The Relationship Between Stage III + IV + REM Sleep and Arousals with Migraine

SYNOPSIS
Three studies are presented investigating the relationship between sleep stages and the onset of migraine on awakening. Study I consists of the polygraphic recording of daytime naps in patients who suffer from sleep-precipitated migraine. All headache naps contained Stages III, IV or REM Sleep.
The second study is that of serotonin levels during napping in which serotonin levels were stable during naps in which only Stages I and II were recorded. During naps when Stages III, IV or REM Sleep were recorded, there was considerable variation in serotonin levels.
The final study is that of nocturnal sleep periods associated with morning awakening with headache or the onset of headache within 1 hour. The results of this study show an association between nights of increased Stage III + IV + REM sleep and those mornings when headaches occur.     

Autonomic pain responses during sleep: A study of heart rate variability

The autonomic nervous system (ANS) reacts to nociceptive stimulation during sleep, but whether this reaction is contingent to cortical arousal, and whether one of the autonomic arms (sympathetic/parasympathetic) predominates over the other remains unknown. We assessed ANS reactivity to nociceptive stimulation during all sleep stages through heart rate variability, and correlated the results with the presence of cortical arousal measured in concomitant 32‐channel EEG. Fourteen healthy volunteers underwent whole‐night polysomnography during which nociceptive laser stimuli were applied over the hand. RR intervals (RR) and spectral analysis by wavelet transform were performed to assess parasympathetic (HF^WV) and sympathetic (LF^WV and LF^WV/HF^WV ratio) reactivity. During all sleep stages, RR significantly decreased in reaction to nociceptive stimulations, reaching a level similar to that of wakefulness, at the 3rd beat post‐stimulus and returning to baseline after seven beats. This RR decrease was associated with an increase in sympathetic LF^WV and LF^WV/HF^WV ratio without any parasympathetic HF^WV change. Albeit RR decrease existed even in the absence of arousals, it was significantly higher when an arousal followed the noxious stimulus. These results suggest that the sympathetic‐dependent cardiac activation induced by nociceptive stimuli is modulated by a sleep dependent phenomenon related to cortical activation and not by sleep itself, since it reaches a same intensity whatever the state of vigilance.     

Comparison of scapular kinematics between elevation and lowering of the arm in the scapular plane

Objective. To compare scapular orientation during both the concentric (elevation) and eccentric (lowering) phases of scapular plane abduction in subjects with and without shoulder impingement.

Design. Mixed model analysis of variance with one between-subjects factor (group) and within-subjects factors of phase, humeral angle, and trial.

Background. Abnormal scapular kinematics have been identified in shoulder impingement patients during the concentric phase of arm elevation, and under static conditions. Because abnormal scapular motion is observed clinically during the eccentric phase of arm elevation, analysis of this phase of motion is warranted.

Methods. Twenty-six symptomatic and 26 healthy subjects performed five repetitions of humeral scapular plane abduction. An electromagnetic tracking device described three-dimensional scapular kinematics during arm elevation and lowering. Angular values for scapular anterior/posterior tipping in the sagittal plane, upward/downward rotation in the scapular plane, and internal/external rotation in the transverse plane were calculated. Scapular orientation relative to the thorax at humeral angles of 40°, 60°, 80°, 100°, and 120° was statistically tested for effects of phase and trial, or for interactions of phase with group or humeral angle.

Results. Internal rotation was significantly increased in the eccentric phase for both groups at the 100° angle (P<0.05) and for the symptomatic group only at the 120° angle (P<0.05). Scapular anterior tipping was significantly decreased during the eccentric phase in both groups at the 80° (P<0.001), 100° (P<0.0001), and 120° (P<0.0001) angles.

Conclusions. Small but statistically significant differences in scapular tipping and internal rotation during the eccentric phase of arm elevation were identified at higher humeral angles in both subject groups, while no significant phase differences for scapular upward rotation or for scapular variables at lower humeral angles were found. Averaged across phases, the symptomatic group demonstrated significant reductions in upward rotation at lower humeral elevation angles, and significant increases in anterior tipping at higher elevation angles as compared to the healthy group.

Relevance Normal and abnormal scapular kinematics during varying types of motion need to be understood in order to optimally design rehabilitation programs for individuals with impingement syndrome.     

