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Chronic Pain - Science topic

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What mediation model should I chose
Hypothesis: Pain Catastrophizing Mediating the effect of Psychological Flexibility on Physical Functioning in Patients with Chronic Pain over time
I have one measure before starting acceptance commitment therapy (in an RCT), 6 months after, 12 months after, and now years after.
Could I use a longitudinal meditation model to look at the relationship between pain catstrophising, psychological flexibility and physical functioning over time?
Is latent difference score mediation appropriate?
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Thank you a lot for your in-depth answer. I will look into the sources you listed, as well as your article- congratulations on your publication. Yes, I have measures for all, at four different points in time.
S
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Dear Colleagues,
I often use Dry Needling (DN) to treat Myofascial Syndrome with is very frequent in Chronic Pain.
Some of the patients are treated with acetylsalicylic acid (ASA).
Is this condition a problem to use DN?
Thank you and have a nice day
Ph. Rault - MD
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@Rault I would settle for a myofacial release technique and rest for the part that experience the chronic pain, and there after prescribe exercises with very low intensity but increase with time. ASA may help block the pain pathway in the brain but for a while.
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Are there any new researches about Therepeutic Touch and its effects? I am desperately looking for studies for my bachelor thesis. It should contain Therapeutic Touch and chronic pain/musculoskeletal pain.
Kind regards
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Therapeutic Touch seems to be a noninvasive nursing intervention for back pain management to provide more professional patient care.
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My lab is looking for a reliable, valid measure of pain for our nonprofit-funded phase 1 clinical trial. We were originally considering the Brief Pain Inventory (BPI) but the paywall (~400) is a bit higher than anticipated. Has anyone had luck with other pain measures similar to the BPI but is either free or more budget-friendly? I did see the McGill Pain Questionnaire, but this appears to require a fee as well (still waiting to hear what that fee will be).
We are looking for a scale that reports both acute and more chronic pain, ideally including history of pain medication/treatment effectiveness. Hence, some of the scales that initially come to mind (e.g., visual analogue scale, numerical rating scale) don't seem like the best fit.
Any help would be appreciated, many thanks!
David
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Hello David,
Here are a couple of sources that might prove helpful for your search:
Good luck with your work.
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We are starting an investigation, in the field of physiotherapy, on the evaluation and clinic of pain.
We are interested in knowing which diagnostic evaluation scales are being evaluated.
We are also interested in knowing how to qualitatively assess pain: do you know interview protocols for patients with chronic pain?
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As we are now in 2021, the "ad hoc" relationship made by the "Pain" Magazine and, likewise, the one made by the IASP, whose website is: https://www.iasp-pain.org/
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Working in the sport and fitness industry since 20 years before studying in a post- graduate program on chronic non-cancer pain management (CNCP), questions raised up about potential therapeutic use of Androgen Anabolic Steroid (AAS).
If anybody knows if these sports enhancing performance agents (mostly known as sports doping agents) can help for CNCP relief ?
Since more than 20 years, mostly in the field of bodybuilding, I've been witness of devastating chronic pain syndrome such as Chronic Regional Pain Syndrome (CRPS), neuropathic pain and also MSK nociceptive somatic pain injuries happening on athletes. In a large proportion of injured subjects, those who continued to use supra-physiological dose of AAS seems to have a much better functionality than everyone else. I would add that the use of those doping agents allows the injured subjects with chronic pain to self-manage their pain condition a hundred times better than every other method, medication, muti-modal pain rehabilitation, regular HRT commonly used in chronic pain clinic and hospital. The users, or I would say, the abusers understand that a decade before now.
Looking what we have in the literature on that topic is fairly poor and limited. It seems to be a totally new spectrum of research in pain science, as on the ground AAS are often used for CNCP control.
Feel free to add your comments and impressions as in a brain storming reflexion. If anyone finds out publications on that topic please let me know. That research avenu is probably brand new, maybe cause of the toxicity and teratogen potentials of AAS ?
If anyone observed the same thing as I, just let me know.
JP
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Anabolic steroids are synthetic — that is, man-made — variations of the male sex hormone testosterone. The correct term for these compounds is anabolic androgenic steroids. Anabolic refers to muscle development, and androgenic to increase in male sexual characteristics. Some common colloquilas names of these are gear, juice, roids, and stackers AND THERE IS NO CLINICAL OR ECPERIMENTALLY CONTRASTED EVIDENCE THAT THEY ARE USEFUL IN ANY KIND OF PAIN.
Its use can lead to negative mental effects such as: paranoid jealousy (extreme and unreasonable jealousy), extreme irritability and aggression (“roid rage”), delirium (false beliefs or ideas), decreased good judgment and obsession.
But in addition to the mental effects, steroid use often causes severe acne. It also causes swelling in the body, especially in the hands and feet.
Long-term effects
The misuse of anabolic steroids can cause serious health problems - which can even become permanent - such as:kidney problems or kidney failure
tumors and liver damage enlarged heart, increased blood pressure, and altered cholesterol levels, all factors that can increase the risk of stroke and heart attack even in young people increased risk of blood clots.
... AND, ALTHOUGH EVERYTHING EXPOSED SHOULD BE DISSUASIVE "PER SE", THERE IS NO CLINICAL EVIDENCE, PROPERLY CONTROLLED AND ANALYZED, THAT ITS USE IS USEFUL FOR ANY TYPE OF PAIN ... EXCEPT WHAT MAY GENERATE THE CONSIDERED EFFECT PLACEBO!
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I'm looking into a possible correlation of some types of chronic pain (those related to ptsd and mood disorders) correlating with balance issues, one-sided pain, or inner ear damage. Thanks for any help!
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Have you looked at studies including the VA population? Im not familiar with any specifically noting vestibular problems but I know the chronic pain and mental health overlap has been documented in this population. Good luck!
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Pain is such sign/symptom that any patient can describe it as high or low although he/she have no pain.
I know there are many pain provocation MSK tests but patient can also express it as false.
Is there any tool to assess pain severity, which patient exactly have, not that patient describe?
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No, not at all, according to the IAPS itself pain IS ALWAYS A SUBJECTIVE SENSATION AND PERCEPTION (in fact, as it says in its famous definition / conceptualization of pain).
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I have a survey with dichotomous variables and need tetrachoric/polycoric analysis.  I used R module but tried to run it also in SPSS and cannot do polycoric analysis (keep getting a message - could not find function "hetcor").  I checked on extensions and it is telling me that extension HETCOR is installed.  Any suggestions? I am running out of options.  Thank you so much!!!
