Background. Neck pain (NP) is strongly associated with cervico-craniofacial pain (CCFP). The primary aim of the present study was to compare the neck pain-related disability, pain catastrophizing, and cervical and mandibular ROM between patients with chronic mechanical NP and patients with CCFP, as well as asymptomatic subjects. Methods. A total of 64 participants formed three groups. All participants underwent a clinical examination evaluating the cervical range of motion and maximum mouth opening, neck disability index (NDI), and psychological factor of Pain Catastrophizing Scale (PCS). Results. There were no statistically significant differences between patients with NP and CCFP for NDI and PCS (P > 0.05). One- way ANOVA revealed significant differences for all ROM measurements. The post hoc analysis showed no statistically significant differences in cervical extension and rotation between the two patient groups (P > 0.05). The Pearson correlation analysis shows a moderate positive association between NDI and the PCS for the group of patients with NP and CCFP. Conclusion. The CCFP and NP patient groups have similar neck disability levels and limitation in cervical ROM in extension and rotation. Both groups had positively correlated the NDI with the PCS. Neck pain (NP) is common in the adult general population, with prevalence estimates of between 30 and 50%  showing Many NP patients will have disability at long-term follow-up, which may lead in physical and psychosocial contributors .Recent research has shown that neck pain-related disability alters the normal function of craniomandibular region , 10. FurMoreover, it appears that an intimate functional relationship exists between the neck and the craniofacial region as suggested by their anatomical and biomechanical interrelationships . The neuFurthermore, craniofacial pain is associated with myofascial pain and can lead to a psychophysiological disorder  involvinWe consider that patients presenting both conditions  could alter cervical function and produce higher levels of disability and lower ranges of cervical motion.Therefore, the primary aim of the present study was to compare the neck pain-related disability, pain catastrophizing, and cervical and mandibular ROM between patients with chronic mechanical NP and patients with CCFP, as well as asymptomatic subjects. The secondary objective is to determine the association between neck pain-related disability and pain catastrophizing with ranges of motion in patients with NP and CCFP.A cross-sectional study was developed. The study was conducted as single-blind  study and following international recommendations for the strengthening and the reporting of observational studies in epidemiology (STROBE) . The proA consecutive nonprobabilistic convenience sample of patients with NP, CCFP, and asymptomatic subjects for the control group were recruited between January 2014 and October 2015. The sample was recruited from our university campus and the local community through flyers, posters, and social media in Madrid (Spain) and they were between 18 and 65 years old. An 11-point NRS  was used to assess pain levels .Patients presenting with chronic NP and patients diagnosed with CCFP were screened for eligibility criteria if they presented at least a pain rating of 3 on NPRS during the last 3 months.Patients for the NP group were included with symptoms isolated to the neck region with cervical mechanical pain  following the recognition of cervical spinal pain based on the procedures described by Visscher et al. (2000)  and a NePatients were excluded for any of the following: previous surgery for treatment of TMD pain; history of rheumatoid disease; extensive anatomical destruction or deterioration of the TMJ; being diagnosed as having pain of neuropathic or odontogenic origin; having a diagnosis of psychosis; current use of antidepressants or anxiolytics; taking narcotic pain medication; or pregnancy .Finally, asymptomatic controls were recruited from volunteers who responded to a local announcement and were excluded if they exhibited a history of neck, facial, or head pain (infrequent episodic tension-type headache was permitted), or any systemic disease or diagnosis compatible with the inclusion criteria.The study protocol was the same for the NP and CCFP patients and the asymptomatic control group, who all signed a consent form before participation. All examinations were done in a quiet, draught-free, temperature- and humidity-controlled laboratory . This protocol was performed by an evaluator who had not participated in the selection and data collection procedures, to ensure blinding status of the investigation.After consenting to the study, the recruited patients were given a battery of questionnaires to complete on the day of the evaluation. These included various self-reports for demographic data and pain-related disability variables. The sociodemographic questionnaire collected information about the following variables: age, gender, and duration of pain. Measures of pain catastrophizing were assessed using the Pain Catastrophizing Scale (PCS); neck pain-related disability was collected using the Spanish version of NDI . Once paNDI was used to measure perceived disability. The NDI consisted of 10 questions measured on a 6-point scale . The NDI has been demonstrated to be a reliable (intraclass correlation coefficients ranging from 0.50 to 0.98) and valid self-assessment for disability in chronic NP patients .Pain Catastrophizing. To evaluate participants' propensity to catastrophize about pain we used the Spanish version  of the PThe ROM of the neck was measured with the cervical ROM (CROM). This device consists of a plastic frame that rests on the nose and ears and is attached to the head via a Velcro strap. Three angles gauges were attached to the frame and arranged perpendicular to each other, indicating the range of cervical movement of the subject. Flexion, extension, and lateral flexion of the neck were recorded with gravity goniometers. Cervical rotation was measured with a goniometer compass that works in conjunction with a magnetic magnet placed around the neck . ValiditPatient was seated in a chair with back to 90 degrees, with feet flat on the floor, arms along the body, and head in neutral position. Verbal commands were given to the subjects to perform the neck movements until the pain or maximal ROM. First, assess mobility in the sagittal plane, followed by the frontal plane, and finally the transverse plane. The mean of 3 trials (intraexaminer reliability) was calculated and used for the analysis.MMO was measured in millimetres with a digital calliper , 43; a rP value less than 0.05 was considered statistically significant. Descriptive statistics was generated for the sociodemographic, psychological, and pain-related disability variables and physical measures. Results are expressed as mean, standard deviation (SD), with 95% confidence intervals (95% CI). A normal distribution of the data was confirmed with the Kolmogorov-Smirnoff test.All data analyses were performed on SPSS for Windows, Version 21.0 . The statistical analyses were conducted at a 95% confidence level and a t-test for independent samples was used. Effect sizes (Cohen's d) were calculated for outcome variables. According to Cohen's method, the magnitude of the effect was classified as small (0.20 to 0.49), medium (0.50 to 0.79), or large (≥0.8)  except for cervical flexion . The post hoc analysis showed no statistically significant differences in cervical extension and rotation between the two patient groups (P > 0.05); however, differences in these variables were found with the control group showing a large effect size (d ≥ 0.8). The ROM of cervical lateral-flexion was lower in the group of CCFP in relation to the other two groups with a medium-large effect size (d = 0.52 to 0.87)  .P < 0.001; d > 0.8)  .The Pearson correlation analysis shows a moderate positive association between NDI and the PCS for the group of patients with NP and CCFP. These results are presented in r = −0.452; P < 0.03) and lateroflexion , with PCS in patients with NP; the lower the ROM in flexion, right and left lateral flexion, and right rotation, the higher the PCS levels.r = −0.507; P < 0.04) with NDI is presented in For patients with CCFP, a significant negative moderate correlation between the cervical ROM in rotation (This survey has the main objective of comparing the data of disability, catastrophism, and ROM between the three groups studied.It was observed that the NP and CCFP patients presented similar neck pain-related disability and pain catastrophizing levels and cervical ROM. Although these outcomes were not statistically significantly different, the lateroflexion ROM and MMO showed a medium effect size between the NP group and asymptomatic subjects with mean difference of the 95% CI included the minimal detectable change , 49; theMoreover, both patient groups had less cervical ROM than asymptomatic subjects. MMO was lower in the CCFP and statistically significant differences were observed with respect to the other two groups. According to the results obtained in this investigation, the null hypothesis for comparing the variables neck pain-related disability, pain catastrophizing, and cervical ROM is assumed, between the NP and CCFP group and is rejected for the comparison of the cervical ROM variable between the CCFP group and the asymptomatic subjects.We propose a hypothesis that presenting craniofacial pain and neck pain could generate greater levels of disability of neck and lower ranges of cervical motion than in patients who had neck pain only and viewing our results this was not found. Current evidence shows that the pain and disability of neck and jaw function alter the nociceptive processing at the trigeminal level  even wheWe found no correlations between cervical ROM and NDI in NP patients. This is in line with the findings of Cramer et al., who reported fair correlations in a large cohort study .Our results for the CCFP group are consistent with Olivo et al. , who repDisability in patients with CCFP was found to be similar to patients with only NP. Although it has been suggested that disability scores of between 15 and 24 represent a moderate disability , other sCervical ROMs for both groups of our study were lower than typically reported values in angular ranges for similar age groups . Also, tVarious authors have studied the association between NP and craniofacial pain and their collected findings support the existence of a functional integration of the anatomic and biomechanical aspects of the craniomandibular and craniocervical regions . Thus, tOur results support the previously proposed association between neck pain and temporomandibular disorders and emotional wellbeing and catastrophic thoughts , 27.Our outcomes are also in agreement with other studies that have found that patients with TMD have higher levels of pain catastrophizing than pain-free subjects . In addiThe positive correlation between NDI and pain catastrophizing in NP and CCFP patients identified in our survey is in line with the findings of other authors that have identified an association between catastrophizing and disability, even when controlling for depression, anxiety, and pain severity .The negative correlation between most of the cervical ranges of motion and PCS in our NP patient group is similar to literature findings that describe how pain-related catastrophizing plays an important role in the physical complaints of patients with chronic whiplash-associated disorders when referred to a physical therapist .Currently, catastrophic behaviours to pain appear to be closely related to depressive symptoms and chronic pain. From a clinical point of view, it is essential to differentiate between patients not only based on physical examination but also on psychological factors. Our data show that patients with chronic NP or chronic CCFP could be involved in a similar trigeminal neurophysiology and exhibit similar levels of catastrophic thoughts. Therefore, such patients could benefit from similar treatments targeting the neck or craniofacial region. As catastrophizing is related to some disability measures, we also wonder whether it might be useful to complement physiotherapy treatment with psychological interventions.This study has some limitations. First, participants were recruited through flyers, posters, and social media, without them having requested health support. Differences between those that seek and those that do not seek health support have been reported, thus potentially introducing a further selection bias. This could have influenced some of our findings, for example, explaining why there was no difference between groups for pain catastrophizing. Second, limitation was not having included patients with craniofacial pain without neck symptoms. Third, although previous surveys similar to this used akin sample size, the results of the present study should be treated with caution because the sample size was small. Finally, we did not use a specific test to measure the craniofacial disability. Future studies resolving these limitations are needed.The CCFP and NP patient groups have similar neck disability levels and limitation in cervical ROM in extension and rotation. Both groups had positively correlated the NDI with the PCS. Longitudinal research is needed to verify these associations.


