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    "textoCompleto" => "<p class="elsevierStylePara"><span class="elsevierStyleBold">INTRODUCTION</span></p><p class="elsevierStylePara">The cardiovascular system modulates the central processing of pain&#44; especially through changes in blood pressure &#40;BP&#41;&#44; constituting an important source of anti-nociception&#46;<span class="elsevierStyleSup">1</span> The subjective experience of pain is inversely correlated with BP levels&#44;<span class="elsevierStyleSup">1-3</span> such that patients with arterial hypertension perceive less pain and have lower sensitivity than normotensive subjects&#44; a phenomenon known as hypertension-induced hypoalgesia&#46;<span class="elsevierStyleSup">4</span> The perception of pain is also reduced in healthy people with moderately high BP values&#46;<span class="elsevierStyleSup">1&#44;2</span> On the contrary&#44; people with chronic arterial hypotension have higher sensitivity and an increased perception of pain as compared to normotensive subjects&#46;5&#44;6 In this manner&#44; courses of action that increase BP lead to reduced response to pain&#46;<span class="elsevierStyleSup">3</span></p><p class="elsevierStylePara">Epidemiologically&#44; some studies have shown that high BP levels protect the body against chronic pain&#44; such as headaches<span class="elsevierStyleSup">7</span> and musculoskeletal pain&#46;<span class="elsevierStyleSup">8</span> In the clinical setting&#44; chest pain experienced during physical exercise is inversely correlated with BP&#44;<span class="elsevierStyleSup">9</span> as occurs in post-operative pain&#46;<span class="elsevierStyleSup">10</span> The baroreflex is the primary mechanism used for the short-term regulation of BP and acts as an important source of autonomic cardiovascular regulation&#46; The central inhibitory effect that it causes is one of the fundamental mediating main mechanisms involved in explaining the pain-reducing effect of increased BP&#46;<span class="elsevierStyleSup">1&#44;4&#44;11&#44;12</span></p><p class="elsevierStylePara">Haemodialysis can present a favourable context for the analysis of the relationship between BP and pain&#46; Firstly&#44; reduced body liquid volume that is produced during haemodialysis could be associated with reduced BP&#44; which would allow for a more direct evaluation of the relationship between BP and pain&#46; Secondly&#44; chronic kidney disease is associated with autonomic cardiovascular changes&#44; which are in turn modified by the process of haemodialysis&#46;<span class="elsevierStyleSup">13-15</span> These autonomic changes could affect the afferent pain inhibition originating in the cardiovascular system&#46; Also&#44; several studies have shown that haemodialysis produces acute improvements in the cognitive deficits present in chronic kidney disease&#44; which could optimise the psychophysiological processes involved in the perception of pain and the relationships between pain and BP&#46;<span class="elsevierStyleSup">16&#44;17</span> Finally&#44; given the long duration of the procedure &#40;more than 4 hours&#41;&#44; haemodialysis provides a large database that can facilitate habituation to the psychological stress-related variables &#40;for example&#44; social interactions or previous activity&#41;&#44; reducing the effects that interfere with the relationship between BP and pain&#46; The importance of obtaining reliable measurements of at-rest cardiovascular activity has been emphasised for a very long time in psychophysiological literature&#46;<span class="elsevierStyleSup">18</span> These studies suggest the importance of using appropriate baseline periods before registering physiological parameters&#44; and it is recommended that they be long enough &#40;no less than 15min&#41;&#46;<span class="elsevierStyleSup">18</span> The haemodialysis procedure widely complies with this requirement&#46;</p><p class="elsevierStylePara">In this context&#44; the objectives of our study were&#58; <span class="elsevierStyleItalic">1&#41;</span> to analyse the relationship between BP and pain at the start and end of haemodialysis&#44; and <span