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PubMedDate not supplied

Overlooked physical diagnoses in chronic pain patients involved in litigation, Part 2. The addition of MRI, nerve blocks, 3-D CT, and qualitative flow meter.

This study followed 120 chronic pain patients referred to a multidisciplinary pain center. The referral diagnosis for many patients, such as "chronic pain," "psychogenic pain," or "lumbar strain," was frequently found to be incomplete or inaccurate (40%) following a multidisciplinary evaluation that used appropriate diagnostic studies, including magnetic resonance imaging, computed tomography, nerve blocks, and qualitative flowmeter. Significant abnormalities were discovered in 76% of the diagnostic tests. An organic origin for pain was found in 98% of these patients. The patients were discharged with objective verification of diagnoses including facet disease, nerve entrapment, temporomandibular joint disease, thoracic outlet syndrome, and herniated discs.

Adolescent↗
PubMed1997

The relationship between nonorganic signs and centralization of symptoms in the prediction of return to work for patients with low back pain.

BACKGROUND AND PURPOSE: The purpose of this study was to assess the relationship between the nonorganic signs (Waddell scores) of patients with low back pain, their response to repetitive end-range lumbar spine test movements (centralization of symptoms), and the rate of return to work at a 6-month follow-up. SUBJECTS: Patients were assessed at five locations of the Canadian Back Institute. A consecutive sample of 126 patients with low back pain, with or without referred leg pain, was selected and reviewed. METHODS: Physical therapists assessed patients' responses to repetitive test movements (centralization), as described by McKenzie, and tested the patients for nonorganic signs (Waddell scores). Therapists completed a data sheet that classified patients as either those who centralize their symptoms or those who do not centralize their symptoms and recorded their Waddell scores. Although the patients were classified at assessment, they remained in treatment. All patients followed a structured Canadian Back Institute protocol of active exercise, regardless of centralization status or Waddell score. RESULTS: The inability to centralize symptoms indicated a decreased likelihood of returning to work, regardless of the Waddell score. A high Waddell score predicted a poor chance of returning to work, regardless of the patients' ability to centralize symptoms. CONCLUSION AND DISCUSSION: A high Waddell score appears to be the best predictor of outcome, as indicated by return to work.

Adult↗
PubMedDate not supplied

Sustained-release oxycodone dosing survey of chronic pain patients.

OBJECTIVE: To determine the dosing of sustained-release oxycodone that is typically prescribed to achieve pain relief in a mixed group of chronic pain patients. METHODS: One hundred twenty-eight chronic pain patients prescribed stable doses of sustained-release oxycodone for at least 6 months were identified through chart review. Total daily dosing for both long- and short-acting opioids were recorded for each patient. RESULTS: The prescribed frequency of dosing sustained-release oxycodone determined through clinical practice was twice daily for 33% of patients, with 67% requiring greater than twice daily dosing. Ninety-three percent of those using greater than twice daily dosing were prescribed sustained-release oxycodone 3 times daily. The median dose of sustained-release oxycodone was 80 mg for patients prescribed twice daily dosing, 60 mg when prescribed 3 times daily, and 120 mg when 4 times daily. Regularly scheduled, daily supplemental short-acting opioids were used by 47% of patients prescribed twice daily sustained-release oxycodone and 21% prescribed greater than twice daily dosing. The median total oxycodone-equivalent daily dosage (short- + long-acting opioids) was 80 mg for patients treated with either twice daily or greater than twice daily dosing. CONCLUSION: In a mixed group of chronic pain patients referred to a university pain management clinic, sustained-release oxycodone was prescribed more often than twice daily (usually every 8 hours) in 67% of patients. Patients maintained on every-12-hour dosing were twice as likely to use regularly scheduled, daily, short-acting opioids to achieve pain relief.

Adult↗
PubMed2006

Patients' experiences of consultations for nonspecific chronic orofacial pain: A phenomenological study.

