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Kregel J.,University of Groningen | van Wilgen C.P.,Transdisciplinary Pain Management Center | van Wilgen C.P.,Pain in Motion Research Group | Zwerver J.,University of Groningen
Pain Medicine (United States) | Year: 2013

Objective: Assessing pain in patellar tendinopathy (PT) is difficult to perform in a standardized way. With this study, we measured pain in athletes with PT by means of pain pressure threshold (PPT) algometry in a standardized manner. Subsequently, the goal of this study is to determine normative values for clinical use. Design: Observational study. Setting: Patients and healthy subjects were recruited from an outpatient clinic of a university medical center and at different sports clubs in northern Netherlands. Subjects: A total of 234 athletes, 114 diagnosed with PT and 120 healthy controls, were included. Outcome Measures: PPT, Victorian Institute of Sport Assessment-Patellar tendinopathy questionnaire, and visual analog scale-pain. Results: PPT scores of PT athletes with tendinopathy were significantly lower compared with healthy athletes (Mann-Whitney U-test; U=293.5; P<0.001). With a receiver operating characteristic (ROC) curve, the optimal cut-off point to distinguish between healthy athletes and PT athletes was calculated at 36.8N. The area under the ROC curve was 0.98 (95% CI: 0.96-1.0). There was a positive predictive value of 96.5% that athletes with a PPT below 36.8N. had PT. Conclusions: PPT algometry should be considered by clinicians as a pain assessment tool in patients with PT. The optimal cut-off point for the PPT to distinguish between PT athletes and healthy athletes was 36.8N. © 2013 Wiley Periodicals, Inc.


Meeus M.,University of Antwerp | Meeus M.,University College Ghent | Meeus M.,Pain in Motion Research Group | Nijs J.,Pain in Motion Research Group | And 7 more authors.
Clinical Rehabilitation | Year: 2015

Objective: To establish the effects of relaxation therapy on autonomic function, pain, fatigue and daily functioning in patients with chronic fatigue syndrome or fibromyalgia. Method: A systematic literature study was performed. Using specific keywords related to fibromyalgia or chronic fatigue syndrome and relaxation therapy, the electronic databases PubMed and Web of Science were searched. Included articles were assessed for their risk of bias and relevant information regarding relaxation was extracted. The review was conducted and reported according to the PRISMA-statement. Results: Thirteen randomized clinical trials of sufficient quality were included, resulting in a total of 650 fibromyalgia patients (11 studies) and 88 chronic fatigue syndrome patients (3 studies). None of the studies reported effects on autonomic function. Six studies reported the effect of guided imagery on pain and daily functioning in fibromyalgia. The acute effect of a single session of guided imagery was studied in two studies and seems beneficial for pain relief. For other relaxation techniques (eg. Muscle relaxation, autogenic training) no conclusive evidence was found for the effect on pain and functioning in fibromyalgia patients comparison to multimodal treatment programs. For fatigue a multimodal approach seemed better than relaxation, as shown in the sole three studies on chronic fatigue syndrome patients. Conclusion: There is moderate evidence for the acute effect of guided imagery on pain, although the content of the visualization is a matter of debate. Other relaxation formats and the effects on functionality and autonomic function require further study. © The Author(s) 2014.


van Ittersum M.W.,Hanze University of Applied Sciences, Groningen | van Ittersum M.W.,University of Groningen | van Wilgen C.P.,Pain in Motion Research Group | van Wilgen C.P.,Transdisciplinary Pain Management Center | And 6 more authors.
Pain Practice | Year: 2014