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This is amazing video explains how to run factor analysis
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We would like to demostrate if the therapy of binaural sounds can modulate the percepetion of chronic pain. We evaluate this perception by meausuring biosignals (EEG, EDA, Heart Rate, etc.)
More information in :
Perales, F.J., Riera, L., Ramis, S. et al. Evaluation of a VR system for Pain Management using binaural acoustic stimulation. Multimed Tools Appl 78, 32869–32890 (2019). https://doi.org/10.1007/s11042-019-07953-y
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it is the biopsychosocial évaluation giving all parts of the chronicity and mechanisms involved . Many sub grounds are involved in pain sensitization ,memory vicious circle .
the interest is from clinical observation to fundamental reasoning ,the multimodal process and treatment improving sensitization .
about amygdala
Front. Neurosci., 24 November 2017 | https://doi.org/10.3389/fnins.2017.00600
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What is your opinion on opioid discontinuation in chronic opioid administration, especially for chronic non cancer pain? May this article be of help? Thank you for a kind answer.
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W. Raffaeli, et al . Safety and efficacy analysis of transdermal buprenorphine in chronic non-cancer pain : an italian register opioids correct use Eur J. Pain Vol 13 , pp S 97 , 2009
W Raffaeli, D Sarti, R Russo, S Mameli Detoxification from intrathecal Morphine for the shift from morphine to ziconotide intrathecal therapy : Italian registry European Journal of Pain, Vol 13 S1 September 2009 pp 51
Campana G, Sarti D, Spampinato S, Raffaeli W. Long-term intrathecal morphine and bupivacaine upregulate MOR gene expression in lymphocytes. Int Immunopharmacol. 2010 Sep;10(9):1149-52
Monterubbianesi MC, Capuccini J, Ferioli I, Tassinari D, Sarti D, Raffaeli W. High opioid dosage rapid detoxification of cancer patient in palliative care with the Raffaeli model : J.Opioid Manag. Sep-Oct;8(5): 292-8. 2012
Maremmani I, Gerra G, Ripamonti IC, Mugelli A, Allegri M, Viganò R, Romualdi P, Pinto C, Raffaeli W, Coluzzi F, Gatti RC, Mammucari M, Fanelli G.: The prevention of analgesic opioids abuse:expert opinion Eur Rev Med Pharmacol Sci. 2015 Nov;19(21):4203-6
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• Are you a fluent English speaker between the ages of 18 – 65?
• Have you been diagnosed with a chronic pain condition?
If you answered ‘Yes’ to these questions, you may be eligible to participate in a pain research study!
What is involved if I qualify to participate?
• Three in-lab appointments, including two blood draws.
• One 45-minute MRI brain scan
• MRI brain scan is free. In addition, you will receive up to $200, and parking or travel reimbursement for your participation
To learn more, please contact the Pain & Perceptions Lab using the information below:
Cortical Pathophysiology of Chronic Pain Study
Chronic Pain Research
(585) 275-4424
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Yes low back ache
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How might a physiotherapy student learning about chronic pain, ie current tools?
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Pain management education course
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For example specific recommendations for hours of sleep, exercises, relaxations strategies.
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IN ADDITION, BEHAVIORAL COGNITIVE TECHNICALS
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I am currently studying the sacroiliac fatty lumps (known as episacroiliac lipomas or back mice or other names) that are related to low back pain and that are little known and OVERLOOKED by the medical community. Does anybody know about them and wants to collaborate in their research? LET’S MAKE THE UNSPECIFIC LOW BACK PAIN more SPECIFIC!
More information in www.backmice.info.
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Yes I have this.... it’s been 2 years of pain and no one can help me. I go to every kind of doctor. It feels like contractions if I do anything, laundry or walk for 15 minutes I end up crying in pain with contraction. So much to say but I just had to say this is real and painful. 😔
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As far as we know the neural basis of emotional processing (amgidala, anterior insula) keep a kind of lineal stimulus dependence that is assumed to go mostly throug conscious regulation but it also go nonconsciuos . Clinically becomes relevant while working with chronic pain patients, in what degree thermosensors role (TRPV1 and 4) may participate to modulate nociception modulation increasing it or shaping an analgesic emotioanl mediated effect (anterior insula contribution)
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Hi,
Year 2010 : Got out from 3,5 months of coma, following my motorbike accident (October 2009).
These Pain-Feeling were sometime "usual", but could be "surprising me".
This neural basis of emotional processing has of course, been following me threw my Rehabilitation.
Getting out from these Rehab Periods (Body and Brain), this "Feeling" quickly became clear :
- "These Hospital, Reeducation Centers and Families having to Argue with these events, are surely as many places of interest, so as to Study and Highlight these Neural Basis of Emotional Processing!"
So, could you quickly describe us,
On which "Public-Grounds" these Neural Basis of Emotional Processing Research-Efforts, Are already/Will be thankful to take place ?
Thanks a lot,
Julien Gloanec
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Hi,
I'm looking for information on Chronic Pain but in the point of view of the partner that support the patient.
There is good insights there :
Is there good scientific studies that you know about this topic ?
Regards
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Dear Thibaut Deveraux, with Giustino Varrassi we conducted an epidemiological study in Italy on chronic pain, and we partially investigated the role of having a partner. Not association on reduction/impact of severe chronic pain was found. Of course the study was not primarly aimed on this topic. I also think that a good systematic review and/or metanalysis should be performed!
Best
Rosaria
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Who is interested in the clinical efficacy of this drug in pain patients?
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Let's start a study
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This is, indeed, a very important question that have been asked on Quora. It is sad there is only one answer. I believe that the next years will bring very important discoveries now that we have identified the action of Microglias. What is you opinion on this point ?
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Drug and non drug strategies including integrative treatment show on the clinical field main improvements .
in background the focus of all vicous circles involved from the pathysiology to metabolism ,gut brain axis and epigenetics factors .....allowed multimodal strategies reducing doses, tolerance and improving all parameters of the alterated Chronobiology
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As i know there is no pain receptors in brain. But the quest is if a person bee shoot in the head, would he suffers pain or not?
is the easiest way to be dead by gun is being shoot in the head?
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I disagree to the statement that shooting in the head can be considered as a good method for people who want to have euthanasias, because of two main reason.
First of all, the ball of the gun must pass throw skin so it surly makes pain.
secondly, methods to exam the mentioned hypothesis face a lot of limitation.
