British Journal of Pain最新文献

Objectives: A significant driver of low back pain (LBP) is adaptations to endogenous pain modulation (EPM). Exercise modulates pain through various mechanisms, however, there is a lack of information on its relation to EPM. The objective of this study was to evaluate the feasibility of a protocol investigating if changes in EPM occurs after exercise therapy.

Methods: Participants were recruited from an ongoing randomized controlled trial comparing graded activity to motor control exercises. Participants attended 2 in person sessions pre and post intervention to assess pain pressure threshold (PPT), temporal summation (TS), conditioned pain modulation (CPM) and exercise induced hypoalgesia (EIH). Feasibility outcomes included attrition, recruitment rate, exercise adherence, protocol burden and consistency. In total, 36 (53%) eligible participants enrolled and completed baseline assessments.

Results: A-priori thresholds for feasibility were met for attrition 32/36 (89%), recruitment rate (53% of eligible participant enrolled and 36 recruited in 6 months), exercise adherence (93.8%) and satisfaction with assessment protocols (bothersome 88.9%, future participation 97.2%), apart from discomfort with assessment (58.3%). Participants reported that the CPM caused the most discomfort. There was a trend for an increase in low back PPT, no change in TS, and a decrease in CPM and thumbnail PPT at follow up. The results demonstrated that the protocol is feasible for all pre-specified outcomes.

Discussion: This article presents a protocol for EPM using PPT, TS, CPM and EIH that is feasible in a clinical trial for LBP. A future study is needed to further investigate EPM changes after exercise therapy in this population.

Background: Knee osteoarthritis (OA) is the most common form of OA. Patients with mild-to-moderate OA, who do not respond to conservative treatment or yet warrant joint replacement, represent a significant clinical challenge. Genicular Arterial Embolisation (GAE) is a promising interventional radiological technique for OA. However, data highlight a consistent subset of patients that do not respond to GAE, despite a successful procedure. Pain Catastrophising (PC) represents a set of cognitive/affective biases to pain, linked to maladaptations in the descending pain modulatory system and has been frequently identified as a predictor of clinical outcomes. Purpose: This study aimed to investigate whether baseline pain catastrophising is associated with treatment outcomes following GAE, and to explore its neural correlates using resting-state functional magnetic resonance imaging (rs-fMRI). Research Design: A prospective, longitudinal cohort design was employed for this study. Study Sample: Thirty patients with mild-to-moderate knee OA scheduled for GAE completed a presurgical assessment including psychometric profiling and quantitative sensory testing. A neuroimaging subset of 17 patients, who met MRI safety criteria, also completed rs-fMRI. Data Collection: Participants completed outcome assessments at 6 weeks, 3 months, and 12 months post-GAE. Pain Catastrophising Scale (PCS) scores were analysed in relation to treatment outcomes and to whole-brain voxel-wise functional connectivity using the dorsolateral prefrontal cortex (DLPFC) as a seed region. PCS scores were included as regressors in rs-fMRI analyses. Results: Pain Catastrophising was associated with a myriad of psychological/lifestyle baseline variables, such as depression, anxiety and poor sleep. Surprisingly, high pain catastrophisers demonstrated the best improvements, with PC scores predicting higher reductions in pain at 6-weeks (R² = .18, p = .024), 3-months (R² = .37, p < .001) and 1-year (R² = .18, p = .027). Resting-state analyses revealed that catastrophising was associated with higher connectivity between the DLPFC and areas of the brain associated with pain processing, suggesting more frequent engagement of top-down modulatory processes. Conclusions: These results highlight that, interestingly, patients who catastrophise may benefit most from GAE. Potential explanations for this are discussed within. Overall, this data indicates GAE is an effective treatment for knee OA, and may be valuable at managing pain for high catastrophisers, who often fare worse in more invasive surgical procedures.

Pain is cited as a fundamental rationale behind the campaign for 'assisted dying' (assisted suicide and euthanasia). However, current legislative proposals for England and Wales before the Westminster Parliament are silent on pain and on suffering. For patients to have real choice, they must be able to access the care they need, not feel coerced into viewing an early death as their only option. Yet current palliative care provision is dependent on voluntary donations, with severe deficits in some areas that urgently need to be addressed.