Objectives. To compare the pain perception and anxiety levels of female patients undergoing scaling and root planing during menstrual  period with those observed during postmenstrual period. Materials and Methods. This was a single blind study, with a split-mouth design. Forty-four women with chronic periodontitis with regular menstrual cycles were subjected to complete Corah's Dental Anxiety Scale (DAS) during their first debridement visit. Patients were randomly selected to undergo their first debridement visit during either their menstrual or postmenstrual period. Scaling was performed under local anesthesia in bilateral quadrants of patients during the periods. Visual Analogue Scale (VAS) was used to score pain levels for each quadrant after performing scaling and root planing. Results. Increase in pain perception among females during their menstrual or perimenstrual period was significantly greater than their postmenstrual period (P < 0.05). It is observed that women whose first appointment was given in perimenstrual period had more pain (VAS) (P = 0.0000) when compared to those women whose first appointment was given in postmenstrual period. Conclusion. Females in their menstrual period demonstrated higher pain responses and high anxiety levels to supra- and subgingival debridement. This increase in the pain levels of women during their menstrual period was statistically significant. If the appointments are given in postmenstrual period, women feel less pain.  It is estimated that some 5% to 20% of any population suffers from severe generalized periodontitis . PeriodoWhen we consider the gender basis of periodontal diseases, there is evidence to support the higher prevalence of destructive periodontal disease in men than women. The important factor to be considered is that women still have varied periodontal conditions due to hormonal fluctuations in their various phases of life .During the treatment phases of periodontitis , scaling and root planing patients feel that the procedure is more painful , 6. TherFrom oral health point of view, there have been studies which have been conducted to demonstrate degree of pain and anxiety experienced by patients during probing and scaling and their perception of pain was directly proportional to anxiety levels .Özçaka et al.  in theirA total of forty-four (44) female subjects between the ages of 20 and 38 (mean 27 years) were recruited from the nursing, medical, and dental college and also the female patients visiting Department of Periodontics, Kamineni Institute of Dental Sciences, Narketpally, Nalgonda District. This study was approved by Ethical Committee of Kamineni Institute of Medical Sciences and Dental Sciences.menstrual phases,postmenstrual phase.The objective of this study is to compare the pain perception of female patients and their anxiety levels when undergoing periodontal debridement duringInclusion criteria:patients should have chronic periodontitis, with at least five teeth in each quadrant;at least 3 teeth in each quadrant were required to have a probing pocket depth of 4 mm or greater;none of the subjects had received periodontal debridement within the preceding 12 months;patients should have regular menstrual cycle.Exclusion criteria:patients on oral contraceptives;patients on antidepressants and analgesics;patients with systemic disease.The total of forty-four patients was selected for the study. This study was a single blind study, with a split-mouth design, where patients were aware of their menstrual status but supporting examiner was not aware of the patients' menstrual status.Based on clinical findings, patients who exhibited moderate-to-advanced chronic periodontitis were included in the study. Orthopantogram (OPG), probing pocket depth (PPD), clinical attachment loss (CAL), gingival index (GI) , periodoThe patients who are on antidepressants and analgesics were excluded from the study because antidepressants and analgesics may have an effect on pain threshold . And it The scheduling of the first treatment appointment was done randomly. Patients took their first appointment during their first 3 days of menstrual period or in perimenstrual period between 3 and 4 days before the menstrual period. Some patients took their first appointment one week after the menstruation, that is, in postmenstruation. Supragingival and subgingival scaling was performed under local anesthesia. All patients received infiltrative anesthesia containing lidocaine 2% with adrenaline 1 : 80000 .This study was performed with a split-mouth design, and another debridement took place according to the menstrual phase of the patient.The treatment was standardized by noting the time taken for debridement, the amount of local anesthesia used, the number and type of teeth to be debrided at each visit were equalized.Before the start of treatment, in their first debridement visit, patients were asked to complete Corah's Dental Anxiety Scale (DAS) that was translated in Telugu.This was a single-blinded study. The supporting investigator was not informed about the menstrual status of the subjects. However, the patients were aware of the study. Supragingival and subgingival debridement was carried out by the same investigator.After applying local anesthesia, supragingival and subgingival scaling was performed. When the effect of local anesthesia wore off after 2 hours, patients started to perceive pain; they were asked to complete Visual Analogue Scale (VAS) numerical. The scale starts from “0” to “100”; the starting point indicates “no pain” and the end point indicates “intolerable pain.” Some patients left the clinic taking VAS form and returned it in their second visit; the rest of the patients completed the procedure within the clinic.A total of 44 female patients participated in the study aging between 20 and 38 years. (mean age 27). Perimenstrual and Postmenstrual Dental Anxiety Scale (DAS) and Visual Analogue Scale (VAS) scores of females were collected and analysed by the Wilcoxon signed rank test  with respect to perimenstrual, postmenstrual, and difference of pre- and postmenstrual DAS and VAS scores was done by Mann-Whitney U test  scores was done by student's paired test see .Frequency distribution of patients' Dental Anxiety Scale and VAS pain responses to periodontal treatment was analyzed.P < 0.0200).It has been observed that the increase in anxiety among females in their perimenstrual period was significantly greater than their postmenstrual period (Wilcoxon's signed rank test) (DAS) (P < 0.05).The increase in pain perception among females in their perimenstrual period was significantly greater than their postmenstrual period (Wilcoxon's signed rank test) (VAS) (P > 0.0461) significant showing increase in pocket depth during perimenstrual period. And student's paired t-test was (2.0537) which is highly significant. It has been observed in the study that perimenstrual bleeding on probing was more (mean score 50.72) than postmenstrual bleeding on probing (mean score 49.57).Perimenstrual PPD% was (mean scores) 53.50 and postmenstrual PPD% was (mean score) 52.88 .P < 0.01). No statistically significant associations were observed between age and pain perception.Statistically significant associations were observed between age and anxiety. Women who are aged 30 and above have demonstrated more anxiety in their perimenstruation phase compared to women who are below 30  (P < 0.0041) compared to those women whose first appointment was given in postmenstrual period.Comparison of order of treatment time, perimenstrual to postmenstrual, with respect to DAS is analyzed by using Mann-Whitney U test. It is observed that women whose first appointment was given in perimenstrual period had more pain (VAS) (P < 0.0000) compared to those women whose first appointment was given in postmenstrual period.Comparison of order of treatment time, perimenstrual to postmenstrual, with respect to VAS is analyzed by using Mann-Whitney A woman's life is continuously affected by reproductive hormones, in puberty, pregnancy, and menopause. Woman's oral health needs can also change at these times, thus affecting their dental treatment plans. In the past, research on women's health has been unfairly neglected and only recently research and health agencies decided to change this . TherefoE2) the major form of estrogen is synthesized by the developing follicle and peaks approximately 2 days before ovulation.Female reproductive hormones play important role in pain perception and response. A menstrual cycle is conventionally defined as the time from the beginning of one menstrual flow (day 1) to the beginning of the next . AlthougIn the second phase which is called luteal phase, the developing corpus luteum synthesizes both estradiol and progesterone. The corpus luteum involutes, ovarian hormones level drops, and menstruation ensue. It has been postulated that ovarian hormones may increase inflammation in gingival tissues and exaggerate the response to local irritants and increase in oral symptoms during menses . Miyagi It is now generally accepted that males and females exhibit important differences in their pain experiences –20. For Finally, experimental pain induction studies reveal that females consistently exhibit lower thresholds and tolerance to a wide range of noxious stimuli , 24. A nAnxiety is believed to disrupt the interpretation of stimuli, resulting in altered perception. It is thought that anxiety disrupts the experience of pain by influencing the cognitive processing of nociceptive information . LaboratThe patients who are on antidepressants and analgesics were excluded from the study because antidepressants and analgesics may have an effect on pain threshold . It is cThe purpose of this study was to determine differences between females' pain levels during their perimenstrual versus their postmenstrual phase by performing debridement under local anesthesia.During this study it has been observed that in campus nursing, dental, and medical students were more cooperative and followed scheduled appointments regularly. The general female patients who visited our department did not keep the track of their menstrual cycle and did not fulfill the study requirement. Six female patients did not complete their second visit.Corah's Dental Anxiety Scale (DAS) was translated into Telugu for those who are comfortable with expressing their feelings in their local language. We preferred the VAS which requires minimal linguistic skills and is therefore easier for patients to use in describing their pain. VAS can be quantified and allows for comparison of patients on a scale of 0–100.P = 0.0000) and also anxiety was greater in perimenstrual period (DAS) (P < 0.0200). It is also observed that women whose first appointment was given in perimenstrual period had more anxiety (DAS) (P < 0.0041) and more pain (VAS) (P = 0.0000) compared to those women whose first appointment was given in postmenstrual period. With respect to this result, we found that patients in their perimenstrual period demonstrated higher pain responses to supra- and subgingival debridement than they did in their postmenstrual period. This increase in the pain levels of women during their menstrual period was statistically significant. There was no statistically significant correlation between the DAS and the VAS. Spearman's “P” was 0.2429. Statistically significant associations were observed between age and anxiety. Women who are aged 30 and above have demonstrated more anxiety in their perimenstruation phase compared to women who are below 30. No statistically significant associations were observed between age and pain perception.In this study the increase in pain perception among females in their perimenstrual period was significantly greater than their postmenstrual period (Wilcoxon's signed rank test) (VAS) (This study also confirms results of the other study by Ozgun Ozcaka and collegues.Gender based medicine and gender based treatment are going to become the norm of the day. By knowing the menstrual cycles of their female patients, periodontists may wish to schedule mechanical periodontal therapy; this will instill positive attitude in female patients regarding dentistry in general and periodontal therapy in particular and improves the comfort level and cooperation from female patients.This study addressed the specific problem of female patients undergoing periodontal therapy in their perimenstrual and postmenstrual period. It has been observed that women perceive more pain during perimenstrual period than in their postmenstruation period. Periodontists can make women more comfortable and cooperative by scheduling their appointment according to their cycle.


