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PubMed2004

Characterization of joint pain in human OA.

Characterization and differentiation of joint pain is difficult. Though degenerative changes in joints are frequent causes of pain in hip and knee, these changes are not always painful, and other possible causes of pain must also be considered. In degenerative changes in the spine, the problem is even more complex, as peripheral neuropathic pain, caused by mechanical compression and/or leakage of cytokines irritating nerve roots may be difficult to differentiate from nociceptive pain from intervertebral joints, discs or muscles. We know now that nociceptive pain has often referred to areas of pain with numbness and parestesthethic sensations, previously regarded as characteristic for neurogenic pain. Furthermore, in patients with painful coxarthrosis quantitative sensory testing (QST) has shown disturbed sensory thresholds not only in regions adjacent to the affected hip but also contralaterally. These sensory disturbances, previously noted in neuropathic pain, normalized after successful surgery with relief of pain, thus confirming the relation to the hip joint. Patients with painful coxarthrosis also have moderately increased substance P activity in cerebrospinal fluid. Thus the findings show some similarities with fibromyalgic patients with highly increased substance P in cerebrospinal fluid and sensory disturbances. In conclusion, joint pain has a profound impact on the sensory system and need a multimodal approach.

Arthralgia↗
PubMed1981

Carotidynia: aetiology, diagnosis and treatment.

The symptom of vascular neck pain, known as carotidynia, refers to throbbing pain of the neck and face with tenderness of the carotid artery. Recent publications suggest that carotidynia is a benign complaint, frequently associated with migraine, and often responding to migraine therapy. Past experience, and our own, indicates that carotidynia may be a symptom of other more serious disorders whose identification is essential to prevent subsequent catastrophic complications. 7 patients discussed in this publication presented with carotidynia. 4 have been reported previously. The associated disorders were dissecting aneurysm of the internal carotid artery (2 patients), long intraluminal clots with incomplete vessel obstruction of the internal carotid artery (2 patients), spontaneous aneurysm of the common carotid bifurcation (2 patients) and giant cell arteritis. We conclude that carotidynia is a symptom to be regarded with suspicion. The majority of patients encountered will have 'benign' carotidynia and angiography or exploratory surgery should not be routine. A rational approach to evaluation, investigation and treatment is presented.

Adult↗
PubMed1995

Caffeine and chronic low back pain.

OBJECTIVE: Although caffeine apparently plays a role in the modulation of pain perception in a variety of acute pain states, little is known about its effects on the experience of chronic pain. This exploratory study examined the relationship between dietary caffeine consumption and the symptoms reported by patients with chronic low back pain. DESIGN AND PATIENTS: A retrospective chart review was conducted of 131 patients with chronic low back pain (64 men and 67 women; mean age = 42.1 years; mean duration of pain = 6.1 years) referred to a multidisciplinary pain clinic over a 2-year period. Patients were classified as low (less than 100 mg; n = 34), moderate (100-400 mg; n = 68) or high (more than 400 mg; n = 29) caffeine users based on their self-reports of daily coffee, tea, and cola consumption. RESULTS: There were no significant differences among the low, medium, and high caffeine consumer groups on any self-report measure of pain severity, affective distress, anxiety-related symptoms, or sleeping behavior. High caffeine users were more likely to be tobacco smokers than low caffeine users (79% and 27%, respectively, p < 0.001). CONCLUSIONS: Our findings indicate that dietary caffeine consumption is not related to the global experience of pain and disability in patients with chronic low back pain, although high caffeine use may be embedded in a context of other unhealthy life-style behaviors.

Adult↗
PubMed1998

Breakthrough pain in cancer patients: characteristics, prevalence, and treatment.

