[On intervertebral disk pain, with special reference to various problems of pain in lumbar vertebral disk lesions].
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Adult↗
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Assessment and exercise in low back pain. With special reference to the management of pain and disability following first time lumbar disc surgery.
Eight articles including 555 low back pain patients have been published. They included the following topics: 1) A ratio interval rating scale (Low Back Pain Rating Scale (RS)) was introduced. The possibility of registering the actual status in low back pain patients including; Back Pain, Sciatica, Functional Disability and Physical Impairment was studied. Methods of evaluating index-scales developed in the field of psychometry were applied in the validation process of RS. RS was found to be both valid and user friendly. 2) Using Low Back Pain Rating Scale the general outcome following first-time lumbar disc surgery was analysed through a survey. The results showed that more than half of the patients still suffered from considerable Back Pain, Sciatica, and Functional Disabilities. Approximately 25% of the patients risked reduced work capabilities, and many receive pensions. 3) By means of a comprehensive statistical analysis of 18 studied preoperative demographic and physical findings, sex, hypoalgesia, smoking and Finneson-index were found to have prognostic value. 4) Attempts at influencing the results obtained from lumbar disc surgery have been tested in 3 randomized trials, including back training and peroperative glucocorticoid administration. 5) Three randomized trials including patients suffering from chronic low back pain (with or without previous lumbar disc surgery) attempted to convey which elements of a training programme provide patients with the greatest effect and the least risk of side-effects. It was concluded that Low Back Pain Rating Scale is a useable assessment instrument in both clinical trials and as a daily quality control instrument of back patients. There is a need of increased patient scrutiny in patient selection prior to lumbar disc surgery. Postoperative rehabilitation should include intensive back training, which has been shown to be of value in behavioural support and restoration of functional deficits. This has resulted in increased work capacities for disc operated patients. The exercise programmes are generally free of side-effects. As regards chronic back pain patients with or without previous lumbar surgery, high dosage exercises with training periods lasting at least 12 to 16 sessions are of crucial importance for success. Exercises should be dynamic and full-range, and carried out following the adage "Don't let the pain be your guide.
Exercise Therapy↗
Pain experienced by patients with terminal head and neck carcinoma.
BACKGROUND: Pain is one of the most feared consequences of cancer and is experienced by up to 80% of patients with head and neck carcinoma (HNC). Pain in terminal HNC patients is common and often defined as severe. This study evaluated the effectiveness of the World Health Organization (WHO) analgesic ladder in the treatment of a cohort of terminal HNC patients. METHODS: The authors prospectively evaluated 62 consecutive terminal HNC patients admitted to the Chaim Sheba Medical Center Tel Hashomer Hospice or the general hospital. Data pertaining to tumor origin, spread, treatment, and results were defined. Pain was assessed with the McGill Pain Questionnaire, using a 10-point visual analogue scale (VAS) and a body map. Pain was diagnosed according to cause and type. Treatment was selected according to the guidelines provided in the WHO analgesic ladder. RESULTS: Only 10 patients suffered from pain that was not locoregional. The results of the VAS score were available in the first reading in all patients with pain (n = 48), with a mean of 4.7 (standard deviation [SD] +/- 2.0). A mean second VAS score obtained 72 hours after the first was 1.9 (SD +/- 1.1). The difference between the two scores was statistically significant (P < 0.001). A third score was available for only 6 patients, with a mean of 1.6. Only 2 patients did not experience improvement of pain after 72 hours of treatment; both of these patients had bony involvement with tumor. Thirty-one patients (65%) were diagnosed with pain of nociceptive origin; these patients were categorized as having actual nociceptive pain (22), nociceptive nerve pain (6), or referred pain to the ear (3). Nonnociceptive pain of neuropathic origin was noted for only 6 patients (12.5%). Pain that could not be well defined but was responsive to opioid analgesic treatment was noted for 11 patients. A different form of non-cancer-related pain was noted for only one patient. CONCLUSIONS: Patients were treated for pain according to the WHO analgesic ladder. They received adequate narcotic analgesics and supportive measures that allowed significant reduction of pain in nearly all cases, with acceptable side effects.
Head and Neck Neoplasms↗
Pain referral from the sternoclavicular joint: a study in normal volunteers.
