Pain: past, present and future

Cross-Education Effects of Isokinetic Eccentric Plantarflexor Training on Flexibility, Strength, and Muscle-Tendon Mechanics

INTRODUCTION

Large increases in joint range of motion (ROM) have been reported after eccentric resistance training; however, limited data exist describing the associated mechanisms or potential cross-education effects in the contralateral limb. Therefore, the effects of a 6-wk isokinetic eccentric plantarflexor training program were examined in 26 participants.

METHODS

Before and after the training program, dorsiflexion ROM, plantarflexor strength, and muscle-tendon unit (MTU) morphology and mechanics were measured in control ( n = 13) and experimental ( n = 13) young adult groups. Training consisted of 5 sets of 12 maximal isokinetic eccentric plantarflexor contractions twice weekly on the right limb.

RESULTS

Significant ( P < 0.05) increases in dorsiflexion ROM (4.0-9.5°), stretch tolerance (40.3-95.9%), passive elastic energy storage (47.5-161.3%), and isometric (38.1-40.6%) and eccentric (46.7-67.0%) peak plantarflexor torques were detected in both trained and contralateral limbs in the experimental group. Significant increases in gastrocnemius medialis and soleus thickness (5.4-6.1%), gastrocnemius medialis fascicle length (7.6 ± 8.5%), passive plantarflexor MTU stiffness (30.1 ± 35.5%), and Achilles tendon stiffness (5.3 ± 4.9%) were observed in the trained limb only. Significant correlations were detected between the changes in trained and contralateral limbs for dorsiflexion ROM ( r = 0.59) and both isometric ( r = 0.79) and eccentric ( r = 0.73) peak torques. No significant changes in any metric were detected in the control group.

CONCLUSIONS

Large ROM increases in the trained limb were associated with neurological, mechanical, and structural adaptations, with evidence of a cross-education effect in the contralateral limb being primarily driven by neurological adaptation (stretch tolerance). The large improvements in ROM, muscle size, and strength confirm that isokinetic eccentric training is a highly effective training tool, with potential for use in athletic and clinical populations where MTU function is impaired and current therapies are ineffective.

Virtual Reality Animal Rescue World: Pediatric virtual reality analgesia during just noticeable pressure pain in children aged 2-10 years old (crossover design)

BACKGROUND AND AIMS

Excessive pain during medical procedures is a worldwide medical problem. Most scald burns occur in children under 6, who are often undermedicated. Adjunctive Virtual Reality (VR) distraction has been shown to reduce pain in children aged 6-17, but little is known about VR analgesia in young children. This study tests whether desktop VR (VR Animal Rescue World) can reduce the just noticeable pressure pain of children aged 2-10.

METHODS

A within-subject repeated measures design was used. With treatment order randomized, each healthy volunteer pediatric participant underwent brief cutaneous pressure stimuli under three conditions: (1) no distraction, (2) a verbal color naming task (no VR), and (3) a large TV-based desktop VR distraction. A hand-held Wagner pressure pain stimulation device was used to generate just noticeable pain sensations. Participants indicated when a steadily increasing non-painful pressure stimulus first turned into a painful pressure sensation (just noticeable pain).

RESULTS

A total of 40 healthy children participated (43% aged 2-5 years; and 57% aged 6-10 years). Compared to the no distraction condition, the 40 children showed significant VR analgesia (i.e., a significant reduction in pain sensitivity during the VR Animal Rescue World condition), t(39) = 9.83, p < 0.001, SD = 6.24. VR was also significantly more effective at reducing pain sensitivity vs. an auditory color naming task, t(39) = 5.42, p < 0.001, SD = 5.94. The subset of children aged 2-5 showed significant reductions in pain during VR. Children under 6 showed greater sensitivity to pain during no distraction than children aged 6-10.

CONCLUSION

During no distraction, children under 6 years old were significantly more sensitive to pain than children aged 6-10. Virtual reality (VR) significantly reduced the "just noticeable" pressure pain sensitivity of children in both age groups.

Phantom bite syndrome: Revelation from clinically focused review

Phantom bite syndrome (PBS), also called occlusal dysesthesia, is characterized by persistent non-verifiable occlusal discrepancies. Such erroneous and unshakable belief of a “wrong bite” might impel patients to visit multiple dental clinics to meet their requirements to their satisfaction. Subsequently, it takes a toll on their quality of life causing, career disruption, financial loss and suicidal thoughts. In general, patients with PBS are quite rare but distinguishable if ever encountered. Since Marbach reported the first two cases in 1976, there have been dozens of published cases regarding this phenomenon, but only a few original studies were conducted. Despite the lack of official classification and guidelines, many authors agreed on the existence of a PBS “consistent pattern” that clinicians should be made aware. Nevertheless, the treatment approach has been solely based on incomplete knowledge of etiology, in which none of the proposed theories are fully explained in all the available cases. In this review, we have discussed the critical role of enhancing dental professionals’ awareness of this phenomenon and suggested a comprehensive approach for PBS, provided by a multidisciplinary team of dentists, psychiatrists and exclusive psychotherapists.

