discussion of the etiological processes involved in whiplash-associated disorders (WAD). OBJECTIVE To summarize the research and identify priorities for future research. SUMMARY OF BACKGROUND DATA Although there is convergent evidence of a peripheral lesion in some individuals after whiplash injury, in the majority of injured people, a lesion cannot be established with current imaging technology. Therefore, it is important to consider processes that underlie the initiation and maintenance of whiplash pain as this may allow for the development and testing of interventions to target these processes and improve outcomes. METHODS A nonsystematic review was performed to summarize current knowledge regarding potential etiological processes involved in the initiation and maintenance of WAD and to identify future research priorities. RESULTS There are several etiological processes potentially involved in the initiation and maintenance of WAD. These include augmented nociceptive processing, stress system responses, and psychosocial and sociocultural factors. Recent findings also indicate that morphological changes in the neck muscles of injured people show some association with poor recovery, but the mechanisms underlying these changes are not clear. Preliminary evidence indicates associations between these processes. Future research priorities include the following: more sophisticated investigation and analysis of interactions between the various processes; whether the modification of these processes is achievable and if modification can improve health outcomes; and to clarify factors involved in the initiation of whiplash pain versus those involved in symptom maintenance. CONCLUSION Research to date indicates that there are several physiological and psychological etiological processes that may underlie the initiation and maintenance of whiplash-related pain and disability. Further research is required to determine relationships and interactions between these factors and to determine whether their modification is possible and will improve outcomes after injury.
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Abstract
STUDY DESIGN A narrative description highlighting preclinical and clinical evidence that physiologic stress systems contribute to whiplash-associated disorders (WAD) pathogenesis. OBJECTIVE To present several lines of evidence supporting the hypothesis that physiologic stress systems contribute to WAD pathogenesis. SUMMARY OF BACKGROUND DATA In addition to subjecting soft tissue to biomechanical strain, a motor vehicle collision (MVC) event is also an acute stressor which activates physiologic stress systems. Increasing data from animal and human studies suggest that the activation of these stress systems may contribute to long-lasting changes in pain sensitivity after tissue injury. METHODS Nonsystematic review of several lines of evidence that together suggest that physiologic systems involved in the stress response may contribute to the development of WAD. RESULTS Stress systems which appear capable of producing hyperalgesia and allodynia include catecholaminergic systems, serotonin systems, and the hypothalamic-pituitary-adrenocortical system. Evidence for the role of these systems comes, in part, from studies examining the association between genetic variants and chronic pain outcomes. For example, in a recent study of acute neck pain after MVC, patients with certain genotypes of an enzyme involved in catecholamine metabolism were more than twice as likely to report moderate or severe neck pain in the emergency department. Such pain vulnerability because of stress system function may interact with the effects of biomechanical injury and psychobehavioral responses to influence the development of WAD. CONCLUSION More research examining the influence of stress systems on WAD are needed. If these systems do influence WAD outcomes, then treatments which diminish the adverse effects of stress systems may be a useful component of multimodal therapeutic interventions for individuals at risk of chronic pain development after MVC.
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The risk assessment score in acute whiplash injury predicts outcome and reflects biopsychosocial factors. Spine (Phila Pa 1976) 2011; 36:S263-7. [PMID: 22020622 DOI: 10.1097/brs.0b013e31823881d6] [Citation(s) in RCA: 30] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
STUDY DESIGN One-year prospective study of 141 acute whiplash patients (WLP) and 40 acute ankle-injured controls. OBJECTIVE This study investigates a priori determined potential risk factors to develop a risk assessment tool, for which the expediency was examined. SUMMARY OF BACKGROUND DATA The whiplash-associated disorders (WAD) grading system that emerged from The Quebec Task-Force-on-Whiplash has been of limited value for predicting work-related recovery and for explaining biopsychosocial disability after whiplash and new predictive factors, for example, risk criteria that comprehensively differentiate acute WLP in a biopsychosocial manner are needed. METHODS Consecutively, 141 acute WLP and 40 ankle-injured recruited from emergency units were examined after 1 week, 1, 3, 6, and 12 months obtaining neck/head visual analog scale score, number of nonpainful complaints, epidemiological, social, psychological data and neurological examination, active neck mobility, and furthermore muscle tenderness and pain response, and strength and duration of neck muscles. Risk factors derived (reduced cervical range of motion, intense neck pain/headache, multiple nonpain complaints) were applied in a risk assessment score and divided into seven risk strata. RESULTS A receiver operating characteristics curve for the Risk Assessment Score and 1-year work disability showed an area of 0.90. Risk strata and number of sick days showed a log-linear relationship. In stratum 1 full recovery was encountered, but for high-risk patients in stratum 6 only 50% and 7 only 20% had returned to work after 1 year (P < 5.4 × 10). Strength measures, psychophysical pain measurements, and psychological and social data (reported elsewhere) showed significant relation to risk strata. CONCLUSION The Risk Assessment score is suggested as a valuable tool for grading WLP early after injury. It has reasonable screening power for encountering work disability and reflects the biopsychosocial nature of whiplash injuries.
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Abstract
STUDY DESIGN A descriptive overview of the relevant literature and the introduction of a new psychological model. OBJECTIVE The fear-avoidance (FA) model and the potential importance of illness beliefs in post-traumatic neck pain are discussed. The causal beliefs-anxiety model is introduced as an adaptation of the FA model, emphasizing the critical role of illness beliefs. SUMMARY OF BACKGROUND DATA Although the FA model is most thoroughly used to investigate chronic low back pain, it seems also highly relevant as a starting point for other chronic pain conditions like whiplash. Kinesophobia and pain catastrophizing form critical components of the FA model. It has been shown that breaking the FA cycle by affecting the critical components of the model may be an effective method to prevent the development of chronicity. METHODS By using the FA model as a starting point, we present the causal beliefs-anxiety model and argue how this might help explain chronic whiplash symptoms and might provide clues for preventive interventions. RESULTS On experiencing muscular neck pain, catastrophizing may give rise to dysfunctional illness beliefs regarding the cause of this pain. The illness identity and other beliefs feed symptom expectation and attribution, as well as expectations regarding the course of muscular neck pain. These negative expectations can contribute to a less favorable outcome or may even cause symptoms. Therefore, it seems important to integrate the alleged role of illness beliefs in an adapted FA model, the "causal beliefs-anxiety model." CONCLUSION In clinical practice, it seems important to have insight into the patient's illness beliefs about the cause of the experienced symptoms. Health care professionals should be aware of the possible detrimental influence of dysfunctional illness beliefs. In the early stage, adequate explanation and information about the probable course may be sufficient to prevent the generation of dysfunctional illness beliefs thereby preventing the development of a chronic course. At the population level, educational campaigns that inform people about probable causes and realistic expectations regarding post-traumatic neck pain could provide an effective strategy for preventing chronic whiplash symptoms.
