The journal of pain : official journal of the American Pain Society
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Randomized Controlled Trial Multicenter Study Clinical Trial
Individually tailored treatment targeting activity, motor behavior, and cognition reduces pain-related disability: a randomized controlled trial in patients with musculoskeletal pain.
This study compares the outcomes of an individually tailored behavioral medicine intervention (experimental) with physical exercise therapy (control). The experimental intervention was systematically individualized according to each participant's behavioral treatment goals and functional behavioral analyses. One hundred twenty-two patients seeking care at 3 primary health care clinics because of musculoskeletal pain were randomized. Ninety-seven completed the trial. Data were collected at baseline, immediately after treatment, and at a 3-month follow-up. Analyses of data from completers, as well as intention-to-treat analyses, showed that the experimental group experienced lower levels of disability (P = .01), lower maximum pain intensity (P = .02), higher levels of pain control (P = .001), and lower fear of movement (P = .022) as a result of treatment condition. Self-efficacy (P = .0001) and physical performance (P = .0001) increased over time for both groups. Participants in the experimental group generally reported more positive effects after treatment. Treatment fidelity was maintained during the course of the study. Activity can be resumed and pain might be managed by the patients themselves if treatment incorporates the biopsychosocial explanatory model of pain and strategies are tailored according to individual's priorities of everyday life activities and empirically derived determinants of pain-related disability. ⋯ This study shows that the biomedical and the psychosocial perspectives of the experiences and consequences of pain complement rather than contradict each other. Primary health care patients with persistent musculoskeletal pain benefit more from a systematic tailoring of treatments according to biopsychosocial factors than from a physically based exercise intervention.
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Comparative Study
Comparison of Fos expression within the ferret's spinal trigeminal nuclear complex evoked by electrical or noxious-thermal pulpal stimulation.
Fos-like immunoreactivity (Fos-LI) was used as a marker of trigeminal neurons that responded to tooth pulp stimulation. The activation of intradental afferents was produced by electrical stimulation of the ferret's intact canine tooth, whereas natural stimuli that activate predominantly Adelta (5 mol/L CaCl2 applied to dentin) or C fibers (slow heating of the intact tooth) were used to stimulate the 2 populations of afferents selectively. Electrical stimulation evoked Fos-LI in ipsilateral dorsomedial of the trigeminal subnucleus caudalis (Vc), dorsomedial and ventrolateral of the transition zone between subnucleus interpolaris and caudalis (Vi/Vc), and the the paratrigeminal nucleus (Pa5). Osmotic stimulation evoked Fos-LI in the ipsilateral dorsomedial Vc and Vi/Vc. The spatial distribution of Fos labeling after heat stimulation was dependent on the duration and location of the stimulus application. Repeated heating of the maxillary canine for 30 minutes evoked labeling bilaterally in ventrolateral Vi/Vc. Stimulation of the maxillary and mandibular canines with heat pulses for 1 hour produced labeling in the ipsilateral dorsomedial Vc, dorsomedial Vi/Vc, and the Pa5. None of the stimulating procedures did evoke Fos expression in regions rostral to Vi/Vc. Regardless of the pulpal stimulation procedures, a similar number of Fos-positive neurons was found in the nucleus of solitary tract and the ventrolateral medulla. Although Fos expression does not reveal all neurons that respond to noxious pulpal stimulation, it marks many neuronal regions that contain neurons that respond to pulpal stimulation and injury. Our results suggest that a population of neurons in Vc and Vi/Vc contribute to painful sensations originating from the dentition. ⋯ We demonstrated that the trigeminal nucleus caudalis and the transitional zone between trigeminal interpolaris and caudalis mediate painful sensation in the dental pulp. Both trigeminal regions might be therapeutic targets for dental pain in the future.
