Home Medicine Sleep, widespread pain and restless legs — What is the connection?
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Sleep, widespread pain and restless legs — What is the connection?

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Published/Copyright: October 1, 2017
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Scandinavian Journal of Pain
From the journal Scandinavian Journal of Pain Volume 17 Issue 1

Stehlik et al. [1] have tackled a difficult subject in this article that addresses the interplay of sleep, multisite pain, and Restless Legs Syndrome (RLS). The data are derived from a questionnaire survey of females in a county in central Sweden. The total study population of 2727 is appropriately large to be representative. It is a bit disappointing that 1313 others were excluded due to incomplete data but this problem is not too unusual with the use of complicated survey questionnaires if they are done with only mail-in responses. As the authors point out, this is not a prevalence study, but an analysis of a particular population so that consideration of bias in the population is not as important. There was a telephone contact to look at the reasons for non-response. The reply “no RLS and/or no pain” was given by one set of non-responders. It would be interesting to have these also as controls when looking at sleep, i.e. a large group with pain but no RLS and a second large group with neither pain nor RLS. Perhaps this could the basis for a subsequent study.

1 Restless legs (RLS), pain, and sleep disturbances

The findings in this study were that RLS subjects who also had pain had shorter sleep duration, longer sleep onset latency, more frequent nocturnal awakenings, and more daytime sleepiness. Longer duration of pain, more severe pain, and more widespread pain increased this association. There is an analysis to exclude the effects of possible confounding factors, including chronic disease (also psychiatric disease), medications, smoking, and alcohol consumption that all could affect sleep. When correcting for these possible other causes for sleep disturbance, the above findings hold, thus indicating that the associations are important to consider when treating patients complaining of sleep disturbance as a primary problem, since there may be associated RLS and also chronic pain [2]. The converse is that those with RLS may also have a sleep disorder or/and chronic pain. If the treatment focus is solely on RLS, the treatment may not be so effective without concurrent treatment for chronic pain and the sleep disorder. This is analogous to the situation with comorbid chronic pain and depression where confining treatment to either diagnosis is not very effective. Concurrent treatment of both is necessary for the best effect [3].

2 Is severe sleep disturbance a psychiatric disease?

It is a little surprising that “severe sleep disturbance” is included in the psychiatric disease diagnoses. This muddies the water a little since those subjects with “severe sleep disturbance” are included in the statistics to analyze the possibility that psychiatric disease has an effect on sleep variables. One would assume that this group under “psychiatric disease” is in the minority and that this contradictory analysis of comparing the effect of sleep on sleep doesn’t alter the results to any extent.

3 Sleeping with painful RLS is a nightmare

What is lacking here for clarity is a table that looks at the prevalence of the pain categories, pain site distributions, and RLS symptom categories that would be helpful in putting the statistics in perspective despite the overlap of all these symptoms. Since painful RLS is a subset of the RLS population that has more severe sleep disturbance as well as anxiety and depressive symptoms [4], it would be interesting to see what proportion of those in the Stehlik et al. population had leg pain only or associated leg pain. Since this is not a prevalence study, these data are not necessary, but they would give a better picture of the study population.

As stated above, the difference between those with pain and those without pain is a little unclear in this article [1]. In the original article by Stehlik and co-workers in 2014 [5] the final cohort for analysis had 1677 subjects with “ongoing pain”, 1663 with pain for more than 3 months, and 1408 with pain for more than 6 months. The “no pain” population was 1383 [5]. It would be interesting to look at a clear comparison between these different populations in terms of sleep variables and see the data in a table form.

4 An important study of a complex pain-disorder with or without RLS and disturbed sleep – but follow-up studies needed [1]

Stehlik and co-workers are to be commended for taking on this project – how to assess the interplay of so many factors with sleep as the focus [1]. There are a few problems with this study, some listed above, which could be considered when designing subsequent studies based on this as a pilot project to improve the design. The first suggestion would be to look at the same population using brief structured interviews as well as the questionnaires. This should decrease the dropout rate for incomplete questionnaires as well since the participants would be prompted to add missing data at the interview time.

