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Besides neuraxial analgesia, non-pharmacological methods are also proposed to help women coping with pain during labor. We aimed to identify the individual and organizational factors associated with the use of non-pharmacological analgesia for labor pain management. Women who attempted vaginal delivery with labor analgesia were selected among participants included in the 2016 National Perinatal Survey, a population-based cross-sectional study. Labor analgesia was studied as neuraxial analgesia alone, non-pharmacological analgesia alone, and neuraxial and non-pharmacological analgesia combined. The associations were studied by multilevel multinomial logistic regression. Among the 9,231 women included, 62.4% had neuraxial analgesia alone, 6.4% had non-pharmacological analgesia alone and 31.2% had both. Non-pharmacological analgesia alone or combined with neuraxial analgesia were both associated with high educational level (adjusted odds ratio 1.55; 95%CI, 1.08 to 2.23 and 1.39; 95%CI, 1.18 to 1.63), antenatal preference to deliver without neuraxial analgesia, and public maternity unit status. Non-pharmacological analgesia alone was more frequent among multiparous women, and in maternity units with an anesthesiologist not dedicated to delivery unit (1.57; 95%CI, 1.16 to 2.12) and with the lowest midwife workload (2.15; 95%CI, 1.43 to 3.22). Neuraxial and non-pharmacological analgesia combined was negatively associated with inadequate prenatal care (0.70; 95%CI, 0.53 to 0.94). In France, most women who had non-pharmacological analgesia during labor used it as a complementary method to neuraxial analgesia. The use of non-pharmacological analgesia combined with neuraxial analgesia mainly depends on the woman's preference, but also on socioeconomic factors, quality of prenatal care and care organization.
Musculoskeletal disorders such as knee osteoarthritis (OA) are the primary cause of chronic pain in older adults. Recommended self-management strategies for knee OA include staying physically active in the face of pain, but many patients avoid activities they are capable of doing. The overall purpose of this study was to examine the extent to which daily pain catastrophizing, a maladaptive coping strategy, could influence OA patients' physical activity and sedentary behavior. The current study utilized data from 143 older knee OA patients who completed electronic daily diaries for 22 days and wore an accelerometer to capture physical activity and sedentary behavior. At the beginning of each day, patients reported their pain catastrophizing regarding the day ahead. Results from multilevel models demonstrated that on mornings when patients catastrophized more than usual about their pain in the day ahead, they spent more time in sedentary behavior and engaged in fewer minutes of moderate to vigorous physical activity that day. Cross-day lagged analyses further showed that the effect of morning pain catastrophizing on subsequent sedentary behavior extended to the next day. More time spent in sedentary behavior, in turn, contributed to greater pain catastrophizing the next morning. These findings support the mechanistic role of daily pain catastrophizing in the avoidance of physical activity for older OA patients, and suggest that effective interventions for pain catastrophizing may also reduce sedentary behavior and enhance physical activity, with longer-term benefits for pain management, physical function, and overall health.
Children diagnosed with Christianson Syndrome (CS), a rare X-linked neurodevelopmental disorder characterized by intellectual disability, epilepsy, ataxia and mutism, also suffer from hyposensitivity to pain. This places them at risk of sustaining serious injuries that often go unattended. CS is caused by mutations in the alkali cation/proton exchanger SLC9A6/NHE6 that regulates recycling endosomal pH homeostasis and trafficking. Yet it remains unclear how defects in this transporter lead to altered somatosensory functions. In this study, we validated a Nhe6 knockout (KO) mouse as a model of CS and used it to identify the cellular mechanisms underlying the elevated pain tolerance observed in CS patients. Within the central nervous system, NHE6 immunolabelling is detected in a small percentage of cortical neurons involved in pain processing, including those within the primary somatosensory and the anterior cingulate cortices as well as the periaqueductal grey. Interestingly, it is expressed in a larger percentage of nociceptors. Behaviourally, Nhe6 KO mice have decreased nocifensive responses to acute noxious thermal, mechanical and chemical (i.e., capsaicin) stimuli. The reduced capsaicin-sensitivity in the KO mice correlates with a decreased expression of the transient receptor potential channel TRPV1 at the plasma membrane and capsaicin-induced Ca influx in primary cultures of nociceptors. These data indicate that NHE6 is a significant determinant of nociceptor function and pain behaviours, vital sensory processes that are impaired in CS.