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Neziri AY, Dickenmann M, Scaramozzino P, Andersen OK, Arendt-Nielsen L, Dickenson AH, Curatolo M. Effect of intravenous tropisetron on modulation of pain and central hypersensitivity in chronic low back pain patients. Pain 2011; 153:311-318. [PMID: 22100357 DOI: 10.1016/j.pain.2011.10.008] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/14/2011] [Revised: 10/04/2011] [Accepted: 10/05/2011] [Indexed: 10/15/2022]
Abstract
The activation of 5-hydroxytryptamine-3 (5-HT-3) receptors in spinal cord can enhance intrinsic spinal mechanisms of central hypersensitivity, possibly leading to exaggerated pain responses. Clinical studies suggest that 5-HT-3 receptor antagonists may have an analgesic effect. This randomized, double-blind, placebo-controlled crossover study tested the hypothesis that the 5-HT-3 receptor antagonist tropisetron attenuates pain and central hypersensitivity in patients with chronic low back pain. Thirty patients with chronic low back pain, 15 of whom were women (aged 53 ± 14 years) and 15 men (aged 48 ± 14 years), were studied. A single intravenous injection of 0.9% saline solution, tropisetron 2mg, and tropisetron 5mg was administrated in 3 different sessions, in a double-blind crossover manner. The main outcome was the visual analogue scale (VAS) score of spontaneous low back pain before, and 15, 30, 60, and 90 minutes after drug administration. Secondary outcomes were nociceptive withdrawal reflexes to single and repeated electrical stimulation, area of reflex receptive fields, pressure pain detection and tolerance thresholds, conditioned pain modulation, and area of clinical pain. The data were analyzed by analysis of variance and panel multiple regressions. All 3 treatments reduced VAS scores. However, there was no statistically significant difference between tropisetron and placebo in VAS scores. Compared to placebo, tropisetron produced a statistically significant increase in pain threshold after single electrical stimulation, but no difference in all other secondary outcomes was found. A single-dose intravenous administration of tropisetron in patients with chronic low back pain had no significant specific effect on intensity of pain and most parameters of central hypersensitivity.
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Affiliation(s)
- Alban Y Neziri
- University Department of Anaesthesiology and Pain Therapy, Bern University Hospital, Inselspital, Bern 3010, Switzerland Department of Financial and Management Studies, School of Oriental and African Studies, University of London, London, UK Department of Economics and Institutions, University of Rome Tor Vergata, Rome, Italy Center for Sensory-Motor Interaction, Department of Health Science and Technology, Aalborg University, Aalborg, Denmark Department of Pharmacology, University College London, London, UK
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Arendt-Nielsen L, Hoeck HC. Optimizing the early phase development of new analgesics by human pain biomarkers. Expert Rev Neurother 2011; 11:1631-1651. [DOI: 10.1586/ern.11.147] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/30/2023]
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Dong L, Guarino BB, Jordan-Sciutto KL, Winkelstein BA. Activating transcription factor 4, a mediator of the integrated stress response, is increased in the dorsal root ganglia following painful facet joint distraction. Neuroscience 2011; 193:377-86. [PMID: 21821103 PMCID: PMC3171593 DOI: 10.1016/j.neuroscience.2011.07.059] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/24/2011] [Revised: 07/01/2011] [Accepted: 07/24/2011] [Indexed: 02/06/2023]
Abstract
Chronic neck pain is one of the most common musculoskeletal disorders in the US. Although biomechanical and clinical studies have implicated the facet joint as a primary source of neck pain, specific cellular mechanisms still remain speculative. The purpose of this study was to investigate whether a mediator (activating transcription factor; 4ATF4) of the integrated stress response (ISR) is involved in facet-mediated pain. Holtzman rats underwent C6/C7 facet joint loading that produces either painful (n=16) or nonpainful (n=8) responses. A sham group (n=9) was also included as surgical controls. Behavioral sensitivity was measured and the C6 dorsal root ganglia (DRGs) were harvested on day 7 to evaluate the total and neuronal ATF4 expression. In separate groups, an intra-articular ketorolac injection was administered either immediately (D0 ketorolac) or 1 day (D1 ketorolac) after painful facet joint loading. Allodynia was measured at days 1 and 7 after injury to assess the effects on behavioral responses. ATF4 and BiP (an indicator of ISR activation) were separately quantified at day 7. Facet joint loading sufficient to elicit behavioral hypersensitivity produced a threefold increase in total and neuronal ATF4 expression in the DRG. After ketorolac treatment at the time of injury, ATF4 expression was significantly (P<0.01) reduced despite not producing any attenuation of behavioral responses. Interestingly, ketorolac treatment at day 1 significantly (P<0.001) alleviated behavioral sensitivity at day 7, but did not modify ATF4 expression. BiP expression was unchanged after either intervention time. Results suggest that ATF4-dependent activation of the ISR does not directly contribute to persistent pain, but it may sensitize neurons responsible for pain initiation. These behavioral and immunohistochemical findings imply that facet-mediated pain may be sustained through other pathways of the ISR.