5 Sleep-laboratory compared with sleep questionnaire studies

Sleep studies using questionnaires may not be the same as data from a sleep laboratory. Stehlik et al. quote two studies that they state show a strong correlation between survey data and sleep lab data but on closer scrutiny, these are not as confirming as one would hope. The study by Gooneratne et al. [6] is in adults 65 years and older using other sleep questionnaires than are used in the Stehlik et al. study. The older adults were studied primarily to see if those with sleep disturbance symptoms were different from those without symptoms. The Gooneratne et al. study [6] states: “While the correlations between subjective and objective sleep efficiency were statistically significant for cases (those reporting sleep problems), it (sic) was (sic) not statistically significant for controls. ... However, for all groups, the correlation was low (<0.3)”. Therefore the data from the controls in the present study may not be accurate and the Gooneratne et al. study indicates that the final verdict has not been reached concerning the correlation between sleep-lab data and questionnaire data. The applicability of the Gooneratne et al. study data [6] to the present study needs to be taken in context. The study by Diaz-Piedra et al. [7] compares sleep in fibromyalgia patients against controls, and the questionnaires address different aspects of sleep from the polysomnographic sleep data at home and the two data sets are not compared. Thus, the question about questionnaire data versus sleep-lab data still appears to be open when examining only these two references more closely.

6 Associations between “predictors” and outcome do not mean causality

It is necessary to point out that statistically derived associations do not imply causality. This article discusses “predictors” which in this case means that by examining a given population at one time point, one can identify symptoms or demographic characteristics that predict the prevalence and/or the quality/quantity of other symptoms or demographic characteristics at the same time point. Stehlik et al. [1] clearly do not suggest causality in this article. They do suggest that longitudinal studies could dissect this problem – the difference between a statistical association and causality.

7 A longitudinal follow-up study needed

The Stehlik group has also tested the stability of both pain and RLS diagnoses with follow up of a small subset of 36 subjects included in this study. This indicated that, in the limited population, the symptoms were stable. What is needed now is a longitudinal study with a pain free, non-RLS population with minimal sleep problems to examine the evolution of the variables tested here over time. With unlimited funds and patience, this is possible. Perhaps it could be added as a component to some of the existing longitudinal demographic studies to look at health in diverse populations [8,9].

8 Which disorder came first: disturbed sleep? RLS? or chronic pain?

Stehlik et al. discuss the need for further research on the relationships of RLS, sleep and widespread pain. From their data and other studies, it seems that there may be several hypotheses to investigate. (1) One hypothesis is that disturbed sleep is the primary problem and that this may be the principal or a major factor contributing to the development of both RLS and multisite pain. Could disturbed sleep or one of the aspects of disturbed sleep be the cause for either syndrome? (2) A second possible hypothesis is that RLS is primary and produces impaired sleep that leads to spreading pain. (3) A third hypothesis is that chronic pain is the primary driver that leads to poor sleep and also to RLS. But which comes first in chronic pain, the RLS or the disturbed sleep? (4) A fourth hypothesis, least likely, is that chronic pain is primary leading to the development of RLS and then poor sleep. Here is a challenge for the sleep, pain and RLS researchers. Perhaps Stehlik et al. will take up the challenge.

DOI of refers to article: http://dx.doi.org/10.1016/j.sjpain.2017.06.003.