OBJECTIVE: The sternoclavicular joint (SCJ) is commonly affected by rheumatological conditions. Case reports suggest that it may refer pain to distant areas, potentially leading to delays in diagnosis and inappropriately targeted investigations. Therefore, we studied the patterns of pain referral from the SCJ of nine healthy volunteers. METHODS: Hypertonic saline was injected into the SCJ of nine normal volunteers and the location of any resulting pain was noted, as was the effect of resisted shoulder abduction and flexion. Composite pain maps were then constructed from individual pain diagrams. RESULTS: An unpleasant, deep aching pain was produced locally in eight subjects and referred to distant sites in all subjects. Tests of shoulder movement had varied and inconstant effects. CONCLUSIONS: We demonstrated that the SCJ is capable of referring pain to areas distant from the joint. Knowledge of these referral patterns will enable the SCJ to be considered in patients with pain in these areas.
Adult↗
Level of distress in a recurrent low back pain population referred for physical therapy.
STUDY DESIGN: Recruitment phase of a randomized clinical trial. OBJECTIVES: To review the published literature on the use of the distress risk assessment method in different back pain populations and healthcare settings and compare results with those obtained from the current trial. SUMMARY OF BACKGROUND: Psychological distress in low back pain is commonplace, and distress increases the relative risk of poor outcome with physical treatment alone. The Distress and Risk Assessment Method is a tool for use in the clinical setting to assist in the identification of distress and clinical decision-making. METHODS: The Distress Risk Assessment Method and Roland Morris Disability Questionnaire were used to assess eligibility of patients with recurrent low back pain for recruitment into a randomized clinical trial examining different physical therapy approaches. RESULTS: In total, 221 patients were assessed, resulting in 212 correctly complete questionnaires. Of those 212, 71 (33%) showed evidence of marked distress (41 depressed and 30 somatic). Functional disability, measured using the Roland Morris Disability Questionnaire, was higher for the distressed group (mean 14.1, SD 4.8, range 3-23) than the nondistressed group (mean 8.0, SD 5.1, range 0-21). Distress and anxiety measured using the distress risk assessment method were correlated to self-reported back-related functional disability. CONCLUSIONS: Distress associated with low back pain is common with one third of patients referred for physical therapy at the units studied exhibiting a level of distress that increased their relative risk of poor outcome by 3 to 4 times. Clinically, screening this group of patients may help indicate when liaison with other professionals is appropriate and possibly identify those patients who may be too distressed to respond to physical therapy intervention alone.
Adolescent↗
Toothache of cardiac origin.
Pain referred to the orofacial structures can sometimes be a diagnostic challenge for the clinician. In some instances, a patient may complain of tooth pain that is completely unrelated to any dental source. This poses a diagnostic and therapeutic problem for the dentist. Cardiac pain most commonly radiates to the left arm, shoulder, neck, and face. In rare instances, angina pectoris may present as dental pain. When this occurs, an improper diagnosis frequently leads to unnecessary dental treatment or, more significantly, a delay of proper treatment. This delay may result in the patient experiencing an acute myocardial infarction. It is the dentist's responsibility to establish a proper diagnosis so that the treatment will be directed toward the source of pain and not to the site of pain. This article reviews the literature concerning referred pain of cardiac origin and presents a case report of toothache of cardiac origin.
Angina Pectoris↗
Myofascial pain syndrome and its suggested role in the pathogenesis and treatment of fibromyalgia syndrome.
Myofascial pain syndrome is a chronic muscle pain disorder in one or more muscles or groups of muscles accompanied by local and referred pain, decreased range of motion, weakness, and often autonomic phenomena. Patients are readily recognized by their history of muscle pain and the presence of myofascial trigger points, which are specific areas of hyperirritability in a muscle that cause local and referred pain on palpation. Failure to recognize MPS often leads to over-investigation, unnecessary medical intervention, and iatrogenic harm with serious cost implications. The purpose of this review is to present clinically relevant data regarding myofascial pain syndrome and to discuss its possible role in the pathophysiology and optimal treatment of fibromyalgia syndrome.
Autonomic Nervous System↗
Clinical review: the differential diagnosis of pain in the quiet eye.
