Introduction:Chronic low back pain (CLBP) is one of the most common chronic pain conditions in pain practice.Objectives:In the current study, we describe phenotypes of patients with CLBP based on... Show moreIntroduction:Chronic low back pain (CLBP) is one of the most common chronic pain conditions in pain practice.Objectives:In the current study, we describe phenotypes of patients with CLBP based on the status of their endogenous pain modulatory system.Methods:Conditioned pain modulation (a measure of central pain inhibition), temporal summation (TS, a measure of pain facilitation), and offset analgesia (a measure of temporal filtering of nociception) were evaluated in 53 patients with CLBP at painful and nonpainful sites. Next, in a double-blind, randomized, placebo-controlled trial, 40 patients with defective conditioned pain modulation responses received treatment with tapentadol prolonged-release or placebo for 3 months.Results:The majority of patients (87%) demonstrated loss of central pain inhibition combined with segmentally increased TS and reduced offset analgesia at the lower back region. During treatment, tapentadol reduced pain intensity more than placebo (tapentadol -19.5 2.1 mm versus placebo -7.1 +/- 1.8 mm, P = 0.025). Furthermore, tapentadol significantly decreased pain facilitation by reduction of TS responses at the lower back (tapentadol -0.94 +/- 1.9 versus placebo 0.01 +/- 1.5, P = 0.020), which correlated with pain reduction (P < 0.001).Conclusion:Patients with CLBP demonstrated different phenotypes of endogenous pain modulation. In patients with reduced conditioned pain modulation, tapentadol produced long-term pain relief that coincided with reduction of signs of pain facilitation. These data indicate that the endogenous pain system may be used as a biomarker in the pharmacological treatment of CLBP, enabling an individualized, mechanism-based treatment approach. Show less
The ageing revolution is changing the composition of our society with more people becoming very old with higher risks for developing both pain and dementia. Pain is normally signaled by verbal... Show moreThe ageing revolution is changing the composition of our society with more people becoming very old with higher risks for developing both pain and dementia. Pain is normally signaled by verbal communication, which becomes more and more deteriorated in people with dementia. Thus, these individuals unnecessarily suffer from manageable but unrecognized pain. Pain assessment in patients with dementia is a challenging endeavor, with scientific advancements quickly developing. Pain assessment tools and protocols (mainly observational scales) have been incorporated into national and international guidelines of pain assessment in aged individuals. To effectively assess pain, interdisciplinary collaboration (nurses, physicians, psychologists, computer scientists, and engineers) is essential. Pain management in this vulnerable population is also preferably done in an interdisciplinary setting. Nonpharmacological management programs have been predominantly tested in younger populations without dementia. However, many of them are relatively safe, have proven their efficacy, and therefore deserve a first place in pain management programs. Paracetamol is a relatively safe and effective first-choice analgesic. There are many safety issues regarding nonsteroidal anti-inflammatory drugs, opioids, and adjuvant analgesics in dementia patients. It is therefore recommended to monitor both pain and potential side effects regularly. More research is necessary to provide better guidance for pain management in dementia. Show less
Manaï, M.; Middendorp, H. van; Veldhuijzen, D.S.; Huizinga, T.W.J.; Evers, A.W.M. 2019
Nocebo effects, such as side effects due to negative expectations regarding the pain treatment, are a concern for health care providers and come with significant costs. This narrative review... Show moreNocebo effects, such as side effects due to negative expectations regarding the pain treatment, are a concern for health care providers and come with significant costs. This narrative review focuses on underlying mechanisms and possible factors that contribute to the susceptibility to the nocebo effect on pain and related outcomes and suggests strategies that can prevent, minimize, or extinguish nocebo effects in clinical settings. Nocebo effects are the result of psychological (eg, conditioning, verbal suggestions, and observational learning) and neurobiological (eg, cholecystokinin and dopamine regulation) mechanisms. Evidence from clinical and experimental studies lead to various recommendations and strategies to alter the nocebo effect in order to optimize pain treatments, such as providing patients with enhanced information, optimizing patient–physician communication and relationships, and offering psychoeducation on coping skills in order omanage patient expectations. The current literature from both clinical and experimental studies provides a better understanding of the nocebo effect and possible factors that modulate its strength on treatment outcomes. This allows for the development of evidencebased strategies aimed at the prevention, minimization, and treatment of the nocebo effect in pain conditions and possible other somatic disorders. Show less