Pain Center, Akademisk Sjukhuset, 751 85 Uppsala, Sweden

  1. Conflict of interest: The author declares no conflict of interest.

References

[1] Stehlik R, Ulfberg I, Zou D, Hedner J, Grote L. Sleep deficit is a strong predictor of RLS in multisite pain - a population based study in middle aged females. Scand J Pain 2017;17:1–7.Search in Google Scholar

[2] Becker PM, Novak M. Diagnosis, comorbidities, and management of restless legs syndrome. Curr Med Res Opin 2014;30:1441–60.Search in Google Scholar

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[4] Cho YW, Song ML, Early CJ, Allen RP. Prevalence and clinical characteristics of patients with restless legs syndrome with painful symptoms. Sleep Med 2015;16:775–8.Search in Google Scholar

[5] Stehlik R, Ulfberg J, Hedner J, Grote L. High prevalence of restless legs syndrome among women with multisite pain: a population-based study in Dalarna, Sweden. Eur J Pain 2014;18:1402–9.Search in Google Scholar

[6] Gooneratne NS, Bellamy SL, Pack F, Staney B, Schutte-Rodin S, Dinges DF, Pack AI. Case-control study of subjective and objective differences in sleep patterns in older adults with insomnia symptoms. J Sleep Res 2011;20:434–44.Search in Google Scholar

[7] Diaz-Piedra C, Catena A, Sánchez A, Miró E, Pilar Martinez M, Buela-Casal G. Sleep disturbances in firbromyalgia syndrome: the role of clinical and polysomnographic variables explaining poor sleep quality in patients. Sleep Med 2015;16:917–25.Search in Google Scholar

[8] Hannisdal E, Rasmussen K. Medical study plan in Tromsø. Experience and proposal for change after 10 years. Tidsskr Nor Laegeforen 1984;104:1070–4.Search in Google Scholar

[9] Krokstad S, Langhammer A, Hveem K, Holmen TL, Midthjell K, Stene TR, Bratberg G, Heggland J, Holmen J. Cohort profile: The HUNT study, Norway. Int J Epidemiol 2013;42:968–77.Search in Google Scholar
Published Online: 2017-10-01
Published in Print: 2017-10-01