class="elsevierStyleItalic">2&#41;</span> to analyse the changes in BP and pain during haemodialysis from start to end&#46; We used pressure algometry to generate pain so as to establish pain thresholds&#46; Our hypotheses were&#58; <span class="elsevierStyleItalic">1&#41;</span> that we would observe a positive relationship between BP and pain threshold&#44; and that this association would be greater at the end of dialysis than at the start&#44; and <span class="elsevierStyleItalic">2&#41;</span> that BP and pain thresholds would be reduced at the end of dialysis as compared to the start&#46;</p><p class="elsevierStylePara"><span class="elsevierStyleBold">METHOD</span></p><p class="elsevierStylePara">Patients with chronic kidney disease undergoing haemodialysis treatment &#40;online&#41; were selected from the Santa Catalina dialysis centre &#40;Jaen&#41;&#46; The inclusion criteria were&#58; age &#60;56 years &#40;in order to ensure optimal understanding of the instructions and a good general state of health&#41; and signed informed consent&#46; The exclusion criteria were&#58; suffering from any type of chronic pain disorder&#44; or the use of analgesic&#44; antidepressive&#44; or anxiolytic agents&#46; All patients that complied with these criteria participated in the study&#46; In this manner&#44; the sample was made of 14 patients &#40;nine men and five women&#41; with ages ranging from 23 years to 55 years &#40;mean&#58; 43&#44; standard deviation &#91;SD&#93;&#58; 9&#46;9&#41; and a mean time on dialysis of 6&#46;28 years&#46; We performed two separate measurements while the patient was comfortably reclined in the dialysis chair&#44; once at the start and another at the end of the 4-hour haemodialysis session&#46; Fifteen minutes after the start of dialysis&#44; we took three oscillometric BP measurements &#40;Omron M4&#44; Hamburg&#44; Germany&#41;&#46; Thirty minutes before the dialysis session ended&#44; we took another three BP measurements&#46; The BP readings were taken with a 5-minute interval between each&#46; We obtained mean systolic and diastolic BP for the first &#40;start&#41; and second &#40;end&#41; measurements&#46; After taking the BP measurements&#44; we evaluated pain thresholds&#46; To this end we used a patented digital algometer &#40;dolorimeter&#41; &#40;<a href="http&#58;&#47;&#47;www&#46;recolecta&#46;net&#47;buscador&#47;single&#95;page&#46;jsp&#63;id&#61;oai&#58;digibug&#46;ugr&#46;es&#58;10481&#47;1123" class="elsevierStyleCrossRefs">http&#58;&#47;&#47;www&#46;recolecta&#46;net&#47;buscador&#47;single&#95;page&#46;jsp&#63;id&#61;oai&#58;digibug&#46;ugr&#46;es&#58;10481&#47;1123</a>&#41; with a &#177;1 gram precision and output values in g&#47;cm<span class="elsevierStyleSup">2</span>&#46; This dolorimeter is composed of two units connected to a cable&#46; In the stimulation unit&#44; a wooden bar is inserted with a circular surface area of 1cm<span class="elsevierStyleSup">2</span> and a height of 10cm&#46; The central unit includes a digital screen that reads out the pressure values and provides a button for interrupting the test and saving the value corresponding to that moment in time&#46; We took individual measurements bilaterally in two tender or trigger points<span class="elsevierStyleSup">19</span>&#58; <span class="elsevierStyleItalic">1&#41;</span> the second rib &#40;in the osteochondral junction&#44; below the clavicle&#41;&#44; and <span class="elsevierStyleItalic">2&#41;</span> the knee &#40;in the medial fat pad proximal to the joint line&#41;&#44; with the first measurements taken from the left side in each case&#46; Pressure increased at approximately 1kg&#47;s&#46; Patients had to press the button on the dolorimeter at the moment that the pressure started to be painful &#40;pain threshold&#41;&#46; In order to avoid the influence of possible sensitisation processes&#44; in the second pain measurement points 1&#46;5cm away from the initial spot were stimulated&#46; Based on these characteristics&#44; our study can be defined as a quasi-experimental study with a pre-post design&#46;</p><p class="elsevierStylePara">The pain threshold values had an asymmetrical distribution&#44; and so we performed a