Because of the mentioned reasons, I stand behind of my opinion.
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My team and myself are currently investigating a low-cost system that will be used to compare the effectiveness of different ablation techniques.
Ablation is a minimally invasive surgical technique used to kill body tissue. A “needle” is inserted into the tissue to be destroyed, a high frequency current ran through it to heat it rapidly, and the surrounding cells in the tissue heated to the point of fatality. This is often done to kill cancerous tissue or treat chronic pain by destroying the nerve endings that are sending the pain signals to the brain.
Because the process is so dependent on heat (the cells die at about 60 degrees Celsius), temperature monitoring during our experimental trials is critical. We are planning on performing trials on animal tissue, such as chicken breast or steak. The following image provides a vague idea of the concept I am shooting for:
📷
I would like to be able to insert an array/system of thermocouples into the tissue, whether that be chicken, steak, pork chop, etc, and get an accurate temperature reading based off the location of that thermocouple in comparison to the heated needle.
The problem is that I am generally unfamiliar with thermocouples. For the task at hand, it would be required that the TC be rigid enough to be repeatedly shoved into and out of raw meat, but small enough as to have minimal heat sync to not throw off temperature readings. Furthermore, the more readings/data points we can collect for a 2 inch x 2 inch piece of tissue, the better. I am also curious as to any suggestions as to the software/interface used to take time sensitive readings from the thermocouples.
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Dear Mitchell,
you will find the best thermocouples at OMEGA. We are specialized in thermal stimulation (www.qst-lab.eu), if you need advice, do not hesitate.
Best regards,
Andre
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Dear fellow researchers,
I am a young practicing osteopath with a Bachelor of Science Honours degree in osteopathy.
Nowadays, I work as a researcher and professor assistant in the Osteopathic Research Department at Istituto Superiore di Osteopatia in Milan (Italy), publishing some scientific articles on indexed journals.
Within one year, I will obtain a Master of Science degree in osteopathic chronic pain management.
Do you know universities that could give osteopaths the opportunity to take part in a PhD studentship in pain management?
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University South Wales offers an online postgraduate diploma degree in pain
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CBD and THC are cannabis sourced moleculs. The use is authorised in some countries. Some associations tends to think that these are the future of fibromialgia treatments. What does the current and serious researchs actually says ?
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As the molecular mechanisms are the same in in vulvodynia and fibromyalgia, and the two often are co-morbid, this might be an answer:
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Trying to find an animal model which you can use to study chronic neuropathic pain in the dorsal column.
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I think sciatic nerve ligation (SNL) of mice is good.
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Hi dear RG members,
Could you please, suggest me any biopsychosocial spiritual model used for chronic pain management especially in older adults? I know Biopsychosocial model for pain wad developed by Engel, but is curious if there is any model that has incorporated spiritual component too.....
I am also interested in any theoretical model in nursing, that would address chronic pain management of older adults...Your suggestion and information is highly appreciated.
Thank you in advance
Shovana
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Specific organic pollutants (SOPs) such as phenolic compounds, PAHs, organic pesticides, and organic herbicides cause desorption problems due to their excessive water-topophilic properties and poor biodegradability. The effect of some major inorganic ions including Na+, K+, Ca2+, Mg2+, and Al3+ on the biosorption was also established.
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  • Pruritus is an unpleasant sensation that is usually secondary to a cytokine-releasing stimulus such as histamine.
  • Histamine frequently produces a local inflammatory state at the site of a noxious stimulus, and its usual manifestation is pruritus.
  • Scratching secondary to pruritus increases its intensity and a vicious circle is established.
  • Pruritus frequently decreases with the use of anti-inflammatory analgesics, suggesting the transmission of the stimulus by means of painful or spinothalamic pathways.
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Dear Alaa Raheem Kazim
Totally agree with your arguments and your response
Regards
José Luis
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I am having trouble to finding the mechanism and biomarkers for neuropathic pain induced anxiety.
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Nicholson, B., & Verma, S. (2004). Comorbidities in chronic neuropathic pain. Pain medicine, 5(suppl_1), S9-S27.
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It has been discovered that microglias plays a key role in chronic pain related diseases such as Fibromyalgia. Some therapetic strategies are studied, such as Naltrexone that binds to Toll-Like Receptor 4 or Cannabidiol that is an indirect inverse agonist or Cannabioid Receptors. What are the different receptors expressed by microglias that are linked with chronic pain ?
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MAPK and cytokines in general are considered key factors in chronic pain, whereas they are linked to expressed microglia in chronic pain conditions.
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I’m looking for information on psychiatric crisis care as it relates to chronic pain patients. The suicide rate is double for chronic pain patients. I’m trying to find out what we know and what’s being done to intervene. Any references are welcome.
Thank you in advance.
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Absolutely. I appreciate the offer.
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I am using the VAS as an outcome measure of spasticity-related chronic pain. The VAS has a minimum clinically important difference (MCID) of 18-19 mm according Hägg and colleagues 2003 (DOI: 10.1007/s00586-002-0464-0 ) in patients with chronic low back pain.
Can i use in my case report the previously mentioned MCID of the VAS to compare my results?
If no, can someone please suggest what should I do in this case.
Thank you in advance
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Calculating the "Standardized Mean Difference" (SMD) using your own data set of mean and standard deviation can give you a suggestion for the degree of clinical importance of your data; small, medium or good size of difference.
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Sickle cell disease is a lifelong, genetic condition characterised by acute and chronic painful exacerbations. There is increasing evidence about experiences of patients transitioning from paediatric to adolescent care. But little is known of the life experiences of young adults (18-35 Yrs) with sickle cell disease.
Our research consortium of 2 UK universities and 2 Nigerian Universities (De Montfort univ, Leeds univ, Lagos State univ, + univ of Ibadan) is interested in understanding the experiences of young adults with sickle cell disease.
We will like to hear from researchers, working with young adults with sickle cell.
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Adil has nailed the underlying issue. As a clinician, I feel "it's a crime to be between 16 - 18 years of age if you have a chronic health problem"
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Drug pumps seem an interesting option for managing chronic pain. I have seen similar devices used for insulin delivery. I wanted to know what are the disadvantages, complications, and limitations of this technology. I also wonder whether such devices could be broadly applied to deliver any medication or there are any fundamental restrictions.
Thank you very much!