Body image is more negative in patients with chronic low back pain than in patients with subacute low back pain and healthy controls

Background and aims Body image as an increasing research field has been integrated into pain research within the last years. However, research on cognitive-affective dimensions of body image dependent on different pain groups like acute/subacute and chronic pain patients, and healthy controls is still lacking. Therefore, this study aims to explore three dimensions of body image, namely self-acceptance, physical efficacy, and health in patients with low back pain and healthy controls. The present study is the first to distinguish between patients with low back pain in different stages of pain with regard to the concept of body image. In a second step we investigated the differences in exercise frequency between the three groups. Methods Seventy seven patients (53.2% female) suffering from low back pain and 57 healthy controls (42.1% female) filled in a battery of questionnaires in terms of body image, pain parameters and exercise frequency. Results Main results indicate first that patients suffering from chronic low back pain revealed a more negative body image in all three body image-dimensions than healthy controls. Second, patients suffering from subacute pain revealed a more negative body image of physical efficacy compared to the healthy controls. Conclusions Our results suggest that body image is relevant for the treatment of low back pain, because patients suffering from low back pain revealed a more negative body image than healthy controls. Implications To investigate the cognitive-affective dimensions of body image in different patient groups suffering from low back pain seems to be an important aspect for future research to improve therapy options and prevention of low back pain. Future research should also focus on improvements or on positive aspects of body image in patients with low back pain.

Pain Gestures: The Orchestration of Speech and Body Gestures

This article is about the use and function of gestures in pain communication. More specifically how we can communicate an internal bodily experience like pain with the help of gestures. This is of great importance both in everyday situations and in medical consultations of various types. Our focus in this article is on the issues of the gesture as a communicative resource, how verbal and nonverbal communicative resources are related to each other and in what way gestures contribute to the structure of different types of pain. Thirty-seven patients have been interviewed about their pain experiences and the main result is that several communicative modalities are interwoven in the pain accounts. Three different functions of gestures were identified: the pointing, iconic and symbolic functions. The clinical relevance of this approach to gestures in pain communication is to take note of the intricate interplay of different communicative resources used in the pain description, and to emphasize both verbal and nonverbal interaction in the clinical conversation as a resource in the care situation.

Comparison of Boric Acid and Combination Drug of Polymyxin, Neomycin and Hydrocortisone (polymyxin NH) in the Treatment of Acute Otitis Externa

INTRODUCTION

Acute otitis externa is an inflammation of the external auditory canal known as "swimmer's ear". Direct costs including medical treatment, painkillers, antibiotics, steroids or both and indirect costs are also remarkable.

AIM

The aim of this study was to compare the effect of boric acid and polymyxin, neomycin and hydrocortisone composition in the treatment of acute otitis externa.

MATERIALS AND METHODS

This randomized clinical trial was carried out on 80 patients aged more than 17-year-old who were referred to Kashani hospital clinic with a diagnosis of acute otitis externa by otolaryngologist. The patients were randomly allocated to two groups (A: Boric acid and B: polymyxin NH ear drops) and Painkiller was prescribed and administered orally for all patients and in the presence of fever, cellulitis around the ears and neck adenopathy, broad-spectrum systemic antibiotics were used besides topical treatment. Symptoms of patients who were evaluated by a physician includes pain, discharge from the ear, swelling of the ear canal, auricle swelling, tenderness, and ear itching. In addition, pain was evaluated in patients and was recorded by Macgill Pain Questionnaire, in the first, third, seventh and tenth days.

RESULTS

Results showed that itching on third day (p=0.007) and swelling of the ear canal in the examination of the third day (p=0.006) and the seventh day (p=0.001) in the polymyxin NH group was more than those of boric acid group. Overall mean pain based on McGill questionnaire was 11.10±1.49 in boric acid group in the examination on the first day and was 4.05±0.22 in the examination on the tenth day and in the polymyxin NH group, it was 10.9±0.99 on the first day and 4.20±0.40 on the tenth day. In both groups, pain relief was the same and there was no significant difference between two groups (p=0.075).

CONCLUSION

The findings of this study showed slight differences in the effectiveness of the boric acid drug and combination of polymyxin, neomycin and hydrocortisone in the treatment of patients with acute otitis externa that is of clinical significance.

Development, Content Validity, and User Review of a Web-based Multidimensional Pain Diary for Adolescent and Young Adults With Sickle Cell Disease

BACKGROUND

Vaso-occlusive pain, the hallmark of sickle cell disease (SCD), is a major contributor to morbidity, poor health-related quality of life, and health care utilization associated with this disease. There is wide variation in the burden, frequency, and severity of pain experienced by patients with SCD. As compared with health care utilization for pain, a daily pain diary captures the breadth of the pain experience and is a superior measure of pain burden and its impact on patients. Electronic pain diaries based on real-time data capture methods overcome methodological barriers and limitations of paper pain diaries, but their psychometric properties have not been formally established in patients with SCD.

OBJECTIVES

To develop and establish the content validity of a web-based multidimensional pain diary for adolescents and young adults with SCD and conduct an end-user review to refine the prototype.

MATERIALS AND METHODS

Following identification of items, a conceptual model was developed. Interviews with adolescents and young adults with SCD were conducted. Subsequently, end-user review with use of the electronic pain diary prototype was conducted.