BACKGROUND: Eye pain, periorbital and retro-orbital pain, and headache or facial pain referred to the orbital region are common presenting complaints. REVIEW SUMMARY: In this review, we discuss the etiologies of eye pain in the quiet eye, which is defined clinically as one with a clear cornea without redness or irritation of the conjunctiva or sclera. CONCLUSIONS: The causes of eye pain may be divided into two groups: (1) those associated with abnormal localizing ophthalmologic and neuro-ophthalmologic findings (including trigeminal neuropathies);(2) those with a normal ophthalmologic and neurologic examinations. The latter group is further divided into the following subgroups: (1) specific short-lasting or long-lasting headache or eye pain syndromes; (2) pain referred to the eye from other pathologic processes (secondary eye pain) sometimes distant from structures concerned with vision; and (3) pain from orbital, superior orbital fissure, cavernous sinus, or intracranial infiltrative, neoplastic, or inflammatory disease processes with normal ophthalmologic and neuro-ophthalmologic exam. Unfortunately, in some patients, no etiology for the pain syndrome is discerned and one is left with a diagnosis of idiopathic eye pain, eye strain, or atypical facial pain.
Journal Article↗
Experimental human muscle pain induced by intramuscular injections of bradykinin, serotonin, and substance P.
After intramuscular (m. tibialis anterior) injection of three different algogenic substances, the pain intensity was continuously scored on a visual analogue scale (VAS) in eight volunteers. The subject drew the distribution of the local and referred pain areas on a map. Four times within the first hour after injection, the pressure pain-thresholds (PPTs) and supra pressure-pain thresholds were assessed at the injection point, 2 cm distal from the injection site, at the arm, and at the contralateral leg. Measurements were done before and after injection of 0.5 ml of the algogenic substance [bradykinin (BKN), serotonin (5-HT), substance P (SP)], and isotonic saline as control. Cutaneous sensitivity to mechanical stimuli was assessed with a Von Frey hair at the same location as PPT determinations.The pain intensity (VAS-peak) after BKN (2, 4, and 10 nmol) and 5-HT (2, 4, and 20 nmol) was significantly higher (p< 0.05) than after SP (0.2, 0.4, and 0.8 nmol) and isotonic saline. The VAS-peak after infusions of hypertonic saline was significantly higher (p< 0.05) compared with VAS-peaks after all other substances. A significantly larger (p< 0.05) local pain area was found after BKN compared with isotonic saline. After injections of hypertonic saline, the offsets of evoked pain were significantly longer (p< 0.05) and the local and referred pain areas were significantly larger (p< 0.05) compared with all other substances. There was no dose-response relation between the pain intensity and the different doses of BKN, 5-HT, and SP. PPTs and skin sensitivity were not affected by any of the injections.We conclude that under the present experimental conditions, BKN and 5-HT can produce low levels of muscle pain after intramuscular injection. In the used concentrations, however, BKN, 5-HT, and SP did not generate cutaneous or muscular hyperalgesia. Copyright 1999 European Federation of Chapters of the International Association for the Study of Pain.
Journal Article↗
How confounding are breast pain confounders?
Nine thousand four hundred evaluable patients with breast complaints were consecutively studied from 1984 to 1994. Their ages ranged between 15-65 years with a median of 33 years. Five thousand, six hundred and seventy-five of these presented on account of pain and a mass was the cause of pain in 74%. Gross fibrocystic disease of the breast was the commonest tumour encountered in this group. Seven hundred and thirty eight patients were found to have 'referred' pain, and splenomegaly was the commonest cause of this 'referred' pain. At present, a simple breast biopsy remains the cheapest and most effective method of investigating this organ in most developing countries.
Adolescent↗
Nonsteroidal antiinflammatory drugs suppress pain-related behaviors, but not referred hyperalgesia of visceral pain in mice.
Visceral pain is characterized by spontaneous pain and referred hyperalgesia. After inducing visceral pain in mice using intracolonic mustard oil administration, we examined the effects of various nonsteroidal antiinflammatory drugs (NSAIDs) on pain-related behavior and on Evans blue dye extravasation. Animals were given one of the following: saline, ethanol, dimethylsulfoxide (DMSO), morphine, ketoprofen, ketorolac, or DFU (a cyclooxygenase-2 inhibitor). After drug treatment, mice underwent intracolonic administration of 50 microL 1.5% mustard oil. Spontaneous pain-related responses were assessed for the next 20 min. The frequency of withdrawal responses to the application of von Frey hairs to the abdomen, foot, and tail was determined. After completion of the behavioral tests, Evans blue was injected into the animals via the tail vein. Two hours later, the colon was removed postmortem and Evans blue content was measured. Spontaneous pain behaviors were significantly less in animals administered 3 and 10 mg/kg morphine, 50 mg/kg ketorolac, 100 mg/kg ketoprofen, and 20 mg/kg DFU (P < 0.05). Response frequencies to the application of von Frey hairs were lower in mice administered 3 and 10 mg/kg morphine (P < 0.05) but were not affected by ketorolac, ketoprofen, or DFU treatment. Colonic Evans blue content was smaller in mice given 100 mg/kg ketoprofen and 20 mg/kg DFU (P < 0.05). We concluded that NSAIDs reduced pain behavior and inflammation but had little effect on referred hyperalgesia.