Pain is highly prevalent in patients with Parkinson’s disease (PD), but little is known about the underlying pathophysiological mechanisms. The susceptibility to pain is known to depend on ascending and descending pathways. Because parts of the descending pain inhibitory system involve dopaminergic pathways, dysregulations in dopaminergic transmission might contribute to altered pain processing in PD. Deficits in endogenous pain inhibition can be assessed using conditioned pain modulation (CPM) paradigms.Applying such a paradigm, we investigated i) whether CPM responses differ between PD patients and healthy controls, ii) whether they are influenced by dopaminergic medication and iii) whether there are effects of disease-specific factors. 25 patients with idiopathic PD and 30 healthy age- and gender-matched controls underwent an established CPM paradigm combining heat pain test stimuli at the forearm and the cold pressor task on the contralateral foot as the conditioning stimulus. PD patients were tested under dopaminergic medication and after at least 12 hours of medication withdrawal.No significant differences between CPM responses of PD patients and healthy controls or between PD patients “on” and “off” medication were found. These findings suggest (i) that CPM is insensitive to dopaminergic modulations and (ii) that PD is not related to general deficits in descending pain inhibition beyond the known age-related decline. However, at a trend level, we found differences between PD subtypes  with the strongest impairment of pain inhibition in the akinetic-rigid subtype.There were no significant differences between CPM responses of patients compared to healthy controls or between patients “on” and “off” medication. Differences between PD subtypes at a trend level point towards different pathophysiological mechanisms underlying the three PD subtypes which warrant further investigation and potentially differential therapeutic strategies in the future. Pain is highly prevalent in patients with Parkinson’s disease (PD). It affects up to 83% of patients , often pThe susceptibility to pain is supposed to depend on the balance of activity in ascending and descending pain pathways –8. The dTo date, pathophysiological hypotheses regarding pain in PD mainly focus on basal ganglia dysfunction , 16. HowTo our knowledge only two studies have investigated descending pain control in PD so far. Both reported no significant differences in CPM magnitude in PD patients compared to controls , 20. MorOther studies investigating the influence of dopaminergic medication on pain processing in PD yielded mixed results with a trend for anti-nociceptive properties of dopamine , 21–24. We used a well-established CPM paradigm , 27 to iPD patients were recruited from our movement disorders outpatient clinic (head: Prof. Carsten Buhmann) of our department of neurology of the University Medical Center Hamburg-Eppendorf and had to fulfill the following inclusion criteria: (1) diagnosis of idiopathic PD according to the UK PD Society Brain Bank criteria, (2) Hoehn & Yahr scale < stage III , (3) ageHealthy controls were recruited locally and had to fulfill the same inclusion criteria except for (1) and (2).The study was conducted in accordance with the Declaration of Helsinki and approved by the Ethics Committee in Hamburg. All participants gave written informed consent and were free to withdraw from the study at any time.In this study we used a well-established CPM paradigm , 27 whicwww.awmf.org) as tremor-dominant (n = 8), akinetic-rigid (n = 7) or mixed (n = 10) depending on the predominant motor symptom  that had to be predominant at symptom onset and over the course of disease.All participants were instructed using a standardized protocol. Participants were told that the purpose of the study was to characterize possible differences in the perception of two simultaneously applied painful stimuli comparing PD patients with healthy participants of the same age. First, participants were informed about the sequence of experimental procedures. These general instructions were followed by a clinical interview (both groups) checking again all inclusion criteria e.g. asking for any chronic pain disorders e.g. rheumatoid arthritis. In the PD group an experienced clinician made a re-evaluation of PD diagnosis and then assessed the individual Hoehn and Yahr stage , UnifiedBoth groups completed the HADS  as deprewww.neurobs.com).The application of the thermal stimuli, the presentation of the VAS and the recording of behavioral data was performed using the software “Presentation”  and the last six stimuli  were applied without any other concomitant procedures. During the application of test stimuli seven to twelve (= block II), the conditioning stimulus was applied.We used phasic heat pain stimuli as test stimuli (TS). The test stimuli were applied to the right volar forearm  of the participants using a 30x30mm Peltier-Thermode . Each stimulus had a duration of six seconds . Pain ratings on the VAS were obtained immediately after each stimulus. A total of 18 test stimuli were applied. The first (= block I), a message on the computer screen prompted the participants to immerse their left foot into a bath with ice water (~0°C). The intensity of the conditioning stimulus was rated once in the middle of the cold pressor task  using a VAS presented on a computer screen with the same endpoint labels 0 = “no sensation” and 100 = “most intense pain imaginable” and a third white line set at 25 labeled as “pain threshold”. At the end of block II another message on the computer screen instructed the participants to take their foot out of the ice water. After taking their foot out of the ice water participants positioned their foot in a towel on the floor next to the tub with ice water. Prior to the experiment subjects were asked to focus their attention on the heat stimuli applied to the arm while having their foot immersed into the ice water and it was pointed out again that they could withdraw from the experiment at any time by telling the supervising experimenter. Finally heat pain stimuli 13–18 (block III) were applied without concomitant painful stimulation to the foot.A cold pressor task was used as the conditioning stimulus (CS). After completion of the first block of six heat pain stimuli   is a selData analysis was performed using IBM SPSS 20.0. Non-parametric tests were used in case the assumptions of variance homogeneity (Levene´s test) and normal distribution (Kolmogorov-Smirnov test) were violated.As in previous studies , 42 the To test for significant CPM responses in healthy controls and patients (including the on and off condition) separate one sample t-tests on CPM responses were performed for the PD group in both the “on” and “off” condition and the control group.For between-group comparisons between PD patients and controls we used two-sample t-tests and non-parametric Mann-Whitney U tests. For comparisons within the PD group (“on” vs. “off”) paired t-tests and non-parametric Wilcoxon tests were used. Kruskal-Wallis tests were used for PD subtype analyses. Correlations were calculated using Pearson’s or non-parametric Spearman’s coefficients. P-values <0.05 were considered statistically significant. Test results were corrected for multiple comparisons using Bonferroni correction.67.2 years+/-7.6 [50–86], 16 male) and 30 healthy controls  matched in age (t(53) = -0.019, p = 0.985) and gender . Due to the exclusion of 10 PD patients, 16 patients were first tested “on” and 9 patients “off” medication. Patient characteristics are shown in 10 PD patients and 2 controls did not fulfill the inclusion criteria or complete the study and were excluded: Four patients and two controls withdrew from the study during the cold pressor task (it was too painful for them), four patients did not attend the second session, one patient did not take any dopaminergic medication and one patient had H & Y score ≥ 3. The final data analysis is therefore based on 25 PD patients . Mean PANDA and HADS scores were comparable between PD patients and controls .Mean stimulation temperatures, pain intensity ratings of TS in block 1, cold pain and expectation ratings were comparable between PD patients and controls and also between patients “on” and “off” medication. Both groups expected the pain intensity not to change considerably during the cold pressor task .CPM responses did not differ between controls and PD patients or between patients “on” and “off” medication .t(29) = 0.139, p = 0.890) and PD patients “off” medication (t(24) = 0.538, p = 0.596), whereas patients “on” medication exhibited a trend for a significant CPM response (t(24) = 1.856, p = 0.076). A frequency analyses about the number of "inhibitors" (= CPM response > 0) and "facilitators" (= CPM response < 0) revealed that in the “on” condition 15 patients could be classified as “inhibitors” and 10 as “facilitators” (40% facilitators). In the off condition, 13 patients were “inhibitors” and 12 “facilitators” (48% “facilitators”). In the group of healthy controls there were 14 inhibitors and 16 facilitators (53% “facilitators”). The proportion of inhibitors and facilitators was not different between the on and off conditions, nor between patients and healthy controls .Analyses of group-specific CPM responses using one sample t-tests revealed no significant CPM responses in controls .Kruskal-Wallis tests revealed no significant differences between the three subtypes regarding stimulation temperatures, mean pain intensity ratings in block 1 or “cold pain ratings” in both the “on” and “off” condition  = 5.596, p = 0.061). The tremor-dominant  and mixed type  showed positive CPM responses whereas akinetic-rigid patients showed negative CPM results . 