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BMJ 2002 Dec 14;325(7377):1408-12
Wolfson Research Institute University of Durham, Queens Campus, University Boulevard, Stockton-on-Tees TS17 6BH. patwright@doctors.org.uk
Publication Types:
PMID: 12480861, UI: 22368055
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Clin J Pain 2003 Jan-Feb;19(1):69-70
[Medline record in process]
BACKGROUND (CRPS I [formerly called reflex sympathetic dystrophy]) is a syndrome with pain and signs of autonomic dysfunction after trauma or immobilization; the pathophysiologic mechanisms of CRPS I, however, remain unknown.DESIGN The authors present a case of CRPS I associated with amyotrophic lateral sclerosis. Along with the motor paresis due to amyotrophic lateral sclerosis, pain, swelling, and signs of autonomic disturbance occurred.CONCLUSIONS This case supports the hypothesis that immobilization is one of the major contributing factors for CRPS I.
PMID: 12514459, UI: 22401603
Clin J Pain 2003 Jan-Feb;19(1):59-68
OBJECTIVE To outline the modes of action of topiramate and to examine the theoretical reasons as to why topiramate may alleviate neuropathic pain. Results of animal and human studies in the use of topiramate for treating pain are reviewed, together with case studies describing situations where topiramate was effective when other treatments have failed.CONCLUSIONS Topiramate acts on neuronal transmission in at least five ways: by modulating voltage-gated sodium ion channels, potentiating gamma-aminobutyric acid inhibition, blocking excitatory glutamate neurotransmission, modulating voltage-gated calcium ion channels, and by inhibiting carbonic anhydrase. This review suggests that there are good theoretical reasons for a trial of topiramate in patients with neuropathic pain where conventional medical treatments have failed. Although not currently licensed for treating pain, topiramate should be considered before invasive methods of pain relief are contemplated. Most of the side effects of topiramate are dose dependent, but by starting medication with a low dose (</=25 mg/d) that is gradually titrated upward, tolerance is much more easily achieved.
PMID: 12514458, UI: 22401602
Clin J Pain 2003 Jan-Feb;19(1):55-8
BACKGROUND Nonsteroidal anti-inflammatory drugs (NSAIDs) are widely used to enhance opioid analgesia in the acute pain service. The question, however, of whether NSAIDs produce a similar extent of potentiation among different types of pain, has not been thoroughly investigated.MATERIALS AND METHODS A randomized, placebo-controlled, double-blind study was performed to characterize the analgesic effect of tenoxicam, a long-acting NSAID, on resting wound pain, evoked wound pain, and uterine cramping pain after cesarean section. Saline (n = 48) or 20 mg tenoxicam (n = 45) was intravenously injected immediately after clamping the umbilical cord. All patients were instructed to obtain maximal postoperative analgesia by intravenous patient-controlled morphine.RESULTS Tenoxicam profoundly reduced the intensity of uterine cramping pain (3.6 [2.0-5.6] versus 5.5 [3.4-6.6]; < 0.01) but had no additional effect on wound pain at rest, with movement, changing position, sitting, and walking. Intraoperative injection of 20 mg tenoxicam decreased the demand ratio for patient-controlled analgesia (PCA) and 24-hour morphine consumption by approximately 30%.CONCLUSIONS The data show that tenoxicam potentiates opioid analgesic effect on the somatic and visceral types of pain to different extents, and they suggest that intraoperative injection of 20 mg tenoxicam is sufficient to enhance intravenous PCA morphine on uterine cramping pain for the first 24 hours after cesarean section.
PMID: 12514457, UI: 22401601
Clin J Pain 2003 Jan-Feb;19(1):48-54
BACKGROUND Chronic pain was believed to be a recognized but infrequent complication after inguinal hernia repair. Evidence suggests that patients with chronic pain place a considerable burden on health services. However, few scientific data on chronic pain after this common elective operation are available.OBJECTIVES To review the frequency of chronic pain and to discuss etiological theories and current treatment options for patients with chronic post herniorrhaphy pain.MATERIALS AND METHODS All studies of postoperative pain after inguinal hernia repair with a minimum follow-up period of 3 months, published between 1987 and 2000, were critically reviewed.RESULTS AND DISCUSSION The frequency of chronic pain after inguinal hernia repair was found to be as high as 54%, much more than previously reported. Quality of life of these patients is affected. Chronic pain is reported less often after laparoscopic and mesh repairs. Recurrent hernia repair, preoperative pain, day case surgery, delayed onset of symptoms, and high pain scores in the first week after surgery, however, were identified to be risk factors for the development of chronic pain. Definition of chronic pain was not explicit in the majority of the reviewed studies. Accurate evaluation of the frequency of chronic pain will require standardization of definition and methods of assessment. Prospective studies are required to define the role of risk factors identified in this review.
