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PubMed1988

Approach to musculoskeletal chest wall pain.

Pain in the chest may be the presenting feature of a diverse number of musculoskeletal chest wall conditions. The more common causes are costochondritis, trauma to the chest wall, benign overuse myalgia, fibrositis, referred pain, and psychogenic regional pain syndrome. These disorders are often mistaken for angina pectoris and other serious disorders. Information about onset, location, character, duration and modulating factors of the pain and other symptoms, a meticulous examination of the ribs, spine, sternum and their articulations, and a few judiciously selected diagnostic studies will establish the diagnosis in most patients. Knowledge and understanding of the underlying pathogenic mechanisms of these musculoskeletal disorders is important for optimal management.

Chest Pain↗

PubMed2001

A comparison of a modified Oswestry Low Back Pain Disability Questionnaire and the Quebec Back Pain Disability Scale.

BACKGROUND AND PURPOSE: The quality of a disability scale should dictate when it is used. The purposes of this study were to examine the validity of a global rating of change as a reflection of meaningful change in patient status and to compare the measurement properties of a modified Oswestry Low Back Pain Disability Questionnaire (OSW) and the Quebec Back Pain Disability Scale (QUE). SUBJECTS: Sixty-seven patients with acute, work-related low back pain referred for physical therapy participated in the study. METHODS: The 2 scales were administered initially and after 4 weeks of physical therapy. The Physical Impairment Index, a measure of physical impairment due to low back pain, was measured initially and after 2 and 4 weeks. A global rating of change survey instrument was completed by each subject after 4 weeks. RESULTS: An interaction existed between patients defined as improved or stable based on the global rating using a 2-way analysis of variance for repeated measures on the impairment index. The modified OSW showed higher levels of test-retest reliability and responsiveness compared with the QUE. The minimum clinically important difference, defined as the amount of change that best distinguishes between patients who have improved and those remaining stable, was approximately 6 points for the modified OSW and approximately 15 points for the QUE. CONCLUSION AND DISCUSSION: The construct validity of the global rating of change was supported by the stability of the Physical Impairment Index across the study period in patients defined as stable by the global rating and by the decrease in physical impairment across the study period in patients defined as improved by the global rating. The modified OSW demonstrated superior measurement properties compared with the QUE.

Activities of Daily Living↗

PubMed2005

Diagnosis and relation to general health of shoulder disorders presenting to primary care.

OBJECTIVES: To prospectively evaluate the incidence, spectrum of disease and relation to general health of shoulder disorders in primary care. METHODS: Patients presenting with shoulder pain to two large general practices in the Cambridge area over a 1-month period were invited to participate. After consulting their general practitioner, patients were administered a demographic information questionnaire, a shoulder pain and disability index (SPADI) and a short form 36 (SF-36) health survey. Subsequent review in a clinic held by a rheumatology registrar every 2 weeks was undertaken. RESULTS: The sex- and age-standardized incidence of shoulder pain was 9.5 per 1000 (95% confidence interval 7.9 to 11.2 per 1000). Rotator cuff tendinopathy was found in 85%, signs of impingement in 74%, acromioclavicular joint disease in 24%, adhesive capsulitis in 15% and referred pain in 7%. On the SPADI the mean disability subscale score was 45 (95% confidence interval 41 to 50) and the mean pain score was 58 (95% confidence interval 53 to 62) (range 0 to 100). Evaluation of general health status using the SF-36 showed the difference between population norms and those with shoulder pain was significant in six of the eight domains, being especially marked (greater than 20 point reduction) for emotional role, physical function and physical role. CONCLUSION: Shoulder pain, most commonly due to rotator cuff tendinopathy, is associated with significantly reduced health when measured by both specific and generic means. Effort towards prevention and early intervention in these complaints is warranted.

Acromioclavicular Joint↗

PubMed2004

Hip osteoarthritis: where is the pain?

BACKGROUND: Pain radiating below the knee is typically thought to originate from the lumbosacral spine rather than degenerative hip pathology. We investigated the lower limb distribution of pain using body image maps in 60 patients awaiting primary hip arthroplasty and in 60 patients awaiting spinal decompression for confirmed spinal stenosis. The perception of 33 orthopaedic registrars regarding distribution of hip pain was also assessed. RESULTS: Groin and buttock pain are significantly more common in hip osteoarthritis. The presence of groin pain is 84.3% of those sensitive for hip dysfunction with a specificity of 70.3%. Patients with hip osteoarthritis had pain below the knee in 47% of cases whereas 88.5% of orthopaedic trainees believed hip pain did not radiate below the knee. Radiographic features of osteoarthritis within the hip joint, visual analogue pain score or Oxford Hip Score have no significant association with a patient's distribution of hip pain. CONCLUSIONS: Hip pain referred below the knee is common with a degenerate hip joint and follows the distribution of the saphenous nerve, which branches from the femoral nerve. Radiographic deterioration of a hip joint does not correlate with pain distribution or patient dysfunction as measured by the Oxford Hip Score.