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Thank you very much for your replies. As far as I know, insulin pumps work with a small canula that is inserted by the patient in adipic tissue in the abdomen. I was suprised by the high rates of infection associated to the use of these devices ( ). I also heard of patients complaining about recurrent skin irritation with these devices. Do you believe infection rates will be as high for intrathecal pain pump users?
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The etiology of back pain could be very complex and often difficult to isolate. While there are numerous surgical interventions to help patients with certain discogenic or stenotic issues, the challenge remains for many patients that have developed chronic pain regardless.
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I would like to add one trivial finding that I have observed through the years treating patients with back pain. I sometimes ask patients to do toe walking to quickly assess the integrity of the motor strength and the nerve that innervates the ankle movements. I have observed that by raising the heels, the lumbar spine is inevitably made to extend itself. Extension of the lumbar spine may ease some of the problem caused by protruding disc disease. The question now becomes "can raised heels alleviate lower back pain due to certain cause such as herniated disc?" I haven't read or am not aware of any research regarding this matter. If any of you would give me your thoughts and comments regarding this issue, it'll add another arsenal to help people with low back pain.
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The cadaveric transverse sections are ideal to observe the fibro-fatty tissue. The superficial and deep fascias and the so called “basic fat pads” . We are planning to do 3D reconstruction of this tissue that has been neglected and it probably explains some of the so called “non specific low back pain”. Www.Backmice.info
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Well done!
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In 2010 Italy has promulgated a law to increase the attention for Pain and Palliative Care. This seems still very poor.
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In my view, what has led the U.S. astray is its lack of understanding of addiction and drug use more generally, which in turn fuels opiophobic attitudes, as people can externalize the blame for the occurrence of addiction onto drugs, ignoring its roots that exist in the way children are parented, genetic influences, early life traumas, lack coping skills, and resultant attachment disorders that drive individuals to seek social bonding from drugs instead of from people. With this in mind, I believe that the most compelling argument for drawing attention to why people should treat pain is to outline the following: the economic costs in terms of lost productivity, the loss of great minds who are unable to attend school because of severe pain, the social isolation and poverty that often results from severe chronic pain, and finally, the most compelling point, the natural physiological consequences of pain from which the "disease in itself" line of thought comes, that entails immunosuppression, slowed wound healing (preventing recovery in acute and chronic conditions, and increasing the risk of the development and worsening of chronic pain), potentially deadly heart complications, stroke, and the entirety of the physiological consequences of allostatic load. I hope that the government in Italy proves more logical and reasonable than that of the U.S.
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Hi everyone,
I would like to know if there are databases where I can search for drugs by disease name/targeted protein...etc
For example, I would like to have a list of currently available drugs for Chronic pain or currently available drugs that target KV7 channels.
Any ideas?
Best.
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Sichaib,
Lexicomp comes to mind, although I am not certain it will be exactly what you are looking for.
Regards,
Christopher
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Hello,
Does anyone have a technique to know if a trigger point is a primary one or satellite (secondary). Are some myofascial trigger points more often secondary than primary?
Thanks a lot - Phil from Dijon (Burgundy - France)
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I’m rather surprised by some of the answers to your question.
I find Trigger Points (TrP) and Taut Bands (TB) to be EXTREMELY relevant and a primary component of chronic myofascial pain. I also find a NUMBER of issues/complaints often with a reasonably high percentage of “unknown etiology” to have a soft tissue/TrP/TB aspect. At this point, it’s only anecdotal, but I’m seeing resolution of similar ancillary issues/complaints other than the chronic pain.
I don’t believe TrP/TBs are the ultimate reason for all issues. They are an element as is resolving fascial tension and addressing fibrosis & fascial “cobwebs” that develop as the soft tissue keeps a static aspect. Resolving TrP/TB issues provides an increased function to the muscles and soft tissues. It creates an environment to help promote further healing. The increased function includes strength, range of motion, and greater assistance to move lymphatic fluid throughout the body.
I do NOT use a Satellite or Primary TrP designation. I do find that during the TrP/TB evolution, one muscle may be the FIRST to have been compromised by a TrP/TB. As the function of the FIRST is compromised, the secondary and tertiary synergistic muscles must step in to provide the function and often THEY are then compromised. Addressing TrP/TBs is sometimes like peeling an onion. But as circulation is enhanced, healing continues. As muscle memory and guarding are reminded about increased function through the course of at-home stretching and other sessions, healing continues and lasts.
Assessment is a critical component of the process. During a detailed assessment, I utilize Travell & Simons, along with other sources, to help clarify pain referral patterns, and understand the functional movement limitations and other elements in the history, along with repetitive activities that could contribute to some of the issues. I CAN feel the TrP/TBs. I can feel them through clothes, drapes and warm, moist towels. I CAN feel when/as they release or soften. I know other colleagues who can as well.
I do NOT use Ischemic Compression – I find that modality to be rather barbaric. I work primarily on the Taut Bands. I don’t differentiate between Active or Latent TrPs either. I address what is causing the overall issue. Often that may be multiple elements. I keep the pain level below a 5 on a 10 scale, and communicate frequently to ensure the work is kept within that tolerance level.
I have been finding multiple types of issues/complaints in physiological conditions that appear to be helped with the reduction of TrP/TBs and fascial tension in different areas. While presently anecdotal, the gratitude of the recipients is beneficial in of itself. I have seen improvement in breathing, enhanced lymph movement, fewer to no headaches, reduction in sinus issues, reduction in pre-menstrual discomfort, reduction in urinary urgency, improved gastrointestinal health, and a LOT less pain and continued improvements to daily life and activities.
Muscles and soft tissue are SUCH a significant component/organ within the body. It appears to have such an effect on health, function and physiology negatively or positively, but it is RARELY considered as a component of different conditions – it seems to fall into the category of “unknown etiology.” We appear to have so many specialists in many systems of the body – cardiology, neurology, urology, etc. – yet no Muscle or Lymph System Doctors. We’re still finding new parts of the Lymphatic System – June 2015 – lymphatic vessels in the dura of the spinal cord, October 2017 – lymphatic vessels in the dura of the brain. And the two systems work so closely together. The muscles move the lymph fluid. You’d think we’d find a way to link them together.
I learn from every session. I’m still learning. But Trigger Points and Taut Bands are a critical component in addressing chronic pain or even just this past weekend’s pain.
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Dear collegues,
I am not a researcher investigating animal behavior, but I need some data and impression from the field.
From evolutionary perspective, weak individuals, for example these who are injured have less chance to survive.
Is it the case, that in some species (I am not talking about humans now), others take care about injured, weakened individuals thus increasing the chances to survive? Which species exhibit such a behavior?