"Breakthrough pain" is a common clinical term that has not been conclusively defined or described. Breakthrough pain is a transitory flare of pain experienced when baseline pain has been reduced to a mild or moderate level. Breakthrough pain may be characterized by its relationship to a fixed around-the-clock (ATC) opioid dose, rapid onset and short duration, precipitating events, predictability, pathophysiology (with nociceptive pain being most easily controlled), and etiology. The only prospective study of breakthrough pain conducted to date found a 63% prevalence of breakthrough pain in cancer patients referred to a pain service. Although prevalence figures from other studies vary widely, partly due to the populations chosen, all of the studies verify that breakthrough pain is a serious problem in cancer patients. In fact, several studies have listed incident pain, a subset of breakthrough pain, as a predictor of poor response to analgesic therapy. Breakthrough pain is currently managed with oral or parenteral breakthrough pain medications given in addition to the ATC analgesic regimen. The ATC dosage may also be increased until limited by side effects. Newer agents with a more rapid onset of analgesia and shorter duration of effect may help in the management of breakthrough pain.

Administration, Oral↗
PubMed1969

Acute abdominal pain in childhood, with special reference to cases not due to acute appendicitis.

Appendicitis is not the only common cause of acute abdominal pain in childhood. Almost equally common is an acute episode which in its early stages resembles acute appendicitis but which subsides without treatment in 24 to 48 hours. The clinical features of this syndrome are contrasted with those of appendicitis. The two conditions cannot always be distinguished on clinical grounds, leading to admission to hospital for observation and the finding of a normal appendix in 14% of operations for suspected appendicitis. Reasons are given for abandoning attempts to diagnose acute mesenteric adenitis at the bedside.

Abdomen, Acute↗
PubMed2006

Women presenting with lower abdominal pain: a missed opportunity for chlamydia screening?

INTRODUCTION: Many young women presenting with lower abdominal pain are referred to general surgeons with possible appendicitis. For some of these patients there will be a gynaecological cause for their pain. There has been a steady increase in the incidence of Chlamydia infections and pelvic inflammatory disease (PID) among the general population. Therefore, are general surgeons considering this as a diagnosis for lower abdominal pain in women? METHODS: One hundred and ninety three women who had been admitted with lower abdominal pain to a single hospital between 1999 and 2001 were identified using computerised records and the notes were examined. One hundred and eighty six women were included in the audit. Investigations and treatments instigated for these patients were then carefully recorded. RESULTS: Seventy-four patients underwent appendicectomy, of which 59 were histologically confirmed. Eighty-nine patients (47.8%) of admissions had no final diagnosis and were not screened for Chlamydia trachomatis. Sexual history was recorded in only 51% of admissions. Vaginal swabs were sent in only 7.3% of admissions. CONCLUSION: Current guidelines for Chlamydia trachomatis screening produced by the Chief Medical Officer (CMO) include screening in women presenting with lower abdominal pain as well as those with post-coital or intermenstrual bleeding. Most women who present with classical symptoms of PID will present to gynaecological specialities for further management. However, a significant number of women presenting atypically will be referred to surgeons to exclude gastrointestinal causes for their lower abdominal pain. These women could and probably should be screened for Chlamydia trachomatis.

Abdominal Pain↗
PubMed1998

Musculoskeletal manifestations, pain, and quality of life in Persian Gulf War veterans referred for rheumatologic evaluation.