Mounting evidence supports the use of face-to-face pain neuroscience education for the treatment of chronic pain patients. This study aimed at examining whether written education about pain neuroscience improves illness perceptions, catastrophizing, and health status in patients with fibromyalgia. A double-blind, multicenter randomized controlled clinical trial with 6-month follow-up was conducted. Patients with FM (n = 114) that consented to participate were randomly allocated to receive either written pain neuroscience education or written relaxation training. Written pain neuroscience education comprised of a booklet with pain neuroscience education plus a telephone call to clarify any difficulties; the relaxation group received a booklet with relaxation education and a telephone call. The revised illness perception questionnaire, Pain Catastrophizing Scale, and fibromyalgia impact questionnaire were used as outcome measures. Both patients and assessors were blinded. Repeated-measures analyses with last observation carried forward principle were performed. Cohen's d effect sizes (ES) were calculated for all within-group changes and between-group differences. The results reveal that written pain neuroscience education does not change the impact of FM on daily life, catastrophizing, or perceived symptoms of patients with FM. Compared with written relaxation training, written pain neuroscience education improved beliefs in a chronic timeline of FM (P = 0.03; ES = 0.50), but it does not impact upon other domains of illness perceptions. Compared with written relaxation training, written pain neuroscience education slightly improved illness perceptions of patients with FM, but it did not impart clinically meaningful effects on pain, catastrophizing, or the impact of FM on daily life. Face-to-face sessions of pain neuroscience education are required to change inappropriate cognitions and perceived health in patients with FM. © 2014 World Institute of Pain.


Nijs J.,Pain in Motion Research Group | Nijs J.,Vrije Universiteit Brussel | Nijs J.,University Hospital | Apeldoorn A.,Medical Center Alkmaar | And 17 more authors.
Pain Physician | Year: 2015

Background: Low back pain (LBP) is a heterogeneous disorder including patients with dominant nociceptive (e.g., myofascial low back pain), neuropathic (e.g., lumbar radiculopathy), and central sensitization pain. In order to select an effective and preferably also efficient treatment in daily clinical practice, LBP patients should be classified clinically as either predominantly nociceptive, neuropathic, or central sensitization pain. Objective: To explain how clinicians can differentiate between nociceptive, neuropathic, and central sensitization pain in patients with LBP. Study Design: Narrative review and expert opinion Setting: Universities, university hospitals and private practices Methods: Recently, a clinical method for the classification of central sensitization pain versus neuropathic and nociceptive pain was developed. It is based on a body of evidence of original research papers and expert opinion of 18 pain experts from 7 different countries. Here we apply this classification algorithm to the LBP population. Results: The first step implies examining the presence of neuropathic low back pain. Next, the differential diagnosis between predominant nociceptive and central sensitization pain is done using a clinical algorithm. Limitations: The classification criteria are substantiated by several original research findings including a Delphi survey, a study of a large group of LBP patients, and validation studies of the Central Sensitization Inventory. Nevertheless, these criteria require validation in clinical settings. Conclusion: The pain classification system for LBP should be an addition to available classification systems and diagnostic procedures for LBP, as it is focussed on pain mechanisms solely. © 2015, American Society of Interventional Pain Physicians. All Rights Reserved.


Nijs J.,Pain in Motion Research Group | Nijs J.,Vrije Universiteit Brussel | Nijs J.,University Hospital Brussels | Malfliet A.,Pain in Motion Research Group | And 9 more authors.
Expert Opinion on Pharmacotherapy | Year: 2014

Introduction: Central sensitization (CS) is present in a variety of chronic pain disorders, including whiplash, temporomandibular disorders, low back pain, osteoarthritis, fibromyalgia, headache, lateral epicondylalgia among others. In spite of our increased understanding of the mechanisms involved in CS pain, its treatment remains a challenging issue.Areas covered: An overview of the treatment options we have for desensitising the CNS in patients with CS pain is provided. These include strategies for eliminating peripheral sources of nociception, as well as pharmacotherapy and conservative interventions that primarily address top-down (i.e., brain-orchestrated) mechanisms.Expert opinion: A combination of different strategies, each targeting a different 'desensitizing' mechanism, might prove superior over monotherapies. Such combined therapy may include both bottom-up and top-down (e.g., opioids, combined μ-opioid receptor agonist and noradrenaline reuptake inhibitor drugs) strategies. Topically applied analgesic therapies have strong potential for (temporally) decreasing peripheral nociceptive input (bottom-up approach). Targeting metabolic (e.g., ketogenic diets) and neurotrophic factors (e.g., decreasing brain-derived neurotrophic factor) are promising new avenues for diminishing hyperexcitability of the CNS in central sensitization pain patients. Addressing conservative treatments, pain neuroscience education, cognitive behavioural therapy and exercise therapy are promising treatments for CS pain. © 2014 Informa UK, Ltd.


