Recommendations on practice of conditioned pain modulation (CPM) testing.

Protocols for testing conditioned pain modulation (CPM) vary between different labs/clinics. In order to promote research and clinical application of this tool, we summarize the recommendations of interested researchers consensus meeting regarding the practice of CPM and report of its results.

Pain perception in women with dysmenorrhea.

OBJECTIVE: To determine if systemic processing of pain differs in women with and without dysmenorrhea. METHODS: Twenty-two dysmenorrheic women and 31 nondysmenorrheic women were studied by pain threshold and supra-threshold magnitude estimation to heat stimuli, pain-evoked potentials by laser stimuli, and anxiety scores four times across their menstrual cycles. RESULTS: Significant differences were found between dysmenorrheic and nondysmenorrheic women. In all four examinations across the menstrual cycle, dysmenorrheic women had longer latencies of pain-evoked potentials (383.08 +/- 6.8 msec versus 345.05 +/- 7.0 msec, P <.001), higher magnitude estimations on visual analog scale of supra-threshold pain (83.29 +/- 2.87 versus 63.50 +/- 3.82, P <.001), and higher state anxiety scores (37.69 +/- 1.7 versus 29.20 +/- 1.9, P =.002). CONCLUSION: Women with dysmenorrhea show enhanced pain perception compared to nondysmenorrheic women. This augmentation of pain perception may be part of the development of dysmenorrhea.

Simultaneous recording of late and ultra-late pain evoked potentials in fibromyalgia.

OBJECTIVE: To characterize laser evoked potentials (LEP), pain psychophysics and local tissue response in fibromyalgia patients. METHODS: LEP were recorded in 14 women with fibromyalgia in response to bilateral stimulation of tender and control points in upper limbs by 4 blocks of 20 stimuli at each point. Subsequently, heat pain thresholds were measured and supra-threshold magnitude estimations of heat pain stimuli were obtained on a visual analogue scale. Finally, the extent of the local tissue response induced by the previous stimuli was evaluated. RESULTS: Laser stimuli elicited two long latency waves: A late wave (mean latency 368.9+/-66.9 ms) in most patients (13/14) from stimuli at all points, and an ultra-late wave (mean latency 917.3+/-91.8 ms) in 78.5% of the patients at the control points and in 71.4% at the tender points. Amplitude of ultra-late waves was higher at the tender points (20.67+/-11.1 microV) than at the control points (10.47+/-4.1 microV) (P=0.016). Pain thresholds were lower in the tender (41.2+/-2.7 degrees C) than the control points (43.9+/-3.2 degrees C) (P=0.008). Local tissue response was significantly more intense at tender than control points (P=0.004). CONCLUSIONS: Ultra-late laser evoked potentials can be recorded simultaneously with late potentials. Our findings are compatible with presence of peripheral C-fiber sensitization, mostly at tender points, probably combined with generalized central sensitization of pain pathways in fibromyalgia.

Internal body perceptions of Ethiopian Jews who emigrated to Israel.

Previous research regarding knowledge about internal organs among school-age children tied this knowledge to the development of cognitive capabilities. Studies have rarely considered the impact of culture on this knowledge. The purpose of this study was to examine internal body perceptions among Ethiopian Jews who emigrated to Israel. A total of 65 children (stratified according to age) and 19 adults were interviewed. Findings indicated that Ethiopian children reported fewer body organs than did Western children. Further, Ethiopian children and adults, unlike people from Western societies, did not think about the body in terms of different biophysical functions. Rather, they perceived the body as a holistic system in which a divine providence was responsible for body organs working together harmoniously. Implications of the differing perceptions about internal body organs, health, illness, and treatment are discussed.

Pregnancy and delivery practices and beliefs of Ethiopian immigrant women in Israel.

This exploratory, qualitative study compared traditional and biomedical pregnancy and delivery practices from the perspective of Ethiopian immigrant women in Israel. Findings documented that certain beliefs, such as the belief that nonmedical factors (i.e., moral behavior, God, and proper nutrition) were responsible for pregnancy outcomes, were relatively unaffected by immigration. After immigration to Israel, Ethiopian women, however, chose to deliver their babies in the hospital rather than import traditional home delivery practices from their homeland. Despite many negative aspects of labor and delivery in Israel, Ethiopian immigrant women felt that it was worth enduring negative Israeli health care practices in order to have "clean," "safe," and expert deliveries. Findings from this study assist health care professionals to provide more culturally sensitive care to this immigrant group.

