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PubMed1985

Edrophonium: a useful provocative test for esophageal chest pain.

Esophageal motility disorders may be an important cause of noncardiac chest pain. To improve our diagnostic yield, we studied the use of edrophonium as a provocative test for inducing esophageal chest pain in 50 symptomatic patients without coronary artery disease and in 25 age-matched controls. Edrophonium (80 micrograms/kg of body weight, intravenous bolus) induced chest pain in 15 (30%) patients and in no controls. Edrophonium increased esophageal amplitude and repetitive contractions to a similar degree in all subjects, but the change in duration (101 +/- 13% [SE] was significantly greater (p less than 0.02) in patients in whom chest pain was induced. Drug specificity was assessed in 9 patients during cardiac catheterization, but no significant change was seen in coronary artery diameter, blood pressure, or heart rate. Further clinical testing using a placebo control confirmed a positivity rate of 28% in 125 unselected patients with chest pain referred to our laboratory; false-positive tests were infrequent (5.6%). No important side effects were seen. Edrophonium is useful for provoking esophageal chest pain.

Adult↗

PubMed1992

[Causes of pain and treatment effect in patients with cancer referred to a multidisciplinary pain clinic].

The causes of pain were analysed in 200 patients referred to a multidisciplinary pain clinic for cancer patients. In 158 patients, pain caused directly by tumour growth was found, 116 patients had pain secondary to the cancer disease or treatment while 33 patients had pain caused by factors unrelated to the cancer disease. The patients had many different combinations of causes of pain and the majority had more than one cause of pain. At the first contact and after treatment for 1-2 weeks, the patients were asked whether they had pain on movement, at rest or pain which interrupted sleep. After treatment for 1-2 weeks and after treatment for more than two weeks, the patients assessed the relief of pain obtained (none, slight, moderate, considerable, complete). The majority of patients achieved relief of pain at rest and during sleep while movement was still accompanied by pain in a number of patients. The majority of patients considered that the relief of pain obtained was moderate or considerable. Treatment consisted of adjustment of medication, blockades and epidural opioids supplemented by psychological intervention and help from social workers in selected patients.

Analgesia↗

PubMed2006

[Tooth and molar pains].

A patient's pain history is the primary source of information in case of toothache (dentoalveolar pain); revealing its location, its main characteristics and its course, both from the onset and during the day. Clinical diagnostic tests that provoke (such as pulp testing or percussion) or eliminate (such as local anaesthesia) pain are most useful. Several mechanisms may underlie dentoalveolar pain. Pain caused by pulpitis shows characteristics of visceral types of pain, whereas pain originating from the periodontal ligament is characterized by musculoskeletal features. It also happens fairly often that the pain is found to originate from a different tooth than the one in which it is perceived, or from an even more distant source (referred pain). These mechanisms emphasize the importance of differential diagnostics.

Anesthetics, Local↗

PubMed1987

Hernia through the foramen of Winslow: a complication of cholecystectomy. A case report.

In 151 years since first described, there have been 112 reported cases of hernia through the foramen of Winslow (HFW). All thus far have described HFW as a primary entity. The case reported appears to be unique with HFW as a surgical complication. HFW is the least common of internal hernias. The primary symptom is pain referred from the herniated organ and the hepatoduodenal ligament. An interesting sign is that the patient is found curled up or stooped over for pain relief. Anatomic factors implicated in HFW are an enlarged epiploic foramen, a floppy cecum and ascending colon, or abnormal length of small bowel mesentery. Tension on these structures causes pain with the torso extended. Distention of bowel in the lesser sac mimics gastric obstruction. Organs herniated are: small bowel (63%); cecum, ascending colon, and terminal ileum (30%); and transverse colon (7%). Of 25 cases reported since 1966, cecal herniation comprised two-thirds. The diagnosis may be made radiologically and the treatment is surgical. The case and a review of the literature are presented with attention to the anatomy. Also provided are the signs and symptoms of this interesting and perplexing diagnosis.