Adult↗

PubMed1989

Sacrococcygeal pain syndromes: diagnosis and treatment.

Sacrococcygeal pain can arise from the sacrococcygeal joint, from contiguous structures sharing the same innervation, or from distant sites. True coccygodynia consists of pain arising from the sacrococcygeal joint, whereas pseudococcygodynia consists of pain referred to but not arising from the coccyx. Coccygodnia can usually be distinguished from pseudococcygodynia by physical examination with the diagnosis being confirmed by injection of local anesthetic into the sacrococcygeal joint. The etiology of pain not relieved by intraarticular injection can be further defined by selective neuroblockade. A method for defining the anatomic basis for sacrococcygeal pain is presented as well as a discussion of the relevant anatomy and differential diagnosis of sacrococcygeal pain.

Anesthetics, Local↗

PubMedDate not supplied

Pain and functional disability.

The pain and functional disability in headache is tentatively presented with respect to the displayed causal relationships, beginning with the nociceptor. The concept is presented that primary deep pain must stem from a pain generator (PG), of which the free C-fiber ending together with the extracellular space constitute the (inflammatory) nociceptor; and that neurogenic pain is a secondary, enhancing measure. Headache is considered to be a result of various PGs in pain-sensitive structures implicated in head locomotion. Headache occurs when nociceptive volleys from either the cephalic or cervical levels traverse the locomotor centres of the head in the upper cervical medulla and are realized as referred pain. Some clinical aspects are presented.

Persons with Disabilities↗

PubMed2004

Lumbar radicular pain.

BACKGROUND: Radicular pain is caused by irritation of the sensory root or dorsal root ganglion of a spinal nerve. The irritation causes ectopic nerve impulses perceived as pain in the distribution of the axon. The pathophysiology is more than just mass effect: it is a combination of compression sensitising the nerve root to mechanical stimulation, stretching, and a chemically mediated noncellular inflammatory reaction. OBJECTIVE: This article discusses the clinical features, assessment and management of lumbar radicular pain (LRP). DISCUSSION: Lumbar radicular pain is sharp, shooting or lancinating, and is typically felt as a narrow band of pain down the length of the leg, both superficially and deep. It may be associated with radiculopathy (objective sensory and/or motor dysfunction as a result of conduction block) and may coexist with spinal or somatic referred pain. In more than 50% of cases, LRP settles with simple analgesics. Significant and lasting pain relief can be achieved with transforaminal epidural steroid injection. Surgery is indicated for those patients with progressive neurological deficits or severe LRP refractory to conservative measures.

Diagnosis, Differential↗

PubMed1999

Sacroiliac joint innervation and pain.

The present paper reviews current knowledge on the innervation of the human sacroiliac joint (SIJ). We conclude, based on a recent anatomic study on adult cadavers, with fetal correlation, that the joint is predominantly, if not entirely, innervated by sacral dorsal rami. This conclusion is in agreement with patterns of referred pain reported by asymptomatic volunteers upon direct SIJ capsular stimulation and with a reduction in pain in patients treated for (presumptive) SIJ pain by injection of an anesthetic into the SIJ. We also present preliminary data suggesting that the periarticular tissues of the SIJ, like those of other synovial joints, contain mechanoreceptors and nociceptors that function to inform the central nervous system about the state of the joint.

Adult↗

PubMedDate not supplied

Intensity mapping of pain referral areas in sacroiliac joint pain patients.