脑梗死恢复期患者的多道睡眠图评价

目的 探讨脑梗死恢复期患者睡眠参数改变的生物学特点。方法 应用多道睡眠图对36例脑梗死恢复期患者进行睡眠描记，分析相关睡眠参数，并与20例正常人比较。结果 脑梗死恢复期患者睡眠伏期延长（38.44min）、总睡眠时间减少（259.71min）、中途醒转次数增多(7.55次）、睡眠效率低（58.06%)、眼动（REM）睡眠潜伏期缩短（62.36min）、REM睡眠时间（32.42min）和REM活动度（67.91单位）减少（P＜0.05-0.01)。结论 脑梗死恢复期患者不但有睡眠量的减少，而且伴有睡眠质的改变，其中REM睡眠潜伏期、REM睡眠时间和REM活动度是评价脑功能恢复的客观指标。     

Pregabalin for the treatment of painful diabetic peripheral neuropathy: a double-blind, placebo-controlled trial

A randomized, double-blind, placebo-controlled, parallel-group, multicenter, 8-week trial (with subsequent open-label phase) evaluated the effectiveness of pregabalin in alleviating pain associated with diabetic peripheral neuropathy (DPN). For enrollment, patients must have had at baseline: 1- to 5-year history of DPN pain; pain score ≥40 mm (Short-Form McGill Pain Questionnaire [SF-MPQ] visual analogue scale); average daily pain score of ≥4 (11-point numerical pain rating scale [0=no pain, 10=worst possible pain]). One hundred forty-six (146) patients were randomized to receive placebo (n=70) or pregabalin 300 mg/day (n=76). Primary efficacy measure was endpoint mean pain score from daily patient diaries (11-point numerical pain rating scale). Secondary measures included SF-MPQ scores; sleep interference scores; Patient and Clinical Global Impression of Change (PGIC and CGIC); Short Form-36 (SF-36) Health Survey scores; and Profile of Mood States (POMS) scores. Safety assessment included incidence and intensity of adverse events, physical and neurological examinations, and laboratory evaluations. Pregabalin produced significant improvements versus placebo for mean pain scores (P<0.0001); mean sleep interference scores (P<0.0001); total SF-MPQ score (P<0.01); SF-36 Bodily Pain subscale (P<0.03); PGIC (P=0.001); and Total Mood Disturbance and Tension–Anxiety components of POMS (P<0.03). Pain relief and improved sleep began during week 1 and remained significant throughout the study (P<0.01). Pregabalin was well tolerated despite a greater incidence of dizziness and somnolence than placebo. Most adverse events were mild to moderate and did not result in withdrawal. Pregabalin was safe and effective in decreasing pain associated with DPN, and also improved mood, sleep disturbance, and quality of life.     

Heart rate variability during sleep in patients with vasovagal syncope

Background: There are a few studies showing no significant heart rate variability (HRV) over a 24-hour period in vasovagal syncope (VVS) patients, but no research has examined HRV and its sympathetic and parasympathetic components during rapid eye movement (REM) and non-REM sleep. The authors hypothesized that REM sleep might be a critical state in which VVS patients would show abnormal responses.
Objectives: To analyze the sympathetic and parasympathetic components of HRV during REM and SWS in patients with VVS compared to normal subjects, and in patients with positive HUTT compared to negative ones.
Methods: Thirty-seven VVS patients and 20 normal age-matched controls were submitted to polysomnography with 24-hour Holter monitoring to assess HRV. Time and frequency domain techniques were carefully performed for 24 hours and during Stages 3 and 4 of REM and non-REM sleep. Variation of sympathetic activity index (VSAI) was defined as the difference in the low frequency (LF) component of HRV between REM and Stages 3 and 4 of non-REM sleep. An analysis of variance was performed to compare patients and controls; patients with positive and negative head-up tilt testing.
Results: The LF component was lower in syncope compared to normal patients (1,769.54 ± 1,738.17, 3,225.37 ± 2,585.05, respectively, P = 0.03). There was a significant decrease in VSAI in the syncope group compared to the control group (−539.39 ± 1,930.78, 1,268.10 ± 2,420.20, respectively, P = 0.01). The other sleep variables analyzed including very LF, high frequency, low frequency/high frequency and time domain parameters did not reach statistical significance. Syncope patients also showed an increase in slow wave sleep (28.2 ± 10.5, 19.7 ± 7.8, P = 0.01).
Conclusions: VVS patients exhibited sympathetic suppression during REM sleep. Possible mechanisms are discussed in this article.     