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The aim of this study was to investigate the associations among 4 measures of pain induction procedures in 244 healthy women. The procedures were (1) pressure pain threshold assessed over the temporalis muscles, masseter muscles, temporomandibular joints, and the wrists; (2) C fiber-mediated heat pain threshold/tolerance assessed on the skin over the forearm, cheek, and dorsal aspect of the foot; (3) temporal summation of C fiber-mediated heat pain; and (4) ischemic pain threshold/tolerance. Strong associations among pressure pain thresholds at the 4 sites examined (rho = 0.7 to 0.8, P values < or = .001) and among heat pain threshold/tolerance values at the 3 sites examined (rho = 0.6 to 0.9, P values < or = .001) were observed. Pressure pain threshold was moderately correlated with each of the heat pain threshold/tolerance values (rho = 0.2 to 0.4, P values < or = .001). Ischemic pain threshold/tolerance was moderately associated with each of the pressure and heat pain measures (rho = 0.2 to 0.3, P values < or = .05 to .001). Derived measures of the temporal summation of heat pain did not correlate strongly with threshold or tolerance measures of pressure, ischemic, or heat pain. We concluded (1) that for a specific pain modality, the correlation between threshold and tolerance values across anatomic sites is high, and (2) that measures of pressure, ischemic, and thermal pain threshold/tolerance are significantly correlated, although the strength of these associations is moderate. These findings demonstrate that a battery of pain-assessing procedures is required to determine an individual's pain sensitivity profile or phenotype. ⋯ By investigating the relationship between pain sensitivity produced by different forms of stimuli, this study demonstrates that a battery of tests should be used to assess an individual's pain sensitivity and one should be careful in making inferences about an individual's sensitivity to pain by using only one pain modality.
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The idiopathic sensorial disturbances of burning mouth syndrome (BMS), taste disturbances (dysgeusia), and dry mouth (xerostomia) have recently been recognized as one entity and given the generic name of oral sensorial complaints (OSC). However, not all patients with OSC complain of all three disturbances, and the underlying mechanism of OSC has not yet been elucidated. This study sought to determine whether OSC was associated with the alteration of oral sensory perception, salivary profile and/or personality traits. It examined 35 patients with OSC and 19 controls. Sensory perception was assessed by Quantitative Sensory Testing (QST) applied to the tongue, including thresholds for thermal sensations and pain, and the magnitude estimation of tonic suprathreshold heat pain stimuli. The salivary profile included flow rate and compositional analysis. Personality traits were examined by both state and trait anxiety and somatization scoring. Results showed significantly elevated thermal sensory thresholds and decreased pain scores for tonic heat pain. In addition, there was an increased level of somatization in the OSC group as compared to the control group (15.1 +/- 1.5 vs. 6.6 +/- 2.1, respectively; P = .003). Concomitantly, altered salivary composition (elevated Na, K, Cl, Ca, IgA, and amylase concentrations)-but not salivary flow rate reduction-was observed in those patients despite their complaints of oral dryness. All parameters were similar among the patients with OSC regardless of their type of complaint. Linear regression analysis revealed that an elevated warm sensory threshold was associated with higher levels of salivary K and Cl concentrations in the patients with OSC. These findings may be attributed to a regional small fiber idiopathic neuropathy affecting oral sensation and salivary secretion in OSC. Alternatively, a primary idiopathic salivary dysfunction might cause sensory neural dysfunction at the receptor level by changing the oral cavity milieu. ⋯ Based on the salivary, psychophysical, and personality traits analysis currently presented, as well as on the available literature, we hypothesize that a comprehensive mechanism for OSC is based on a regional neuropathy, which is expressed by complaints of BMS, taste disturbances, and/or xerostomia. All are clearly distinguishable from similar conditions with established organic/therapeutic-related etiologies.
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The present study examined the interactive effects of state and trait anxiety on pain threshold and subjective pain intensity. State anxiety was manipulated in 15 low trait anxious (LTA) individuals and 17 high trait anxious (HTA) individuals, who rated their anxiety level and subjective pain intensity in response to noxious electrical experimental pain stimuli. A difference in pain threshold between HTA and LTA participants was not found; however, higher state anxiety led to an increase in reported pain intensity for all participants. Furthermore, HTA individuals reported significantly higher levels of anxiety and pain intensity than LTA individuals across all pain and anxiety conditions. There was no interaction between state and trait anxiety on pain perception and anxiety ratings. These findings show an additive rather than synergistic effect between state-trait anxiety and subjective pain intensity. ⋯ Use of anxiety-reducing techniques for individuals experiencing pain might reduce the perceived severity/intensity of pain. Furthermore, individuals with higher trait anxiety (a greater disposition to experience anxiety) might benefit from these techniques because higher trait anxious individuals tend to exacerbate perceived pain stimulations more than lower trait anxious individuals.