OBJECTIVE: To identify differences in pain referral areas, using intensity maps, between responders and nonresponders to a double diagnostic sacroiliac joint injection with a short- and long-acting local anesthetic in patients with chronic low back pain. METHODS: From a group of 140 consecutive patients with chronic low back pain, 60 patients who met clinical criteria were included in the study. Twenty-seven demonstrated a positive response to a double diagnostic fluoroscopically guided intra-articular sacroiliac joint block and were compared with 33 patients with a negative response. Each patient's preinjection pain diagram was used to determine areas of pain referral. The summation of these pain referral zones for both groups was used to construct intensity maps. RESULTS: No major differences were observed between responders and nonresponders with regard to mean size and distribution of referral pain areas. Intensity maps, however, showed differences in pain referral at the buttock in the areas overlying the sacroiliac joint (100% of the responders vs 80% of the nonresponders) and the ischial tuberosity (10% of the responders vs 100% of the nonresponders). CONCLUSIONS: Overall referred pain maps appeared not to be useful to discriminate patients with an identified sacroiliac joint pain from chronic low back pain patients with pain from other sources. Differences were only found using intensity maps. By implementing these data, it could be concluded that patients with sacroiliac joint pain are less likely to experience pain in both the 'Fortin' and 'tuber' areas. This knowledge can be used as additional selection criterion for putative sacroiliac joint patients, next to sacroiliac joint pain provocation tests.

Adult↗

PubMed1981

Prognostic indicators in low back pain.

Nearly four per cent of the population over the age of 15 years in a Danish general practice reported episodes of low back pain at least once a year. A one-year follow-up of 72 patients provided data regarding symptoms, length of absence from work, use of analgesics and bed rest. An indication of the prognosis was reached by relating these data to the history (including occupation), symptoms and signs noted at the initial interview. The following factors indicated a long or relapsing course:1. More than three previous episodes of low back pain.2. Gradual onset of symptoms.3. Pain referred distal to the femur.4. More than four weeks' delay in reporting symptoms.Other factors of prognostic significance were difficulty in moving, onset in relation to work, absence from work, positive straight leg raising test and unilateral pain in the loin.

Adolescent↗

PubMed2000

Interaction between cutaneous and muscle afferent activity in polysynaptic reflex pathways: a human experimental study.

Interactions between the input from cutaneous and nociceptive muscle afferents in polysynaptic reflex pathways were investigated in man. Interaction was tested by evoking reflexes before, during, and after a period of muscle pain induced by intramuscular injection of hypertonic saline. Muscle pain was induced either in the ankle flexor (tibialis anterior, TA) or in the extensor (soleus, SOL) muscles by injection of 1 ml hypertonic saline. Electrical skin stimulation (1.1 x initial reflex threshold) at the dorsum of the foot over the tarsal joint was used to elicit cutaneo-muscular polysynaptic reflexes in the knee flexor semitendinosus (ST). The injected hypertonic saline evoked a robust muscle pain (the subjects made a continuous score of the muscle pain on a 0-10 cm VAS scale, and the mean VAS area was 1229+/-251 cm x s and lasting 390+/-30 s). In five of 12 subjects, the infusion of hypertonic saline into TA evoked referred pain to the dorsal aspect of the ankle. A significant inhibition (17+/-8.2%, P<0.05) of the ST-reflex by pain in SOL was observed. Pain in TA facilitated (92+/-36%, P<0.05) the short-latency part (50-70 ms post stimulation) of the reflex. The muscle pain did not modulate the perceived sensory intensity of the electrical stimuli. The findings indicate an interaction of input from thin muscle afferents and cutaneous group A-fibre afferents in polysynaptic segmental reflex pathways, which seems to depend on the location of the muscle pain.

Adult↗

PubMed2005

Effect of a brief cognitive training programme in patients with long-lasting back pain evaluated as unfit for surgery.

The aim of the study was to evaluate the effect of cognitive intervention (information and physical exercise), on patients with long-lasting back pain referred for surgical evaluation at an orthopaedic hospital, but evaluated as unfit for surgery. One hundred and fifty-two patients were randomized to a five days intervention or control. The intervention had no significant effects on pain. At three-month follow-up, the patients in the intervention group used significantly more active strategies to cope with the back pain compared to the control group. This effect seemed to increase over time, being more pronounced at one-year follow-up evaluation.

Adult↗

PubMed2000

Fibro-fatty nodules and low back pain. The back mouse masquerade.