Aged↗

PubMed2000

The development of cutaneous allodynia during a migraine attack clinical evidence for the sequential recruitment of spinal and supraspinal nociceptive neurons in migraine.

Recently, we showed that most migraine patients exhibit cutaneous allodynia inside and outside their pain-referred areas when examined during a fully developed migraine attack. In this report, we studied the way in which cutaneous allodynia develops by measuring the pain thresholds in the head and forearms bilaterally at several time points during a migraine attack in a 42-year-old male. Prior to the headache, he experienced visual, sensory, motor and speech aura. During the headache, he experienced photo-, phono- and odour-phobia, nausea and vomiting, worsening of the headache by coughing or moving his head, and cutaneous pain when shaving, combing his hair or touching his scalp. Comparisons between his pain thresholds in the absence of migraine and at 1, 2 and 4 h after the onset of migraine revealed the following. (i) After 1 h, mechanical and cold allodynia started to develop in the ipsilateral head but not in any other site. (ii) After 2 h, this allodynia increased on the ipsilateral head and spread to the contralateral head and ipsilateral forearm. (iii) After 4 h, heat allodynia was also detected while mechanical and cold allodynia continued to increase. These clinical observations suggest the following sequence of events along the trigeminovascular pain pathway of this patient. (i) A few minutes after the initial activation of his peripheral nociceptors, they became sensitized; this sensitization can mediate the symptoms of intracranial hypersensitivity. (ii) The barrage of impulses that came from the peripheral nociceptors activated second-order neurons and initiated their sensitization; this sensitization can mediate the development of cutaneous allodynia on the ipsilateral head. (iii) The barrage of impulses that came from the sensitized second-order neurons activated and eventually sensitized third-order neurons; this sensitization can mediate the development of cutaneous allodynia on the contralateral head and ipsilateral forearm at the 2-h point, over 1 h after the appearance of allodynia on the ipsilateral head. This interpretation calls for an early use of anti-migraine drugs that target peripheral nociceptors, before the development of central sensitization. If central sensitization develops, the therapeutic rationale is to suppress it. Because currently available drugs that aim to suppress central sensitization are ineffective, this study stresses the need to develop them for the treatment of migraine.

Adult↗

PubMed1998

A clinical test for superior glenoid labral or 'SLAP' lesions.

OBJECTIVE: To describe a clinical test associated with unstable lesions of the superior glenoid labrum-long head biceps tendon origin, or SLAP (superior labrum anterior to posterior). DESIGN: Description of a newly discovered clinical sign that correlated with SLAP pathology. Retrospective review of 66 consecutive arthroscopically confirmed SLAP lesions to determine the sensitivity of the SLAPprehension test. SETTING: Orthopedic sports medicine clinics with an emphasis on shoulder problems. PATIENTS: Patients with shoulder pain and arthroscopically verified lesions of the superior glenoid labrum and conjoined long head biceps tendon. INTERVENTION: Shoulder arthroscopy and in some cases arthroscopic SLAP lesion repair. OUTCOME MEASURES: Nonapplicable. RESULTS: The SLAPprehension test involves cross chest adduction (horizontal flexion) of the affected shoulder with the elbow extended and forearm pronated. A positive maneuver produces either apprehension, pain referable to the bicipital groove, and an audible or palpable click. The test is repeated with the forearm supinated, which must cause diminution of the pain. Mechanically, elbow extension and forearm pronation places traction on the long head biceps tendon. When anterior scapular protraction is limited by the clavicle, further adduction entraps the unstable biceps tendon and superior glenoid labrum between the glenoid fossa and humeral head. Forearm supination decreases traction on the long head biceps tendon and allows for reduction of the unstable labrum complex with lessening of the pain. A retrospective chart review of 66 consecutive arthroscopically verified shoulders with SLAP lesions revealed the SLAPprehension test to be 87.5% sensitive for unstable SLAP lesions. CONCLUSIONS: The SLAPprehension test is helpful in the clinical evaluation of patients with unstable superior glenoid labrum lesions whose symptoms are often confused and overlap with those of shoulder impingement or acromioclavicular arthrosis.