logarithmic transformation so they would comply with the criteria of normality&#46; We compared the measurements taken for each measurement &#40;start vs end&#41; using Student&#8217;s t-tests for related samples&#46; We analysed the relationship between BP and pain threshold using Pearson&#8217;s correlation&#46; We set the level of statistical significance at <span class="elsevierStyleItalic">P</span>&#60;&#46;05&#46;</p><p class="elsevierStylePara"><span class="elsevierStyleBold">RESULTS</span></p><p class="elsevierStylePara"><span class="elsevierStyleBold">Effects of haemodialysis on blood pressure and pain</span></p><p class="elsevierStylePara">BP and pain threshold values at the start and end of dialysis are presented in Table 1&#46; BP&#44; both systolic and diastolic&#44; did not vary significantly during dialysis &#40;<span class="elsevierStyleItalic">P</span>&#62;&#46;7&#41;&#46; However&#44; the progression of the dialysis session was related to a decrease in pain thresholds in the second left rib &#40;<span class="elsevierStyleItalic">t</span>&#91;14&#93;&#61;2&#46;17&#59; <span class="elsevierStyleItalic">P</span>&#61;&#46;049&#41; and left &#40;<span class="elsevierStyleItalic">t</span>&#91;14&#93;&#61;3&#46;71&#59; <span class="elsevierStyleItalic">P</span>&#61;&#46;003&#41; and right &#40;<span class="elsevierStyleItalic">t</span>&#91;14&#93;&#61;3&#46;68&#59; <span class="elsevierStyleItalic">P</span>&#61;&#46;003&#41; knee&#46; The decrease in pain thresholds for the second right rib was not significant &#40;<span class="elsevierStyleItalic">t</span>&#91;14&#93;&#61;1&#46;40&#59; <span class="elsevierStyleItalic">P</span>&#60;&#46;185&#41;&#46;</p><p class="elsevierStylePara"><span class="elsevierStyleBold">Relationship between blood pressure and pain</span></p><p class="elsevierStylePara">The correlations obtained between BP and pain thresholds are presented in Table 2&#46; At the start of dialysis&#44; we did not obtain any significant correlations &#40;<span class="elsevierStyleItalic">P</span>&#62;&#46;7&#41;&#46; At the end of dialysis&#44; both systolic and diastolic blood pressure had strong correlations with pain thresholds&#44; such that higher BP levels were associated with higher pain thresholds&#46; In order to show this effect&#44; we have presented a scatter plot and regression line&#44; showing how diastolic BP is associated with pain thresholds for the left knee &#40;Figure&#41;&#46; Here we can observe how increases in diastolic BP are linearly correlated with higher pain thresholds &#40;that is to say&#44; reduced sensitivity to pain&#41;&#46;</p><p class="elsevierStylePara"><span class="elsevierStyleBold">DISCUSSION</span></p><p class="elsevierStylePara">The results from our study show important positive relationships between BP and pain thresholds at the end of dialysis&#44; but not at the start&#46; Also&#44; despite the fact that BP did not change between the two measurements performed&#44; pain thresholds were lower in the second one as compared to the first&#44; which would suggest increased sensitivity to pain at the end of dialysis&#46; Our hypothesis was that BP would decrease during the course of dialysis&#46; This hypothesis was not fulfilled&#44; since BP values did not change between the two measurements&#46; Whereas intra-dialysis episodes of acute hypotension are somewhat frequent&#44; there is no agreement in the medical literature regarding the changes produced during haemodialysis in tonic BP values&#46; In some studies&#44; dialysis has been associated with reductions in BP&#44;<span class="elsevierStyleSup">13</span> whereas in other studies&#44; this effect has not been observed&#46;<span class="elsevierStyleSup">14</span> This discrepancy is probably due to possible differences in the cardiovascular state of these patients&#46; If an individual has optimal cardiovascular functioning&#44; homeostatic mechanisms can be put into place &#40;changes in vascular tone&#44; heart rate&#44; ventricular function&#44; baroreceptor function&#44; etc&#46;&#41;&#46;that compensate the reduced volume of body liquids&#46; In this sense&#44; our sample was made up of patients with renal problems of a