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Affiliation(s)
- Ling Dong
- Department of Bioengineering University of Pennsylvania Philadelphia, PA 19104, USA
| | - Benjamin B. Guarino
- Department of Bioengineering University of Pennsylvania Philadelphia, PA 19104, USA
| | | | - Beth A. Winkelstein
- Department of Bioengineering University of Pennsylvania Philadelphia, PA 19104, USA
- Department of Neurosurgery University of Pennsylvania Philadelphia, PA 19104, USA
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125
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Brandow AM, Weisman SJ, Panepinto JA. The impact of a multidisciplinary pain management model on sickle cell disease pain hospitalizations. Pediatr Blood Cancer 2011; 56:789-93. [PMID: 21370412 PMCID: PMC3069506 DOI: 10.1002/pbc.22874] [Citation(s) in RCA: 24] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/24/2010] [Accepted: 09/20/2010] [Indexed: 11/11/2022]
Abstract
BACKGROUND Sickle cell disease (SCD) pain is acute or chronic, leads to school absenteeism, impaired health-related quality of life and early mortality. Given that little is known about children with SCD and chronic pain, we (1) described characteristics of these children and (2) evaluated the impact of a multidisciplinary pain management model on health care utilization. PROCEDURE A retrospective cohort study of children with SCD evaluated and treated in our institution's multidisciplinary pain clinic between 1999 and 2008 was conducted. Referrals occur when children require chronic opioids and/or have frequent pain hospitalizations. Descriptive statistics evaluated patient characteristics and Wilcoxon-Signed Rank evaluated change in median number of pain hospitalizations 1 year before and after referral. RESULTS Median age of 19 children identified was 15 years (IQR 11-17); significantly more were female (78.9% vs. 21.1%; P = 0.012). At time of referral, all patients reported taking opioids, 68.4% were taking hydroxyurea, half of those not on hydroxyurea started it (n = 3), none were chronically transfused and one initiated transfusions upon referral. Majority (89.5%) learned non-pharmacologic pain management techniques. Median number of pain hospitalizations between the year before and after referral significantly decreased [5(IQR 3-6) to 1(IQR 0-4); P = 0.006]. To further delineate the pain clinic's effect, analysis was repeated after removing children initiating hydroxyurea/transfusions upon referral. The significant decrease in hospitalizations persisted [5(IQR 3-6) to 1(IQR 0-4; P = 0.022]. CONCLUSIONS A multidisciplinary pain management model appears to have decreased SCD pain hospitalizations. Results of this retrospective study will need to be tested in a prospective randomized trial.
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Affiliation(s)
- Amanda M. Brandow
- Section of Pediatric Hematology/Oncology, Milwaukee, WI, United States, Medical College of Wisconsin/Children’s Research Institute of the Children’s Hospital of Wisconsin, Milwaukee, WI, United States
| | - Steven J. Weisman
- Department of Anesthesiology, Milwaukee, WI, United States, Medical College of Wisconsin/Children’s Research Institute of the Children’s Hospital of Wisconsin, Milwaukee, WI, United States
| | - Julie A. Panepinto
- Section of Pediatric Hematology/Oncology, Milwaukee, WI, United States, Medical College of Wisconsin/Children’s Research Institute of the Children’s Hospital of Wisconsin, Milwaukee, WI, United States
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Neziri AY, Curatolo M, Nüesch E, Scaramozzino P, Andersen OK, Arendt-Nielsen L, Jüni P. Factor analysis of responses to thermal, electrical, and mechanical painful stimuli supports the importance of multi-modal pain assessment. Pain 2011; 152:1146-1155. [PMID: 21396782 DOI: 10.1016/j.pain.2011.01.047] [Citation(s) in RCA: 100] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/03/2010] [Revised: 11/21/2010] [Accepted: 01/24/2011] [Indexed: 11/30/2022]
Abstract
During the last decade, a multi-modal approach has been established in human experimental pain research for assessing pain thresholds and responses to various experimental pain modalities. Studies have concluded that differences in responses to pain stimuli are mainly related to variation between individuals rather than variation in response to different stimulus modalities. In a factor analysis of 272 consecutive volunteers (137 men and 135 women) who underwent tests with different experimental pain modalities, it was determined whether responses to different pain modalities represent distinct individual uncorrelated dimensions of pain perception. Volunteers underwent single painful electrical stimulation, repeated painful electrical stimulation (temporal summation), test for reflex receptive field, pressure pain stimulation, heat pain stimulation, cold pain stimulation, and a cold pressor test (ice water test). Five distinct factors were found representing responses to 5 distinct experimental pain modalities: pressure, heat, cold, electrical stimulation, and reflex-receptive fields. Each of the factors explained approximately 8% to 35% of the observed variance, and the 5 factors cumulatively explained 94% of the variance. The correlation between the 5 factors was near null (median ρ=0.00, range -0.03 to 0.05), with 95% confidence intervals for pairwise correlations between 2 factors excluding any relevant correlation. Results were almost similar for analyses stratified according to gender and age. Responses to different experimental pain modalities represent different specific dimensions and should be assessed in combination in future pharmacological and clinical studies to represent the complexity of nociception and pain experience.
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Affiliation(s)
- Alban Y Neziri
- University Department of Anaesthesiology and Pain Therapy, Bern University Hospital, Inselspital, Bern, Switzerland Division of Clinical Epidemiology and Biostatistics, Institute of Social and Preventive Medicine, University of Bern, Switzerland, and Clinical Trial Unit (CTU) Bern, Bern University Hospital, Inselspital, Bern, Switzerland DeFiMS, School of Oriental and African Studies (SOAS), University of London, London, United Kingdom, and DEI, University of Rome Tor Vergata, Rome, Italy Center for Sensory-Motor Interaction, Department of Health Science and Technology, Aalborg University, Aalborg, Denmark
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Neziri AY, Haesler S, Petersen-Felix S, Müller M, Arendt-Nielsen L, Manresa JB, Andersen OK, Curatolo M. Generalized expansion of nociceptive reflex receptive fields in chronic pain patients. Pain 2011; 151:798-805. [PMID: 20926191 DOI: 10.1016/j.pain.2010.09.017] [Citation(s) in RCA: 49] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2010] [Revised: 08/09/2010] [Accepted: 09/13/2010] [Indexed: 11/18/2022]
Abstract
Widespread central hypersensitivity is present in chronic pain and contributes to pain and disability. According to animal studies, expansion of receptive fields of spinal cord neurons is involved in central hypersensitivity. We recently developed a method to quantify nociceptive receptive fields in humans using spinal withdrawal reflexes. Here we hypothesized that patients with chronic pelvic pain display enlarged reflex receptive fields. Secondary endpoints were subjective pain thresholds and nociceptive withdrawal reflex thresholds after single and repeated (temporal summation) electrical stimulation. 20 patients and 25 pain-free subjects were tested. Electrical stimuli were applied to 10 sites on the foot sole for evoking reflexes in the tibialis anterior muscle. The reflex receptive field was defined as the area of the foot (fraction of the foot sole) from which a muscle contraction was evoked. For the secondary endpoints, the stimuli were applied to the cutaneous innervation area of the sural nerve. Medians (25-75 percentiles) of fraction of the foot sole in patients and controls were 0.48 (0.38-0.54) and 0.33 (0.27-0.39), respectively (P=0.008). Pain and reflex thresholds after sural nerve stimulation were significantly lower in patients than in controls (P<0.001 for all measurements). This study provides for the first time evidence for widespread expansion of reflex receptive fields in chronic pain patients. It thereby identifies a mechanism involved in central hypersensitivity in human chronic pain. Reverting the expansion of nociceptive receptive fields and exploring the prognostic meaning of this phenomenon may become future targets of clinical research.