PIP: In order to gather information which will allow health care professionals to improve the cultural sensitivity of the care they offer to Ethiopian women immigrants in Israel, a 1991 qualitative study compared pregnancy and delivery practices in the two countries from the perspective of these women. The study sample consisted of 19 women who had migrated from Ethiopia 23-25 months previously. Six had given birth only in Ethiopia, four only in Israel, and nine in both countries. Analysis of data gained through interviews revealed that the women believed that the outcome of pregnancy and delivery depended upon proper nutrition and upon "God's will or power." Thus, the women failed to avail themselves of prenatal care. In Ethiopia, the women delivered their babies at home with the support of female family members, friends, and a traditional birth attendant. In Israel, the women delivered in a hospital alone and unsupported. In Ethiopia, the pregnant woman's modesty was considered important and was protected, but, in Israel, no regard was given to issues of modesty. In Ethiopia, the women had more control over their labor and the position in which they gave birth. In order to avoid restrictions to their activities while in labor, the women stayed at home as long as possible in Israel before rushing to the hospital. While hospital delivery was associated with loneliness, a lack of support, a lack of personal control, and invasions of privacy, these negative experiences were accepted in order to obtain the clean, safe, and "clever" care available in the hospitals. These findings indicate that culturally competent care for this group would involve respecting the need for modesty during prenatal care, increasing access to nutritional foods instead of routinely prescribing iron and vitamin supplementation, allowing a support group to accompany the woman during labor and delivery, and delaying the use of the lithotomy position and other restrictions on mobility until the last possible moment.

Learning about another culture: project and curricular reflections.

Over the past two years, an innovative collaborative project in the care of Ethiopian Jews who immigrated to Israel has been carried out. In this project, both students and faculty joined in activities of research and practice through a clinic at a trailer court that houses 96 Ethiopian immigrant families. This project brought about several favorable changes: a) Health of the underprivileged and underserved was enhanced through bi-weekly services provided to the poor and sick trailer court inhabitants; b) An educational program for learning in a cross-cultural community setting was developed. This curricula advanced recognition of the growing cultural and racial diversity of both individual and family lifestyles, as well as allowed for learning events that are based on substantive contact with, or participation by, persons at health risk; c) An educational milieu that fosters the use of research-based interventions was developed. This article describes the cross-cultural educational project which was designed as a pilot for a new baccalaureate program in nursing, and critiques it based on the criteria of the five major concepts--primacy of the teacher-student relationship, social responsibility, centrality of caring, interpretive stance and theoretical pluralism, proposed by the promoters of the "curriculum revolution."

Preoperative scar hyperalgesia is associated with post-operative pain in women undergoing a repeat Caesarean delivery.

BACKGROUND: Over 1.4 million Caesarean deliveries are performed annually in the United States, out of which 30% are elective repeat procedures. Post-operative hyperalgesia is associated with an increased risk for persistent post-surgical pain; however, there are no data on whether residual scar hyperalgesia (SHA) from a previous Caesarean delivery (CD) persists until the next delivery. We hypothesized that residual SHA may be present in a substantial proportion of women and is associated with increased post-operative pain. METHODS: One hundred and sixty-three women scheduled for a repeat CD under spinal anaesthesia were enrolled into the study. Mechanical temporal summation (mTS) and SHA index were measured preoperatively. SHA was considered present when the index was >0. Post-operative pain scores at 12, 24 and 48 h and wound hyperalgesia (WHA) at 48 h were recorded. RESULTS: SHA was present in 67 women 41% with a median SHA index of 0.42 (Q (25) = 0.25; Q (75) = 1.1, range 0.03-4.25). Women with SHA had overall higher post-operative pain scores and SHA was correlated with preoperative mTS (r = 0.164, p < 0.05), post-operative pain severity (r = 0.25, p < 0.002) and WHA at 48 h (r = 0.608, p < 0.001). Severe pain (visual analogue pain scale-S48 ≥ 7, n = 20) was predicted with a sensitivity and specificity of 60% and 62%, respectively. Positive predictive value was 18% and negative predictive value was 92%. CONCLUSIONS: Preoperative SHA is present in 41% of women scheduled for repeat CD and is associated with increased mTS and post-operative pain. Screening for preoperative SHA may predict women at risk for increased post-operative pain, and guide post-operative analgesia to include anti-hyperalgesic drugs.

The effect of post-surgical neuroplasticity on the stability of systemic pain perception: a psychophysical study.

BACKGROUND: Surgery-induced neuroplasticity at spinal and supra-spinal levels is assumed to evoke a clinical acute post-operative pain (cAPOP) experience, which is expressed by allodynia and/or hyperalgesia. It remains unclear whether the systemic pain perception measured outside the incision area remains unchanged and whether it is affected by the presence of cAPOP. AIMS: This study explored whether the systemic perception of experimental pain would be altered towards hypersensitivity following elective gynecological surgery unmasked by opioids. METHODS: A perioperative psychophysical evaluation of heat pain thresholds (HPT) and pain estimations were obtained in a remote bodily area before and after surgery among 35 women. RESULTS: The ratings for both pain dimensions of intensity and unpleasantness remained stable following surgery. However, there was a reduction found in HPT the day after surgery (43.6 ± 2.2 °C to 42.2 ± 3.1 °C, p = 0.002). This reduction was associated with lower HPT measured before surgery (r = .56, p < 0.000) and with higher cAPOP intensity obtained at rest (r = -.44, p = 0.008). CONCLUSIONS: This post-surgical allodynia, as reflected by the systemic enhancement of pain perception, may represent plasticity in the central pain pathways at the supra-spinal level. Pre-surgical assessment of a patient's pain perception profile may predict certain pain dimensions of post-surgical pain plasticity. The evaluation of individual pain profiles may contribute to a mechanism-based approach aimed to attenuate the cAPOP.