Musculoskeletal pain is the greatest cause of disability worldwide. Due to its increasing prevalence and burden, the importance of affordable treatments has been highlighted. Text messages interventions are accessible, low-cost and effective in promoting healthy behaviour and managing chronic diseases. However, little is known about their role in musculoskeletal pain. This systematic review was conducted to appraise the literature on the effects of text messages (as an intervention or a component of an intervention) compared to any control on pain and function in people with musculoskeletal pain (PROSPERO: CRD42018117371). MEDLINE, EMBASE, CINAHL, Cochrane and PEDro databases were searched from inception to April 2020. Keywords relating to musculoskeletal pain, text messages and randomised controlled trials were combined. Methodological quality was assessed using the PEDro score. Of the 12,022 studies identified, 11 were included, with a mean PEDro score of 5.4/10 points (SD 1.3). Pooled analyses were not performed due to heterogeneity of interventions and clinical characteristics. When text messages were added to and compared with usual care, some positive effects were found only on treatment adherence. Although small and inconsistent, some positive effects were reported for pain intensity, function, care seeking behaviour, adherence and quality of life when text messages were added to multicomponent interventions. Moreover, text message and telephone counselling interventions had similar effects on function. Overall included studies were of limited methodological quality and heterogeneous. However, our results indicate potential benefits of text messages in the treatment of musculoskeletal pain which need to be confirmed in future trials.
Although pain is defined as a sensory and emotional experience, it is traditionally researched and clinically treated separately from emotion. Conceptual and mechanistic relationships between these constructs highlight the need for better understanding of their bi-directional influences and the value of bridging the pain and emotion research and clinical communities.
The main cause of trigeminal neuralgia (TN) is compression of a blood vessel at the root entry zone of the trigeminal nerve. However, a neurovascular conflict does not seem to be the only etiology and other mechanisms are implicated in the development of the disease. We hypothesized that TN patients may have distinct protein expression in the CSF. In this study, lumbar CSF from TN patients (n=17), scheduled to undergo microvascular decompression (MVD), and from controls (n=20) was analyzed and compared with mass spectrometry-based shotgun proteomics. 2552 unique proteins were identified of which 46 were significantly altered (26 increased, and 20 decreased, q-value < 0.05) in TN patients compared with controls. An over-representation analysis showed proteins involved in high-density lipoprotein (HDL), such as APOA-4, APOM and APOA-1, and the extracellular region, including proteins involved in the complement cascade to be over-represented. We conclude that TN patients have distinct protein expression in the CSF compared to controls. The pathophysiological background of the protein alterations found in this study warrants further investigation in future studies. Perspective: In this article, cerebrospinal fluid from patients with trigeminal neuralgia was analyzed using in depth shotgun proteomics, revealing 46 differentially expressed proteins compared to controls. Among these, apolipoproteins and proteins involved in the complement system were elevated and significantly over-represented, implying an inflammatory component in the pathophysiology of the disease.
In exposure for chronic pain, avoidance is often forbidden (extinction with response prevention; RPE) to prevent misattributions of safety. Although exposure is an effective treatment, relapse is common. Little is known about the underlying mechanisms of return of pain-related avoidance. We hypothesized that pain-related avoidance would recover when becoming available again after RPE and after unexpected pain episodes ("reinstatement"), especially when restricting avoidance during RPE (compared to instructing not to use it). In an operant pain-related avoidance conditioning paradigm, healthy volunteers used a robotic arm to perform various arm reaching movements differing in pain-effort trade-off. During acquisition, participants learned to avoid pain by performing more effortful movements. During RPE they only performed the formerly pain-associated movement under extinction, and were either forbidden (Restricted group) or merely instructed (Instructed group) not to perform other movements. One day later, we tested spontaneous recovery and reinstatement of pain-related fear and avoidance with availability of all movements. Results showed that pain-related fear and avoidance re-emerge after RPE, though not to pre-treatment levels. The reinstatement manipulation had no additional effect. No group differences were observed. We discuss findings in the context of learning processes in (chronic) pain disability and relapse prevention in chronic pain treatment. Perspective: Using experimental models of relapse, we investigated the return of pain-related avoidance behaviour after extinction with response prevention. Findings are potentially informative for clinicians performing exposure treatment with chronic pain patients.