RESULTS

Two iterative cycles of in-depth cognitive interviews in adolescents and young adults with SCD informed the design and guided the addition, removal, and modification of items in the multidimensional pain diary. Potential end-users provided positive feedback on the design and prototype of the electronic diary.

CONCLUSION

A multidimensional web-based electronic pain diary for adolescents and young adults with SCD has been developed and content validity and initial end-user reviews have been completed.

Acute effects of contract-relax (CR) stretch versus a modified CR technique

PURPOSE

Contract-relax (CR) stretching increases range of motion (ROM) substantively, however its use in athletic environments is limited as the contractions performed in a highly stretched position require partner assistance, are often painful, and may induce muscle damage. Therefore, the acute effects of performing the contractions 'off stretch' in the anatomical position [stretch-return-contract (SRC)] were compared with traditional CR stretching in 14 healthy human volunteers.

METHODS

Passive ankle joint moment and dorsiflexion ROM were recorded on an isokinetic dynamometer with electromyographic monitoring of the triceps surae, whilst simultaneous real-time motion analysis and ultrasound imaging recorded gastrocnemius medialis muscle and Achilles tendon elongation. The subjects then performed CR or SRC stretches (4 × 10-s stretches and 5-s contractions) randomly on separate days before reassessment.

RESULTS

Significant increases in dorsiflexion ROM (4.1°-4.0°; P < 0.01) and peak passive moment (10.9-15.1%; P < 0.05) and decreases in the slope of the passive moment curve (19.1-13.3%; P < 0.05), muscle stiffness (21.7-21.3%; P < 0.01) and tendon stiffness (20.4-15.7%; P < 0.01) were observed in CR and SRC, respectively. No between-condition differences were found in any measure (P > 0.05).

CONCLUSIONS

Similar mechanical and neurological changes were observed between conditions, indicating that identical mechanisms underpin the ROM improvements. These data have important practical implications for the use of this stretching mode in athletic environments as performing the contractions 'off stretch' eliminates the pain response, reduces the risk of inducing muscle damage, and removes the need for partner assistance. Thus, it represents an equally effective, simpler, and yet potentially safer, stretching paradigm.

A Functional Magnetic Resonance Imaging Study to Investigate the Utility of a Picture Imagination Task in Investigating Neural Responses in Patients with Chronic Musculoskeletal Pain to Daily Physical Activity Photographs

Pain-related anxiety and fear are associated with increased difficulties in attention, increased awareness of pain, impaired disengagement from pain, and can moderate the effects of attentional coping attempts. Accurately assessing the direct impact of pain-related anxiety and fear on pain behavior has proved difficult. Studies have demonstrated no or limited influence of pain-related fear and anxiety on behavior but this may be due to inherent problems with the scales used. Neuroimaging has improved the understanding of neural processes underlying the factors that influence pain perception. This study aimed to establish if a Picture and Imagination Task (PIT), largely developed from the Photographs of Daily Activity (PHODA) assessment tool, could help explore how people living with chronic pain process information about daily activities. Blood oxygenation level dependent (BOLD) functional magnetic resonance imaging (fMRI) was used to compare brain responses in patients with chronic musculoskeletal pain (CMSKP) (n = 15) and healthy controls (n = 15). Subjects were asked to imagine how they would feel mentally and physically if asked to perform daily activities illustrated in PIT. The results found that a number of regions involved in pain processing saw increased BOLD activation in patients compared with controls when undertaking the task and included the insula, anterior cingulate cortex, thalamus and inferior and superior parietal cortices. Similarly, increased BOLD responses in patients compared to controls in the frontal pole, paracingulate and the supplementary motor cortex may be suggestive of a memory component to the responses The amygdala, orbitofrontal cortex, substantia nigra/ventral tegmentum, putamen, thalamus, pallidum, inferior parietal (supramarginal and angular gyrus) and cingulate cortex were also seen to have greater differences in BOLD signal changes in patients compared with controls and many of these regions are also associated with general phobic responses. Therefore, we suggest that PIT is a useful task to explore pain- and movement-related anxiety and fear in fMRI studies. Regions in the Default Mode Network remained active or were less deactivated during the PIT task in patients with CMSKP compared to healthy controls supporting the contention that the DMN is abnormal in patients with CMSKP.

Self-touch modulates the somatosensory evoked P100

It has recently been shown that contact between one's own limbs (self-touch) reduces the perceived intensity of pain, over and above the well-known modulation of pain by simultaneous colocalized tactile input Kammers et al. (Curr Biol 20:1819-1822, 2010). Here, we investigate how self-touch modulates somatosensory evoked potentials (SEPs) evoked by afferent somatosensory input. We show that the P100 SEP component, which has previously been implicated in the conscious perception of a tactile stimulus, is enhanced during self-touch, as compared to when one is touching nothing, an inanimate object, or another person. A follow-up experiment showed that there was no effect of self-touch on SEPs when the body parts in contact were not symmetric. Altogether, our findings suggest the interpretation that the secondary somatosensory cortex might underlie the specific analgesic effect of self-touch.

