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Rasmussen TK, Borghammer P, Finnerup NB, Jensen TS, Hansen J, Knudsen K, Singer W, Lamotte G, Terkelsen AJ. Functional and 123I-MIBG scintigraphy assessment of cardiac adrenergic dysfunction in diabetes. Auton Neurosci 2024; 252:103155. [PMID: 38354456 DOI: 10.1016/j.autneu.2024.103155] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/03/2023] [Revised: 01/12/2024] [Accepted: 02/06/2024] [Indexed: 02/16/2024]
Abstract
OBJECTIVES To assess the agreement between clinical cardiovascular adrenergic function and cardiac adrenergic innervation in type 2 diabetes patients (T2D). METHODS Thirty-three patients with T2D were investigated bimodally through (1) a standardized clinical cardiovascular adrenergic assessment, evaluating adequacy of blood pressure responses to the Valsalva maneuver and (2) 123I-meta-iodobenzylguanidine (MIBG) scintigraphy assessing myocardial adrenergic innervation measured as early and delayed heart heart/mediastinum (H/M) ratio, and washout rate (WR). RESULTS T2D patients had significantly lower early and delayed H/M-ratios, and lower WR, compared to laboratory specific reference values. Thirteen patients had an abnormal adrenergic composite autonomic severity score (CASS > 0). Patients with abnormal CASS scores had significantly higher early H/M ratios (1.76 [1.66-1.88] vs. 1.57 [1.49-1.63], p < 0.001), higher delayed H/M ratios (1.64 [1.51:1.73] vs. 1.51 [1.40:1.61] (p = 0.02)), and lower WR (-0.13(0.10) vs -0.05(0.07), p = 0.01). Lower Total Recovery and shorter Pressure Recovery Time responses from the Valsalva maneuver was significantly correlated to lower H/M early (r = 0.55, p = 0.001 and r = 0.5, p = 0.003, respectively) and lower WR for Total Recovery (r = -0.44, p = 0.01). CONCLUSION The present study found impairment of sympathetic innervation in T2D patients based on parameters derived from MIBG cardiac scintigraphy (low early H/M, delayed H/M, and WR). These results confirm prior studies. We found a mechanistically inverted relationship with favourable adrenergic cardiovascular responses being significantly associated unfavourable MIBG indices for H/M early and delayed. This paradoxical relationship needs to be further explored but could indicate adrenergic hypersensitivity in cardiac sympathetic denervated T2D patients.
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Affiliation(s)
- Thorsten K Rasmussen
- Danish Pain Research Center, Department of Clinical Medicine, Aarhus University, Denmark.
| | - Per Borghammer
- Department of Nuclear Medicine and PET, Aarhus University Hospital, Denmark
| | - Nanna B Finnerup
- Danish Pain Research Center, Department of Clinical Medicine, Aarhus University, Denmark; Department of Neurology, Aarhus University Hospital, Denmark
| | - Troels S Jensen
- Danish Pain Research Center, Department of Clinical Medicine, Aarhus University, Denmark
| | - John Hansen
- Department of Health Science and Technology, Aalborg University, Denmark
| | - Karoline Knudsen
- Department of Nuclear Medicine and PET, Aarhus University Hospital, Denmark
| | | | - Guillaume Lamotte
- Movement Disorders and Autonomic Disorders Clinic, University of Utah, USA
| | - Astrid J Terkelsen
- Danish Pain Research Center, Department of Clinical Medicine, Aarhus University, Denmark; Department of Neurology, Aarhus University Hospital, Denmark
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Vinkel MN, Rackauskaite G, Østergaard JR, Finnerup NB, Jensen MP. Pain coping and catastrophizing in youth with and without cerebral palsy. Scand J Pain 2024; 24:sjpain-2023-0062. [PMID: 38451484 DOI: 10.1515/sjpain-2023-0062] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/22/2023] [Accepted: 12/08/2023] [Indexed: 03/08/2024]
Abstract
OBJECTIVES The aim of this study is to compare the use of pain coping strategies and pain catastrophizing in youth with and without cerebral palsy (CP), and to examine how these two groups differ with respect to the associations between pain coping, catastrophizing, and measures of psychological function and sleep disturbance. METHODS Twenty-seven individuals with CP and 49 healthy controls aged 15-22 were included in this cross-sectional observational study. Pain was assessed using a semi-structured interviews and participants completed measures of pain coping, pain catastrophizing, psychological function, and sleep. RESULTS Youth with CP used information seeking and problem solving (p = 0.003, Cohen's d (d) = -0.80) and sought social support (p = 0.044, d = -0.51) less often, and used internalizing as a coping strategy more often (p = 0.045, d = 0.59) than healthy controls. The use of information seeking and problem solving correlated more strongly with measures of depression (p = 0.023, Cohen's f (f) = 0.08) and sleep disturbance (p = 0.022, f = 0.08), while behavioral distraction correlated more strongly with measures of anxiety (p = 0.006, f = 0.11) and sleep disturbance (p = 0.017, f = 0.09) in youth with CP, compared to healthy controls. CONCLUSIONS The study findings raise the possibility that youth with CP may benefit more in terms of psychological function and sleep quality from coping training interventions that focus on behavioral distraction, information seeking, and problem solving. Research to test these ideas in additional samples of youth with CP is warranted.
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Affiliation(s)
- Michael N Vinkel
- Danish Pain Research Center, Department of Clinical Medicine, Aarhus University Hospital, Palle Juul-Jensens Boulevard 165, DK-8200, Aarhus, Denmark
| | - Gija Rackauskaite
- Department of Paediatrics and Adolescent Medicine, Aarhus University Hospital, Aarhus, Denmark
| | - John R Østergaard
- Department of Paediatrics and Adolescent Medicine, Aarhus University Hospital, Aarhus, Denmark
| | - Nanna B Finnerup
- Danish Pain Research Center, Department of Clinical Medicine, Aarhus University Hospital, Palle Juul-Jensens Boulevard 165, DK-8200, Aarhus, Denmark
- Department of Neurology, Aarhus University Hospital, Aarhus, Denmark
| | - Mark P Jensen
- Department of Rehabilitation Medicine, University of Washington, Seattle, USA
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Vollert J, Fardo F, Attal N, Baron R, Bouhassira D, Enax-Krumova EK, Freynhagen R, Hansson P, Jensen TS, Kersebaum D, Maier C, Pogatzki-Zahn E, Rice AS, Sachau J, Schaldemose EL, Segerdahl M, Sendel M, Tölle TR, Finnerup NB, Treede RD. Paradoxical heat sensation as a manifestation of thermal hypesthesia: a study of 1090 patients with lesions of the somatosensory system. Pain 2024; 165:216-224. [PMID: 37578447 PMCID: PMC10723641 DOI: 10.1097/j.pain.0000000000003014] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/23/2023] [Revised: 06/22/2023] [Accepted: 06/26/2023] [Indexed: 08/15/2023]
Abstract
ABSTRACT Paradoxical heat sensation (PHS) is the perception of warmth when the skin is cooled. Paradoxical heat sensation rarely occurs in healthy individuals but more frequently in patients suffering from lesions or disease of the peripheral or central nervous system. To further understand mechanisms and epidemiology of PHS, we evaluated the occurrence of PHS in relation to disease aetiology, pain levels, quantitative sensory testing parameters, and Neuropathic Pain Symptom Inventory (NPSI) items in patients with nervous system lesions. Data of 1090 patients, including NPSI scores from 404 patients, were included in the analysis. We tested 11 quantitative sensory testing parameters for thermal and mechanical detection and pain thresholds, and 10 NPSI items in a multivariate generalised linear model with PHS, aetiology, and pain (yes or no) as fixed effects. In total, 30% of the neuropathic patients reported PHS in contrast to 2% of healthy individuals. The frequency of PHS was not linked to the presence or intensity of pain. Paradoxical heat sensation was more frequent in patients living with polyneuropathy compared with central or unilateral peripheral nerve lesions. Patients who reported PHS demonstrated significantly lower sensitivity to thermal perception, with lower sensitivity to normally painful heat and cold stimuli. Neuropathic Pain Symptom Inventory scores were lower for burning and electric shock-like pain quality for patients with PHS. Our findings suggest that PHS is associated with loss of small thermosensory fibre function normally involved in cold and warm perception. Clinically, presence of PHS could help screening for loss of small fibre function as it is straightforward to measure or self-reported by patients.
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Affiliation(s)
- Jan Vollert
- Pain Research, MSk Lab, Department of Surgery and Cancer, Imperial College, London, United Kingdom
- Division of Neurological Pain Research and Therapy, Department of Neurology, University Hospital Schleswig-Holstein, Campus Kiel, Germany
- Department of Anaesthesiology, Intensive Care and Pain Medicine, University Hospital Muenster, Münster, Germany
- Department of Neurophysiology, Mannheim Center for Translational Neuroscience MCTN, Medical Faculty Mannheim, Ruprecht Karls University, Heidelberg, Germany
| | - Francesca Fardo
- Center of Functionally Integrative Neuroscience, Department of Clinical Medicine, Aarhus University, Aarhus, Denmark
- Danish Pain Research Center, Department of Clinical Medicine, Aarhus University, Aarhus, Denmark
| | - Nadine Attal
- INSERM U-987, Centre d'Evaluation et de Traitement de la Douleur, CHU Ambroise Paré, Boulogne-Billancourt, France, Université Versailles-Saint-Quentin, Versailles, France
| | - Ralf Baron
- Division of Neurological Pain Research and Therapy, Department of Neurology, University Hospital Schleswig-Holstein, Campus Kiel, Germany
| | - Didier Bouhassira
- INSERM U-987, Centre d'Evaluation et de Traitement de la Douleur, CHU Ambroise Paré, Boulogne-Billancourt, France, Université Versailles-Saint-Quentin, Versailles, France
| | - Elena K. Enax-Krumova
- Department of Neurology, BG University Hospital Bergmannsheil gGmbH, Ruhr-University Bochum, Bochum, Germany
| | - Rainer Freynhagen
- Department of Anaesthesiology, Critical Care Medicine, Pain Therapy and Palliative Care, Pain Center Lake Starnberg, Benedictus Hospital, Tutzing, Germany
- Department of Anaesthesiology, Klinikum Rechts der Isar, Technische Universität München, Munich, Germany
| | - Per Hansson
- Department of Pain Management and Research, Division of Emergencies and Critical Care, Oslo University Hospital, Oslo, Norway
- Department of Molecular Medicine and Surgery, Karolinska Institutet, Stockholm, Sweden
| | - Troels S. Jensen
- Danish Pain Research Center, Department of Clinical Medicine, Aarhus University, Aarhus, Denmark
- Department of Neurology, Aarhus University Hospital, Aarhus, Denmark
| | - Dilara Kersebaum
- Division of Neurological Pain Research and Therapy, Department of Neurology, University Hospital Schleswig-Holstein, Campus Kiel, Germany
| | - Christoph Maier
- University Hospital of Pediatrics and Adolescent Medicine, Ruhr-University Bochum, Bochum, Germany
| | - Esther Pogatzki-Zahn
- Department of Anaesthesiology, Intensive Care and Pain Medicine, University Hospital Muenster, Münster, Germany
| | - Andrew S.C. Rice
- Pain Research, MSk Lab, Department of Surgery and Cancer, Imperial College, London, United Kingdom
| | - Juliane Sachau
- Division of Neurological Pain Research and Therapy, Department of Neurology, University Hospital Schleswig-Holstein, Campus Kiel, Germany
| | - Ellen L. Schaldemose
- Danish Pain Research Center, Department of Clinical Medicine, Aarhus University, Aarhus, Denmark
| | - Märta Segerdahl
- Department of Neurobiology, Care Sciences and Society, Karolinska Institutet, Stockholm, Sweden
- MS Medical Consulting, Stockholm, Sweden
| | - Manon Sendel
- Division of Neurological Pain Research and Therapy, Department of Neurology, University Hospital Schleswig-Holstein, Campus Kiel, Germany
| | - Thomas R. Tölle
- Department of Neurology, Klinikum Rechts der Isar, Technische Universität München, Munich, Germany
| | - Nanna B. Finnerup
- Danish Pain Research Center, Department of Clinical Medicine, Aarhus University, Aarhus, Denmark
- Department of Neurology, Aarhus University Hospital, Aarhus, Denmark
| | - Rolf-Detlef Treede
- Department of Neurophysiology, Mannheim Center for Translational Neuroscience MCTN, Medical Faculty Mannheim, Ruprecht Karls University, Heidelberg, Germany
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Rosner J, de Andrade DC, Davis KD, Gustin SM, Kramer JLK, Seal RP, Finnerup NB. Central neuropathic pain. Nat Rev Dis Primers 2023; 9:73. [PMID: 38129427 DOI: 10.1038/s41572-023-00484-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 11/21/2023] [Indexed: 12/23/2023]
Abstract
Central neuropathic pain arises from a lesion or disease of the central somatosensory nervous system such as brain injury, spinal cord injury, stroke, multiple sclerosis or related neuroinflammatory conditions. The incidence of central neuropathic pain differs based on its underlying cause. Individuals with spinal cord injury are at the highest risk; however, central post-stroke pain is the most prevalent form of central neuropathic pain worldwide. The mechanisms that underlie central neuropathic pain are not fully understood, but the pathophysiology likely involves intricate interactions and maladaptive plasticity within spinal circuits and brain circuits associated with nociception and antinociception coupled with neuronal hyperexcitability. Modulation of neuronal activity, neuron-glia and neuro-immune interactions and targeting pain-related alterations in brain connectivity, represent potential therapeutic approaches. Current evidence-based pharmacological treatments include antidepressants and gabapentinoids as first-line options. Non-pharmacological pain management options include self-management strategies, exercise and neuromodulation. A comprehensive pain history and clinical examination form the foundation of central neuropathic pain classification, identification of potential risk factors and stratification of patients for clinical trials. Advanced neurophysiological and neuroimaging techniques hold promise to improve the understanding of mechanisms that underlie central neuropathic pain and as predictive biomarkers of treatment outcome.
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Affiliation(s)
- Jan Rosner
- Danish Pain Research Center, Department of Clinical Medicine, Aarhus University, Aarhus, Denmark
- Spinal Cord Injury Center, Balgrist University Hospital, University of Zurich, Zurich, Switzerland
- Department of Neurology, University Hospital Bern, Inselspital, University of Bern, Bern, Switzerland
| | - Daniel C de Andrade
- Center for Neuroplasticity and Pain (CNAP), Department of Health Science and Technology, Faculty of Medicine, Aalborg University, Aalborg, Denmark
| | - Karen D Davis
- Division of Brain, Imaging and Behaviour, Krembil Brain Institute, Toronto Western Hospital, University Health Network, Toronto, Ontario, Canada
- Department of Surgery and Institute of Medical Science, University of Toronto, Toronto, Ontario, Canada
| | - Sylvia M Gustin
- Centre for Pain IMPACT, Neuroscience Research Australia, Sydney, New South Wales, Australia
- NeuroRecovery Research Hub, School of Psychology, University of New South Wales, Sydney, New South Wales, Australia
| | - John L K Kramer
- International Collaboration on Repair Discoveries, ICORD, University of British Columbia, Vancouver, Canada
- Department of Anaesthesiology, Pharmacology & Therapeutics, Faculty of Medicine, University of British Columbia, Vancouver, Canada
| | - Rebecca P Seal
- Pittsburgh Center for Pain Research, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
- Departments of Neurobiology and Otolaryngology, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
| | - Nanna B Finnerup
- Danish Pain Research Center, Department of Clinical Medicine, Aarhus University, Aarhus, Denmark.
- Department of Neurology, Aarhus University Hospital, Aarhus, Denmark.
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5
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de Andrade DC, Mylius V, Perez-Lloret S, Cury RG, Bannister K, Moisset X, Taricani Kubota G, Finnerup NB, Bouhassira D, Chaudhuri KR, Graven-Nielsen T, Treede RD. Pain in Parkinson disease: mechanistic substrates, main classification systems, and how to make sense out of them. Pain 2023; 164:2425-2434. [PMID: 37318012 DOI: 10.1097/j.pain.0000000000002968] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/25/2023] [Accepted: 05/02/2023] [Indexed: 06/16/2023]
Abstract
ABSTRACT Parkinson disease (PD) affects up to 2% of the general population older than 65 years and is a major cause of functional loss. Chronic pain is a common nonmotor symptom that affects up to 80% of patients with (Pw) PD both in prodromal phases and during the subsequent stages of the disease, negatively affecting patient's quality of life and function. Pain in PwPD is rather heterogeneous and may occur because of different mechanisms. Targeting motor symptoms by dopamine replacement or with neuromodulatory approaches may only partially control PD-related pain. Pain in general has been classified in PwPD according to the motor signs, pain dimensions, or pain subtypes. Recently, a new classification framework focusing on chronic pain was introduced to group different types of PD pains according to mechanistic descriptors: nociceptive, neuropathic, or neither nociceptive nor neuropathic. This is also in line with the International Classification of Disease-11 , which acknowledges the possibility of chronic secondary musculoskeletal or nociceptive pain due to disease of the CNS. In this narrative review and opinion article, a group of basic and clinical scientists revise the mechanism of pain in PD and the challenges faced when classifying it as a stepping stone to discuss an integrative view of the current classification approaches and how clinical practice can be influenced by them. Knowledge gaps to be tackled by coming classification and therapeutic efforts are presented, as well as a potential framework to address them in a patient-oriented manner.
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Affiliation(s)
- Daniel Ciampi de Andrade
- Center for Neuroplasticity and Pain (CNAP), Department of Health Science and Technology, Faculty of Medicine, Aalborg University, Aalborg, Denmark
| | - Veit Mylius
- Department of Neurology, Centre for Neurorehabilitation, Valens, Switzerland
- Department of Neurology, Philipps University, Marburg, Germany
- Department of Neurology, Kantonsspital, St. Gallen, Switzerland
| | - Santiago Perez-Lloret
- Observatorio de Salud Pública, Universidad Católica Argentina, Consejo de Investigaciones Científicas y Técnicas (UCA-CONICET), Buenos Aires, Argentina
- Facultad de Medicina, Pontificia Universidad Católica Argentina, Buenos Aires, Argentina
- Departamento de Fisiología, Facultad de Medicina, Universidad de Buenos Aires, Buenos Aires, Argentina
| | - Rubens G Cury
- Movement Disorders Center, Department of Neurology, University of Sao Paulo, Sao Paulo, Brazil
| | - Kirsty Bannister
- Institute of Psychiatry, Psychology and Neuroscience, King's College London, London, United Kingdom
| | - Xavier Moisset
- Université Clermont Auvergne, CHU de Clermont-Ferrand, Inserm, Neuro-Dol, Clermont-Ferrand, France
| | - Gabriel Taricani Kubota
- Department of Neurology, Centre for Neurorehabilitation, Valens, Switzerland
- Pain Center, University of Sao Paulo Clinics Hospital, Sao Paulo, Brazil
- Center for Pain Treatment, Institute of Cancer of the State of Sao Paulo, University of Sao Paulo Clinics Hospital, Sao Paulo, Brazil
| | - Nanna B Finnerup
- Danish Pain Research Center, Department of Clinical Medicine, Aarhus University, Aarhus, Denmark
- Department of Neurology, Aarhus University Hospital, Aarhus, Denmark
| | - Didier Bouhassira
- Inserm U987, APHP, UVSQ, Paris-Saclay University, Ambroise Pare Hospital, Boulogne-Billancourt, France
| | - Kallol Ray Chaudhuri
- Division of Neuroscience, Department of Basic and Clinical Neuroscience, Institute of Psychiatry, Psychology and Neuroscience, King's College London, London, United Kingdom
- Parkinson Foundation Centre of Excellence in Care and Research, King's College Hospital NHS Foundation Trust, London, United Kingdom
| | - Thomas Graven-Nielsen
- Center for Neuroplasticity and Pain (CNAP), Department of Health Science and Technology, Faculty of Medicine, Aalborg University, Aalborg, Denmark
| | - Rolf-Detlef Treede
- Department of Neurophysiology, Mannheim Center for Translational Neurosciences, Heidelberg University, Mannheim, Germany
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6
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Widerström-Noga E, Biering-Sørensen F, Bryce TN, Cardenas DD, Finnerup NB, Jensen MP, Richards JS, Rosner J, Taylor J. The international spinal cord injury pain basic data set (version 3.0). Spinal Cord 2023; 61:536-540. [PMID: 37491608 DOI: 10.1038/s41393-023-00919-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2022] [Revised: 07/12/2023] [Accepted: 07/18/2023] [Indexed: 07/27/2023]
Abstract
STUDY DESIGN Expert opinion, feedback, revisions, and final consensus. OBJECTIVES To update the International Spinal Cord Injury Pain Basic Data Set (ISCIPBDS version 2.0) and incorporate suggestions from the SCI pain clinical and research community with respect to overall utility. SETTING International. METHODS The ISCIPBDS working group evaluated these suggestions and made modifications. The revised ISCIPBDS (Version 3.0) was then reviewed by members of the International SCI Data Sets Committee, the American Spinal Injury Association (ASIA) Board, the International Spinal Cord Society (ISCoS) Executive and Scientific Committees, individual reviewers and societies, and posted on the ASIA and ISCoS websites for 1 month to elicit comments before final approval by ASIA and ISCoS. RESULTS The ISCIPBDS (Version 3.0) was updated to make the dataset more flexible and useful: 1. The assessment can be based on the patient's perception of several of his/her "worst" pain(s) or based on the International SCI Pain (ISCIP) Classification-defined or other pain types, depending on the specific research questions or clinical needs. 2. Pain interference should usually be rated for overall pain but may also be used for specific pain problems if needed. 3. An optional pain drawing was added to complement the check box documentation of pain location. 4. Data categories consistent with the Extended Pain Dataset list of current treatments were added. 5. Several new training cases were added.
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Affiliation(s)
- Eva Widerström-Noga
- Miami Project to Cure Paralysis, University of Miami, Miller School of Medicine, Miami, FL, USA.
- Department of Physical Medicine and Rehabilitation, University of Miami, Miller School of Medicine, Miami, FL, USA.
| | - Fin Biering-Sørensen
- Department for Brain and Spinal Cord Injuries, Rigshospitalet, and Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
| | - Thomas N Bryce
- Department of Rehabilitation and Human Performance, The Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Diana D Cardenas
- Department of Physical Medicine and Rehabilitation, University of Miami, Miller School of Medicine, Miami, FL, USA
| | - Nanna B Finnerup
- Danish Pain Research Center, Department of Clinical medicine, Aarhus University, Aarhus, Denmark
| | - Mark P Jensen
- Department of Rehabilitation Medicine, University of Washington, Seattle, WA, USA
| | - J Scott Richards
- Department of Physical Medicine and Rehabilitation, University of Alabama at Birmingham, Birmingham, AL, USA
| | - Jan Rosner
- Spinal Cord Injury Center, Balgrist University Hospital, University of Zurich, Zurich, Switzerland
- Department of Neurology, University Hospital Bern, Inselspital, University of Bern, Bern, Switzerland
| | - Julian Taylor
- Sensorimotor Function Group, Hospital Nacional de Parapléjicos, Servicio de Salud Castilla-La Mancha (SESCAM), Toledo, Spain
- Harris Manchester College, University of Oxford, Oxford, UK
- Instituto de Investigación Sanitaria de Castilla-La Mancha (SESCAM), Hospital Nacional de Parapléjicos, Toledo, Spain
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Peters E, Itani M, Kristensen AG, Terkelsen AJ, Krøigård T, Tankisi H, Jensen TS, Finnerup NB, Gylfadottir SS. Cardiovascular autonomic neuropathy in patients with type 2 diabetes with and without sensorimotor polyneuropathy. J Peripher Nerv Syst 2023; 28:450-459. [PMID: 37449440 DOI: 10.1111/jns.12580] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/21/2023] [Revised: 07/07/2023] [Accepted: 07/11/2023] [Indexed: 07/18/2023]
Abstract
BACKGROUND AND AIMS Cardiovascular autonomic neuropathy (CAN) in patients with diabetes is associated with poor prognosis. We aimed to assess signs of CAN and autonomic symptoms and to investigate the impact of sensorimotor neuropathy on CAN by examining type 2 diabetes patients with (DPN [distal sensorimotor polyneuropathy]) and without distal sensorimotor polyneuropathy (noDPN) and healthy controls (HC). Secondarily, we aimed to describe the characteristics of patients with CAN. METHODS A population of 374 subjects from a previously described cohort of the Danish Centre for Strategic Research in Type 2 Diabetes (DD2) were included. Subjects were examined with the Vagus™ device for the diagnosis of CAN, where two or more abnormal cardiovascular autonomic reflex tests indicate definite CAN. Autonomic symptoms were assessed with Composite Autonomic Symptom Score 31 (COMPASS 31) questionnaire. DPN was defined according to the Toronto consensus panel definition. RESULTS Definite CAN was present in 22% with DPN, 7% without DPN and 3% of HC, and 91% of patients with definite CAN had DPN. Patients with DPN and definite CAN reported higher COMPASS 31 scores compared to patients with noDPN (20.0 vs. 8.3, p < 0.001) and no CAN (22.1 vs. 12.3, p = 0.01). CAN was associated with HbA1c and age in a multivariate logistic regression analysis but was not associated with IEFND or triglycerides. INTERPRETATION One in five patients with DPN have CAN and specific CAN characteristics may help identify patients at risk for developing this severe diabetic complication. Autonomic symptoms were strongly associated with having both DPN and CAN, but too unspecific for diagnosing CAN.