Laser evoked responses to painful stimulation persist during sleep and predict subsequent arousals

We studied behavioural responses and 32-channel brain potentials to nociceptive stimuli during all-night sleep in 12 healthy subjects, using sequences of thermal laser pulses delivered over the dorsum of the hand. Laser stimuli less than 20 dB over perception threshold had clear awakening properties, in accordance with the intrinsic threatening value of nociceptive signals. Even in cases where nociceptive stimulation did not interrupt sleep, it triggered motor responses in 11% of trials. Only four subjects reported dreams, and on morning questionnaires there was no evidence of incorporation to dreams of nociceptive stimuli. Contrary to previous reports suggesting the absence of cortical nociceptive responses during sleep, we were able to record brain-evoked potentials to laser (LEPs) during all sleep stages. Sleep LEPs were in general attenuated, but their morphology was sleep-stage-dependent: in stage 2, the weakened initial response was often followed by a high-amplitude negative wave with typical features of a K-complex. During paradoxical sleep (PS) LEP morphology was similar to that of waking, but frontal components showed strong attenuation, consistent with the reported frontal metabolic deactivation. A late positive component (450–650 ms) was recorded in both stage 2 and PS, the amplitude of which was significantly enhanced in trials that were followed by an arousal. This response appeared functionally related to the P3 wave, which in waking subjects has been associated to conscious perception and memory encoding.     

松郁安神方对PCPA致失眠大鼠睡眠时相的影响

目的:观察松郁安神方对失眠大鼠睡眠时相的影响.方法:采用腹腔注射对氯苯丙氨酸(Para-chlorophenylalanine,PCPA)建立失眠大鼠模型,用松郁安神方进行干预,通过动物睡眠生物解析系统,记录脑电(Electroencephalogram,EEG)和肌电(Electromyogram,EMG),分析睡眠...     

Tonic pain: a SPET study in normal subjects and cluster headache patients

Whether the pathogenesis of cluster headache (CH) is peripheral or central is still matter of debate. An involvement of central structures related to pain perception and modulation, which also causes an alteration of the physiological pattern of pain perception in CH, has been hypothesized. We investigated the pattern of brain response to pain in normal subjects and CH patients by evaluating the cerebral blood flow (CBF) changes using an experimental model of tonic aching pain stimulation, the cold water pressor test (CWPT). CBF was assessed quantitatively by the Xe-133 inhalation method and single photon emission tomography (SPET), at rest and during CWPT, as previously described (Di Piero et al., 1994). CWPT was performed in 12 volunteers and in seven patients with CH. All the CH patients had a left-sided headache and were studied in a headache-free phase out of the cluster period. During CWPT, volunteers showed a significant CBF increase in the contralateral primary sensorimotor (P<0.001), frontal (P<0.01) and temporal (P<0.002) regions and thalamus (P<0.01) and in the ipsilateral temporal (P<0.005) and anterior cingulate (P<0.01) regions. During left-hand stimulation (ipsilateral to the headache side) by CWPT in CH patients, CBF changes were significantly lower than those observed in volunteers in the contralateral primary sensorimotor region (P<0.0005) and thalamus region (P<0.01). There were no significant differences in the brain response observed during the stimulation of the hand contralateral to the headache side. In conclusion, in a headache-free phase out of the cluster period, the pattern of cerebral activation during tonic pain stimulation of the hand ipsilateral to the headache side is critically modified in CH patients in areas which are probably involved in the detection of the stimulus intensity. This modification may reflect a marker of a biological modification of the pain conveyance system. The fact that it is also present out of the active period of the disease, suggests a possible involvement of central tonic pain mechanisms in the pathogenesis of CH.     