Comparative effectiveness of B and e vitamins with diclofenac in reducing pain due to osteoarthritis of the knee

Background:

Knee osteoarthritis is one of the most prevalent chronic disorders. Several pharmacological and non pharmacological approaches are used to treat this disease. Today, the effect of B and E vitamins on rheumatology diseases is being discussed. In this study, the efficacy of B and E vitamins accompanied with diclofenac on pain relief in patients with knee osteoarthritis was investigated and compared.

Methods:

In this double-blinded clinical trial, 120 patients with knee osteoarthritis referring training Rheumatology and Orthopedics Clinic of Shahrekord University of Medical sciences were investigated. Of these patients, 12 were excluded throughout the study. The patients underwent treatment in three groups (oral diclofenac + oral B vitamin, oral diclofenac + oral vitamin E, and oral diclofenac + placebo). Pain relief was assessed by visual analogue scale (VAS) questionnaire and morning stiffness and physical function were assessed by WOMAC standard questionnaire at three times; the first examination, two weeks, and three weeks after referring.

Results:

The mean score of WOMAC questionnaire at VASs of knee pain, total pain severity, knee joint stiffness, and function of the last 48 hours decreased significantly in all three groups (diclofenac, E and B vitamins) from the first to third examination (P<0.001). Decrease in VAS of knee pain and function of the last 48 hours was higher in B vitamin group than the diclofenac and E vitamin group (P=0.008) and decrease in total pain severity was reported higher in B vitamin group than E vitamin and diclofenac group (P=0.019). Decrease in knee joint stiffness underwent a similar trend in the three groups.

Conclusion:

In view similar analgesic and anti-inflammatory properties, as well as very few, non prevalent complications of B and E vitamins, use of two or more drugs with a different mechanism of effect seems necessary to enhance their effect on osteoarthritis treatment.

"Imprisoned" in pain: analyzing personal experiences of phantom pain

This article explores the phenomenon of "phantom pain." The analysis is based on personal experiences elicited from individuals who have lost a limb or live with a paralyzed body part. Our study reveals that the ways in which these individuals express their pain experience is an integral aspect of that experience. The material consists of interviews undertaken with men who are living with phantom pain resulting from a traumatic injury. The phenomenological analysis is inspired by Zahavi (J Conscious Stud 8(5-7):151-167, 2001) and Merleau-Ponty (Phenomenology of perception. Routledge and Kegan Paul, London, 1962/2000). On a descriptive level the metaphors these patients invoke to describe their condition reveal immense suffering, such as a feeling of being invaded by insects or of their skin being scorched and stripped from their body. Such metaphors express a dimension of experience concerning the self that is in pain and others whom the sufferer relates to through this pain, as well as the agony that this pain inflicts in the world of lived experience. This pain has had a profound impact on their lives and altered their relationship with self (body), others and the world. Their phantom pain has become a reminder of their formerly intact and functioning body; they describe the contrast between their past and present body as an ambiguous and disturbing experience. We conclude that these sensitive and personalized experiences of phantom pain illuminates how acts of expression--spoken pain--constitute a fundamental dimension of a first-person perspective which contribute to the field of knowledge about "phantom pain".

The efficacy of thermotherapy and cryotherapy on pain relief in patients with acute low back pain, a clinical trial study

INTRODUCTION

Acute low back pain is one of the most common health problems especially in industrialized countries where 75 per cent of the population develop it at least once during their life. This study examined the efficacy of thermotherapy and cryotherapy, alongside a routine pharmacologic treatment, on pain relief in patients with acute low back pain referring an orthopedic clinic in Shahrekord, Iran.

MATERIALS AND METHODS

This clinical trial study was conducted on 87 patients randomly assigned to three (thermotherapy and cryotherapy as intervention, and naproxen as control) groups of 29 each. The first (thermotherapy) group underwent treatment with hot water bag and naproxen, the second (cryotherapy) group was treated with ice and naproxen, and the naproxen group was only treated with naproxen, all for one week. All patients were examined on 0, 3(rd), 8(th), and 15(th) day after the first visit and the data gathered by McGill Pain Questionnaire. The data were analyzed by SPSS software using paired t-test, ANOVA, and chi-square.

RESULTS

In this study, mean age of the patients was 34.48 (20-50) years and 51.72 per cent were female. Thermotherapy patients reported significantly less pain compared to cryotherapy and control (p≤0.05). In thermotherapy and cryotherapy groups, mean pain in the first visit was 12.70±3.7 and 12.06±2.6, and on the 15(th) day after intervention 0.75±0.37 and 2.20±2.12, respectively.

CONCLUSION

The results indicated that the application of thermo-therapy and cryotherapy accompanied with a pharmacologic treatment could relieve pain in the patients with acute low back pain.