Cagnie B.,Ghent University | Coppieters I.,Ghent University | Denecker S.,Ghent University | Six J.,Ghent University | And 4 more authors.
Seminars in Arthritis and Rheumatism | Year: 2014

Objectives: The aim of the present study was to systematically review the literature addressing pain-induced changes in the brain related to central sensitization in patients with fibromyalgia (FM) using specific functional (rs-fMRI and fMRI) and structural (voxel-based morphometry-VBM) brain MRI techniques. Methods: PubMed and Web of Science were searched for relevant literature using different key word combinations related to FM, brain MRI, and central sensitization. Full-text reports fulfilling the inclusion criteria were assessed on risk of bias and reviewed by two independent reviewers. Results: From the 61 articles that were identified, 22 met the inclusion criteria and achieved sufficient methodological quality. Overall, eight articles examined structural brain (VBM) changes in patients with FM, showing moderate evidence that central sensitization is correlated with gray matter volume decrease in specific brain regions (mainly anterior cingulate cortex and prefrontal cortex). However, global gray matter volume remains unchanged. A total of 13 articles evaluated brain activity (fMRI) in response to a nociceptive stimulus. Findings suggest a higher but similar pattern of activation of the pain matrix in FM patients compared to controls. There is also evidence of decreased functional connectivity in the descending pain-modulating system in FM patients. Overall, two articles examined intrinsic brain connectivity in FM patients with rs-fMRI. In conclusion, there is moderate evidence for a significant imbalance of the connectivity within the pain network during rest in patients with FM. Conclusions: The included studies showed a moderate evidence for region-specific changes in gray matter volume, a decreased functional connectivity in the descending pain-modulating system, and an increased activity in the pain matrix related to central sensitization. More research is needed to evaluate the cause-effect relationship. © 2014 Elsevier Inc.


Meeus M.,Vrije Universiteit Brussel | Meeus M.,University of Antwerp | Meeus M.,Ghent University | Meeus M.,Pain in Motion Research Group | And 18 more authors.
Pain Practice | Year: 2015

Temporal summation (TS) of pain, conditioned pain modulation (CPM), and exercise-induced analgesia (EIA) are often investigated in chronic pain populations as an indicator for enhanced pain facilitation and impaired endogenous pain inhibition, respectively, but interactions are not yet clear both in healthy controls and in chronic pain patients. Therefore, the present double-blind randomized placebo-controlled study evaluates pains cores, TS, and CPM in response to exercise in healthy controls, patients with chronic fatigue syndrome and comorbid fibromyalgia (CFS/FM), and patients with rheumatoid arthritis (RA), both under placebo and paracetamol condition. Methods: Fifty-three female volunteers - of which 19 patients with CFS/FM, 16 patients with RA, and 18 healthy controls - underwent a submaximal exercise test on a bicycle ergometer on 2 different occasions (paracetamol vs. placebo), with an interval of 7 days. Before and after exercise, participants rated pain intensity during TS and CPM. Results: Patients with rheumatoid arthritis showed decreased TS after exercise, both after paracetamol and placebo (P < 0.05). In patients with CFS/FM, results were less univocal. A nonsignificant decrease in TS was only observed after taking paracetamol. CPM responses to exercise are inconclusive, but seem to worsen after exercise. No adverse effects were seen. Conclusion: This study evaluates pain scores, TS, and CPM in response to submaximal exercise in 2 different chronic pain populations and healthy controls. In patients with RA, exercise had positive effects on TS, suggesting normal EIA. In patients with CFS/FM, these positive effects were only observed after paracetamol and results were inconsistent. © 2014 World Institute of Pain.