10 had chronic pain lasting at least 3 months  and 8 reported remittent, but no acute pain .all p>0.5). As revealed by one sample t-tests both, patients with chronic pain and without pain, showed no significant CPM responses “on” or “off” medication at all . Comparing all patients who reported pain (chronic and remittent n = 18) with those without pain (n = 7) using Mann-Whitney U tests regarding stimulation temperatures, pain intensity ratings in block 1, ice ratings and CPM magnitudes, we could not detect any differences between both groups in any of the two conditions, either . As revealed by one sample t-tests both, patients with pain (chronic and remittent) and patients without pain showed no significant CPM responses “on” or “off” medication .Data of the remaining 7 patients without and 10 patients with chronic pain were compared using Mann-Whitney U tests. Stimulation temperatures, pain intensity ratings in block 1, ice ratings and CPM magnitudes did not differ between both groups in either of the two conditions  whether CPM responses differ between PD patients and age and gender-matched controls, (ii) whether they are influenced by dopaminergic medication in PD and (iii) whether other PD-specific factors affect CPM responses.No difference in CPM responses was observed between patients and controls.There was no significant effect of dopaminergic medication (“on” vs.”off”) on CPM responses in PD.PD subtype analysis suggests potential CPM differences, with strongest impairment of descending pain inhibition in akinetic-rigid patients.Several important findings derived from this study:CPM responses of PD patients so far  or chroThere are some limitations regarding the results of our study: The sample size analyzing differences in CPM responses between PD subtypes is rather small. Although the study was not powered to detect significant subgroup differences, we feel that this first evidence for potential differences in CPM responses between PD subtypes helps to draw attention to this interesting observation and to motivate investigations in larger samples in the future. As in a previous study with PD patients studying the endogenous pain modulation , we deciTaken together, our study speaks against the assumption that PD is associated with general deficits in endogenous pain inhibition beyond the known age-related decline. However, we observed descriptive subtype differences in pain inhibitory capacities of PD patients which may explain the absence of statistical differences between controls and patients in our and previous studies. Further studies are needed to explore the role of dopamine in pain modulation in general and the underlying mechanisms of the high prevalence of pain in Parkinson´s disease in particular.


Increasing number of patients with post-herpetic neuralgia (PHN) leads to clinical observation of the fact that it worsening the condition of patients with other chronic pain syndromes such as migraine and tension-type headache (TTH).The aim of this study was assessment of cephalgic pain severity and quality of life (QoL) in patients with primary headaches in comparison with those who additionally suffers of PHN.12 patients with PHN and comorbid migraine and TTH  and 14 patients with migraine and TTH only (4 and 10) as controls were assessed for headache pain severity by visual analog scale (VAS) and QoL by short form (SF-36) screening tools.Patients with PHN had worse results of headache pain intensity and QoL vs patients of control group. Headache pain severity in PHN group was 7-8 vs 5-6 in control group, and QoL scoring was lower in PHN group vs control.PHN as the reason of central sensitization leads to further increase of the other chronic pain syndromes, such as primary headaches, elevate the cephalgic pain and decrease the QoL.No conflict of interest.


Increasing evidence indicates that features suggestive of neuropathic pain may also be present in patients with common rheumatic conditions. The objective of this study was to examine neuropathic-like pain symptoms and associated factors in patients with rheumatoid arthritis.We used the painDETECT screening tool to identify possible or likely neuropathic pain in 159 outpatients with rheumatoid arthritis. Patients additionally completed other self-reported measures, while clinical measures were assessed to calculate the 28-joint Disease Activity Score. Univariate analyses and multivariable logistic regression were used to identify factors associated with neuropathic pain features.P < 0.001) and mental health status (P = 0.006) remained significantly associated with neuropathic pain features, even after controlling for pain severity.According to the painDETECT, 27 patients (17.0 %) were classified as having likely neuropathic pain and 34 patients (21.4 %) as having possible neuropathic pain. Besides reporting more severe pain, patients with likely or possible neuropathic pain were more likely to meet the diagnostic criteria for fibromyalgia, to use analgesics, and to have more tender joints and a worse physical and mental health status as measured by the 36-item Short-Form health survey. In multivariable analysis, physical (These findings suggest that a sizeable proportion of patients with relatively well-controlled rheumatoid arthritis report symptoms suggestive of neuropathic pain. Neuropathic-like pain symptoms are independently associated with worse self-reported physical and mental health. Rheumatoid arthritis (RA) is the most common type of autoimmune arthritis. For patients with RA, pain is the predominant impairment and most important priority for improvement . RA painThis suggests that inflammation or subsequent joint damage might not be the only factor causing pain in RA. Although pain in RA is often described as ‘gnawing’ or ‘aching’, descriptors that have typically been associated with nociceptive pain, some RA patients also use typical neuropathic pain (NP) qualities such as ‘burning’ or ‘prickling’ –6. NP isAlthough there is generally no apparent lesion of the nervous system, accumulating evidence suggests that symptoms of NP may also be present in patients with rheumatic conditions such as fibromyalgia (FM) or osteoarthritis. Prevalence estimates of NP-like features have ranged from around 30 % in osteoarthritis –11 to 50Screening tools based on verbal pain descriptors and pain qualities are frequently used to distinguish NP from other types of chronic pain . One of Data for this study were collected within the Dutch Rheumatoid Arthritis Monitoring (DREAM) registry. The DREAM registry is a prospective, multicenter initiative to monitor the course of RA patients in the Netherlands. Both patient-reported and clinical outcomes are collected and monitored using a web-based data acquisition and storage system. Patient-reported outcomes are generally completed preceding each visit to the outpatient clinic. Between June 2013 and April 2014, RA patients from the Medisch Spectrum Twente hospital participating in the DREAM registry were informed about the study and invited to participate upon logging on to their patient portal. According to the Dutch Medical Research Involving Human Subjects Act, the study did not need approval of the ethical review board as only (nonintervention) studies with a high burden for patients have to be reviewed. All DREAM patients have provided written informed consent to participate in the registry. Patients were fully informed about the nature of this additional survey study and the voluntary nature was emphasized.Patients completed a series of standardized questionnaires. Additional information was gathered on sociodemographics, disease duration, self-reported pain medication, and smoking and alcohol use.NP symptoms were assessed using the Dutch version of the painDETECT . The paiThe Fibromyalgia Survey Questionnaire (FSQ) was used to assess whether the RA patients met the modified ACR 2010 diagnostic criteria for FM . The FSQPhysical disability was assessed with the Health Assessment Questionnaire disability index (HAQ-DI) which contains 20 items measuring physical disabilities over the past week in eight categories of daily living . Items aHealth status was measured using the 36-item Short-Form (SF-36) Health Survey version 2 (SF-36v2) which assesses eight different aspects of health . Item scClinical data were collected during the patient’s visit to the outpatient clinic, including a 28-tender joint count (TJC), 28-swollen joint count (SJC), the erythrocyte sedimentation rate (ESR) and C-reactive protein (CRP). The TJC and SJC examinations were conducted by a trained rheumatology nurse. The TJC, SJC, and ESR were used to compute the CRP, C-reactive protein (DAS28). DAS28 scores range between 0 and 10, with a score <2.6 indicating clinical remission and ≤3.2 representing low disease activity .t-tests for normally distributed variables, Mann–Whitney U tests for non-normally distributed variables, and chi-square tests (with Yates’ continuity correction as appropriate) for categorical variables. Variables with a marginal significance (P ≤ 0.20) in the univariate analyses were included in a multivariable binary logistic regression model to identify unique associations with NP symptoms. To avoid multicollinearity problems, Pearson correlations were calculated between the independent variables. In case of highly related variables (r > 0.5), only one variable was considered for the