Phantom limbs: pain, embodiment, and scientific advances in integrative therapies

Research over the past two decades has begun to identify some of the key mechanisms underlying phantom limb pain and sensations; however, this continues to be a clinically challenging condition to manage. Treatment of phantom pain, like all chronic pain conditions, demands a holistic approach that takes into consideration peripheral, spinal, and central neuroplastic mechanisms. In this review, we focus on nonpharmacological treatments tailored to reverse the maladaptive neuroplasticity associated with phantom pain. Recent scientific advances emerging from interdisciplinary research between neuroscience, virtual reality, robotics, and prosthetics show the greatest promise for alternative embodiment and maintaining the integrity of the multifaceted representation of the body in the brain. Importantly, these advances have been found to prevent and reduce phantom limb pain. In particular, therapies that involve sensory and/or motor retraining, most naturally through the use of integrative prosthetic devices, as well as peripheral (e.g., transcutaneous electrical nerve stimulation) or central (e.g., transcranial magnetic stimulation or deep brain stimulation) stimulation techniques, have been found to both restore the neural representation of the missing limb and to reduce the intensity of phantom pain. While the evidence for the efficacy of these therapies is mounting, but well-controlled and large-scale studies are still needed. WIREs Cogn Sci 2014, 5:221-231. doi: 10.1002/wcs.1277 CONFLICT OF INTEREST: The authors have no financial or other relationship that might lead to a conflict of interest. For further resources related to this article, please visit the WIREs website.

'You don't need a body to feel a body': phantom limb syndrome and corporeal transgression

One of the central tensions within the literature on body studies concerns the degree to which the physical body is constituted by or through language, knowledges, and practices and the degree to which the body has foundational, purely material, or essential attributes. Three theoretical approaches have been at the heart of this debate: social constructionism, phenomenology, and structuration theory. Recently, body studies theorists have challenged scholars to move beyond the widely recognised limitations of dominant theorising by taking into account all three perspectives and conceptualising the body as surface, vehicle, and circuit. Because they embrace agnosticism and relational materialism, science and technology studies scholars are in a distinctive position to answer this call. Proponents fully acknowledge the materiality of the body without espousing essentialist claims by effacing the analytic division between agency and structure. Starting from this perspective, I use the concept of corporeal transgression and the phenomenon of phantom limb to reveal how 'immaterial'--indeed, at times, fictive and fanciful--body parts became socially and materially substantive, engendering transformations within the bodies, minds, and brains of amputees, as well as within the field of neuroscience.

Occlusal dysesthesia: a qualitative systematic review of the epidemiology, aetiology and management

Occlusal dysesthesia refers to a persistent complaint of uncomfortable bite sensation with no obvious occlusal discrepancy. This systematic review aimed to draw a picture of such patients, to present an agreement of previously reported diagnostic criteria and to analyse the evidence level of the recommended management approaches. An electronic search for all relevant reports on occlusal dysesthesia was thoroughly performed based on previous nomenclatures (e.g. phantom bite, occlusal hyperawareness) in PubMed and The Cochrane Library in July, 2011. A total of 84 reports were matched, among which only 11 studies were included after a two-step (abstract and detailed full-text revision) screening process. Additionally, a thorough manual review of reference lists of the included reports enabled the inclusion of two additional studies. Data analysis revealed that 37 occlusal dysesthesia patients presented a mean age of 51.7 ± 10.6 years and were predominantly women (male/female: 1/5.1) with symptom duration of more than 6 years (average: 6.3 ± 7.5 years) and with concomitant psychological disturbances (e.g. mood disorders, somatoform disorders, personality disorders). Only four authors presented diagnostic criteria for occlusal dysesthesia, which served as the basis for an agreement in the diagnostic criteria. Treatment approaches included psychotherapy, cognitive/behaviour therapy, splint therapy and prescription of anti-depressants or anti-anxiety drugs. Classification of evidence level of management approaches, however, revealed that most of them were expert opinions with single- or multiple-case report(s). Future studies are necessary for a deeper understanding of the mechanisms behind the occlusal dysesthesia symptoms, and consequently, for improvements in evidence-based management approaches.

Proprioceptive Neuromuscular Facilitation (PNF): Its Mechanisms and Effects on Range of Motion and Muscular Function

Proprioceptive neuromuscular facilitation (PNF) is common practice for increasing range of motion, though little research has been done to evaluate theories behind it. The purpose of this study was to review possible mechanisms, proposed theories, and physiological changes that occur due to proprioceptive neuromuscular facilitation techniques. Four theoretical mechanisms were identified: autogenic inhibition, reciprocal inhibition, stress relaxation, and the gate control theory. The studies suggest that a combination of these four mechanisms enhance range of motion. When completed prior to exercise, proprioceptive neuromuscular facilitation decreases performance in maximal effort exercises. When this stretching technique is performed consistently and post exercise, it increases athletic performance, along with range of motion. Little investigation has been done regarding the theoretical mechanisms of proprioceptive neuromuscular facilitation, though four mechanisms were identified from the literature. As stated, the main goal of proprioceptive neuromuscular facilitation is to increase range of motion and performance. Studies found both of these to be true when completed under the correct conditions. These mechanisms were found to be plausible; however, further investigation needs to be conducted. All four mechanisms behind the stretching technique explain the reasoning behind the increase in range of motion, as well as in strength and athletic performance. Proprioceptive neuromuscular facilitation shows potential benefits if performed correctly and consistently.

