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PubMed1983

The role of fusion for chronic low back pain.

The demonstration of a rich nerve supply in the outer half of the disc and the occurrence of deep pain referred from the vertebral column to the leg without nerve root compression are both important aspects in understanding low back pain and in making a decision regarding its surgical management. Discography is invaluable as a diagnostic test in patients with chronic back pain if one is to demonstrate discogenic lesions. For sufferers of postlaminectomy syndrome, a difficult patient group, a simultaneous combined anterior and posterior fusion offers a real hope for relief of pain and rehabilitation.

Adult↗

PubMedDate not supplied

Osteoid osteoma of the proximal femur simulating spinal root compression.

In a 6 1/2-year-old boy and a 9 1/2-year-old girl, spinal root compression was suspected on the basis of muscle wasting and weakness, diminished deep tendon reflexes, and severe pain, all in a radicular distribution. However, extensive and invasive neuroradiologic evaluation failed to demonstrate compression of spinal roots. Only several months later was the correct diagnosis of osteoid osteoma reached. In one patient, the tumor was removed and on histologic examination groups of unmyelinated nerve fibers were found near the center of the tumor nidus, generally surrounding small arterioles. In the other patient parental consent was not given for the operation. The symptoms gradually subsided, although the typical radiologic features of the tumor went unchanged. The presence of unmyelinated autonomic nerve fibers in the nidus of osteoid osteoma may explain the severe pain commonly experienced by the patients. The spinal origin of such fibres can account for the radicular syndrome, while the localization of pain and sensory findings remote from the tumor site might be explained by a mechanism similar to that responsible for "referred pain."

Child↗

PubMed2000

Shoulder pain as an unusual presentation of pneumonia in a stroke patient: a case report.

Etiologies of shoulder pain in the hemiplegic population, such as glenohumeral subluxation, frozen shoulder, and reflex sympathetic dystrophy (RSD), have been described extensively. We present an 89-year-old woman with right hemiparesis secondary to ischemic lacunar infarction who developed sudden onset of right shoulder pain on the fifth day of inpatient rehabilitation. The pain was severe, limiting range of motion (ROM) and participation in therapy. Extensive investigations to rule out subluxation, fracture, connective tissue disease, RSD, and pulmonary embolism were negative. Ultimately, her shoulder pain and decreased ROM completely resolved with antibiotic treatment for right lower lobe pneumonia. We conclude that her symptoms were possibly referred pain from diaphragmatic irritation transmitted via right C4 sensory axons in the phrenic nerve, which shares the same dermatome as the right acromion area. This case was an unusual presentation of pneumonia in an elderly woman with hemiplegia. We recommend that pneumonia be considered in the differential diagnoses of shoulder pain.

Aged↗

PubMed2004

The nature of anterior knee pain following injection of hypertonic saline into the infrapatellar fat pad.

The infrapatellar fat pad has been implicated as a possible source of anterior knee pain. This study examined the nature, distribution and time-course of experimentally induced pain in the infrapatellar fat pad. Hypertonic saline (5%) was injected into the medial fat pad of 11 healthy individuals with no history of knee pain. Severity of pain was assessed at rest and during activity using an 11 point numerical rating scale (NRS) at regular intervals over 15-30 min following injection. Participants described the size of the pain region from a series of different sized circles while the area and type of pain was established from a body chart and the McGill pain questionnaire. The effect of pain on temperature-pain threshold and sensory thresholds of the anterior knee was assessed. Participants generally reported a deep aching pain that peaked in severity around 3 min and gradually declined over 15 min. Pain levels were not altered by clinical manoeuvres designed to impinge the fat pad. The size of the pain region was related to pain intensity. Pain was most commonly felt in the region of the fat pad medial to the patella, although some individuals reported proximal referred pain as far as the groin region. Thermal and sensory thresholds were not altered at a region close to the injection site during the experimental pain. These results suggest that nociceptive stimulation of the infrapatellar fat pad may cause anterior knee pain that is not necessarily confined locally particularly if pain is severe. This has implications for the investigation of pathological structures in patients presenting clinically with anterior knee pain and provides an experimental model of anterior knee pain.

