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PubMed2000

Evidence for thoracolumbar spinal cord processing of inflammatory, but not acute colonic pain.

The lower bowel is innervated by visceral afferents projecting to the lumbosacral and thoracolumbar spinal segments. The present study tested the hypothesis that sensory processing from the normal colon occurs in the lumbosacral spinal cord with little or no activity in the thoracolumbar segments. Following colonic inflammation, viscerosensory processing in the thoracolumbar spinal cord is recruited, contributing to visceral hyperalgesia. A baseline visceromotor reflex to colorectal distention recorded in intact rats was eliminated following bilateral L6-S3 dorsal rhizotomies. The visceromotor reflex recovered to 29% of baseline following colonic inflammation. These results suggest that visceral hyperalgesia and referred pain in patients with lower bowel disorders partly result from novel viscerosensory processing in the thoracolumbar spinal cord.

Abdominal Muscles↗

PubMed1999

[Examining the shoulder in general practice].

When the cause of pain or the loss of function lies in the shoulder area itself, in most cases it can be related to a certain anatomical structure by means of a precise clinical examination. The individual tests are depicted in illustrations and concise texts. As a memory aid, the structure being tested has been added in each picture. Also, the clinically most relevant trigger points are depicted, along with their corresponding pseudoradicular symptomatology (referred pain). The aim of this article is to assist in the day-to-day treatment of common shoulder problems.

Diagnosis, Differential↗

PubMed1993

Extracranial blood flow, pain and tenderness in migraine. Clinical and experimental studies.

Migraine pain has traditionally been ascribed to dilatation of primarily extracranial arteries. Such dilatation has, however, not been demonstrated so far. Studies of microcirculation reveal no major hyperperfusion or ischemia in the temporal muscle or the subcutaneous tissue in the temporal region during attacks of migraine. However, a reduction in the orthostatic reactivity of the subcutaneous arterioles was observed on the side of the headache. Increased tenderness of the pericranial myofascial tissues is observed during migraine attacks, particularly on the side of the headache. Increased tension of pericranial muscles on the other hand is not a constant finding and migraine attacks are not induced by experimentally increased tension of the temporal and masseter muscles. Extracranial pain and tenderness may, however, be induced experimentally by intramuscular injections of hypertonic saline and potassium chloride as well as of endogenous substances like bradykinin with 5-hydroxytryptamine and bradykinin with substance P. The extracranial arteries and myofascial structures are both supplied by unmyelinated trigeminal sensory nerve fibers containing a variety of neuropeptides which are released during migraine attacks. Axonal reflexes between extracranial arteries and neighbouring myofascial tissues as well as referred pain mechanisms may account for the observed tenderness during migraine attacks.

Female↗

PubMed1999

Acute pain mechanisms.

The systems activated by tissue-injuring stimuli are complex. The nociceptive primary afferents have little spontaneous activity under normal conditions; however, after tissue injury, they display longlasting, ongoing activity. This results, in part, because the injury elicits the release of active factors that sensitize or excite the peripheral nerve terminal. A threshold that is lowered to the extent that body temperature and the pressure of edema are adequate stimuli results in spontaneous pain. This phenomenon is mediated by a variety of blood-borne active factors released during plasma extravasation, by agents released from local inflammatory cells, and by neurotransmitters released from the peripheral terminals of the primary afferent fibers themselves. Well-defined projections into the dorsal horn convey the "pain message" to at least two well-defined populations of neurons: those that are nociceptive specific and those that display an intensity-linked discharge over a range of stimuli from innocuous to noxious. Convergence from various fiber types, modalities, and end organs permits the encoding of afferent traffic with respect to intensity and location. The convergence of axons from somatic and visceral structures reflects the mechanism for the so-called "referred pain state." Most importantly, these dorsal horn systems have a dynamic component in addition to the hard-wiring; their output can be regulated both up and down. The up-regulation provides the basis for much of the facilitated processing that is believed to account for a significant percentage of the postinjury pain state. The facilitated state has a unique pharmacology, with the underlying mechanisms reflecting a cascade of actions that starts with the NMDA receptor and proceeds through the spinal release of intermediaries, such as prostaglandins and nitric oxide. Conversely, the ability to down-regulate the dorsal horn stimulus response function accounts for the powerful control exerted by a wide variety of diverse factors, including the spinal delivery of opioid and nonopioid analgesics and the "endogenous analgesia system." These linkages reflect the complexity of the encoding mechanisms that transduce the tissue injury into the behavioral sequela known as pain. This article also emphasizes that, although considerable progress has been made in the past decade, the current pace of research promises greater insights.