Arthroscopy↗

PubMed2004

Extracephalic yawning pain.

The aim of this study was to report on two patients with recurrent, paroxysmal, extracephalic pain triggered by yawning. Pain with yawning may occur in several conditions (secondary yawning pain) or develop in the absence of precipitating lesions (primary yawning pain). Primary yawning pain is normally of cephalic location. Methods used were clinical neurological examinations, magnetic resonance imaging of the brain, computerized head tomography, electroencephalogram, blink reflex studies and Panorex X-ray views of the skull. The first patient had intense right shoulder pain and brief apnea for 2 years triggered by yawning. The second patient had yawning pain referred to an area of the neck where a thyroid tumour (Hürthle cell carcinoma) was later found. Neither of the two patients could precipitate their pain with imitation of yawning and neither had evidence of Eagle syndrome. Only the second patient had a history of migraine. Yawning pain may have an extratrigeminal and extracephalic distribution. It rarely serves to identify a lesion underlying the area where the pain is perceived.

Adenoma, Oxyphilic↗

PubMed1982

[Multidisciplinary approach in neurotic head and back ache. Clinical contribution].

Stress is laid on the need for a multidisciplinary approach to the treatment of pain. Reference is made to personal experience, during which the presence of a psychiatric specialist in the team permitted the discovery of 4% of patients with pain of a purely psychological origin in a series of 300 subjects, together with 10% with pain of mixed origin. Attention is drawn to the usefulness of centering treatment on recognition and evaluation of the psychological component, and on treatment with antidepressive drugs in association with classic antalgic procedures.

Adult↗

PubMed1997

Management of ambiguous genitalia in pseudohermaphrodites: new perspectives on vaginal dilation.

OBJECTIVE: To evaluate vaginal size and sexual activity after different techniques of feminization of external genitalia in patients with pseudohermaphroditism. DESIGN: Retrospective clinical study. SETTING: Pseudohermaphrodite patients seen at our institution. PATIENT(S): Three female and 20 male pseudohermaphrodites raised as females. INTERVENTION(S): Bilateral orchidectomy, feminization of external genitalia (clitoridectomy or clitoroplasty, urogenital sinus enlargement), and/or neovaginoplasty or vaginal dilation with acrylic molds. MAIN OUTCOME MEASURE(S): Psychological evaluation, vaginal size, and quality of intercourse. RESULT(S): All patients referred sexual drive to men. Fifty percent of the patients who were submitted to neovaginoplasty referred pain or bleeding during sexual intercourse. On the other hand, 87% of the patients who were submitted to vaginal dilation with acrylic molds, after genitoplasty or not, referred satisfactory sexual intercourse. All patients who were submitted to clitoroplasty referred orgasm and 29% of the patients submitted to clitoridectomy referred no orgasm. Of three patients with congenital adrenal hyperplasia due to 21-hydroxylase deficiency, two became pregnant and delivered normal children through cesarian section. CONCLUSION(S): In pseudohermaphrodites with female social sex, surgical correction of external genitalia performed in childhood and vaginal dilation with acrylic molds performed when they wished to start having sexual intercourse resulted in best outcome.

Adolescent↗

PubMed1999

Intertester reliability of a low back pain classification system.