OBJECTIVE: Pain in the joints and other areas has been a frequent complaint among veterans of Operation Desert Storm who are experiencing unexplained illness. We characterized the rheumatic manifestations of a group of veterans of the Persian Gulf War who were referred to a rheumatology clinic. METHODS: Consecutive South Texas veterans of the Persian Gulf War who were referred for evaluation of rheumatic manifestations underwent a comprehensive evaluation of their musculoskeletal symptoms, pain, and health related quality of life. RESULTS: Of 928 veterans evaluated in a screening clinic for unexplained symptoms, 145 had rheumatic manifestations (15.6%) and were referred to a rheumatology clinic. The most common diagnosis was fibromyalgia, present in 49 patients (33.8%), followed by various soft tissue problems in 25 (17.2%), nonspecific arthralgias in 14 (9.6%), and clinical or radiographic osteoarthritis in 16 (11.0%). In 39 patients (26.9%), no symptoms were present at the time of the evaluation, a careful musculoskeletal examination and laboratory tests were normal, and no diagnosis was possible. Two patients had Reiter's syndrome. Four had a positive rheumatoid factor and 3 had antinuclear antibodies, but none of these had clinical evidence of rheumatoid arthritis or systemic lupus erythematosus. Pain was present in nearly all patients and was widely distributed, with no body area spared in this group of patients. The most frequent painful areas were the knees in > 65%, the lower back in > 60%, the shoulders in 50%, and the hands and wrists in 35%. Widespread body pain was present in 65.1% of the veterans. Average values of all 8 scales measured by the SF-36 health survey were below the 25th percentile of published national norms, with pain and the number of nonarticular rheumatic symptoms explaining most of the decreased health related quality of life in the veterans we evaluated. CONCLUSION: No specific rheumatic diagnosis is characteristic of Gulf War veterans with unexplained illness referred to a rheumatology clinic. However, pain is common and widespread in these patients, and their health related quality of life is poor. Further research is necessary to determine the cause of the symptoms of veterans of the Gulf War.

Adult↗
PubMed1983

Treatment of primary dysmenorrhea.

The management of primary dysmenorrhea is discussed, firstly from the viewpoint of the adolescent girl and secondly of the adult woman. Sexually active girls wishing to use contraceptive agents are recommended low-dose oral contraceptives (OC). Teenagers with severe dysmenorrhea who do not require OC are prescribed a prostaglandin synthetase inhibitor. The adult woman has first the choice between OC and prostaglandin synthetase inhibitor as well. When all these are ineffective, secondary causes of dysmenorrhea must be sought and specific treatment eventually required. When no medication affords pain relief, however, and no organic cause can be found, the patient is referred for pain consultation. Hysterectomy is discussed as the final solution for the elderly woman.

Aging↗
PubMed1990

Auriculotemporal syndrome (Frey's syndrome) presenting as tic douloureux. Report of two cases.

Two cases of auriculotemporal nerve syndrome (Frey's syndrome) presenting as trigeminal tic douloureux are reported. This condition, characterized by gustatory sweating and facial hyperemia, is occasionally associated with pain, which is usually described as aching or burning, and long-lasting. In these two cases, however, a tantalizing gustatory pain occurred in excruciating brief paroxysms. The pathophysiology of the syndrome, with particular reference to pain, and possible treatment modalities are discussed.

Aged↗
PubMed1994

Chest pain in women: clinical, investigative, and prognostic features.

OBJECTIVE: To characterise clinical, investigative, and prognostic features of women referred with chest pain who subsequently underwent coronary angiography. DESIGN: Analysis of all women with angina referred to one consultant during 1987-91 who subsequently underwent coronary angiography, with follow up to present day. SETTING: Cardiothoracic centre. SUBJECTS: Women with normal coronary arteries; women with coronary artery disease shown on angiography; men with coronary artery disease matched for age; men referred with chest pain during the same period subsequently found to have normal coronary arteries. MAIN OUTCOME MEASURES: Risk factor analysis; results of exercise testing and coronary angiography; intervention; morbidity and mortality. RESULTS: Women comprised 23% (202/886) of patients referred with chest pain who subsequently underwent angiography. 83/202 women had normal coronary angiograms compared with 55/684 men (41% v 8%, P < 0.01). Diabetes mellitus was the only risk factor more frequently encountered in women with coronary artery disease (P = 0.001). The specificity and positive predictive value of exercise testing before angiography were significantly lower in women than men (71% v 93%, P < 0.001 and 76% v 95%, P < 0.001, respectively). Revascularisation procedures were as common in women with coronary artery disease as in men (81 (68%) v 70 (59%)), and there was no difference in event rate during follow up. Many patients with normal coronary arteries, irrespective of sex, had symptoms during follow up (61 (73%) women, 36 (65%) men) and continued to take antianginal drugs (27 (33%) women, 14 (28%) men); 14 (17%) women and six (11%) men required hospital readmission for severe symptoms. CONCLUSIONS: In this series, although women comprised the minority of patients referred with chest pain, a diagnosis of normal coronary arteries was five times more common in women than men. Risk factor analysis and exercise testing were of limited value in predicting coronary artery disease in women. There was no sex bias regarding revascularisation procedures, and outcome was similar. A diagnosis of non-cardiac chest pain in patients with normal coronary arteries was of little benefit to the patient with regard to morbidity.

