Pain
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Scientific evidence support the notion that migraine pathophysiology involves inherited alteration of brain excitability, intracranial arterial dilatation, recurrent activation and sensitization of the trigeminovascular pathway, and consequential structural and functional changes in genetically susceptible individuals. Evidence of altered brain excitability emerged from clinical and preclinical investigation of sensory auras, ictal and interictal hypersensitivity to visual, auditory and olfactory stimulation, and reduced activation of descending inhibitory pain pathways. ⋯ Also, structural and functional alterations include the presence of subcortical white mater lesions, thickening of cortical areas involved in processing sensory information, and cortical neuroplastic changes induced by cortical spreading depression. Here, we review recent anatomical data on the trigeminovascular pathway and its activation by cortical spreading depression, a novel understanding of the neural substrate of migraine-type photophobia, and modulation of the trigeminovascular pathway by the brainstem, hypothalamus and cortex.
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Cut points that classify pain intensity into mild, moderate, and severe levels are widely used in pain research and clinical practice. At present, there are no agreed-upon cut points for the visual analog scale (VAS) in pediatric samples. We applied a method based on Serlin and colleagues' procedure (Serlin RC, Mendoza TR, Nakamura Y, Edwards KR, Cleeland CS. ⋯ We found a set of cut points that can be used both parental ratings of their children's pain and self-reports for adolescents. Adopting these cut points greatly enhances the comparability of trials. We call for more systematic assessment of diagnostic procedures in pain research.
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Randomized Controlled Trial Multicenter Study
Duloxetine and pregabalin: High-dose monotherapy or their combination? The "COMBO-DN study" - a multinational, randomized, double-blind, parallel-group study in patients with diabetic peripheral neuropathic pain.
This multicentre, double-blind, parallel-group study in diabetic peripheral neuropathic pain addressed whether, in patients not responding to standard doses of duloxetine or pregabalin, combining both medications is superior to increasing each drug to its maximum recommended dose. For initial 8-week therapy, either 60 mg/day duloxetine (groups 1, 2) or 300 mg/day pregabalin (groups 3, 4) was given. Thereafter, in the 8-week combination/high-dose therapy period, only nonresponders received 120 mg/day duloxetine (group 1), a combination of 60 mg/day duloxetine and 300 mg/day pregabalin (groups 2, 3), or 600 mg/day pregabalin (group 4). ⋯ In exploratory analyses of the initial 8-week therapy uncorrected for multiple comparisons, 60 mg/day duloxetine was found superior to 300 mg/day pregabalin (P < 0.001). Both drugs and their combination were well tolerated. Although not significantly superior to high-dose monotherapy, combination therapy was considered to be effective, safe, and well tolerated.
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Radiographic knee osteoarthritis (OA) is a highly prevalent condition that has been the focus of a number of studies identifying factors that are prognostic of continued or worsening pain and function. Although prior prognostic studies have identified a number of demographic, physical, and psychological factors that are predictive of outcome, minimal focus has been placed on pain coping skills as prognostic factors, despite cross-sectional evidence suggesting that pain coping skills are associated with pain and function in knee OA. The present study reports on the use of pain coping skills as prognostic factors for changes in pain and/or function over a 1-year period. ⋯ Data from the Coping Strategies Questionnaire were compared against 1-year change in pain, function, or both, using established criteria for defining whether the patient got better, worse, or stayed the same over the 1-year period. Results revealed a significant effect for praying/hoping, increased behavioral activities, and pain catastrophizing as prognostic of pain outcomes; ignoring pain and praying/hoping were prognostic of function outcomes; and increased behavioral activities and pain catastrophizing were prognostic of a combined pain and function outcome. The findings provide important new evidence regarding the potential clinical relevance of a number of pain coping responses hypothesized to influence future pain and function in persons with arthritis.