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At least 181 records · Page 10Linked to original sources
PubMed2006

Breakthrough pain in opioid-treated chronic non-malignant pain patients referred to a multidisciplinary pain centre: a preliminary study.

BACKGROUND: Breakthrough pain (BTP) has not formerly been discussed as such in chronic non-malignant pain patients referred to pain centres and clinics. The purpose of the study was to investigate the prevalence, characteristics and mechanisms of BTP in opioid-treated chronic non-malignant pain patients referred to a pain centre and to assess the short-term effects of pain treatment. METHODS: Patients were assessed at referral (T(0)) and after a treatment period of 3 months (T(3)) using the visual analogue scale (VAS) of the brief pain inventory (BPI) within somatic nociceptive, neuropathic and/or visceral pain conditions, the mini mental state examination (MMSE) and the hospital anxiety and depression scale (HADS). The main treatment intervention from T(0) to T(3) was to convert short-acting oral opioids to long-acting oral opioids and to discontinue on demand and parenteral use of opioids. RESULTS: Thirty-three patients were assessed at T(0) and 27 at T(3). The prevalence of BTP declined significantly from T(0) (90%) to T(3) (70.4%). Worst, least, average and current pain intensities as well as duration of BTP were significantly reduced from T(0) to T(3.) The majority of BTPs were exacerbation of background pain assumed to be of the same pain mechanisms. High average pain intensity (BPI) was significantly associated with high scores for both anxiety and depression (HADS). CONCLUSION: BTP in chronic non-malignant pain patients seems to be surprisingly frequent and severe. Stabilizing the opioid regimen seems to reduce pain intensity in general as well as the intensity and duration of BTP. Average pain intensity was associated with anxiety and depression.

Administration, Oral↗
PubMed2005

Segmental inhibition of cutaneous heat sensation and of laser-evoked potentials by experimental muscle pain.

The aim of the study was to evaluate the effect of tonic muscle pain evoked by injection of 5% hypertonic saline in the right brachioradialis muscle on the somatosensory sensation of laser-evoked heat pain and laser-evoked potentials. The heat pain pathways were studied in 9 healthy human subjects by recording the scalp potentials evoked by CO(2) laser stimuli delivered on four sites: the skin above the right brachioradialis muscle (ipsilateral local pain), the wrist area where muscle pain was referred in all subjects (ipsilateral referred pain), and two areas on the left arm symmetrical to both local and referred pain (contralateral local pain and contralateral referred pain). Laser-evoked potentials were obtained from 31 scalp electrodes before saline injection, during saline infusion (bolus injection with 0.3 ml saline infused over 20 s, followed by a steady infusion rate of 30 ml/h for the next 25 min), and 20 min after muscle pain had disappeared. While the early N1/P1 component (around 130 ms and 145 ms of latency after stimulation of the skin over the brachioradialis muscle and the wrist, respectively) was not affected by muscle pain, the amplitudes of the later vertex laser-evoked potentials (N2 latency of around 175 ms and 210 ms after stimulation of the skin over the brachioradialis muscle and the wrist, respectively; P2 latency of around 305 ms and 335 ms after stimulation of the skin over the brachioradialis muscle and the wrist, respectively) evoked from ipsilateral local pain, ipsilateral referred pain, and contralateral local pain sites were significantly decreased during muscle pain compared with the baseline recording, while they recovered after pain had disappeared. At the same stimulation sites, the rating of the laser-evoked pain sensation was reduced significantly during muscle pain as compared with the baseline and it recovered after pain had disappeared. On the contrary, muscle pain did not show any effect on both laser-evoked pain and laser-evoked potential amplitude when the contralateral referred pain site was stimulated. The muscle pain inhibitory effect on both heat pain sensation and laser-evoked potential amplitude is probably mediated by an ipsilateral and contralateral segmental mechanism which acts also on the referred pain area, while more general inhibitory mechanisms, such as a distraction effect or a diffuse noxious inhibitory control, are excluded by the absence of any effect of muscle pain on laser-evoked pain and laser-evoked potentials obtained from a remote site, such as the contralateral referred pain area. Since muscle pain induced by hypertonic saline injection is very similar to clinical pain, our results can be useful in understanding the pathophysiology of the somatosensory modifications which can be observed in patients with musculoskeletal pain syndromes.

Adult↗
PubMed2005

Test-retest reliability of myofascial trigger point detection in patients with rotator cuff tendonitis.