PMID: 12514456, UI: 22401600
Clin J Pain 2003 Jan-Feb;19(1):39-47
OBJECTIVES First, to define the clinical characteristics of nonpainful sensations (NP) that commonly appear after spinal cord injury (SCI); and second, to compare the clinical characteristics of NP and chronic pain (CP) after SCI.METHODS Two sets of questions concerning CP and NP were mailed to 330 subjects. Responses from 197 persons experiencing CP as well as NP were analyzed.RESULTS The most common locations for CP and NP were back and lower extremities. Although the number of areas in which the subjects perceived CP and NP to be located was significantly correlated, a factor analysis showed separate groupings of areas with CP and NP, respectively. Self-reported allodynia or hyperesthesia in the lower extremities, however, was significantly associated with CP in the same areas. The number of descriptive adjectives used for CP and NP was also significantly correlated, as was the perceived intensity of CP versus NP. Additionally, significant correlations were found in onset and temporal pattern of CP and NP. Similarly to CP, NP interfered with sleep, work, and other daily activities, and the patterns of interference due to CP and NP were significantly correlated.DISCUSSION While many aspects of the clinical picture of CP and NP are similar after SCI, the CP and spontaneous NP are not necessarily located in the same areas. Although the observed similarities between CP and NP may be based on pathophysiologic mechanisms, the significant relations between the interference patterns suggest that psychosocial mechanisms related to coping are also involved.
PMID: 12514455, UI: 22401599
Clin J Pain 2003 Jan-Feb;19(1):31-8
OBJECTIVE To develop and establish the psychometric properties of a pain treatment willingness scale and identify factors associated with willingness to try specific pain treatments for spinal cord injury (SCI)-related pain.DESIGN As part of a larger study, a questionnaire was designed to assess willingness to use various pain medications and other types of pain treatments. This questionnaire, which included measures of pain severity, pain interference, mood, hope, and current use of pain treatments, was completed by persons with SCI recruited through the mail or in person.SUBJECTS One hundred fifteen persons completed the questionnaire (35% response rate). Seventy-two percent of the participants were men, mean age was 49.1 years, and average time elapsed since injury was 8 years.RESULTS Factor analysis indicated two factors-willingness to use opioids and willingness to use nonpharmacological treatment (i.e., physical therapy, relaxation methods and stress management, and alternative medicine). Internal consistency and convergent and divergent validity were established. Persons experiencing SCI-related pain were more willing to use pain treatments than those without current pain, and those who were currently using opioids reported greater willingness to use that treatment. Persons who reported SCI-related pain were more willing to use nonpharmacological treatments than opioid medications. Finally, participants demonstrated different degrees of willingness to use an opioid medication based on its name (i.e., "narcotic," "codeine," "morphine," "methadone").CONCLUSIONS Willingness to use a specific pain treatment may be a key factor mediating the behavior of using that specific treatment. Assessment of patient attitudes toward various treatments options, particularly regarding opioid medications, is warranted to optimize treatment adherence. Once the factors that determine these attitudes are identified, interventions to increase willingness to use nonpharmacological or opioid treatments can be designed and evaluated.