Sanchis M.N.,Satakunta University of Applied Sciences | Lluch E.,University of Valencia | Lluch E.,Pain in Motion Research Group | Lluch E.,Vrije Universiteit Brussel | And 5 more authors.
Seminars in Arthritis and Rheumatism | Year: 2015

Introduction: Hyperexcitability of the central nervous system has been suggested to play an important role in pain experienced by patients with unilateral shoulder pain. A systematic literature review following the PRISMA guidelines was performed to evaluate the existing evidence related to the presence of central sensitization in patients with unilateral shoulder pain of different etiologies including those with chronic subacromial impingement syndrome. Studies addressing neuropathic pain (e.g., post-stroke shoulder pain) were not considered. Methods: Electronic databases PubMed, EBSCO, and Web of Science were searched to identify relevant articles using predefined keywords regarding central sensitization and shoulder pain. Articles were included till September 2013. Full-text clinical reports addressing studies of central sensitization in human adults with unilateral shoulder complaints including those diagnosed with subacromial impingement syndrome were included and screened for methodological quality by two independent reviewers. Results: A total of 10 articles were retrieved for quality assessment and data extraction. All studies were cross-sectional (case-control) or longitudinal in nature. Different subjective and objective parameters, considered manifestations of central sensitization, were established in subjects with unilateral shoulder pain of different etiologies, including those receiving a diagnosis of subacromial impingement syndrome. Overall results suggest that, although peripheral mechanisms are involved, hypersensitivity of the central nervous system plays a role in a subgroup within the shoulder pain population. Conclusions: Although the majority of the literature reviewed provides emerging evidence for the presence of central sensitization in unilateral shoulder pain (including those diagnosed with subacromial impingement syndrome), our understanding of the role central sensitization plays in the shoulder pain population is still in its infancy. Future studies with high methodical quality are therefore required to investigate this further. © 2015 Elsevier Inc..


PubMed | Pain in Motion Research Group, Hasselt University and Vrije Universiteit Brussel
Type: Journal Article | Journal: Pain practice : the official journal of World Institute of Pain | Year: 2015

Chronic whiplash-associated disorders (chronic WAD) cover a large variety of clinical manifestations that can occur after a whiplash injury. Women have an increased risk of developing chronic WAD, and it is suggested that psychosocial factors are related to long-term pain and functioning following whiplash injury and persistence of chronic pain. This leads to the question whether there are sex differences in psychosocial factors in chronic WAD.This study included 117 subjects who had experienced a whiplash injury at least 3months before the start of the study (mean duration of pain: 67.2963.86months, range: 297months). They were selected as chronically symptomatic, by excluding those who had recovered from their whiplash injury. Psychosocial aspects (including depression, fear, somatization, social support, and personality traits) were assessed by validated questionnaires, and sex differences were tested using a univariate analysis of variance (ANCOVA), with age and time from whiplash injury as covariates.No differences in depression, fear, somatization, discrepancy in social support personality trait, Neck Disability Index scores, physical functioning, bodily pain, or general health were present between women and men with chronic WAD. Women with chronic WAD reported higher levels of emotional support in problem situations and social companionship.Except for emotional support in problem situations and social companionship, psychosocial factors do not differ between men and women with chronic WAD. These findings imply little to no risk for sex bias in studies investigating psychosocial issues in patients with chronic WAD.


PubMed | Pain in Motion Research Group
Type: Journal Article | Journal: Expert opinion on pharmacotherapy | Year: 2014

Central sensitization (CS) is present in a variety of chronic pain disorders, including whiplash, temporomandibular disorders, low back pain, osteoarthritis, fibromyalgia, headache, lateral epicondylalgia among others. In spite of our increased understanding of the mechanisms involved in CS pain, its treatment remains a challenging issue.An overview of the treatment options we have for desensitising the CNS in patients with CS pain is provided. These include strategies for eliminating peripheral sources of nociception, as well as pharmacotherapy and conservative interventions that primarily address top-down (i.e., brain-orchestrated) mechanisms.A combination of different strategies, each targeting a different desensitizing mechanism, might prove superior over monotherapies. Such combined therapy may include both bottom-up and top-down (e.g., opioids, combined -opioid receptor agonist and noradrenaline reuptake inhibitor drugs) strategies. Topically applied analgesic therapies have strong potential for (temporally) decreasing peripheral nociceptive input (bottom-up approach). Targeting metabolic (e.g., ketogenic diets) and neurotrophic factors (e.g., decreasing brain-derived neurotrophic factor) are promising new avenues for diminishing hyperexcitability of the CNS in central sensitization pain patients. Addressing conservative treatments, pain neuroscience education, cognitive behavioural therapy and exercise therapy are promising treatments for CS pain.

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