© 2017 Scandinavian Association for the Study of Pain

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  3. Clinical pain research
  4. Prospective, double blind, randomized, controlled trial comparing vapocoolant spray versus placebo spray in adults undergoing intravenous cannulation
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  8. Clinical outcome following anterior arthrodesis in patients with presumed sacroiliac joint pain
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  16. Comparison of patients diagnosed with “complex pain” and “somatoform pain”
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  25. Observational study
  26. Long-term treatment in chronic noncancer pain: Results of an observational study comparing opioid and nonopioid therapy
  27. Clinical pain research
  28. COMBAT study – Computer based assessment and treatment – A clinical trial evaluating impact of a computerized clinical decision support tool on pain in cancer patients
  29. Original experimental
  30. Quantitative sensory tests fairly reflect immediate effects of oxycodone in chronic low-back pain
  31. Editorial comment
  32. Spatial summation of pain and its meaning to patients
  33. Original experimental
  34. Effects of validating communication on recall during a pain-task in healthy participants
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  37. Editorial comment
  38. Behavioural inhibition in the context of pain: Measurement and conceptual issues
  39. Clinical pain research
  40. A randomized study to evaluate the analgesic efficacy of a single dose of the TRPV1 antagonist mavatrep in patients with osteoarthritis
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  42. Quantitative sensory tests (QST) are promising tests for clinical relevance of anti–nociceptive effects of new analgesic treatments
  43. Educational case report
  44. Pregabalin as adjunct in a multimodal pain therapy after traumatic foot amputation — A case report of a 4-year-old girl
  45. Editorial comment
  46. Severe side effects from intrathecal morphine for chronic pain after repeated failed spinal operations
  47. Editorial comment
  48. Opioids in chronic pain – Primum non nocere
  49. Editorial comment
  50. Finally a promising analgesic signal in a long-awaited new class of drugs: TRPV1 antagonist mavatrep in patients with osteoarthritis (OA)
  51. Observational study
  52. The relationship between chronic musculoskeletal pain, anxiety and mindfulness: Adjustments to the Fear-Avoidance Model of Chronic Pain
  53. Clinical pain research
  54. Opioid tapering in patients with prescription opioid use disorder: A retrospective study
  55. Editorial comment
  56. Sleep, widespread pain and restless legs — What is the connection?
  57. Editorial comment
  58. Broadening the fear-avoidance model of chronic pain?
  59. Observational study
  60. Identifying characteristics of the most severely impaired chronic pain patients treated at a specialized inpatient pain clinic
  61. Editorial comment
  62. The burden of central anticholinergic drugs increases pain and cognitive dysfunction. More knowledge about drug-interactions needed
  63. Editorial comment
  64. A case-history illustrates importance of knowledge of drug-interactions when pain-patients are prescribed non-pain drugs for co-morbidities
  65. Editorial comment
  66. Why can multimodal, multidisciplinary pain clinics not help all chronic pain patients?
  67. Topical review
  68. Individual variability in clinical effect and tolerability of opioid analgesics – Importance of drug interactions and pharmacogenetics
  69. Editorial comment
  70. A new treatable chronic pain diagnosis? Flank pain caused by entrapment of posterior cutaneous branch of intercostal nerves, lateral ACNES coined LACNES
  71. Clinical pain research
  72. PhKv a toxin isolated from the spider venom induces antinociception by inhibition of cholinesterase activating cholinergic system
  73. Clinical pain research
  74. Lateral Cutaneous Nerve Entrapment Syndrome (LACNES): A previously unrecognized cause of intractable flank pain
  75. Editorial comment
  76. Towards a structured examination of contextual flexibility in persistent pain
  77. Clinical pain research
  78. Context sensitive regulation of pain and emotion: Development and initial validation of a scale for context insensitive avoidance
  79. Editorial comment
  80. Is the search for a “pain personality” of added value to the Fear-Avoidance-Model (FAM) of chronic pain?
  81. Editorial comment
  82. Importance for patients of feeling accepted and understood by physicians before and after multimodal pain rehabilitation