STUDY DESIGN: This prospective study of intertester reliability examined pairs of therapists' ability to agree independently on a patient's low back pain diagnosis. OBJECTIVE: To determine the intertester reliability of a low back pain classification system among experienced and novice clinicians. BACKGROUND: Many of the disparate categorization schemes for patients with low back pain are purely nominal, assigning designations based on the presumptive source of the problem without providing any practical guide for rehabilitation. A useful classification scheme reliably groups patients into treatment-directing categories. METHODS: The study included 204 patients with low back pain referred to 10 clinics across Canada. Paired physiotherapists performed separate physical examinations on each patient. Both examiners then completed a simple ballot choosing one of five pain patterns. RESULTS: Agreement on patient classification by independent examiners was 78.9% (kappa = 0.61). CONCLUSION: This clinically relevant and clearly defined pain pattern system uses key elements of the history and examination to classify patients with low back pain. The pattern provides a framework for initiating active rehabilitation strategy. Using this approach, clinicians agreed on the categorization of 78.9% of mechanical low back pain cases.

Adolescent↗

PubMed1994

Limb pain and headache.

The occurrence of limb pain in close temporal relationship with headache was sought in 245 (185 women and 60 men) patients. Eleven patients (4.4% three men and eight women) had referred pain at least once, in one or more limbs in close temporal relationship with headache. Usually the pain was located in the upper limbs, was concomitant with the headache but could precede or follow it. The severity and length varied between patients but was relatively stable in the same subject. It is possible that this symptom is more frequent than believed so far and that many patients are misdiagnosed.

Adolescent↗

PubMed1990

The painful arm.

The painful arm often presents a diagnostic challenge. The cause is often obvious, especially with regional pain syndromes including the carpal tunnel and the tennis elbows. However, pain reference syndromes can be confusing and it is advisable to first examine the cervical spine because it is a common and often overlooked cause of arm pain or paraesthesia. It is common for arm pain to cause sleep disturbances and in such cases it is worth considering cervical causes, carpal tunnel syndrome and the thoracic outlet syndromes. The working rule is: patients with thoracic outlet syndrome cannot fall asleep; a carpal tunnel lesion wakes the patient in the middle of the night; and cervical spondylosis wakes the patient with pain and stiffness that persists well into the day.

Aged↗

PubMed1996

Dental pulpalgia contributing to bilateral preauricular pain and tinnitus.

The case of a patient with bilateral preauricular pain and tinnitus is reported. Minimal relief was obtained with traditional temporomandibular disorders therapy, and complete relief was obtained after endodontic therapy. Pulpal conditions that can refer pain are discussed, and recommendations are made to help practitioners identify a possible pulpal etiology for symptoms and tests of temporomandibular disorders.

Dental Pulp Diseases↗

PubMed2000

Prevalence of gastroesophageal reflux disease in patients with extraesophageal symptoms referred from otolaryngology, allergy, and cardiology practices: a prospective study.

AIM: To investigate the prevalence of gastroesophageal reflux disease (GERD) as well as the clinical, endoscopic, and manometric characteristics in 57 adult patients with otolaryngeal symptoms, asthma, or noncardiac chest pain referred from specialized services. METHODS: The following evaluations were performed: (1) upper endoscopy, (2) 24-hour ambulatory esophageal pH monitoring, and (3) esophageal manometry. The prevalence of GERD was determined, and demographic, clinical, endoscopic, and manometric characteristics of patients with or without GERD were evaluated. RESULTS: Thirty-four out of 57 patients (60%) had GERD. The 95% confidence interval ranged from 48 to 72%. There was no statistical difference between patients with or without GERD regarding gender, age, or time of evolution of symptoms. Cough was more frequent in the subjects with GERD (75 vs. 25%, p<0.05). Nevertheless, cough was observed in only 53% of the patients with GERD. Patients suffering from laryngitis had a greater proximal and distal esophageal acid exposure time than those without. CONCLUSIONS: The prevalence of GERD was 60%. There is not a definite demographic or clinical profile that permits us to distinguish between patients with and without GERD among those with ear, nose, and throat and pulmonary symptoms or chest pain.

Adult↗

PubMed1991

Hyoid bone syndrome: a degenerative injury of the middle pharyngeal constrictor muscle with photomicroscopic evidence of insertion tendinosis.