To simplify, are there examples in animal world that some representatives of e.g primates take care about injured, weakened individuals?
Thank you
Wacław
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My experience is mostly with domestic livestock (cattle, sheep, swine, horses, chickens, turkeys). Among these species, older animals, especially mammalian females, will protect young from predators. I have seen videos where many females in a herd of cattle will work together to keep bears from attacking a calf or weak calf. Hens will protect their chicks. I have not seen this type of behavior toward aged, older or dying mature animals. This behavior may be different than your interests, because the young are the future of the herd or flock, whereas the older animals represent the past.
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I draw your attention to a McGill 2015 rodent study, Overlapping signatures of chronic pain in the DNA methylation landscape of prefrontal cortex and peripheral T cells, https://www.nature.com/articles/srep19615 which supported the plausibility of DNA methylation involvement in pain as measured in T cells.
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very interesting and conforms to much of what I have believed for years.
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As an osteopath, I often come into contact with chronic pain, which is more and more due to a drowning inflammation.
In addition to manual techniques for optimizing blood flow, innervation and mobility, advice is given about nutrition and possible supplementation.
All too often, patients (especially in professional sports) with chronic inflammation have long taken NSAIDs. However, this is increasingly questioned by scientists.
Medication management obviously does not belong to the treatment strategy of an osteopath. Nevertheless, I often get questions from patients themselves what they should do with this.
What do you recommend? What products/supplements do you work with? What advice do you give?
References:
 
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Dear Bart De Swaef,
I am a chronic OA patient since 8 years...it affected my quality of life (could not  walk fast, run)...but never resorted to taking any medications....still successfully able to manage the problems...i followed a simple yet an effective practice...i was an overweight earlier....started doing a regular mild exercises (mostly stretches, squats and mild weight bearing exercises as well) and reduced my weight by 5-7 kg....regular exercise improved my immune status as well (earlier i had chronic bouts of common cold, allergic rhinitis, but frequency of illness are very less now)...changed my food habits....more protein, more fibers and less carbohydrates....my fat intake is as usual as earlier...no more pain... now I walk fast, run... we should not arrest the normal protective role of inflammation by taking medicines....inflammation is very essential for our own survival...I am not a medical practitioner to recommend a treatment strategy, but got a lot of benefits from simply changing my lifestyle and diet...
Happy weekend!
Regards
Selvam
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I would like to know about correlation between that syndrome ad psychosomatic disorder.
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i am currently treating a GBS patient in the hospital. i am a neurologist with fellowship training in multiple sclerosis/neuroimmunology. psychosomatic disorder can present as GBS initially, but it can easily be differentiated from GBS, based on the history, exam, and ancillary testing. thanks, mustafa.
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The effects of Daith ear piercings on migraines was first noticed by chance.
After Dr Thomas Cohn a respected pain physician in the USA noted on his blog in March 2015 that people were reporting improvements in their migraines, increasing numbers of migraine sufferers are having Daith Piercings.
Is anybody studying this effect?
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 I read your discussion with great interest as it touches the underlying mechanisms of the potential effect that Daith piercing may have on migraines. My background is from biomaterials and I confess immediately that I'm a complete novice in migraine and it's treatment. However, I realised that since the interest in using the piercing as a potential treatment or placebo treatment is high among the patients and apparently some doctors now, there is an opportunity to offer my knowhow for use. Daith piercings have a relatively high complication rate due to the difficult area, type of tissue, piercing models used and lack of standardisation of the actual procedure. No one seems to even know in which exact spot should the piercing be placed to be effective.
Our technology has been developed to alleviate the problems soft tissues have around titanium implants. Basically our material is able to achieve a strong bonding between the cell's and tissues and the implant surface. It is already in use in dental implants and there it's function is to speed up the healing and closure of the gingival tissue wound around the implant, thus reducing the risk of bacteria being able to enter the wound. Other effects observed are that no fibrous encapsulation forms around the implant, inflammatory response is reduced and general healing is improved.
I'm interested in starting a project on the daith piercing, because I read from Dr. Blatchley's internet survey results that exactly these type of complications are common also around the piercings. The goals of the project should be such that the potential treatment would be as safe and effective as the current knowhow already allows. Now, I understand that such project would be foolish to run without the expertise of people like yourselves, because without the understanding of the underlying mechanisms, it would have a high potential going wrong. I wish to therefore ask you all what you think of the potential of Daith piercing as a treatment option. In my mind from an implantology point of view it's a fairly straight forward project. But what are your thoughts on the neurological evidence? what are the main objectives and biggest failure pits?
best regards
Ilkka
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I do not mean steroids, all we know steroids, I mean some really new drugs. 
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You may find few in the following article: Generally the natural products derived from Food  are safe and long lasting.
 I have worked on  Apigenin flavonoid which is a good alternate found in dried parsley leaves.
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Is it necessary to take a lower limit as inclusion criteria for the ODQ? The design from our low back pain study is planned as randomized, sham treatment controlled trial. I am concerned about  getting a to small difference for the stats, if we don´t choose a lower limit.... Especially the between group difference...
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We published a paper in which we show an absolute ODI-value corresponding to patient acceptabel symptomen state (PASS) for the official ODI v.2.1a. An ODI <=22 equals PASS and seems corresponding to 'normal', healthy populations as well. I suggest to use ODI <=22 as a lower limit. Furthermore, it is known that a minimal clinical important difference is at least 10 points or 30% of the baseline value (Ostelo et al. 2008) and literature shows that an ODI >= 41 corresponds to longstanding chronicLBP. Hopefully, this information is of use.
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Dear Sentaro, 
I am interested in your knee injury prevention, are you looking at exercises for pre-habilitation or just understanding the mechanism of injury? I have a student here working on something similar, he might like to collaborate with you.
Kind regards
Bob
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Hi,
There are much data supporting the use of the FIFA 11+ warm up program for the prevention of knee injuries in football (soccer). The overall reduction in injuries by 30--55% in males, females and children players is notable. Please see reference below:
Does the FIFA 11+ Injury Prevention Program Reduce the Incidence of ACL Injury in Male Soccer Players?
Silvers-Granelli HJ, Bizzini M, Arundale A, Mandelbaum BR, Snyder-Mackler L.
Clin Orthop Relat Res. 2017 Apr 7.
Yu could also do a FIFA 11 + search on Pubmed
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I am looking for literature and research for proving graded activity as an appropriate item for treatment of people with msk pain.