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Affiliation(s)
- Alban Y Neziri
- University Department of Anesthesiology and Pain Therapy, University Hospital of Bern, Inselspital, 3010 Bern, Switzerland University Department of Obstetrics and Gynecology, University Hospital of Bern, Inselspital, Bern, Switzerland Center for Sensory-Motor Interaction, Department of Health Science and Technology, Aalborg University, Denmark
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Nijs J, Meeus M, Van Oosterwijck J, Roussel N, De Kooning M, Ickmans K, Matic M. Treatment of central sensitization in patients with 'unexplained' chronic pain: what options do we have? Expert Opin Pharmacother 2011; 12:1087-98. [PMID: 21254866 DOI: 10.1517/14656566.2011.547475] [Citation(s) in RCA: 82] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
Abstract
INTRODUCTION Central sensitization accounts for chronic 'unexplained' pain in a wide variety of disorders, including chronic whiplash-associated disorders, temporomandibular disorders, chronic low back pain, osteoarthritis, fibromyalgia, chronic fatigue syndrome and chronic tension-type headache among others. Given the increasing evidence supporting the clinical significance of central sensitization in those with unexplained chronic pain, the awareness is growing that central sensitization should be a treatment target in these patients. AREAS COVERED This article provides an overview of the treatment options available for desensitizing the CNS in patients with chronic pain due to central sensitization. It focuses on those strategies that specifically target pathophysiological mechanisms known to be involved in central sensitization. In addition, pharmacological options, rehabilitation and neurotechnology options are discussed. EXPERT OPINION Acetaminophen, serotonin-reuptake inhibitor drugs, selective and balanced serototin and norepinephrine-reuptake inhibitor drugs, the serotonin precursor tryptophan, opioids, N-methyl-d-aspartate (NMDA)-receptor antagonists, calcium-channel alpha(2)delta (a2δ) ligands, transcranial magnetic stimulation, transcutaneous electric nerve stimulation (TENS), manual therapy and stress management each target central pain processing mechanisms in animals that - theoretically - desensitize the CNS in humans. To provide a comprehensive treatment for 'unexplained' chronic pain disorders characterized by central sensitization, it is advocated to combine the best evidence available with treatment modalities known to target central sensitization.
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Affiliation(s)
- Jo Nijs
- Artesis University College Antwerp, Antwerp, Belgium.
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129
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Reduced force steadiness in women with neck pain and the effect of short term vibration. J Electromyogr Kinesiol 2010; 21:283-90. [PMID: 21195628 DOI: 10.1016/j.jelekin.2010.11.011] [Citation(s) in RCA: 39] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2010] [Revised: 11/02/2010] [Accepted: 11/29/2010] [Indexed: 11/21/2022] Open
Abstract
This study compares neck force steadiness in women with neck pain and controls and the way this is influenced by short term vibration of the neck. In the first experiment, 9 women with chronic neck pain and 9 controls performed 10-s isometric cervical flexion at 15N. Intramuscular EMG was recorded from the sternocleidomastoid muscle. In the second experiment, 10 women with neck pain and 10 controls performed 10-s isometric cervical flexion at 25% of their maximal force before and after vibration to the neck (bursts of 50Hz with duration 20, 40, 60 and 120s). Surface EMG was acquired from the sternocleidomastoid and splenius capitis. In both experiments, force steadiness was characterized by the coefficient of variation (CoV) and the relative power in three frequency subbands (low: 0-3Hz; middle: 4-6Hz; high: 8-12Hz) of the force signal. Women with neck pain exhibited decreased force steadiness (Exp 1: patients 3.9±1.3%, controls 2.7±0.9%, P<0.05; Exp 2: patients 3.4±1.2%, controls 1.7±0.6%, P<0.01) which was associated with higher power in the low-frequency band (patients 71.2±9.6%, controls 56.7±9.2%, P<0.01). Following vibration, CoV (2.6±1.1%, P<0.05) and the power in the low-frequency band of the force signal decreased (63.1±13.9%, P<0.05) in the patient group. These effects were not present in controls. Motor unit behavior and surface EMG amplitude were similar between groups. In conclusion, women with neck pain have reduced force steadiness, likely due to alterations in Ia afferent input. Vibration, which modulates Ia afferent input, increases force steadiness in patients with neck pain.