Oral mucosal blood flow in patients with burning mouth syndrome

The pathophysiology of burning mouth syndrome (BMS) is largely unknown. Thus, the aim was to study oral mucosal blood flow in BMS-patients using laser Doppler flowmetry (LDF). Thirteen BMS patients (11 female, two male; mean age±SD 64.3±7.9 years, mean disease duration 18.9±6.2 months) and 13 healthy non-smoking controls matched for age and gender (11 female, two male; mean age 64.7±8.1 years) were investigated. Using the LDF technique mucosal blood flow (mBF) was measured at the hard palate, the tip of the tongue, on the midline of the oral vestibule, and on the lip. Measurements were made at rest and over 2 min following dry ice application of 10 s duration using a pencil shaped apparatus. In addition, blood pressure (BP), heart rate (HR), peripheral cutaneous blood flow, and transcutaneous pCO₂ were continuously recorded. Mucosal blood flow (mBF) increased at all measurement sites in response to dry ice application (P<0.001) with peak flow at 0.5–1.5 min after stimulation onset. During the following 1.5–2 min, blood flow decreased at all sites with a tendency to return to baseline towards the end of the observation period. Except for BP and peripheral blood flow, all of the cardiovascular changes exhibited significant changes during the observation period; no differences between groups were detected. When compared to healthy controls BMS patients generally exhibited larger changes in mBF. These changes were significant for recordings made on the hard palate (F[1,24]=13.9, P<0.001). Dry ice stimulation appears to be an effective, non-invasive and reasonably tolerable means to investigate mucosal blood flow at different mucosal sites. In general, vasoreactivity in BMS patients was higher than in healthy controls. BMS patients exhibited a higher response on the hard palate compared to controls. These changes in oral blood flow appear to be specifically related to BMS symptoms indicating a disturbed vasoreactivity.     

Sleep arousal response to experimental thermal stimulation during sleep in human subjects free of pain and sleep problems

Although the interaction between sleep and pain is generating considerable interest (NIH Technology Assessment Panel, 1996), it is still unknown if chronic pain is the cause or effect of poor sleep. To further this understanding, subjects free of pain and sleep problems need to be studied in order to assess their response to pain during sleep, defined as a behavioral and a physiological state in which sensory processing is altered. (For example, while auditory perception remains active, other sensory inputs are facilitated, attenuated, or suppressed (Velluti, 199746 degrees C) was statistically greater in the lighter sleep stage 2 (48.3%) than in the deeper stages 3&4 (27.9%). A nocifensive behavioral-motor response was associated with only 2.5% of the 351 heat pain stimuli. Two other markers of sleep quality-sleep stage shift and awakening-were not influenced by the thermal stimuli. None of the subjects demonstrated any burns in the morning following the thermal stimulations applied during sleep. We conclude that the processing of nociceptive inputs is attenuated across sleep stages.     

The effects of a non-competitive NMDA receptor antagonist, MK-801, on behavioral hyperalgesia and dorsal horn neuronal activity in rats with unilateral inflammation

The involvement of NMDA receptors in rats with peripheral inflammation and hyperalgesia was evaluated by administration of the non-competitive NMDA receptor antagonist, MK-801. Inflammation and hyperalgesia was induced by intradermal injection of complete Freund's adjuvant (CFA) or carrageenan into the left hind paw. The latency of paw withdrawal from a thermal stimulus was used as a measure of hyperalgesia in awake rats. MK-801 (1.6 mg/kg, i.p., or 31.5 μg, intrathecal) significantly attenuated thermal hyperalgesia and reduced its duration in comparison to saline-injected rats (P < 0.05). The receptive field size of nociceptive-specific and wide-dynamic-range neurons in the superficial and deep spinal dorsal horn recorded 24 h after injection of CFA was significantly reduced to 73 ± 6% (P < 0.05, n = 8) and 74 ± 4% (P < 0.05, n = 8) of control values, respectively, by a cumulative dose of 3 mg/kg of MK-801 (i.v.). MK-801 (2 mg/kg) prevented the expansion of the receptive fields of dorsal horn neurons recorded 5 ± 0.4 h (n = 5) after intradermal injection of CFA as compared to saline-injected rats (P < 0.05). MK-801 had no significant effect on receptive field size of dorsal horn neurons in rats without CFA-induced inflammation but blocked a transient expansion of the receptive fields induced by 1 Hz, C-fiber intensity electrical stimulation of the sciatic nerve. The background activity and noxious heat-evoked response of dorsal horn neurons in rats with CFA-induced inflammation were primarily inhibited and noxious pinch-evoked activity was both facilitated and inhibited by the administration of MK-801. These results support the hypothesis that NMDA receptors are involved in the dorsal horn neuronal plasticity and behavioral hyperalgesia that follows peripheral tissue inflammation.     

Sleep quality of mechanically ventilated patients sedated with dexmedetomidine

Purpose

Dexmedetomidine is thought to activate an endogenous pathway that naturally promotes non-rapid eye movement (NREM) sleep. Dexmedetomidine may induce restorative sleep, that is, NREM stage 3 and 4 (slow wave sleep; SWS) or sleep continuity in mechanically ventilated patients. Few data have been published, however, on the sleep characteristics of mechanically ventilated patients during dexmedetomidine infusion.