Would be great if someone could help me on this...
- Thomas
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Hi Thomas,
a few more:
"Effectiveness-of-Behavioral-Graded-Activity-in-patients-with-OA"- 
CINDY VEENHOF,1 ALBE`RE J. A. KO¨ KE,2 JOOST DEKKER,3 ROB A. OOSTENDORP,4
JOHANNES W. J. BIJLSMA,5 MAURITS W. VAN TULDER,3 AND CORNELIA H. M. VAN DEN ENDE1 - 2006
"Graded Activity for Older Adults with Chronic Low Back Pain: Program Development and Mixed Methods Feasibility Cohort Study"
Katrin Kuss, PT, MSc, Corinna Leonhardt, PhD, Sabine Quint, PhD, Dagmar Seeger, PT, Michael Pfingsten, PhD, Udo Wolf PT, PhD, Heinz-Dieter Basler, MD, PhD, and Annette Becker, MD, PhD, MPH*
"Effectiveness of a graded exercise therapy program for patients with chronic shoulder complaints" 
Jacques JXR Geraets, Mariëlle EJB Goossens, Imelda JM de Groot, Camiel PC de Bruijn, Rob A de Bie, Geert-Jan Dinant, Geert van der Heijden and Wim JA van den Heuvel
Greetz
Jonas
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Hello,
  I am a 57 year old female who is morbidly obese and have suffered three strokes on the right side. I suffer from chronic pain and numbness. Not only on my right side but my lower back as well. Are there any medications for chronic pain that work that are not narcotics? I would appreciate any information you could provide.
Thank you,
Kathi J Peacock
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Every day-  did i say every day !  I meant 2x a day... LOL. It's the most common thing I see .....
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Low Level Laser Therapy (LLLT) seems to be effective to treat musculoskeletal pain. Do you have any scientific informations: indications, mechanisms, long term safety. Thanks!
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Dear colleague,
Thank you very much for your answer. Have you somme informations about compared efficiency between Low and High Level Laser Therapy?
Best Regards - Phil. Rault - MD
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Treatment of osteoarthritis hip is mainly surgical.Attempts to look at treatment options and traditional medication has not been well cited or published.
Do outline treatment options seeked by your patients in dealing with hip osteoarthritic pain and its success rate
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Do you mean "osteoartritis" (inflamation of the joint) or "osteoarthrosis" (degeneration of the joint)? There is a big difference, as far as conseravtive or surgical treatment is also concerned. 
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 stingray in aquarium with white patches on skin i need the diagnosis and treatment
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Swimming pool granuloma,The Swimming pool granuloma is a chronic skin
infection caused by Mycobacterium marinum (atypical
mycobacteria). The bacteria are found in fresh, aquarium and
sea waters and in some fish species. They cause an infection
in fish and humans. It permeates broken skin, and 3 – 4
weeks after the injury the infection develops, usually on the
injured spots /upper and lower limbs/.
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Is it inflammatory pain or normal pain
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the inflammation of the hemorrhoidal plexus can be supported by an altered intestinal microbiota with a loss of lactobacilli and bifidobacteria that lead to butyric acid production. .the absence of butyrate leads to an alteration of the tissue control system (PPAR alpha and Gamma able to block NfKB transcription) resulting in an inflammatory status that cause sensitization of afferent fibers due to prostaglandins. acidic pH also causes afferent fibers sensitization but makes available opioid receptors normally inactive, capable of responding to opiate drugs.
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I am doing a qualitative report on what it is like to have Fibromyalgia. I plan on doing this research at the pain clinic at Rochester, MN. The sampling strategy will be a deliberate sampling strategy. I will be choosing participants from chronic pain patients circa twenty to thirty applicants. The criteria will be Fibromyalgia for at least one year.
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Fibromyalgia is a complex and complicated condition. 
I have patients who have had it for years.
the problems are
Psychological
Pain
Restricted mobility
Tiredness
Lack of support.
Lack of definitive treatment.
Lack of or inability to provide necessary support by NHS.
I am Locum Chronic Pain Consultant and Anaesthesiologist 
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Looking for research on short and longterm effects of trigeminal neuralgia on patients. All aspects of condition, treatment, physical course and outcome, emotional and psychological course and outcomes are of interest.
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Thank you - I agree with your statement about RG. Knowing, though, what is being researched leads me to information I can take to my doctor for discussion regarding my person case.
At the same time, I am also researching chronic pain conditions and their relation to what's considered a mind/body split, and how a doctor's relationship with their patient might contribute to, or help to heal, a mind/body split. Are you familiar with any research and articles related to these subjects? 
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Can someone help me with back pain questionnaire?
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you can use oswestry disability index and nordic musculoskeletel questionnaire 
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I have a patient with high vagal tone and anxiety who does not respond to CBT(Cognitive Behavioral Treatment) so well. What is the best medical intervention?
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@Richard; Thank you for your advice.
My patient may be not used to aerobic exercise, so I should advice " Why not try speedy walking or running, checking your symptom worsen or not?" after 24 hour ECG checked.
He  works for mega industry as SE(System Engineer) since last April. Feels vocal tension most in the day saying "Good morning!"  arriving at his company. Can present his degree of progress to his colleague and boss without symptom. He had had symptom since he entered collage, among  classmates with grade A's , he enjoys one of amateur band member, without bad feeling at his vocal cord. After 5, he enjoys  to drink with colleagues at same age. He begins to feel the symptom when they rise in chat.
So as you say, I should rule out he has organic disorder rather than mental, although being introduced to our clinic by psychiatrist.
Best Regards;
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Many patient complain of gluteal pain post L5/S1 sequestectomy or discectomy and continue for few months ,is there eexplanation for that. 
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There is good number of patient complain of gluteal pain post L5 S1 sequestectomy or discectomy , is there any explanation for that ?
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Can any body tell me the best and simple "Pain Assessment scale" which can be used in all pain predomiant diseases?
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The most simple pain assessment scale is the Visual Analogue Scale (VAS). The reliability and vality of this scale has been published and it has been used in a lot of studies and populations. 
These two studies might help you
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According to my experience, acupuncture works excellent for PTSD patients. Please follow the link to read. If you want, you can use my treatment method to do a clinical trial. If you have any question about the article such as do not know the Chinese medicine, you can ask. 
