Vulvodynia¿It Is Time to Accept a New Understanding from a Neurobiological Perspective

Vulvodynia is one the most common causes of pain during sexual intercourse in premenopausal women. The burden of vulvodynia in a woman's life can be devastating due to its consequences in the couple's sexuality and intimacy, in activities of daily living, and psychological well-being. In recent decades, there has been considerable progress in the understanding of vulvar pain. The most significant change has been the differentiation of vulvar pain secondary to pathology or disease from vulvodynia. However, although it is currently proposed that vulvodynia should be considered as a primary chronic pain condition and, therefore, without an obvious identifiable cause, it is still believed that different inflammatory, genetic, hormonal, muscular factors, etc. may be involved in its development. Advances in pain neuroscience and the central sensitization paradigm have led to a new approach to vulvodynia from a neurobiological perspective. It is proposed that vulvodynia should be understood as complex pain without relevant nociception. Different clinical identifiers of vulvodynia are presented from a neurobiological and psychosocial perspective. In this case, strategies to modulate altered central pain processing is necessary, changing the patient's erroneous cognitions about their pain, and also reducing fear avoidance-behaviors and the disability of the patient

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In conclusion, it is key for physical therapists to acknowledge that an important subgroup of patients with OA develop hyperexcitability of the central nervous system and that CS plays a crucial role in the pain reported by these patients. Recent studies published in wellrespected journals support our argument

Pain Treatment for patients with osteoarthritis and central sensitization

Osteoarthritis is one of the most frequent, disabling, and costly pathologies of modern society. Among the main aims of osteoarthritis management are pain control and functional ability improvement. The exact cause of osteoarthritis pain remains unclear. In addition to the pathological changes in articular structures, changes in central pain processing or central sensitization appear to be involved in osteoarthritis pain. The latter calls for a broader approach to the management of patients with osteoarthritis. Yet, the scientific literature offers scant information addressing the treatment of central sensitization, specifically in patients with osteoarthritis. Inter-ventions such as cognitive-behavioral therapy and neuroscience education potentially target cognitive-emotional sensitization (and descending facilitation), and centrally acting drugs and exercise therapy can improve endogenous analgesia (descending inhibition) in patients with osteoarthritis. Future studies should assess these new treatment avenues

Fisioterapia del dolor miofascial y de la fibromialgia

114 páginasExiste una gran variedad de problemas de los tejidos blandos que son claramente reconocibles: efectos de traumatismos, procesos inflamatorios, debilidad, etc. El síndrome de dolor miofascial es una entidad extraordinariamente frecuente, diferente de las anteriores, pero, hasta la fecha, mal comprendida y escasamente difundida. En este libro tratamos de recoger tanto los síntomas como la importancia en el diagnóstico y su posible tratamiento

Effectiveness of a pain neuroscience education program in women with vulvodynia and correlations with brain connectivity studied by functional magnetic resonance: a single case experimental design.