OBJECTIVES: To investigate the test-retest reliability of the following clinical diagnostic characteristics of myofascial trigger points: taut band, spot tenderness, jump sign, pain recognition, referred pain and local twitch responses (LTRs). DESIGN: Test-retest reliability study. SETTING: This study was undertaken in an outpatient physiotherapy department. SUBJECTS: Fifty-eight patients (31 males and 27 females) with rotator cuff tendonitis were recruited into this study. INTERVENTION: Rotator cuff muscles were assessed by an expert for the presence or absence of the main clinical diagnostic characteristics of trigger point assessment. The process was then repeated three days later by the same expert. MAIN MEASURES: Outcomes included the presence or absence of: a taut band, spot tenderness, jump sign, pain recognition, referred pain and LTRs. RESULTS: Kappa values between testing situations for the taut band, spot tenderness, jump sign and pain recognition were 1. Kappa scores for referred pain ranged between 0.79 and 0.88 and for the local twitch response between 0.75 and 1 depending on the muscles under investigation. CONCLUSIONS: The presence or absence of the taut band, spot tenderness, jump sign and pain recognition was highly reliable between sessions. Referred pain and local twitch response reliability varied depending on the muscle being studied.

Adult↗
PubMed1989

Pressure pain thresholds, clinical assessment, and differential diagnosis: reliability and validity in patients with myogenic pain.

Four studies are presented testing the validity and reliability of pressure pain thresholds (PPTs) and of examination parameters believed to be important in the clinical assessment of sites commonly used for such measures in patient samples. Forty-five patients with a myogenous temporomandibular disorder were examined clinically prior to PPT measures. Criteria for history and examination included functional aspects of the pain, tissue quality of the pain site, and the type of pain elicited from palpation. Control sites within the same muscle and in the contralateral muscle were also examined. PPTs were measured as an index of tenderness using a strain gauge algometer at these sites. The data from the 5 male subjects were excluded from subsequent analyses due to the higher PPT in the males and to their unequal distribution among the various factorial conditions. The first study demonstrated strong validity in PPT measures between patients (using pain sites replicating the patients' pain) and matched controls (n = 11). The PPT was not significantly different between the primary pain site (referred pain and non-referred pain collapsed) and the no-pain control site in the same muscle (n = 16). The PPT was significantly lower at the pain site compared to the no-pain control site in the contralateral muscle (n = 13). The second study indicated adequate reliability in patient samples of the PPT measures. In the third study, the PPT was significantly lower at sites producing referred pain on palpation compared to sites producing localized pain on palpation. The PPT findings from the control sites were inconsistent on this factor. The fourth study presented preliminary evidence that palpable bands and nodular areas in muscle were most commonly associated with muscle regions that produce pain; such muscle findings were not specific, however, for regions that produce pain. Further, the intraexaminer reliability in reassessing these pain sites qualitatively was only fair. Referred pain had a poor association with the pain pattern and physical findings, which may suggest a need to reevaluate part of the theory regarding referred muscle pain. The reliability of PPT measures was better overall than the reliability of the signs and site-specific symptoms, suggesting that pressure pain thresholds may be an important tool in clinical studies of pain. PPT measures demonstrate a high within-subject variability in pain patient subjects as well as non-pain subjects.(ABSTRACT TRUNCATED AT 400 WORDS)

Adult↗
PubMed1999

Referred Muscle Pain: Clinical and Pathophysiologic Aspects.

Referred pain, that is, pain perceived in an area other than that in which the noxious stimulation takes place, is very frequent in the clinical setting. There are various forms of referred muscle pain from viscera and from somatic structures. Examples of the latter are referred pain from one muscle to another muscle (as in myofascial pain syndromes) and referred pain from joints (as in osteoarthritis of the knee). Whatever the origin of the symptom, a condition of secondary hyperalgesia very often takes place in the referred zones, together with trophic tissue changes. Referred muscle pain from viscera without hyperalgesia is explained on the basis of the convergence of visceral and somatic afferent fibers on the same central neurons. Referred muscle pain from viscera with hyperalgesia is not completely understood; it is hypothesized that it is due to both central (sensitization process) and peripheral (intervention of reflex arcs) mechanisms. Referred muscle pain from other muscles or from joints is not easily explained by the mechanism of "central convergence" in its original form, because in dorsal horn neurons there is little convergence from deep tissues. It has been proposed that convergent connections from deep tissues to dorsal horn neurons are not present from the beginning but are opened by nociceptive input from skeletal muscle, and referral to myotomes outside the lesion is due to a spread of central sensitization to adjacent spinal segments.

Journal Article↗
PubMed2006

Discrete changes in cortical activation during experimentally induced referred muscle pain: a single-trial fMRI study.