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Affiliation(s)
- Emil Peters
- Danish Pain Research Center, Department of Clinical Medicine, Aarhus University, Aarhus, Denmark
| | - Mustapha Itani
- Department of Neurology, Odense University Hospital, Odense, Denmark
| | - Alexander G Kristensen
- Danish Pain Research Center, Department of Clinical Medicine, Aarhus University, Aarhus, Denmark
- Department of Clinical Neurophysiology, Aarhus University Hospital, Aarhus, Denmark
| | - Astrid Juhl Terkelsen
- Danish Pain Research Center, Department of Clinical Medicine, Aarhus University, Aarhus, Denmark
- Department of Neurology, Aarhus University Hospital, Aarhus, Denmark
| | - Thomas Krøigård
- Department of Neurology, Odense University Hospital, Odense, Denmark
| | - Hatice Tankisi
- Department of Clinical Neurophysiology, Aarhus University Hospital, Aarhus, Denmark
- Department of Clinical Medicine, Aarhus University, Aarhus, Denmark
| | - Troels S Jensen
- Danish Pain Research Center, Department of Clinical Medicine, Aarhus University, Aarhus, Denmark
| | - Nanna B Finnerup
- Danish Pain Research Center, Department of Clinical Medicine, Aarhus University, Aarhus, Denmark
- Department of Neurology, Aarhus University Hospital, Aarhus, Denmark
| | - Sandra Sif Gylfadottir
- Danish Pain Research Center, Department of Clinical Medicine, Aarhus University, Aarhus, Denmark
- Department of Neurology, Aarhus University Hospital, Aarhus, Denmark
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8
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Truini A, Aleksovska K, Anderson CC, Attal N, Baron R, Bennett DL, Bouhassira D, Cruccu G, Eisenberg E, Enax-Krumova E, Davis KD, Di Stefano G, Finnerup NB, Garcia-Larrea L, Hanafi I, Haroutounian S, Karlsson P, Rakusa M, Rice ASC, Sachau J, Smith BH, Sommer C, Tölle T, Valls-Solé J, Veluchamy A. Joint European Academy of Neurology-European Pain Federation-Neuropathic Pain Special Interest Group of the International Association for the Study of Pain guidelines on neuropathic pain assessment. Eur J Neurol 2023; 30:2177-2196. [PMID: 37253688 DOI: 10.1111/ene.15831] [Citation(s) in RCA: 10] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/15/2022] [Revised: 04/03/2023] [Accepted: 04/12/2023] [Indexed: 06/01/2023]
Abstract
BACKGROUND AND PURPOSE In these guidelines, we aimed to develop evidence-based recommendations for the use of screening questionnaires and diagnostic tests in patients with neuropathic pain (NeP). METHODS We systematically reviewed studies providing information on the sensitivity and specificity of screening questionnaires, and quantitative sensory testing, neurophysiology, skin biopsy, and corneal confocal microscopy. We also analysed how functional neuroimaging, peripheral nerve blocks, and genetic testing might provide useful information in diagnosing NeP. RESULTS Of the screening questionnaires, Douleur Neuropathique en 4 Questions (DN4), I-DN4 (self-administered DN4), and Leeds Assessment of Neuropathic Symptoms and Signs (LANSS) received a strong recommendation, and S-LANSS (self-administered LANSS) and PainDETECT weak recommendations for their use in the diagnostic pathway for patients with possible NeP. We devised a strong recommendation for the use of skin biopsy and a weak recommendation for quantitative sensory testing and nociceptive evoked potentials in the NeP diagnosis. Trigeminal reflex testing received a strong recommendation in diagnosing secondary trigeminal neuralgia. Although many studies support the usefulness of corneal confocal microscopy in diagnosing peripheral neuropathy, no study specifically investigated the diagnostic accuracy of this technique in patients with NeP. Functional neuroimaging and peripheral nerve blocks are helpful in disclosing pathophysiology and/or predicting outcomes, but current literature does not support their use for diagnosing NeP. Genetic testing may be considered at specialist centres, in selected cases. CONCLUSIONS These recommendations provide evidence-based clinical practice guidelines for NeP diagnosis. Due to the poor-to-moderate quality of evidence identified by this review, future large-scale, well-designed, multicentre studies assessing the accuracy of diagnostic tests for NeP are needed.
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Affiliation(s)
- Andrea Truini
- Department of Human Neuroscience, University Sapienza, Rome, Italy
| | - Katina Aleksovska
- European Academy of Neurology, Vienna, Austria
- Department of Neurology, Ss. Cyril and Methodius University, Skopje, North Macedonia
| | - Christopher C Anderson
- Division of Clinical and Translational Research, Department of Anesthesiology, Pain Center, Washington University School of Medicine, St. Louis, Missouri, USA
- Department of Neurology, Washington University School of Medicine, St. Louis, Missouri, USA
| | - Nadine Attal
- Université Versailles Saint Quentin en Yvelines, Versailles, France
- Inserm U987, Pathophysiology and Clinical Pharmacology of Pain, Centre d'évaluation et de Traitement de la Douleur, Hôpital Ambroise Paré, Boulogne-Billancourt, France
| | - Ralf Baron
- Division of Neurological Pain Research and Therapy, Department of Neurology, Universitätsklinikum Schleswig-Holstein, Campus Kiel, Kiel, Germany
| | - David L Bennett
- Nuffield Department of Clinical Neurosciences, University of Oxford, Oxford, UK
| | - Didier Bouhassira
- Inserm U987, Pathophysiology and Clinical Pharmacology of Pain, Centre d'évaluation et de Traitement de la Douleur, Hôpital Ambroise Paré, Boulogne-Billancourt, France
| | - Giorgio Cruccu
- Department of Human Neuroscience, University Sapienza, Rome, Italy
| | - Elon Eisenberg
- Faculty of Medicine, Technion, Israel Institute of Technology, Haifa, Israel
| | - Elena Enax-Krumova
- Department of Neurology, BG University Hospital Bergmannsheil, Ruhr-University Bochum, Bochum, Germany
| | - Karen Deborah Davis
- Division of Brain, Imaging, and Behaviour, Krembil Brain Institute, Krembil Research Institute, Toronto Western Hospital, University Health Network, Toronto, Ontario, Canada
| | | | - Nanna B Finnerup
- Department of Clinical Medicine, Danish Pain Research Centre, Aarhus University, Aarhus, Denmark
| | - Luis Garcia-Larrea
- Central Integration of Pain (NeuroPain) Lab-Lyon Neuroscience Research Centre, INSERM U1028, CNRS, UMR5292, Université Claude Bernard, Bron, France
- Centre D'évaluation et de Traitement de la Douleur, Hôpital Neurologique, Lyon, France
| | - Ibrahem Hanafi
- Department of Neurology, University Hospital Würzburg, Würzburg, Germany
| | - Simon Haroutounian
- Division of Clinical and Translational Research, Department of Anesthesiology, Pain Center, Washington University School of Medicine, St. Louis, Missouri, USA
| | - Pall Karlsson
- Department of Clinical Medicine, Danish Pain Research Centre, Aarhus University, Aarhus, Denmark
- Core Centre for Molecular Morphology, Section for Stereology and Microscopy, Aarhus University, Aarhus, Denmark
| | - Martin Rakusa
- Division of Neurology, University Medical Centre Maribor, Maribor, Slovenia
| | - Andrew S C Rice
- Pain Research, Department of Surgery and Cancer, Imperial College London, London, UK
| | - Juliane Sachau
- Division of Neurological Pain Research and Therapy, Department of Neurology, Universitätsklinikum Schleswig-Holstein, Campus Kiel, Kiel, Germany
| | - Blair H Smith
- Division of Population Health and Genomics, Ninewells Hospital and Medical School, University of Dundee, Dundee, UK
| | - Claudia Sommer
- Department of Neurology, University Hospital Würzburg, Würzburg, Germany
| | - Thomas Tölle
- Department of Neurology, Klinikum rechts der Isar, Technische Universität München, Munich, Germany
| | - Josep Valls-Solé
- Institut d'Investigació Biomèdica August Pi i Sunyer, Barcelona, Spain
| | - Abirami Veluchamy
- Division of Population Health and Genomics, Ninewells Hospital and Medical School, University of Dundee, Dundee, UK
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9
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Schmid AB, Tampin B, Baron R, Finnerup NB, Hansson P, Hietaharju A, Konstantinou K, Lin CWC, Markman J, Price C, Smith BH, Slater H. Recommendations for terminology and the identification of neuropathic pain in people with spine-related leg pain. Outcomes from the NeuPSIG working group. Pain 2023; 164:1693-1704. [PMID: 37235637 PMCID: PMC10348639 DOI: 10.1097/j.pain.0000000000002919] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/24/2022] [Revised: 02/16/2023] [Accepted: 02/24/2023] [Indexed: 05/28/2023]
Abstract
ABSTRACT Pain radiating from the spine into the leg is commonly referred to as "sciatica," "Sciatica" may include various conditions such as radicular pain or painful radiculopathy. It may be associated with significant consequences for the person living with the condition, imposing a reduced quality of life and substantial direct and indirect costs. The main challenges associated with a diagnosis of "sciatica" include those related to the inconsistent use of terminology for the diagnostic labels and the identification of neuropathic pain. These challenges hinder collective clinical and scientific understanding regarding these conditions. In this position paper, we describe the outcome of a working group commissioned by the Neuropathic Pain Special Interest Group (NeuPSIG) of the International Association for the Study of Pain (IASP) which was tasked with the following objectives: (1) to revise the use of terminology for classifying spine-related leg pain and (2) to propose a way forward on the identification of neuropathic pain in the context of spine-related leg pain. The panel recommended discouraging the term "sciatica" for use in clinical practice and research without further specification of what it entails. The term "spine-related leg pain" is proposed as an umbrella term to include the case definitions of somatic referred pain and radicular pain with and without radiculopathy. The panel proposed an adaptation of the neuropathic pain grading system in the context of spine-related leg pain to facilitate the identification of neuropathic pain and initiation of specific management in this patient population.
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Affiliation(s)
- Annina B. Schmid
- Nuffield Department of Clinical Neurosciences, University of Oxford, Oxford, United Kingdom
| | - Brigitte Tampin
- Department of Physiotherapy, Sir Charles Gairdner Hospital, Perth, Australia
- Curtin School of Allied Health, Faculty of Health Sciences, Curtin University, Perth, Australia
- Faculty of Business and Social Sciences, Hochschule Osnabrueck, University of Applied Sciences, Osnabrueck, Germany
| | - Ralf Baron
- Division of Neurological Pain Research and Therapy, Department of Neurology, University Medical Center Schleswig-Holstein, Kiel, Germany
| | - Nanna B. Finnerup
- Danish Pain Research Center, Department of Clinical Medicine, Aarhus University, Aarhus, Denmark
- Department of Neurology, Aarhus University Hospital, Aarhus, Denmark
| | - Per Hansson
- Department of Pain Management & Research, Norwegian National Advisory Unit on Neuropathic Pain, Division of Emergencies and Critical Care, Oslo University Hospital, Oslo, Norway
- Department of Molecular Medicine and Surgery, Karolinska Institutet, Stockholm, Sweden
| | - Aki Hietaharju
- Department of Neurology, Tampere University Hospital, Tampere, Finland
- Faculty of Medicine and Health Technology, Tampere University, Tampere, Finland
| | - Kika Konstantinou
- School of Medicine, Keele University, Keele, Staffordshire, United Kingdom
- Haywood Hospital, Midlands Partnership Foundation NHS Trust, Staffordshire, United Kingdom
| | - Chung-Wei Christine Lin
- Institute for Musculoskeletal Health, The University of Sydney and Sydney Local Health District, Sydney, Australia
- Sydney Musculoskeletal Health, the University of Sydney, Sydney Australia
| | - John Markman
- Translational Pain Research Program, Departments of Neurosurgery and Neurology, University of Rochester, Rochester, NY, United States
| | - Christine Price
- Patient Advocate Nuffield Department of Clinical Neurosciences, University of Oxford, Oxford, United Kingdom
| | - Blair H. Smith
- Division of Population Health and Genomics, University of Dundee, Dundee, Scotland
| | - Helen Slater
- Curtin School of Allied Health, Faculty of Health Sciences, Curtin University, Perth, Australia
- Division of Population Health and Genomics, University of Dundee, Dundee, Scotland
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10
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Hohenschurz-Schmidt D, Vase L, Scott W, Annoni M, Ajayi OK, Barth J, Bennell K, Berna C, Bialosky J, Braithwaite F, Finnerup NB, Williams ACDC, Carlino E, Cerritelli F, Chaibi A, Cherkin D, Colloca L, Côté P, Darnall BD, Evans R, Fabre L, Faria V, French S, Gerger H, Häuser W, Hinman RS, Ho D, Janssens T, Jensen K, Johnston C, Juhl Lunde S, Keefe F, Kerns RD, Koechlin H, Kongsted A, Michener LA, Moerman DE, Musial F, Newell D, Nicholas M, Palermo TM, Palermo S, Peerdeman KJ, Pogatzki-Zahn EM, Puhl AA, Roberts L, Rossettini G, Tomczak Matthiesen S, Underwood M, Vaucher P, Vollert J, Wartolowska K, Weimer K, Werner CP, Rice ASC, Draper-Rodi J. Recommendations for the development, implementation, and reporting of control interventions in efficacy and mechanistic trials of physical, psychological, and self-management therapies: the CoPPS Statement. BMJ 2023; 381:e072108. [PMID: 37230508 DOI: 10.1136/bmj-2022-072108] [Citation(s) in RCA: 8] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 05/27/2023]
Affiliation(s)
- David Hohenschurz-Schmidt
- Pain Research, Department of Surgery and Cancer, Faculty of Medicine, Imperial College London, London, UK
- Research Department, University College of Osteopathy, London, UK
| | - Lene Vase
- Department of Psychology and Behavioural Sciences, School of Business and Social Sciences, Aarhus University, Denmark
| | - Whitney Scott
- Health Psychology Section, Department of Psychology, Institute of Psychiatry, Psychology and Neuroscience, King's College London; INPUT Pain Management Unit, Guy's and St Thomas' NHS Foundation Trust, London, UK
| | - Marco Annoni
- Italian National Research Council, Interdepartmental Centre for Research Ethics and Integrity, Rome, Italy
| | - Oluwafemi K Ajayi
- Department of Arts and Music, College of Human Sciences, University of South Africa, Pretoria, South Africa
| | - Jürgen Barth
- Institute for Complementary and Integrative Medicine, University Hospital Zurich and University of Zurich, Switzerland
| | - Kim Bennell
- Centre for Health, Exercise and Sports Medicine, Department of Physiotherapy, University of Melbourne, VIC, Australia
| | - Chantal Berna
- Centrer for Integrative and Complementary Medicine, Pain Center, Division of Anesthesiology, Sense Institute, Lausanne University Hospital, Lausanne University, Lausanne, Switzerland
| | - Joel Bialosky
- Department of Physical Therapy, University of Florida, Gainesville FL, USA; Brooks-PHHP Research Collaboration, Jacksonville, FL, USA
| | | | - Nanna B Finnerup
- Danish Pain Research Centre, Department of Clinical Medicine, Aarhus University, Aarhus, Denmark
| | - Amanda C de C Williams
- Research Department of Clinical, Educational & Health Psychology, University College London, London, UK
| | - Elisa Carlino
- Department of Neuroscience Rita Levi Montalcini, University of Turin, Turin, Italy
| | | | - Aleksander Chaibi
- Department for Interdisciplinary Health Sciences, Institute of Health and Society, Faculty of Medicine, University of Oslo, Oslo, Norway
| | - Dan Cherkin
- Osher Center for Integrative Health, Department of Family Medicine, University of Washington, Seattle, WA, USA
| | - Luana Colloca
- Department of Pain and Translational Symptom Science, School of Nursing; Department of Anesthesiology, School of Medicine; University of Maryland, Baltimore, MD, USA
| | - Pierre Côté
- Faculty of Health Sciences, Institute for Disability and Rehabilitation Research, Ontario Tech University, Oshawa, ON, Canada
| | - Beth D Darnall
- Stanford Pain Relief Innovations Lab; Stanford University School of Medicine, Department of Anesthesiology, Perioperative and Pain Medicine, Stanford, CA, USA
| | - Roni Evans
- Integrative Health & Wellbeing Research Program; Center for Spirituality and Healing, University of Minnesota, Minneapolis, MN, USA
| | - Laurent Fabre
- Centre Européen d'Enseignement Supérieur de l'Ostéopathie, Paris, France
| | - Vanda Faria
- Department of Psychology, Uppsala University, Uppsala, Sweden; Smell & Taste Clinic, Department of Otorhinolaryngology, TU Dresden, Dresden, Germany; Brain and Eye Pain Imaging Lab, Pain and Affective Neuroscience Center, Boston Children's Hospital, Harvard Medical School, Boston, MA, USA; Department of Anesthesiology, Critical Care and Pain Medicine, Boston Children's Hospital, Harvard Medical School, Boston, MA, USA
| | - Simon French
- Department of Chiropractic, Faculty of Medicine, Health and Human Sciences, Macquarie University, NSW, Australia
| | - Heike Gerger
- Erasmus MC, University Medical Centre Rotterdam, Department of General Practice, Rotterdam, the Netherlands; Care and Public Health Research Institute (CAPHRI), Maastricht University, Maastricht, the Netherlands
| | - Winfried Häuser
- Department Psychosomatic Medicine and Psychotherapy, Technische Universität München, Munich, Germany
| | - Rana S Hinman
- Centre for Health, Exercise & Sports Medicine, University of Melbourne, Melbourne, VIC, Australia
| | - Dien Ho
- Center for Health Humanities, School of Arts and Sciences, Massachusetts College of Pharmacy and Health Sciences, Boston MA, USA
| | - Thomas Janssens
- Health Psychology, KU Leuven; Ebpracticenet, Leuven, Belgium
| | - Karin Jensen
- Department of Clinical Neuroscience, Karolinska Institutet, Stockholm, Sweden
| | - Chris Johnston
- BC Patient Safety & Quality Council's Patient Voices Network; Health Research BC's Partnership-Ready Network; Health Standards Organization's Emergency Management Technical Committee & Working Group
| | - Sigrid Juhl Lunde
- Department of Psychology and Behavioural Sciences, School of Business and Social Sciences, Aarhus University, Denmark
| | - Francis Keefe
- Duke University, School of Medicine, Durham, NC, USA
| | - Robert D Kerns
- Departments of Psychiatry, Neurology, and Psychology, Yale University, New Haven, CT, USA
| | - Helen Koechlin
- Division of Psychosomatics and Psychiatry, University Children's Hospital Zurich; Division of Child and Adolescent Health Psychology, Department of Psychology, University of Zurich, Zurich, Switzerland; Department of Anesthesiology, Critical Care and Pain Medicine, Boston Children's Hospital, Harvard Medical School, Boston, MA, USA
| | - Alice Kongsted
- Department of Sports Science and Clinical Biomechanics, University of Southern Denmark, Odense, Denmark; Chiropractic Knowledge Hub, Odense, Denmark
| | - Lori A Michener
- Division of Biokinesiology and Physical Therapy, University of Southern California, Los Angeles CA, USA
| | - Daniel E Moerman
- College of Arts, Sciences, and Letters, Behavioral Sciences, University of Michigan, Dearborn, MI, USA
| | - Frauke Musial
- National Research Centre in Complementary and Alternative Medicine, Department of Community Medicine, Faculty of Health Science UiT, Arctic University of Norway, Tromsø, Norway
| | | | - Michael Nicholas
- Pain Management Research Institute, University of Sydney Medical School (Northern) and Kolling Institute of Medical Research at Royal North Shore Hospital, Sydney, Australia
| | - Tonya M Palermo
- Department of Anesthesiology and Pain Medicine, University of Washington, Seattle, WA, USA
| | - Sara Palermo
- Diagnostic and Technology Department, Neuroradiology Unit, Fondazione IRCCS Istituto Neurologico Carlo Besta, Milan, Italy; Department of Psychology, University of Turin, Turin, Italy
| | - Kaya J Peerdeman
- Unit Health, Medical and Neuropsychology, Leiden University, Leiden, the Netherlands
| | - Esther M Pogatzki-Zahn
- Department of Anaesthesiology, Intensive Care and Pain Medicine, University Hospital Münster, Münster, Germany
| | | | - Lisa Roberts
- University of Southampton and University Hospital Southampton NHS Foundation Trust, Southampton, UK
| | - Giacomo Rossettini
- Department of Neuroscience, Rehabilitation, Ophthalmology, Genetics, Maternal and Child Health, University of Genoa, Campus of Savona, Savona, Italy; School of Physiotherapy, University of Verona, Verona, Italy
| | - Susan Tomczak Matthiesen
- Department of Psychology and Behavioural Sciences, School of Business and Social Sciences, Aarhus University, Denmark
| | - Martin Underwood
- Warwick Clinical Trials Unit; University of Warwick, Coventry, UK; University Hospitals Coventry and Warwickshire, Coventry, UK
| | - Paul Vaucher
- School of Health Sciences Fribourg, HES-SO University of Applied Sciences and Arts Western Switzerland, Switzerland
| | - Jan Vollert
- Pain Research, Department of Surgery and Cancer, Faculty of Medicine, Imperial College London, London, UK; Division of Neurological Pain Research and Therapy, Department of Neurology, University Hospital of Schleswig-Holstein, Campus Kiel, Germany; Neurophysiology, Mannheim Centre of Translational Neuroscience, Medical Faculty Mannheim, Heidelberg University, Germany; Department of Anaesthesiology, Intensive Care and Pain Medicine, University Hospital Muenster, Germany
| | - Karolina Wartolowska
- Nuffield Department of Clinical Neurosciences, University of Oxford, John Radcliffe Hospital, Oxford, UK
| | - Katja Weimer
- Department of Psychosomatic Medicine and Psychotherapy, Ulm University Medical Centre, Ulm, Germany
| | - Christoph Patrick Werner
- School of Psychology, Faculty of Science, University of Sydney, Australia; Department of Clinical Research, University Hospital Basel, Switzerland
| | - Andrew S C Rice
- Pain Research, Department of Surgery and Cancer, Faculty of Medicine, Imperial College London, London, UK
| | - Jerry Draper-Rodi
- Research Department, University College of Osteopathy, London, UK
- National Council for Osteopathic Research, London, UK
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11
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Gylfadottir SS, Itani M, Kristensen AG, Nyengaard JR, Sindrup SH, Jensen TS, Finnerup NB, Karlsson P. Assessing Corneal Confocal Microscopy and Other Small Fiber Measures in Diabetic Polyneuropathy. Neurology 2023; 100:e1680-e1690. [PMID: 36750383 PMCID: PMC10115507 DOI: 10.1212/wnl.0000000000206902] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2022] [Accepted: 12/23/2022] [Indexed: 02/09/2023] Open
Abstract
BACKGROUND AND OBJECTIVES Damage to small nerve fibers is common in diabetic polyneuropathy (DPN), and the diagnosis of DPN relies on subjective symptoms and signs in a combination with objective confirmatory tests, typically electrophysiology or intraepidermal nerve fiber density (IENFD) from skin biopsy. Corneal confocal microscopy (CCM) has been introduced as a tool to detect DPN. However, it is unclear if CCM can reliably be used to diagnose DPN and how the technique compares with other commonly used measures of small fiber damage, such as IENFD, cold detection threshold (CDT), and warm detection threshold (WDT). Therefore, we assessed and compared the use of CCM, IENFD, CDT, and WDT in the diagnosis of DPN in patients with type 2 diabetes. METHODS In this cohort study, the participants underwent detailed neurologic examination, electrophysiology, quantification of IENFD, CCM, and quantitative sensory testing. Definition of DPN was made in accordance with the Toronto criteria for diabetic neuropathy (without relying on IENFD and thermal thresholds). RESULTS A total of 214 patients with at least probable DPN, 63 patients without DPN, and 97 controls without diabetes were included. Patients with DPN had lower CCM measures (corneal nerve fiber length [CNFL], nerve fiber density, and branch density), IENFD, CDT, and WDT compared with patients without DPN (p ≤ 0.001, <0.001, 0.002, p < 0.001, p = 0.003, and <0.005, respectively), whereas there was no difference between controls and patients with diabetes without DPN. All 3 CCM measures showed a very low diagnostic sensitivity with CNFL showing the highest (14.4% [95% CI 9.8-18.4]) and a specificity of 95.7% (88.0-99.1). In comparison, the sensitivity of abnormal CDT and/or WDT was 30.5% (24.4-37.0) with a specificity of 84.9% (74.6-92.2). The sensitivity of abnormal IENFD was highest among all measures with a value of 51.1% (43.7-58.5) and a specificity of 90% (79.5-96.2). CCM measures did not correlate with IENFD, CDT/WDT, or neuropathy severity in the group of patients with DPN. DISCUSSION CCM measures showed the lowest sensitivity compared with other small fiber measures in the diagnosis of DPN. This indicates that CCM is not a sensitive method to detect DPN in recently diagnosed type 2 diabetes. CLASSIFICATION OF EVIDENCE This study provides Class III evidence that CCM measures aid in the detection of DPN in recently diagnosed type 2 diabetics but with a low sensitivity when compared with other small fiber measures.