Adipose Tissue↗

PubMed1995

Anterior iliopsoas impingement after total hip arthroplasty.

Pain after total hip arthroplasty (THA) can be caused by a multitude of conditions, including infection, aseptic loosening, heterotopic ossification, and referred pain. It is also recognized that soft tissue inflammation about the hip, such as trochanteric bursitis, can lead to hip pain after THA. Two cases of persistent iliopsoas tendinitis following THA are reported, which are believed to be caused by psoas tendon impingement against a malpositioned, uncemented, metal-backed acetabular component. The authors are unaware of previous reports of this problem, and suggest that the problem be considered in the differential diagnosis of groin pain following THA.

Aged↗

PubMed2004

Central sensitisation and cutaneous allodynia in migraine: implications for treatment.

Cutaneous allodynia, pain resulting from application of a non-noxious stimulus to normal skin, is a recently described symptom of migraine, with a potential role in directing optimal treatment for migraine attacks. Manifestations of cutaneous allodynia include discomfort when combing the hair, shaving, and wearing glasses, contact lenses, earrings or tight clothing. The exact mechanism by which a migraine attack is triggered is not known, but it has been theorised that, in some patients, once the attack has begun, central neurons can propagate information about the pain process without the need for further external stimuli. This process is termed central sensitisation. The trigeminal nerves, which innervate intracranial and extracranial tissues, account for head pain and other symptoms in migraine. The first-order neurons in the trigeminal ganglion receive input from the dural blood vessels, which is transmitted to second-order neurons in the trigeminal brain stem nuclear complex and is finally sent to the third-order neurons in the thalamus. Studies in humans and animals have shown that migraine pain progresses along this neural pathway, with throbbing head pain occurring early in the attack (sensitisation of first-order neurons), followed by central sensitisation and cutaneous allodynia within the referred pain area (second-order) and finally extracephalic allodynia (third-order). The data also indicate that once central sensitisation is established in the second- and third-order neurons, migraine treatment designed to prevent the initiation of central sensitisation can lessen the pain to some extent but cannot reverse it. Thus, treatment affecting the initiation of central sensitisation should be administered immediately after the onset of migraine pain to prevent intracranial hypersensitivity and the establishment of allodynia. The serotonin 5-HT(1B/1D) agonist anti-migraine agents (the 'triptans') block meningeal nociceptor transmission at presynaptic sites in the dorsal horn. Studies have shown that triptan therapy can abort pain prior to the development of central sensitisation, but not after allodynia has been established. Therefore, in the subset of patients who report symptoms of cutaneous allodynia with migraine attacks, early initiation of triptan therapy is currently the best intervention to achieve rapid, complete and sustained pain relief.

Central Nervous System↗

PubMed1998

Cancer-related neuropathic pain.

Neuropathic pain refers to syndromes that may be related to peripheral or central neural structure compression, infiltration, or damage. Cancer-related neuropathic pain results from compression or infiltration of nerves by the tumor, nerve trauma from operative procedures, or neuropathic pain related to cancer treatment. Management of neuropathic pain includes the use of opioids, antidepressants, anticonvulsants, local anesthetics, and other adjuvant medications. Intractable neuropathic pain may require the use of intraspinal delivery or anesthetic and neurosurgical procedures. The nurse practitioner plays an important role in the assessment and "trial and error" management of cancer-related neuropathic pain.

Analgesics↗

PubMed1994

Neurobiology of the myofascial trigger point.

The clinical phenomenon of the MTrP is accessible to any clinician who takes the time to learn to palpate skeletal muscle gently and carefully, and who is willing to learn the functional anatomy necessary to understand the regional spread of MTrPs through functional muscle units (Travell and Simons, 1992). Yet despite the years of clinical study of MPS, the pathophysiology of the central feature, the trigger point, has remained elusive. Many investigators have contributed to the general understanding of the mechanisms of pain perception, but we owe a particular debt of gratitude to Dr Seigfried Mense of Heidelberg for his pursuit of the study of pain originating in muscle lesions. However, Dr Mense would be the first to caution us against the direct transference of the results obtained with an inflammatory lesion produced in the experimental animal to the pain of MTrPs in the clinic patient. Notwithstanding that, researchers in the field of pain have given us an understanding of the basis for the hyperalgesia, allodynia and the previously difficult-to-understand finding of referred pain zones that we see daily in our patients. Finally, the interesting initial observations of Hubbard and Berkoff (1993), suggesting that the muscle spindle may be associated with the trigger point, open yet another door in our understanding of the nature of MPS.