Afferent Pathways↗

PubMed1984

Abdominal pain in quadriparesis: myofascial syndrome as unsuspected cause.

This is a case report of a 47-year-old man with C6 quadriparesis who presented with tenderness in the right lower quandrant of his abdomen which was diagnosed as iliocostalis myofascial syndrome. Diagnosis of nephrolithiasis and appendicitis were considered, but the complete blood count, abdominal x-ray, intravenous pyelogram, and sonogram were all normal. His symptoms became progressively more severe over the ensuing 2-week period. Examination at that time revealed extreme tenderness to light touch in the right lower quandrant, right flank, and right posterior subcostal area. A trigger point in the right iliocostalis muscle referred pain to the right lower quandrant. In the absence of evidence of internal derangement a diagnosis of iliocostalis myofascial syndrome was made. A 3-day course of "spray and stretch" to the iliocostalis cleared the symptoms. This case illustrates that myofascial syndrome should be considered in the differential diagnosis of soft tissue pain in the patient with spinal cord injury and sensory sparing.

Abdomen↗

PubMed2000

Sonography for hip joint effusion in adults with hip pain.

OBJECTIVE: To study the prevalence of ultrasonic hip joint effusion and its relation with clinical, radiological and laboratory (ESR) findings in adults with hip pain. METHODS: Patients (n = 224) aged 50 years or older with hip pain, referred by the general practitioner for radiological investigation, underwent a standardised examination. The distance between the ventral capsule and the femoral neck, an increase in which represents joint effusion, was measured sonographically. Joint effusion was defined in three different ways: "effusion" according to Koski's definition, "major effusion", and "asymmetrical effusion" based on only individual side differences. RESULTS: "Effusion" was present in 80 (38%), "major effusion" in 20 (9%), and "asymmetrical effusion" in 47 (22%) patients. Pain in the groin or medial thigh, pain aggravated by lying on the side, decreased extension/internal rotation/abduction/flexion, painful external rotation, and pain on palpation in the groin showed a significant relation (adjusted for age and radiological osteoarthritis of the hip) with ultrasonic hip joint effusion. "Major effusion" showed a significant relation with an increased ESR. When patients with bilateral pain and increased ESR were excluded, a side difference in the range of motion of extension of the hip was shown to be a good predictor for "asymmetrical effusion" (positive predictive value: 71%, negative predictive value: 80%). CONCLUSION: This study showed a relatively high prevalence of ultrasonic joint effusion in adults with hip pain in general practice. Furthermore the results indicate a relation between joint effusion and clinical signs.

Aged↗

PubMed1982

Pain and dysphagia in patients with squamous carcinomas of the head and neck: the role of perineural spread.

Clinical and pathological features of perineural spread have been investigated in patients with squamous carcinomas at several sites in the head and neck. In 100 surgical cases, the clinical and pathological findings were congruent in 76%. Combined clinical and histological evidence of perineural invasion was recorded in 33% and the overall incidence of nerve involvement detected morphologically was 44%. Perineural infiltration was demonstrated histologically in 51% of major excisions from the buccal cavity and in 34% of resections from the oropharynx, hypopharynx and cervical oesophagus. The neurological findings were dominated by hypoaesthesia, dysaesthesia and referred pain - mainly in the territories of cranial nerves V and IX. Multiple and/or sequential nerve involvement was occasionally seen. No correlation was established between nerve invasion and metastasis to regional lymph nodes. Long-distance infiltration of nerve trunks, and multiple involvement, are grave prognostic features.In 17 terminal patients submitted to autopsy, 65% had combined clinical and pathological evidence of perineural spread and the overall incidence of nerve involvement detected morphologically was 88%. Sensory changes again predominated. Multiple nerve involvement was observed in 35%. An apparently new `dysphagia syndrome' is described in 4 patients with oropharyngeal carcinomas in whom gross mechanical obstruction was simulated by a combination of perineural spread of tumour into the ipsilateral vagal trunk, sometimes accompanied by segmental infarction, variable invasion of the sympathetic chain, and `splinting' of the pharynx by local fibrosis and tumour in the soft tissues of the neck. Short-term palliation was achieved in these patients with high-dose steroids.