AIMS: To use a qualitative research study to analyze the experiences of patients with nonspecific chronic orofacial pain with respect to consultations for their pain condition. METHODS: Fourteen patients (11 women and 3 men; age range, 21 to 77 years) were strategically selected through a purposive sampling of the chronic orofacial pain patients referred to the Orofacial Pain Unit at the Faculty of Odontology, Malmö University, Malmö, Sweden. A qualitative research strategy based on phenomenological philosophy was chosen. Thematic in-depth interviews were conducted twice with each patient in order to expose the context of the orofacial pain condition. The interviews were audiotaped and transcribed verbatim. The text material was analyzed to determine the attitude of the patients concerning their experience from the consultations. RESULTS: All selected patients consented to participate. The patients expressed dissatisfaction with the consultations and related many examples of poor communication and understanding. The patients also felt a great need to be taken care of and expressed contradictory statements concerning pain improvement. CONCLUSION: The results suggest that the communication between the patients and the care providers was unsatisfactory and that the patients were limited in their ability to develop a personal coping strategy.

Adaptation, Psychological↗
PubMedDate not supplied

Hyperalgesic pain: a review.

Pain induced by a stimulus that is normally not painful is referred to as hyperalgesic pain. Inhibition of arachidonic acid metabolism and/or sympathectomy have been found to be effective treatment for this type of pain. We propose that the lowered pain threshold is induced by arachidonic acid metabolites produced in inflamed tissue or by sympathetic postganglionic neurons after nerve injury. The most extensively studied hyperalgesic mediators are prostaglandin E(2) (PGE(2)) and prostacyclin (PGI(2)), products of the cyclooxygenase pathway of arachidonic acid metabolism, whose production is inhibited by nonsteroidal antiinflammatory analgesics (NSAIAs). Recent studies, however, have demonstrated that products of the NSAIA-resistant lipoxygenase pathway of arachidonic acid metabolism are also hyperalgesic. Their production is inhibited by corticosteroids and current experimental agents.

Arachidonic Acids↗
PubMed1997

Somatic or sympathetic block for reflex sympathetic dystrophy. Which is indicated?

Patients with reflex sympathetic dystrophy (complex regional pain syndromes) are often referred to pain medicine physicians for assistance in providing pain control during rehabilitation of their painful upper extremity. When deciding which pain control technique to use in an individual patient, physicians must consider both somatic and sympathetic blocks. Each of these nerve blocks has advantages and disadvantages that may be tailored to an individual patient's pain state and rehabilitation program to optimize recovery.

Arm↗
PubMed2002

[Etiology and diagnosis of otalgia].

Otalgia is the sensation of pain in the ear, while referred otalgia is pain felt in the ear but originating from a nonotologic source. Ear pain is a diagnostic problem when examination of the ear shows no pathology. Pain in the ear can be caused by inflammation of the external meatus or the middle ear. Nonotogenic otalgia may be due to referred or reflex pain, neuralgia, or to a psychogenic problem. Otalgia may be referred also from primary carcinoma of the head and neck. A thorough understanding of the anatomy of the head and neck is required. Referred pain is due to irritative lesions involving the fifth, ninth, or tenth cranial nerves and spinal nerves C2 and C3. If pathologic problems in the area supplied by these nerves have been ruled out, the neuralgia should be considered in the differential diagnosis. Psychogenic factors must be identified and treated before any type of surgical therapy is recommended. A basic knowledge of neuroanatomy, with emphasis on the cranial nerves, their course, distribution, and function, is also necessary. The complexity of this field may sometimes require the treating physician to call for consultations from colleagues in the fields of oral surgery, neurology, or neurosurgery. The therapy depends of the causes of the ear-ache.

Diagnosis, Differential↗
PubMed2005

Agreement between diagnoses reached by clinical examination and available reference standards: a prospective study of 216 patients with lumbopelvic pain.