If you need my help for the clinical trial, you can apply for a grant and ask me to help. However, I want to point out that double-blind does not fit for acupuncture clinical trial. However, if can change the acupuncture treatments to be the magnet therapy, it can work for the double blind test. The difference is that the acupuncture can influence longer distance than the magnet therapy according to my experience.
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Acupuncture can never be a part of allopathic medicine. It is an alternative treatment form.
Acupuncture is extremely practioner dependent. The acupuncture doctor has to be thoroughly trained and has to be in practice for years. Countries like China do produce the best of acupuncture medicine.
The experience in the USA  has been no better than placebo. Majority of the acupuncturists are not well trained. Some take a brief course and start an acupuncture clinic. I believe acupuncture can help people with headaches, neck and back pain.
To state ' acupuncture can treat almost all diseases ', sounds like fiction . I would like to see the research. I understand about activating QI. But your statement  provided implies we do not need conventional allopathic therapy any more. No more antibiotics, chemotherapy, radiation therapy , nerve blocks, etc.. 
I am glad you believe in your treatment . You have the passion.. Now, just make the statement true.
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In an experimental study with healthy volunteers, we are going to test the effect of breathing pattern manipulation on esophageal pain. Esophageal pain will be induced by electrical stimulation.
First, and for each subject, with threshold determination we will find the stimulus intensity (electrical current in mA) to be used during the intervention. The current method is to find the stimulus that can induce a pain rated by the subject as 6 in an 11-point NRS with 2 anchors; 0 = no pain, 10 = most intense pain imaginable. Then, we use this stimulus during the intervention and see how pain perception is influenced by the intervention. 15 stimuli will be applied during each intervention and subjects will rate the pain immediately after each stimulus using the NRS (from 0 to 10). In this way, all subjects are receiving same pain intensity in terms of the score, 6.
But why 6? because we assume that 6 is a "moderate" pain. However, although many subjects may consider 6 as a moderate pain, for some (not few) 6 is a "severe" pain and this is our concern. So, although all subjects will receive same pain intensity by score, it's not the same if we ask them to label it.
The question is: which one is more important? to have same pain intensity among subjects by same score or by same label?
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According to McCaffery, 0 is defined as “no pain at all”, 1 - 3 as “mild pain”, 4 - 6 as “moderate pain”, 7 – 9 as “severe pain”, and 10 as “the worst imaginable pain”.
McCaffery M. Using the 0-to-10 pain rating scale. Am J Nurs. 2001;101(10):81-2.
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Need to measure function instead of pain intensity in adolescents with fibromyalgia, migraines, chronic musculoskeletal pain, abd pain
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I would suggest caution in using function as a surrogate for pain (if that is your intention). Individuals may adjust function due to pain, and /or may continue to function at high levels inspite of pain. The Human capacity for soldiering on inspirte of pain is under appreciated in today's anti pain management climate. Finally, be cautious regarding underreported pain precisely because indiviiduals want to avoid labels or be looked at as a potential pain med "user". This is a very sad and unfortunate facet of today's media hyped anti pain management climate, and is a terrible commentary for those of us who fought s hard to make pain a key vital sign of health.
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Opioid-induced bowel dysfunction (OIBD) is an increasing problem due to the common use of opioids for chronic pain worldwide. It manifests with different symptoms, such as dry mouth, gastro-oesophageal reflux, vomiting, bloating, abdominal pain, anorexia, hard stools, constipation and incomplete evacuation. Opioid-induced constipation (OIC) is one of its many symptoms and probably the most prevalent.
There are no available tools to assess OIBD, but many rating scales have been developed to assess constipation, and a few specifically address OIC. A clinical treatment strategy for OIBD/OIC was proposed and presented in a flowchart. First-line treatment of OIC is conventional laxatives, lifestyle changes, tapering the opioid dosage and alternative analgesics. While opioid rotation may also improve symptoms, these remain unalleviated in a substantial proportion of patients. Should conventional treatment fail, mechanism-based treatment with opioid antagonists should be considered, and they show advantages over laxatives. It should not be overlooked that many reasons for constipation other than OIBD exist, which should be taken into consideration in the individual patient.
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I agree, it's a great problem for all these patients.
In our pain center we only treat non cancer pain and I use opioids as litlle as possible due to OIBD and others problems.
I mix Trans Electrical Nerve Stimulation (TENS), ketamine, physiotherapy, acupuncture, psychotherapy, hypnosis, patient education, topics (lidocaïne, capsaïcine), transcranial stimulation (rTMS), physical activity and medications with good results.
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How good are epidural stimulators for this?
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What do you mean by  'prosthesis ?"  please see my article on the ACOPM website (American College of Physical Medicine) and click on "JOURNAL."  There is only one article listed and it is not really peer -reviewed but is a study of 551 patients treated with the ReBuilder electrical device.  The results are excellent but since this was a convenience study I am now planning a prospective study with this device. 
Neuropathy can be improved !  And probably prevented.  I also have an article coming out in December PPM (Practical Pain Management) about the necessity of EMG- NCV in lower extremity pain.  Hope these help.
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Does pain etiology have a moderation and/or mediation effect on the association between pain intensity/interference and psychological functioning associated variables?
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Thank you both for your kind reply to my question.
By pain etiology I mean the cause/diagnosis underlying chronic pain, very much as Rhiannon understood it.
Thank you for these helpful references.
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I want to run an online study and ask parents to provide information about their child who is between ages 8-17 years old. It is likely that some parents have more than one child in that range. What child we have to choose, the youngest or the oldest? it is not possible to randomize.
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What I have done in the past is ask them to pick the child who had the most recent birthday. 
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i was thinking of adapting the sitting items of long IPAQ due to its accepted reliability & validity scores among participants from several countries.
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Why not consider using a motion tracker to provide more solid backup for your questionnaire.  This will help you to calculate how reliable your questionnaire data is.
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My research is in Mobile VR and its potential use for pain management. I chose Cardboard VR for my experiments because of its affordability and simplicity. Previously my colleagues experimented to find out the effectiveness of VR with a traditional head mounted display (Oculus DK2 and DeepStream). I want to figure out how effective the Cardboard can be compared to these traditional HMDs. What would be an effective way of conducting this research?
If I take 25 pain patients as participants, let them play a VR game for around 15mins and then record their responses using a pain questionnaire(McGill or VAS)–will that be a good approach? I can compare the results with our lab's previous experiments where the same questionnaires were used but the participants played the VR game using traditional HMDs. I should mention, the game I want to use for the Cardboard is not the same as the one used on the traditional HMDs although these are built on the same principles. 
Thanks in advance.