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Affiliation(s)
- Sandra S Gylfadottir
- From the Department of Clinical Medicine (S.S.G., T.S.J., N.B.F., P.K.), Danish Pain Research Centre, and Core Centre for Molecular Morphology (J.R.N., P.K.), Aarhus University; Departments of Neurology (S.S.G, T.S.J., N.B.F.), Clinical Neurophysiology (A.G.K.), and Pathology (J.R.N.), Aarhus University Hospital; and Department of Neurology (M.I., S.H.S.), Odense University Hospital, Denmark
| | - Mustapha Itani
- From the Department of Clinical Medicine (S.S.G., T.S.J., N.B.F., P.K.), Danish Pain Research Centre, and Core Centre for Molecular Morphology (J.R.N., P.K.), Aarhus University; Departments of Neurology (S.S.G, T.S.J., N.B.F.), Clinical Neurophysiology (A.G.K.), and Pathology (J.R.N.), Aarhus University Hospital; and Department of Neurology (M.I., S.H.S.), Odense University Hospital, Denmark
| | - Alexander G Kristensen
- From the Department of Clinical Medicine (S.S.G., T.S.J., N.B.F., P.K.), Danish Pain Research Centre, and Core Centre for Molecular Morphology (J.R.N., P.K.), Aarhus University; Departments of Neurology (S.S.G, T.S.J., N.B.F.), Clinical Neurophysiology (A.G.K.), and Pathology (J.R.N.), Aarhus University Hospital; and Department of Neurology (M.I., S.H.S.), Odense University Hospital, Denmark
| | - Jens R Nyengaard
- From the Department of Clinical Medicine (S.S.G., T.S.J., N.B.F., P.K.), Danish Pain Research Centre, and Core Centre for Molecular Morphology (J.R.N., P.K.), Aarhus University; Departments of Neurology (S.S.G, T.S.J., N.B.F.), Clinical Neurophysiology (A.G.K.), and Pathology (J.R.N.), Aarhus University Hospital; and Department of Neurology (M.I., S.H.S.), Odense University Hospital, Denmark
| | - Søren Hein Sindrup
- From the Department of Clinical Medicine (S.S.G., T.S.J., N.B.F., P.K.), Danish Pain Research Centre, and Core Centre for Molecular Morphology (J.R.N., P.K.), Aarhus University; Departments of Neurology (S.S.G, T.S.J., N.B.F.), Clinical Neurophysiology (A.G.K.), and Pathology (J.R.N.), Aarhus University Hospital; and Department of Neurology (M.I., S.H.S.), Odense University Hospital, Denmark
| | - Troels S Jensen
- From the Department of Clinical Medicine (S.S.G., T.S.J., N.B.F., P.K.), Danish Pain Research Centre, and Core Centre for Molecular Morphology (J.R.N., P.K.), Aarhus University; Departments of Neurology (S.S.G, T.S.J., N.B.F.), Clinical Neurophysiology (A.G.K.), and Pathology (J.R.N.), Aarhus University Hospital; and Department of Neurology (M.I., S.H.S.), Odense University Hospital, Denmark
| | - Nanna B Finnerup
- From the Department of Clinical Medicine (S.S.G., T.S.J., N.B.F., P.K.), Danish Pain Research Centre, and Core Centre for Molecular Morphology (J.R.N., P.K.), Aarhus University; Departments of Neurology (S.S.G, T.S.J., N.B.F.), Clinical Neurophysiology (A.G.K.), and Pathology (J.R.N.), Aarhus University Hospital; and Department of Neurology (M.I., S.H.S.), Odense University Hospital, Denmark
| | - Pall Karlsson
- From the Department of Clinical Medicine (S.S.G., T.S.J., N.B.F., P.K.), Danish Pain Research Centre, and Core Centre for Molecular Morphology (J.R.N., P.K.), Aarhus University; Departments of Neurology (S.S.G, T.S.J., N.B.F.), Clinical Neurophysiology (A.G.K.), and Pathology (J.R.N.), Aarhus University Hospital; and Department of Neurology (M.I., S.H.S.), Odense University Hospital, Denmark.
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12
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Ferreira GE, Abdel-Shaheed C, Underwood M, Finnerup NB, Day RO, McLachlan A, Eldabe S, Zadro JR, Maher CG. Efficacy, safety, and tolerability of antidepressants for pain in adults: overview of systematic reviews. BMJ 2023; 380:e072415. [PMID: 36725015 PMCID: PMC9887507 DOI: 10.1136/bmj-2022-072415] [Citation(s) in RCA: 7] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
OBJECTIVE To provide a comprehensive overview of the efficacy, safety, and tolerability of antidepressants for pain according to condition. DESIGN Overview of systematic reviews. DATA SOURCES PubMed, Embase, PsycINFO, and the Cochrane Central Register of Controlled Trials from inception to 20 June 2022. ELIGIBILITY CRITERIA FOR SELECTING STUDIES Systematic reviews comparing any antidepressant with placebo for any pain condition in adults. DATA EXTRACTION AND SYNTHESIS Two reviewers independently extracted data. The main outcome measure was pain; for headache disorders it was frequency of headaches. Continuous pain outcomes were converted into a scale of 0 (no pain) to 100 (worst pain) and were presented as mean differences (95% confidence intervals). Dichotomous outcomes were presented as risk ratios (95% confidence intervals). Data were extracted from the time point closest to the end of treatment. When end of treatment was too variable across trials in a review, data were extracted from the outcome or time point with the largest number of trials and participants. Secondary outcomes were safety and tolerability (withdrawals because of adverse events). Findings were classified from each comparison as efficacious, not efficacious, or inconclusive. Certainty of evidence was assessed with the grading of recommendations assessment, development, and evaluation framework. RESULTS 26 reviews (156 unique trials and >25 000 participants) were included. These reviews reported on the efficacy of eight antidepressant classes covering 22 pain conditions (42 distinct comparisons). No review provided high certainty evidence on the efficacy of antidepressants for pain for any condition. 11 comparisons (nine conditions) were found where antidepressants were efficacious, four with moderate certainty evidence: serotonin-norepinephrine reuptake inhibitors (SNRIs) for back pain (mean difference -5.3, 95% confidence interval -7.3 to -3.3), postoperative pain (-7.3, -12.9 to -1.7), neuropathic pain (-6.8, -8.7 to -4.8), and fibromyalgia (risk ratio 1.4, 95% confidence interval 1.3 to 1.6). For the other 31 comparisons, antidepressants were either not efficacious (five comparisons) or the evidence was inconclusive (26 comparisons). CONCLUSIONS Evidence of efficacy of antidepressants was found in 11 of the 42 comparisons included in this overview of systematic reviews-seven of the 11 comparisons investigated the efficacy of SNRIs. For the other 31 comparisons, antidepressants were either inefficacious or evidence on efficacy was inconclusive. The findings suggest that a more nuanced approach is needed when prescribing antidepressants for pain conditions. SYSTEMATIC REVIEW REGISTRATION PROSPERO CRD42022311073.
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Affiliation(s)
- Giovanni E Ferreira
- Sydney School of Public Health, Faculty of Medicine and Health, The University of Sydney, Sydney, NSW 2050, Australia
- Institute for Musculoskeletal Health, Sydney, NSW, Australia
| | - Christina Abdel-Shaheed
- Sydney School of Public Health, Faculty of Medicine and Health, The University of Sydney, Sydney, NSW 2050, Australia
- Institute for Musculoskeletal Health, Sydney, NSW, Australia
| | - Martin Underwood
- Warwick Clinical Trials Unit, University of Warwick, Coventry, UK
- University Hospitals Coventry and Warwickshire, Coventry, UK
| | - Nanna B Finnerup
- Danish Pain Research Center, Department of Clinical Medicine, Aarhus University, Aarhus, Denmark
- Department of Neurology, Aarhus University Hospital, Aarhus, Denmark
| | - Richard O Day
- St Vincent's Clinical School, Faculty of Medicine, University of New South Wales, Sydney, NSW, Australia
- Department of Clinical Pharmacology and Toxicology, St Vincent's Hospital, Sydney, NSW, Australia
| | - Andrew McLachlan
- Sydney Pharmacy School, Faculty of Medicine and Health, University of Sydney, Sydney, NSW, Australia
| | - Sam Eldabe
- James Cook University Hospital, Middlesbrough, UK
| | - Joshua R Zadro
- Sydney School of Public Health, Faculty of Medicine and Health, The University of Sydney, Sydney, NSW 2050, Australia
- Institute for Musculoskeletal Health, Sydney, NSW, Australia
| | - Christopher G Maher
- Sydney School of Public Health, Faculty of Medicine and Health, The University of Sydney, Sydney, NSW 2050, Australia
- Institute for Musculoskeletal Health, Sydney, NSW, Australia
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13
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Rasmussen TK, Karlsson P, Finnerup NB, Jensen TS, Nyengaard JR, Terkelsen AJ. Functional and structural markers of peripheral microvascular autonomic neuropathy. Muscle Nerve 2023; 67:146-153. [PMID: 36504143 PMCID: PMC10108116 DOI: 10.1002/mus.27770] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2022] [Revised: 12/05/2022] [Accepted: 12/06/2022] [Indexed: 12/14/2022]
Abstract
INTRODUCTION/AIMS Autonomic dysfunction is a common complication of small-fiber neuropathy (SFN). In this study we aimed to assess the applicability of autonomic microvascular indices as a potential marker for SFN assessment. METHODS Fifteen patients with confirmed SFN (idiopathic neuropathy [n = 10], chemotherapy-induced peripheral neuropathy [n = 2], impaired glucose tolerance [n = 1], hereditary transthyretin amyloidosis (hATTR) [n = 1], pulmonary sarcoidosis [n = 1]) and 15 matched control subjects underwent assessment of vascular skin responses assessed through laser Doppler flowmetry and evaluation of microvascular vessel and nerve density in skin biopsies. All participants underwent peripheral autonomic evaluation by quantitative sudomotor axon reflex testing (QSART). RESULTS We found no significant differences in vascular skin responses, or in any microvascular skin biopsy markers, when comparing SFN with control subjects. We found no correlation between vascular skin responses and skin biopsy indices. We saw no significant difference in any microvascular indices when comparing subjects with and without impaired sudomotor function. DISCUSSION Our findings suggest markers of peripheral microvascular innervation and function are not associated with the diagnosis of SFN. Furthermore, we saw no association between microvascular markers and sudomotor function, suggesting that these are independent and unrelated components of the autonomic nervous system.
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Affiliation(s)
- Thorsten K Rasmussen
- Danish Pain Research Center, Department of Clinical Medicine, Aarhus University, Aarhus, Denmark
| | - Páll Karlsson
- Danish Pain Research Center, Department of Clinical Medicine, Aarhus University, Aarhus, Denmark.,Core Center for Molecular Morphology, Section for Stereology and Microscopy, Department of Clinical Medicine, Aarhus University, Aarhus, Denmark
| | - Nanna B Finnerup
- Danish Pain Research Center, Department of Clinical Medicine, Aarhus University, Aarhus, Denmark.,Department of Neurology, Aarhus University Hospital, Aarhus, Denmark
| | - Troels S Jensen
- Danish Pain Research Center, Department of Clinical Medicine, Aarhus University, Aarhus, Denmark
| | - Jens R Nyengaard
- Core Center for Molecular Morphology, Section for Stereology and Microscopy, Department of Clinical Medicine, Aarhus University, Aarhus, Denmark.,Department of Pathology, Aarhus University Hospital, Aarhus, Denmark
| | - Astrid J Terkelsen
- Danish Pain Research Center, Department of Clinical Medicine, Aarhus University, Aarhus, Denmark.,Department of Neurology, Aarhus University Hospital, Aarhus, Denmark
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14
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Bennedsgaard K, Grosen K, Attal N, Bouhassira D, Crombez G, Jensen TS, Bennett DL, Ventzel L, Andersen IS, Finnerup NB. Neuropathy and pain after breast cancer treatment: a prospective observational study. Scand J Pain 2023; 23:49-58. [PMID: 35636394 DOI: 10.1515/sjpain-2022-0017] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/19/2022] [Accepted: 05/17/2022] [Indexed: 01/17/2023]
Abstract
OBJECTIVES Neurological complications including pain are common after treatment for breast cancer. This prospective study investigated the symptoms, intensity and interference of chemotherapy-induced peripheral neuro-pathy. (CIPN) in the feet and hands compared to surgery- and radiation-induced neuropathy in the breast and upper arm. METHODS Consecutive patients referred to surgery for breast cancer were included in a prospective study and completed a questionnaire at baseline and a follow-up questionnaire and interview after one year. CIPN was assessed with the CIPN20 questionnaire and the Michigan Neuropathy Screening Instrument questionnaire (MNSIq). Pain intensity was rated on a numeric rating scale (NRS, 0-10). RESULTS In total 144 patients were included, of which 73 received chemotherapy. At one-year follow-up, symptoms of polyneuropathy were more common in patients treated with chemotherapy. Tingling or numbness in the feet in those treated/not treated with chemotherapy was reported by 44 (62%) and 15 (21%), respectively. Pain was present in 22 (30%) and 10 (14%), respectively. Pain in the area of surgery was reported by 66 (46%). Although less common, pain in the feet in those treated with chemotherapy was rated as more intense and with more daily life interference than pain in the surgical area (NRS 5.5 (SD 1.9) vs. 3.1 (SD 1.9). CONCLUSIONS Neurological complications including pain following surgery and chemotherapy represent a burden to breast cancer survivors. In those who had received chemotherapy, pain in the feet was less common than pain in the surgical area, but pain in the feet was more intense and had a higher interference with daily life. Our study emphasizes the need for either baseline data or a control population for improved estimation of the presence and severity of CIPN and pain from questionnaires.
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Affiliation(s)
- Kristine Bennedsgaard
- Danish Pain Research Center, Department of Clinical Medicine, Aarhus University, Aarhus, Denmark
- Department of Oncology, Aarhus University Hospital, Aarhus, Denmark
| | - Kasper Grosen
- Danish Pain Research Center, Department of Clinical Medicine, Aarhus University, Aarhus, Denmark
- Research Centre for Health and Welfare Technology, VIA University College, Aarhus, Denmark
| | - Nadine Attal
- Inserm U987, AP-HP, CHU Ambroise Paré hospital, UVSQ, Paris-Saclay University, Boulogne-Billancourt, France
| | - Didier Bouhassira
- Inserm U987, AP-HP, CHU Ambroise Paré hospital, UVSQ, Paris-Saclay University, Boulogne-Billancourt, France
| | - Geert Crombez
- Department of Experimental Clinical and Health Psychology, Ghent University, Ghent, Belgium
| | - Troels S Jensen
- Danish Pain Research Center, Department of Clinical Medicine, Aarhus University, Aarhus, Denmark
| | - David L Bennett
- Nuffield Department of Clinical Neuroscience, University of Oxford, Oxford, UK
| | - Lise Ventzel
- Danish Pain Research Center, Department of Clinical Medicine, Aarhus University, Aarhus, Denmark
- Department of Oncology, University Hospital of Southern Denmark, Vejle, Denmark
| | - Inge S Andersen
- Department of Breast Surgery, Hospitalsenheden Midt, Viborg, Denmark
| | - Nanna B Finnerup
- Danish Pain Research Center, Department of Clinical Medicine, Aarhus University, Aarhus, Denmark
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15
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Rasmussen TK, Finnerup NB, Singer W, Jensen TS, Hansen J, Terkelsen AJ. Preferential impairment of parasympathetic autonomic function in type 2 diabetes. Auton Neurosci 2022; 243:103026. [PMID: 36137485 DOI: 10.1016/j.autneu.2022.103026] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/04/2021] [Revised: 07/07/2022] [Accepted: 09/07/2022] [Indexed: 11/18/2022]
Abstract
OBJECTIVE Cardiovascular autonomic neuropathy is a known complication in type 2 diabetes (T2D). However, the extent of sympathetic dysfunction and its relation to blood pressure (BP) dysregulation is insufficiently studied. We therefore assessed the cardiovascular sympathetic function using a standardized autonomic test-battery. RESEARCH DESIGN AND METHODS Forty T2D patients (mean age and duration of diabetes ±SD, 65.5 ± 7.3 and 9.5 ± 4.2 years) and 40 age- and gender-matched controls were examined through autonomic testing, assessing cardiovascular responses to deep breathing, Valsalva maneuver and tilt-table testing. Additionally, 24-hour oscillometric BP and self-reported autonomic symptoms on COMPASS-31 questionnaire was recorded. RESULTS Patients with T2D had reduced parasympathetic activity with reduced deep breathing inspiratory:expiratory-ratio (median [IQR] T2D 1.11 [1.08-1.18] vs. controls 1.18 [1.11-1.25] (p = 0.01)), and reduced heart rate variability (p < 0.05). We found no differences in cardiovascular sympathetic function measured through BP responses during the Valsalva maneuver (p > 0.05). 24-hour-BP detected reduced night-time systolic BP drop in T2D (9.8 % ± 8.8 vs. controls 15.8 % ± 7.7 (p < 0.01)) with more patients having reverse dipping. Patients with T2D reported more symptoms of orthostatic intolerance on the COMPASS-31 (p = 0.04). CONCLUSIONS Patients with T2D showed reduced parasympathetic activity but preserved short-term cardiovascular sympathetic function, compared to controls, indicating autonomic dysfunction with predominantly parasympathetic impairment. Despite this, T2D patients reported more symptoms of orthostatic intolerance in COMPASS-31 and had reduced nocturnal BP dipping, indicating that these are not a consequence of cardiovascular sympathetic dysfunction.
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Affiliation(s)
- Thorsten K Rasmussen
- Danish Pain Research Center, Department of Clinical Medicine, Aarhus University, Denmark; International Diabetic Neuropathy Consortium (IDNC), Department of Clinical Medicine, Aarhus University, Aarhus, Denmark.
| | - Nanna B Finnerup
- Danish Pain Research Center, Department of Clinical Medicine, Aarhus University, Denmark; International Diabetic Neuropathy Consortium (IDNC), Department of Clinical Medicine, Aarhus University, Aarhus, Denmark; Department of Neurology, Aarhus University Hospital, Denmark
| | | | - Troels S Jensen
- Danish Pain Research Center, Department of Clinical Medicine, Aarhus University, Denmark; International Diabetic Neuropathy Consortium (IDNC), Department of Clinical Medicine, Aarhus University, Aarhus, Denmark
| | - John Hansen
- Department of Health Science and Technology, Aalborg University, Denmark
| | - Astrid J Terkelsen
- Danish Pain Research Center, Department of Clinical Medicine, Aarhus University, Denmark; International Diabetic Neuropathy Consortium (IDNC), Department of Clinical Medicine, Aarhus University, Aarhus, Denmark; Department of Neurology, Aarhus University Hospital, Denmark
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16
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Schaldemose EL, Andersen NT, Finnerup NB, Fardo F. When cooling of the skin is perceived as warmth: Enhanced paradoxical heat sensation by pre-cooling of the skin in healthy individuals. Temperature (Austin) 2022; 10:248-263. [PMID: 37332303 PMCID: PMC10274555 DOI: 10.1080/23328940.2022.2088028] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/25/2022] [Revised: 05/25/2022] [Accepted: 06/06/2022] [Indexed: 10/17/2022] Open
Abstract
A paradoxical heat sensation (PHS) is the misperception of warmth when the skin is cooled. PHS is uncommon in healthy individuals but common in patients with neuropathy and is associated with reduced thermal sensitivity. Identifying conditions that contribute to PHS may indirectly help us understand why some patients experience PHS. We hypothesized that pre-warming increased the number of PHS and that pre-cooling had minimal effect on PHS. We tested 100 healthy participants' thermal sensitivity on the dorsum of their feet by measuring detection and pain thresholds to cold and warm stimuli and PHS. PHS was measured using the thermal sensory limen (TSL) procedure from the quantitative sensory testing protocol of the German Research Network on Neuropathic Pain and by using a modified TSL protocol (mTSL). In the mTSL we examined the participants' thermal detection and PHS after pre-warming of 38°C and 44°C and pre-cooling of 26°C and 20°C. Compared to a baseline condition, the number of PHS responders was significantly increased after pre-cooling (20°C: RR = 1.9 (1.1; 3.3), p = 0.023 and 26°C: RR = 1.9 (1.2; 3.2), p = 0.017), but not significantly after pre-warming (38°C: RR = 1.5 (0.86; 2.8), p = 0.21 and 44°C: RR = 1.7 (.995; 2.9), p = 0.078). Pre-warming and pre-cooling increased the detection threshold of both cold and warm temperatures. We discussed these findings in relation to thermal sensory mechanisms and possible PHS mechanisms. In conclusion, PHS and thermosensation are closely related and pre-cooling can induce PHS responses in healthy individuals.
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Affiliation(s)
- Ellen L. Schaldemose
- Danish Pain Research Center, Department of Clinical Medicine, Aarhus University, Aarhus, Denmark
| | - Niels T. Andersen
- Biostatistics, Department of Public Health, Aarhus University, Aarhus, Denmark
| | - Nanna B. Finnerup
- Danish Pain Research Center, Department of Clinical Medicine, Aarhus University, Aarhus, Denmark
- Department of Neurology, Aarhus University Hospital, Aarhus, Denmark
| | - Francesca Fardo
- Danish Pain Research Center, Department of Clinical Medicine, Aarhus University, Aarhus, Denmark
- Center of Functionally Integrative Neuroscience, Department of Clinical Medicine, Aarhus University, Aarhus, Denmark
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17
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Abstract
Pain in patients with cerebral palsy (CP) is a major health issue strongly associated with reduced quality of life. In this study, we provide an overview of pain conditions in children with CP using the International Classification of Diseases, 11th Revision (ICD-11), which has been updated with a classification of chronic pain. Common causes of pain in children with CP, including hip displacement, muscle spasms, and procedures, are discussed; less studied pain types including headaches, neuropathic pain, visceral pain, and acute versus chronic pain are also highlighted. The addition of chronic pain to the ICD-11 is an important step forward in optimizing both the registration and assessment of pain conditions. However, a tool designed specifically for the different types of pain in patients with CP is imperative. In this paper, we propose a Cerebral Palsy Pain Classification that is aligned with the underlying mechanisms of pain and the ICD-11 pain classification.
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Affiliation(s)
- Michael N Vinkel
- Danish Pain Research Center, Department of Clinical Medicine, Aarhus University, Aarhus, Denmark
| | - Gija Rackauskaite
- Danish Pain Research Center, Department of Clinical Medicine, Aarhus University, Aarhus, Denmark.,Department of Paediatrics and Adolescent Medicine, Aarhus University Hospital, Aarhus, Denmark
| | - Nanna B Finnerup
- Danish Pain Research Center, Department of Clinical Medicine, Aarhus University, Aarhus, Denmark.,Department of Neurology, Aarhus University Hospital, Aarhus, Denmark
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18
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Khan KS, Overgaard K, Tankisi H, Karlsson P, Devantier L, Gregersen S, Jensen TS, Finnerup NB, Pop-Busui R, Dalgas U, Andersen H. Effects of progressive resistance training in individuals with type 2 diabetic polyneuropathy: a randomised assessor-blinded controlled trial. Diabetologia 2022; 65:620-631. [PMID: 35048156 DOI: 10.1007/s00125-021-05646-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/31/2021] [Accepted: 11/05/2021] [Indexed: 11/29/2022]
Abstract
AIMS/HYPOTHESIS The aim of this study was to evaluate the effects of progressive resistance training (PRT) on muscle strength, intraepidermal nerve fibre density (IENFD) and motor function in individuals with type 2 diabetic polyneuropathy (DPN) and to compare potential adaptations to those of individuals with type 2 diabetes without DPN and healthy controls. METHODS This was an assessor-blinded trial conducted at the Neurology department, Aarhus University Hospital. Adults with type 2 diabetes, with and without DPN and healthy control participants were randomised to either supervised PRT or non-PRT for 12 weeks. Allocation was concealed by a central office unrelated to the study. The co-primary outcomes were muscle strength in terms of the peak torque of the knee and ankle extensors and flexors, and IENFD. Secondary outcome measures included the 6 min walk test (6MWT), five-time sit-to-stand test (FTSST) and postural stability index obtained by static posturography. RESULTS A total of 109 individuals were enrolled in three groups (type 2 diabetes with DPN [n = 42], type 2 diabetes without DPN [n = 32] and healthy control [n = 35]). PRT resulted in muscle strength gains of the knee extensors and flexors in all three groups using comparative analysis (DPN group, PRT 10.3 ± 9.6 Nm vs non-PRT -0.4 ± 8.2 Nm; non-DPN group, PRT 7.5 ± 5.8 Nm vs non-PRT 0.6 ± 8.8 Nm; healthy control group, PRT 6.3 ± 9.0 Nm vs non-PRT -0.4 ± 8.4 Nm; p<0.05, respectively). Following PRT the DPN group improved the 6MWT (PRT 34.6 ± 40.9 m vs non-PRT 2.7 ± 19.6 m; p=0.001) and the FTSST (PRT -1.5 ± 2.2 s vs non-PRT 1.5 ± 4.6 s; p=0.02). There was no change in IENFD following PRT in any of the groups. CONCLUSIONS/INTERPRETATION PRT improved muscle strength of the knee extensors and flexors and motor function in individuals with type 2 diabetic polyneuropathy at levels comparable with those seen in individuals with diabetes without DPN and healthy control individuals, while no effects were observed in IENFD. TRIAL REGISTRATION ClinicalTrials.gov NCT03252132 FUNDING: Research reported in this paper is part of the International Diabetic Neuropathy Consortium (IDNC) research programme, supported by a Novo Nordisk Foundation Challenge Program grant (grant no. NNF14OC0011633) and Aarhus University.