Methods

We recorded polysomnography (PSG) for 24?h in mechanically ventilated patients sedated with dexmedetomidine. Dexmedetomidine (0.2–0.7 μg/kg/h) was administered intravenously to maintain the Richmond Agitation–Sedation Scale between ?1 and ?4 only during the nighttime (9:00 p.m. to 6:00 a.m.). During the daytime, we interrupted the sedatives and analgesics unless the patient complained of discomfort. When this occurred midazolam or opioids were administered intermittently. Sleep stages and the frequency of arousal/awakening during the nighttime were analyzed using Rechtschaffen and Kales criteria.

Results

For the ten mechanically ventilated adult patients recruited into the study, the median total sleep time (TST) during the night was 4.7?h (IQR, 4.2–8.1?h), and 78?% of sleep occurred during the night (median 78?%, IQR: 69–88?%). Sleep architecture was exclusively NREM sleep stage 1 (median 28.9?% of TST) and stage 2 (median 71.2?% of TST). Neither SWS (median 0?% of TST) nor rapid eye movement (REM) sleep (median 0?% of TST) was observed. Median frequency of arousals/awakenings was 9.3/h (IQR, 3–19.5/h).

Conclusions

In mechanically ventilated patients, nighttime infusion of dexmedetomidine preserved the day-night cycle of sleep but induced severely disturbed sleep architecture without evidence of SWS or REM sleep.     

Effect of nootropic drugs on normal and disturbed sleep of the elderly: controlled studies with pyridoxilate and street noise

The effect of the nootropic drug, piridoxilate on normal and on exogenously (by traffic noise) disturbed sleep and awakening quality was investigated in a double-blind placebo-controlled study. 10 elderly subjects with a mean age of 62 years spent 13 nights in the sleep laboratory: 2 adaptation nights, 1 baseline night, 3 drug nights (placebo, 300 and 600 mg piridoxilate), as well as 2 drug nights with nocturnal traffic noise (placebo and 600 mg piridoxilate) and the subsequent wash-out nights. Polysomnographic recordings (including EEG, EMG and EOG) were carried out between 10:30 p.m. and 6.00 a.m. Traffic noise was pre-recorded at a busy Viennese street and presented continuously by a loudspeaker with a sound pressure level at the ear of between 68 and 83 dB (A) [mean 75.6 dB (A)]. In the morning the subjects completed a sleep questionnaire for the subjective evaluation of their quality of sleep and awakening. Thereafter objective awakening quality was measured by a psychometric test battery. Piridoxilate did not induce any significant changes in objective and subjective sleep variables. Nocturnal traffic noise produced a decrease in total sleep time and sleep efficiency, an increase in wakefulness and drowsiness (stage 1), as well as a decrease in REM and deep sleep stages, the last-mentioned being of statistical significance. Subjectively, the elderly subjects reported a deterioration in sleep quality due to traffic noise, an increase in middle and late insomnia, as well as a deterioration in awakening quality (dizziness, tiredness, headaches). Piridoxilate did not ameliorate these sleep disturbances.(ABSTRACT TRUNCATED AT 250 WORDS)     

Ventricular Repolarization Dynamics During Different Sleep Stages in the Subacute Phase of Myocardial Infarction

Background: Ventricular arrhythmias after myocardial infarction (MI) are often nocturnal. However, the arrhythmogenic effects of sleep after MI are unknown. We examined the effects of sleep stages on QT dynamicity and tested the hypothesis of a differential effect of sleep stage on the QT/RR relationship after recent MI, versus in healthy controls (HC).
Methods: Polysomnography and electrocardiograms were simultaneously recorded in 21 men in the subacute phase of a first uncomplicated MI, and in 10 age-matched, male HC. QT dynamicity (QT/RR slope) and parameters of QT interval were measured during wakefulness, stages 1–4 of nonrapid eye movement (non-REM) sleep, and REM sleep.
Results: Mean QT and RR intervals increased through all sleep stages in both MI survivors and HC. The Bazett-corrected QT interval remained stable from wakefulness throughout all sleep stages. QT/RR slopes remained stable from wakefulness to stage 3 in both groups. However, unlike in MI survivors, the QT/RR slopes decreased and remained significantly lower during deep sleep and REM sleep in HC.
Conclusion: An abnormal QT/RR relationship in deep sleep and REM sleep was observed after a recent MI, reflecting an insufficient shortening of ventricular repolarization with increasing heart rates, which might have important implications in the nocturnal distribution of ventricular arrhythmias after MI.     