initial logistic regression model. Final models were additionally controlled for current, worst, and average pain severity. Multivariable models were tested for goodness of fit with the Hosmer and Lemeshow test. The explained variance was examined using Nagelkerke’s pseudo R2. Statistical significance was defined as P ≤ 0.05 (two-tailed). All analyses were performed with SPSS 22 .Patients with possible or likely NP symptoms (painDETECT ≥13) were compared to patients without NP symptoms. Univariate differences were examined using independent In total, 174 patients completed the painDETECT before their visit to the outpatient clinic. Complete medical and clinical data were available for 159 patients. Most patients had well-controlled disease activity (Table r = 0.51 for current pain to r = 0.56 for strongest pain (P < 0.001 for both).Despite relatively low disease activity, 70 patients (44 %) reported clinically significant pain in the past 4 weeks (average pain score ≥4 on the 10-point NRS) on the painDETECT Table . AccordiP = 0.67), NP patients were almost twice as likely to report actual current use of paracetamol and NSAIDs. Additionally, significantly more patients with NP symptoms also met the criteria for FM. Besides experiencing more severe pain, patients with NP symptoms reported more disability on the HAQ-DI and worse physical and mental health on the SF-36. Finally, patients with NP had significantly higher tender joint scores and total DAS28 scores therefore tended to be somewhat higher in the NP group.Patients with possible or likely NP symptoms did not significantly differ from those with no NP symptoms on any of the measured sociodemographic characteristics Table . Prescrir = 0.49–0.53), HAQ-DI scores (r = 0.64–0.66), and PCS scores (r = 0.67–0.69), pain severity was not included in the initial multivariable model. Additionally, the HAQ-DI and PCS (r = −0.75) and the total DAS28 and TJC28 (r = 0.58) correlated strongly with each other. As the TJC28 was more strongly associated with NP in univariate analysis than the total DAS28, it was selected for inclusion in the multivariable model. Although the HAQ-DI was slightly more strongly associated with NP than the PCS, the latter was selected over the HAQ-DI as it provides a more comprehensive assessment of physical health status than physical disabilities alone. The initial model without pain severity as a covariate (Table χ2(8) = 2.215, P = 0.974). NP symptoms were independently associated with worse physical and mental health status. Meeting the FM criteria, self-reported pain medication, CRP values and number of tender joints were not associated with NP symptoms in multivariable analysis. Controlling for current pain severity in the final model (Hosmer and Lemeshow test: χ2(8) = 4.139, P = 0.844) did not substantially alter the odds ratios nor the significance of any of the associations. Additional models controlling for strongest or average pain severity instead of current pain severity yielded very similar results.Since current, average and strongest pain were strongly correlated with pain medication use r = 0.9–0.53, HThis study assessed the occurrence and associations of NP-like symptoms in a cohort of patients with relatively well-controlled RA. Despite almost 75 % of patients being in DAS28 remission, 44 % still reported clinically significant pain. According to the PainDETECT, 17 % of all patients had likely NP, while 21 % had possible NP features. These patients were shown to have more severe pain, used pain medication more often, and reported lower quality of life. Multivariable logistic analysis showed that the occurrence of possible or likely NP-like features was independently associated with worse physical and mental health, even when controlling for pain severity.Despite the relatively low disease activity in the current cohort, nearly half of the patients still reported clinically significant pain. Clinically significant pain was defined as an average pain score ≥4. This threshold was based on several previous studies that identified pain intensity levels ≥4 out of 10 as moderate to severe or unacceptable , 29. ThiThe findings of this study suggest that the pain of a substantial number of RA patients may have neuropathic features or a neuropathic component, as has also been shown in other rheumatic conditions. NP symptoms have only been sporadically tested in RA samples. The 17 % proportion of RA patients with likely NP found in this study was very similar to the 19 % prevalence reported by Meirinhos et al. . ConversWith respect to possible NP symptoms in patients with RA, it should be noted that although inflammatory pain and NP are attributed to different mechanisms, they do have some features in common which may confound the results of NP screeners. Most notably, the painDETECT item dealing with pain with slight pressure may also reflect typical inflammatory joint pain. Removing this item from the total painDETECT score lowered the proportion of patients with possible NP from 38.4 % to 29 % in the current study.The proportion of RA patients with likely NP was clearly lower than that usually reported in patients with osteoarthritis –11 and mNo previous studies have thoroughly examined multivariable associations of NP symptoms with sociodemographic, clinical, and quality of life-related factors in patients with RA. In the current study, NP symptoms were not related to any of the sociodemographic characteristics included. Moreover, while the TJC was significantly higher in the NP group, the more objective parameters of disease activity, such as CRP, ESR and the SJC, did not differ between the two groups. The TJC and the global health score are largely subjective measures and thus may not necessarily reflect clinical disease activity. Previous studies have shown that some patients fail to reach RA remission criteria due to poor patient-reported health scores only , 43. WheFinally, the finding that NP symptoms were independently associated with physical and mental health status is in accordance with studies in patients with established peripheral or central neuropathology, such as diabetic neuropathy and spinal cord injury. These studies have consistently shown that the presence and severity of NP is associated with substantial impairments in most important health-related quality of life domains , 47. StuTaken together, the findings of the current study provide preliminary support of a noninflammatory pain component in RA. This could have important implications for RA treatment strategies. The current goal in the treatment of RA is to reach early sustained remission. This is increasingly done by intensive treat-to-target strategies, aimed at DAS28 remission criteria. When remission is not reached, drug therapy is adjusted. This can range from a dose change, starting combination therapy with a second DMARD or glucocorticoids, or the start of biologicals. These latter are expensive therapies and have, as do all medications, unwanted and in some cases serious side effects. Furthermore, all these strategies specifically target inflammation. If, however, mechanisms other than inflammation, for example hypersensitivity, contribute to a high DAS28 and therefore not reaching remission, these expensive medications will not likely have the desired effect. Overtreatment could therefore be an outcome in some RA patients. In these cases, pain treatment targeting the NP-like symptoms might be more appropriate than intensifying anti-inflammatory treatment. This treatment could comprise neuromodulators and certain antidepressants. Both these drug groups appear to be effective in NP . In FM, Our study has several strengths. First, it combines the painDETECT questionnaire with clinical data, the DAS28 score and measurements of FM, quality of life, and disability. This gives insight into the origin of pain in RA patients, but also the effect it has on the daily life of patients. Second, the patients included in this study were recruited from normal daily clinical practice and therefore closely resemble the current ‘well-controlled’ RA patient. The findings, however, may not be applicable to RA populations with less well-controlled disease. Furthermore, since our population consisted of predominately white patients, the findings may not be generalizable to more ethnically diverse populations.The major limitation of the study is the absence of a gold standard for NP or central sensitization. This is a problem inherent to the field. Central sensitization especially is a relatively new concept, and objective measurements do not yet exist. The gold standard is thus usually based on a combination of quantitative sensory testing and clinical or expert opinion. Additionally, the cross-sectional nature of this study does not allow any determination of the direction of associations between NP symptoms and clinical variables. Finally, the painDETECT was developed as a screening tool for NP, not central sensitization. Although symptoms of NP and central sensitization may be similar, they are by no means the same. The occurrence of NP symptoms according to the painDETECT therefore does not measure central sensitization per se, but may be useful in assisting in the identification of central sensitization . More reThis study demonstrates that neuropathic-like pain symptoms are present in a substantial number of patients with RA and are associated with worse physical and mental health. These symptoms may represent central sensitization and underscore the need for further research and screening of pain mechanisms in RA patients.