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Affiliation(s)
- Karolina S Khan
- Department of Neurology, Aarhus University Hospital, Aarhus, Denmark.
- International Diabetic Neuropathy Consortium, Department of Clinical Medicine, Faculty of Health, Aarhus University, Aarhus, Denmark.
| | - Kristian Overgaard
- Exercise Biology, Department of Public Health, Aarhus University, Aarhus, Denmark
| | - Hatice Tankisi
- International Diabetic Neuropathy Consortium, Department of Clinical Medicine, Faculty of Health, Aarhus University, Aarhus, Denmark
- Department of Clinical Neurophysiology, Aarhus University, Aarhus, Denmark
| | - Pall Karlsson
- Danish Pain Research Center, Department of Clinical Medicine, Aarhus University, Aarhus, Denmark
- Core Centre for Molecular Morphology, Section for Stereology and Microscopy, Department of Clinical Medicine, Aarhus University, Aarhus, Denmark
| | - Louise Devantier
- Department of Oto-Rhino-Laryngology, Regional Hospital West Jutland, Holstebro, Denmark
| | | | - Troels S Jensen
- Department of Neurology, Aarhus University Hospital, Aarhus, Denmark
- International Diabetic Neuropathy Consortium, Department of Clinical Medicine, Faculty of Health, Aarhus University, Aarhus, Denmark
- Danish Pain Research Center, Department of Clinical Medicine, Aarhus University, Aarhus, Denmark
| | - Nanna B Finnerup
- Department of Neurology, Aarhus University Hospital, Aarhus, Denmark
- International Diabetic Neuropathy Consortium, Department of Clinical Medicine, Faculty of Health, Aarhus University, Aarhus, Denmark
- Danish Pain Research Center, Department of Clinical Medicine, Aarhus University, Aarhus, Denmark
| | - Rodica Pop-Busui
- Division of Metabolism, Endocrinology and Diabetes, Department of Internal Medicine, University of Michigan, Ann Arbor, MI, USA
| | - Ulrik Dalgas
- Exercise Biology, Department of Public Health, Aarhus University, Aarhus, Denmark
| | - Henning Andersen
- Department of Neurology, Aarhus University Hospital, Aarhus, Denmark
- International Diabetic Neuropathy Consortium, Department of Clinical Medicine, Faculty of Health, Aarhus University, Aarhus, Denmark
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Gillving M, Demant D, Holbech JV, Vase L, Bach FW, Jensen TS, Finnerup NB, Sindrup SH. Impact of variability in baseline pain on the placebo response in randomized, placebo-controlled, crossover trials in peripheral neuropathic pain. Pain 2022; 163:483-488. [PMID: 34407033 DOI: 10.1097/j.pain.0000000000002374] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/26/2021] [Accepted: 06/09/2021] [Indexed: 11/25/2022]
Abstract
ABSTRACT Large placebo responses often negatively affect randomized controlled trials within the pain area. Understanding different possible factors that influence the placebo response is therefore important. In this retrospective analysis, we hypothesized that a large variability in baseline pain score would predict a greater placebo response and analyzed the impact of the coefficient of variation, SD, and difference between the highest and lowest numeric rating scale (NRS) score at baseline on the placebo response. A total of 160 observations on placebo response from 3 controlled clinical trials with a crossover design were included in this study. In general, the placebo response was low with a mean reduction in pain intensity of 0.5 points (range -5 to 7) measured on a 0 to 10 point NRS, and only 15% were placebo responders as defined by more than 30% reduction in NRS pain score from baseline to the end of the placebo treatment period. We found no significant impact of baseline pain coefficient of variation, SD, or the difference between lowest and highest baseline pain score on the placebo response. Placebo response in one trial did not predict placebo response in another trial. A large placebo response was not associated with a large treatment response. In conclusion, in this retrospective data analysis, there was no impact of baseline pain variability on the placebo response in controlled clinical trials with a crossover design in patients with peripheral neuropathic pain.
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Affiliation(s)
- Mimmi Gillving
- Department of Neurology and Neurology Research Unit, Odense University Hospital and University of Southern Denmark, Odense, Denmark
| | - Dyveke Demant
- Department of Neurology and Neurology Research Unit, Odense University Hospital and University of Southern Denmark, Odense, Denmark
| | - Jakob V Holbech
- Department of Neurology and Neurology Research Unit, Odense University Hospital and University of Southern Denmark, Odense, Denmark
| | - Lene Vase
- Department of Clinical Medicine, Danish Pain Research Center, Aarhus University, Aarhus, Denmark
| | - Flemming W Bach
- Department of Neurology, Aarhus University Hospital, Aarhus, Denmark
| | - Troels S Jensen
- Department of Clinical Medicine, Danish Pain Research Center, Aarhus University, Aarhus, Denmark
| | - Nanna B Finnerup
- Department of Clinical Medicine, Danish Pain Research Center, Aarhus University, Aarhus, Denmark
| | - Søren H Sindrup
- Department of Neurology and Neurology Research Unit, Odense University Hospital and University of Southern Denmark, Odense, Denmark
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Nochi Z, Pia H, Bloms-Funke P, Boesl I, Caspani O, Chapman SC, Fardo F, Genser B, Goetz M, Kostenko AV, Leone C, Li T, Mouraux A, Pelz B, Pogatzki-Zahn E, Schilder A, Schnetter E, Schubart K, Stouffs A, Tracey I, Troconiz IF, Truini A, Van Niel J, Vela JM, Vincent K, Vollert J, Wanigasekera V, Wittayer M, Tankisi H, Finnerup NB, Phillips KG, Treede RD. IMI2-PainCare-BioPain-RCT1: study protocol for a randomized, double-blind, placebo-controlled, crossover, multi-center trial in healthy subjects to investigate the effects of lacosamide, pregabalin, and tapentadol on biomarkers of pain processing observed by peripheral nerve excitability testing (NET). Trials 2022; 23:163. [PMID: 35183242 PMCID: PMC8857873 DOI: 10.1186/s13063-022-06087-1] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/08/2021] [Accepted: 02/05/2022] [Indexed: 12/12/2022] Open
Abstract
Abstract
Background
Few new drugs have been developed for chronic pain. Drug development is challenged by uncertainty about whether the drug engages the human target sufficiently to have a meaningful pharmacodynamic effect. IMI2-PainCare-BioPain-RCT1 is one of four similarly designed studies that aim to link different functional biomarkers of drug effects on the nociceptive system that could serve to accelerate the future development of analgesics. This study focusses on biomarkers derived from nerve excitability testing (NET) using threshold tracking of the peripheral nervous system.
Methods
This is a multisite single-dose, subject and assessor-blind, randomized, placebo-controlled, 4-period, 4-way crossover, pharmacodynamic (PD), and pharmacokinetic (PK) study in healthy subjects. Biomarkers derived from NET of large sensory and motor fibers and small sensory fibers using perception threshold tracking will be obtained before and three times after administration of three medications known to act on the nociceptive system (lacosamide, pregabalin, tapentadol) and placebo, given as a single oral dose with at least 1 week apart. Motor and sensory NET will be assessed on the right wrist in a non-sensitized normal condition while perception threshold tracking will be performed bilaterally on both non-sensitized and sensitized forearm skin. Cutaneous high-frequency electrical stimulation is used to induce hyperalgesia. Blood samples will be taken for pharmacokinetic purposes and pain ratings as well as predictive psychological traits will be collected. A sequentially rejective multiple testing approach will be used with overall alpha error of the primary analysis split across the two primary outcomes: strength-duration time constant (SDTC; a measure of passive membrane properties and nodal persistent Na+ conductance) of large sensory fibers and SDTC of large motor fibers comparing lacosamide and placebo. The key secondary endpoint is the SDTC measured in small sensory fibers. Remaining treatment arm effects on key NET outcomes and PK modelling are other prespecified secondary or exploratory analyses.
Discussion
Measurements of NET using threshold tracking protocols are sensitive to membrane potential at the site of stimulation. Sets of useful indices of axonal excitability collectively may provide insights into the mechanisms responsible for membrane polarization, ion channel function, and activity of ionic pumps during the process of impulse conduction. IMI2-PainCare-BioPain-RCT1 hypothesizes that NET can serve as biomarkers of target engagement of analgesic drugs in this compartment of the nociceptive system for future Phase 1 clinical trials. Phase 2 and 3 clinical trials could also benefit from these tools for patient stratification.
Trial registration
This trial was registered 25/06/2019 in EudraCT (2019-000942-36).
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21
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Themistocleous AC, Kristensen AG, Sola R, Gylfadottir SS, Bennedsgaard K, Itani M, Krøigård T, Ventzel L, Sindrup SH, Jensen TS, Bostock H, Serra J, Finnerup NB, Tankisi H, Bennett DLH. Axonal excitability does not differ between painful and painless diabetic or chemotherapy-induced distal symmetrical polyneuropathy in a multi-centre observational study. Ann Neurol 2022; 91:506-520. [PMID: 35150149 PMCID: PMC9313833 DOI: 10.1002/ana.26319] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/09/2021] [Revised: 01/18/2022] [Accepted: 02/07/2022] [Indexed: 11/16/2022]
Abstract
Objective Axonal excitability reflects ion channel function, and it is proposed that this may be a biomarker in painful (vs painless) polyneuropathy. Our objective was to investigate the relationship between axonal excitability parameters and chronic neuropathic pain in deeply phenotyped cohorts with diabetic or chemotherapy‐induced distal symmetrical polyneuropathy. Methods Two hundred thirty‐nine participants with diabetic polyneuropathy were recruited from sites in the UK and Denmark, and 39 participants who developed chemotherapy‐induced polyneuropathy were recruited from Denmark. Participants were separated into those with probable or definite neuropathic pain and those without neuropathic pain. Axonal excitability of large myelinated fibers was measured with the threshold tracking technique. The stimulus site was the median nerve, and the recording sites were the index finger (sensory studies) and abductor pollicis brevis muscle (motor studies). Results Participants with painless and painful polyneuropathy were well matched across clinical variables. Sensory and motor axonal excitability measures, including recovery cycle, threshold electrotonus, strength–duration time constant, and current–threshold relationship, did not show differences between participants with painful and painless diabetic polyneuropathy, and there were only minor changes for chemotherapy‐induced polyneuropathy. Interpretation Axonal excitability did not significantly differ between painful and painless diabetic or chemotherapy‐induced polyneuropathy in a multicenter observational study. Threshold tracking assesses the excitability of myelinated axons; the majority of nociceptors are unmyelinated, and although there is some overlap of the "channelome" between these axonal populations, our results suggest that alternative measures such as microneurography are required to understand the relationship between sensory neuron excitability and neuropathic pain. ANN NEUROL 2022;91:506–520
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Affiliation(s)
| | - Alexander Gramm Kristensen
- Department of Clinical Medicine, Aarhus University, Aarhus, Denmark.,Department of Clinical Neurophysiology, Aarhus University Hospital, Aarhus, Denmark
| | - Roma Sola
- Neuroscience Technologies, Barcelona, Spain.,MC Mutual, Barcelona, Spain
| | - Sandra Sif Gylfadottir
- Danish Pain Research Center, Department of Clinical Medicine, Aarhus University, Aarhus, Denmark.,Department of Neurology, Aarhus University Hospital, Aarhus, Denmark
| | - Kristine Bennedsgaard
- Danish Pain Research Center, Department of Clinical Medicine, Aarhus University, Aarhus, Denmark.,Department of Neurology, Aarhus University Hospital, Aarhus, Denmark
| | - Mustapha Itani
- Department of Neurology, Odense University Hospital, Odense, Denmark
| | - Thomas Krøigård
- Department of Neurology, Odense University Hospital, Odense, Denmark
| | - Lise Ventzel
- Danish Pain Research Center, Department of Clinical Medicine, Aarhus University, Aarhus, Denmark
| | | | - Troels Staehelin Jensen
- Danish Pain Research Center, Department of Clinical Medicine, Aarhus University, Aarhus, Denmark.,Department of Neurology, Aarhus University Hospital, Aarhus, Denmark
| | - Hugh Bostock
- UCL Queen Square Institute of Neurology, London, United Kingdom
| | - Jordi Serra
- Neuroscience Technologies, Barcelona, Spain.,MC Mutual, Barcelona, Spain
| | - Nanna B Finnerup
- Danish Pain Research Center, Department of Clinical Medicine, Aarhus University, Aarhus, Denmark.,Department of Neurology, Aarhus University Hospital, Aarhus, Denmark
| | - Hatice Tankisi
- Department of Clinical Medicine, Aarhus University, Aarhus, Denmark.,Department of Clinical Neurophysiology, Aarhus University Hospital, Aarhus, Denmark
| | - David L H Bennett
- Nuffield Department of Clinical Neurosciences, University of Oxford, Oxford, UK
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22
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Lim J, Chen D, McNicol E, Sharma L, Varaday G, Sharma A, Wilson E, Wright-Yatsko T, Yaeger L, Gilron I, Finnerup NB, Haroutounian S. Risk factors for persistent pain after breast and thoracic surgeries: a systematic literature review and meta-analysis. Pain 2022; 163:3-20. [PMID: 34001769 DOI: 10.1097/j.pain.0000000000002301] [Citation(s) in RCA: 19] [Impact Index Per Article: 9.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/20/2020] [Accepted: 03/09/2021] [Indexed: 11/25/2022]
Abstract
ABSTRACT Persistent postsurgical pain (PPSP) is common after breast and thoracic surgeries. Understanding which risk factors consistently contribute to PPSP will allow clinicians to apply preventive strategies, as they emerge, to high-risk patients. The objective of this work was to systematically review and meta-analyze the literature on risk factors of PPSP after breast and thoracic surgeries. A systematic literature search using Ovid Medline, Cochrane Central Register of Controlled Trials, Cumulative Index to Nursing and Allied Health Literature, Embase, PsycINFO, and Scopus databases was conducted. Study screening with inclusion and exclusion criteria, data extraction, and risk of bias assessment was performed independently by 2 authors. The data for each surgical group were analyzed separately and meta-analyzed where possible. The literature search yielded 5584 articles, and data from 126 breast surgery and 143 thoracic surgery articles were considered for meta-analysis. In breast surgery, younger age, higher body mass index, anxiety, depression, diabetes, smoking, preoperative pain, moderate to severe acute postoperative pain, reoperation, radiotherapy, and axillary lymph node dissection were the main factors associated with higher risk of PPSP. In thoracic surgery, younger age, female sex, hypertension, preoperative pain, moderate to severe acute postoperative pain, surgical approach, major procedure, and wound complications were associated with PPSP. This systematic review demonstrated certain consistent risk factors of PPSP after breast and thoracic surgeries, as well as identified research gaps. Understanding the factors that increase susceptibility to PPSP can help selectively allocate resources to optimize perioperative care in high-risk patients and help develop targeted, risk-stratified interventions for PPSP prevention.
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Affiliation(s)
- Joshua Lim
- Saint Louis University School of Medicine, St. Louis, MO, United States
| | - Dili Chen
- University of Sydney School of Medicine, Sydney, Australia
| | | | - Lokesh Sharma
- Department of Anesthesiology, Washington University in St. Louis School of Medicine, St. Louis, MO, United States
| | - Grihith Varaday
- Department of Anesthesiology, Washington University in St. Louis School of Medicine, St. Louis, MO, United States
| | - Anshuman Sharma
- Department of Anesthesiology, Washington University in St. Louis School of Medicine, St. Louis, MO, United States
| | - Elizabeth Wilson
- Department of Anesthesiology, Washington University in St. Louis School of Medicine, St. Louis, MO, United States
| | - Tiffany Wright-Yatsko
- Department of Anesthesiology, Washington University in St. Louis School of Medicine, St. Louis, MO, United States
| | - Lauren Yaeger
- Becker Medical Library, Washington University in St. Louis School of Medicine, St. Louis, MO, United States
| | - Ian Gilron
- Departments of Anesthesiology & Perioperative Medicine, Biomedical & Molecular Sciences, Centre for Neuroscience Studies, and School of Policy Studies, Queen's University, Kingston, Ontario, Canada
| | - Nanna B Finnerup
- Department of Clinical Medicine, Danish Pain Research Center, Aarhus University, Aarhus, Denmark
| | - Simon Haroutounian
- Department of Anesthesiology, Washington University in St. Louis School of Medicine, St. Louis, MO, United States
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23
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Jensen TS, Finnerup NB. Distal symmetric polyneuropathy in diabetes: a progressive disorder? Brain 2021; 144:2912-2914. [PMID: 34849597 DOI: 10.1093/brain/awab355] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/21/2021] [Accepted: 09/21/2021] [Indexed: 11/13/2022] Open
Abstract
This scientific commentary refers to ‘Progression and regression of nerve fibre pathology and dysfunction early in diabetes over 5 years’ by Ziegler et al. (doi:10.1093/brain/awab330).
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Affiliation(s)
- Troels S Jensen
- Danish Pain Research Center, Department of Clinical Medicine, Aarhus University, Aarhus, Denmark.,Department of Neurology, Aarhus University Hospital, Aarhus, Denmark
| | - Nanna B Finnerup
- Danish Pain Research Center, Department of Clinical Medicine, Aarhus University, Aarhus, Denmark.,Department of Neurology, Aarhus University Hospital, Aarhus, Denmark
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24
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Rice ASC, Dworkin RH, Finnerup NB, Attal N, Anand P, Freeman R, Piaia A, Callegari F, Doerr C, Mondal S, Narayanan N, Ecochard L, Flossbach Y, Pandhi S. Efficacy and safety of EMA401 in peripheral neuropathic pain: results of 2 randomised, double-blind, phase 2 studies in patients with postherpetic neuralgia and painful diabetic neuropathy. Pain 2021; 162:2578-2589. [PMID: 33675631 DOI: 10.1097/j.pain.0000000000002252] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/25/2020] [Accepted: 02/09/2021] [Indexed: 11/26/2022]
Abstract
ABSTRACT The analgesic efficacy and safety of 2 phase 2b studies of EMA401 (a highly selective angiotensin II type 2 receptor antagonist) in patients with postherpetic neuralgia (EMPHENE) and painful diabetic neuropathy (EMPADINE) were reported. These were multicentre, randomised, double-blind treatment studies conducted in participants with postherpetic neuralgia or type I/II diabetes mellitus with painful distal symmetrical sensorimotor neuropathy. Participants were randomised 1:1:1 to either placebo, EMA401 25 mg, or 100 mg twice daily (b.i.d) in the EMPHENE and 1:1 to placebo or EMA401 100 mg b.i.d. in the EMPADINE. The primary outcome for both the studies was change in weekly mean of the 24-hour average pain score, using a numeric rating scale from baseline to week 12. Both the studies were prematurely terminated due to preclinical hepatotoxicity on long-term dosing, although not observed in these studies. Out of the planned participants, a total of 129/360 (EMPHENE) and 137/400 (EMPADINE) participants were enrolled. The least square mean reduction in numeric rating scale pain score was numerically in favour of EMA401 100 mg arm in both EMPHENE (treatment difference: -0.5 [95% confidence interval: -1.6 to 0.6; P value: 0.35]) and EMPADINE (treatment difference: -0.6 [95% confidence interval: -1.4 to 0.1; P value: 0.10]) at the end of week 12. However, as the studies were terminated prematurely, no firm conclusion could be drawn but the consistent clinical improvement in pain intensity reduction across these 2 studies in 2 different populations is worth noting.
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Affiliation(s)
- Andrew S C Rice
- Department of Surgery and Cancer, Pain Research, Imperial College London, London, United Kingdom
| | - Robert H Dworkin
- Department of Anesthesiology and Perioperative Medicine, University of Rochester Medical Center, Rochester, NY, United States
| | - Nanna B Finnerup
- Department of Clinical Medicine, Danish Pain Research Center, Aarhus University, Aarhus, Denmark
| | - Nadine Attal
- INSERM U987, Ambroise Paré Hospital, APHP, Boulogne-Billancourt, Paris, France
- Université Versailles Saint Quentin- en Yvelines (UVSQ), Versailles, France
| | - Praveen Anand
- Department of Brain Sciences, Imperial College London, London, United Kingdom
| | - Roy Freeman
- Center for Autonomic and Peripheral Nerve Disorders, Beth Israel Deaconess Medical Center, Harvard Medical School Boston, Boston, MA, United States
| | | | | | - Christie Doerr
- Novartis Pharmaceuticals Corporation, East Hanover, NJ, United States
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25
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Kemp HI, Eliahoo J, Vase L, Nguyen S, Ben Abdallah A, Rice ASC, Finnerup NB, Haroutounian S. Meta-analysis comparing placebo responses in clinical trials of painful HIV-associated sensory neuropathy and diabetic polyneuropathy. Scand J Pain 2021; 20:439-449. [PMID: 32106088 DOI: 10.1515/sjpain-2019-0152] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/04/2019] [Accepted: 01/15/2020] [Indexed: 11/15/2022]
Abstract
Background and aims The placebo response has been identified as one factor responsible for the lack of therapeutic trials with positive outcomes in neuropathic pain. Reviews have suggested that certain neuropathic pain conditions, including HIV-associated sensory neuropathy (HIV-SN), exhibit a greater placebo response than other neuropathic aetiologies. If true, such a finding could substantially affect clinical trial design and therapeutic developments for these conditions. This study aimed to identify any difference in placebo response between trials of systemic pharmacological intervention in HIV-SN and a comparable neuropathic condition, diabetic polyneuropathy (DPN) and to identify factors influencing the placebo response. Methods A systematic review search to identify randomised, double-blind studies of systemic pharmacological interventions for painful HIV-SN and DPN published between January 1966 and June 2019 was performed. A meta-analysis of the magnitude of placebo response and the proportion of placebo responders was conducted and compared between the two disease conditions. A meta-regression was used to assess for any study and participant characteristics that were associated with the placebo response. Only studies meeting a methodological quality threshold were included. Results Seventy-five trials were identified. There was no statistically significant difference in the proportion of placebo responders (HIV-SN = 0.35; versus DPN = 0.27, p = 0.129). The difference observed in the magnitude of the placebo response [pain reduction of 1.68 (1.47-1.88) DPN; 2.38 (1.87-2.98) in HIV-SN] was based on only 2 trials of HIV-SN and 35 of DPN. Potential factors influencing the placebo response such as psychological measures, were reported inconsistently. Conclusions We found no statistically significant difference in the placebo response rate between painful HIV-SN and DPN. Too few studies were available that reported the necessary information to clarify potential differences in the magnitude of placebo response or to elucidate parameters that could be contributing such differences. Implications The placebo response is one factor that may contribute to a lack of positive trials in neuropathic pain; some etiologies may display larger responses than others. This meta-analysis found no significant difference in placebo response between trials of HIV-associated sensory neuropathy and painful diabetic polyneuropathy, although limited data were available.
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Affiliation(s)
- Harriet I Kemp
- Pain Research Group, Imperial College London, London, UK
| | - Joseph Eliahoo
- Statistical Advisory Service, Imperial College London, London, UK
| | - Lene Vase
- Department of Psychology and Behavioral Science, Aarhus University, Aarhus, Denmark
| | | | - Arbi Ben Abdallah
- Department of Anesthesiology, Washington University in St Louis School of Medicine, St Louis, MO, USA
| | | | - Nanna B Finnerup
- Danish Pain Research Center, Department of Clinical Medicine, Aarhus University and Department of Neurology, Aarhus University Hospital, Aarhus, Denmark
| | - Simon Haroutounian
- Department of Anesthesiology, Washington University in St Louis School of Medicine, St Louis, MO, USA.,Washington University Pain Center, St Louis, MO, USA
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26
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Rosner J, Negraeff M, Bélanger LM, Tsang A, Ritchie L, Mac-Thiong JM, Christie S, Wilson JR, Dhall S, Charest-Morin R, Street J, Ailon T, Paquette S, Dea N, Fisher CG, Dvorak MF, Finnerup NB, Kwon BK, Kramer JLK. Characterization of Hyperacute Neuropathic Pain after Spinal Cord Injury: A Prospective Study. J Pain 2021; 23:89-97. [PMID: 34302956 DOI: 10.1016/j.jpain.2021.06.013] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/12/2020] [Revised: 06/19/2021] [Accepted: 06/25/2021] [Indexed: 10/20/2022]
Abstract
There is currently a lack of information regarding neuropathic pain in the very early stages of spinal cord injury (SCI). In the present study, neuropathic pain was assessed using the Douleur Neuropathique 4 Questions (DN4) for the patient's worst pain within the first 5 days of injury (i.e., hyperacute) and on follow-up at 3, 6, and 12 months. Within the hyperacute time frame (i.e., 5 days), at- and below-level neuropathic pain were reported as the worst pain in 23% (n = 18) and 5% (n = 4) of individuals with SCI, respectively. Compared to the neuropathic pain observed in this hyperacute setting, late presenting neuropathic pain was characterized by more intense painful electrical and cold sensations, but less itching sensations. Phenotypic differences between acute and late neuropathic pain support the incorporation of timing into a mechanism-based classification of neuropathic pain after SCI. The diagnosis of acute neuropathic pain after SCI is challenged by the presence of nociceptive and neuropathic pains, with the former potentially masking the latter. This may lead to an underestimation of the incidence of neuropathic pain during the very early, hyperacute time points post-injury. TRIAL REGISTRATION: ClinicalTrials.gov (Identifier: NCT01279811) PERSPECTIVE: This article presents distinct pain phenotypes of hyperacute and late presenting neuropathic pain after spinal cord injury and highlights the challenges of pain assessments in the acute phase after injury. This information may be relevant to clinical trial design and broaden our understanding of neuropathic pain mechanisms after spinal cord injury.