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130
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Woolf CJ. Central sensitization: implications for the diagnosis and treatment of pain. Pain 2010; 152:S2-S15. [PMID: 20961685 DOI: 10.1016/j.pain.2010.09.030] [Citation(s) in RCA: 2656] [Impact Index Per Article: 189.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/09/2010] [Revised: 09/24/2010] [Accepted: 09/24/2010] [Indexed: 02/07/2023]
Abstract
Nociceptor inputs can trigger a prolonged but reversible increase in the excitability and synaptic efficacy of neurons in central nociceptive pathways, the phenomenon of central sensitization. Central sensitization manifests as pain hypersensitivity, particularly dynamic tactile allodynia, secondary punctate or pressure hyperalgesia, aftersensations, and enhanced temporal summation. It can be readily and rapidly elicited in human volunteers by diverse experimental noxious conditioning stimuli to skin, muscles or viscera, and in addition to producing pain hypersensitivity, results in secondary changes in brain activity that can be detected by electrophysiological or imaging techniques. Studies in clinical cohorts reveal changes in pain sensitivity that have been interpreted as revealing an important contribution of central sensitization to the pain phenotype in patients with fibromyalgia, osteoarthritis, musculoskeletal disorders with generalized pain hypersensitivity, headache, temporomandibular joint disorders, dental pain, neuropathic pain, visceral pain hypersensitivity disorders and post-surgical pain. The comorbidity of those pain hypersensitivity syndromes that present in the absence of inflammation or a neural lesion, their similar pattern of clinical presentation and response to centrally acting analgesics, may reflect a commonality of central sensitization to their pathophysiology. An important question that still needs to be determined is whether there are individuals with a higher inherited propensity for developing central sensitization than others, and if so, whether this conveys an increased risk in both developing conditions with pain hypersensitivity, and their chronification. Diagnostic criteria to establish the presence of central sensitization in patients will greatly assist the phenotyping of patients for choosing treatments that produce analgesia by normalizing hyperexcitable central neural activity. We have certainly come a long way since the first discovery of activity-dependent synaptic plasticity in the spinal cord and the revelation that it occurs and produces pain hypersensitivity in patients. Nevertheless, discovering the genetic and environmental contributors to and objective biomarkers of central sensitization will be highly beneficial, as will additional treatment options to prevent or reduce this prevalent and promiscuous form of pain plasticity.
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Affiliation(s)
- Clifford J Woolf
- Program in Neurobiology and FM Kirby Neurobiology Center, Children's Hospital Boston, Department of Neurobiology, Harvard Medical School, Boston, MA, USA
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131
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He W, Liu X, Zhang Y, Guo SW. Generalized hyperalgesia in women with endometriosis and its resolution following a successful surgery. Reprod Sci 2010; 17:1099-111. [PMID: 20923950 DOI: 10.1177/1933719110381927] [Citation(s) in RCA: 58] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
Abstract
Although pains of various kinds top the list of complaints from women with endometriosis and are the most debilitating of the disease, little is known about the mechanism/mechanisms of endometriosis-associated pains. To test the hypothesis that women with endometriosis have generalized hyperalgesia which may be alleviated by a successful surgery, we recruited 100 patients with surgically and histologically confirmed endometriosis and 70 women without, and tested their responses to pain stimulations. Before the surgery, all patients rated their dysmenorrhea severity by Visual Analog scale (VAS) and went through an ischemic pain test (IPT) and an electrical pain test (EPT). The controls were also administrated with IPT/EPT. Three and 6 months after surgery, all patients were administrated with IPT/EPT and rated their severity of dysmenorrhea. We found that patients with endometriosis had significantly higher IPT VAS scores and lower EPT pain threshold than controls, but after surgery their IPT scores and EPT pain threshold were significantly and progressively improved, along with their dysmenorrhea severity. Thus, we conclude that women with endometriosis have generalized hyperalgesia, which was alleviated by surgery. Consequently, central sensitization may be a possible mechanism underlying various forms of pain associated with endometriosis, and its recognition should have important implications for the development of novel therapeutics and better clinical management of endometriosis.
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Affiliation(s)
- Weiwei He
- Shanghai OB/GYN Hospital, Fudan University, Shanghai, China
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132
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Dysfunction of endogenous pain inhibition during exercise with painful muscles in patients with shoulder myalgia and fibromyalgia. Pain 2010; 151:77-86. [DOI: 10.1016/j.pain.2010.06.021] [Citation(s) in RCA: 163] [Impact Index Per Article: 11.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/19/2009] [Revised: 04/26/2010] [Accepted: 06/18/2010] [Indexed: 11/21/2022]
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133
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134
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Biurrun Manresa JA, Neziri AY, Curatolo M, Arendt-Nielsen L, Andersen OK. Test–retest reliability of the nociceptive withdrawal reflex and electrical pain thresholds after single and repeated stimulation in patients with chronic low back pain. Eur J Appl Physiol 2010; 111:83-92. [DOI: 10.1007/s00421-010-1634-0] [Citation(s) in RCA: 44] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/23/2010] [Indexed: 12/22/2022]
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135
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Javanshir K, Ortega-Santiago R, Mohseni-Bandpei MA, Miangolarra-Page JC, Fernández-de-las-Peñas C. Exploration of Somatosensory Impairments in Subjects With Mechanical Idiopathic Neck Pain: A Preliminary Study. J Manipulative Physiol Ther 2010; 33:493-9. [DOI: 10.1016/j.jmpt.2010.08.022] [Citation(s) in RCA: 42] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/28/2010] [Revised: 06/06/2010] [Accepted: 06/27/2010] [Indexed: 11/25/2022]
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136
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Quinn KP, Dong L, Golder FJ, Winkelstein BA. Neuronal hyperexcitability in the dorsal horn after painful facet joint injury. Pain 2010; 151:414-421. [PMID: 20739124 DOI: 10.1016/j.pain.2010.07.034] [Citation(s) in RCA: 55] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/02/2010] [Revised: 06/23/2010] [Accepted: 07/31/2010] [Indexed: 12/24/2022]
Abstract
Excessive cervical facet capsular ligament stretch has been implicated as a cause of whiplash-associated disorders following rear-end impacts, but the pathophysiological mechanisms that produce chronic pain in these cases remain unclear. Using a rat model of C6-C7 cervical facet joint capsule stretch that produces sustained mechanical hyperalgesia, the presence of neuronal hyperexcitability was characterized 7 days after joint loading. Extracellular recordings of spinal dorsal horn neuronal activity between C6 and C8 (117 neurons) were obtained from anesthetized rats, with both painful and non-painful behavioral outcomes established by the magnitude of capsule stretch. The frequency of neuronal firing during noxious pinch (p<0.0182) and von Frey filaments applications (4-26g) to the forepaw was increased (p<0.0156) in the painful group compared to the non-painful and sham groups. In addition, the incidence and frequency of spontaneous and after discharge firing were greater in the painful group (p<0.0307) relative to sham. The proportion of cells in the deep laminae that responded as wide dynamic range neurons also was increased in the painful group relative to non-painful or sham groups (p<0.0348). These findings suggest that excessive facet capsule stretch, while not producing visible tearing, can produce functional plasticity of dorsal horn neuronal activity. The increase in neuronal firing across a range of stimulus magnitudes observed at day 7 post-injury provides the first direct evidence of neuronal modulation in the spinal cord following facet joint loading, and suggests that facet-mediated chronic pain following whiplash injury is driven, at least in part, by central sensitization.