Adult↗

PubMed2005

Effectiveness of a graded exercise therapy program for patients with chronic shoulder complaints.

An operant behavioural and time-contingent graded exercise therapy program was developed to improve functional ability irrespective of pain experience in patients with chronic shoulder complaints. The clinical effectiveness of graded exercise therapy compared to usual care was evaluated in a randomised clinical trial. Assessments were carried out before and after 12 weeks of treatment. Performance of daily activities was measured by two outcome measures: the main complaints instrument and the Shoulder Disability Questionnaire (SDQ). Patients were eligible for participation if they had suffered from shoulder complaints for at least three months. Patients suffering from systemic diseases, referred pain or severe biomedical or psychiatric disorders were excluded. Patients (n = 176) were randomised and allocated either to graded exercise therapy (n = 87) or usual care (n = 89). Graded exercise therapy led to greater improvement in the performance of daily activities than usual care. However, only mean differences between groups in performance of activities related to the main complaints reached statistical significance (p = 0.049; 95% CI 0.0 to 15.0). The observed beneficial effects were considered to be small to moderate (calculated effect sizes: 0.30 for the main complaints instrument and 0.07 for the SDQ). Subgroup analysis showed larger improvements on the mean complaints instrument in patients not reporting pain reduction over time. Graded exercise therapy seems to be less effective in restoring performance of daily activities as assessed by the SDQ in patients showing a painful arc during physical examination. Results showed that graded exercise therapy is more effective in restoring the ability to daily activities in patients with chronic shoulder complaints than usual care, although beneficial effects are small.

Activities of Daily Living↗

PubMed1980

Neurophysiology of nociception and pain in the spinal cord.

Our experiments on the primate spinothalamic tract cells are consistent with the traditional view that the spinothalamic tract in primates is the main pathway responsible for pain sensation. However, we have no evidence concerning the possible role of other pathways, either in pain sensation or in the motivational-affective or reflex responses to painful stimuli. At least two different classes of spinothalamic tract cells, the high-threshold and the wide-dynamic-range neurons, appear to be involved in nociception, although they may well play different roles. High-threshold spinothalamic cells seem well suited to signal stimulus location, as well as intensity. Wide-dynamic-range cells can signal intensity, but they are not likely to provide good spatial resolution of stimuli. On the contrary, they are well suited to explain such phenomena as referred pain and pain radiation.

Animals↗

PubMed2006

Beyond needling--therapeutic processes in acupuncture care: a qualitative study nested within a low-back pain trial.