Animals↗

PubMed1987

Shoulder pain. Guidelines to diagnosis and management.

The cause of shoulder pain can usually be diagnosed after a pertinent history has been obtained and a relevant physical examination performed. To carry out such an evaluation, the examiner must understand the salient anatomic relationships of the shoulder. Causes of shoulder pain include supraspinatus tendinitis (the most common), bicipital tendinitis, impingement syndromes, supraspinatus rupture, subacromial bursitis, arthritis, frozen shoulder, and various conditions that refer pain to the shoulder. Treatment in most cases consists of rest and administration of a nonsteroidal antiinflammatory drug or injection of a corticosteroid preparation, or both.

Bursitis↗

PubMed2001

One-peg versus three-peg patella component fixation in total knee arthroplasty.

In many designs of total knee arthroplasty, the patella with one central peg has been replaced by a patella with three small pegs for cement fixation. There have been recent reports of failure of this design. This is a prospective, consecutive study of two types of patella component fixation in 228 posterior-stabilized knee arthroplasties done by one surgeon. A central peg all-polyethylene component was used for 84 consecutive knees in 63 patients (Group A) and a three-peg patella was used for the next 144 consecutive knees in 99 patients (Group B). The mean followup was 6.7 years (range, 2-10 years) for Group A and 3.5 years (range, 2-6 years) for Group B. Except for the patellar component fixation, all knees had the same posterior-stabilized prosthesis using a specific protocol for patellar resurfacing. No patient required reoperation for a patellofemoral complication. The prevalence of patella fracture was higher in Group A, 4.7% (four knees), compared with 2.1% (three knees) in Group B, but this difference was not statistically significant. The presence of anterior knee pain referable to the patella was 7.1% (five patients, six knees) in Group A (one patient with two knees had severe anterior knee pain) and 9% (13 knees in 13 patients) in Group B. There was no patella clunk syndrome, subluxation, or fracture of a fixation peg in either group. With this specific protocol for patella resurfacing, there was a higher rate of complications with the one central peg patella (4.7%) than with the three-peg patella (2.1%), but this did not reach statistical significance. The results do not support an increased risk of component failure with this three-peg patella design, but do not, at this length of followup, show any significant advantage of three-peg fixation.

Adult↗

PubMed2000

[Mechanisms of myofascial pain].

The aim of this paper is to review available data and current hypotheses concerning myofascial pain syndrome pathophysiology and implications for clinical practice. A muscular hypothesis has been proposed for episodic and chronic tension headache as well as for myofascial syndrome and fibromyalgia. These different syndromes may be compared as, besides their frequent combination, they have common features characterized by spontaneous pain, painful points, and lack of objective findings. They must be distinguished because each has its own diagnostic criteria. Pressure algometry appears to be a reliable method for assessing pressure sensitivity in myofascial pain. Pressure pain is not specific to tension headache and can be observed in other chronic headaches. It has not been demonstrated that the trigger points of fibromyalgia are specific in idiopathic cases. It is difficult to find an electrophysiological investigation which is specific for myofascial pain. For daily practice, the clinical approach with interview and examination remain the advisable attitude. Pathophysiological hypotheses help in better understanding of referred pain by sensitization of nociceptive central pathways according to the Ruch convergence projection theory (1965), modified by Mense in 1994. These theories do not however provide an explanation of the primary muscular mechanisms. Implications for myofascial pain patient management is discussed.

Facial Muscles↗

PubMed1975

The straight leg raising test: its relevance to possible disc pathology.

The records of 40 patients who had suffered from low back pain, and who had a marked restriction of straight leg raising (SLR) have been studied. Thirty-four of these cases had referred pain down the lower limb. They were all treated, at least in the first place, by manipulation. The response to manipulation demonstrates that, in the absence of evidence of interference with nerve root conduction, limitation of SLR is an unreliable sign of possible disc pathology. Furthermore, the immediate response to manipulation, particularly in the known disc protrusions, strongly suggests that muscle spasm plays a major role in limiting SLR. These points are discussed.