Antecedentes: La vulvodinia es una condición dolorosa que afecta al 8-10% de las mujeres de todas las edades y se caracteriza por dolor en la vulva que se presenta de forma espontánea o provocada, frecuentemente por las relaciones sexuales. La vulvodinia tiene un efecto negativo en la calidad de vida de las mujeres y sus parejas, y supone una profunda carga tanto personal como económica y social. A nivel internacional, no existe un consenso general sobre los algoritmos de tratamiento de la vulvodinia, y las pautas recomendadas se basan principalmente en la opinión de expertos y un número limitado de ensayos clínicos. La educación en neurociencia del dolor es una estrategia emergente que está ofreciendo resultados prometedores en el manejo del dolor crónico. El objetivo de esta tesis es estudiar la eficacia terapéutica de este tipo de tratamiento en pacientes con vulvodinia y dispareunia y si este tipo de intervención es capaz de modificar los patrones de conectividad cerebral. Varios ensayos controlados aleatorizados (ECA) han investigado la eficacia de la educación en neurociencia del dolor (END) en diversas condiciones dolorosas. Se cuenta asimismo con varias revisiones sistemáticas que han mostrado una evidencia consistente de que la END tiene un efecto positivo en el dolor y la discapacidad. La última revisión sistemática publicada en 2019 ha demostrado que la END puede disminuir el dolor, la discapacidad, el catastrofismo y la cinesiofobia a corto y medio plazo, aunque la heterogeneidad de los resultados es muy amplia. Sin embargo, hasta ahora no se ha realizado ningún estudio que haya empleado la END en el tratamiento de la vulvodinia y cuyos objetivos hayan sido la reducción del dolor y de la discapacidad asociada. Diseño: Se ha empleado un diseño experimental de caso único de tipo AB, en el que las mediciones se realizan en una primera fase dividida en 2 tiempos (A1 y A2), una fase intermedia (fase de tratamiento), con una intervención simultánea en 15 pacientes y finalmente una segunda fase de evaluación de resultados, también dividida en 2 tiempos (B1 y B2). La tesis presentada consta de dos estudios: El estudio1 es un estudio prospectivo controlado de los efectos de un programa de intervención basado en END en mujeres con vulvodinia y el estudio 2 analiza los efectos de este programa en la conectividad cerebral mediante imágenes de resonancia magnética funcional. Pacientes: Se reclutaron 15 mujeres que presentaban vulvodinia y dispareunia, con una edad comprendida entre los 21 y los 54 años y con una media de 6 años de evolución del cuadro doloroso. Métodos: El estudio 1 consistió en un programa de intervención basado en END y exposición gradual. Cada paciente recibió una media de unas 7 sesiones de educación durante aproximadamente 6-8 semanas, más unas sesiones de seguimiento a lo largo de aproximadamente 1 año. Tras las sesiones de educación la mayoría de mujeres recibieron recomendaciones sobre estrategias para facilitar su desensibilización. En el estudio 2 se realizaron a cada paciente 3 Resonancias Magnéticas Funcionales (RMf) y estructurales (DTI): 1ª RM basal al inicio del estudio, en el tiempo A1 (RM1), 2ª RM antes del programa de intervención (RM2), en el tiempo A2, y una 3ª de seguimiento (RM3). Se obtuvo un estudio completo en 14 de las 15 pacientes, ya que una paciente abandonó el estudio durante el periodo de intervención. El tiempo desde RM1 (A1) a RM2 (A2) fue de 53 días, de la RM2 (A2) a RM3 (B1) de 366 días y de la RM3 (B1) a final del estudio (B2) de 225 como media. Mediciones: Para evaluar la eficacia del tratamiento en el estudio I se analizaron las siguientes variables: (1) Variables extraídas de la entrevista clínica en 2 tiempos [A1 y B1]. (2) Variables del cuestionario on-line, que las pacientes cumplimentaron semanalmente desde el inicio del estudio [A1] hasta la evaluación final del seguimiento [B2]. (3) Cuestionarios de aspectos relacionados con el dolor en 3 tiempos, inicio [A1] coincidiendo con la 1ª RM; tras el periodo de espera y 2ª RM [A2] y finalmente en la fase de evaluación, coincidiendo con la 3ª RM [B1]. (4) Mapas de dolor y de alodinia [A1, B1]. (5) Test sensoriales cuantitativos [A1, A2 y B1]. El estudio 2 consistió en: (1) Estudio de conectividad funcional mediante el análisis de componentes independientes (ICA). (2) Estudio de conectividad funcional mediante el análisis de regiones de interés (ROIs). (3) Estudio de la correlación entre las variables clínicas y la conectividad global de cada red y la conectividad de cada par de nodos. (4) Análisis discriminante del valor predictivo de la conectividad en el dolor experimentado durante las pruebas de RMf. (5) Estudio de conectividad estructural mediante el tensor de difusión (DTI). Resultados: Se ha observado que un programa de intervención basado en END es efectivo en el tratamiento del dolor, obteniéndose una eliminación completa del dolor y de la alodinia en la mayoría de mujeres con vulvodinia y dispareunia. Este tratamiento disminuyó la ansiedad, la depresión, el catastrofismo, la cinesiofobia, las cogniciones erróneas relacionadas con el dolor, la interferencia del dolor en la vida del paciente y la discapacidad y consiguió mejorar la calidad de la vida sexual en mujeres con vulvodinia. El tratamiento realizado redujo significativamente las áreas de dolor y de alodinia tanto de la vulva como del resto de regiones corporales. Se ha observado además que los efectos terapéuticos se mantienen más allá de los 12 meses. Se han redujo de forma significativa los umbrales de dolor a la presión y de la alodinia en cada uno de los seis puntos anatómicos de la mucosa vulvar estudiados. No se encontraron diferencias en las pruebas de analgesia condicionada (CPM effect) antes de después del tratamiento y aunque los resultados de la ratio de sumación temporal (WUR) parecen indicar una mejoría en la intensidad del dolor, debido al número de pacientes de los que no se tienen datos tras el tratamiento, los resultados no se consideran como relevantes. Se ha observado que el tratamiento realizado es capaz de modificar los patrones de conectividad cerebral en pacientes con vulvodinia y dispareunia. Tras el tratamiento se observó un aumento significativo de la conectividad funcional entre los componentes anteriores y posteriores de la Red por Defecto (DMN). Se observó una disminución significativa de la conectividad funcional entre la Ínsula Anterior Derecha (raINS) y el Cerebelo Posterior (vermis cerebeloso) que forma parte del circuito de procesamiento de la saliencia. Se observó una correlación entre la conectividad global de algunas redes cerebrales y distintas variables clínicas tanto antes como después de la intervención. Se observó una correlación entre el dolor y la conectividad de nodos de la red visual (VN). La disminución del dolor en las pacientes con vulvodinia tras el tratamiento se asoció a una disminución significativa de la conectividad de los nodos de la VN, de esta red con nodos de la red sensitivomotora (SMN) y con nodos de la red de saliencia (SN). El análisis discriminante mostró que la conectividad entre los nodos de las redes DMN, SN y de la Red Atencional Dorsal Frontoparietal (DA_FPN), es capaz de predecir