PMID: 12514454, UI: 22401598
Clin J Pain 2003 Jan-Feb;19(1):18-30
OBJECTIVES First, to identify what physical performance differences existed between a group of disabled individuals with chronic pain and a control group of pain-free individuals with comparable disabilities; and second, to test a psychosocial model designed to evaluate which psychosocial constructs were predictive of performance in disabled individuals with chronic pain.DESIGN Case-comparison study.SETTING Ambulatory university laboratory.PARTICIPANTS A community sample of 62 individuals with lower limb amputations or paraplegia, 31 with chronic pain and 31 pain-free.INTERVENTION Standardized lifting and wheel-turning tasks.MAIN OUTCOME MEASURES Static strength, endurance, lifting speed, lateral and anterior-posterior sway, and multidimensional psychosocial measures.RESULTS Disabled individuals with chronic pain had decreased endurance for both the lifting ( <0.001) and the wheel-turning ( <0.05) tasks. A psychosocial model of physical performance also was evaluated. Using confirmatory factor analysis, 31 measures were used to validate 8 theoretical constructs: emotional functioning, pain intensity, pain cognitions, physical functioning, social functioning, task-specific self-efficacy, performance outcome, and performance style. Regression analyses indicated that more than 90% of the variance in performance was predicted by psychosocial factors, with self-efficacy, perceived emotional and physical functioning, pain intensity, and pain cognitions showing the highest associations.CONCLUSIONS Chronic pain was found to significantly reduce the performance in individuals with lower limb amputations and paraplegia. A strong association was found between performance and psychosocial factors in disabled individuals with chronic pain. These findings extend the existing literature by validating that psychosocial models of chronic pain can be applied to the disabled population, with results similar to those of other chronic pain samples.
PMID: 12514453, UI: 22401597
Clin J Pain 2003 Jan-Feb;19(1):3-17
BACKGROUND Until recently, very little has been written regarding chronic pain as a secondary problem in persons who already have a physical disability, despite the potential for pain to increase the negative impact of what may already be a very disabling condition. The purpose of this review is to summarize what is currently known concerning the nature and scope of chronic pain as a secondary condition to disability, specifically spinal cord injury, acquired amputations, cerebral palsy, multiple sclerosis, neuromuscular disease, and postpolio syndrome.METHOD What is known concerning the frequency, severity, impact, and treatment of pain in these specific conditions is reviewed, as are the factors that contribute to, or are associated with, adjustment to chronic pain in these disability groups. The authors conclude with several research questions that emerge from this knowledge, the answers to which will contribute to the long-term goal of the reduction of pain and suffering in persons with disabilities.CONCLUSIONS The existing literature clearly documents that many persons with disabilities experience chronic pain. Many questions remain unanswered regarding the scope, severity, and treatment of chronic pain in these groups.
PMID: 12514452, UI: 22401596
JAMA 2002 Dec 25;288(24):3124-9
Department of Medicine, University of Pennsylvania, Philadelphia, USA. howard.herrmann@uphs.upenn.edu
CONTEXT: Women who present with acute coronary syndromes (ACSs) have different characteristics than men. Reports have conflicted about whether different outcomes exist for women with use of a routine invasive management strategy. However, these studies were performed prior to the widespread use of platelet glycoprotein IIb/IIIa inhibitors and intracoronary stents. OBJECTIVE: To determine sex differences in baseline characteristics and outcomes in ACS and whether women benefit from a contemporary early invasive management strategy. DESIGN AND SETTING: Prospective analysis of women and men enrolled in the TACTICS-TIMI 18 randomized trial, conducted December 1997 to December 1999 in 169 centers in 9 countries in North America and Europe, with follow-up at 1 and 6 months. PARTICIPANTS: A total of 2220 patients (757 women and 1463 men) with ACS. INTERVENTIONS: All patients received aspirin, 325 mg/d; intravenous unfractionated heparin; and tirofiban for 48 hours or until revascularization, with tirofiban administered for at least 12 hours after percutaneous coronary revascularization. Patients assigned to the early invasive strategy (n = 1114) underwent coronary angiography 4 to 48 hours after randomization and revascularization when appropriate. Patients assigned to the early conservative strategy (n = 1106) were treated medically and underwent coronary angiography and appropriate revascularization only if they met specified criteria. MAIN OUTCOME MEASURES: Baseline characteristics and the primary composite end point of death, myocardial infarction, or rehospitalization for ACS at 6 months in women and men assigned to early invasive vs conservative management. RESULTS: Women were older and more frequently had hypertension (P<.001 for both). Women less frequently had previous myocardial infarction, coronary artery bypass grafting, and elevations in cardiac markers (P<.001 for all), but there was no difference in distribution of TIMI risk scores (P =.76). Angiography and intervention rates were similar, but women had less severe coronary artery disease, including no critical lesions in 17% of women vs 9% of men (P<.001). Women had a 28% odds reduction in the primary end point with an early invasive strategy (adjusted odds ratio [OR], 0.72; 95% confidence interval [CI], 0.47-1.11), similar to the benefit in men (adjusted OR, 0.64; 95% CI, 0.47-0.88; P =.60 for sex interaction). When adjusted for baseline characteristics, the benefit of invasive therapy in women with elevated troponin T levels was further enhanced (adjusted OR, 0.47; 95% CI, 0.26-0.83). CONCLUSIONS: Despite differences between women and men in baseline characteristics, the benefit of an early invasive strategy incorporating tirofiban and intracoronary stents was similar in women and men and was enhanced in women presenting with markers of increased risk.