Objective: In this study, a meta-analysis was conducted to characterize the therapeutic benefits of repetitive transcranial magnetic stimulation (rTMS) on musculoskeletal (MSK) pain and potential factors affecting the effect.

Methods: A comprehensive search was performed in PubMed, Web of Science, Embase, Cochrane Library, and ClinicalTrials.gov for randomized and sham-controlled trials published from inception to 13 March 2024. We conducted this meta-analysis following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses statement. Based on the heterogeneity among studies, fixed effects or random-effects model was used for the effective analysis of rTMS on pain, quality of life, and depression.

Results: A total of 23 eligible randomized controlled trials (RCTs) comprising 1158 patients were included in our systematic search. The analysis showed effect sizes of -0.94 (95% CI: -1.30 to -0.59), indicating that real rTMS was better than sham stimulation in reducing pain (p < 0.01). Also, rTMS reduced depression scores and improved follow-up effects and the quality of life of MSK pain patients. In the subgroup analysis, stimulation frequency, intensity, and session frequency were important factors affecting the therapeutic effect.

Conclusions: Our review demonstrated that rTMS had the potential to relieve pain and depression, enhance the quality of life for patients with MSK pain. Stimulation frequency, intensity, and session frequency were important factors affecting the therapeutic effect.

Background: Opioids can heighten sensitivity to noxious stimuli, leading to opioid-induced hyperalgesia (OIH). Despite the frequent use of high opioid doses in ICU settings, the presence of OIH following ICU stays remains undocumented.

Methods: This prospective observational study aimed to assess OIH presence and its clinical implications in post-ICU patients. Adults with confirmed Sars-CoV-2 infection hospitalized in the ICU for over 48 h were included, with opioid dosage recorded. At ICU discharge, 11 quantitative sensory tests (QSTs) were conducted at two non-painful sites, and pain presence, intensity, and characteristics were assessed at discharge and 4 months later.

Results: Analysis of 41 patients (20 opioid-treated, 21 controls) revealed significantly higher hyperalgesia levels in the opioid-treated group across six tests at both sites, including cold pain thresholds, heat and cold tolerance thresholds, duration of tolerance to a 47°C stimulus, and thermal and mechanical temporal summation.

Conclusions: Our findings underscore the importance of QST in early OIH detection, identifying thermal tolerance thresholds and thermal/mechanical temporal summation tests as sensitive indicators. Subclinical hyperalgesia in ICU patients on opioids heightens susceptibility to chronic pain development, emphasizing the need for vigilant opioid monitoring and adjustment in ICU care.

Cancer pain is one of the most severe components of the symptom burden among cancer patients, especially those with advanced or metastatic disease. Palliative interventions are necessary to alleviate cancer pain and reduce opioid-related side effects, thereby minimizing patient suffering. Radiosurgery has been effectively used to target the medial thalamus and the hypophysis for the treatment of chronic pain syndromes. These two areas are critical for pain modulation and control, and their precise targeting with radiosurgery and its non-invasive nature can provide relief for patients suffering from cancer-related intractable pain. Our previous work with single target irradiation of the hypophysis revealed promising pain relief in terminal cancer patients, albeit more suited for hormone-mediated tumours or bone-derived pain rather than complex mixed pain syndromes. Given that, we previously introduced the concept of triple-target irradiation (hypophysis + both thalami) in a small report of terminally ill cancer patients. Here, we report a larger case series of terminally ill patients (n = 8) with complex cancer pain treated with a triple-target approach, with radiation doses generally considered low or non-ablative (90 Gy), in contrast to the usual single-target, ablative approach comprising higher doses. We noted a substantial decrease in VAS scores and the medications needed to manage pain across all patients, experiencing minimal to no side effects. Our findings indicate that a minimally invasive triple-target method, utilising low radiation doses, effectively alleviates pain, lowers medication dependency, and enhances the quality of life with few side effects. Furthermore, additional research is essential to optimise pain relief and ensure long-term effectiveness.

Objectives: Waitlists for pain management services are often extensive, risking psychological and physical decline and patient non-engagement in treatment once accessed. Currently, for outpatient pain management, no standardised waiting list interventions exist, resulting in passive waiting. To arrest prospective wait-related decline(s), this study aimed to identify the barriers and facilitators to pain self-management while waiting, forming the foundation for a waitlist intervention development.