  83. Editorial comment
  84. A glimpse into a neglected population – Emerging adults
  85. Observational study
  86. Assessment and treatment at a pain clinic: A one-year follow-up of patients with chronic pain
  87. Clinical pain research
  88. Randomized, double-blind, placebo-controlled, dose-escalation study: Investigation of the safety, pharmacokinetics, and antihyperalgesic activity of L-4-chlorokynurenine in healthy volunteers
  89. Clinical pain research
  90. Prevalence and characteristics of chronic pain: Experience of Niger
  91. Observational study
  92. The use of rapid onset fentanyl in children and young people for breakthrough cancer pain
  93. Original experimental
  94. Acid-induced experimental muscle pain and hyperalgesia with single and repeated infusion in human forearm
  95. Original experimental
  96. Swearing as a response to pain: A cross-cultural comparison of British and Japanese participants
  97. Clinical pain research
  98. The cognitive impact of chronic low back pain: Positive effect of multidisciplinary pain therapy
  99. Clinical pain research
  100. Central sensitization associated with low fetal hemoglobin levels in adults with sickle cell anemia
  101. Topical review
  102. Targeting cytokines for treatment of neuropathic pain
  103. Original experimental
  104. What constitutes back pain flare? A cross sectional survey of individuals with low back pain
  105. Original experimental
  106. Coping with pain in intimate situations: Applying the avoidance-endurance model to women with vulvovaginal pain
  107. Clinical pain research
  108. Chronic low back pain and the transdiagnostic process: How do cognitive and emotional dysregulations contribute to the intensity of risk factors and pain?
  109. Original experimental
  110. The impact of the Standard American Diet in rats: Effects on behavior, physiology and recovery from inflammatory injury
  111. Educational case report
  112. Erector spinae plane (ESP) block in the management of post thoracotomy pain syndrome: A case series
  113. Original experimental
  114. Hyperbaric oxygenation alleviates chronic constriction injury (CCI)-induced neuropathic pain and inhibits GABAergic neuron apoptosis in the spinal cord
  115. Observational study
  116. Predictors of chronic neuropathic pain after scoliosis surgery in children
  117. Clinical pain research
  118. Hospitalization due to acute exacerbation of chronic pain: An intervention study in a university hospital
  119. Clinical pain research
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  122. Implicit evaluations and physiological threat responses in people with persistent low back pain and fear of bending
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  124. Unpredictable pain timings lead to greater pain when people are highly intolerant of uncertainty
  125. Original experimental
  126. Initial validation of the exercise chronic pain acceptance questionnaire
  127. Clinical pain research
  128. Exploring patient experiences of a pain management centre: A qualitative study
  129. Clinical pain research
  130. Narratives of life with long-term low back pain: A follow up interview study
  131. Observational study
  132. Pain catastrophizing, perceived injustice, and pain intensity impair life satisfaction through differential patterns of physical and psychological disruption
  133. Clinical pain research
  134. Chronic pain disrupts ability to work by interfering with social function: A cross-sectional study
  135. Original experimental
  136. Evaluation of external vibratory stimulation as a treatment for chronic scrotal pain in adult men: A single center open label pilot study
  137. Observational study
  138. Impact of analgesics on executive function and memory in the Alzheimer’s Disease Neuroimaging Initiative Database
  139. Clinical pain research
  140. Visualization of painful inflammation in patients with pain after traumatic ankle sprain using [11C]-D-deprenyl PET/CT
  141. Original experimental
  142. Developing a model for measuring fear of pain in Norwegian samples: The Fear of Pain Questionnaire Norway
  143. Topical review
  144. Psychoneuroimmunological approach to gastrointestinal related pain
  145. Letter to the Editor
  146. Do we need an updated definition of pain?
  147. Narrative review
  148. Is acetaminophen safe in pregnancy?
  149. Book Review
  150. Physical Diagnosis of Pain
  151. Book Review
  152. Advances in Anesthesia
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https://doi.org/10.1016/j.sjpain.2017.09.011