Chronic pain patients (90%) are satisfied with Spanish centers care; 80% had their pain control expectations met. Quality of life improved remarkably: 71% felt moderately to significantly better. However, waiting times need improvement. Chronic pain is a serious problem in Spain. This multicenter, epidemiological 3-month follow-up study investigates pain management efficacy in Spanish centers using patient satisfaction criteria. 3,414 eligible adult patients  with moderate to severe chronic pain from 146 pain centers were included. Patient satisfaction was assessed based onto question 18 of Spanish healthcare barometer-CSI. Pain evolution (Brief Pain Inventory-Short Form (BPI-SF) and visual analog scale (VAS)), quality of life/EuroQol-5, and pain control expectations fulfillment were also assessed. Mean age was 61.3 years. 64.4% of participating centers employed multidisciplinary pain management approach. After 3 months, mean patient satisfaction was 7.8 (1–10) on the CIS barometer. Medical staff received the highest scores, whereas waiting for tests, appointment request to appointment date time, and waiting times at the center the lowest. Mean pain decreased from 7.4 to 4.0; BPI-SF intensity decreased from 6.5 to 3.8; pain control expectations were met in 78.7% of patients; EuroQoL-5D utility index increased from 0.37 to 0.62,  Chronic pain is a serious public health problem in Spain. It has a prevalence of 23.4% in the Spanish general population and important health and economic repercussions . The 1-yControlling pain becomes increasingly difficult as pain becomes chronic . In addiInappropriate pain management is associated not only with increased patient suffering but also with great financial costs, in terms of loss of work time, reduced levels of productivity, and ability to function in society . In SpaiHowever, studies on the efficacy of pain centers or pain units in Spain are scarce.Information regarding the effectiveness of pain management is based more on experience from routine clinical practices rather than on studies measuring the efficacy of a single drug treatment or therapeutic intervention . PatientThe high prevalence of chronic pain with its associated allocation of resources and corresponding economic impact justifies the need to assess the effectiveness of patient management in the Spanish pain centers. Measurement of patient satisfaction was the selected method to evaluate the centers in terms of effectiveness and to identify existing gaps in management that could be further analyzed and improved.A 3-month follow-up prospective, longitudinal, multicenter, descriptive, and epidemiological study was conducted among the participating Spanish pain centers. Pain observational studies in general have short follow-up times. A 3-month follow-up time was considered sufficient for valid conclusions. Patients' degree of satisfaction with such centers was assessed by means of a questionnaire, based onto the question 18 of the Spanish healthcare barometer or CIS barometer, which is related to the healthcare service. As secondary objective, we assessed the evolution of pain, according to the Brief Pain Inventory-Short Form (BPI-SF) and to a visual analog scale (VAS), and the quality of life (QoL) as well, according to EuroQol-5, in patients followed up in the pain units.The target pain, as estimated by the participating researchers, was 2.2 based on a VAS. The target pain of 2.2 is the median value calculated for each patient by the participating physicians, according to the clinical condition of the patient and the experience of the physician. In addition, the following variables were assessed: patient satisfaction with pain control by means of a VAS, patient global clinical impression of change (PGCI-C), and compliance with patients expectations regarding pain control, based on the Patients Expectations Questionnaire (PEQ) .The study protocol was carried out in accordance with the declaration of Helsinki . Spanish regulations were taken into account as well, including approvals by the Ethics Committee for Clinical Research of the University Hospital of Getafe (registration number E-08/018), and all other relevant Ethics Committees, as it was deemed necessary for the evaluation of the patients.One hundred and seventy-three investigators from 146 centers throughout the Spanish national territory participated in the study. To avoid selection bias, inclusion and exclusion criteria were established. The inclusion criteria in the study were as follows: every participating researcher recruited the first 10 to 30 adult patients over the age of 18 that visited the outpatient during the agreed study period. The pain intensity was ≥4 (according to a 1–10 VAS), and the patients were visiting the pain center for the first time. Pain referrals  from all clinical specialties, all social backgrounds, and working status were included . InformeThe following data were collected: medical specialties and analgesic techniques available at the pain unit; sociodemographic and clinical data of the patients, including pain origin, types of pain, and baseline pain, which was classified as moderate-intense (VAS < 7) and very intense (VAS ≥ 7). In addition, the following data were also collected at 3 months: intensity of pain and its impact on activities of everyday living (BPI-SF); current pain intensity (VAS) as assessed by the physician; quality of life (EuroQoL-5). At the 3-month follow-up visit, the following data were collected: patient satisfaction with pain control (VAS), fulfillment of expectations regarding pain control (PEQ), patient's impression of change in pain (PGCI-C), and patient satisfaction with the pain unit (CIS barometer).The mean pain intensity (VAS) and total pain interference reductions were divided into two variable categories (mean pain reduction <30% and ≥30% and pain interference reduction <30% and ≥30%), according to the percentage of change, following the definition of “moderately important improvement” by the Initiative on Methods, Measurement, and Pain Assessment in Clinical Trials (IMMPACT) group [The Spanish healthcare barometer or CIS barometer is an annual opinion survey conducted since 1995 by the Spanish Ministry of Health  in collaboration with the Sociological Investigation Center (CIS). Its purpose is to understand the general public perception of the public healthcare services (whether they have used them or not) . The patThe Brief Pain Inventory (BPI) , 34 is aThe EuroQoL-5D (EQ-5D) is a standardized, non-disease-specific instrument for describing and valuing health-related quality of life . The useThe patient global clinical impression of change (PGCI-C)  is a selThe Patients Expectations Questionnaire (PEQ)  gathers Descriptive statistics were performed for every variable, including central and dispersion measurements for continuous variables, and absolute and relative frequencies for categorical variables, with 95% confidence intervals (CIs), at baseline, 1 month, and 3 months. Missing data were not included in the analyses and were considered as lost. t-test in case of parametric data. Categorical variables were compared by the chi-square test or by nonparametric tests  for parametric and nonparametric data, respectively. For the main and secondary variables, the effect size, comparing 3 months versus baseline, was calculated according to the Cohen formula [Continuous variables were compared between baseline and 3 months by means of the Student's formula , using tStatistical tests were performed with a bilateral 0.05 significance level. The SPSS software version 17.0 was used for the statistical analyses.Out of 3,507 patients initially enrolled, 93 patients were excluded: for 74 of them, there was no data available and 19 patients did not comply with the inclusion criteria. Out of the 3,414 eligible patients, 3,127 (91.6%) completed the study, 6 patients died, 7 withdrew their consent, 14 were discharged, 63 were lost to follow-up, and 197 did not complete the study due to other reasons .Every Spanish region (Autonomous Community) had at least one pain center. Out of the 146 participating pain centers, 64.4% were multidisciplinary  and 37% had at least three different specialties. In multidisciplinary pain units, medical staff from various specialties  is involved in the pain management. Regarding available techniques, the most commonly used in almost every center is nerve blocking (96.6%), followed by TENS (83.6%), while spinal stimulation is provided in 50% of pain centers. Almost half of the centers (47.9%) had both spinal stimulation and intrathecal therapy techniques. One-third of the centers had every available pain controlling technique .Patients mean age was 61.3 years and 65.6% were female . They weAfter three months of care, mean patient satisfaction with the pain center, as assessed by the CIS barometer, was 7.8, with more than 90% of the patients being satisfied . The iteAt three months, baseline mean pain (VAS) decreased from 7.4 to 4.0 , and 67.In addition, 70.7% of patients at three months felt moderately to much better, according to the PGCI , and meap < 0.001 (effect size d = 1.19) and the health status (VAS) from 40.6 to 61.9, p < 0.001 (effect size d = 1.1)  . Eighty-d = 1.1) , while td = 1.1) .p < 0.005) by the baseline pain intensity (moderate-intense VAS < 7 and very intense VAS ≥ 7).Logistic regression analysis showed that patient satisfaction with the pain unit (satisfied VAS ≥ 6 and not satisfied VAS < 6) was affected  not being satisfied with their treatment . HoweverIn 64% of the centers, a multidisciplinary approach to the pain management was employed. Patients managed at multidisciplinary pain centers have shown to have better outcomes when compared to those managed by nonmultidisciplinary rehabilitation, usual care, or other strategies –48. ImprThe most recent data of the Spanish CIS Barometer are those of 2012 , showingThe 146 pain centers participating in the study were distributed across the entire Spanish territory. Every Spanish region (Autonomous Community) had at least one center, which is an improvement from 2002, when only 11 of the 17 Autonomous Communities had at least one . In addiPatients are satisfied with the management of their painful condition at three months of treatment and studies have shown that the positive effects of the multidisciplinary approach to chronic pain persist long after the cessation of the intervention , 54. It On the other hand, the waiting time for the diagnostic tests results, from the clinic appointment date and to actually seeing the doctor once at the center, was the item with which, patients were satisfied the least. Other studies have shown a negative association between waiting time for pain clinic appointment and healthcare system grade . Therefop < 0.01) [As expected, there were more female patients than male, since several chronic pain conditions are more prevalent in women –4, and,  < 0.01) .As it was discussed already BPI-SF intensity summary decreased from 6.5 to 3.8 and interference summary decreased from 44.8 to 26.4. Sixty-three percent of patients showed a pain interference reduction of at least 30%. The BPI-SF is used to evaluate the severity of a patient's pain and the impact of this pain on the patient's daily functioning. The psychometric properties of the tool have been analyzed with acceptable reliability in various populations suffering from cancer and noncancer related pain. Various studies have shown that a two-factor model has better validity for noncancer pain patients , 63, as d = 1.2 and health status d = 1.1) are quite significant, according to Cohen's results for effect size interpretation (large d ≥ 0.80) [The quality of life of the patients also improved remarkably as it was tested by the Spanish version of the EQ-5D, which is a simple, valid, and practical measure and can be used as an outcome variable for research purposes and in the allocation of resources. Its ability to discriminate between healthy population and chronic patients is considered to be good . The mea ≥ 0.80) . Seventy ≥ 0.80) .Various other studies have shown that in general Spanish patients are satisfied with their pain management. Malouf et al. conducted a study with the aim to document the satisfaction with pain management in a Spanish inpatient population. The study showed that patients were satisfied with the received treatment, even when they were in pain, and that patient dissatisfaction was related to the pain intensity and satisfaction with caregivers . On the In a survey of chronic pain in Europe across 16 countries (Spain included), interesting differences between countries were observed, possibly because of different cultural backgrounds and local therapeutic preferences. The authors concluded that chronic pain occurs in 19% of adult Europeans with serious effects on the quality of their lives. Only few patients were managed by pain specialists, nearly 50% were treated inadequately and about 60% were satisfied with the effect of treatment . When paIn conclusion, chronic pain patients are satisfied with the management provided by Spanish pain centers more than the overall population with the hospital specialist services. Ninety percent of patients were satisfied with the management of their pain. Almost 70% of patients experienced a decrease of their pain intensity and a pain interference reduction of at least 30%. They said that at three months they felt better and that their pain control expectations were met.There is some area for improvement regarding waiting times: time needed for diagnostic tests, time from medical appointment request to appointment date, and waiting time at the center until seeing the doctor. Waiting time shortening will provide better care to patients and higher rates of satisfaction. Many healthcare institutions use methods like revamping of the front-line scheduling process, incorporation of patient preferences, considering alternate ways of care delivery, and making the reduction of waiting times part of the hospital's culture.Chronic pain management can have important economic repercussions. Pain management in a multidisciplinary setting may decrease the chronic pain-associated costs, since it can reduce pension expenditures, sick leave days, and usage of healthcare resource. The care provided by the Spanish pain centers seems to be successful, and, thus, although expensive, it might save costs in the long run, which should be the objective of another study.