Animals↗
Discriminant validity and relative precision for classifying patients with nonspecific neck and back pain by anatomic pain patterns.
STUDY DESIGN: Secondary analysis of a previously described cohort of prospective, consecutive patients with acute neck or low back pain referred to outpatient rehabilitation was performed. OBJECTIVE: To estimate discriminant validity and relative precision of two classification procedures (first visit vs multiple visit) in discriminating short-term pain intensity and perceived disability outcomes. SUMMARY OF BACKGROUND DATA: Centralization and noncentralization are pain responses used to classify patients and predict outcomes. Different time frames have been proposed for operationally defining these responses, which are problematic for comparing outcomes across clinical trials. Classifying patients according to pain response observed from initial examination (first visit) and over time (multiple visits) influences prevalence within categories and interpretation of classification usefulness, which merits further investigation. METHODS: Patients with acute onset of nonspecific neck or low back pain referred to two outpatient physical therapy clinics completed body pain diagrams, pain intensity ratings, and disability questionnaires at initial evaluation, during each visit, and at discharge. Therapists collected data enabling patient classification on initial examination and throughout treatment. Differences in pain and disability from intake to discharge from rehabilitation across classification categories were used to assess discriminant validity. Relative precision was estimated by determining ratios of analysis of covariance F values between classification procedures for pain and disability. RESULTS: Both classification procedures discriminated categories for change in pain and disability. The multiple-visit classification procedure was more precise for discriminating outcomes than the first-visit classification procedure. CONCLUSION: Multiple-visit classification of patients into specific pain pattern subgroups is recommended when pain intensity and disability outcomes are of interest.
Adult↗
Prevention and treatment of postoperative pain with particular reference to children.
Pain therapy is an important aspect of medical practice for patients of all ages, to optimize care, to obtain an adequate quality of life and to improve their general conditions. Pain is among the most prevalent symptoms experienced by patients undergoing surgery. The success of postoperative pain therapy depends on the ability of the clinician to assess the presenting problems, identify and evaluate pain syndromes and formulate a plan for comprehensive continuing care. The prevalence of acute pain has led to the need to develop techniques for the assessment and management of this symptom in order to focus the attention on an interdisciplinary therapeutic approach (including pharmacologic, cognitive-behavioral, psychologic and physical treatment) and on the timing of different interventions (pre and postoperative). In this chapter we describe the principal therapeutic approaches to control pain in post-operative patients, such as non-opioid, opioid and adjuvant analgesics with particular attention in paediatric age. Moreover we report the principal scales to assess the pain intensity in the post-operative period. The need of a multidisciplinatory team and of a pre and postoperative pain management program represents an important goal in order to obtain effective pain relief and optimize pediatric care and rapid recovery. The introduction of a perioperative team service will improve the approach to pain management programs and it is considered the most important challenge for future.
Analgesics↗
Myofascial pain syndromes in the upper extremity.
Myofascial pain syndromes of the upper extremity are common causes of pain that may follow trauma and are associated with acute or chronic musculoskeletal stress. The syndromes are characterized by the presence of the myofascial trigger point, a physical finding that is reliably identified by palpation. Local and referred pain are hallmarks of the syndrome, and the referred pain patterns may mimic such conditions as radiculopathy and nerve entrapment syndromes. Treatment is directed toward inactivating the myofascial trigger point, correcting underlying perpetuating factors, and restoring the normal relationships between the muscles of the affected functional motor units.
Arm↗
Myofascial origins of low back pain. 2. Torso muscles.
Trigger points (TPs) in muscles of the lower torso associated with the spine are an important cause of low back pain. The quadratus lumborum is the muscle most commonly involved, but TPs located there are often overlooked because of inadequate physical examination techniques. TPs in the lower rectus abdominis refer pain horizontally across the low back, and those in the iliopsoas refer pain in a vertical pattern, parallel to the lumbosacral spine. The pain pattern of TPs in the serratus posterior inferior is noted in the region of the muscle itself.