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Affiliation(s)
- Jan Rosner
- International Collaboration on Repair Discoveries (ICORD), University of British Columbia, Vancouver, British Columbia, Canada; Spinal Cord Injury Center, Balgrist University Hospital, University of Zurich, Zurich, Switzerland; Department of Neurology, University Hospital Bern, Inselspital, University of Bern, Bern, Switzerland
| | - Michael Negraeff
- International Collaboration on Repair Discoveries (ICORD), University of British Columbia, Vancouver, British Columbia, Canada; Department of Anesthesiology, Pharmacology, and Therapeutics, Faculty of Medicine, University of British Columbia, British Columbia, Canada
| | - Lise M Bélanger
- Vancouver Spine Program, Vancouver General Hospital, Vancouver, British Columbia, Canada
| | - Angela Tsang
- Vancouver Spine Program, Vancouver General Hospital, Vancouver, British Columbia, Canada
| | - Leanna Ritchie
- Vancouver Spine Program, Vancouver General Hospital, Vancouver, British Columbia, Canada
| | - Jean-Marc Mac-Thiong
- Hôpital du Sacré-Coeur de Montréal, Montréal, Quebec, Canada; Faculty of Medicine, Université de Montréal, Montréal, Quebec, Canada
| | - Sean Christie
- Division of Neurosurgery, Department of Surgery, Dalhousie University, Halifax, Nova Scotia, Canada
| | - Jefferson R Wilson
- Division of Neurosurgery, Department of Surgery, University of Toronto, St Michael's Hospital, Toronto, Ontario, Canada
| | - Sanjay Dhall
- Department of Neurological Surgery, University of California, San Francisco, San Francisco, California
| | - Raphaële Charest-Morin
- Vancouver Spine Surgery Institute, Department of Orthopaedics, University of British Columbia, Vancouver, British Columbia, Canada
| | - John Street
- International Collaboration on Repair Discoveries (ICORD), University of British Columbia, Vancouver, British Columbia, Canada; Vancouver Spine Surgery Institute, Department of Orthopaedics, University of British Columbia, Vancouver, British Columbia, Canada
| | - Tamir Ailon
- Division of Neurosurgery, University of British Columbia, Vancouver, British Columbia, Canada
| | - Scott Paquette
- International Collaboration on Repair Discoveries (ICORD), University of British Columbia, Vancouver, British Columbia, Canada; Division of Neurosurgery, University of British Columbia, Vancouver, British Columbia, Canada
| | - Nicolas Dea
- Division of Neurosurgery, University of British Columbia, Vancouver, British Columbia, Canada
| | - Charles G Fisher
- Vancouver Spine Surgery Institute, Department of Orthopaedics, University of British Columbia, Vancouver, British Columbia, Canada
| | - Marcel F Dvorak
- International Collaboration on Repair Discoveries (ICORD), University of British Columbia, Vancouver, British Columbia, Canada; Vancouver Spine Surgery Institute, Department of Orthopaedics, University of British Columbia, Vancouver, British Columbia, Canada
| | - Nanna B Finnerup
- Danish Pain Research Center, Department of Clinical Medicine, Aarhus University, Aarhus, Denmark; Department of Neurology, Aarhus University Hospital, Aarhus, Denmark
| | - Brian K Kwon
- International Collaboration on Repair Discoveries (ICORD), University of British Columbia, Vancouver, British Columbia, Canada; Vancouver Spine Surgery Institute, Department of Orthopaedics, University of British Columbia, Vancouver, British Columbia, Canada
| | - John L K Kramer
- International Collaboration on Repair Discoveries (ICORD), University of British Columbia, Vancouver, British Columbia, Canada; Department of Anesthesiology, Pharmacology, and Therapeutics, Faculty of Medicine, University of British Columbia, British Columbia, Canada.
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27
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Moore RA, Fisher E, Finn DP, Finnerup NB, Gilron I, Haroutounian S, Krane E, Rice ASC, Rowbotham M, Wallace M, Eccleston C. Cannabinoids, cannabis, and cannabis-based medicines for pain management: an overview of systematic reviews. Pain 2021; 162:S67-S79. [PMID: 32804833 DOI: 10.1097/j.pain.0000000000001941] [Citation(s) in RCA: 22] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/25/2020] [Accepted: 05/22/2020] [Indexed: 01/08/2023]
Abstract
ABSTRACT Cannabinoids, cannabis, and cannabis-based medicines (CBM) are increasingly used to manage pain, with limited understanding of their efficacy and safety. We assessed methodological quality, scope, and results of systematic reviews of randomised controlled trials of these treatments. Several search strategies sought self-declared systematic reviews. Methodological quality was assessed using both AMSTAR-2 and techniques important for bias reduction in pain studies. Of the 106 articles read, 57 were self-declared systematic reviews, most published since 2010. They included any type of cannabinoid, cannabis, or CBM, at any dose, however administered, in a broad range of pain conditions. No review examined the effects of a particular cannabinoid, at a particular dose, using a particular route of administration, for a particular pain condition, reporting a particular analgesic outcome. Confidence in the results in the systematic reviews using AMSTAR-2 definitions was critically low (41), low (8), moderate (6), or high (2). Few used criteria important for bias reduction in pain. Cochrane reviews typically provided higher confidence; all industry-conflicted reviews provided critically low confidence. Meta-analyses typically pooled widely disparate studies, and, where assessable, were subject to potential publication bias. Systematic reviews with positive or negative recommendation for use of cannabinoids, cannabis, or CBM in pain typically rated critically low or low (24/25 [96%] positive; 10/12 [83%] negative). Current reviews are mostly lacking in quality and cannot provide a basis for decision-making. A new high-quality systematic review of randomised controlled trials is needed to critically assess the clinical evidence for cannabinoids, cannabis, or CBM in pain.
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Affiliation(s)
| | - Emma Fisher
- Centre for Pain Research, University of Bath, Bath, United Kingdom
- Cochrane Pain, Palliative, and Supportive Care Review Groups, Oxford University Hospitals, Oxford, United Kingdom
| | - David P Finn
- Pharmacology and Therapeutics, School of Medicine, Galway Neuroscience Centre and Centre for Pain Research, NCBES, National University of Ireland Galway, Galway, Ireland
| | - Nanna B Finnerup
- Department of Clinical Medicine, Danish Pain Research Center, Aarhus University, Aarhus, Denmark
- Department of Neurology, Aarhus University Hospital, Aarhus, Denmark
| | - Ian Gilron
- Department of Anesthesiology and Perioperative Medicine, Kingston General Hospital and Queen's University, Kingston, ON, Canada
- Centre for Neuroscience Studies, Queen's University, Kingston, ON, Canada
- School of Policy Studies, Queen's University, Kingston, ON, Canada
| | - Simon Haroutounian
- Division of Clinical and Translational Research, Washington University Pain Center, St. Louis, MO, United States
- Department of Anesthesiology, Washington University School of Medicine, St Louis, MO, United States
| | - Elliot Krane
- Department of Anesthesiology, Perioperative and Pain Medicine, and Pediatrics, Stanford University School of Medicine, Stanford, Palo Alto, CA, United States
| | - Andrew S C Rice
- Pain Research, Department of Surgery and Cancer, Faculty of Medicine, Imperial College London, United Kingdom
| | - Michael Rowbotham
- Department of Anesthesia, Pain Management Center, University of California San Francisco, San Francisco, CA, United Kingdom
- Sutter Health, CPMC Research Institute, California Pacific Medical Center Research Institute, San Francisco, CA, United States
| | - Mark Wallace
- Division of Pain Medicine, Department of Anesthesiology, University of California San Diego, San Diego, CA, United States
| | - Christopher Eccleston
- Centre for Pain Research, University of Bath, Bath, United Kingdom
- Cochrane Pain, Palliative, and Supportive Care Review Groups, Oxford University Hospitals, Oxford, United Kingdom
- Department of Clinical and Health Psychology, Ghent University, Ghent, Belgium
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28
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Fisher E, Moore RA, Fogarty AE, Finn DP, Finnerup NB, Gilron I, Haroutounian S, Krane E, Rice ASC, Rowbotham M, Wallace M, Eccleston C. Cannabinoids, cannabis, and cannabis-based medicine for pain management: a systematic review of randomised controlled trials. Pain 2021; 162:S45-S66. [PMID: 32804836 DOI: 10.1097/j.pain.0000000000001929] [Citation(s) in RCA: 59] [Impact Index Per Article: 19.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/27/2020] [Accepted: 04/28/2020] [Indexed: 02/07/2023]
Abstract
ABSTRACT Cannabinoids, cannabis, and cannabis-based medicines (CBMs) are increasingly used to manage pain, with limited understanding of their efficacy and safety. We summarised efficacy and adverse events (AEs) of these types of drugs for treating pain using randomised controlled trials: in people of any age, with any type of pain, and for any treatment duration. Primary outcomes were 30% and 50% reduction in pain intensity, and AEs. We assessed risk of bias of included studies, and the overall quality of evidence using GRADE. Studies of <7 and >7 days treatment duration were analysed separately. We included 36 studies (7217 participants) delivering cannabinoids (8 studies), cannabis (6 studies), and CBM (22 studies); all had high and/or uncertain risk of bias. Evidence of benefit was found for cannabis <7 days (risk difference 0.33, 95% confidence interval 0.20-0.46; 2 trials, 231 patients, very low-quality evidence) and nabiximols >7 days (risk difference 0.06, 95% confidence interval 0.01-0.12; 6 trials, 1484 patients, very low-quality evidence). No other beneficial effects were found for other types of cannabinoids, cannabis, or CBM in our primary analyses; 81% of subgroup analyses were negative. Cannabis, nabiximols, and delta-9-tetrahydrocannabinol had more AEs than control. Studies in this field have unclear or high risk of bias, and outcomes had GRADE rating of low- or very low-quality evidence. We have little confidence in the estimates of effect. The evidence neither supports nor refutes claims of efficacy and safety for cannabinoids, cannabis, or CBM in the management of pain.
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Affiliation(s)
- Emma Fisher
- Centre for Pain Research, University of Bath, Bath, United Kingdom
- Cochrane Pain, Palliative, and Supportive Care Review Groups, Oxford University Hospitals, Oxford, United Kingdom
| | - R Andrew Moore
- Appledore, Court Road, Newton Ferrers, Plymouth, United Kingdom
| | - Alexandra E Fogarty
- Department of Neurology, Division of Physical Medicine and Rehabilitation, Washington University in St. Louis School of Medicine, St Louis, MO, United States
| | - David P Finn
- Pharmacology and Therapeutics, School of Medicine, Galway Neuroscience Centre and Centre for Pain Research, Human Biology Building, National University of Ireland Galway, University Road, Galway, Ireland
| | - Nanna B Finnerup
- Department of Clinical Medicine, Danish Pain Research Center, Aarhus University, Aarhus, Denmark
- Department of Neurology, Aarhus University Hospital, Aarhus, Denmark
| | - Ian Gilron
- Department of Anesthesiology and Perioperative Medicine, Kingston General Hospital, Kingston, ON, Canada
- Centre for Neuroscience Studies, Queen's University, Kingston, ON, Canada
- School of Policy Studies, Queen's University, Kingston, ON, Canada
| | - Simon Haroutounian
- Division of Clinical and Translational Research, Department of Anesthesiology, Washington University School of Medicine, Washington University Pain Center, St Louis, MO, United States
| | - Elliot Krane
- Department of Anesthesiology, Perioperative, and Pain Medicine, and Pediatrics, Stanford University School of Medicine, Stanford, CA, United States
- Palo Alto, Santa Clara, CA, United States
| | - Andrew S C Rice
- Pain Research, Department of Surgery and Cancer, Faculty of Medicine, Imperial College London, London, United Kingdom
| | - Michael Rowbotham
- Department of Anesthesia, University of California, San Francisco, CA, United States
- Sutter Health, CPMC Research Institute, California Pacific Medical Center Research Institute, San Francisco, CA, United States
| | - Mark Wallace
- Division of Pain Medicine, Department of Anesthesiology, University of California, San Francisco, CA, United States
| | - Christopher Eccleston
- Centre for Pain Research, University of Bath, Bath, United Kingdom
- Cochrane Pain, Palliative, and Supportive Care Review Groups, Oxford University Hospitals, Oxford, United Kingdom
- Department of Clinical and Health Psychology, Ghent University, Ghent, Belgium
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Haroutounian S, Arendt-Nielsen L, Belton J, Blyth FM, Degenhardt L, Forti MD, Eccleston C, Finn DP, Finnerup NB, Fisher E, Fogarty AE, Gilron I, Hohmann AG, Kalso E, Krane E, Mohiuddin M, Moore RA, Rowbotham M, Soliman N, Wallace M, Zinboonyahgoon N, Rice ASC. International Association for the Study of Pain Presidential Task Force on Cannabis and Cannabinoid Analgesia: research agenda on the use of cannabinoids, cannabis, and cannabis-based medicines for pain management. Pain 2021; 162:S117-S124. [PMID: 34138827 PMCID: PMC8855877 DOI: 10.1097/j.pain.0000000000002266] [Citation(s) in RCA: 15] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/28/2021] [Accepted: 03/10/2021] [Indexed: 01/08/2023]
Abstract
ABSTRACT The President of the International Association for the Study of Pain established a task force on cannabis and cannabinoid analgesia to systematically examine the evidence on (1) analgesic pharmacology of cannabinoids and preclinical evidence on their efficacy in animal models of injury-related or pathological persistent pain; (2) the clinical efficacy of cannabis, cannabinoids, and cannabis-based medicines for pain; (3) harms related to long-term use of cannabinoids; as well as (4) societal issues and policy implications related to the use of these compounds for pain management. Here, we summarize key knowledge gaps identified in the task force outputs and propose a research agenda for generating high-quality evidence on the topic. The systematic assessment of preclinical and clinical literature identified gaps in rigor of study design and reporting across the translational spectrum. We provide recommendations to improve the quality, rigor, transparency, and reproducibility of preclinical and clinical research on cannabis and cannabinoids for pain, as well as for the conduct of systematic reviews on the topic. Gaps related to comprehensive understanding of the endocannabinoid system and cannabinoid pharmacology, including pharmacokinetics and drug formulation aspects, are discussed. We outline key areas where high-quality clinical trials with cannabinoids are needed. Remaining important questions about long-term and short-term safety of cannabis and cannabinoids are emphasized. Finally, regulatory, societal, and policy challenges associated with medicinal and nonmedicinal use of cannabis are highlighted, with recommendations for improving patient safety and reducing societal harms in the context of pain management.
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Affiliation(s)
- Simon Haroutounian
- Division of Clinical and Translational Research and Washington University Pain Center. Department of Anesthesiology, Washington University School of Medicine. St Louis, MO, USA
| | - Lars Arendt-Nielsen
- Center for Neuroplasticity and Pain (CNAP) and Center for Sensory-Motor Interaction (SMI), Department of Health Science and Technology, School of Medicine, Aalborg University, Aalborg, Denmark
| | - Joletta Belton
- Endless Possibilities Initiative, Fraser, CO, USA; Global Alliance of Pain Patient Advocates (GAPPA) Presidential Task Force
| | - Fiona M. Blyth
- Sydney School of Public Health, Faculty of Medicine and Health, University of Sydney, Camperdown, NSW 2006, Australia
| | - Louisa Degenhardt
- National Drug and Alcohol Research Centre, University of New South Wales, Sydney, NSW 2052, Australia
| | - Marta Di Forti
- Social, Genetic and Developmental Psychiatry Centre, Institute of Psychiatry, Psychology and Neuroscience, King’s College London, London SE5 8AF, UK. National Institute for Health Research (NIHR) Mental Health Biomedical Research Centre at South London and Maudsley NHS Foundation Trust and King’s College London, UK. South London and Maudsley NHS Mental Health Foundation Trust, London, UK
| | - Christopher Eccleston
- Centre for Pain Research. The University of Bath, Bath, UK, & Department of Clinical and Health Psychology, The University of Ghent, Belgium
| | - David P. Finn
- Pharmacology and Therapeutics, School of Medicine, Galway Neuroscience Centre and Centre for Pain Research, Human Biology Building, National University of Ireland Galway, University Road, Galway, Ireland
| | - Nanna B Finnerup
- Danish Pain Research Center, Department of Clinical Medicine, Aarhus University, Aarhus, Denmark
| | - Emma Fisher
- Centre for Pain Research. The University of Bath, Bath, UK
| | - Alexandra E. Fogarty
- Department of Neurology, Division of Physical Medicine & Rehabilitation, Washington University School of Medicine. St Louis, MO, USA
| | - Ian Gilron
- Departments of Anesthesiology & Perioperative Medicine and Biomedical & Molecular Sciences, Kingston Health Sciences Centre and Queen’s University; Centre for Neuroscience Studies, Queen’s University; School of Policy Studies, Queen’s University, Kingston, Canada
| | - Andrea G. Hohmann
- Department of Psychological and Brain Sciences, Program in Neuroscience, Gill Center for Biomolecular Science, Indiana University, Bloomington, IN, USA
| | - Eija Kalso
- Department of Pharmacology and SleepWell Research Programme, University of Helsinki; Department of Anaesthesiology, Intensive Care and Pain Medicine, Helsinki University Hospital
| | - Elliot Krane
- Departments of Anesthesiology, Perioperative, and Pain Medicine, & Pediatrics, Stanford University School of Medicine, Stanford, California, USA
| | - Mohammed Mohiuddin
- Department of Anesthesiology & Perioperative Medicine and, Queen’s University, Kingston, Canada
| | | | - Michael Rowbotham
- Department of Anesthesia, University of California, San Francisco, California, USA
| | - Nadia Soliman
- Pain Research, Department of Surgery & Cancer, Faculty of Medicine, Imperial College London, UK
| | - Mark Wallace
- Division of Pain Medicine, Department of Anesthesiology, University of California San Diego
| | | | - Andrew SC Rice
- Pain Research, Department of Surgery & Cancer, Faculty of Medicine, Imperial College London, UK
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Doshi TL, Dworkin RH, Polomano RC, Carr DB, Edwards RR, Finnerup NB, Freeman RL, Paice JA, Weisman SJ, Raja SN. AAAPT Diagnostic Criteria for Acute Neuropathic Pain. Pain Med 2021; 22:616-636. [PMID: 33575803 DOI: 10.1093/pm/pnaa407] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
OBJECTIVE Acute neuropathic pain is a significant diagnostic challenge, and it is closely related to our understanding of both acute pain and neuropathic pain. Diagnostic criteria for acute neuropathic pain should reflect our mechanistic understanding and provide a framework for research on and treatment of these complex pain conditions. METHODS The Analgesic, Anesthetic, and Addiction Clinical Trial Translations, Innovations, Opportunities, and Networks (ACTTION) public-private partnership with the U.S. Food and Drug Administration (FDA), the American Pain Society (APS), and the American Academy of Pain Medicine (AAPM) collaborated to develop the ACTTION-APS-AAPM Pain Taxonomy (AAAPT) for acute pain. A working group of experts in research and clinical management of neuropathic pain was convened. Group members used literature review and expert opinion to develop diagnostic criteria for acute neuropathic pain, as well as three specific examples of acute neuropathic pain conditions, using the five dimensions of the AAAPT classification of acute pain. RESULTS AAAPT diagnostic criteria for acute neuropathic pain are presented. Application of these criteria to three specific conditions (pain related to herpes zoster, chemotherapy, and limb amputation) illustrates the spectrum of acute neuropathic pain and highlights unique features of each condition. CONCLUSIONS The proposed AAAPT diagnostic criteria for acute neuropathic pain can be applied to various acute neuropathic pain conditions. Both the general and condition-specific criteria may guide future research, assessment, and management of acute neuropathic pain.
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Affiliation(s)
- Tina L Doshi
- Department of Anesthesiology and Critical Care Medicine, Division of Pain Medicine, Johns Hopkins University, Baltimore, Maryland, USA
| | - Robert H Dworkin
- Department of Anesthesiology, University of Rochester School of Medicine and Dentistry, Rochester, New York, and Department of Neurology, Center for Human Experimental Therapeutics, University of Rochester School of Medicine and Dentistry, Rochester, New York, USA
| | - Rosemary C Polomano
- Division of Biobehavioral Health Sciences, University of Pennsylvania-School of Nursing, Philadelphia, Pennsylvania, USA
| | - Daniel B Carr
- Public Health and Community Medicine Program, Tufts University School of Medicine, Boston, Massachusetts, USA
| | - Robert R Edwards
- Department of Anesthesiology, Perioperative, and Pain Medicine, Brigham and Women's Hospital, Boston, Massachusetts, USA
| | - Nanna B Finnerup
- Danish Pain Research Center, Department of Clinical Medicine, Aarhus University, and Department of Neurology, Aarhus University Hospital, Aarhus, Denmark
| | - Roy L Freeman
- Center for Autonomic and Peripheral Nerve Disorders, Beth Israel Deaconess Medical Center, Boston, Massachusetts, USA
| | - Judith A Paice
- Cancer Pain Program, Northwestern University, Feinberg School of Medicine, Chicago, Illinois, USA
| | - Steven J Weisman
- Jane B. Pettit Pain and Headache Center, Children's Wisconsin, Departments of Anesthesiology and Pediatrics, Medical College of Wisconsin, Milwaukee, Wisconsin, USA
| | - Srinivasa N Raja
- Department of Anesthesiology and Critical Care Medicine, Division of Pain Medicine, Johns Hopkins University, Baltimore, Maryland, USA
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31
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Kristensen AG, Gylfadottir S, Itani M, Kuwabara S, Krøigård T, Khan KS, Finnerup NB, Andersen H, Jensen TS, Sindrup S, Tankisi H. Sensory and motor axonal excitability testing in early diabetic neuropathy. Clin Neurophysiol 2021; 132:1407-1415. [PMID: 34030050 DOI: 10.1016/j.clinph.2021.02.397] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/28/2020] [Revised: 01/30/2021] [Accepted: 02/01/2021] [Indexed: 11/16/2022]
Abstract
OBJECTIVE The aim of the present study was to gain insight into the pathophysiology of diabetic polyneuropathy (DPN) and examine the diagnostic value of sensory and motor axonal excitability testing. METHODS One hundred and eleven type 2 diabetics with and without DPN (disease duration: 6.36 ± 0.25 years) and 60 controls were included. All participants received a thorough clinical examination including Michigan Neuropathy Screening Instrument (MNSI) score, nerve conduction studies (NCS), and sensory and motor excitability tests. Patients were compared by the likelihood of neuropathy presence, ranging from no DPN (17), possible/probable DPN (46) to NCS-confirmed DPN (48). RESULTS Motor excitability tests showed differences in rheobase and depolarizing threshold electrotonus measures between NCS-confirmed DPN group and controls but no changes in hyperpolarising threshold electrotonus or recovery cycle parameters. Sensory excitability showed even less changes despite pronounced sensory NCS abnormalities. There were only weak correlations between the above motor excitability parameters and clinical scores. CONCLUSIONS Changes in excitability in the examined patient group were subtle, perhaps because of the relatively short disease duration. SIGNIFICANCE Less pronounced excitability changes than NCS suggest that axonal excitability testing is not of diagnostic value for early DPN and does not provide information on the mechanisms.
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Affiliation(s)
- A G Kristensen
- Department of Clinical Neurophysiology, Aarhus University Hospital, Denmark; Danish Pain Research Center, Department of Clinical Medicine, Aarhus University, Denmark
| | - S Gylfadottir
- Danish Pain Research Center, Department of Clinical Medicine, Aarhus University, Denmark; Department of Neurology, Aarhus University Hospital, Denmark
| | - M Itani
- Department of Neurology, Odense University Hospital, Denmark
| | - S Kuwabara
- Department of Neurology, Graduate School of Medicine, Chiba University, Japan
| | - T Krøigård
- Department of Neurology, Odense University Hospital, Denmark
| | - K S Khan
- Department of Neurology, Aarhus University Hospital, Denmark
| | - N B Finnerup
- Danish Pain Research Center, Department of Clinical Medicine, Aarhus University, Denmark; Department of Neurology, Aarhus University Hospital, Denmark
| | - H Andersen
- Department of Neurology, Aarhus University Hospital, Denmark
| | - T S Jensen
- Danish Pain Research Center, Department of Clinical Medicine, Aarhus University, Denmark; Department of Neurology, Aarhus University Hospital, Denmark
| | - S Sindrup
- Department of Neurology, Odense University Hospital, Denmark
| | - H Tankisi
- Department of Clinical Neurophysiology, Aarhus University Hospital, Denmark.