BACKGROUND: In the medical and scientific literature, there is a dearth of reports about how acupuncturists work and deliver care in practice. An informed characterization of the treatment process is needed to support the appropriate design of evaluative studies in acupuncture. METHODS: The design was that of a nested qualitative study within a pragmatic clinical trial. Six acupuncturists who treated up to 25 patients each were interviewed after the treatment phase of the trial to obtain an account of their experiences of providing acupuncture care to patients with low back pain referred by their GP. Using semistructured interviews and a topic guide, data were collected and analyzed for both a priori and emergent themes. This paper focuses on practitioners' accounts of the goals and processes of care, and describes the strategies employed in addition to needling and other hands-on treatments. RESULTS: From the interview data, it is clear that a coherent body of theoretical knowledge informed clinical decisions and practice, and that the goals of treatment went beyond the alleviation of immediate pain-related symptoms. Acupuncturists in this study all described a pattern of patient-centered care based on a therapeutic partnership. Study participants confirmed the importance of three processes that characterized acupuncture care in this trial, each contributing to the goal of a positive long-term outcome; building a therapeutic relationship; individualizing care; and facilitating the active engagement of patients in their own recovery. Acupuncturists described elements of care that characterized these processes including establishing rapport, facilitating communication throughout the period of care, using an interactive diagnostic process, matching treatment to the individual patient, and the use of explanatory models from Chinese medicine to aid the development of a shared understanding of the patient's condition and to motivate lifestyle changes that reinforce the potential for a recovery of health. Acupuncturists did not view these therapeutic goals, processes, and strategies as a departure from their usual practice. CONCLUSIONS: This study suggests that acupuncture care for patients with chronic conditions such as low back pain is likely to be a complex intervention that utilizes a number of patient-centered strategies to elicit longterm therapeutic benefits. Research designed to evaluate the effectiveness of acupuncture as it is practiced in the UK needs to accommodate the full range of therapeutic goals and related treatment processes.

Acupuncture↗

PubMed1996

Specificity of diagnostic nerve blocks: a prospective, randomized study of sciatica due to lumbosacral spine disease.

Temporary nerve blocks using local anesthetic are employed extensively in the evaluation of pain problems, particularly lumbosacral spine disease. Their specificity and sensitivity in localizing anatomic sources of pain have never been studied formally, however, and so their diagnostic and prognostic value is questionable. There have been anecdotal reports of relief of pain by temporary blocks directed to areas of pain referral, as opposed to areas of documented underlying pathology; but there has been no study to define the frequency or magnitude of this effect. We have examined the specificity and sensitivity of a battery of local anesthetic blocks in a series of 33 patients with a chief complaint of sciatica, attributable in all cases to spinal disease (radiculopathy, with some clinical features of arthropathy). As determined by blinded patient analog ratings in randomized sequence, three different nerve blocks were significantly more effective than control lumbar subcutaneous injection of an identical volume of 3 ml of 0.5% bupivacaine (P < 0.05). Not only paraspinal lumbosacral root blocks and medial branch posterior primary ramus blocks (at or proximal to the pathology), but also sciatic nerve blocks (distal or collateral to the pathology) produced temporary relief in a majority of patients. This confirmed the study hypothesis that false positive results are common, and specificity is low. For sciatic nerve blocks, specificity was between 24% and 36%. Patterns of responses specific to the established diagnosis of radiculopathy (i.e., root block most effective) had sensitivities between 9% and 42%. Statistical analysis of clinical and technical prognostic factors revealed that the only association with pain relief by any block were the effects of other blocks. The strongest association was between relief by sciatic nerve block and relief by medial branch posterior primary ramus (facet) block (P = 0.001, odds ratio 16.0). There were no associations between the results of blocks and clinical findings (history, physical examination, diagnostic imaging) in these patients, chosen for their homogeneous clinical presentation and absence of functional signs. Our findings indicate a limited role for uncontrolled local anesthetic blocks in the diagnostic evaluation of sciatica and referred pain syndromes in general. Negative blocks or a pattern of responses may have some predictive value, but isolated, positive blocks are non-specific. This lack of specificity may, however, be advantageous in therapeutic applications.

Adult↗

PubMed2002

How does neuropathophysiology affect the signs and symptoms of spinal disease?

A complex relationship exists between back pain and the presence of spinal disease. Particularly in chronic situations, back pain and its behavioural and emotional consequences are as likely to reflect the influence of psychosocial factors as any underlying spinal pathology. Nevertheless, physical factors are clearly important and it is significant that whereas in normal discs only the outer third of the annulus fibrosus is innervated, a much more extensive innervation develops in the presence of degeneration. Inflammation, as evidenced by leukocyte infiltration and expression of inflammatory mediators, is associated with disc degeneration and serves to alter the neural responses resulting in local and referred pain. It is probable that similar inflammatory processes, as well as direct root compression, contribute to radicular symptoms following disc herniation. An appreciation of these mechanisms encourages the search for novel treatments and permits a more rational and effective use of existing strategies for relieving pain.