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Affiliation(s)
- Kyle P Quinn
- Department of Bioengineering, University of Pennsylvania, Philadelphia, PA, USA Department of Clinical Studies - Philadelphia, School of Veterinary Medicine, University of Pennsylvania, Philadelphia, PA, USA Department of Neurosurgery, University of Pennsylvania, Philadelphia, PA, USA
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137
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Repeated nociceptive stimulation for detecting drug effects. Scand J Pain 2010; 1:142. [DOI: 10.1016/j.sjpain.2010.01.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
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138
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Han SR, Yeo SP, Lee MK, Bae YC, Ahn DK. Early dexamethasone relieves trigeminal neuropathic pain. J Dent Res 2010; 89:915-20. [PMID: 20581355 DOI: 10.1177/0022034510374056] [Citation(s) in RCA: 35] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
The analgesic effects of dexamethasone on neuropathic pain have been controversial. The present study investigated the effects of dexamethasone on mechanical allodynia in rats with mal-positioned dental implants. Under anesthesia, the left mandibular second molar was extracted and replaced by a miniature dental implant to injure the inferior alveolar nerve. Nociceptive behavior was examined on each designated day after surgery. Mal-positioned dental implants significantly decreased air-puff thresholds both ipsilateral and contralateral to the injury site. Distinct mechanical hyperalgesia and cold and thermal hypersensitivity were also observed bilaterally. Daily administration of dexamethasone produced prolonged anti-allodynic effects (25 or 50 mg/kg, i.p.), but failed to reduce mechanical allodynia when it had already been established. Therefore, our findings provide that early treatment with dexamethasone is important in the treatment of nociceptive behavior suggestive of trigeminal neuropathic pain.
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Affiliation(s)
- S R Han
- Department of Oral Physiology, School of Dentistry, Kyungpook National University, 188-1 Sam Deok 2ga, Chung-gu, Daegu (700-412), Korea
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139
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Arendt-Nielsen L, Nie H, Laursen MB, Laursen BS, Madeleine P, Simonsen OH, Graven-Nielsen T. Sensitization in patients with painful knee osteoarthritis. Pain 2010; 149:573-581. [PMID: 20418016 DOI: 10.1016/j.pain.2010.04.003] [Citation(s) in RCA: 719] [Impact Index Per Article: 51.4] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/19/2009] [Revised: 02/24/2010] [Accepted: 04/06/2010] [Indexed: 11/30/2022]
Abstract
Pain is the dominant symptom in osteoarthritis (OA) and sensitization may contribute to the pain severity. This study investigated the role of sensitization in patients with painful knee OA by measuring (1) pressure pain thresholds (PPTs); (2) spreading sensitization; (3) temporal summation to repeated pressure pain stimulation; (4) pain responses after intramuscular hypertonic saline; and (5) pressure pain modulation by heterotopic descending noxious inhibitory control (DNIC). Forty-eight patients with different degrees of knee OA and twenty-four age- and sex-matched control subjects participated. The patients were separated into strong/severe (VAS>or=6) and mild/moderate pain (VAS<6) groups. PPTs were measured from the peripatellar region, tibialis anterior (TA) and extensor carpi radialis longus muscles before, during and after DNIC. Temporal summation to pressure was measured at the most painful site in the peripatellar region and over TA. Patients with severely painful OA pain have significantly lower PPT than controls. For all locations (knee, leg, and arm) significantly negative correlations between VAS and PPT were found (more pain, more sensitization). OA patients showed a significant facilitation of temporal summation from both the knee and TA and had significantly less DNIC as compared with controls. No correlations were found between standard radiological findings and clinical/experimental pain parameters. However, patients with lesions in the lateral tibiofemoral knee compartment had higher pain ratings compared with those with intercondylar and medial lesions. This study highlights the importance of central sensitization as an important manifestation in knee OA.
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Affiliation(s)
- Lars Arendt-Nielsen
- Center for Sensory-Motor Interaction (SMI), Department of Health Science and Technology, Aalborg University, Denmark Clinical Nursing Research Unit, Hobrovej 18-22, Aalborg Hospital, DK-9000 Aalborg, Denmark Northern Orthopaedic Division, Hobrovej 18-22, Aalborg Hospital, DK-9000 Aalborg, Denmark
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140
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Recognition of central sensitization in patients with musculoskeletal pain: Application of pain neurophysiology in manual therapy practice. ACTA ACUST UNITED AC 2010; 15:135-41. [DOI: 10.1016/j.math.2009.12.001] [Citation(s) in RCA: 327] [Impact Index Per Article: 23.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2009] [Accepted: 10/18/2009] [Indexed: 11/23/2022]
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141
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Siegenthaler A, Eichenberger U, Schmidlin K, Arendt-Nielsen L, Curatolo M. What Does Local Tenderness Say About the Origin of Pain? An Investigation of Cervical Zygapophysial Joint Pain. Anesth Analg 2010; 110:923-7. [PMID: 20185669 DOI: 10.1213/ane.0b013e3181cbd8f4] [Citation(s) in RCA: 26] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
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142
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Schneider GM, Smith AD, Hooper A, Stratford P, Schneider KJ, Westaway MD, Frizzell B, Olson L. Minimizing the source of nociception and its concurrent effect on sensory hypersensitivity: an exploratory study in chronic whiplash patients. BMC Musculoskelet Disord 2010; 11:29. [PMID: 20144214 PMCID: PMC2829507 DOI: 10.1186/1471-2474-11-29] [Citation(s) in RCA: 30] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/27/2009] [Accepted: 02/09/2010] [Indexed: 12/21/2022] Open
Abstract
Background The cervical zygapophyseal joints may be a primary source of pain in up to 60% of individuals with chronic whiplash associated disorders (WAD) and may be a contributing factor for peripheral and centrally mediated pain (sensory hypersensitivity). Sensory hypersensitivity has been associated with a poor prognosis. The purpose of the study was to determine if there is a change in measures indicative of sensory hypersensitivity in patients with chronic WAD grade II following a medial branch block (MBB) procedure in the cervical spine. Methods Measures of sensory hypersensitivity were taken via quantitative sensory testing (QST) consisting of pressure pain thresholds (PPT's) and cold pain thresholds (CPT's). In patients with chronic WAD (n = 18), the measures were taken at three sites bilaterally, pre- and post- MBB. Reduced pain thresholds at remote sites have been considered an indicator of central hypersensitivity. A healthy age and gender matched comparison group (n = 18) was measured at baseline. An independent t-test was applied to determine if there were any significant differences between the WAD and normative comparison groups at baseline with respect to cold pain and pressure pain thresholds. A dependent t-test was used to determine whether there were any significant differences between the pre and post intervention cold pain and pressure pain thresholds in the patients with chronic WAD. Results At baseline, PPT's were decreased at all three sites in the WAD group (p < 0.001). Cold pain thresholds were increased in the cervical spine in the WAD group (p < 0.001). Post-MBB, the WAD group showed significant increases in PPT's at all sites (p < 0.05), and significant decreases in CPT's at the cervical spine (p < 0.001). Conclusions The patients with chronic WAD showed evidence of widespread sensory hypersensitivity to mechanical and thermal stimuli. The WAD group revealed decreased sensory hypersensitivity following a decrease in their primary source of pain stemming from the cervical zygapophyseal joints.