relatively young age as compared to other studies&#44; and our results suggest that the self-regulating mechanisms for controlling BP in these patients were conserved and could successfully compensate for the changes in liquid volumes&#44; maintaining the integrity of BP regulation&#46;</p><p class="elsevierStylePara">Although BP did not change between our two measurements&#44; we did observe increased sensitivity to pain at the end of the dialysis session as compared to the beginning&#46; Pain thresholds&#44; especially for the left side&#44; were higher at the second measurement&#46; In the absence of changes in BP&#44; the possible explanations for this effect are inherently speculative&#46; In our opinion&#44; it may be due to one of three different mechanisms&#46;</p><p class="elsevierStylePara">Firstly&#44; chronic kidney disease is associated with peripheral neuropathy and several different autonomic deficits&#46;<span class="elsevierStyleSup">13-15</span> Due to the autonomic origin of the afferent pain inhibition system mediated by changes in BP&#44; disorders in this system may be affecting these patients&#46; It is known that haemodialysis improves some of the these autonomic alterations&#44;<span class="elsevierStyleSup">13-15</span> and so one could assume a better functioning of this anti-nociceptive system at the end of haemodialysis as compared to the start&#46; Secondly&#44; we do know that several different neuropsychological deficits arise in patients with chronic kidney disease&#44; and that the process of blood purifying during dialysis is associated with a normalisation of neuronal activity and improved cognitive ability in several different neuropsychological functions&#46;<span class="elsevierStyleSup">16&#44;17</span> In this sense&#44; normalised blood composition and liquid volume could also favour improved functioning of the perceptive and psychophysiological processes involved in the afferent inhibition of pain mediated by the baroreflex&#46; Finally&#44; another explanation could be found in the factors associated with the stress-induced analgesia phenomenon&#46;<span class="elsevierStyleSup">20</span> The dialysis procedure starts in a relatively stressful environment &#40;nurses&#44; machines&#44; tubes&#44; smells&#44; needles&#44; disrobing&#44; white coat phenomenon&#44; etc&#46;&#41; Among the most stressful elements of the procedure is the connection of needles to the arteriovenous fistula&#46; In addition to the pain produced by the piercing of the needles&#44; the patient tends to be worried about possible problems with the fistula&#46; Additionally&#44; the appearance of intra-dialysis pain can also have an influence&#44; and this is relatively common&#46;<span class="elsevierStyleSup">21&#44;22</span> The most common causes of this phenomenon are derived from the dialysis procedure itself &#40;fistulas can produce ischaemic and neurological pain&#44; complications associated with catheters that result in pain&#44; etc&#46;&#41; and ischaemic and musculoskeletal pain&#46;<span class="elsevierStyleSup">21&#44;22</span> These pains&#44; especially those associated with the dialysis procedure&#44; tend to be less severe at the end of the procedure&#46; Given the long duration of dialysis sessions&#44; one might expect a progressive habituation or reduction in stress-related factors&#44; activation&#44; and pain &#40;at least in patients that are used to the procedure&#44; such as those that have participated in this study&#41;&#44; moreover&#44; these adverse conditions are less severe at the end of the dialysis session than at the beginning&#46; The stress-induced analgesia effect is mediated by several different mechanisms&#44; such as endogenous opiates&#44; cannabinoids&#44; monoamines&#44; gamma-aminobutyric acid&#44; glutamate&#44; CRF&#44; cortisol&#44; etc&#46;<span class="elsevierStyleSup">20</span></p><p class="elsevierStylePara">The associations observed here between BP and pain are very interesting and perhaps the strongest described in the literature&#46; For example&#44; and so as to compare our results to those in other studies&#44; Myers et al<span class="elsevierStyleSup">23</span> used the