Articles in the same Issue

  1. Observational study
  2. Perceived sleep deficit is a strong predictor of RLS in multisite pain – A population based study in middle aged females
  3. Clinical pain research
  4. Prospective, double blind, randomized, controlled trial comparing vapocoolant spray versus placebo spray in adults undergoing intravenous cannulation
  5. Clinical pain research
  6. The Functional Barometer — An analysis of a self-assessment questionnaire with ICF-coding regarding functional/activity limitations and quality of life due to pain — Differences in age gender and origin of pain
  7. Clinical pain research
  8. Clinical outcome following anterior arthrodesis in patients with presumed sacroiliac joint pain
  9. Observational study
  10. Chronic disruptive pain in emerging adults with and without chronic health conditions and the moderating role of psychiatric disorders: Evidence from a population-based cross-sectional survey in Canada
  11. Educational case report
  12. Management of patients with pain and severe side effects while on intrathecal morphine therapy: A case study
  13. Clinical pain research
  14. Behavioral inhibition, maladaptive pain cognitions, and function in patients with chronic pain
  15. Observational study
  16. Comparison of patients diagnosed with “complex pain” and “somatoform pain”
  17. Original experimental
  18. Patient perspectives on wait times and the impact on their life: A waiting room survey in a chronic pain clinic
  19. Topical review
  20. New evidence for a pain personality? A critical review of the last 120 years of pain and personality
  21. Clinical pain research
  22. A multi-facet pain survey of psychosocial complaints among patients with long-standing non-malignant pain
  23. Clinical pain research
  24. Pain patients’ experiences of validation and invalidation from physicians before and after multimodal pain rehabilitation: Associations with pain, negative affectivity, and treatment outcome
  25. Observational study
  26. Long-term treatment in chronic noncancer pain: Results of an observational study comparing opioid and nonopioid therapy
  27. Clinical pain research
  28. COMBAT study – Computer based assessment and treatment – A clinical trial evaluating impact of a computerized clinical decision support tool on pain in cancer patients
  29. Original experimental
  30. Quantitative sensory tests fairly reflect immediate effects of oxycodone in chronic low-back pain
  31. Editorial comment
  32. Spatial summation of pain and its meaning to patients
  33. Original experimental
  34. Effects of validating communication on recall during a pain-task in healthy participants
  35. Original experimental
  36. Comparison of spatial summation properties at different body sites
  37. Editorial comment
  38. Behavioural inhibition in the context of pain: Measurement and conceptual issues
  39. Clinical pain research
  40. A randomized study to evaluate the analgesic efficacy of a single dose of the TRPV1 antagonist mavatrep in patients with osteoarthritis
  41. Editorial comment
  42. Quantitative sensory tests (QST) are promising tests for clinical relevance of anti–nociceptive effects of new analgesic treatments
  43. Educational case report
  44. Pregabalin as adjunct in a multimodal pain therapy after traumatic foot amputation — A case report of a 4-year-old girl
  45. Editorial comment
  46. Severe side effects from intrathecal morphine for chronic pain after repeated failed spinal operations
  47. Editorial comment
  48. Opioids in chronic pain – Primum non nocere
  49. Editorial comment
  50. Finally a promising analgesic signal in a long-awaited new class of drugs: TRPV1 antagonist mavatrep in patients with osteoarthritis (OA)
  51. Observational study
  52. The relationship between chronic musculoskeletal pain, anxiety and mindfulness: Adjustments to the Fear-Avoidance Model of Chronic Pain
  53. Clinical pain research
  54. Opioid tapering in patients with prescription opioid use disorder: A retrospective study
  55. Editorial comment
  56. Sleep, widespread pain and restless legs — What is the connection?
  57. Editorial comment
  58. Broadening the fear-avoidance model of chronic pain?
  59. Observational study
  60. Identifying characteristics of the most severely impaired chronic pain patients treated at a specialized inpatient pain clinic
  61. Editorial comment
  62. The burden of central anticholinergic drugs increases pain and cognitive dysfunction. More knowledge about drug-interactions needed
  63. Editorial comment
  64. A case-history illustrates importance of knowledge of drug-interactions when pain-patients are prescribed non-pain drugs for co-morbidities
  65. Editorial comment
  66. Why can multimodal, multidisciplinary pain clinics not help all chronic pain patients?
  67. Topical review
  68. Individual variability in clinical effect and tolerability of opioid analgesics – Importance of drug interactions and pharmacogenetics
  69. Editorial comment
  70. A new treatable chronic pain diagnosis? Flank pain caused by entrapment of posterior cutaneous branch of intercostal nerves, lateral ACNES coined LACNES
  71. Clinical pain research
  72. PhKv a toxin isolated from the spider venom induces antinociception by inhibition of cholinesterase activating cholinergic system
  73. Clinical pain research
  74. Lateral Cutaneous Nerve Entrapment Syndrome (LACNES): A previously unrecognized cause of intractable flank pain