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Affiliation(s)
- Geoff M Schneider
- Faculty of Medicine, University of Calgary, Calgary, Alberta, Canada.
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Chien A, Sterling M. Sensory hypoaesthesia is a feature of chronic whiplash but not chronic idiopathic neck pain. ACTA ACUST UNITED AC 2010; 15:48-53. [DOI: 10.1016/j.math.2009.05.012] [Citation(s) in RCA: 54] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/29/2008] [Revised: 05/15/2009] [Accepted: 05/26/2009] [Indexed: 10/20/2022]
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Srbely JZ, Dickey JP, Bent LR, Lee D, Lowerison M. Capsaicin-induced central sensitization evokes segmental increases in trigger point sensitivity in humans. THE JOURNAL OF PAIN 2009; 11:636-43. [PMID: 20015704 DOI: 10.1016/j.jpain.2009.10.005] [Citation(s) in RCA: 49] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/06/2008] [Revised: 09/22/2009] [Accepted: 10/02/2009] [Indexed: 12/19/2022]
Abstract
UNLABELLED This study investigated whether inducing central sensitization evokes segmental increases in trigger point pressure sensitivity. We evoked central sensitization at the C(5) segment and validated its presence via mechanical cutaneous sensitivity (brush allodynia) testing. Trigger point pressure sensitivity was quantified using the pain pressure threshold (PPT) value. A 50 cm(2) area of the C(5) dermatome at the right lateral elbow was pretreated with 45 degrees heat for 10 minutes. Test subjects (n = 20) then received topical capsaicin cream (0.075%; Medicis, Toronto, Canada) to the C(5) dermatome, whereas control subjects (n = 20) received a topical placebo cream (Biotherm Massage, Montreal, Canada). PPT readings were recorded from the infraspinatus (C(5,6)) and gluteus medius (L(4,5)S(1)) trigger points at zero (pre-intervention), 10, 20, and 30 minutes after intervention; all PPT readings were normalized to pre-intervention (baseline) values. The difference between the PPT readings at the 2 trigger point sites represents the direct influence of segmental mechanisms on the trigger point sensitivity at the infraspinatus site (PPT(seg)). Test subjects demonstrated statistically significant increases in Total Allodynia scores and significant decreases in PPT(seg) at 10, 20, and 30 minutes after application, when compared with control subjects. These results demonstrate that increases in central sensitization evoke increases in trigger point pressure sensitivity in segmentally related muscles. PERSPECTIVE Myofascial pain is the most common form of musculoskeletal pain. Myofascial trigger points play an important role in the clinical manifestation of myofascial pain syndrome. Elucidating the role of central sensitization in the pathophysiology of trigger points is fundamental to developing optimal strategies in the management of myofascial pain syndrome.
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Affiliation(s)
- John Z Srbely
- Department of Human Health and Nutritional Sciences, University of Guelph, Guelph, Ontario, Canada.
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Kindler LL, Bennett RM, Jones KD. Central sensitivity syndromes: mounting pathophysiologic evidence to link fibromyalgia with other common chronic pain disorders. Pain Manag Nurs 2009; 12:15-24. [PMID: 21349445 DOI: 10.1016/j.pmn.2009.10.003] [Citation(s) in RCA: 101] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/14/2009] [Revised: 10/22/2009] [Accepted: 10/22/2009] [Indexed: 10/20/2022]
Abstract
The aim of this study was to review emerging data from the fields of nursing, rheumatology, dentistry, gastroenterology, gynecology, neurology, and orthopedics that support or dispute pathophysiologic similarities in pain syndromes studied by each specialty. A literature search was performed through PubMed and Ovid using the terms fibromyalgia, temporomandibular joint disorder, irritable bowel syndrome, irritable bladder/interstitial cystitis, headache, chronic low back pain, chronic neck pain, functional syndromes, and somatization. Each term was linked with pathophysiology and/or central sensitization. This paper presents a review of relevant articles with a specific goal of identifying pathophysiologic findings related to nociceptive processing. The extant literature presents considerable overlap in the pathophysiology of these diagnoses. Given the psychosomatic lens through which many of these disorders are viewed, demonstration of evidence-based links supporting shared pathophysiology between these disorders could provide direction to clinicians and researchers working to treat these diagnoses. "Central sensitivity syndromes" denotes an emerging nomenclature that could be embraced by researchers investigating each of these disorders. Moreover, a shared paradigm would be useful in promoting cross-fertilization between researchers. Scientists and clinicians could most effectively forward the understanding and treatment of fibromyalgia and other common chronic pain disorders through an appreciation of their shared pathophysiology.
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Affiliation(s)
- Lindsay L Kindler
- Center for Comprehensive Pain Research, University of Florida, Gainesville, Florida, USA.