correctamente en el 88.9% de los casos si la paciente experimentaba o no dolor durante la prueba de RMf. No se observó ningún cambio en la conectividad estructural mediante el análisis de DTI antes y después del tratamiento, ni ninguna correlación con variables clínicas.Background: Vulvodynia is a painful condition that affects 8-10% of women of all ages and is characterized by pain in the vulva that occurs spontaneously or provoqued, often by sexual intercourse. Vulvodynia has a negative effect on the quality of life of women and their partners, and is associated to a significant personal, economic and social burden. Internationally, there is no general consensus on vulvodynia treatment algorithms, and recommended guidelines are based primarily on expert opinion and a limited number of clinical trials. Education in pain neuroscience is an emerging strategy that is offering promising outcomes in the management of chronic pain. The objective of this thesis is to study the therapeutic effectiveness of this treatment in patients with vulvodynia and dyspareunia and if this type of treatment is able of modifying brain connectivity patterns. Several randomized controlled trials (RCTs) have investigated the efficacy of pain neuroscience education (PNE) in various pain conditions. There have also been published several systematic reviews that have shown consistent evidence that PNE has a positive effect on pain and disability. The latest systematic review published in 2019 has shown that PNE can reduce pain, disability, catastrophism and kinesiophobia in the short and medium term, although the heterogeneity of the outcomes is very wide. However, so far no study has been conducted implementing PNE in the treatment of vulvodynia and whose objectives have been to reduce pain and its associated disability. Study design: A single case type AB experimental design has been used, in which the measurements have been done in a first phase divided into 2 times (A1 and A2), an intermediate phase (treatment phase), with a simultaneous intervention in 15 patients and finally a second phase of outcomes assessment, also divided into 2 times (B1 and B2). The thesis presented consists of two studies: Study 1 is a prospective controlled study of the effects of an intervention program based on PNE in women with vulvodynia and Study 2 analyses the effects of this treatment on brain connectivity using functional magnetic resonance imaging (fMRI). Patients: 15 women with vulvodynia and dyspareunia were recruited, whose age ranged from 21 to 54 years and with an average of 6 years of evolution of the pain condition. Methods: Study I consisted of an intervention program based on PNE and gradual exposure. Each patient received an average of seven educational sessions over approximately 6-8 weeks, plus follow-up sessions over approximately 1 year. After the educational sessions, most of the women received recommendations on strategies to facilitate their desensitization. In study 2, three fMRI and structural MRI (DTI) were performed on each patient: 1st MRI at baseline at the start of the study, at time A1 (MRI 1); 2nd MRI before the intervention program (MRI 2) in the time A2 and a 3rd MRI at follow-up (MRI 3). A full study was obtained in 14 of the 15 patients, as one patient dropped out of the study during the intervention period. The time from MRI 1 (A1) to MRI 2 (A2) was 53 days, from MRI 2 (A2) to MRI 3 (B1) 366 days and from MRI 3 (B1) to the end of the study (B2) 225 on average. Measurements: To assess the treatment efficacy in study I, the following variables were analysed: (1) Variables from the clinical interview in 2 times A1 and B1. (2) Variables from the online questionnaire that the patients have completed weekly from the beginning of the study [A1] until the final assessment of the follow-up [B2]. (3) Questionnaires of pain and disability in 3 times: at beginning [A1] matching with the 1st MRI, after the waiting period and 2nd MRI [A2] and finally in the assessment phase, matching with the 3rd MRI [B1]. (4) Maps of pain and allodynia [A1, B1]. (5) Quantitative sensory testing [A1, A2 and B1]. In study II, the following studies were carried out: (1) Brain functional connectivity MRI study through independent component analysis (ICA). (2) Study of functional connectivity through the analysis of regions of interest (ROIs). (3) Study of the correlations between clinical variables and the global connectivity of each network and the connectivity of each pair of nodes (4) Discriminant analysis to assess the predictive value of brain connectivity in the pain experienced during the MRI (5). Structural connectivity study using the diffusion tensor imaging (DTI). Outcomes: It has been observed that a treatment program based on PNE is effective in the treatment of pain, obtaining a complete suppression of pain and allodynia in the majority of women with vulvodynia and dyspareunia. This treatment reduced anxiety, depression, catastrophism, kinesiophobia, miscognitions related to pain, interference of pain in the patient’s life and disability and improved the quality of sexual life in women with vulvodynia. The treatment carried out significantly reduced the areas of pain and allodynia both in the vulva and in the rest of the body regions. It has also been observed that the therapeutic effects were maintained beyond 12 months. Pressure pain and allodynia thresholds were significantly reduced at each of the six anatomical points of the vulvar mucosa studied. No differences were found in the tests of conditioned pain modulation (CPM effect) before and after the treatment and although the values of the temporal summation ratio (WUR) seem to indicate an improvement in pain intensity, due to the number of patients in whom there were no data after treatment, the results are not considered relevant. It has been observed that this treatment is able of modifying brain connectivity patterns in patients with vulvodynia and dyspareunia. After treatment, a significant increase in functional connectivity was observed between the anterior and posterior components of the Default Network (DMN). A significant decrease in functional connectivity was observed between the Right Anterior Insula (raINS) and the Posterior Cerebellum (vermix), which is part of the salience processing circuit. A correlation was observed between the global connectivity of some brain networks and different clinical variables both before and after the intervention. A correlation between pain and visual network (VN) nodes connectivity was observed. The decrease in pain in patients with vulvodynia after treatment was associated with a significant decrease in the connectivity of the VN nodes, of this network with sensorimotor network nodes (SMN) and with nodes of the salience network (SN). The discriminant analysis showed that the connectivity between the nodes of the DMN, SN and the Dorsal Attention Network Frontoparietal is able to predict in 88.9% of the cases whether or not the patient experienced pain during the fMRI study. No change in structural connectivity was observed by DTI analysis before and after treatment, nor any correlation with clinical variables.MedicinaCiencias de la Salu