Back Pain↗

PubMed1990

Characteristics of children presenting with chest pain to a pediatric emergency department.

Chest pain among children is a common complaint in primary care practice. However, the demographic features and treatment of such patients are controversial. We distributed a questionnaire to 336 consecutive patients with a complaint of chest pain seen during 1 year at an urban pediatric emergency department. Such visits represented 0.6% of all emergency encounters; the male:female ratio was 1.0. Physical examination was done in 325 patients. Chest-wall pain was the most common diagnosis (in 28% of cases). Other causes included pulmonary (in 19%), minor traumatic (in 15%), idiopathic (in 12%) and psychogenic (in 5%); miscellaneous causes (in 21%) most often indicated pain referred from the upper respiratory tract and the abdomen. The most common physical finding was chest tenderness (in 41% of cases). Investigations included chest radiography (in 50% of cases), electrocardiography (in 18%) and determination of the hemoglobin concentration and of the leukocyte count (in 13%); the results were rarely positive. Only eight patients (2%) required admission to hospital, and there were no cases of myocardial ischemia. The findings suggest that health care costs may be reduced by more judicious use of investigations. We conclude that chest pain is an uncommon and usually benign complaint in the pediatric emergency department. Most causes are evident on careful physical examination.

Adolescent↗

PubMed1988

[Cardiac mechanisms for the development of angina pectoris pain].

Despite numerous experimental and clinical investigations, the exact mechanisms involved in the development of cardiac pain are not completely understood. Sensory receptors for painful stimuli, presumably sympathetic sensory nerve endings, are located in the atria, the ventricles, and in the walls of the coronary arteries. These receptors fire at a background rate under normal hemodynamic conditions. They respond to chemical stimuli and are therefore similar to polymodal nociceptors. The afferent fibers (slow-conducting, unmyelinated group IV-fibers, or fast-conducting myelinated group III-fibers) run in the cardiac sympathetic nerves and converge with somatosensory fibers on the same ascending spinothalamic neurons, which may explain the phenomenon of "referred pain". Still unknown is the role of the afferent vagal fibers in pain perception; however, a modulating influence on pain threshold and characteristics seems possible. Two main mechanisms may be responsible for cardiac pain during ischemic periods: a) chemical excitation of free sensory nerve endings by substances such as bradykinin, PGE2, adenosine, histamine, serotonin, or K+; b) abnormal motion of ischemic segments (dyskinesia, bulging) during systole and excitation of mechanical receptors by passive stretching, and probably a combination of a) and b): the release of chemical substances sensitizes mechanical receptors and lowers their threshold for nociceptive stimuli. These can be suppressed at various spinal or supraspinal levels.

Afferent Pathways↗

PubMed1991

"Pseudotrochanteric bursitis": the differential diagnosis of lateral hip pain.

Eighteen patients who were initially diagnosed as having trochanteric bursitis refractory to conventional therapy are reported. The most common causes of pseudotrochanteric bursitis were lumbar radiculopathy (L2, L3), lumbar facet syndrome with pain referred to the lateral thigh, and entrapment neuropathies involving the subcostal, and the lateral cutaneous branches of the iliohypogastric nerves. Less common causes were undisplaced femoral neck fracture, adiposa dolorosa, and hip abductor muscle strain. Diagnosis was facilitated by selective neuroblockade.

Adult↗

PubMed1982

Acute otalgia in children - findings and diagnosis.

One hundred and seventy-one children up to 15 years of age and with acute otalgia were examined to find out whether otalgia or any other symptoms were so closely related to acute otitis media (AOM) as to make otoscopic examination unnecessary. AOM was diagnosed in 46%, simplex otitis in 15%, serous otitis media (SOM) in 17%, and normal eardrums in 22%. Children with AOM had fever and spontaneous perforation of the eardrums in 78% and 30% of the cases, respectively. Of the children who had not AOM (54%), the otalgia could in most cases be classified as referred pain due to, for instance, discomfort when swallowing, nasal obstruction or throat pain. Other reasons were general irritability due to fever, teething or moderate hearing loss. The difficulties in diagnosing AOM simply on the basis of symptoms were demonstrated in the investigation. Symptoms such as otalgia, otorrhea, fever or upper respiratory tract infection (URI), possibly except for the combination of otorrhea and fever, can occur without AOM. A correct otoscopic examination and evaluation of the eardrums is necessary in children with otalgia, other symptoms of URI or in doubtful cases of acute illness. Physicians without possibilities to evaluate the eardrums properly should thus refer the patient to an otologist without delay.