  75. Editorial comment
  76. Towards a structured examination of contextual flexibility in persistent pain
  77. Clinical pain research
  78. Context sensitive regulation of pain and emotion: Development and initial validation of a scale for context insensitive avoidance
  79. Editorial comment
  80. Is the search for a “pain personality” of added value to the Fear-Avoidance-Model (FAM) of chronic pain?
  81. Editorial comment
  82. Importance for patients of feeling accepted and understood by physicians before and after multimodal pain rehabilitation
  83. Editorial comment
  84. A glimpse into a neglected population – Emerging adults
  85. Observational study
  86. Assessment and treatment at a pain clinic: A one-year follow-up of patients with chronic pain
  87. Clinical pain research
  88. Randomized, double-blind, placebo-controlled, dose-escalation study: Investigation of the safety, pharmacokinetics, and antihyperalgesic activity of L-4-chlorokynurenine in healthy volunteers
  89. Clinical pain research
  90. Prevalence and characteristics of chronic pain: Experience of Niger
  91. Observational study
  92. The use of rapid onset fentanyl in children and young people for breakthrough cancer pain
  93. Original experimental
  94. Acid-induced experimental muscle pain and hyperalgesia with single and repeated infusion in human forearm
  95. Original experimental
  96. Swearing as a response to pain: A cross-cultural comparison of British and Japanese participants
  97. Clinical pain research
  98. The cognitive impact of chronic low back pain: Positive effect of multidisciplinary pain therapy
  99. Clinical pain research
  100. Central sensitization associated with low fetal hemoglobin levels in adults with sickle cell anemia
  101. Topical review
  102. Targeting cytokines for treatment of neuropathic pain
  103. Original experimental
  104. What constitutes back pain flare? A cross sectional survey of individuals with low back pain
  105. Original experimental
  106. Coping with pain in intimate situations: Applying the avoidance-endurance model to women with vulvovaginal pain
  107. Clinical pain research
  108. Chronic low back pain and the transdiagnostic process: How do cognitive and emotional dysregulations contribute to the intensity of risk factors and pain?
  109. Original experimental
  110. The impact of the Standard American Diet in rats: Effects on behavior, physiology and recovery from inflammatory injury
  111. Educational case report
  112. Erector spinae plane (ESP) block in the management of post thoracotomy pain syndrome: A case series
  113. Original experimental
  114. Hyperbaric oxygenation alleviates chronic constriction injury (CCI)-induced neuropathic pain and inhibits GABAergic neuron apoptosis in the spinal cord
  115. Observational study
  116. Predictors of chronic neuropathic pain after scoliosis surgery in children
  117. Clinical pain research
  118. Hospitalization due to acute exacerbation of chronic pain: An intervention study in a university hospital
  119. Clinical pain research
  120. A novel miniature, wireless neurostimulator in the management of chronic craniofacial pain: Preliminary results from a prospective pilot study
  121. Clinical pain research
  122. Implicit evaluations and physiological threat responses in people with persistent low back pain and fear of bending
  123. Original experimental
  124. Unpredictable pain timings lead to greater pain when people are highly intolerant of uncertainty
  125. Original experimental
  126. Initial validation of the exercise chronic pain acceptance questionnaire
  127. Clinical pain research
  128. Exploring patient experiences of a pain management centre: A qualitative study
  129. Clinical pain research
  130. Narratives of life with long-term low back pain: A follow up interview study
  131. Observational study
  132. Pain catastrophizing, perceived injustice, and pain intensity impair life satisfaction through differential patterns of physical and psychological disruption
  133. Clinical pain research
  134. Chronic pain disrupts ability to work by interfering with social function: A cross-sectional study
  135. Original experimental
  136. Evaluation of external vibratory stimulation as a treatment for chronic scrotal pain in adult men: A single center open label pilot study
  137. Observational study
  138. Impact of analgesics on executive function and memory in the Alzheimer’s Disease Neuroimaging Initiative Database
  139. Clinical pain research
  140. Visualization of painful inflammation in patients with pain after traumatic ankle sprain using [11C]-D-deprenyl PET/CT
  141. Original experimental
  142. Developing a model for measuring fear of pain in Norwegian samples: The Fear of Pain Questionnaire Norway
  143. Topical review
  144. Psychoneuroimmunological approach to gastrointestinal related pain
  145. Letter to the Editor
  146. Do we need an updated definition of pain?
  147. Narrative review
  148. Is acetaminophen safe in pregnancy?
  149. Book Review
  150. Physical Diagnosis of Pain
  151. Book Review
  152. Advances in Anesthesia
  153. Book Review
  154. Atlas of Pain Management Injection Techniques
  155. Book Review
  156. Sedation: A Guide to Patient Management
  157. Book Review
  158. Basics of Anesthesia
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