This article describes the condition known as hyoid bone syndrome, its diagnosis by exclusion, and the histopathologic evidence of focal, degenerative muscle injury. The injury involves the origin fibers of the middle pharyngeal constrictor muscle on the greater cornu of the hyoid bone. The importance of the dentist and physician in recognizing the condition is emphasized, because dental and nondental pain reference sites make up the syndrome.

Adult↗

PubMedDate not supplied

Headaches and sinus disease: the endoscopic approach.

Headaches can be of sinugenic origin even if this cause may not be suspected from the case history. Endoscopy of the lateral nasal wall with rigid cold light endoscopes in combination with polytomography or computed tomography usually will reveal the underlying causes hidden from the unaided eye, the operating microscope, and standard x-ray examination. Small lesions in the lesser cells of the ethmoid complex may give rise to headaches, especially when located in the key areas of the ethmoid infundibulum or frontal recess. Many anatomic variations of the structures in the middle meatus can narrow the stenotic clefts even more and thus predispose to more or less intense contact of opposing mucosal surfaces. This may impede or block ventilation and drainage of the ethmoid and surrounding larger sinuses and thus affect those as well. After identification of these underlying causes, functional endoscopic sinus surgery with usually minimal operations often can provide dramatic relief of symptoms that may have been present for months or even years. The neuropeptides recently were newly identified as a group of mediators besides the neurotransmitters noradrenalin and acetylcholine. Substance P (SP) is one of the most important neuropeptides that we can identify in the human nasal mucosa. It mediates pain impulses to the cortex via afferent C fibers. Simultaneously from polymodal receptors in the nasal mucosa, local reflexes are mediated by SP via an axon reflex, causing vasodilatation, plasma extravasation ("neurogenic edema"), and hypersecretion. The receptors can be stimulated by chemical and caloric irritants and also mechanical irritants such as pressure. The pressure exerted on nasal mucosa by polyps or mucosal swelling due to other reasons in the ethmoid clefts, cells, and narrow spaces apparently can be enough to trigger an SP-mediated pain sensation via afferent C fibers. Over the axon reflex an initially small lesion may lead in a vicious circle to quite significant symptoms. The model of "referred pain" explains why the pain is not necessarily felt at its origin, but may be projected onto corresponding dermatomes. The pain-mediating function of SP can be blocked selectively by capsaicin, the pungent component of red pepper, which leads to desensitization of the receptors and degeneration of the afferent C fibers without affecting other sensory qualities. In patients with vasomotor rhinitis we were able to block all the patients' symptoms including headaches by topical administration of capsaicin. After identification of underlying causes with endoscopy and CT, lesions and contact areas should be operated upon if medical treatment fails.(ABSTRACT TRUNCATED AT 400 WORDS)

Capsaicin↗

PubMed1991

The painful shoulder: Part I. Extrinsic disorders.

Shoulder disorders are most commonly manifested by pain and limited function. Careful history and examination help the physician localize the problem to the shoulder joint, the surrounding tissues or adjacent sites that can cause referred pain to the shoulder. Common extrinsic causes of shoulder pain include postural problems and cervical spine disorders.

Diagnosis, Differential↗

PubMed1981

Maternal and foetal drug levels after epicutaneous application of a local anaesthetic formulation containing ketocaine for possible use as pain relief in labour.

A local anaesthetic formulation (A 2358) containing ketocaine, a local anaesthetic drug, was applied epicutaneously to the low back. Two compresses soaked with A 2358 were applied for 1 hour in 26 normal labours for relieving referred pain from the low back. The maternal blood ketocaine levels remained low, compared to higher systemic levels reported in other studies. Maternal heart rate and blood pressure were stable during the application time. The mean umbilical vein/maternal vein and umbilical artery/maternal vein concentration ratios were 0.20 +/- 0.10 and 0.21 +/- 0.09. In addition, the foetal heart rate findings and the conditions of the neonates were satisfactory, thus suggesting the foetal safety of this analgesic method.

Adolescent↗