Chronic use of triazolam: the effects on the sleep patterns of insomniacs

The present study was designed to evaluate the effects of triazolam 0.5 mg on the sleep of insomniac patients when given for 3 weeks. The results showed that both acute and chronic triazolam administration are effective in decreasing sleep latency, increasing sleep duration, increasing sleep efficiency and decreasing total wake time without producing major effects on sleep staging. Sleep Stages 1 and 2 were significantly altered by drug treatment but in a positive direction. This change is primarily attributable to the significant decrease in sleep onset. Deep sleep and REM were not significantly changed during triazolam treatment nor was there any evidence of REM rebound after discontinuation of the medication. It was noted that some of the sleep parameters measured shifted toward baseline measures in the first night after triazolam treatment was terminated. However, the total recovery period recorded (7 days) showed the quality and quantity of sleep obtained to be improved over baseline measures. The recovery data compared favourably with those improvements noted during chronic administration of triazolam. It was also found that 3 weeks of triazolam 0.5 mg usage did not result in tolerance to its hypnotic properties. Thus, triazolam maintains its hypnotic effectiveness throughout 3 weeks of administration.     

The effects of total and REM sleep deprivation on laser-evoked potential threshold and pain perception

We investigated the effects of total and rapid eye movement (REM) sleep deprivation on the thermal nociceptive threshold and pain perception using the objective laser-evoked potential (LEP) and the subjective visual analogue scale (VAS). Twenty-eight male adult volunteers were assigned into Control (CTRL), Total (T-SD), and REM (REM-SD) Sleep Deprivation groups. The T-SD and REM-SD volunteers were totally or selectively deprived of sleep for 2 and 4 consecutive nights, respectively. Pain parameters were measured daily during the experimental period. Volunteers were stimulated on the back of the hand by blocks of 50 diode laser pulses. Intensities increased between successive blocks, ranging from nonnoxious to noxious levels, and the LEP threshold was identified based on the evoked-response onset. Both the LEP threshold and VAS ratings were significantly increased after the second night of T-SD. No significant variations were observed in the REM-SD group, suggesting a predominant role for slow wave sleep rather than selective REM-SD in pain perception. Also, for both sleep-deprived groups, the mean values of the LEP threshold and VAS ratings showed a gradual increase that was proportional to the SD deprivation time, followed by a decrease after 1 night of sleep restoration. These findings demonstrate a hyperalgesic modification to pain perception (as reflected by the augmented VAS) and a concomitant increase in the LEP threshold following T-SD, an apparently contradictory effect that can be explained by differences in the ways that attention affects these pain measurements.     

Hypnosis in the management of persistent idiopathic orofacial pain--clinical and psychosocial findings

This controlled and patient blinded study tested the effect of hypnosis on persistent idiopathic orofacial pain (PIOP) in terms of clinical and psychosocial findings. Forty-one PIOP were randomized to active hypnotic intervention or simple relaxation as control for five individual 1-h sessions. Primary outcome was average pain intensity scored three times daily in a pain diary using visual analogue scale (VAS). Secondary outcome measures were pain quality assessed by McGill pain questionnaire (MPQ), psychological symptoms assessed by symptom check list (SCL), quality of life assessed by SF36, sleep quality, and consumption of analgesic. Data were compared between groups before and after treatment using ANOVA models and paired t-tests. The change in VAS pain scores from baseline to the last treatment (t4) was (33.1 ± 7.4%) in the hypnosis group and (3.2 ± 5.4%) in the control group (P < 0.03). In the hypnosis group, highly hypnotic susceptible patients had greater decreases in VAS pain scores (55.0 ± 12.3%) when compared to less susceptible patients (17.9 ± 6.7%) (P < 0.02). After the last treatment there were also statistically significant differences between groups in perceived pain area (MPQ) and the use of weak analgesics (P < 0.03). There were no statistically significant changes in SCL or SF36 scores from baseline to t4. In conclusion, hypnosis seems to offer clinically relevant pain relief in PIOP, particularly in highly susceptible patients. However, stress coping skills and unresolved psychological problems need to be included in a comprehensive management plan in order also to address psychological symptoms and quality of life.