PMID: 12495392, UI: 22384592
Lancet 2003 Jan 4;361(9351):21-6
Division of Perioperative Medicine, Anaesthesiology, and Pain Management, University Medical Centre Utrecht, Utrecht, Netherlands
Background Results of observational studies have shown pain reduction with percutaneous radiofrequency lesioning of dorsal root ganglia for lumbosacral radicular pain, but there are few randomised controlled trials. We aimed to assess the efficacy of radiofrequency lesioning of dorsal root ganglia for lumbosacral radicular pain.Methods We screened 1001 patients, who were mostly referred by their family doctor, in four hospitals for a double-blind randomised trial. 83 patients met inclusion criteria and thus were randomly assigned to receive a radiofrequency lesion or control treatment of the involved dorsal root ganglion. Control treatment was done in the same way as radiofrequency lesioning, but without radiofrequency current. Preoperatively and during 3-month follow-up, patients reported visual analogue leg-pain and back-pain scores, physical impairment, and use of analgesics in a diary. Primary outcome was success or failure of treatment, defined by a multidimensional decision rule, which included median outcome variables from the diary. Post-hoc analysis for possible covariate interference with outcome variables was done. Primary outcome data were analysed on an intention-to-treat basis.Findings 45 patients were assigned radiofrequency lesioning and 38 control treatment. Three patients dropped out before 3 months. After 3 months, seven (16%) of 44 patients treated with radiofrequency lesioning and nine (25%) of 36 in the control group had successful treatment (difference -9.1% [95% CI -33.0 to 12.0], p=0.43). No differences between groups in side-effects were seen.Interpretation Lumbosacral radiofrequency lesioning of dorsal root ganglia failed to show advantage over control treatment with local anaesthetics. Thus, its use as routine treatment in lumbosacral radicular pain should not be advocated.
PMID: 12517462, UI: 22406045
Lancet 2002 Dec 14;360(9349):1974
PMID: 12493288, UI: 22381668
Lancet 2002 Dec 14;360(9349):1973; author reply 1973-4
PMID: 12493286, UI: 22381666
Lancet 2002 Dec 14;360(9349):1972-3; author reply 1973-4
PMID: 12493285, UI: 22381665
Lancet 2002 Dec 14;360(9349):1972; author reply 1973-4
PMID: 12493284, UI: 22381664
Lancet 2002 Dec 14;360(9349):1971-2; author reply 1973-4
PMID: 12493283, UI: 22381663
Lancet 2002 Dec 14;360(9349):1971; author reply 1973-4
PMID: 12493282, UI: 22381662
Spine 2002 Nov 15;27(22):2574-83
Northern Rockies Pain and Palliative Treatment Center, Billings, Montana 59101, USA. joshir@aol.com
STUDY DESIGN: A literature review and synthesis were performed. OBJECTIVE: To present the current understanding of the mechanisms of spinal cord stimulation in relation to the physiology of pain. SUMMARY OF BACKGROUND DATA: Spinal cord stimulation has been used for more than 30 years in the armamentarium of the interventional pain specialist to treat a variety of pain syndromes. Traditionally used for persisting leg pain after lumbar spinal surgery, it has been applied successfully in the treatment of angina pectoris, ischemic pain in the extremity, complex regional pain syndrome Types 1 and 2, and a variety of other pain states. This review presents the current status of what is known concerning how electrical stimulation of the spinal cord may achieve pain relief. METHODS: A literature review was conducted. RESULTS: The literature supports the theory that the mechanism of spinal cord stimulation cannot be completely explained by one model. It is likely that multiple mechanisms operate sequentially or simultaneously. CONCLUSION: Some clinical or experimental support can be found in the literature for 10 specific mechanisms or proposed mechanisms of spinal cord stimulation.
PMID: 12435996, UI: 22323883