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Spinal manipulative therapy has an immediate effect on thermal pain sensitivity in people with low back pain: a randomized controlled trial. Phys Ther 2009; 89:1292-303. [PMID: 19797305 PMCID: PMC2794479 DOI: 10.2522/ptj.20090058] [Citation(s) in RCA: 115] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
BACKGROUND Current evidence suggests that spinal manipulative therapy (SMT) is effective in the treatment of people with low back pain (LBP); however, the corresponding mechanisms are unknown. Hypoalgesia is associated with SMT and is suggestive of specific mechanisms. OBJECTIVE The primary purpose of this study was to assess the immediate effects of SMT on thermal pain perception in people with LBP. A secondary purpose was to determine whether the resulting hypoalgesia was a local effect and whether psychological influences were associated with changes in pain perception. DESIGN This study was a randomized controlled trial. SETTING A sample of convenience was recruited from community and outpatient clinics. PARTICIPANTS Thirty-six people (10 men, 26 women) currently experiencing LBP participated in the study. The average age of the participants was 32.39 (SD=12.63) years, and the average duration of LBP was 221.79 (SD=365.37) weeks. INTERVENTION AND MEASUREMENTS Baseline demographic and psychological measurements were obtained, followed by quantitative sensory testing to assess temporal summation and Adelta fiber-mediated pain perception. Next, participants were randomly assigned to ride a stationary bicycle, perform low back extension exercises, or receive SMT. Finally, the same quantitative sensory testing protocol was reassessed to determine the immediate effects of each intervention on thermal pain sensitivity. RESULTS Hypoalgesia to Adelta fiber-mediated pain perception was not observed. Group-dependent hypoalgesia of temporal summation specific to the lumbar innervated region was observed. Pair-wise comparisons indicated significant hypoalgesia in participants who received SMT, but not in those who rode a stationary bicycle or performed low back extension exercises. Psychological factors did not significantly correlate with changes in temporal summation in participants who received SMT. LIMITATIONS Only immediate effects of SMT were measured, so the authors are unable to comment on whether the inhibition of temporal summation is a lasting effect. Furthermore, the authors are unable to comment on the relationship between their findings and changes in clinical pain. CONCLUSIONS Inhibition of Adelta fiber-mediated pain perception was similar for all groups. However, inhibition of temporal summation was observed only in participants receiving SMT, suggesting a modulation of dorsal horn excitability that was observed primarily in the lumbar innervated area.
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Rivest K, Côté JN, Dumas JP, Sterling M, De Serres SJ. Relationships between pain thresholds, catastrophizing and gender in acute whiplash injury. ACTA ACUST UNITED AC 2009; 15:154-9. [PMID: 19892580 DOI: 10.1016/j.math.2009.10.001] [Citation(s) in RCA: 53] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/06/2009] [Revised: 09/29/2009] [Accepted: 10/07/2009] [Indexed: 10/20/2022]
Abstract
The mechanisms underlying sensory hypersensitivity (SH) in acute whiplash associated disorders (WAD) are not well understood. We examined the extent of the relationships between the sensory measures of pressure pain threshold (PPT) and cold pain threshold (CPT), catastrophizing, pain and disability levels and gender in acute WAD. Thirty-seven subjects reporting neck pain following a motor vehicle accident were examined within five weeks post-injury. Measures of neck pain and disability (Neck Disability Index, NDI) and catastrophizing (Pain Catastrophizing Scale, PCS) were taken. CPT was assessed in the cervical spine and PPTs were assessed in the cervical spine (PPTcx) and at a remote site (PPTdistal). CPT and PCS were moderately correlated (r=0.46; p < 0.01); however there were no significant relationships between PPT (cervical and distal) and PCS. Both CPT (r=0.55, p < 0.01) and PPTcx (r=-0.42, p < 0.01) were significantly correlated with NDI but PPTdistal was not (r=-0.08, p=0.65). Finally, gender modulated the relationships between sensory measures, catastrophizing, and pain and disability levels. In conclusion, subjects with higher levels of catastrophizing presented with sensory hypersensitivity to cold stimuli in the acute phase of whiplash. Differences between genders are in accordance with the growing body of evidence suggesting that the relationships between some psychological factors and injury-related symptoms are modulated by gender.
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Affiliation(s)
- Karine Rivest
- CRIR, Jewish Rehabilitation Hospital site, Research Center, 3205 Place Alton Goldbloom, Laval, Quebec, Canada H7V 1R2.
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Sterling M, Pedler A, Chan C, Puglisi M, Vuvan V, Vicenzino B. Cervical lateral glide increases nociceptive flexion reflex threshold but not pressure or thermal pain thresholds in chronic whiplash associated disorders: A pilot randomised controlled trial. ACTA ACUST UNITED AC 2009; 15:149-53. [PMID: 19884037 DOI: 10.1016/j.math.2009.09.004] [Citation(s) in RCA: 47] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/09/2008] [Revised: 09/05/2009] [Accepted: 09/30/2009] [Indexed: 10/20/2022]
Abstract
Sensory hypersensitivity indicative of augmented central pain processing is a feature of chronic whiplash associated disorders (WAD). This study investigated the immediate effects of a cervical spine manual therapy (SMT) technique on measures of central hyperexcitability. In a randomised, single blind, clinical trial, 39 participants with chronic WAD were randomly assigned to a cervical SMT (lateral glide) or manual contact intervention. The Neck Disability Index (NDI) and GHQ-28 were administered at baseline. Pressure pain thresholds (PPTs), thermal pain thresholds (TPTs) and Nociceptive Flexion Reflex (NFR) responses (threshold and VAS of pain) were measured pre and post intervention. There was a significantly greater increase in NFR threshold following SMT compared to the manual contact intervention (p = 0.04). PPTs at the cervical spine increased following both SMT (mean +/- SE: 24.1 +/- 7.3%) and manual contact (21 +/- 8.4%) with no difference between interventions. There was no difference between interventions for pain ratings with the NFR test, PPTs at the Median Nerve or Tibialis Anterior, heat or cold TPT. SMT may be effective in reducing spinal hyperexcitability in chronic WAD.
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Affiliation(s)
- Michele Sterling
- Centre for National Research on Disability and Rehabilitation Medicine (CONROD), The University of Queensland, Herston Rd, Herston, Brisbane 4006, Queensland, Australia.
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21 Topical Seminar Summary: CENTRAL HYPERSENSITIVITY IN MUSCULOSKELETAL PAIN. Eur J Pain 2009. [DOI: 10.1016/s1090-3801(09)60024-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
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