Adult↗

PubMed1980

[The gynaecologist's view of lower back pain (author's transl)].

Pain is a sensation, "lower back" a vague anatomical term, and lower back pain no disease, but a multilayered symptom. Women with this condition usually first see the gynaecologist, but in only approximately 10% of these cases is the pain referable to disease of the genital organs. 90% are due to inflammatory or degenerative skeletal disease. The differential diagnosis of lower back pain requires knowledge of innervation. Head's or Mackenzie's zones, blood supply, and anatomy of the pelvic area. The effects of pregnancy on the sacroiliac joints, anomalies of positive adnexitis, endometriosis, weakness of the pelvic muscles and connective tissue as a result of trauma during childbirth or on a genetic basis, as well as psychosexual vasomotor alterations may play a causative role. Differentiating pointers and therapeutic methods are presented.

Adult↗

PubMed1981

Identification of myofascial trigger point syndromes: a case of atypical facial neuralgia.

Myofascial trigger points (TPs) in a muscle are usually activated by acute or chronic overload of the muscle. They are identified by objective and subjective findings. Objective signs include a palpably firm, tense band in the muscle, production of a local twitch response, restricted stretch range-of-motion, weakness without atrophy, and no neurologic deficit. Subjectively, the patient reports stiffness and easy fatigability, spontaneous pain in a distribution predictable for that TP, an exquisite deep tenderness specifically at the TP. Sustained pressure on the TP induces referred pain in the predicted pattern. Some muscles are likely to produce additional objective and subjective autonomic concomitants. Laboratory and radiographic findings are negative. The affected muscle is treated by passive stretch while a jet stream of vapocoolant spray is applied over it, or by injection of the TP with a local anesthetic. A case report describes in detail the treatment of a patient who, for 13 years, had suffered from a medically enigmatic, intense right facial pain with severe dysfunction and who is now pain-free, with a full schedule of unrestricted activities 23 years later.

Adult↗

PubMed2003

Coccygodynia: a proposal for an algorithm for treatment.

Coccygodynia (coccydynia, coccygalgia) or coccygeal pain is a well-known but rarely studied painful syndrome affecting the coccyx region. Its etiology is not well understood. Symptoms include development of pericoccygeal soft tissues, pelvic floor muscle spasms, referred pain from lumbar pathology, arachnoiditis of the lower sacral nerve roots, local post-traumatic lesions, and somatization. In spite of advances in the treatment of other pain conditions, coccygodynia remains in a position for which therapeutic options are not clearly designed. On the basis of an anatomic review, proposed pathogenesis of coccygodynia, and the number of treatment approaches that have been proposed, we propose an algorithm for therapeutic decision making in the treatment of this syndrome.

Algorithms↗

PubMedDate not supplied

Ethnic differences in pain tolerance: clinical implications in a chronic pain population.

OBJECTIVE: Although numerous studies have independently examined ethnic differences in clinical and experimental pain, few have investigated differences in both sensitivity to controlled noxious stimuli and clinical pain reports in the same sample. The present experiment examined the effects of ethnicity (African American vs. white) on experimental pain tolerance and adjustment to chronic pain. METHODS: Three hundred thirty-seven (68 African American and 269 white) patients with chronic pain referred to a multidisciplinary treatment center participated in the study. In addition to completing a number of standardized questionnaires assessing adjustment to chronic pain, participants underwent a submaximal effort tourniquet procedure. This experimental pain procedure yields a measure of tolerance for a controlled noxious stimulus (ie, arm ischemia). RESULTS: African American subjects reported higher levels of clinical pain as well as greater pain-related disability than white participants. In addition, substantial group differences were observed for ischemic pain tolerance, with African Americans demonstrating less tolerance than whites. Correlational analyses revealed a small but significant inverse relationship between ischemic pain tolerance and the reported severity of chronic pain. CONCLUSIONS: Collectively these findings support previous research revealing ethnic differences in responses to both clinical and experimental pain. Moreover, the present results suggest that enhanced sensitivity to noxious stimuli on the part of African Americans may be associated with ethnic differences in reported clinical pain, although the magnitude of ethnic differences was much greater for ischemic pain tolerance than for clinical pain measures.