cold pressor test and found correlations between systolic BP and pain thresholds of 0&#46;22 and pain tolerance of 0&#46;31&#59; Fillingham&#44; et al<span class="elsevierStyleSup">24</span> used thermal and ischaemic pain and observed correlations between 0&#46;02 and 0&#46;35 in women and 0&#46;13 and 0&#46;50 in men for pain thresholds and tolerance&#44; whereas the correlations with the subjective perception of thermal pain were -0&#46;37 in women and -0&#46;44 in men&#59; McCubbin and Bruelhl<span class="elsevierStyleSup">25</span> found a correlation of -0&#46;54 between systolic BP and the intensity of pain perceived during the cold pressor test&#59; Duschek&#44; et al<span class="elsevierStyleSup">6</span> used thermal pain and found correlations between systolic BP and pain thresholds&#44; tolerance&#44; and subjective perception of the intensity and discomfort of pain of 0&#46;30&#44; 0&#46;42&#44; -0&#46;32&#44; -0&#46;35&#44; respectively&#59; using the cold pressor test&#44; Duschek&#44; et al<span class="elsevierStyleSup">5</span> found correlations between systolic BP and pain threshold&#44; tolerance&#44; and subjective intensity of 0&#46;26&#44; 0&#46;26&#44; and -0&#46;32&#44; respectively&#44; etc&#46;</p><p class="elsevierStylePara">One limitation to our study was the small sample size used&#44; since we included patients from only one single haemodialysis centre&#46; This suggests the need to replicate the results obtained in our study with a larger sample size of patients&#46; In conclusion&#44; haemodialysis is associated with changes in sensitivity to pain and the relationships between BP and pain&#44; which points towards a modification to the mechanism of afferent pain inhibition originating in the cardiovascular system&#46; The possible origin of these changes is not clear&#44; and future research will be needed to elucidate the changes produced by haemodialysis in cognitive-perceptive functions and cardiovascular autonomic regulation &#40;especially the baroreflex&#41;&#46;</p><p class="elsevierStylePara"><span class="elsevierStyleBold">ACKNOWLEDGEMENTS</span></p><p class="elsevierStylePara">We would like to thank the <span class="elsevierStyleItalic">Asociaci&#243;n de Enfermos Renales de Ja&#233;n</span> &#40;association of renal patients of Jaen&#41; for their collaboration with this study&#46; This research was funded by a project of the Spanish Ministry of Science and Innovation &#40;PSI2009-09812&#41;&#46;</p><p class="elsevierStylePara"><a href="grande&#47;10902&#95;108&#95;24600&#95;en&#95;t1&#46;jpg" class="elsevierStyleCrossRefs"><img src="10902_108_24600_en_t1.jpg" alt="Mean &#177; standard deviation of systolic BP &#40;SBP&#41;&#44; diastolic BP &#40;DBP&#41;&#44; and pain thresholds at the start and end of haemodialysis"></img></a></p><p class="elsevierStylePara">Table 1&#46; Mean &#177; standard deviation of systolic BP &#40;SBP&#41;&#44; diastolic BP &#40;DBP&#41;&#44; and pain thresholds at the start and end of haemodialysis</p><p class="elsevierStylePara"><a href="grande&#47;10902&#95;108&#95;24601&#95;en&#95;t2&#46;jpg" class="elsevierStyleCrossRefs"><img src="10902_108_24601_en_t2.jpg" alt="Pearson&#191;s correlation between systolic BP &#40;SBP&#41; and diastolic BP &#40;DBP&#41; and pain thresholds at the start &#40;1&#41; and end &#40;2&#41; of haemodialysis"></img></a></p><p class="elsevierStylePara">Table 2&#46; Pearson&#191;s correlation between systolic BP &#40;SBP&#41; and diastolic BP &#40;DBP&#41; and pain thresholds at the start &#40;1&#41; and end &#40;2&#41; of haemodialysis</p><p class="elsevierStylePara"><a href="grande&#47;10902&#95;108&#95;24602&#95;en&#95;f1&#46;jpg" class="elsevierStyleCrossRefs"><img src="10902_108_24602_en_f1.jpg" alt="Scatter plot and regression line for diastolic BP &#40;DBP&#41; and pain thresholds in the left knee"></img></a></p><p class="elsevierStylePara">Figure 1&#46; Scatter plot and regression line for diastolic BP &#40;DBP&#41; and pain thresholds in the left knee</p>"