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32
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Karlsson P, Gylfadottir SS, Kristensen AG, Ramirez JD, Cruz P, Le N, Shillo PR, Tesfaye S, Rice ASC, Tankisi H, Finnerup NB, Nyengaard JR, Jensen TS, Bennett DLH, Themistocleous AC. Axonal swellings are related to type 2 diabetes, but not to distal diabetic sensorimotor polyneuropathy. Diabetologia 2021; 64:923-931. [PMID: 33483760 PMCID: PMC7940290 DOI: 10.1007/s00125-020-05352-9] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/12/2020] [Accepted: 10/23/2020] [Indexed: 12/14/2022]
Abstract
AIMS/HYPOTHESIS Distal diabetic sensorimotor polyneuropathy (DSP) is a common complication of diabetes with many patients showing a reduction of intraepidermal nerve fibre density (IENFD) from skin biopsy, a validated and sensitive diagnostic tool for the assessment of DSP. Axonal swelling ratio is a morphological quantification altered in DSP. It is, however, unclear if axonal swellings are related to diabetes or DSP. The aim of this study was to investigate how axonal swellings in cutaneous nerve fibres are related to type 2 diabetes mellitus, DSP and neuropathic pain in a well-defined cohort of patients diagnosed with type 2 diabetes. METHODS A total of 249 participants, from the Pain in Neuropathy Study (UK) and the International Diabetic Neuropathy Consortium (Denmark), underwent a structured neurological examination, nerve conduction studies, quantitative sensory testing and skin biopsy. The study included four groups: healthy control study participants without diabetes (n = 45); participants with type 2 diabetes without DSP (DSP-; n = 31); and participants with evidence of DSP (DSP+; n = 173); the last were further separated into painless DSP+ (n = 74) and painful DSP+ (n = 99). Axonal swellings were defined as enlargements on epidermal-penetrating fibres exceeding 1.5 μm in diameter. Axonal swelling ratio is calculated by dividing the number of axonal swellings by the number of intraepidermal nerve fibres. RESULTS Median (IQR) IENFD (fibres/mm) was: 6.7 (5.2-9.2) for healthy control participants; 6.2 (4.4-7.3) for DSP-; 1.3 (0.5-2.2) for painless DSP+; and 0.84 (0.4-1.6) for painful DSP+. Swelling ratios were calculated for all participants and those with IENFD > 1.0 fibre/mm. When only those participants with IENFD > 1.0 fibre/mm were included, the axonal swelling ratio was higher in participants with type 2 diabetes when compared with healthy control participants (p < 0.001); however, there was no difference between DSP- and painless DSP+ participants, or between painless DSP+ and painful DSP+ participants. The axonal swelling ratio correlated weakly with HbA1c (r = 0.16, p = 0.04), but did not correlate with the Toronto Clinical Scoring System (surrogate measure of DSP severity), BMI or type 2 diabetes duration. CONCLUSIONS/INTERPRETATION In individuals with type 2 diabetes where IENFD is >1.0 fibre/mm, axonal swelling ratio is related to type 2 diabetes but is not related to DSP or painful DSP. Axonal swellings may be an early marker of sensory nerve injury in type 2 diabetes.
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Affiliation(s)
- Pall Karlsson
- Danish Pain Research Centre, Department of Clinical Medicine, Aarhus University, Aarhus, Denmark
- Core Centre for Molecular Morphology, Section for Stereology for Microscopy, Department of Clinical Medicine, Aarhus University, Aarhus, Denmark
| | - Sandra S Gylfadottir
- Danish Pain Research Centre, Department of Clinical Medicine, Aarhus University, Aarhus, Denmark
- Department of Neurology, Aarhus University Hospital, Aarhus, Denmark
| | - Alexander G Kristensen
- Danish Pain Research Centre, Department of Clinical Medicine, Aarhus University, Aarhus, Denmark
- Department of Clinical Neurophysiology, Aarhus University Hospital, Aarhus, Denmark
| | - Juan D Ramirez
- Nuffield Department of Clinical Neurosciences, University of Oxford, Oxford, UK
| | - Pedro Cruz
- Faculty of Medicine, Universidade de Coimbra, Coimbra, Portugal
| | - Nhu Le
- Radboud University Medical Centre, Nijmegen, the Netherlands
| | - Pallai R Shillo
- Diabetes Research Unit, Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield, UK
| | - Solomon Tesfaye
- Diabetes Research Unit, Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield, UK
| | - Andrew S C Rice
- Pain Research Group, Department of Surgery and Cancer, Faculty of Medicine, Imperial College London, Chelsea and Westminster Hospital Campus, London, UK
- Pain Medicine, Chelsea and Westminster Hospital NHS Foundation Trust, London, UK
| | - Hatice Tankisi
- Department of Clinical Neurophysiology, Aarhus University Hospital, Aarhus, Denmark
| | - Nanna B Finnerup
- Danish Pain Research Centre, Department of Clinical Medicine, Aarhus University, Aarhus, Denmark
- Department of Neurology, Aarhus University Hospital, Aarhus, Denmark
| | - Jens R Nyengaard
- Core Centre for Molecular Morphology, Section for Stereology for Microscopy, Department of Clinical Medicine, Aarhus University, Aarhus, Denmark
| | - Troels S Jensen
- Danish Pain Research Centre, Department of Clinical Medicine, Aarhus University, Aarhus, Denmark
- Department of Neurology, Aarhus University Hospital, Aarhus, Denmark
| | - David L H Bennett
- Nuffield Department of Clinical Neurosciences, University of Oxford, Oxford, UK
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Jensen TS, Karlsson P, Gylfadottir SS, Andersen ST, Bennett DL, Tankisi H, Finnerup NB, Terkelsen AJ, Khan K, Themistocleous AC, Kristensen AG, Itani M, Sindrup SH, Andersen H, Charles M, Feldman EL, Callaghan BC. Painful and non-painful diabetic neuropathy, diagnostic challenges and implications for future management. Brain 2021; 144:1632-1645. [PMID: 33711103 DOI: 10.1093/brain/awab079] [Citation(s) in RCA: 69] [Impact Index Per Article: 23.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/19/2020] [Revised: 02/15/2021] [Accepted: 02/21/2021] [Indexed: 12/12/2022] Open
Abstract
Peripheral neuropathy is one of the most common complications of both type 1 and type 2 diabetes. Up to half of patients with diabetes develop neuropathy during the course of their disease, which is accompanied by neuropathic pain in 30-40% of cases. Peripheral nerve injury in diabetes can manifest as progressive distal symmetric polyneuropathy, autonomic neuropathy, radiculo-plexopathies, and mononeuropathies. The most common diabetic neuropathy is distal symmetric polyneuropathy, which we will refer to as DN, with its characteristic glove and stocking like presentation of distal sensory or motor function loss. DN or its painful counterpart, painful DN, are associated with increased mortality and morbidity; thus, early recognition and preventive measures are essential. Nevertheless, it is not easy to diagnose DN or painful DN, particularly in patients with early and mild neuropathy, and there is currently no single established diagnostic gold standard. The most common diagnostic approach in research is a hierarchical system, which combines symptoms, signs, and a series of confirmatory tests. The general lack of long-term prospective studies has limited the evaluation of the sensitivity and specificity of new morphometric and neurophysiological techniques. Thus, the best paradigm for screening DN and painful DN both in research and in clinical practice remains uncertain. Herein, we review the diagnostic challenges from both clinical and research perspectives and their implications for managing patients with DN. There is no established DN treatment, apart from improved glycaemic control, which is more effective in type 1 than in type 2 diabetes, and only symptomatic management is available for painful DN. Currently, less than one-third of patients with painful DN derive sufficient pain relief with existing pharmacotherapies. A more precise and distinct sensory profile from patients with DN and painful DN may help identify responsive patients to one treatment versus another. Detailed sensory profiles will lead to tailored treatment for patient subgroups with painful DN by matching to novel or established DN pathomechanisms and also for improved clinical trials stratification. Large randomized clinical trials are needed to identify the interventions, i.e. pharmacological, physical, cognitive, educational, etc., which lead to the best therapeutic outcomes.
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Affiliation(s)
- Troels S Jensen
- Department of Neurology, Aarhus University Hospital, Aarhus, Denmark.,Danish Pain Research Center, Aarhus University, Aarhus, Denmark
| | - Pall Karlsson
- Danish Pain Research Center, Aarhus University, Aarhus, Denmark
| | - Sandra S Gylfadottir
- Department of Neurology, Aarhus University Hospital, Aarhus, Denmark.,Danish Pain Research Center, Aarhus University, Aarhus, Denmark
| | - Signe T Andersen
- Department of Neurology, Aarhus University Hospital, Aarhus, Denmark.,Department of Public Health, Aarhus University, Aarhus, Denmark
| | - David L Bennett
- Nuffield Department of Clinical Neuroscience, Oxford University, Oxford, UK
| | - Hatice Tankisi
- Department of Neurophysiology, Aarhus University Hospital, Aarhus, Denmark
| | | | - Astrid J Terkelsen
- Department of Neurology, Aarhus University Hospital, Aarhus, Denmark.,Danish Pain Research Center, Aarhus University, Aarhus, Denmark
| | - Karolina Khan
- Department of Neurology, Aarhus University Hospital, Aarhus, Denmark
| | | | | | - Mustapha Itani
- Department of Neurology, Odense University Hospital, Odense, Denmark
| | - Søren H Sindrup
- Department of Neurology, Odense University Hospital, Odense, Denmark
| | - Henning Andersen
- Department of Neurology, Aarhus University Hospital, Aarhus, Denmark
| | - Morten Charles
- Department of Public Health, Aarhus University, Aarhus, Denmark
| | - Eva L Feldman
- Department of Neurology, University of Michigan, Ann Arbor, MI, USA
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Bennedsgaard K, Ventzel L, Andersen NT, Themistocleous AC, Bennett DL, Jensen TS, Tankisi H, Finnerup NB. Oxaliplatin- and docetaxel-induced polyneuropathy: clinical and neurophysiological characteristics. J Peripher Nerv Syst 2020; 25:377-387. [PMID: 32902058 PMCID: PMC7756561 DOI: 10.1111/jns.12413] [Citation(s) in RCA: 20] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/09/2020] [Revised: 09/01/2020] [Accepted: 09/01/2020] [Indexed: 12/13/2022]
Abstract
The aim of this study was to evaluate the presence and characterization of chemotherapy-induced neuropathy (CIPN) and neuropathic pain 5 years after adjuvant chemotherapy with docetaxel or oxaliplatin. Patients from an ongoing prospective study, who had received adjuvant chemotherapy with docetaxel or oxaliplatin in 2011 to 2012 were invited to participate. The patients underwent a thorough examination with interview, neurological examination, questionnaires, assessment tools, nerve conduction studies (NCS), quantitative sensory testing, MScan motor unit number estimation (MUNE), and corneal confocal microscopy (CCM). Patients were divided into no, possible, probable, and confirmed CIPN. Out of the 132 eligible patients, 63 agreed to participate: 28 had received docetaxel and 35 had received oxaliplatin. Forty-one percent had confirmed CIPN, 34% possible or probable CIPN, and 22% did not have CIPN. The CIPN was characterized mainly by sensory nerve fiber loss, with a more pronounced large fiber than small fiber loss but also some motor fiber loss identified on NCS and MUNE. In general, patients had mild neuropathy with relatively low scores on assessment tools and no association with mood and quality of life. CCM was not useful as a diagnostic tool. Of the patients with probable or confirmed CIPN, 30% experienced pain, which was most often mild, but still interfered moderately with daily life in 20% to 25% and was associated with lower quality of life. In conclusion CIPN was confirmed in 41% 5 years after chemotherapy. The neuropathy was generally mild, but in patients with neuropathic pain it was associated with lower quality of life.
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Affiliation(s)
- Kristine Bennedsgaard
- Danish Pain Research Center, Department of Clinical Medicine, Aarhus University, Aarhus, Denmark
| | - Lise Ventzel
- Danish Pain Research Center, Department of Clinical Medicine, Aarhus University, Aarhus, Denmark.,Department of Oncology, Aarhus University Hospital, Aarhus, Denmark
| | - Niels T Andersen
- Biostatistics, Department of Public Health, Aarhus University, Aarhus, Denmark
| | - Andreas C Themistocleous
- Nuffield Department of Clinical Neuroscience, University of Oxford, UK.,Brain Function Research Group, School of Physiology, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - David L Bennett
- Nuffield Department of Clinical Neuroscience, University of Oxford, UK
| | - Troels S Jensen
- Danish Pain Research Center, Department of Clinical Medicine, Aarhus University, Aarhus, Denmark.,Department of Neurology, Aarhus University Hospital, Aarhus, Denmark
| | - Hatice Tankisi
- Department of Neurophysiology, Aarhus University Hospital, Aarhus, Denmark
| | - Nanna B Finnerup
- Danish Pain Research Center, Department of Clinical Medicine, Aarhus University, Aarhus, Denmark.,Department of Neurology, Aarhus University Hospital, Aarhus, Denmark
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35
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Gylfadottir SS, Itani M, Krøigård T, Kristensen AG, Christensen DH, Nicolaisen SK, Karlsson P, Callaghan BC, Bennett DL, Andersen H, Tankisi H, Nielsen JS, Andersen NT, Jensen TS, Thomsen RW, Sindrup SH, Finnerup NB. Diagnosis and prevalence of diabetic polyneuropathy: a cross-sectional study of Danish patients with type 2 diabetes. Eur J Neurol 2020; 27:2575-2585. [PMID: 32909392 DOI: 10.1111/ene.14469] [Citation(s) in RCA: 24] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/27/2020] [Accepted: 07/29/2020] [Indexed: 01/16/2023]
Abstract
BACKGROUND AND PURPOSE Diabetic polyneuropathy (DPN) is a common complication of diabetes. Using the Toronto criteria for diabetic polyneuropathy and the grading system for neuropathic pain, the performance of neuropathy scales and questionnaires were assessed by comparing them to a clinical gold standard diagnosis of DPN and painful DPN in a cohort of patients with recently diagnosed type 2 diabetes. METHODS A questionnaire on neuropathy and pain was sent to a cohort of 5514 Danish type 2 diabetes patients. A sample of 389 patients underwent a detailed clinical examination and completed neuropathy questionnaires and scales. RESULTS Of the 389 patients with a median diabetes duration of 5.9 years, 126 had definite DPN (including 53 with painful DPN), 88 had probable DPN and 53 had possible DPN. There were 49 patients with other causes of polyneuropathy, neuropathy symptoms or pain, 10 with subclinical DPN and 63 without DPN. The sensitivity of the Michigan Neuropathy Screening Instrument questionnaire to detect DPN was 25.7% and the specificity 84.6%. The sensitivity of the Toronto Clinical Neuropathy Scoring System, including questionnaire and clinical examination, was 62.9% and the specificity was 74.6%. CONCLUSIONS Diabetic polyneuropathy affects approximately one in five Danish patients with recently diagnosed type 2 diabetes but neuropathic pain is not as common as previously reported. Neuropathy scales with clinical examination perform better compared with questionnaires alone, but better scales are needed for future epidemiological studies.
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Affiliation(s)
- S S Gylfadottir
- Danish Pain Research Center, Department of Clinical Medicine, Aarhus University, Aarhus, Denmark
- Department of Neurology, Aarhus University Hospital, Aarhus, Denmark
| | - M Itani
- Department of Neurology, Odense University Hospital, Odense, Denmark
| | - T Krøigård
- Department of Neurology, Odense University Hospital, Odense, Denmark
| | - A G Kristensen
- Danish Pain Research Center, Department of Clinical Medicine, Aarhus University, Aarhus, Denmark
- Department of Clinical Neurophysiology, Aarhus University Hospital, Aarhus, Denmark
| | - D H Christensen
- Department of Clinical Epidemiology, Aarhus University Hospital, Aarhus, Denmark
| | - S K Nicolaisen
- Department of Clinical Epidemiology, Aarhus University Hospital, Aarhus, Denmark
| | - P Karlsson
- Danish Pain Research Center, Department of Clinical Medicine, Aarhus University, Aarhus, Denmark
- Core Center for Molecular Morphology, Section for Stereology and Microscopy, Aarhus University, Aarhus, Denmark
| | - B C Callaghan
- Department of Neurology, University of Michigan, Ann Arbor,, MI, USA
| | - D L Bennett
- Nuffield Department of Clinical Neuroscience, University of Oxford, Oxford, UK
| | - H Andersen
- Department of Neurology, Aarhus University Hospital, Aarhus, Denmark
| | - H Tankisi
- Department of Clinical Neurophysiology, Aarhus University Hospital, Aarhus, Denmark
| | - J S Nielsen
- Danish Centre for Strategic Research in Type 2 Diabetes, Steno Diabetes Center, Odense, Denmark
| | - N T Andersen
- Biostatistics, Department of Public Health, Aarhus University, Aarhus, Denmark
| | - T S Jensen
- Danish Pain Research Center, Department of Clinical Medicine, Aarhus University, Aarhus, Denmark
- Department of Neurology, Aarhus University Hospital, Aarhus, Denmark
| | - R W Thomsen
- Department of Clinical Epidemiology, Aarhus University Hospital, Aarhus, Denmark
| | - S H Sindrup
- Department of Neurology, Odense University Hospital, Odense, Denmark
| | - N B Finnerup
- Danish Pain Research Center, Department of Clinical Medicine, Aarhus University, Aarhus, Denmark
- Department of Neurology, Aarhus University Hospital, Aarhus, Denmark
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Kristensen AG, Khan KS, Bostock H, Khan BS, Gylfadottir S, Andersen H, Finnerup NB, Jensen TS, Tankisi H. MScanFit motor unit number estimation and muscle velocity recovery cycle recordings in diabetic polyneuropathy. Clin Neurophysiol 2020; 131:2591-2599. [PMID: 32927215 DOI: 10.1016/j.clinph.2020.07.017] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/13/2020] [Revised: 07/04/2020] [Accepted: 07/22/2020] [Indexed: 12/13/2022]
Abstract
OBJECTIVE Motor Unit Number Estimation (MUNE) methods may be valuable in tracking motor unit loss in diabetic polyneuropathy (DPN). Muscle Velocity Recovery Cycles (MVRCs) provide information about muscle membrane properties. This study aimed to examine the utility of the MScanFit MUNE in detecting motor unit loss and to test whether the MVRCs could improve understanding of DPN pathophysiology. METHODS Seventy-nine type-2 diabetic patients were compared to 32 control subjects. All participants were examined with MScanFit MUNE and MVRCs in anterior tibial muscle. Lower limb nerve conduction studies (NCS) in peroneal, tibial and sural nerves were applied to diagnose large fiber neuropathy. RESULTS NCS confirmed DPN for 47 patients (DPN + ), with 32 not showing DPN (DPN-). MScanFit showed significantly decreased MUNE values and increased motor unit sizes, when comparing DPN + patients with controls (MUNE = 71.3 ± 4.7 vs 122.7 ± 3.8), and also when comparing DPN- patients (MUNE = 103.2 ± 5.1) with controls. MVRCs did not differ between groups. CONCLUSIONS MScanFit is more sensitive in showing motor unit loss than NCS in type-2 diabetic patients, whereas MVRCs do not provide additional information. SIGNIFICANCE The MScanFit results suggest that motor changes are seen as early as sensory, and the role of axonal membrane properties in DPN pathophysiology should be revisited.
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Affiliation(s)
- A G Kristensen
- Department of Clinical Neurophysiology, Aarhus University Hospital, Denmark; Danish Pain Research Center, Department of Clinical Medicine, Aarhus University, Denmark
| | - K S Khan
- Danish Pain Research Center, Department of Clinical Medicine, Aarhus University, Denmark; Department of Neurology, Aarhus University Hospital, Denmark
| | - H Bostock
- Institute of Neurology, University College London, Queen Square, London, UK
| | - B S Khan
- Department of Neurology, Aarhus University Hospital, Denmark
| | - S Gylfadottir
- Danish Pain Research Center, Department of Clinical Medicine, Aarhus University, Denmark; Department of Neurology, Aarhus University Hospital, Denmark
| | - H Andersen
- Department of Neurology, Aarhus University Hospital, Denmark
| | - N B Finnerup
- Danish Pain Research Center, Department of Clinical Medicine, Aarhus University, Denmark; Department of Neurology, Aarhus University Hospital, Denmark
| | - T S Jensen
- Danish Pain Research Center, Department of Clinical Medicine, Aarhus University, Denmark; Department of Neurology, Aarhus University Hospital, Denmark
| | - H Tankisi
- Department of Clinical Neurophysiology, Aarhus University Hospital, Denmark.
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Christensen DH, Knudsen ST, Gylfadottir SS, Christensen LB, Nielsen JS, Beck-Nielsen H, Sørensen HT, Andersen H, Callaghan BC, Feldman EL, Finnerup NB, Jensen TS, Thomsen RW. Metabolic Factors, Lifestyle Habits, and Possible Polyneuropathy in Early Type 2 Diabetes: A Nationwide Study of 5,249 Patients in the Danish Centre for Strategic Research in Type 2 Diabetes (DD2) Cohort. Diabetes Care 2020; 43:1266-1275. [PMID: 32295810 DOI: 10.2337/dc19-2277] [Citation(s) in RCA: 28] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/13/2019] [Accepted: 03/17/2020] [Indexed: 02/03/2023]
Abstract
OBJECTIVE To investigate the association of metabolic and lifestyle factors with possible diabetic polyneuropathy (DPN) and neuropathic pain in patients with early type 2 diabetes. RESEARCH DESIGN AND METHODS We thoroughly characterized 6,726 patients with recently diagnosed diabetes. After a median of 2.8 years, we sent a detailed questionnaire on neuropathy, including the Michigan Neuropathy Screening Instrument questionnaire (MNSIq), to identify possible DPN (score ≥4) and the Douleur Neuropathique en 4 Questions (DN4) questionnaire for possible associated neuropathic pain (MNSIq ≥4 + pain in both feet + DN4 score ≥3). RESULTS Among 5,249 patients with data on both DPN and pain, 17.9% (n = 938) had possible DPN, including 7.4% (n = 386) with possible neuropathic pain. In regression analyses, central obesity (waist circumference, waist-to-hip ratio, and waist-to-height ratio) was markedly associated with DPN. Other important metabolic factors associated with DPN included hypertriglyceridemia ≥1.7 mmol/L, adjusted prevalence ratio (aPR) 1.36 (95% CI 1.17; 1.59); decreased HDL cholesterol <1.0/1.2 mmol/L (male/female), aPR 1.35 (95% CI 1.12; 1.62); hs-CRP ≥3.0 mg/L, aPR 1.66 (95% CI 1.42; 1.94); C-peptide ≥1,550 pmol/L, aPR 1.72 (95% CI 1.43; 2.07); HbA1c ≥78 mmol/mol, aPR 1.42 (95% CI 1.06; 1.88); and antihypertensive drug use, aPR 1.34 (95% CI 1.16; 1.55). Smoking, aPR 1.50 (95% CI 1.24; 1.81), and lack of physical activity (0 vs. ≥3 days/week), aPR 1.61 (95% CI 1.39; 1.85), were also associated with DPN. Smoking, high alcohol intake, and failure to increase activity after diabetes diagnosis associated with neuropathic pain. CONCLUSIONS Possible DPN was associated with metabolic syndrome factors, insulin resistance, inflammation, and modifiable lifestyle habits in early type 2 diabetes.