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There are some differences between mobile and desktop VR that should be taken into account. Compared to more traditional HMDs mobile VR currently lacks positional tracking and the computing power of desktop PCs. Furthermore, the cardboard provides only 90° FOV compared to the 110° of the Vive and Rift Consumer Versions. The more the game relies on any of these, the more differences between the hardware platforms should be expected.
I would recommend to use the same game for data collection, because else it will be hard to tell if differences between the treatments are caused by the hardware or the software you used. This is rather important, since phenomena like presence or simulator sickness can be influenced by even small details. You will have to split your participants, but in turn your results will be much easier to interpret.
15 mins exposure should be fine. We used similar durations in VR experiments before and no severe simulator sickness symptoms occured (at least not from prolonged exposure). This is however influenced by your VR application, so pre-testing your setup is a must.
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My special interest is to evaluate sleep quality in patients with chronic pain.
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Clinical pain is an important public health problem world wide. It is vital to understand the pain mechanism contributing to acute and chronic levels. It is noted that the inter-individual variability as the most crucial factor of pain prediction. 
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Wasana, not clear exactly what you are asking here.  Pain is extremely complex, and a physiological process strongly influenced by perceptual processes, particularly so in chronic pain. The meaning of acute pain is injury avoidance or damage notification; that of chronic pain is much more ambiguous. Pain comprises several components, not only nociception (physical sensation). Cognitive, motivational, emotional and communicative elements make up the "pie" of pain.  Numerous studies show that expectations and anxiety, mood and other psychological dimensions all modify both degree of reported pain and amount of self-medicaltion with different analgesics. People who are anxious and depressed report more pain, irrespective of the level of nociception. Phantom limb pain illustrates that pain is a central process as much as it is due to peripheral release of inflammatory agents at the injury site.  Changes to the local biochemical environment occur but cognitive and emotional changes interact to confer different meanings on the nociception.  So chronic pain from disc herniation can be as severe as that from cancer, sometimes worse, but the meaning of the two are completely different and this affects the resultant experience of suffering.  All of this needs disentangling.  Good pain control requires good psychological skill as well as pharmacological knowledge.
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the main convergence between these syndroms is a particular memory development, accompanied with pain or fear, expressed as a fragmentation of sensory snapshots (visual, auditory, olfactory) from the original scene, or bodily distributed painful sensations. A mode of information processing perhaps akin to the one accompanying emergency situations, but deprived of relevant feedback action possibility.
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Thank you Paul for your  answer. My question was aimed at discussing diverse perspectives allowing to find more general principles across "neurosciences", from the cellular-molecular to the system and infividual levels.
Behind the chronic pain PTSD comparison was an interest for the vague (or too precise) concept of binding, i.e. whether it is possible to describe a common condition in which memory reactivations appear as unrelated fragments
Your answer suports the Harris proposition that pain results from an invalidated action hypothesis. Not simply one that requires correction, but one that invalidates further correction attempts, as in phantom pain or hand or elbow dystonias.
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I am interested in collaborating with other clinicians/ researchers regarding creative / new / effective (either / or) ACT techniques (metaphors, breathing, exercises, rituals, etc) for application in clinical practice with patients with Chronic Pain.
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Milton Erickson used metaphors in his naturalistic hypnosis to control severe pain.
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Some of chronic pain patients are deconditionning spending a lot of their time in bed. Motivate them to begin a physical activity is often difficult. Tai Chi seems to be a good alternative. Do you know some papers about that topic?
Thanks a lot, Phill
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Dear Philippe,
Maybe you can use the following publications:
Chen CH, Yen M, Fetzer S, Lo LH, Lam P. The effects of tai chi exercise on elders with osteoarthritis: a longitudinal study. Asian Nurs Res (Korean Soc Nurs Sci). 2008;2(4):235-241.
Hall AM, Maher CG, Latimer J, Ferreira ML, Lam P. A randomized controlled trial of tai chi for long-term low back pain (TAI CHI): study rationale, design, and methods. BMC Musculoskelet Disord. 2009;10:55.
Hall AM, Maher CG, Lam P, Ferreira M, Latimer J. Tai chi exercise for treatment of pain and disability in people with persistent low back pain: a randomized controlled trial. Arthritis Care Res (Hoboken). 2011;63(11):1576-1583.
Peng PW. Tai chi and chronic pain. Reg Anesth Pain Med. 2012;37(4):372-82.
Wang XQ, Huang LY, Liu Y, Li JX, Wu X, Li HP, Wang L. Effects of tai chi program on neuromuscular function for patients with knee osteoarthritis: study protocol for a randomized controlled trial. Trials. 2013;14:375.
Wang C, Iversen MD, McAlindon T, Harvey WF, Wong JB, Fielding RA, Driban JB, Price LL, Rones R, Gamache T, Schmid CH. Assessing the comparative effectiveness of Tai Chi versus physical therapy for knee osteoarthritis: design and rationale for a randomized trial. BMC Complement Altern Med. 2014;14:333.
Best wishes from Germany,
Martin
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we want to plan a research study to determine the  impact of latissimus dorsi extensibility on chronic mechanical low back pain, while intervene in combination with lumber segmental spinal joints mobilization.
Target segment will be T1 - L5.
need your feed back? 
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It is a key global back stabilizer muscle, and its tightness can cause changes in the mechanics of human spine, which may further cause pain and loss of function at lumber spine. It is also clinically very prone to tightness in human beings.
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Invasive or noninvasive sham? Or a complete alternative?
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Surface skin contact only with a slight blunt needle which does not penetrate the skin is a good choice.  If the acupuncture is in a site not visible by the recepient. More tricky if they can see.  However, subjects should all be acupuncture naive individuals as those who have received it previously might be able to tell the difference between the actual penetration and the sham condition, which would introduce bias.
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I can find lots of work surrounding pain reconceptualisation through the use of metaphors by clinicians and researchers, but very little on the use of metaphors by patients, and how such language can impact outcomes such as pain-related catastrophising, pain intensity etc.
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The Metaphor in end-of-life care (MELC) project at Lancaster University (UK) might interest you. 
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Chronic, non-specific and widespread pain is very common among older adults. Traditional interventions which usually use physical means to deal with individual joints only cannot address the problem. Is there any effective interventions that incorporate physical, psychological and social needs of this population? 
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Here are some possible publications related to a 3 week, outpatient based multidisciplinary pain program that could be helpful for you to review--W. Michael Hooten had been the main physician champion in the past.