BACKGROUND: Few useful interventions exist for patients with persistent low back pain. We suggest that a fibro-fatty nodule ("back mouse") may be an identifiable and treatable cause of this and other types of pain. METHODS: We describe 2 patients with painful nodules in the lower back and lateral iliac crest areas. In both cases, the signs and symptoms were unusual and presented at locations distant from the nodule. One patient complained of severe acute lower abdominal pain, and the other had been treated for chronic recurrent trochanteric bursitis for several years. RESULTS: In both patients, symptoms appeared to be relieved by multiple injection of the nodule. DISCUSSION: There is agreement that back mice exist. Referred pain from the nodules might explain the distant symptoms and signs in these cases. Multiple puncture may be an effective treatment because it lessens the tension of a fibro-fatty nodule. CONCLUSIONS: Randomized trials on this subject are needed. In the meantime, physicians should keep back mice in mind when presented with atypical and unaccountable symptoms in the lower abdomen, inguinal region, or legs.

Bursitis↗

PubMed1986

Pseudovisceral pain due to posterior joint pathology in the dorsolumbar spine.

In cases presenting with abdominal pain in which the clinical findings and investigations are negative there is often associated dorsolumbar pain. The pathology in such cases often resides in the posterior apophyseal spinal joints, which should therefore be investigated as follows: a) Clinical. The abdomen is examined for areas of hypoaesthesia. The level of vertebral anomaly and related referred pain are determined using the Maigne test. b) The affected area of the spine is investigated by standard and dynamic radiographs and CT scan for evidence of transitional anomalies or signs of instability. Is should be noted that in many cases these tests are negative. Local infiltration of the posterior joints has given satisfactory results, as also has manipulation in some cases. The temporary use of a lumbar support and physiotherapy is advised to prevent recurrence.

Abdomen↗

PubMed2005

Peripheral projections of sensory fascicles in the human superficial radial nerve.

The sensory territories of different cutaneous fascicles of the superficial radial nerve were delineated by microneurography at the level of the distal forearm in humans. Three fascicular patterns were found at this level: one supplying the dorsum of the radial aspect of the dorsum of the hand over the first dorsal interosseous space; another supplying the lateral aspect of the first metacarpal extending to the lateral aspect of the thumb; and a third innervating the second interosseous space and the proximal phalanx of the index and middle fingers. The compound fascicular territory is comparable to the classical territory described for the superficial radial nerve. Intraneural microstimulation of individual fascicles did not evoke paraesthesiae or pain beyond their fascicular territory, regardless of the stimulus intensity. We conclude that the superficial radial nerve at the forearm in man is composed of only three fascicles, as shown by the present study and from previous anatomical work. Referred pain seems related to nerve activity in afferent fibres from fascicles supplying deep tissues and muscles, not from cutaneous afferents.

Electric Stimulation↗

PubMed2000

An association between migraine and cutaneous allodynia.

Recent animal studies on the mechanism of migraine show that intracranial pain is accompanied by increased periorbital skin sensitivity. These findings suggest that the pathophysiology of migraine involves not only irritation of meningeal perivascular pain fibers but also a transient increase in the responsiveness (ie, sensitization) of central pain neurons that process information arising from intracranial structures and skin. The purpose of this study was to determine whether the increased skin sensitivity observed in animal also develops in humans during migraine attacks. Repeated measurements of mechanical and thermal pain thresholds of periorbital and forearm skin areas in the absence of, and during, migraine attacks enabled us to determine the occurrence of cutaneous allodynia during migraine. Cutaneous allodynia is pain resulting from a nonnoxious stimulus to normal skin. In 79% of the patients, migraine was associated with cutaneous allodynia as defined, and in 21% of the patients it was not. The cutaneous allodynia occurred either solely within the referred pain area on the ipsilateral head, or within and outside the ipsilateral head. Cutaneous allodynia in certain well-defined regions of the skin during migraine is an as yet unreported neurological finding that points to hyperexcitability of a specific central pain pathway that subserves intracranial sensation.

Adolescent↗

PubMed1990

Spinal lesions simulating hip joint disorders.

In three patients pain in the groin and thigh which was initially attributed to either a malfunctioning hip prosthesis or osteoarthritic hip, was shown to arise in the spine. All patients had positive myelograms and one had electromyographic evidence of nerve root compression. Referred pain from the spine must always be considered in the differential diagnosis of pain thought to be arising from a hip replacement.

Aged↗

PubMed1983

Do intracranial and extracranial trigeminal afferents represent divergent axon collaterals?

Trigeminal nerves provide the principal afferent pathways for the transmission of intracranial and extracranial head pain. This study, using two retrograde axonal tracers, demonstrated that first division afferents projecting to intracranial and extracranial targets are not commonly axon collaterals of the same neuron. Therefore, divergent axon collaterals probably are not responsible for the phenomenon of referred pain within the first trigeminal division.

Afferent Pathways↗