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        "resumen" => "<p class="elsevierStylePara"><span class="elsevierStyleBold">Antecedentes&#58;</span> La presi&#243;n arterial se asocia negativamente con la percepci&#243;n del dolor&#46; <span class="elsevierStyleBold">Objetivos&#58;</span> En este estudio se comparan el dolor y las relaciones entre presi&#243;n arterial y umbral doloroso al inicio y final de la hemodi&#225;lisis&#46; <span class="elsevierStyleBold">M&#233;todos&#58;</span> 14 pacientes con trastorno renal cr&#243;nico bajo di&#225;lisis participaron en el estudio&#46; Los umbrales de dolor fueron evaluados mediante algometr&#237;a de presi&#243;n de forma bilateral en dos puntos &#171;gatillo&#187;&#58; la segunda costilla y la rodilla&#46; La presi&#243;n arterial y los umbrales de dolor se evaluaron&#58; <span class="elsevierStyleItalic">1&#41;</span> 15 minutos despu&#233;s del inicio de la di&#225;lisis&#44; y <span class="elsevierStyleItalic">2&#41;</span> 30 minutos antes de su final&#46; <span class="elsevierStyleBold">Resultados&#58;</span> La presi&#243;n arterial no cambi&#243; significativamente durante la di&#225;lisis&#46; Se observ&#243; una disminuci&#243;n significativa del umbral de dolor en la segunda costilla izquierda y en la rodilla izquierda y derecha desde el inicio al final de la hemodi&#225;lisis&#46; Al inicio de la di&#225;lisis no se obtuvieron correlaciones significativas entre presi&#243;n arterial y dolor&#44; mientras que al final de la di&#225;lisis la presi&#243;n arterial se correlacion&#243; positivamente con los umbrales de dolor &#40;<span class="elsevierStyleItalic">rs</span> entre 0&#44;552 y 0&#44;806&#41;&#46; <span class="elsevierStyleBold">Conclusiones&#58;</span> La hemodi&#225;lisis se asocia a cambios en la<br /> sensibilidad al dolor y en las relaciones entre presi&#243;n arterial y dolor&#44; y sugiere una modificaci&#243;n en el mecanismo de inhibici&#243;n aferente del dolor originado a nivel cardiovascular&#46; Como posibles explicaciones de este efecto se discuten los cambios que produce la hemodi&#225;lisis en las funciones cognitivo-perceptivas&#44; en la regulaci&#243;n auton&#243;mica cardiovascular y en la habituaci&#243;n de variables relacionadas con el estr&#233;s&#46;</p>"
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        "resumen" => "<p class="elsevierStylePara"><span class="elsevierStyleItalic"><span class="elsevierStyleBold">Antecedents&#58;</span> Arterial pressure is negatively associated to pain perception&#46; <span class="elsevierStyleBold">Objectives&#58;</span> In this study&#44; pain and the relations between arterial pressure and pain threshold were compared at the beginning and end of the heamodialysis&#46; <span class="elsevierStyleBold">Methods&#58;</span> 14 patients with chronic renal disease participated in the study&#46; Pain thresholds were evaluated with pressure algometry bilaterally at two tender points&#58; the second rib and the knee&#46; Arterial pressure and pain thresholds were assessed twice&#58;</span> 1&#41;<span class="elsevierStyleItalic"> 15 min alter dialysis onset and</span> 2&#41;<span class="elsevierStyleItalic"> 30 min before dialysis ended&#46; <span class="elsevierStyleBold">Results&#58;</span> Arterial pressure remains unchanged through the dialysis&#46; The course of dialysis was associated to a decrease in pain threshold in the second left rib and left and right knees&#46; At the beginning of dialysis arterial pressure were uncorrelated with pain&#44; while at the end of the dialysis both systolic and diastolic arterial pressure were strongly associated to pain thresholds &#40;rs between 0&#46;552 and 0&#46;806&#41;&#58; increased arterial pressure was associated to lower pain in terms of increased threshold&#46; <span class="elsevierStyleBold">Conclusions&#58;</span> Heamodialysis is associated to changes in pain sensitivity and in the relationships between arterial pressure and pain&#44; suggesting a modification in the ascending pain inhibition system arising from the cardiovascular system&#46; Possible explanations of this effect include the changes produced by heamodialysis in cognitive-perceptive functions&#44; in autonomic cardiovascular regulation&#44; and in the habituation of stress-related variables&#46;</span></p>"
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