BACKGROUND: The tissue origin of low back pain (LBP) or referred lower extremity symptoms (LES) may be identified in about 70% of cases using advanced imaging, discography and facet or sacroiliac joint blocks. These techniques are invasive and availability varies. A clinical examination is non-invasive and widely available but its validity is questioned. Diagnostic studies usually examine single tests in relation to single reference standards, yet in clinical practice, clinicians use multiple tests and select from a range of possible diagnoses. There is a need for studies that evaluate the diagnostic performance of clinical diagnoses against available reference standards. METHODS: We compared blinded clinical diagnoses with diagnoses based on available reference standards for known causes of LBP or LES such as discography, facet, sacroiliac or hip joint blocks, epidurals injections, advanced imaging studies or any combination of these tests. A prospective, blinded validity design was employed. Physiotherapists examined consecutive patients with chronic lumbopelvic pain and/or referred LES scheduled to receive the reference standard examinations. When diagnoses were in complete agreement regardless of complexity, "exact" agreement was recorded. When the clinical diagnosis was included within the reference standard diagnoses, "clinical agreement" was recorded. The proportional chance criterion (PCC) statistic was used to estimate agreement on multiple diagnostic possibilities because it accounts for the prevalence of individual categories in the sample. The kappa statistic was used to estimate agreement on six pathoanatomic diagnoses. RESULTS: In a sample of chronic LBP patients (n = 216) with high levels of disability and distress, 67% received a patho-anatomic diagnosis based on available reference standards, and 10% had more than one tissue origin of pain identified. For 27 diagnostic categories and combinations, chance clinical agreement (PCC) was estimated at 13%. "Exact" agreement between clinical and reference standard diagnoses was 32% and "clinical agreement" 51%. For six pathoanatomic categories (disc, facet joint, sacroiliac joint, hip joint, nerve root and spinal stenosis), PCC was 33% with actual agreement 56%. There was no overlap of 95% confidence intervals on any comparison. Diagnostic agreement on the six most common patho-anatomic categories produced a kappa of 0.31. CONCLUSION: Clinical diagnoses agree with reference standards diagnoses more often than chance. Using available reference standards, most patients can have a tissue source of pain identified.

Humans↗
PubMedDate not supplied

A comparison of modality-specific somatosensory changes during menstruation in dysmenorrheic and nondysmenorrheic women.

OBJECTIVE: The objective was to evaluate somatosensory thresholds to a multimodality stimulation regimen applied both within and outside areas of referred menstrual pain in dysmenorrheic women, over four phases of confirmed ovulatory cycles, and to compare them with thresholds in nondysmenorrheic women during menstruation. DESIGN: Twenty dysmenorrheic women with menstrual pain scoring 5.45 +/- 0.39 cm (mean +/- standard error of mean) on a visual analog scale (10 cm) participated. Fifteen nondysmenorrheic women with a menstrual pain score of 0.4 +/- 0.2 cm participated as controls. Ovulation was confirmed by an enzyme-multiplied immunoassay technique. Menstrual pain was described with the McGill Pain Questionnaire. Areas within menstrual pain referral were two abdominal sites and the midline of the low back, and the arm and thigh were the control areas. The pressure pain threshold (PPT) and pinch pain threshold were determined by a hand-held electronic pressure algometer, the heat pain threshold (HPT) by a contact thermode, and the tactile threshold with von Frey hairs. RESULTS: In dysmenorrheic women the McGill Pain Questionnaire showed a larger sensory and affective component of pain than the evaluative and miscellaneous groups. The HPT and PPT were lower in the menstrual phase than in the ovulatory, luteal, and premenstrual phases, both within and outside areas of referred menstrual pain (p <0.01), with a more pronounced decrease at the referral pain areas. The pinch pain threshold was lower in the menstrual phase than in the ovulatory phase (p <0.02), and the tactile threshold did not differ significantly across the menstrual phases or within any site. Dysmenorrheic women had a lower HPT at the control sites and a lower PPT at the abdomen, back, and control sites, than in those of nondysmenorrheic women in the menstrual phase. CONCLUSIONS: The results show reduced somatosensory pain thresholds during menstruation to heat and pressure stimulation, both within and outside areas of referred menstrual pain in dysmenorrheic women. Dysmenorrheic women showed a lower HPT at the control sites and a lower PPT at all the sites than those for nondysmenorrheic women in the menstrual phase. The altered somatosensory thresholds may be dependent on a spinal mechanism of central hyperexcitability, induced by recurrent moderate to severe menstrual pain.