Adult↗

PubMedDate not supplied

Esophageal dysfunction in patients with atypical chest pain investigated with esophageal scintigraphy and myocardial perfusion imaging: an outcome study.

BACKGROUND: The objectives of this study were to determine the role of esophageal scintigraphy (ES) and myocardial perfusion imaging (MPI) in patients with atypical chest pain investigated for ischemic heart disease (IHD). METHODS AND RESULTS: One hundred five consecutive patients with atypical chest pain were investigated by dual-isotope MPI (1-day rest-stress protocol). Within a 10-day period, each patient also had liquid and semisolid ES performed with dynamic imaging over a 2-minute period for each phase. All patients were risk-stratified, and 28 patients were also investigated by coronary angiography. Patient outcome was assessed with the use of endpoints including cardiac death, myocardial infarction, and coronary revascularization procedures. Of the patients, 53 (50%) had esophageal dysfunction (ED) but no IHD, 41 (39%) had both ED and IHD, 5 (5%) had normal ES and IHD, and 6 (6%) had neither ED nor IHD. On the basis of outcome findings (n = 105) and coronary angiogram results (n = 28), MPI showed sensitivity for the detection of IHD of 92% in this patient population. Of the 94 patients (89%) with ED, 48 (51%) showed esophageal dysmotility, 9 (10%) showed gastroesophageal reflux, 17 (18%) showed esophageal spasm and dysmotility, 17 (18%) showed both reflux and dysmotility, and 3 showed other abnormalities. The median follow-up period after MPI was 20 months (range, 9-30 months). Twenty-one patients had cardiac events. These included 2 cardiac deaths, 2 myocardial infarctions, 6 coronary artery bypass graft surgeries, and 11 angioplasty/stent procedures. All but 2 of these patients had abnormal ES studies, and 7 had no prior history of IHD. MPI detected IHD in all but 2 of these patients. CONCLUSIONS: There is a high incidence of ED in patients with atypical chest pain referred for cardiologic assessment. The low proportion of patients with IHD alone and of those with neither IHD nor ED presenting with atypical chest pain (5%), as well as the high proportion with ED alone (50%), indicates the high likelihood of chest pain derived from ED. However, of the 21 patients with cardiac events, 7 had no prior history of IHD, indicating the importance of the use of MPI in the investigation of patients with atypical chest pain syndromes.

Adult↗

PubMed2007

A prospective double blind placebo-controlled randomized trial of ultrasound in the physiotherapy treatment of shoulder pain.

OBJECTIVE: To compare the effectiveness of manual therapy and ultrasound (US) with manual therapy and placebo ultrasound (placebo US) in the treatment of new episodes of unilateral shoulder pain referred for physiotherapy. METHODS: In a multicentre, double blind, placebo-controlled randomized trial, participants were recruited with a clinical diagnosis of unilateral shoulder pain from nine primary care physiotherapy departments in Birmingham, UK. Recruitment took place from January 1999 to September 2001. Participants were 18 yrs old and above. Participants all received advice and home exercises and were randomized to additionally receive manual therapy plus US or manual therapy plus placebo US. The primary outcome measure was the Shoulder Disability Questionnaire (SDQ-UK). Outcomes were assessed at baseline, 2 weeks, 6 weeks and 6 months. Analysis was by intention to treat. RESULTS: A total of 221 participants (mean age 56 yrs) were recruited. 113 participants were randomized to US and 108 to placebo US. There was 76% follow up at 6 weeks and 71% at 6 months. The mean (95% CI) reduction in SDQ scores at 6 weeks was 17 points (13-26) for US and 13 points (9-17) for placebo US (P = 0.06). There were no statistically significant differences at the 5% level in mean changes between groups at any of the time points. CONCLUSIONS: The addition of US was not superior to placebo US when used as part of a package of physiotherapy in the short-term management of shoulder pain. This has important implications for physiotherapy practice.

Adult↗