Back↗
Pain referral patterns in the pelvis.
STUDY OBJECTIVE: To determine if right-left pelvic pain orientation exists in all patients, and to estimate the frequency of pain referral patterns in the pelvis. DESIGN: Prospective, nonrandomized trial (Canadian Task Force classification II-1). SETTING: University-affiliated hospital. PATIENTS: One hundred consecutive women with no pain undergoing tubal sterilization or investigation of infertility (group A) were compared with 225 women with chronic pelvic pain of greater than 6 months' duration (group B). INTERVENTION: Patient-assisted laparoscopy with intravenous conscious sedation and pelvic pain mapping. MEASUREMENTS AND MAIN RESULTS: Of women in group A, 69% had correct right-left orientation, 18% had pain perceived on the opposite side of the abdomen, and 31% had pain referred to another location in the abdomen. The results were similar in women in group B, 65% of whom had correct orientation, 15% had pain perceived on the opposite side of the abdomen, and 35% had pain referred to another location. CONCLUSION: This demonstrates the need to ask on which side a woman feels pain during physical examination. It is not correct to assume that an answer of "yes" means the same side of the pelvis that is being examined. Patient-assisted laparoscopy and pelvic pain mapping are excellent in correlating the symptom with the pathology.
Procedural Sedation↗
Sensory manifestations in experimental and work-related chronic neck-shoulder pain.
Little is known about the mechanisms leading to chronic neck-shoulder musculo-skeletal disorders. The aim of the present study was to investigate and compare the sensory manifestations of experimental or chronic neck-shoulder pain under controlled, low load, repetitive work. Experimental and clinical experiments were carried out. In Experiment 1, experimental muscle pain was induced in healthy subjects by intramuscular injection of hypertonic saline in the trapezius (n = 10) and infraspinatus (n = 10) muscles. Experiment 2 was performed on 18 workers with (n = 12) and without (n = 6) chronic neck-shoulder pain. Sensory assessments were performed before and/or after a session of controlled, low load, repetitive work. The pain intensity was assessed by a visual analogue scale. The pain quality and location(s) were monitored together with pressure-pain thresholds. Moderate-to-strong deep pain intensity was experienced in the experimental and clinical part of the working session (six patients out of 12). The verbal descriptors used to describe the experimental or chronic pain qualities were partially similar, i.e. first of all verbal descriptors from the sensory class. The patterns of local and referred pain characteristics were similar (around the shoulder girdle), but it is difficult to evoke pain in extensive areas with hypertonic saline. Patients exhibited hypersensitivity or tenderness to pressure stimuli in both sides of the upper body, i.e. in the trapezius, supraspinatus, infraspinatus and pectoralis major muscles (p < 0.05). This hypersensitivity was only seen at the referred pain site in the healthy volunteers exposed to infraspinatus experimental muscle pain. In conclusion, the present study demonstrated similar sensory manifestations in the experimental and clinical neck-shoulder pain experiments. The presented experimental model can most likely be used to investigate the underlying pain mechanisms involved in work-related chronic musculoskeletal pain.
Journal Article↗
Effect of sympathetic muscle vasoconstrictor activity on capsaicin-induced muscle pain.
Neuropathic pain syndromes with sympathetically maintained pain are often associated with a deep somatic pain component. An adrenergic interaction between sympathetic vasoconstrictor neurons and cutaneous afferents has been demonstrated. To determine whether a sympathetic-afferent interaction exists in deep somatic tissues, we investigated the effect of sympathetic muscle vasoconstrictor activity on experimentally induced pain. In 12 healthy volunteers, capsaicin was infused into the anterior tibial muscle. Intensity and quality of muscle and referred pain were assessed. The analyses were performed during the presence of low sympathetic muscle vasoconstrictor activity induced by breathing 100% O(2) gas (normocapnia), and during high activity induced by inspiration of 95% O(2) and 5% CO(2) (hypercapnia). The degree of sympathetic muscle vasoconstrictor discharge was monitored indirectly by measuring systemic blood pressure and end-expiratory CO(2) and by performing duplex sonography of muscle resistance vessels. The intensity, quality, and spatial distribution of muscle and referred pain were not significantly different during resting and increased sympathetic muscle vasoconstrictor discharge, indicating that such activity does not influence pain after intramuscular infusion of capsaicin.
Adult↗