Poor acute pain control and inflammation are important risk factors for Persistent Postsurgical Pain (PPSP). The aim of the study is to investigate, in the context of a prospective cohort of patients undergoing hernia repair, potential risk factors for PPSP. Data about BMI, anxious-depressive disorders, neutrophil-tolymphocyte ratio (NLR), proinflammatory medical comorbidities were collected. An analysis for correlation between comorbidities and PPSP was performed in those patients experiencing chronic pain at 3 months after surgery. Tramadol resulted less effective in pain at movement in patients with a proinflammatory status. Preoperative hypertension and NLR > 4 were correlated with PPSP intensity. Regional anesthesia was significantly protective on PPSP when associated with ketorolac. Patients with pain at 1 month were significantly more prone to develop PPSP at 3 months. NSAIDs or weak opioids are equally effective on acute pain and on PPSP development after IHR, but Ketorolac has better profile in patients with inflammatory background or undergoing regional anesthesia. Drug choice should be based on their potential side effects, patient's profile , and type of anesthesia. Close monitoring is necessary to early detect pain conditions more prone to progress to a chronic syndrome. Persistent postsurgical pain (PPSP) influences patients' quality of life  –3 and isAmong risk factors for PPSP development, the severity of acute postoperative pain is often mentioned, which implies that individuals prone to suffer intense postoperative pain may be the most vulnerable to PPSP , 6. HowePostoperative pain involves an inflammatory reaction and its nonresolution might be an important determinant of both acute pain severity and pain persistence after surgery , 10. PerFurthermore, the relation between pain and blood pressure has been partially documented. Pain and cardiovascular modulatory pathways are overlapped and connected , 14, and incidence and intensity) and to verify any difference in the efficacy of perioperative analgesic treatment like ketorolac and tramadol/acetaminophen according to the patient's systemic proinflammatory status. Pain trajectories were used to evaluate the evolution of pain over the period of observation and investigate the effect of acute pain on pain resolution over three months.Since physicians are still seeking tools to target patients at risk for PPSP, it is reasonable to investigate whether the above-mentioned preoperative conditions can help in identifying patients more prone to develop PPSP and whether analgesic strategies have different efficacy according to basal inflammation's level. We thus performed a longitudinal study in the context of a prospective cohort of patients receiving a specific type of surgery. The aim of this study was to assess any predictive value of preoperative BMI, hypertension, anxious depressive disorders, and proinflammatory status on PPSP  and EUDRACT (2009-011-856-23). Two hospitals enrolled all of the patients , from March 2010 to May 2012.We performed a longitudinal analysis on patients previously enrolled for a prospective, single blind, open-label clinical trial, registered on Clinicaltrials.gov , patient's medical history including the presence of a chronic pain condition, inflammatory conditions , preoperative arterial hypertension, and anxious depressive disorders under treatment. All of these data were prospectively registered during preoperative anesthesiology consultation and were therefore available for all the patients included in the study; data were recorded on a specific form used by all anesthesiologist as part of anesthesia chart, encompassing all medical history of the patient . We registered all those conditions only once a previous diagnosis was already defined by other clinicians (not just trusting in patients' report).Since all patients scheduled for hernia repair in our institutions routinely receive preoperative blood analyses, the preoperative neutrophils-to-lymphocytes ratio (NLR) was retrospectively retrieved from clinical charts and considered as a marker of systemic inflammation.Pain evaluations were performed by blinded observer (details about blinding are available in our previous paper ). All thAt one month and three months from surgery, a phone interview was performed to ask the patients if they were complaining from pain in the area of surgery .A visit to the pain center was scheduled for PPSP patients for a detailed evaluation and for proper treatment. Pain intensities at rest and with mobilization were assessed, and a surgical evaluation was carried out to eliminate any surgical complication as the main cause of pain persistence . affected by PPSP only patients with an NRS score ≥ 3/10 at rest and/or during movement, that is, patients who reported at least moderate PPSP at one or three months after inguinal hernia repair. Then, the patients (with and without PPSP) were separated into four groups according to the postoperative analgesic treatment, that is, tramadol or ketorolac.For analysis of risk factors, we have considered as preoperative proinflammatory status was defined as either the presence or combination of BMI ≥ 30 kg/m2, NLR ≥ 4, or a proinflammatory medical condition .Thet-test and nonparametric data by Mann-Whitney rank sum test or Kruskal-Wallis one-way analysis of variance on ranks with Dunn's Method for pairwise multiple comparison; a p value <0.05 was considered to be significant . Categorical data were compared using Chi-square test and Fisher exact test using a two-tailed probability. Spearman rank order correlations were also used.Data were summarized within groups as mean and standard deviation (SD) for continuous variables and counts and % for categorical variables. According to a Kolmogorov-Smirnov normality test, parametric data between the groups were compared by unpaired Student's Two hundred patients were enrolled in the clinical study. Two patients in group K and four patients in group T were excluded from the final analysis due to protocol violations (they did not accept the prescribed therapy or stopped it before the third day after surgery). Ninety-eight patients in group K and 96 in group T were included in the final analysis. Preoperative data were available for all the patients; we were able to retrieve NLR values in 80 patients of group K (81.6%) and 79 of group T (82.3%), with a total of 159 patients (82%) whose NLR values were available for this study.Eighteen patients (9.3%) reported chronic pain at 3 months, 12 patients (12.2%) in group K and 6 patients (6.3%) in group T .n = 18) had lower pain scores at day one (24 h after surgery) than patients who did not present with PPSP. At one month after surgery, patients who had PPSP already demonstrated higher pain intensity than patients without PPSP. Accordingly, the presence of PPSP at three months was statistically correlated with the presence of pain at one month after surgery .We first evaluated evolution of pain over the time of observation. The pain trajectories for dynamic pain of patients from day 0 (PACU) until three months after surgery, with and without PPSP, are presented in Both postoperative treatments, ketorolac and tramadol, were effective in controlling acute pain. Data also seem to show that spinal anesthesia and local infiltration provide some protective effect against the development of persistent pain in patients receiving ketorolac . incidence was found for the following factors, that is, BMI, hypertension, anxiety depressive disorders, and preoperative NLR value. Preoperative NLR value was 2.3 ± 0.9 (95% CI: 2.2) in patients without PPSP at 3 months versus 1.9 ± 0.3 (95% CI: 0.2) in patients with PPSP. Interestingly, when analyzing PPSP intensity, a positive correlation was found with the preoperative NLR value  as well as the presence of preoperative hypertension .No positive correlation with PPSPOn the postoperative pain trajectories, patients with an established preoperative proinflammatory condition who were treated with tramadol had less effective pain control during mobilization and displayed significantly higher postoperative pain scores at day two and day three after surgery than patients without preoperative proinflammatory status . No signp = 0.086) nor at 3 months . Finally, considering only patients with a proinflammatory status, no difference in PPSP incidence was noted according to ketorolac or tramadol use, neither at 1 month  nor at 3 months .Regarding severe postoperative pain . We cannot explain such difference in the PPSP versus no PPSP patients at day 1, but what is more important (and innovative), in our opinion, is that the dynamic progression of pain (given by pain trajectories) predicts chronicization, and not the static measurement at a prespecified time point (such as day 1): patients in PPSP group (despite lower pain scores at day 1) display a tendency to reduced pain resolution, and pain trajectories tend to invert along time in the two groups. In other words, it is not pain at day 1 but the “nonresolution” of pain that leads to chronicization, and stratification basing on a single (static) evaluation may be misleading in anticipating PPSP development.The early postoperative period deserves also the attention as the severity of acute pain; that is, the failure of postoperative pain management seems to be the most striking risk factor for PPSP , 6, 21. It is noteworthy that the “nonresolution” leads to significant differences in NRS already at 1 month: that time point is when anesthesiologists or surgeons usually lose patients to follow-up, but also when subacute pain (anticipating longer pain persistence) may be detected. Our data seems to strongly support the concept of dynamic evaluation of pain and, of course, the creation of PPSP-dedicated, dynamic pain facilities, in order to keep the pace with each patient's pain experience and detect those at risk of chronicization, even after minor surgical procedures.Other risk factors for PPSP are currently a matter of debate. Since