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Affiliation(s)
- Diana H Christensen
- Department of Clinical Epidemiology, Aarhus University Hospital, Aarhus, Denmark .,International Diabetic Neuropathy Consortium (IDNC), Department of Clinical Medicine, Aarhus University, Aarhus, Denmark
| | - Søren T Knudsen
- Steno Diabetes Center Aarhus, Aarhus University Hospital, Aarhus, Denmark
| | - Sandra S Gylfadottir
- International Diabetic Neuropathy Consortium (IDNC), Department of Clinical Medicine, Aarhus University, Aarhus, Denmark.,Danish Pain Research Center, Department of Clinical Medicine, Aarhus University, Aarhus, Denmark.,Department of Neurology, Aarhus University Hospital, Aarhus, Denmark
| | - Lotte B Christensen
- Department of Clinical Epidemiology, Aarhus University Hospital, Aarhus, Denmark
| | - Jens S Nielsen
- Danish Center for Strategic Research in Type 2 Diabetes, Steno Diabetes Center Odense, Odense, Denmark
| | - Henning Beck-Nielsen
- Danish Center for Strategic Research in Type 2 Diabetes, Steno Diabetes Center Odense, Odense, Denmark
| | - Henrik T Sørensen
- Department of Clinical Epidemiology, Aarhus University Hospital, Aarhus, Denmark
| | - Henning Andersen
- International Diabetic Neuropathy Consortium (IDNC), Department of Clinical Medicine, Aarhus University, Aarhus, Denmark.,Department of Neurology, Aarhus University Hospital, Aarhus, Denmark
| | - Brian C Callaghan
- International Diabetic Neuropathy Consortium (IDNC), Department of Clinical Medicine, Aarhus University, Aarhus, Denmark.,Department of Neurology, University of Michigan, Ann Arbor, MI
| | - Eva L Feldman
- International Diabetic Neuropathy Consortium (IDNC), Department of Clinical Medicine, Aarhus University, Aarhus, Denmark.,Department of Neurology, University of Michigan, Ann Arbor, MI
| | - Nanna B Finnerup
- International Diabetic Neuropathy Consortium (IDNC), Department of Clinical Medicine, Aarhus University, Aarhus, Denmark.,Danish Pain Research Center, Department of Clinical Medicine, Aarhus University, Aarhus, Denmark.,Department of Neurology, Aarhus University Hospital, Aarhus, Denmark
| | - Troels S Jensen
- International Diabetic Neuropathy Consortium (IDNC), Department of Clinical Medicine, Aarhus University, Aarhus, Denmark.,Danish Pain Research Center, Department of Clinical Medicine, Aarhus University, Aarhus, Denmark.,Department of Neurology, Aarhus University Hospital, Aarhus, Denmark
| | - Reimar W Thomsen
- Department of Clinical Epidemiology, Aarhus University Hospital, Aarhus, Denmark
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Bennedsgaard K, Ventzel L, Themistocleous AC, Bennett DL, Jensen AB, Jensen AR, Andersen NT, Jensen TS, Tankisi H, Finnerup NB. Long-term symptoms of polyneuropathy in breast and colorectal cancer patients treated with and without adjuvant chemotherapy. Cancer Med 2020; 9:5114-5123. [PMID: 32469145 PMCID: PMC7367625 DOI: 10.1002/cam4.3129] [Citation(s) in RCA: 17] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/13/2020] [Revised: 04/14/2020] [Accepted: 04/22/2020] [Indexed: 01/05/2023] Open
Abstract
Background The aim of this study was to assess chemotherapy‐induced polyneuropathy (CIPN) 5 years after adjuvant chemotherapy in patients with breast and colorectal cancer. The association of CIPN with quality of life, anxiety, and depression was analyzed. Methods Of a set of 100 patients with breast cancer and of 74 with colorectal cancer who had undergone surgery and adjuvant chemotherapy in 2011‐2012, 80 and 52 patients alive, respectively, were included together with two reference groups of 249 breast cancer patients and 83 colorectal cancer patients who had undergone surgery only. All patients were sent a questionnaire on alcohol consumption, smoking habits, comorbidity, medicine consumption, and oxaliplatin‐specific questions, as well as the Michigan Neuropathy Screening Instrument questionnaire (MNSIq), the Douleur Neuropathique 4 Questions (DN4q), the EQ‐5D, and the Hospital Anxiety and Depression Scale. Possible polyneuropathy was defined as the presence of numbness and/or tingling in the feet, secondly as a score of ≥4 on the MNSIq. Possible painful polyneuropathy was defined as pain in both feet and a score ≥3 on the DN4q. Results The prevalence of possible polyneuropathy defined by numbness and/or tingling in the feet was 38.8% (28.1‐50.3) after adjuvant docetaxel and 57.7% (43.2‐71.3) after adjuvant oxaliplatin, with no significant difference from a previous 1‐year follow‐up (P >.35). Fewer had possible polyneuropathy as defined by the MNSIq. Patients with possible polyneuropathy after adjuvant chemotherapy reported significantly lower quality of life than patients treated with surgery only. Conclusion Symptoms of polyneuropathy following adjuvant docetaxel and oxaliplatin persist 5 years after treatment and affect quality of life negatively.
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Affiliation(s)
- Kristine Bennedsgaard
- Danish Pain Research Center, Department of Clinical Medicine, Aarhus University, Aarhus, Denmark
| | - Lise Ventzel
- Danish Pain Research Center, Department of Clinical Medicine, Aarhus University, Aarhus, Denmark.,Department of Oncology, Aarhus University Hospital, Aarhus, Denmark
| | - Andreas C Themistocleous
- Nuffield Department of Clinical Neuroscience, University of Oxford, Oxford, UK.,Brain Function Research Group, School of Physiology, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - David L Bennett
- Nuffield Department of Clinical Neuroscience, University of Oxford, Oxford, UK
| | - Anders B Jensen
- Department of Oncology, Aarhus University Hospital, Aarhus, Denmark
| | - Anni R Jensen
- Department of Oncology, Aarhus University Hospital, Aarhus, Denmark
| | - Niels T Andersen
- Biostatistics, Department of Public Health, Aarhus University, Aarhus, Denmark
| | - Troels S Jensen
- Danish Pain Research Center, Department of Clinical Medicine, Aarhus University, Aarhus, Denmark.,Department of Neurology, Aarhus University Hospital, Aarhus, Denmark
| | - Hatice Tankisi
- Department of Clinical Neurophysiology, Aarhus University Hospital, Aarhus, Denmark
| | - Nanna B Finnerup
- Danish Pain Research Center, Department of Clinical Medicine, Aarhus University, Aarhus, Denmark.,Department of Neurology, Aarhus University Hospital, Aarhus, Denmark
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Bennedsgaard K, Ventzel L, Grafe P, Tigerholm J, Themistocleous AC, Bennett DL, Tankisi H, Finnerup NB. Cold aggravates abnormal excitability of motor axons in oxaliplatin-treated patients. Muscle Nerve 2020; 61:796-800. [PMID: 32133655 PMCID: PMC7318596 DOI: 10.1002/mus.26852] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/19/2019] [Revised: 02/26/2020] [Accepted: 02/29/2020] [Indexed: 12/30/2022]
Abstract
INTRODUCTION Cold allodynia is often seen in the acute phase of oxaliplatin treatment, but the underlying pathophysiology remains unclear. METHODS Patients scheduled for adjuvant oxaliplatin for colorectal cancer were examined with quantitative sensory testing and nerve excitability tests at baseline and after the second or third oxaliplatin cycle at different skin temperatures. RESULTS Seven patients were eligible for examination. All patients felt evoked pain and tingling when touching something cold after oxaliplatin infusion. Oxaliplatin decreased motor nerve superexcitability (P < .001), increased relative refractory period (P = .011), and caused neuromyotonia-like after-activity. Cooling exacerbated these changes and prolonged the accommodation half-time. DISCUSSION The findings suggest that a combined effect of oxaliplatin and cooling facilitates nerve excitability changes and neuromyotonia-like after-activity in peripheral nerve axons. A possible mechanism is the slowing in gating of voltage-dependent fast sodium and slow potassium channels, which results in symptoms of cold allodynia.
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Affiliation(s)
- Kristine Bennedsgaard
- Danish Pain Research Center, Department of Clinical Medicine, Aarhus University, Aarhus, Denmark
| | - Lise Ventzel
- Danish Pain Research Center, Department of Clinical Medicine, Aarhus University, Aarhus, Denmark
| | - Peter Grafe
- Institute of Physiology, Ludwig-Maximilians University, Munich, Germany
| | - Jenny Tigerholm
- Center of Neuroplasticity and Pain, Department of Health Science and Technology, Aalborg University, Aalborg, Denmark
| | | | - David L Bennett
- Nuffield Department of Clinical Neuroscience, University of Oxford, Oxford, UK
| | - Hatice Tankisi
- Department of Neurophysiology, Aarhus University Hospital, Aarhus, Denmark
| | - Nanna B Finnerup
- Danish Pain Research Center, Department of Clinical Medicine, Aarhus University, Aarhus, Denmark
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Meyer-Frießem CH, Attal N, Baron R, Bouhassira D, Finnerup NB, Freynhagen R, Gierthmühlen J, Haanpää M, Hansson P, Jensen TS, Kemp H, Kennedy D, Leffler AS, Rice ASC, Segerdahl M, Serra J, Sindrup S, Solà R, Tölle T, Schuh-Hofer S, Treede RD, Pogatzki-Zahn E, Maier C, Vollert J. Pain thresholds and intensities of CRPS type I and neuropathic pain in respect to sex. Eur J Pain 2020; 24:1058-1071. [PMID: 32096888 DOI: 10.1002/ejp.1550] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/24/2019] [Revised: 01/19/2020] [Accepted: 02/18/2020] [Indexed: 11/09/2022]
Abstract
BACKGROUND AND AIMS Healthy women have generally been found to have increased experimental pain perception and chronic pain has a higher prevalence in female as compared to male patients. However, no study has investigated whether pain intensity and pain perception thresholds are distinct or similar between sexes within various chronic pain entities. We investigated whether average pain intensities and pain thresholds assessed using quantitative sensory testing (QST) differed between women and men suffering from three distinct chronic pain conditions: Complex Regional Pain Syndrome (CRPS type I), peripheral nerve injury (PNI) or polyneuropathy (PNP), as compared to paired healthy volunteers. METHODS QST data of 1,252 patients (669 female, 583 male) with PNI (n = 342), PNP (n = 571) or CRPS (n = 339), and average pain intensity reports from previously published studies were included. Absolute and z-values (adjusted for age and body region) of cold, heat, pressure (PPT) and pinprick pain thresholds were compared in generalized linear models with aetiology, duration of underlying pain disease and average pain intensity as fixed effects. RESULTS Average pain intensity during the past four weeks did not differ between women and men, in both mean and range. In women absolute pain thresholds for cold, heat and pinprick were lower than in males across all diagnoses (p < .05). However, after z-transformation these differences disappeared except for PPT in CRPS (p = .001). DISCUSSION Pain thresholds in patients show only minor sex differences. However, these differences mimic those observed in healthy subjects and do not seem to be linked to specific pathophysiological processes. SIGNIFICANCE Female healthy participants and female patients with neuropathic pain conditions or CRPS I report lower pain thresholds compared to males, but pain intensity is similar and there is no sex difference in the extent to which the thresholds are altered in neuropathic pain or CRPS. Thus, the sex differences observed in various chronic pain conditions mimic those obtained in healthy participants, indicating that these differences are not linked to specific pathophysiological processes and are of minor clinical relevance.
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Affiliation(s)
- Christine H Meyer-Frießem
- Department of Anesthesiology, Intensive Care, Palliative and Pain Medicine, University Hospital Bergmannsheil Bochum, Bochum, Germany.,Department of Pain Medicine, BG University Hospital Bergmannsheil GmbH, Ruhr-University Bochum, Bochum, Germany
| | - Nadine Attal
- INSERM U-987, Centre d'Evaluation et de Traitement de la Douleur, CHU Ambroise Paré, Boulogne-Billancourt, France.,Université Versailles-Saint-Quentin, Versailles, France
| | - Ralf Baron
- Division of Neurological Pain Research and Therapy, Department of Neurology, Universitätsklinikum Schleswig-Holstein, Campus Kiel, Kiel, Germany
| | - Didier Bouhassira
- INSERM U-987, Centre d'Evaluation et de Traitement de la Douleur, CHU Ambroise Paré, Boulogne-Billancourt, France.,Université Versailles-Saint-Quentin, Versailles, France
| | - Nanna B Finnerup
- Department of Neurology, Aarhus University Hospital, Aarhus, Denmark.,Danish Pain Research Center, Department of Clinical Medicine, Aarhus University, Aarhus, Denmark
| | - Rainer Freynhagen
- Department of Anaesthesiology, Critical Care Medicine, Pain Therapy & Palliative Care, Pain Center Lake Starnberg, Benedictus Hospital Tutzing, Tutzing, Germany.,Anaesthesiological Clinic, Klinikum Rechts der Isar, Technische Universität München, Munich, Germany
| | - Janne Gierthmühlen
- Division of Neurological Pain Research and Therapy, Department of Neurology, Universitätsklinikum Schleswig-Holstein, Campus Kiel, Kiel, Germany
| | - Maija Haanpää
- Department of Helsinki University Central Hospital, Helsinki, Finland.,Etera Mutual Pension Insurance Company Helsinki, Helsinki, Finland
| | - Per Hansson
- Division of Emergencies and Critical Care, Department of Pain Management and Research, Oslo University Hospital, Oslo, Norway.,Department of Molecular Medicine and Surgery, Karolinska Institute, Stockholm, Sweden
| | - Troels S Jensen
- Department of Neurology, Aarhus University Hospital, Aarhus, Denmark.,Danish Pain Research Center, Department of Clinical Medicine, Aarhus University, Aarhus, Denmark
| | - Harriet Kemp
- Pain Research, Department of Surgery and Cancer, Imperial College, London, UK
| | - Donna Kennedy
- Pain Research, Department of Surgery and Cancer, Imperial College, London, UK
| | - Anne-Sofie Leffler
- Department of Molecular Medicine and Surgery, Karolinska Institute, Stockholm, Sweden
| | - Andrew S C Rice
- Pain Research, Department of Surgery and Cancer, Imperial College, London, UK
| | - Märta Segerdahl
- H. Lundbeck A/S, Copenhagen, Denmark.,Department of Physiology and Pharmacology, Karolinska Institute, Stockholm, Sweden
| | - Jordi Serra
- Neuroscience Technologies, Ltd., Barcelona, Spain
| | - Soeren Sindrup
- Department of Neurology, Odense University Hospital, Odense, Denmark
| | - Roma Solà
- Neuroscience Technologies, Ltd., Barcelona, Spain
| | - Thomas Tölle
- Department of Neurology, Klinikum Rechts der Isar, Technische Universität München, Munich, Germany
| | - Sigrid Schuh-Hofer
- Center of Biomedicine and Medical Technology Mannheim CBTM, Medical Faculty Mannheim, Heidelberg University, Heidelberg, Germany
| | - Rolf-Detlef Treede
- Center of Biomedicine and Medical Technology Mannheim CBTM, Medical Faculty Mannheim, Heidelberg University, Heidelberg, Germany
| | - Esther Pogatzki-Zahn
- Department of Anaesthesiology, Intensive Care and Pain Medicine, University Hospital Muenster, Muenster, Germany
| | - Christoph Maier
- Department of Pain Medicine, BG University Hospital Bergmannsheil GmbH, Ruhr-University Bochum, Bochum, Germany
| | - Jan Vollert
- Pain Research, Department of Surgery and Cancer, Imperial College, London, UK.,Center of Biomedicine and Medical Technology Mannheim CBTM, Medical Faculty Mannheim, Heidelberg University, Heidelberg, Germany
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Calvo M, Davies AJ, Hébert HL, Weir GA, Chesler EJ, Finnerup NB, Levitt RC, Smith BH, Neely GG, Costigan M, Bennett DL. The Genetics of Neuropathic Pain from Model Organisms to Clinical Application. Neuron 2019; 104:637-653. [PMID: 31751545 PMCID: PMC6868508 DOI: 10.1016/j.neuron.2019.09.018] [Citation(s) in RCA: 58] [Impact Index Per Article: 11.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/10/2019] [Revised: 09/05/2019] [Accepted: 09/12/2019] [Indexed: 12/14/2022]
Abstract
Neuropathic pain (NeuP) arises due to injury of the somatosensory nervous system and is both common and disabling, rendering an urgent need for non-addictive, effective new therapies. Given the high evolutionary conservation of pain, investigative approaches from Drosophila mutagenesis to human Mendelian genetics have aided our understanding of the maladaptive plasticity underlying NeuP. Successes include the identification of ion channel variants causing hyper-excitability and the importance of neuro-immune signaling. Recent developments encompass improved sensory phenotyping in animal models and patients, brain imaging, and electrophysiology-based pain biomarkers, the collection of large well-phenotyped population cohorts, neurons derived from patient stem cells, and high-precision CRISPR generated genetic editing. We will discuss how to harness these resources to understand the pathophysiological drivers of NeuP, define its relationship with comorbidities such as anxiety, depression, and sleep disorders, and explore how to apply these findings to the prediction, diagnosis, and treatment of NeuP in the clinic.
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Affiliation(s)
- Margarita Calvo
- Departamento de Fisiología, Facultad de Ciencias Biológicas, Pontificia Universidad Católica de Chile, Santiago, Chile
| | - Alexander J Davies
- Neural Injury Group, Nuffield Department of Clinical Neuroscience, John Radcliffe Hospital, University of Oxford, Oxford, UK
| | - Harry L Hébert
- Chronic Pain Research Group, Division of Population Health and Genomics, Mackenzie Building, Ninewells Hospital & Medical School, University of Dundee, Dundee, UK
| | - Greg A Weir
- Neural Injury Group, Nuffield Department of Clinical Neuroscience, John Radcliffe Hospital, University of Oxford, Oxford, UK
| | | | - Nanna B Finnerup
- Department of Clinical Medicine, Danish Pain Research Center, Aarhus University, Aarhus 8000, Denmark
| | - Roy C Levitt
- Department of Anesthesiology, Perioperative Medicine and Pain Management, and John T. MacDonald Foundation Department of Human Genetics, Miller School of Medicine, University of Miami, Miami, FL, USA
| | - Blair H Smith
- Chronic Pain Research Group, Division of Population Health and Genomics, Mackenzie Building, Ninewells Hospital & Medical School, University of Dundee, Dundee, UK
| | - G Gregory Neely
- Dr. John and Anne Chong Lab for Functional Genomics, Camperdown, University of Sydney, Sydney, NSW, Australia
| | - Michael Costigan
- Departments of Anesthesia and Neurobiology, Children's Hospital Boston and Harvard Medical School, Boston, MA, USA.
| | - David L Bennett
- Neural Injury Group, Nuffield Department of Clinical Neuroscience, John Radcliffe Hospital, University of Oxford, Oxford, UK.
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Carmland ME, Kreutzfeldt M, Holbech JV, Andersen NT, Jensen TS, Bach FW, Sindrup SH, Finnerup NB. Effect of lacosamide in peripheral neuropathic pain: study protocol for a randomized, placebo-controlled, phenotype-stratified trial. Trials 2019; 20:588. [PMID: 31604475 PMCID: PMC6788106 DOI: 10.1186/s13063-019-3695-7] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2019] [Accepted: 08/31/2019] [Indexed: 11/22/2022] Open
Abstract
Background Neuropathic pain is a common pain condition that has a major negative impact on health-related quality of life. However, despite decades of research, it remains difficult to treat neuropathic pain. Lacosamide is a sodium-channel blocker that is efficacious in animal models of neuropathic pain. In humans, its effect in neuropathic pain is inconclusive, based on inconsistent results and very large placebo responses. Previous trials have not used patient stratification or looked for predictors for response. Methods This study will be conducted as a multicenter, randomized, double-blind, placebo-controlled, parallel, phase 2, proof-of-concept, phenotype-stratified study. The study will enroll 108 patients with peripheral neuropathic pain who will be randomized to a 12-week treatment with lacosamide or placebo up to 400 mg/day in a 2:1 ratio. The primary objective is to compare the change in the mean value of the patients’ daily ratings of average pain intensity from baseline to the last week of treatment in patients with and without the irritable nociceptor phenotype in the per-protocol population. A supportive objective is to compare the effect of lacosamide with that of placebo in the two phenotypes. Secondary and tertiary outcomes include the Patient Global Impression of Change, pain relief, presence of 30% and 50% pain reduction, sleep disturbance, depression, and anxiety. Discussion We will examine the concept of individualized therapy based on phenotyping, and expect that this study will provide important information on the usefulness of lacosamide in the treatment of peripheral neuropathic pain. Trial registration ClinicalTrials.gov, NCT03777956. Registered on 18 December 2018. Electronic supplementary material The online version of this article (10.1186/s13063-019-3695-7) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Malin E Carmland
- Danish Pain Research Center, Department of Clinical Medicine, Aarhus University, Palle Juul-Jensens Boulevaard 99, DK-8200, Aarhus N, Denmark.,Department of Neurology, Aarhus University Hospital, Aarhus, Denmark
| | | | - Jakob V Holbech
- Department of Neurology, Odense University Hospital, Odense, Denmark
| | | | - Troels S Jensen
- Danish Pain Research Center, Department of Clinical Medicine, Aarhus University, Palle Juul-Jensens Boulevaard 99, DK-8200, Aarhus N, Denmark.,Department of Neurology, Aarhus University Hospital, Aarhus, Denmark
| | - Flemming W Bach
- Department of Neurology, Aarhus University Hospital, Aarhus, Denmark
| | - Søren H Sindrup
- Department of Neurology, Odense University Hospital, Odense, Denmark
| | - Nanna B Finnerup
- Danish Pain Research Center, Department of Clinical Medicine, Aarhus University, Palle Juul-Jensens Boulevaard 99, DK-8200, Aarhus N, Denmark. .,Department of Neurology, Aarhus University Hospital, Aarhus, Denmark.
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43
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Affiliation(s)
- Nanna B Finnerup
- From the Department of Clinical Medicine, Danish Pain Research Center, Aarhus University, and the Department of Neurology, Aarhus University Hospital - both in Aarhus, Denmark
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Fisher E, Eccleston C, Degenhardt L, Finn DP, Finnerup NB, Gilron I, Haroutounian S, Krane E, Rice AS, Rowbotham M, Wallace M, Moore RA. Cannabinoids, cannabis, and cannabis-based medicine for pain management: a protocol for an overview of systematic reviews and a systematic review of randomised controlled trials. Pain Rep 2019; 4:e741. [PMID: 31583356 PMCID: PMC6749927 DOI: 10.1097/pr9.0000000000000741] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2019] [Revised: 03/05/2019] [Accepted: 03/09/2019] [Indexed: 01/08/2023] Open
Abstract
Pain is an experience that affects many people worldwide and is associated with higher mortality and lower quality of life. Cannabinoid, cannabis, and cannabis-based medicines (CBMs) are thought to reduce pain, but a proliferation of different products has led to variability in trials, creating a challenge when determining the assessment of efficacy in systematic reviews. We will conduct 2 systematic reviews commissioned by the International Association for the Study of Pain Task Force on the use of cannabinoids, cannabis, and CBMs for pain management: first, an overview review of systematic reviews to summarise the evidence base and second, a systematic review of randomised controlled trials of cannabinoids, cannabis, and CBMs. In these reviews we will determine the harm and benefit of CBM from the current literature and will interpret the findings in light of the quality of evidence and reviews included. We will search online databases and registries in any language for systematic reviews and randomised controlled trials. We will include studies that evaluate any cannabinoid or CBM vs any control for people with acute and chronic pain. Our primary outcomes for both reviews are the number of participants achieving (1) a 30% and (2) 50% reduction in pain intensity, (3) moderate improvement, and (4) substantial improvement. A number of secondary outcome measures will also be included. We will assess risk of bias and quality of evidence. We will analyse data using fixed and random effect models, with separate comparators for cannabis and CBMs. Prospero ID (CRD42019124710; CRD42019124714).
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Affiliation(s)
- Emma Fisher
- Centre for Pain Research, University of Bath, Bath, United Kingdom
- Cochrane Pain, Palliative, and Supportive Care Review Groups, Oxford University Hospitals, Oxford, United Kingdom
| | - Christopher Eccleston
- Centre for Pain Research, University of Bath, Bath, United Kingdom
- Cochrane Pain, Palliative, and Supportive Care Review Groups, Oxford University Hospitals, Oxford, United Kingdom
- Department of Clinical and Health Psychology, Ghent University, Ghent, Belgium
| | - Louisa Degenhardt
- National Drug and Alcohol Research Centre, University of New South Wales, Sydney, Australia
| | - David P. Finn
- Pharmacology and Therapeutics, School of Medicine, Galway Neuroscience Centre and Centre for Pain Research, NCBES, National University of Ireland Galway, Galway, Ireland
| | - Nanna B. Finnerup
- Department of Clinical Medicine, Danish Pain Research Center, Aarhus University, Aarhus, Denmark
| | - Ian Gilron
- Department of Neurology, Aarhus University Hospital, Aarhus, Denmark
- Department of Anesthesiology and Perioperative Medicine, Kingston General Hospital, Queen's University, Kingston, ON, Canada
- Centre for Neuroscience Studies, Queen's University, Kingston, ON, Canada
- School of Policy Studies, Queen's University, Kingston, ON, Canada
| | - Simon Haroutounian
- Division of Clinical and Translational Research, Department of Anesthesiology, Washington University Pain Center, Washington University School of Medicine, St Louis, MO
| | - Elliot Krane
- Department of Anesthesiology, Perioperative, and Pain Medicine, and Pediatrics, Stanford University School of Medicine, Stanford, Palo Alto, CA
| | - Andrew S.C. Rice
- Department of Surgery and Cancer, Faculty of Medicine, Imperial College London, London, United Kingdom
| | - Michael Rowbotham
- Department of Anesthesia, University of California, San Francisco, CA
- Sutter Health, CPMC Research Institute, California Pacific Medical Center Research Institute, San Francisco, CA
| | - Mark Wallace
- Division of Pain Medicine, Department of Anesthesiology, University of California San Diego, San Diego, CA
| | - R. Andrew Moore
- Pain Research, Nuffield Department of Clinical Neurosciences, The Churchill, University of Oxford, Oxford, United Kingdom
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Pascal MMV, Themistocleous AC, Baron R, Binder A, Bouhassira D, Crombez G, Finnerup NB, Gierthmühlen J, Granovsky Y, Groop L, Hebert HL, Jensen TS, Johnsen K, McCarthy MI, Meng W, Palmer CNA, Rice ASC, Serra J, Solà R, Yarnitsky D, Smith BH, Attal N, Bennett DLH. DOLORisk: study protocol for a multi-centre observational study to understand the risk factors and determinants of neuropathic pain. Wellcome Open Res 2019; 3:63. [PMID: 30756091 DOI: 10.12688/wellcomeopenres.14576.1] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/21/2018] [Indexed: 12/15/2022] Open
Abstract
Background: Neuropathic pain is an increasingly prevalent condition and has a major impact on health and quality of life. However, the risk factors for the development and maintenance of neuropathic pain are poorly understood. Clinical, genetic and psychosocial factors all contribute to chronic pain, but their interactions have not been studied in large cohorts. The DOLORisk study aims to study these factors. Protocol: Multicentre cross-sectional and longitudinal cohorts covering the main causes leading to neuropathic pain (e.g. diabetes, surgery, chemotherapy, traumatic injury), as well as rare conditions, follow a common protocol for phenotyping of the participants. This core protocol correlates answers given by the participants on a set of questionnaires with the results of their genetic analyses. A smaller number of participants undergo deeper phenotyping procedures, including neurological examination, nerve conduction studies, threshold tracking, quantitative sensory testing, conditioned pain modulation and electroencephalography. Ethics and dissemination: All studies have been approved by their regional ethics committees as required by national law. Results are disseminated through the DOLORisk website, scientific meetings, open-access publications, and in partnership with patient organisations. Strengths and limitations: Large cohorts covering many possible triggers for neuropathic painMulti-disciplinary approach to study the interaction of clinical, psychosocial and genetic risk factorsHigh comparability of the data across centres thanks to harmonised protocolsOne limitation is that the length of the questionnaires might reduce the response rate and quality of responses of participants.