Adult↗
PubMed1990

Referred otalgia.

Otalgia is the sensation of pain in the ear, while referred otalgia is pain felt in the ear but originating from a nonotologic source. The rich sensory innervation of the ear derives from four cranial nerves and two cervical nerves which also supply other areas in the head, neck, thorax, and abdomen. Pain referred to the ear may originate in areas far removed from the ear itself. Neoplastic, infectious, inflammatory, musculoskeletal, and vascular disorders must all be considered when evaluating the patient with otalgia and a normal ear examination. Otalgia is frequently the presenting complaint in patients with carcinoma of the oropharynx or hypopharynx. This article reviews the anatomic basis for referred otalgia and overviews the common etiologies responsible for this symptom.

Ear↗
PubMed2002

Treatment of postherpetic neuralgia: tricyclic antidepressants still the reference.

(1) Pain generally disappears when herpes zoster lesions have healed, but the risk of postherpetic neuralgia, though it is low, increases with age. (2) Antivirals prescribed during the acute phase do not reduce the risk of postherpetic neuralgia, but they do reduce its duration. (3) Common non specific analgesics such as paracetamol seem inadequate against postherpetic neuralgia. Amitriptyline and desipramine, despite their limited efficacy, are the reference. Gabapentin, although somewhat less effective, is a possible second line option. It is unclear how long treatment should last.

Acetates↗
PubMed2006

A double-blind, controlled study of botulinum toxin A in chronic myofascial pain.

BACKGROUND: Recent studies have reported a potential analgesic effect of botulinum toxin A (BTXA) in musculoskeletal pain. The present double-blind, randomized, placebo-controlled, parallel clinical trial studied the effect of BTXA on pain from muscle trigger points and on EMG activity at rest and during voluntary contraction. METHODS: Thirty patients with trigger points in the infraspinatus muscles received either 50 units/0.25 mL of BTXA or 0.25 mL of isotonic saline. Baseline measures were determined during a run-in period of 1 week. Outcome measures including local and referred spontaneous pain, pain detection and tolerance thresholds to mechanical pressure, and shoulder movement were assessed at 3 and 28 days after injection. The interference pattern of the EMG during maximal voluntary effort of infraspinatus muscle was recorded and a standardized search for spontaneous electrical motor endplate activity at the trigger points was performed before and 28 days after BTXA or saline injection. RESULTS: BTXA reduced motor endplate activity and the interference pattern of EMG significantly but had no effect on either pain (spontaneous or referred) or pain thresholds compared with isotonic saline. CONCLUSIONS: The results do not support a specific antinociceptive and analgesic effect of botulinum toxin A.

Analgesics↗
PubMed1980

Nonotogenic otalgia: diagnosis and treatment.

Nonotogenic otalgia may be due to referred or reflex pain, neuralgia, or to a psychogenic problem. Referred pain is due to irritative lesions involving the fifth, ninth, or tenth cranial nerves and spinal nerves C2 and C3. If pathologic problems in the area supplied by these nerves have been ruled out, the neuralgia should be considered in the differential diagnosis. Psychogenic factors must be identified and treated before any type of surgical therapy is recommended.

Ear↗
PubMed1988

Finger pain.