inflammation is one of the main determinants of peripheral/central sensitization and hyperalgesia (which are believed to be the main mechanisms involved in PPSP) , inflamm intensity. Still, we cannot rule out the specific mechanism involved in this susceptibility. NLR may be directly influenced by cytokines productions [Our study did not demonstrate any relationship between basal inflammatory status and pain, neither acute nor chronic pain, with the only exception of preoperative NLR, which is correlated with higher PPSPductions  and was ductions , as wellductions , 25. A cductions . Thus, wductions , 10. HowFurthermore, preoperative patients' stratification according to basal inflammation might be useful to predict analgesics' effectiveness and thus protect from PPSP: we observed better analgesia in patients with inflammatory background treated with ketorolac instead of tramadol, pointing out basal inflammation as a prognostic factor for proper drug choice (to identify patients more likely to be treated with NSAIDs). Inflammation is a base mechanism for transduction and transmission of pain stimuli, both at peripheral and at central site ; it is sThe association between local/spinal anesthesia and ketorolac shows to be protective against PPSP. Still, the protective effect may be enhanced by using more COX2-selective NSAIDs (such as diclofenac) because of their higher specificity towards mechanisms involved in central hyperalgesia and sensitization . HoweverExcept for NLR, the only other independent risk factor for PPSP intensity was the preoperative arterial hypertension. No other correlations were retrieved for single comorbidities usually identified as more prevalent in the chronic pain-affected population , leading to hypertension and central sensitization (and persistent pain). Interactions in blood pressure/pain pathways are believed to reflect a homeostatic feedback based on baroreceptors, which activate descending pain inhibition once stimulated by elevated blood pressure , resultiWe found that ketorolac had better analgesic profile in patients with an inflammatory background and in patients undergoing regional anesthesia. Hypertension and NLR were, for the first time, identified as risk factors for PPSP intensity. Larger studies with accurate patient selection are required to confirm these data; however, preoperative stratification of patients at risk and targeted therapies according to basal inflammation should be considered to improve postoperative pain relief and protection from PPSP. Finally, independently of risk factors, close monitoring is necessary to identify subacute pain conditions, which are more prone to progress to a chronic, invalidating situation. all patients with pain at 1 or 3 months are included , population gets wider: indeed, this larger population may provide more significance to our results, but it might also establish less clinically meaningful correlations. Finally, the PPSP group in the ketorolac group is approximately 10 years younger than all other groups , this may influence our results, and different cut-off should be established for this kind of patients: further studies are needed to clarify this issue. Third, the actual sample size for this study is limited to patients experiencing PPSP, that is, a reduced part of the larger trial population. This may limit to some extent the strength of our findings and the ability to make definitive conclusions; however, this is, to our knowledge, one of the biggest populations analyzed for correlations between preoperative comorbidity and persistent pain, with homogeneous surgical procedure and postoperative treatment. Fourth, the number of patients with PPSP considered for analysis may theoretically be higher: actually, we considered only patients with NRS ≥ 3/10 at rest and/or during movement . Oncer groups : increas


Pain is a common nonmotor symptom in Parkinson's disease (PD). The pathophysiology of pain in PD is not well understood. Pain characteristics have rarely been studied in atypical parkinsonian disorders such as Multiple System Atrophy (MSA) and Progressive Supranuclear Palsy (PSP).We aimed to evaluate pain intensity, location, and associated symptoms in atypical parkinsonian disorders compared to PD.Twenty-one patients with MSA, 16 patients with PSP, and 65 patients with PD were screened for pain using question 1.9 of the MDS-UPDRS. Pain intensity was quantified using the short form McGill Pain Questionnaire (SFMPQ). Pain locations were documented. Motor disability was measured using UPDRS-III. Affective symptoms were assessed using the Hospital Anxiety and Depression Scale (HADS).P < 0.01). Pain locations were similar with limb pain being the most common followed by neck and back pain. Pain intensity correlated with HADS scores but not motor severity.Pain was significantly more common and more severe in PD and MSA compared to PSP (Pain is more common and more intense in PD and MSA than PSP. Differences in distribution of neurodegenerative pathologies may underlie these differential pain profiles. Pain is an important and common nonmotor symptom in Parkinson's disease (PD)  and the Leeds Assessment of Neuropathic Symptoms and Signs (LANSS) scale, which can, respectively, quantify pain intensity and distinguish pain mechanisms (neuropathic or nociceptive) among patients and observers Melzack . These sConsecutive patients were recruited from movement disorders outpatient clinics at the Greater Manchester Neurosciences Centre. Patients with clinically probable diagnosis of PD, MSA, or PSP according to published criteria and with a mini-mental state examination score of 24 and above were included . Scores of 1 and above were considered positive for the presence of pain.Pain intensity was calculated using the SFMPQ Melzack . The sitAge, gender, disease duration, use of analgesia, and pain response to dopaminergic therapy were recorded. Motor disability in all patients was assessed using UPDRS-III. Affective symptoms were assessed using the hospital anxiety and depression scale (HADS)  was used to analyze data. Means were compared using Student's P < 0.01). Overall mean pain intensity was significantly greater in MSA and PD compared to PSP (P < 0.01)  compared to MSA-C  (P < 0.01). There was a trend toward higher overall mean pain intensity scores in MSA-P (21.7 ± 3.5) compared to MSA-C (9.3 ± 5.1) (P = 0.056).Sixty-five patients with PD, 21 patients with MSA , and 16 patients with PSP were enrolled in the study. Pain was reported in 58 PD patients (89%), 17 MSA patients (81%), and four PSP patients (25%)  and three MSA (18%) patients. No patient fulfilled the criteria for neuropathic pain in the PSP group.Twenty-eight patients with PD (43%) were on regular analgesia with nine patients 15%) taking neuropathic pain treatments . Eleven patients with MSA (52%) were on regular analgesia and four patients were taking neuropathic pain treatments (19%). Five patients with PSP were using regular analgesia (31%) and one patient was on amitriptyline. There was no significant statistical difference between these proportions  was similarly prevalent in MSA and PD Fig..Fifty-one percent of PD patients with pain reported improvement with dopaminergic medications compared to 57% of MSA patients and 25% of PSP patients Table .r = 0.579, P < 0.01) and MSA . There was no correlation between pain intensity and disease duration or UPDRS-III scores.Pain intensity scores correlated significantly with total HADS scores in both PD  have been considered to be a feature of MSA. We found neck and shoulder pain to be similarly prevalent in PD. The results suggest that coat-hanger pain may not necessarily constitute a “red flag” for MSA.When assessed using the LANSS scale a small proportion of patients' pain had probable neuropathic mechanisms. This is also supported by the number of patients who were taking regular neuropathic pain treatments Table . AlthougOver half of our patients with PD and MSA reported improvement of their pain with dopaminergic medications. Thus, optimizing dopaminergic treatment may be important in MSA for the management of nonmotor symptoms such as pain even when the motor symptoms are poorly responsive to treatment.The strong correlations between pain intensity and affective symptoms may reflect common pathophysiological substrates or a secondary effect of pain. This has been documented in previous reports investigating pain in PD (Negre-Pages et al. There are a number of limitations to our study, the main one being the relatively small sample size. This is largely due to the relative rarity of atypical parkinsonian disorders and the exclusion of patients with dementia, limiting the number of suitable PSP patients. Motor disability was not evenly matched between the three groups, as atypical parkinsonian syndromes are more aggressive conferring higher motor scores and PD patients were assessed in the “ON” state in an outpatient setting. Assessing PD patients in the “OFF” state would have probably been more reflective of the degree of motor impairment. This was difficult given the cross-sectional design of the study, which was conducted in an outpatient setting. However, contrary to what one would expect, pain intensity in PSP and MSA was either less or matching pain intensity in PD despite higher motor disability. Therefore, the discrepancy in motor scores is unlikely to have contributed to the difference in reported pain. Disease duration and age were also different between the groups reflecting the natural disease course and age groups at which these conditions present. Due to sample size we could not correct for these variables and we accept this as another limitation to our study.To our knowledge, this is the first study to prospectively evaluate pain in atypical parkinsonian disorders using validated pain scales. Further work with larger cohort and multiple regression analysis is needed to understand the causes of pain in parkinsonian disorders and alleviate the burden of this common and disabling symptom.