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Karolina Wartolowska

MD DPhil (Oxon)

Postdoctoral Researcher

Neuroimaging in chronic pain conditions

My background is in medicine. I came to Oxford for a DPhil in neuroimaging in rheumatoid arthritis. We found that treatment with tumour necrosis factor inhibitors resulted in improvement in pain, inflammation, and depression, as well as in reduction in pain-related brain activation; mainly in the amygdala/hippocampus and the ipsilateral insular cortex. These regions were more activated at baseline in the responders group, offering a possible future marker of treatment efficacy. Brain structure analysis showed an increase in grey matter in the basal ganglia of patients with rheumatoid arthritis when compared to age- and sex-matched controls, which we hypothesised, was due to either adaptation of pain processing or to altered movement control.

Subsequently, I have investigated the effect of analgesics (first and second-line treatment) in comparison to placebo on allodynia-evoked brain activation and resting state functional connectivity in patients with post-traumatic neuropathic pain. We observed that only the first-line analgesic reduced the allodynia-evoked activation. In the recent years, I have lead the neuroimaging part of the “Can Shoulder Arthroscopy Work? (CSAW)” trial, which was a randomised controlled trial investigating the efficacy of shoulder decompression in shoulder impingement by comparing it to a placebo intervention, i.e., diagnostic arthroscopy, and to a non-interventional group.

Placebo in surgical randomised controlled trials

I have also performed a large systematic review and meta-analysis of surgical randomised controlled trials with a placebo arm. The main finding was that interventional trials with a placebo arm are feasible, at least for less invasive procedures. The biggest challenge is to find a sufficient number of suitable patients in a reasonable period of time. Placebo-controlled surgical trials are useful to identify procedures that are not better than placebo. Such trials are not free from adverse events, but the harms can be minimised and trials can be carried out in an ethical way. I have also used surveys among surgeons and trainee surgeons to explain the reasons for the paucity of placebo-controlled surgical trials. I also analysed trial- and patient-level data from placebo-controlled surgical trials to investigate temporal changes in the placebo arm, and found a large effect for subjective outcomes (but not for objective outcomes), and no significant effect of time at the trial level.

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