Reliability of subjective pain ratings and nociceptive flexion reflex responses as measures of conditioned pain modulation.

BACKGROUND: The endogenous modulation of pain can be assessed through conditioned pain modulation (CPM), which can be quantified using subjective pain ratings or nociceptive flexion reflexes. However, to date, the test-retest reliability has only been investigated for subjective pain ratings. OBJECTIVE: To compare the test-retest reliability of CPM-induced changes, measured using subjective pain ratings and nociceptive flexion reflexes, to provide a reliable scoring parameter for future studies. METHOD: A total of 40 healthy volunteers each received painful electrical stimuli to the sural nerve to elicit nociceptive flexion reflexes. Reflex sizes and subjective pain ratings were recorded before and during the immersion of the contralateral hand in hot water to induce CPM as well as innocuous water as control. Measurements were repeated in a retest 28 days later. RESULTS: Intraclass correlation coefficients showed good test-retest reliabilities of CPM during the hot water stimulus for both scoring parameters. Subjective pain ratings also correlated between test and retest during the control stimulus. CONCLUSIONS: Subjective pain ratings and nociceptive flexion reflexes show comparable test-retest reliabilities, but they reflect different components of CPM. While subjective pain ratings appear to incorporate cognitive influences to a larger degree, reflex responses appear to reflect spinal nociception more purely.

How to treat a patient with chronic low back pain - methodology and results of the first international case conference of integrative medicine.

BACKGROUND AND OBJECTIVE: Complementary and alternative medicine (CAM) is frequently used in patients in industrialised countries. Despite this popularity, there remains a considerable deficit of discourse and cooperation between physicians practicing CAM and conventional medicine. The aim is to present the methodology and results of the first international case conference on integrative medicine (IM) dealing with a patient with low back pain. In this paper the methodological tool "case conference on IM" is also described. METHODS: The interactive case conference took place on November 20th, 2009 as part of the "2nd European Congress of IM" in Berlin, Germany. An experienced expert panel from both conventional medicine and CAM developed integrative medical diagnoses and therapeutic strategies using as their starting point an individual patient case on chronic low back pain (LBP). The case was selected because LBP is a common diagnosis with considerable economic impact and a problem which is often treated with CAM. RESULTS: In this case conference, the expert panel agreed on a diagnosis of "chronic non-specific LBP with somatic and psychological factors" and proposed multi-modal short- and long-term treatment including of CAM. The importance of the patient-physician-relationship and the consultation process with appropriate consultation time for treatment success was highlighted. There was consensus that the diagnostic process and resulting treatment plan should be individualised and focussed on the patient as a complete person, identifying the significance the disease has for the patient and not just on the disease for itself. Considerable differences were found amongst the experts regarding the first steps of treatment and each expert saw possibilities of "effective and adequate treatment" being met by their own individual treatment method. CONCLUSION: The case conference on integrative medicine stimulated an intensive exchange between the approaches used by conventional medicine and CAM clarifying different treatment possibilities for low back pain. Therefore, case conferences on integrative medicine could serve as a model for evaluating similar activities in academic hospitals and establishing such approaches in routine medical care. This strategy has the potential to improve patient centred care.