Essential guide to the cervical spine : clinical syndromes and manipulative treatment, vol.02/ Edit.: Rafael Torres Cueco

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Essential guide to the cervical spine : clinical syndromes and manipulative treatment, vol.02/ Edit.: Rafael Torres Cueco

xv, p. 525: ill.; tab.; 24 c

Evidence for central sensitization in patients with osteoarthritis pain: a systematic literature review

Hyperexcitability of the central nervous system (CNS) has been suggested to play an important role in the chronic pain experienced by osteoarthritis (OA) patients. A systematic review following PRISMA guidelines was performed to evaluate the existing evidence from the literature related to the presence of central sensitization (CS) in patients with OA.Electronic databases PubMed and Web of Science were searched to identify relevant articles using pre-defined keywords regarding CS and OA. Full-text clinical reports addressing studies of CS in human adults with chronic complaints due to osteoarthritis were included and screened for methodological quality by two independent reviewers. From the 40 articles that were initially eligible for methodological quality assessment, 36 articles achieved sufficient scores and therefore were discussed. The majority of these studies were case-control studies and addressed OA of the knee joint. Different subjective and objective parameters considered manifestations of CS, which have been previously reported in other chronic pain conditions such as whiplash or rheumatoid arthritis, were established in subjects with OA pain. Overall results suggest that, although peripheral mechanisms are involved in OA pain, hypersensitivity of the CNS plays a significant role in a subgroup of subjects within this population. Although the majority of the literature provides evidence for the presence of CS in chronic OA pain, clinical identification and treatment of CS in OA is still in its infancy, and future studies with good methodological quality are necessary