Acoustic analysis and mood classification of pain-relieving music

Listening to preferred music (that which is chosen by the participant) has been shown to be effective in mitigating the effects of pain when compared to silence and a variety of distraction techniques. The wide range of genre, tempo, and structure in music chosen by participants in studies utilizing experimentally induced pain has led to the assertion that structure does not play a significant role, rather listening to preferred music renders the music "functionally equivalent" as regards its effect upon pain perception. This study addresses this assumption and performs detailed analysis of a selection of music chosen from three pain studies. Music analysis showed significant correlation between timbral and tonal aspects of music and measurements of pain tolerance and perceived pain intensity. Mood classification was performed using a hierarchical Gaussian Mixture Model, which indicated the majority of the chosen music expressed contentment. The results suggest that in addition to personal preference, associations with music and the listening context, emotion expressed by music, as defined by its acoustical content, is important to enhancing emotional engagement with music and therefore enhances the level of pain reduction and tolerance.

Understanding the paradox of patient pain and patient satisfaction

Pain, in all probability, is the most common symptom experienced by individuals who interact with health care providers. It is understood as a complex and highly individual experience. This complexity is reflected in the paradoxical relationship between patient satisfaction and patient reported pain scores. Using a holistic, caring approach, nurses can optimize the effect of analgesia and facilitate comfort for the person living in pain. Caring for the patient in pain begins with heartfelt compassion and intention to help the person who is suffering. The author describes how the complex relationship and interchange between the patient and the holistic nurse explains the paradox.

Depression and its correlation with in patients pain in the rheumatology service of a Mexican teaching hospital

The depressive symptoms are associated with chronic pain in this study. A cross-sectional study was performed. A visual analog scale was used to register pain intensity. Depressive symptoms were measured using the Center of Epidemiological Studies (CES-Dr) scale as modified by Eaton and reviewed for use in the Mexican population. The study included 245 patients, with a mean age of 46 years, 86.1% of whom were female. The prevalence of some degree of depression was 55.1%. Patients with fibromyalgia had the highest prevalence of symptoms of depression (78.38%) and major depression (29.73%). Stepwise multiple regressions indicated that the best model (r2 = 0.26) to predict the CES-Dr score included the global pain score (P < 0.0001) and education level (P < 0.004). The Cronbach's alpha of the CES-Dr was high (alpha = 0.888). There was moderate correlation (r = 0.442), P < 0.0001 of the CES-Dr numeric score with the intensity of global pain.

Steps toward massage therapy guidelines: a first report to the profession

The massage profession has grown rapidly since the late 1980s. As with business startups that begin informally and successfully mature into larger enterprises, growth brings new organizational challenges, together with greater visibility and opportunity. The maturation of massage as a health care profession increases the need for a process to formalize the synthesis of massage therapy knowledge from clinical experience and research-to collect what we know and to make such baseline knowledge widely available to practitioners, consumers, and other health care stakeholders. In short, we need to create a process for setting guidelines.The present paper lays out the motivations and framework for creating massage therapy guidelines that are informed both by research and by clinical experience. It also acts as a report to the massage therapy profession and to other stakeholders about the work of the Best Practices Committee of the Massage Therapy Foundation since 2006. And it has the additional goal of providing a health care literature basis for future academic discussions of massage.The discussion here is based on a definition from the Institute of Medicine and on research into the nature of expertise. Guidelines are targeted for submission to the National Guideline Clearinghouse. Challenges in creating guidelines for massage therapy are discussed. Various stakeholders are considered. Current literature from the wider scope of health care is extensively reviewed. Topics addressed include guideline creation, credentialing of complementary and alternative medicine practitioners, definition of competence, and the increasing role of technology (that is, informatics) in managing training and task-necessary competencies. Finally, a process for creation of massage therapy guidelines is proposed. A central feature of the proposal is the use of a "World Café" symposium to elicit knowledge and solutions from diverse experts. The role of transparency and broad and open peer review is emphasized as essential to the usability and credibility of guidelines.

The biochemical origin of pain--proposing a new law of pain: the origin of all pain is inflammation and the inflammatory response. Part 1 of 3--a unifying law of pain

We are proposing a unifying theory or law of pain, which states: the origin of all pain is inflammation and the inflammatory response. The biochemical mediators of inflammation include cytokines, neuropeptides, growth factors and neurotransmitters. Irrespective of the type of pain whether it is acute or chronic pain, peripheral or central pain, nociceptive or neuropathic pain, the underlying origin is inflammation and the inflammatory response. Activation of pain receptors, transmission and modulation of pain signals, neuro plasticity and central sensitization are all one continuum of inflammation and the inflammatory response. Irrespective of the characteristic of the pain, whether it is sharp, dull, aching, burning, stabbing, numbing or tingling, all pain arise from inflammation and the inflammatory response. We are proposing a re-classification and treatment of pain syndromes based upon their inflammatory profile. Treatment of pain syndromes should be based on these principles: 1. Determination of the inflammatory profile of the pain syndrome; 2. Inhibition or suppression of production of the appropriate inflammatory mediators, e.g. with inflammatory mediator blockers or surgical intervention where appropriate; 3. Inhibition or suppression of neuronal afferent and efferent (motor) transmission, e.g. with anti-seizure drugs or local anesthetic blocks; 4. Modulation of neuronal transmission, e.g. with opioid medication. At the L.A. Pain Clinic, we have successfully treated a variety of pain syndromes by utilizing these principles. This theory of the biochemical origin of pain is compatible with, inclusive of, and unifies existing theories and knowledge of the mechanism of pain including the gate control theory, and theories of pre-emptive analgesia, windup and central sensitization.