Design: An inductive qualitative approach was utilised to explore the barriers and drivers of pain self-management while waiting for chronic pain management.

Method: Semi-structured interviews, underpinned by the Theoretical Domains Framework and COM-B model, were conducted with people waiting for pain management services (N = 38). Interviews were audio-recorded, transcribed verbatim, and analysed via reflexive thematic analysis.

Results: The analysis demonstrated four thematised barriers and one facilitator: (1) Shunted Around the System (barrier); (2) The Information Gap (barrier); (3) Resisting Adaptation (barrier); (4) Losing Hope (barrier); and (5) Help Yourself or Lose Yourself (facilitator).

Conclusion: This study demonstrates the severe emotional and motivational impact of waiting, increasing treatment disengagement. The waitlist represents a prime opportunity for prehabilitation to protect wellbeing and optimise self-management engagement. Infrastructural and interpersonal barriers of poor communication and healthcare professional pain invalidation must be addressed to improve emotional wellbeing and motivation to engage with planned treatment. Enhancing self-efficacy, pain acceptance, self-compassion, and internal HLOC are fundamental to increasing pain self-management. These can all be met within a prehabilitation framework. This study is foundational for the development of psychological prehabilitation in outpatient chronic pain management.

Introduction: Experimental evidence supports the hypothesis of reciprocal influence between neural systems involved in cognition and central pain processing circuits. Furthermore, studies have demonstrated bidirectional communication between central pain processing areas and the immune system, leading to changes in behaviour, sensory perception, mood, and cognition. However, the academic community has not yet reached a consensus on whether effective analgesic interventions can mitigate or reverse cognitive deterioration.

Methods: This systematic review evaluated the effectiveness of various therapeutic interventions in improving cognitive functions (primary outcome) and altering the profile of immunological markers (secondary outcome) in chronic pain patients. The review was limited to randomised controlled trials addressing chronic pain of any aetiology, with searches conducted in PubMed, EMBASE, and Scopus databases.

Results: The qualitative synthesis of twelve studies conducted between 2003 and 2021, involving 1432 participants in experimental (n = 950) and control (n = 482) groups, revealed some interesting patterns. Only half of the studies (6/12) reported cognitive improvement, with attention being the most analysed cognitive domain, followed by memory and executive function. Fibromyalgia was the most studied aetiology of chronic pain. The strategies of intervention/treatment and durations varied widely; however, milnacipran versus placebo emerged as the most frequently employed intervention. Only one study reported immunological markers, limiting the evaluation of this outcome.

Conclusion: Based on this analysis, it is not possible to affirm that interventions targeting chronic pain improve cognition. This review suggests new research directions and calls for more robust methodological approaches.

Background: Digital pain drawings are an emerging method for pain assessment, but it is still unclear how these could best support pain treatment and management decisions. Therefore, this study explored the potential clinical utility of digital pain drawings.

Methods: We conducted a narrative study, involving qualitative interviews with healthcare professionals providing pain management services to people living with musculoskeletal pain conditions working across different disciplines and care levels in the healthcare system of the United Kingdom. We transcribed interviews, conducted thematic content analysis to identify themes and presented results using a framework approach.

Results: We interviewed three general practitioners, five rheumatology healthcare professionals, four physiotherapists, two pain consultants and one rheumatology nurse. We identified four themes describing current pain assessment practices, potential advantages of digital pain drawings either alone or in combination with other pain information (e.g. perceived pain triggers and relieving factors) and outcome measures (e.g. quality of sleep, function and anxiety). Digital pain drawings provide an opportunity of enriching patient-provider communication, particularly for people with language barriers. Digital pain drawings may also support healthcare professionals across different disciplines and care levels (e.g. primary and secondary care) in decisions related to referrals, differential diagnosis, treatment planning, evaluating response to treatment and scheduling follow-up visits when combining pain drawings with other pain information, such as pain consequences and perceived causes.

Conclusion: Digital pain drawings are clinically useful because of their potential to guide diagnosis, treatment and management choices in managing musculoskeletal chronic pain. Future research should investigate how these potential benefits are achieved by integrating digital pain drawings in clinical practice across different disciplines and care levels in the UK's healthcare system and beyond.