Angina Pectoris↗
PubMed1985

Cross-validation of the Back Pain Classification Scale with chronic, intractable pain patients.

The current study investigated the utility of the Back Pain Classification Scale with chronic, intractable low back pain and headache patients. Subjects consisted of 50 chronic low back pain and 50 chronic headache patients referred to a university based Pain Center for evaluation. Data indicated that subjects were a representative sample of severely intractable chronic pain patients typically referred for Pain Center evaluation and treatment. Each was administered the Back Pain Classification Scale as part of a thorough physical and psychological/behavioral evaluation. All subjects were classified by blind review of medical records into one of two categories: (1) presence of psychopathologically based pain complaint with little or no pathophysiological findings and (2) presence of pathophysiologically based pain complaints with little or no psychopathological findings. Subjects were also independently classified from blind review of their scores on the Back Pain Classification Scale into one of these two categories. Findings revealed that the Back Pain Classification Scale accurately predicted the actual classification of 80% of the low back pain patients (i.e., 30% above baseline prediction rate) and only 60% of the chronic headache patients (i.e., only equal to the baseline prediction rate). Furthermore, the scale was found to be most accurate in predicting low back pain patients with primary psychopathologically based pain. It was concluded that the Back Pain Classification Scale was an empirically valid instrument to use with chronic low back pain patients, but not with chronic headache patients. This lack of utility with chronic headache patients was also viewed as support for the construct validity of the scale. Wider use of the scale with chronic low back pain patients was suggested.

Adult↗
PubMed2000

Sex-specific effects of pain-related anxiety on adjustment to chronic pain.

OBJECTIVE: Considerable research indicates that both high levels of anxiety and female sex are associated with increased sensitivity to experimental pain and greater experience of clinical pain. In general, however, previous research has not investigated the joint effects of sex and anxiety on pain responses. A single previous laboratory-based study indicated that anxiety was inversely related to pain thresholds among men but not among women. The present study examined the relation between pain-related anxiety and adjustment to chronic pain in a sex-dependent manner. DESIGN AND SETTING: A total of 215 (114 women, 101 men) chronic pain patients referred to a multidisciplinary treatment center completed questionnaires assessing anxiety and adjustment to chronic pain. RESULTS: Results generally supported the previous laboratory-based finding indicating that an inverse relation between anxiety and adjustment to chronic pain was present only among male patients. Although male patients with high pain-related anxiety reported greater pain severity, greater interference of pain, and lower levels of daily activity than male patients with low anxiety, this effect was not present among female patients. Moreover, the effects of pain-related anxiety on adjustment to chronic pain were not attributable to either hypervigilance or use of passive coping strategies. Potential explanations and implications for the present findings are discussed.

Activities of Daily Living↗
PubMed2000

Drug treatment of neuropathic pain.

Neuropathic pain results from damage to or dysfunction in the nervous system. The term usually refers to pain caused by a primary abnormality in the peripheral nervous system, while pain caused by damage to the central nervous system tends to be called central pain. Once established, neuropathic pain frequently runs a chronic course and can be severe and difficult to treat. Most doctors (but especially GPs, neurologists, neurosurgeons, oncologists and pain clinic specialists) will encounter patients with neuropathic pain. Management, ideally in a multidisciplinary pain-relief clinic, often involves the combined use of a range of pharmacological and non-drug approaches, the latter including transcutaneous electrical nerve stimulation, psychological treatments, and specialist procedures to stimulate, block or destroy discrete areas of the nervous system. Here, we review just the drug treatments for neuropathic pain.