The role of work stress as a moderating variable in the chronic pain and depression association

OBJECTIVE

This article aims to examine the role of work stress as a moderating variable in the chronic pain-depression association, as well as sex differences in this link.

METHODS

The analyses were carried out using the Canadian Community Health Survey Cycle 1.1. Key variables were chronic pain conditions (fibromyalgia, arthritis/rheumatism, back problems, and migraine headaches), work stress, and depression. The total sample comprises 78,593 working individuals.

RESULTS

In this working sample, 7.6% met criteria for major depression, but the prevalence increased to 12% in those also reporting chronic pain. Both depression and comorbid chronic pain and depression were twice as prevalent in women as in men. Having a chronic pain condition and overall work stress emerged as the strongest predictors of depression. Unexpectedly, however, none of the work stress domains moderated the chronic pain and depression association.

CONCLUSION

The impact of work stress should be considered in the etiology and management of major depression.

Experiencing hypnotizability scale motor items by an amputee: a brief report

The following brief report describes the experiences of a hand and arm amputee following the administration of the Harvard Group Scale of Hypnotic Susceptibility, Form A (HGSHS:A) of Shor and Orne, 1962. The participant passed two of the three motor items involving his missing limb. This report discusses the results of a postsession interview regarding our participant's experiences during hypnosis and briefly discusses phantom limb sensations in general.

The biopsychosocial model and hypothyroidism

This paper comments on the role and emergence of the biopsychosocial model in modern medical literature and health care settings. The evolution of the biopsychosocial model and its close association with modern pain theory is also examined. This paper seeks to discuss the place of this model with respect to the management of hypothyroidism. This discussion represents a forerunner to a randomised control trial that will seek to investigate the effect of a biopsychosocial-based treatment regime on hypothyroidism.

A Conceptual Model of Pain Assessment for Noncommunicative Persons With Dementia

PURPOSE

Our objectives are to present a conceptual model of the pain assessment process in persons with dementia and discuss methods for validating our model within this population.

DESIGN AND METHODS

This conceptual work is based on an integrative review and current pain theory, pain assessment research in demented and nondemented populations, and research on the science of self-report.

RESULTS

We present a multidimensional model of pain assessment that emphasizes the role of the external rater. Our model posits that a nociceptive stimulus leads to pain sensation, followed by pain perception, followed by the exhibition of external signs of pain by the patient, followed by an external rater's observation and interpretation of those external signs. Further, the model specifies the effects of nociceptive stimulus factors on pain sensation; patient-specific factors on pain perception; method-specific factors on external sign observation; and rater-specific factors on external sign interpretation.

IMPLICATIONS

Pain assessment in persons with dementia must go beyond a unidimensional model of pain assessment. This multidimensional model also directly addresses the challenges of using external ratings to assess pain in persons with dementia. Finally, we present clinical recommendations for applying the model to pain assessment endeavors and research recommendations for evaluating models of pain in this population.

Painless Depo-medroxyprogesterone acetate (DMPA) injections using the 'pinch technique'

This study was done to see if pinching the skin, prior to injection of DMPA, would reduce the pain of the injection, as suggested by the gate theory. Seventy-eight patients scheduled to receive DMPA for contraception were enrolled into a randomised controlled trial. The injections were given in the gluteal region, with 39 receiving a pinch before and during the injection, while 39 others received the injection only. They were all asked if the pain was severe. Six of 39 patients in the pinch group were positive for severe pain while 15 of 39 in the injection only group were positive (P = 0.02). This simple technique appears to be useful to ensure compliance for the DMPA injection.

Neural correlates of the prolonged salience of painful stimulation

Pain is a unique class of sensory experience from the perspective of salience. Nonpainful somatosensory stimuli usually require behavioral relevance or voluntary attention to maintain salience. In contrast, painful stimuli tend to have sustained salience even without explicit behavioral relevance or voluntary attention. We have previously identified a frontal-parietal-cingulate network of regions responding transiently to nonpainful sensory events. This network is sensitive to the task relevance and novelty of sensory events and likely represents the salience of events in the sensory environment. Since pain can remain salient for a prolonged period, we hypothesized that this network should show transient responses to the onset or offset of a nonpainful stimulus, but sustained responses throughout the duration of a painful stimulus. To test this hypothesis, we used functional MRI to examine the response of these regions to sustained (60-s) periods of painful and nonpainful transcutaneous electrical nerve stimulation. As predicted, the temporoparietal, inferior frontal, and anterior cingulate cortex showed only transient responses to the onset or offset of nonpainful stimulation, but a sustained response throughout the duration of painful stimulation. These regions therefore show tonic responses to stimuli with tonic salience, supporting a general role for these areas in representing stimulus salience. The thalamus and putamen also responded tonically throughout painful but not nonpainful stimulation. Previous studies have implicated the basal ganglia in supporting voluntary sustained attention. Our findings suggest that the basal ganglia may play a more general role in supporting sustained salience, whether through voluntary or involuntary mechanisms.