Acute Disease↗

PubMed2000

Treatment of chronic cervical-associated headache with botulinum toxin A: a pilot study.

OBJECTIVE: To see whether therapy with botulinum toxin A may prove to be an effective treatment for headache of musculoskeletal origin. BACKGROUND: Headache is a common finding associated with neck injury. Cervicogenic headache, which is believed to be attributable to injury of the ligaments, muscles, or joints of the cervical spine, is centered in the occipital region with pain referred to the frontotemporal region. Botulinum toxin A produces prolonged muscle relaxation, which is dose dependent and can be easily targeted to affected muscles. METHODS: This randomized, double-blind, placebo-controlled study compares outcome measures in 26 patients suffering from chronic headache subsequent to a cervical whiplash injury. One half of the patients received botulinum toxin A, 100 units, diluted in 1 mL of saline, while the other half received just saline (1 mL). Five cervical trigger points received 0.2 mL each of injectant via a 30-gauge needle. Outcome measures included subjective head pain based on visual analog scales, as well as range of neck motion. Follow-up assessments were carried out at 2 and 4 weeks after treatment. RESULTS: Fourteen subjects who received botulinum toxin A and 12 who received saline completed the study. At both 2 and 4 weeks post injection, the treatment group showed a significant improvement in pain and range of motion from preinjection levels (P<.01). The placebo group demonstrated no statistically significant changes at any posttreatment time.

Adult↗

PubMed1992

Mechanisms of esophageal pain.

Esophageal pain is transmitted via the sympathetic nervous system to the spinal cord, in which pain from visceral and somatic sources ascends to higher centers in the brain. Primary afferent neurons are bipolar, with the peripheral end specialized to be a sensory receptor. Nociceptors of somatosensory afferents are free nerve endings that can be activated by mechanical, thermal, or chemical stimuli. Esophageal nociceptive neurons have not been specifically identified but probably are also free nerve endings. Most esophageal spinal mechanoreceptors have been shown to be nociceptive. Some esophageal mechanonociceptors have a wide dynamic range and respond to physiologic and painful stimuli, while others have a high threshold of stimulation and are solely nociceptive. Esophageal spinal afferents have their cell bodies in the dorsal root ganglia and contain substance P and calcitonin gene-related peptide. These putative neurotransmitters are transported in both the peripheral and central directions of bipolar afferent neurons. Primary afferent neurons are likely to also contain an excitatory amino acid neurotransmitter such as glutamate. Centrally, nociceptive primary afferents terminate on neurons in specific layers of the dorsal horn of the spinal cord. Convergence of multiple visceral afferents with somatic afferents onto the same dorsal horn neurons may explain referred pain. A patient's inability to distinguish esophageal from cardiac pain may be due to convergence of pain pathways. Second-order neurons in the dorsal horn project in the anterolateral system to the brain. Within the anterolateral system, nociception ascends in the spinothalamic, spinoreticular, and spinomesencephalic tracts. The thalamus relays fast pain to the postcentral areas of the parietal lobe of the cortex. Pathways to the reticular formation are slow and may mediate the increased arousal that occurs in response to pain. The spinomesencephalic tract projects to midbrain sites including the periaqueductal gray. Organ-specific pathways in the brain have yet to be defined, but neuroanatomic tracing techniques employing neurotropic viruses are being developed. The perception of pain can be influenced at multiple levels, such as the receptor in the esophagus, the synapses in the dorsal horn of the spinal cord or thalamus, or the cortex. A fundamental mechanism of modulating nociception is descending inhibition.(ABSTRACT TRUNCATED AT 400 WORDS)

Chest Pain↗