Acute and chronic pain delay recovery and impair outcomes after major pediatric surgery. Understanding unique risk factors for acute and chronic pain is critical to developing effective treatments for youth at risk. We aimed to identify adolescent and family psychosocial predictors of acute and chronic postsurgical pain following major surgery in adolescents. Participants included 119 youth age 10-18 years (M=14.9;78.2% white) undergoing major musculoskeletal surgery and their parents. Participants completed pre-surgery baseline questionnaires, with youth reporting on baseline pain, anxiety, depression, insomnia and sleep quality, and parents reporting on parental catastrophizing and family functioning. At baseline, 2-weeks, and 4-months post-surgery, youth completed 7-days of daily pain diaries and reported on health-related quality of life. Sequential logistic regression models examined pre-surgery predictors of acute and chronic postsurgical pain, defined as significant pain with impairment in health-related quality of life. Acute pain was experienced by 27.2% of youth at 2-weeks, while 19.8% of youth met criteria for chronic pain at 4-months. Baseline pain predicted acute pain (OR=1.96; 95%CI=1.32-2.90), while depressive symptoms (OR=1.22; 95%CI=1.01-1.47) and sleep quality (OR=0.26; 95%CI=0.08-0.83) predicted chronic pain. Tailored interventions need to be developed and incorporated into perioperative care to address risk factors for acute and chronic pain. Perspective: Longitudinal results demonstrate adolescents' pre-surgery pain severity predicts acute postsurgical pain, while depressive symptoms and poor sleep quality predict chronic postsurgical pain. Tailored interventions should address separate risk factors for acute and chronic pain after adolescent surgery.
A challenge in understanding chronic musculoskeletal pain is that research is often siloed between neuroscience, physical therapy/rehabilitation, orthopedics and rheumatology which focus respectively on 1) neurally-mediated effects on pain processes, 2) behavior and muscle activity, 3) tissue structure and 4) inflammatory processes. Although these disciplines individually study important aspects of pain, there is a need for more cross-disciplinary research that can bridge between them. Identifying the gaps in knowledge is important to understand the whole body, especially at the interfaces between the silos-between brain function and behavior, between behavior and tissue structure, between musculoskeletal and immune systems, and between peripheral tissues and the nervous system. Research on "mind and body" practices can bridge across these silos and encourage a "whole person" approach to better understand musculoskeletal pain by bringing together the brain and the rest of the body. Perspective: Research on chronic musculoskeletal pain is limited by significant knowledge gaps. To be fully integrated, musculoskeletal pain research will need to bridge across tissues, anatomical areas, and body systems. Research on mind and body approaches encourages a "whole person" approach to better understand musculoskeletal pain.
Avoidance behavior is protective, yet in the absence of genuine bodily threat, it may become disabling. Therefore, we investigated whether avoidance generalizes to novel safe contexts based on the similarity with the acquisition context. Healthy participants performed arm movements using a robotic arm to reach a target. Three trajectories (T1-3) led to the target. During acquisition, a painful stimulus could be partly/completely prevented by performing more effortful trajectories (i.e. longer and more force needed), T2/T3, in the pain-avoidance context (e.g. black background); in the yoked context (e.g. white background), the same reinforcement schedule was applied irrespective of the chosen trajectories. Generalization of avoidance was tested in two novel contexts (e.g. shades of grey backgrounds). We assessed self-reported pain-expectancy and pain-related fear for all trajectories, and avoidance behavior (i.e. maximal deviation from T1). Results confirm that fear and expectancy ratings reflect the response-outcome contingencies and differential learning selectively generalized to the novel context resembling the original pain-avoidance context. Furthermore, a linear trend in avoidance behavior across contexts emerged, which is indicative of a generalization gradient. Participants avoided more in the context resembling the original pain-avoidance context than in the one resembling the yoked context, but this effect was not statistically significant. PERSPECTIVE: We demonstrated acquisition of pain-related avoidance behavior in a within-subjects design, showing modulation of pain-related fear and pain-expectancy by context and providing limited evidence that avoidance selectively generalizes to novel, similar contexts. These results provide insight regarding the underlying mechanisms of the spreading of protective behavior in chronic pain patients.