Psychiatric assessment and treatment of pediatric pain

TOPIC

The clinical nurse specialist's role as part of a multidisciplinary pain team in assessing and treating children with pain, and children with co-morbid pain and a psychiatric diagnosis.

PURPOSE

To help nurse clinicians use relatively new assessment and treatment strategies in the arena of children's pain, gain a better understanding of pain's co-morbidity with psychiatric problems, and understand the nurse's important role in working with children with pain.

SOURCES

Published literature: Pain assessment, theories of pain, psychiatric assessment, pain and psychiatric co-morbidity, treatment modalities for pain. A case study of a teenage girl with chronic pain and a psychiatric disorder.

CONCLUSIONS

Nursing interventions in pediatric pain assessment and treatment play a vital role in the child's and adolescent's physical and emotional rehabilitation from pain and psychiatric symptoms.

A role for ASIC3 in the modulation of high-intensity pain stimuli

Acid-sensing ion channel 3 (ASIC3), a proton-gated ion channel of the degenerins/epithelial sodium channel (DEG/ENaC) receptor family is expressed predominantly in sensory neurons including nociceptive neurons responding to protons. To study the role of ASIC3 in pain signaling, we generated ASIC3 knockout mice. Mutant animals were healthy and responded normally to most sensory stimuli. However, in behavioral assays for pain responses, ASIC3 null mutant mice displayed a reduced latency to the onset of pain responses, or more pain-related behaviors, when stimuli of moderate to high intensity were used. This unexpected effect seemed independent of the modality of the stimulus and was observed in the acetic acid-induced writhing test (0.6 vs. 0.1-0.5%), in the hot-plate test (52.5 and 55 vs. 50 degrees C), and in tests for mechanically induced pain (tail-pinch vs. von Frey filaments). We postulate that ASIC3 is involved in modulating moderate- to high-intensity pain sensation.

Intradermal ketorolac for reduction of epidural back pain

Between 30 and 45% of all parturients receiving epidural laboring analgesia complain of postpartum back pain. Although long-term or chronic back pain has been reported, our study focuses on acute or short-term back pain that resolves within 72 h. The purpose of this randomized double-blind, placebo-controlled investigation was to determine if a ketorolac/lidocaine intradermal anesthesia combination could decrease post-epidural back pain. A total of 81 non-complicated parturients requesting epidural analgesia were approached for inclusion and randomized to receive either 3 mL of 1% lidocaine (control group) or 3 mL of 1% lidocaine with 6 mg ketorolac (experimental group) for dermal anesthesia. A 0-10 verbal numeric scale was used to assess pain at rest and with activity at 24 and 72 h. Demographics, mode of delivery, and duration of labor were noted. A chi2 test was used to analyse frequency data and a Student's t-test and generalized estimation equation were used to analyze ordinal and interval data. Demographics, mode of delivery and length of labor were similar between groups. Significantly lower verbal numeric scores were noted in the experimental group at the 24-h active measurements after vaginal delivery and at 24 and 72 h for both active and resting measurements after cesarean delivery. Based on these findings it can be recommended that intradermal ketorolac given at the time of epidural catheter placement may result in a reduction in post-epidural back pain in the parturient, especially in the event of cesarean delivery.

Depression and reactivity to stress in older women with rheumatoid arthritis and osteoarthritis

OBJECTIVE

The purpose of this study was to examine the role of depressive symptoms in reactivity to stress and pain in older women with rheumatoid arthritis (RA) and osteoarthritis (OA).

METHODS

Participants were 188 older women with RA (N = 87) and OA (N = 101). They were initially assessed for depressive symptoms and interviewed weekly for 12 to 20 weeks regarding interpersonal stress, arthritis pain, and negative affect.

RESULTS

Hierarchical linear modeling (HLM) revealed that depressive symptoms were related to weekly elevations in arthritis pain, negative events, perceived stress, and negative affect for RA respondents and elevations in arthritis pain and negative affect for OA respondents. HLM analyses also indicated that depressive symptoms were related to increased reactivity to perceived stress and arthritis pain in people with RA, but not those with OA.

CONCLUSIONS

Depression may be related to elevations in pain for people with RA and OA and to elevations in stress and increased reactivity to stress and pain for those with RA.

Theoretical perspectives on the relation between catastrophizing and pain

The tendency to "catastrophize" during painful stimulation contributes to more intense pain experience and increased emotional distress. Catastrophizing has been broadly conceived as an exaggerated negative "mental set" brought to bear during painful experiences. Although findings have been consistent in showing a relation between catastrophizing and pain, research in this area has proceeded in the relative absence of a guiding theoretical framework. This article reviews the literature on the relation between catastrophizing and pain and examines the relative strengths and limitations of different theoretical models that could be advanced to account for the pattern of available findings. The article evaluates the explanatory power of a schema activation model, an appraisal model, an attention model, and a communal coping model of pain perception. It is suggested that catastrophizing might best be viewed from the perspective of hierarchical levels of analysis, where social factors and social goals may play a role in the development and maintenance of catastrophizing, whereas appraisal-related processes may point to the mechanisms that link catastrophizing to pain experience. Directions for future research are suggested.