Noxious stimulation of skeletal muscle evokes pain that is often referred into distal areas. Despite referred pain being of significant clinical importance, the brain regions responsible for the perception of referred pain remain unexplored. The aim of this investigation is to define these regions using functional magnetic resonance imaging. We induced muscle pain by hypertonic saline injections (0.5 ml) into the tibialis anterior (TA) or flexor carpi radialis (FCR) muscle. TA injections evoked pain that was referred to the ankle/foot in 10/17 subjects, whereas FCR injections evoked pain that was projected into the wrist/hand in 6/12 subjects. Regional brain responses were statistically tested by convolving the temporal profile of the subjective pain intensity rating with the hemodynamic response function. For all subjects, signal increased in the region of primary somatosensory cortex (SI), which represents the leg or arm, that is, the area corresponding to the injection site. However, for those subjects who reported referred pain, signal intensity increases also occurred in the SI region representing the foot or hand. Interestingly, differential signal changes also occurred in anterior cingulate, cerebellar, and insular cortices. This is the first study to provide evidence of cortical differentiation in the processing of primary and referred pain.

Adult↗
PubMed2002

Interstitial cystitis, pelvic pain, and the relationship to myofascial pain and dysfunction: a report on four patients.

Treatment of chronic pelvic pain (CPP), interstitial cystitis (IC), prostatodynia, and irritative voiding symptoms can be frustrating for both patients and physicians. The usual approaches do not always produce the desired results. We found that when we treated myofascial trigger points (TrP) in pelvic floor muscles as well as the gluteus, piriform, infraspinatus, and supraspinatus muscles, symptoms improved or resolved. Various palpation techniques were used to isolate active myofascial TrPs in these muscles of four patients with severe CPP, IC, and irritative voiding symptoms. Injection and stretch techniques for these muscles were performed. Visual twitch responses at the skin surface and in the muscles were used to verify successful needle piercing of a TrP. The patients were asked to verbally describe exactly where the flash of distant pain was felt, a process that permitted an accurate recording of the precise pattern of pain referred by that TrP. The findings involved with the four patients substantiate the need for myofascial evaluation prior to considering more invasive treatments for IC, CPP, and irritative voiding symptoms. Referred pain and motor activity to the pelvic floor muscles (sphincters), as well as to the pelvic organs, can be the sole cause of IC, CPP, and irritative voiding dysfunction and certainly needs further investigation.

Adult↗
PubMed1996

Vagal, sympathetic and somatic sensory inputs to upper cervical (C1-C3) spinothalamic tract neurons in monkeys.

1. Myocardial ischemia activates vagal and sympathetic cardiac afferent fibers. The purpose of this study was to determine a neuro physiological basis for cardiac pain referred to C1-C3 somatic dermatomes. We hypothesized that afferent fibers traveling in vagal or sympathetic nerves transmit nociceptive information to C1-C3 spinothalamic tract (STT) neurons. 2. Electrical stimulation of the left stellate ganglion to excite cardiopulmonary sympathetic afferent fibers increased extracellular activity of 44 of 77 C1-C3 STT neurons examined in 33 anesthetized male monkeys (Macaca fascicularis); responses increased as stimulus strength increased. Additionally, this stimulus inhibited 5 cells, increased/decreased activity of 2 cells, and did not affect 26 cells. 3. Electrical stimulation of the left (ipsilateral) thoracic vagus nerve excited 41 of 78 C1-C3 STT neurons, inhibited 4 neurons, increased/decreased activity of 2 neurons, and did not affect 31 neurons. Responses increased with increasing stimulus strength Contralateral vagal stimulation excited 7 of 39 cells tested, inhibited 4 cells and did not affect 28 cells. 4. Effects of stimulating one or more vagal branches were examined on 22 C1-C3 STT neurons excited by input from left thoracic vagus nerve. Stimulation of the cardiac branch excited 11 of 16 cells tested; stimulation of the recurrent laryngeal nerve excited 11 of 18 cells; stimulation of vagal fibers just rostral to the diaphragm excited 8 of 19 cells. 5. Excitatory somatic receptive fields ranged from small ipsilateral fields to large, sometimes bilateral or noncontinuous fields. Many fields included the ipsilateral neck and/or inferior jaw. Thirty-nine of 74 neurons examined were wide dynamic range (WDR), 21 were high threshold (HT), 6 were low threshold (LT), and 8 did not respond to brushing or noxious pinching of somatic tissues. Most (38 of 39) WDR cells responded to stimulation of the stellate ganglion or vagal fibers, as did 18 of 21 HT cells, 3 of 6 LT cells, and 2 of 8 cells unresponsive to brush or pinch stimuli. 6. Results of this study supported the concept that vagal and/ or sympathetic afferent activation of C1-C3 STT neurons might provide a neural mechanism for referred pain that originates in the heart or other visceral organs but is perceived in the neck and jaw region. Additionally, C1-C3 STT neurons processed sensory information from widespread regions of the body.