Aged↗
PubMed2004

Some children with growing pains may actually have restless legs syndrome.

STUDY OBJECTIVES: Growing pains may be an important clue to the diagnosis of childhood restless legs syndrome (RLS). However, there are no previous studies to determine whether a subpopulation of children with growing pains meet the diagnostic criteria for RLS. The purpose of this study is to determine if some children with growing pains meet diagnostic criteria for RLS and to compare the polysomnographic characteristics of these children to controls. DESIGN/PARTICIPANTS/MEASUREMENTS: Eleven children from a pediatric neurology clinic with an emphasis on attention-deficit/hyperactivity disorder (ADHD) and with a diagnosis of growing pains were referred. They were interviewed with the parent to determine if their symptoms of growing pains met criteria for definite RLS. Those who met clinical criteria for RLS underwent polysomnography, and the results of their polysomnographic studies were compared to those of a control group (10 children, mean age 9.7 years). SETTING: Academic medical center. RESULTS: Ten (mean age 10.4 years) of the 11 children with growing pains met clinical criteria for RLS. In 4 of 8 families of these 10 children, 1 parent had RLS. Six of the 10 children had ADHD. There were no differences in the polysomnographic findings between the growing-pain and control groups, and none of the children with RLS had what is considered to be a clinically significant number of periodic limb movements of sleep. There were no differences in the polysomnographic findings between the "growing-pain ADHD" and "growing-pain non-ADHD" subgroups. The growing pains were severe enough for the patients and family to ask for treatment in 4 cases, and carbidopa/levodopa was utilized. CONCLUSIONS: Some children diagnosed with growing pains meet diagnostic criteria for RLS, and a family history of RLS is common in these children. In some cases symptoms are severe enough to warrant treatment.

Adolescent↗
PubMed1991

Thigh pain and multiple vertebral osteonecroses: value of magnetic resonance imaging.

We describe a 74-year-old woman who presented with referred thigh pain associated with multiple osteonecroses of the T12, L1 and L2 vertebrae. Magnetic resonance imaging was found to be a valuable diagnostic aid, revealing signs of spinal cord and nerve root compression related to the collapsed vertebrae. Biopsy of T12 confirmed the benign nature of the vertebral compression fracture. Our patient also showed histologically documented osteoporosis.

Aged↗
PubMed2002

[Chronic pain management under daily clinical conditions].

BACKGROUND: For lack of specialized pain centers patients with chronic pain are referred to medical, neurological or geriatric departments. One third of these patients are dissatisfied with pain management during stay in hospital (patients interviews 1998). To improve this situation, a pain management system was developed and tested under daily clinical conditions. METHODS: If the history-taking resulted chronic pain (longer than 3 months), the first step was staging the chronicity of pain by the Mainz Pain Staging System. In case of advanced chronic pain (stages II or III), a comprehensive history-taking of the patient's pain including psychometric tests (ADS, SES, PDI) followed. For each patient we worked out an individual and interdisciplinary therapy. To verify the results, each patient was interviewed on the day before dismissal. RESULTS: 27,8% of our patients in half a year period (n = 381) suffered from chronic pain. By pain management activities we were able to rise significantly the satisfaction of the patients with pain therapy. DISCUSSION: It is necessary to search consequently for chronic pain. Especially elder people do not mention their suffer, often believing, that pain is an unavoidable sign of old age. Concentrating on medical reports alone is not adequate for chronic pain and even can aggravate the condition to a significant extent. Chronic pain can neither be explained nor treated without integrating psychological and social factors. A routine diagnostic- and therapy-practice facilitates an interdisciplinary pain therapy, raises the therapeutic capability of the staff and increases the therapeutic outcome.

Chronic Disease↗