The local, systemic, and referred causes of finger pain are generally recognizable by historical features and physical examination findings, although radiographs and laboratory evaluation are often required to support the diagnostic impression. Most minor traumatic causes of finger pain require only conservative management, including immobilization followed by exercise. Infectious causes of finger pain include cellulitis, tendinitis, paronychia, felon, and infectious emboli, which generally require antibiotics with or without drainage. Certain patients with finger pain resulting from infection should be referred to a hand surgeon. Vascular and ischemic causes of finger pain represent true emergencies, because tissue viability is dependent on prompt intervention. Whereas any sensory neuropathy may present with finger pain, carpal tunnel syndrome is among the most common. Systemic rheumatic disease, such as rheumatoid arthritis or vasculitis, may begin with finger pain. In addition, such pain may be the first manifestation of a serious systemic illness, as in hypertrophic pulmonary osteoarthropathy. Reflex sympathetic dystrophy is an example of referred pain, presumably by way of neural mechanisms. Certain infectious, traumatic, and ischemic causes of finger pain must be diagnosed promptly to avoid significant morbidity; depending upon the cause of the symptoms, referral to a hand surgeon, rheumatologist, or neurologist may be appropriate. Symptomatic and functional improvement may also be hastened by the input of an occupational therapist.

Diagnosis, Differential↗
PubMed2002

Multimodal assessment of pain in the esophagus: a new experimental model.

A new multimodal pain assessment model was developed integrating electrical, mechanical, cold, and warmth stimuli into the same device. The device, with a bag and electrodes for electrical stimulation, was positioned in the lower part of the esophagus in 11 healthy subjects. Mechanical stimuli were delivered with an impedance planimetric system. Thermal stimuli were performed by circulating water of different temperatures (5-50 degrees C) inside the bag. All subjects reported both nonpainful and painful local and referred sensations to all stimuli. Temporal summation to repeated electrical stimuli could be studied. For all stimuli, there was a relationship between stimulus intensity and pain intensity. The referred pain area increased with increasing intensity of the electrical and mechanical stimuli. There were several differences between the sensations evoked by the four stimulus modalities, indicating activation of different visceral nerve pathways. This model offers the possibility for controlled multimodal stimuli activating the superficial and deeper layers of the human gut and should be used in basic, clinical, and pharmacological pain studies.

Adult↗
PubMed2005

Cortical modulation of pain.

The sensation commonly referred to as 'pain' has two components. The first is the sensory-discriminative component and provides information on location, modality and intensity of stimuli. The second is the affective-motivational component and refers to the emotional responses (fear, distress etc.) and the urge to respond evoked by the somatic sensation, and at the cortical level these two components appear to be located in different regions. The cortex probably influences pain by two different mechanisms. There is good evidence that the cortex can reduce pain by interrupting the transmission of noxious information from the spinal cord level by activating descending pain modulatory systems located in the brainstem. Less well established is the idea that modulation can also occur at the cortical level to change the affective-motivational aspects of nociception so that pain is perceived but looses its emotional and aversive component.

Animals↗
PubMed1995

Invasive dental treatment, pain reports, and disease conviction in chronic facial pain patients. A retrospective study.

Patients with chronic orofacial pain often undergo endodontic therapy or surgery in an attempt to eliminate or relieve their symptoms. This study examined the relationship among invasive dental treatment, pain reports, and disease conviction in a group of patients referred for pain management. Forty-eight patients referred to the Facial Pain Diagnostic Group at the Karolinska Institute, School of Dentistry, Stockholm, were investigated retrospectively. There were 43 women and 5 men (age range, 30-81 years) with orofacial pain of more than 6 months' duration, which the patients considered to be of dental or paradental origin. Despite dental treatment intended to relieve the pain, no permanent relief had been achieved. There was no statistical correlation among the different pain reports, the individual types of treatment, and the disease conviction. The reason for the high degree of disease conviction in this type of patient warrants further investigation.

Adult↗