Adrenergic Fibers↗
PubMed1980

Lumbar dorsal ramus syndrome.

Low back pain, referred pain in the lower limbs, and spasm of the back, gluteal, and hamstring muscles are clinical features which can be induced in normal volunteers by stimulating structures which are innervated by the lumbar dorsal rami. Conversely, they can be relieved in certain patients by selective interruption of conduction along dorsal rami. These facts permit the definition of a lumbar dorsal ramus syndrome, which can be distinguished from the intervertebral disc syndrome and other forms of low back pain. The distinguishing feature is that, in lumbar dorsal ramus syndrome, all the clinical features are exclusively mediated by dorsal rami and do not arise from nerve-root compression. The pathophysiology, pathology, and treatment of this syndrome are described. Recognition of this syndrome, and its treatment with relatively minor procedures, can obviate the need for major surgery which might otherwise be undertaken.

Animals↗
PubMed2002

New trends in myofascial pain syndrome.

This review article summarizes recent studies on myofascial trigger point (MTrP) to further clarify the mechanism of MTrP. MTrP is the major cause of muscle pain (myofascial pain) in clinical practice. There are multiple MTrP loci in an MTrP region. An MTrP locus contains a sensory component (sensitive locus) and a motor component (active locus). A sensitive locus is the site from which pain, referred pain (ReP), and local twitch response (LTR) can be elicited by needle stimulation. Sensitive loci are probably sensitized nociceptors based on a histological study. They are widely distributed in the whole muscle, but are concentrated in the endplate zone. An active locus is the site from which spontaneous electrical activity (SEA) can be recorded. Active loci are dysfunctional endplates since SEA is essentially the same as endplate noise (EPN) recorded from an abnormal endplate as reported by neurophysiologists. Both ReP and LTRs are mediated through spinal cord mechanisms, demonstrated in both human and animal studies. The pathogenesis of MTrPs appears to be related to the integration in the spinal cord (formation of MTrP circuits) in response to the disturbance of the nerve endings and abnormal contractile mechanism at multiple dysfunctional endplates. Methods usually applied to treat MTrPs include stretch, massage, thermotherapy, electrotherapy, laser therapy, MTrP injection, dry needling, and acupuncture. The mechanism of acupuncture is similar to dry needling or MTrP injection. The new technique of MTrP injection can also be used to treat neurogenic spasticity.

Acupuncture↗
PubMedDate not supplied

Clinical aspects of visceral pain.

Pain producing stimuli in viscera are different from the stimuli which induce somatic pain. Two main clinical aspects of visceral pain are observed: true visceral pain and referred pain. The distinction among visceral pain, referred pain and somatic pain may be difficult in the so-called "intricate conditions". Furthermore, mnemonic traces may play an important role in determining clinical aspects of visceral pain.

Humans↗
PubMed2000

Referred craniofacial pain patterns in patients with temporomandibular disorder.

BACKGROUND: Referred pain is prevalent in the craniofacial region, and it would be helpful for dental practitioners to have drawings delineating regions with a high probability for a patient's referred pain source. METHODS: The author applied firm pressure for approximately five seconds to trigger points, nodules of spot tenderness, and selected masticatory structures within the head and neck region on 230 patients with temporomandibular disorder, or TMD. As firm pressure was being applied, subjects were asked whether pain was developing or intensifying in a location different than that being palpated. RESULTS: One hundred ninety-six subjects (85 percent) reported that referred pain was being generated. The cheek area, ear and forehead were the most frequently reported sites of referred pain generation; palpation over the trapezius muscle, lateral pterygoid area and masseter muscle were the most common sources of referred pain to the craniofacial region. The author provides figures displaying common referred pain sites and their sources. CONCLUSIONS: Patients with TMD often report referred craniofacial pain arising from palpation of the head and neck region. The author found that the pattern between referred pain source and site was consistent and predictable. PRACTICE IMPLICATIONS: Practitioners should consider craniofacial pain's propensity for referral when treating patients with TMD. Practitioners can use the figures presented to determine regions of high probability for a patient's referred pain source.

Adolescent↗