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Affiliation(s)
- Mathilde M V Pascal
- Nuffield Department of Clinical Neurosciences, University of Oxford, Oxford, OX3 9DU, UK
| | | | - Ralf Baron
- Division of Neurological Pain Research and Therapy, Department of Neurology, Universitätsklinikum Schleswig-Holstein, Kiel, 24105, Germany
| | - Andreas Binder
- Division of Neurological Pain Research and Therapy, Department of Neurology, Universitätsklinikum Schleswig-Holstein, Kiel, 24105, Germany
| | - Didier Bouhassira
- INSERM U-987, Centre d'Evaluation et de Traitement de la Douleur, APHP, CHU Ambroise Paré, Boulogne-Billancourt, France and University Versailles Saint Quentin en Yvelines, Versailles, 78000, France
| | - Geert Crombez
- Department of Experimental-Clinical and Health Psychology, Ghent University, Ghent, 9000, Belgium
| | - Nanna B Finnerup
- Department of Clinical Medicine, Danish Pain Research Center, Aarhus University, Aarhus, 8000, Denmark.,Department of Neurology, Aarhus University Hospital, Aarhus, 8200, Denmark
| | - Janne Gierthmühlen
- Division of Neurological Pain Research and Therapy, Department of Neurology, Universitätsklinikum Schleswig-Holstein, Kiel, 24105, Germany
| | - Yelena Granovsky
- Department of Neurology, Rambam Health Care Campus, Technion Faculty of Medicine, Haifa, Israel
| | - Leif Groop
- Department of Clinical Sciences, Diabetes and Endocrinology, University of Lund, Malmö, Sweden
| | - Harry L Hebert
- Division of Population Health Sciences, University of Dundee, Dundee, DD1 9SY, UK
| | - Troels S Jensen
- Department of Neurology, Aarhus University Hospital, Aarhus, 8200, Denmark
| | | | - Mark I McCarthy
- Wellcome Trust Centre for Human Genetics, University of Oxford, Oxford, OX3 7BN, UK
| | - Weihua Meng
- Division of Population Health Sciences, University of Dundee, Dundee, DD1 9SY, UK
| | - Colin N A Palmer
- Centre for Pharmacogenetics and Pharmacogenomics, Medical Research Institute, Ninewells Hospital and School of Medicine, University of Dundee, Dundee, DD1 9SY, UK
| | - Andrew S C Rice
- Pain Research Group, Imperial College London, London, SW10 9NH, UK
| | - Jordi Serra
- Neuroscience Technologies, Ltd, Barcelona, Spain
| | - Romà Solà
- Neuroscience Technologies, Ltd, Barcelona, Spain
| | - David Yarnitsky
- Department of Neurology, Rambam Health Care Campus, Technion Faculty of Medicine, Haifa, Israel
| | - Blair H Smith
- Division of Population Health Sciences, University of Dundee, Dundee, DD1 9SY, UK
| | - Nadine Attal
- INSERM U-987, Centre d'Evaluation et de Traitement de la Douleur, APHP, CHU Ambroise Paré, Boulogne-Billancourt, France and University Versailles Saint Quentin en Yvelines, Versailles, 78000, France
| | - David L H Bennett
- Nuffield Department of Clinical Neurosciences, University of Oxford, Oxford, OX3 9DU, UK
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46
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Pascal MMV, Themistocleous AC, Baron R, Binder A, Bouhassira D, Crombez G, Finnerup NB, Gierthmühlen J, Granovsky Y, Groop L, Hebert HL, Jensen TS, Johnsen K, McCarthy MI, Meng W, Palmer CNA, Rice ASC, Serra J, Solà R, Yarnitsky D, Smith BH, Attal N, Bennett DLH. DOLORisk: study protocol for a multi-centre observational study to understand the risk factors and determinants of neuropathic pain. Wellcome Open Res 2019; 3:63. [PMID: 30756091 PMCID: PMC6364377 DOI: 10.12688/wellcomeopenres.14576.2] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/29/2019] [Indexed: 01/02/2023] Open
Abstract
Background: Neuropathic pain is an increasingly prevalent condition and has a major impact on health and quality of life. However, the risk factors for the development and maintenance of neuropathic pain are poorly understood. Clinical, genetic and psychosocial factors all contribute to chronic pain, but their interactions have not been studied in large cohorts. The DOLORisk study aims to study these factors. Protocol: Multicentre cross-sectional and longitudinal cohorts covering the main causes leading to neuropathic pain (e.g. diabetes, surgery, chemotherapy, traumatic injury), as well as rare conditions, follow a common protocol for phenotyping of the participants. This core protocol correlates answers given by the participants on a set of questionnaires with the results of their genetic analyses. A smaller number of participants undergo deeper phenotyping procedures, including neurological examination, nerve conduction studies, threshold tracking, quantitative sensory testing, conditioned pain modulation and electroencephalography. Ethics and dissemination: All studies have been approved by their regional ethics committees as required by national law. Results are disseminated through the
DOLORisk website, scientific meetings, open-access publications, and in partnership with patient organisations. Strengths and limitations:Large cohorts covering many possible triggers for neuropathic pain Multi-disciplinary approach to study the interaction of clinical, psychosocial and genetic risk factors High comparability of the data across centres thanks to harmonised protocols One limitation is that the length of the questionnaires might reduce the response rate and quality of responses of participants
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Affiliation(s)
- Mathilde M V Pascal
- Nuffield Department of Clinical Neurosciences, University of Oxford, Oxford, OX3 9DU, UK
| | | | - Ralf Baron
- Division of Neurological Pain Research and Therapy, Department of Neurology, Universitätsklinikum Schleswig-Holstein, Kiel, 24105, Germany
| | - Andreas Binder
- Division of Neurological Pain Research and Therapy, Department of Neurology, Universitätsklinikum Schleswig-Holstein, Kiel, 24105, Germany
| | - Didier Bouhassira
- INSERM U-987, Centre d'Evaluation et de Traitement de la Douleur, APHP, CHU Ambroise Paré, Boulogne-Billancourt, France and University Versailles Saint Quentin en Yvelines, Versailles, 78000, France
| | - Geert Crombez
- Department of Experimental-Clinical and Health Psychology, Ghent University, Ghent, 9000, Belgium
| | - Nanna B Finnerup
- Department of Clinical Medicine, Danish Pain Research Center, Aarhus University, Aarhus, 8000, Denmark.,Department of Neurology, Aarhus University Hospital, Aarhus, 8200, Denmark
| | - Janne Gierthmühlen
- Division of Neurological Pain Research and Therapy, Department of Neurology, Universitätsklinikum Schleswig-Holstein, Kiel, 24105, Germany
| | - Yelena Granovsky
- Department of Neurology, Rambam Health Care Campus, Technion Faculty of Medicine, Haifa, Israel
| | - Leif Groop
- Department of Clinical Sciences, Diabetes and Endocrinology, University of Lund, Malmö, Sweden
| | - Harry L Hebert
- Division of Population Health Sciences, University of Dundee, Dundee, DD1 9SY, UK
| | - Troels S Jensen
- Department of Neurology, Aarhus University Hospital, Aarhus, 8200, Denmark
| | | | - Mark I McCarthy
- Wellcome Trust Centre for Human Genetics, University of Oxford, Oxford, OX3 7BN, UK
| | - Weihua Meng
- Division of Population Health Sciences, University of Dundee, Dundee, DD1 9SY, UK
| | - Colin N A Palmer
- Centre for Pharmacogenetics and Pharmacogenomics, Medical Research Institute, Ninewells Hospital and School of Medicine, University of Dundee, Dundee, DD1 9SY, UK
| | - Andrew S C Rice
- Pain Research Group, Imperial College London, London, SW10 9NH, UK
| | - Jordi Serra
- Neuroscience Technologies, Ltd, Barcelona, Spain
| | - Romà Solà
- Neuroscience Technologies, Ltd, Barcelona, Spain
| | - David Yarnitsky
- Department of Neurology, Rambam Health Care Campus, Technion Faculty of Medicine, Haifa, Israel
| | - Blair H Smith
- Division of Population Health Sciences, University of Dundee, Dundee, DD1 9SY, UK
| | - Nadine Attal
- INSERM U-987, Centre d'Evaluation et de Traitement de la Douleur, APHP, CHU Ambroise Paré, Boulogne-Billancourt, France and University Versailles Saint Quentin en Yvelines, Versailles, 78000, France
| | - David L H Bennett
- Nuffield Department of Clinical Neurosciences, University of Oxford, Oxford, OX3 9DU, UK
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Scholz J, Finnerup NB, Attal N, Aziz Q, Baron R, Bennett MI, Benoliel R, Cohen M, Cruccu G, Davis KD, Evers S, First M, Giamberardino MA, Hansson P, Kaasa S, Korwisi B, Kosek E, Lavand’homme P, Nicholas M, Nurmikko T, Perrot S, Raja SN, Rice ASC, Rowbotham MC, Schug S, Simpson DM, Smith BH, Svensson P, Vlaeyen JW, Wang SJ, Barke A, Rief W, Treede RD. The IASP classification of chronic pain for ICD-11: chronic neuropathic pain. Pain 2019; 160:53-59. [PMID: 30586071 PMCID: PMC6310153 DOI: 10.1097/j.pain.0000000000001365] [Citation(s) in RCA: 462] [Impact Index Per Article: 92.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
The upcoming 11th revision of the International Statistical Classification of Diseases and Related Health Problems (ICD) of the World Health Organization (WHO) offers a unique opportunity to improve the representation of painful disorders. For this purpose, the International Association for the Study of Pain (IASP) has convened an interdisciplinary task force of pain specialists. Here, we present the case for a reclassification of nervous system lesions or diseases associated with persistent or recurrent pain for ≥3 months. The new classification lists the most common conditions of peripheral neuropathic pain: trigeminal neuralgia, peripheral nerve injury, painful polyneuropathy, postherpetic neuralgia, and painful radiculopathy. Conditions of central neuropathic pain include pain caused by spinal cord or brain injury, poststroke pain, and pain associated with multiple sclerosis. Diseases not explicitly mentioned in the classification are captured in residual categories of ICD-11. Conditions of chronic neuropathic pain are either insufficiently defined or missing in the current version of the ICD, despite their prevalence and clinical importance. We provide the short definitions of diagnostic entities for which we submitted more detailed content models to the WHO. Definitions and content models were established in collaboration with the Classification Committee of the IASP's Neuropathic Pain Special Interest Group (NeuPSIG). Up to 10% of the general population experience neuropathic pain. The majority of these patients do not receive satisfactory relief with existing treatments. A precise classification of chronic neuropathic pain in ICD-11 is necessary to document this public health need and the therapeutic challenges related to chronic neuropathic pain.
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Affiliation(s)
- Joachim Scholz
- Departments of Anesthesiology and Pharmacology, Columbia University Medical Center, New York, NY, USA
| | - Nanna B. Finnerup
- Department of Clinical Medicine, Danish Pain Research Center, Aarhus University, Aarhus, Denmark
- Department of Neurology, Aarhus University Hospital, Aarhus, Denmark
| | - Nadine Attal
- INSERM U 987 and Assistance Publique – Hôpitaux de Paris, Hôpital Ambroise Paré, Boulogne Billancourt, France and Université Versailles Saint Quentin en Yvelines, Versailles, France
| | - Qasim Aziz
- Wingate Institute of Neurogastroenterology, Centre for Neuroscience and Trauma, Blizard Institute, Barts and The London School of Medicine and Dentistry, Queen Mary, University of London, London, United Kingdom
| | - Ralf Baron
- Department of Neurology, Universitätsklinikum Schleswig-Holstein, Kiel, Germany
| | - Michael I. Bennett
- Academic Unit of Palliative Care, University of Leeds, Leeds, United Kingdom
| | - Rafael Benoliel
- Department of Diagnostic Sciences, Rutgers School of Dental Medicine, Rutgers, Newark, NJ, USA
| | - Milton Cohen
- St. Vincent’s Clinical School, University of New South Wales, Sydney, Australia
| | - Giorgio Cruccu
- Department of Human Neuroscience, Sapienza University, Rome, Italy
| | - Karen D. Davis
- Department of Surgery and Institute of Medical Science, University of Toronto, and Division of Brain, Imaging and Behavior in Systems Neuroscience, Krembil Research Institute, University Health Network, Toronto, ON, Canada
| | - Stefan Evers
- Department of Neurology, Krankenhaus Lindenbrunn, and Faculty of Medicine, University of Münster, Münster, Germany
| | - Michael First
- Department of Psychiatry, Columbia University, and New York State Psychiatric Institute, New York, NY, USA
| | - Maria Adele Giamberardino
- Department of Medicine and Science of Aging, and Centro Studi dell’ Invecchiamento e Medicina Traslazionale (CeSI-Met), G D’Annunzio University of Chieti, Chieti, Italy
| | - Per Hansson
- Department of Pain Management and Research Division of Emergencies and Critical Care, Oslo University Hospital, Oslo, Norway, and Department of Molecular Medicine and Surgery, Karolinska Institutet, Stockholm, Sweden
| | - Stein Kaasa
- European Palliative Care Research Centre (PRC); Department of Oncology, Oslo University Hospital, Norway; University of Oslo, Oslo, Norway
| | - Beatrice Korwisi
- Clinical Psychology and Psychotherapy, Philipps-University Marburg, Marburg, Germany
| | - Eva Kosek
- Department of Clinical Neuroscience, Karolinska Institute Stockholm, Stockholm, Sweden
| | - Patricia Lavand’homme
- Department of Anesthesiology and Acute Postoperative Pain Service, Saint Luc Hospital, Catholic University of Louvain, Brussels, Belgium
| | - Michael Nicholas
- Pain Management Research Institute, University of Sydney and Royal North Shore Hospital, Sydney, Australia
| | - Turo Nurmikko
- Institute of Aging and Chronic Disease, University of Liverpool, Liverpool, United Kingdom
| | - Serge Perrot
- Pain Clinic, Hôtel Dieu Hospital, Paris Descartes University, INSERM U 987, Paris, France
| | - Srinivasa N. Raja
- Division of Pain Medicine, Department of Anesthesiology and Critical Care Medicine, Johns Hopkins University School of Medicine, Baltimore, USA
| | - Andrew S. C. Rice
- Pain Research, Department of Surgery and Cancer, Imperial College, London, United Kingdom
| | - Michael C. Rowbotham
- California Pacific Medical Center Research Institute, San Francisco, California, USA
| | - Stephan Schug
- Medical School, University of Western Australia, and Anaesthesia and Pain Medicine, Royal Perth Hospital, Perth, Australia
| | - David M. Simpson
- Department of Neurology, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Blair H. Smith
- Division of Population Health Sciences, University of Dundee, Dundee, Scotland
| | - Peter Svensson
- Section of Clinical Oral Physiology, School of Dentistry, Aarhus University, Aarhus, Denmark, and Department of Dental Medicine, Karolinska Institute, Huddinge, Sweden
| | - Johan W.S. Vlaeyen
- Research Group Health Psychology, University of Leuven, Leuven, Belgium and Department of Clinical Psychological Science, Maastricht University, Maastricht, the Netherlands
| | - Shuu-Jiun Wang
- Neurological Institute, Taipei Veterans General Hospital and Faculty of Medicine, National Yang-Ming University School of Medicine, Taipei, Taiwan
| | - Antonia Barke
- Clinical Psychology and Psychotherapy, Philipps-University Marburg, Marburg, Germany
| | - Winfried Rief
- Clinical Psychology and Psychotherapy, Philipps-University Marburg, Marburg, Germany
| | - Rolf-Detlef Treede
- Department of Neurophysiology, CBTM, Medical Faculty Mannheim of Heidelberg University, Germany
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Kural MA, Andersen ST, Andersen NT, Andersen H, Charles M, Finnerup NB, Jensen TS, Tankisi H. The utility of a point-of-care sural nerve conduction device for detection of diabetic polyneuropathy: A cross-sectional study. Muscle Nerve 2018; 59:187-193. [PMID: 30582180 DOI: 10.1002/mus.26361] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2018] [Revised: 10/11/2018] [Accepted: 10/14/2018] [Indexed: 01/02/2023]
Abstract
INTRODUCTION Rapid and accessible methods for diagnosing diabetic polyneuropathy (DPN) have been developed, but not validated, in large cohorts of people with diabetes. METHODS The performance of a point-of-care device (POCD) was studied in 168 patients with type 2 diabetes, estimating the sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV) compared with conventional sural nerve conduction studies (NCS). RESULTS A POCD amplitude limit of 6 µV increased the sensitivity (96%) and NPV (98%), but decreased the specificity (71%) and PPV (54%) compared with the 4-µV limit, which had values of 78%, 92%, 89%, and 71%, respectively. POCD on both legs showed better performance than on 1 leg. POCD amplitudes and conduction velocities correlated significantly with conventional sural NCS, but POCD values were underestimated compared with NCS. DISCUSSION The POCD may be used as a suitable screening tool for detection of DPN. Patients with abnormal and borderline results should undergo conventional NCS. Muscle Nerve 59:187-193, 2019.
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Affiliation(s)
- Mustafa A Kural
- Department of Clinical Neurophysiology, Aarhus University Hospital, Nørrebrogade 44, DK-8000, Aarhus C, Denmark
| | | | - Niels T Andersen
- Department of Public Health-Section for Biostatistics, Aarhus University, Aarhus, Denmark
| | - Henning Andersen
- Department of Neurology, Aarhus University Hospital, Aarhus, Denmark
| | - Morten Charles
- Department of Public Health, Aarhus University, Aarhus, Denmark
| | - Nanna B Finnerup
- Danish Pain Research Center, Department of Clinical Medicine, Aarhus University, Aarhus, Denmark
| | - Troels S Jensen
- Department of Neurology, Aarhus University Hospital, Aarhus, Denmark.,Danish Pain Research Center, Department of Clinical Medicine, Aarhus University, Aarhus, Denmark
| | - Hatice Tankisi
- Department of Clinical Neurophysiology, Aarhus University Hospital, Nørrebrogade 44, DK-8000, Aarhus C, Denmark
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Petersen PL, Bredahl P, Perch M, Møller CH, Finnerup NB, Nikolajsen L. Chronic pain after bilateral thoracotomy in lung transplant patients. Scand J Pain 2018; 19:271-277. [DOI: 10.1515/sjpain-2018-0126] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/09/2018] [Accepted: 10/29/2018] [Indexed: 01/01/2023]
Abstract
Abstract
Background and aims
The relative contribution of patient-related factors and intraoperative nerve damage for the development of chronic pain after surgery is unclear. This study aimed to examine chronic pain after bilateral thoracotomy. We hypothesized, that individual patient-related risk factors would be important resulting in an intraindividual uniformity of pain and hyperphenomena between the two sides of the thorax.
Methods
Twenty patients who had undergone lung transplantation via bilateral thoracotomy 6–12 months previously were included from the Danish Lung Transplant program, Rigshospitalet, Denmark, from October 2016 to August 2017. All patients answered questionnaires about pain in and around the scar, completed the Neuropathic Pain Symptom Inventory, and underwent bedside examination for hyperphenomena (brush- and cold-evoked allodynia, pinprick hyperalgesia) and pinprick hypoalgesia.
Results
Nine patients reported spontaneous pain bilaterally, five patients had pain on one side only, and six patients had no pain. Hyperphenomena were present on both sides of the thorax in 13 patients, on one side in four patients, and three patients had no hyperphenomena. The intraindividual uniformity of pain (p=0.029) and hyperphenomena (p=0.011) between the two sides of the thorax suggests that patient-related factors play an important role in the development of chronic pain.
Conclusions
The results of the present study provide support for the hypothesis of an individual predisposition for the development of chronic pain after thoracotomy.
Implications
Patient-related risk factors contribute to the development of chronic pain after thoracotomy. This result most likely can be transferred to chronic pain after other surgical procedures and therefore help us understand risk factors for chronic pain after surgery.
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Affiliation(s)
- Pernille L. Petersen
- Department of Ambulatory Surgery , Hvidovre Hospital, Copenhagen University Hospital , Kettegårdsalle 30, 2650 Hvidovre , Copenhagen , Denmark
| | - Pia Bredahl
- Department of Thoracic Anaesthesiology, Rigshospitalet , Copenhagen University Hospital , Copenhagen , Denmark
| | - Michael Perch
- Department of Cardiology , Section for Lung Transplantation, Rigshospitalet, Copenhagen University Hospital , Copenhagen , Denmark
| | - Christian H. Møller
- Department of Cardiothoracic Surgery , Rigshospitalet, Copenhagen University Hospital , Copenhagen , Denmark
| | - Nanna B. Finnerup
- Danish Pain Research Center, Department of Clinical Medicine , Aarhus University , Aarhus , Denmark
- Department of Neurology , Aarhus University Hospital , Aarhus , Denmark
| | - Lone Nikolajsen
- Department of Anaesthesiology and Intensive Care , Aarhus University Hospital , Aarhus , Denmark
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50
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Warner FM, Cragg JJ, Jutzeler CR, Finnerup NB, Werhagen L, Weidner N, Maier D, Kalke YB, Curt A, Kramer JLK. Progression of Neuropathic Pain after Acute Spinal Cord Injury: A Meta-Analysis and Framework for Clinical Trials. J Neurotrauma 2018; 36:1461-1468. [PMID: 30417730 DOI: 10.1089/neu.2018.5960] [Citation(s) in RCA: 29] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/14/2023] Open
Abstract
The translation of therapeutic interventions to humans with spinal cord injury with the goal of promoting growth and repair in the central nervous system could, inadvertently, drive mechanisms associated with the development of neuropathic pain. A framework is needed to evaluate the probability that a therapeutic intervention for acute spinal cord injury modifies the progression of neuropathic pain. We analyzed a large, longitudinal dataset from the European Multi-Center Study about Spinal Cord Injury (EMSCI) and compared these observations with a previously published Swedish/Danish cohort. A meta-analysis was performed to produce aggregate estimates for the transition period between 1-6 months and the transition period between 1-12 months after injury. A secondary analysis used logistic regression to explore associations between the progression of neuropathic pain and demographics, pain characteristics, and injury characteristics. For overall neuropathic pain, 72% presenting with pain symptoms at one month reported persisting symptoms at six months, and 23% who did not have neuropathic pain at one month later had it develop. From 1-12 months, there was a similar likelihood of pain persisting (69%) and slightly higher rate of pain developing (36%). Characteristics that were significantly associated with the progression of pain included age and sensory and motor preservation. We provide historical benchmarks for estimating the progression of neuropathic pain during the first year after acute SCI. This information will be useful for comparison and evaluating safety during early phase acute spinal cord injury trials.
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Affiliation(s)
- Freda M Warner
- 1 International Collaboration on Repair Discoveries (ICORD), and University of British Columbia, Vancouver, British Columbia, Canada.,2 School of Kinesiology, University of British Columbia, Vancouver, British Columbia, Canada
| | - Jacquelyn J Cragg
- 1 International Collaboration on Repair Discoveries (ICORD), and University of British Columbia, Vancouver, British Columbia, Canada.,3 Spinal Cord Injury Center University Hospital Balgrist, University of Zurich, Zurich, Switzerland
| | - Catherine R Jutzeler
- 1 International Collaboration on Repair Discoveries (ICORD), and University of British Columbia, Vancouver, British Columbia, Canada.,2 School of Kinesiology, University of British Columbia, Vancouver, British Columbia, Canada
| | - Nanna B Finnerup
- 5 Danish Pain Research Centre, Department of Clinical Medicine, Aarhus University, Aarhus, Denmark
| | - Lars Werhagen
- 6 Division of Rehabilitation Medicine, Department of Clinical Sciences, Karolinska Institut at Danderyds Hospital, Stockholm, Sweden
| | - Norbert Weidner
- 7 Spinal Cord Injury Center, Heidelberg University Hospital, Heidelberg, Germany
| | - Doris Maier
- 8 Berufsgenossenschaftliche Klinik, Murnau, Germany
| | | | - Armin Curt
- 3 Spinal Cord Injury Center University Hospital Balgrist, University of Zurich, Zurich, Switzerland.,4 European Multi-Centre Study on Spinal Cord Injury (EMSCI) Study Group
| | - John L K Kramer
- 1 International Collaboration on Repair Discoveries (ICORD), and University of British Columbia, Vancouver, British Columbia, Canada.,2 School of Kinesiology, University of British Columbia, Vancouver, British Columbia, Canada
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