Etiology

The most common cause of musculoskeletal chest pain is costochondritis, with an incidence of up to 30 percent of all musculoskeletal chest pains,103'104 with inflammation of the costal cartilages and up to 42 percent of patients with recurrent costochondritis complaining of widespread pain.103 In a number of patients the chest pain still prevails once the clinical signs of costochondritis have subsided. The incidence of costochondritis has risen steadily in the last few years because of an...

Nerve conduction studies

Nerve conduction studies determine the velocity of conduction and magnitude of evoked action potentials in peripheral nerves. Slowing of conduction across a selected segment of the nerve indicates compression or focal damage to the nerve at that segment. Decreased amplitude indicates loss of nerve fibers. Electromyography selectively tests alpha motor neurons. Loss of motor neurons is indicated by denervation fibrillation potentials in the muscles innervated, or by the presence of large and...

Key Learning Points

Fibromyalgia is characterized by chronic widespread pain, whereas pain in myofascial pain is localized. Fibromyalgia is a syndrome associated with a wide range of symptoms and other conditions, one of which is myofascial pain Fibromyalgia arises at least in part due to an alteration in central pain processing. Elevated levels of substance P, central sensitization, wind-up and extrinsic factors are all involved in the pathophysiology. There are (at least) three different subgroups of...

Is opioid responsiveness different for nociceptive or neuropathic pain central or peripheral

Kalso et al.14 I provide some help here. They reviewed 15 randomized placebo controlled trials. Four looked at intravenous opioid testing and included 120 patients, the other 11 compared oral opioids with placebo in 1025 patients. The opioids tested were described as World Health Organization (WHO) step 3 analgesics, including fentanyl, hydromorphone, methadone, morphine, oxy-codone, and oxymorphone and a wide variety of nociceptive and neuropathic pain disorders were treated. Trials lasted...

Pain Intensity Difference Versus Pain Relief

Pain intensity scales may be categorical (e.g. none, mild, moderate, or severe), numerical rating (e.g. 11-point integer, 0-10), or numerical derived from a VAS. Pain relief scales are usually categorical (e.g. none, slight, moderate, good, or complete). Categorical data can often be converted directly to integers and analyzed as numerical data,81 differences are calculated by subtraction. Pain relief (PAR) may be more meaningful to patients however, they need to refer back to the initial pain...

Somatic Chest Pain Musculoskeletal

After coronary artery disease and gastroesophageal reflux, the next most common cause is musculoskeletal chest wall syndromes. Around 70 percent of these patients have chest wall tenderness on palpation that in up to 16 percent can resemble classical angina.101 The most common areas of musculoskeletal chest pain are sternum, xiphoid, left costosternal junctions, and left anterior chest wall.101 A musculoskeletal cause for a chest pain is suspected when the pain is specific of certain postures...

Chronic pain after hernia surgery

The epidemiology of chronic pain after inguinal hernia surgery is well documented. Indeed, the volume of literature reporting CPSP after hernia surgery has increased dramatically in the last two decades. Many studies have been specifically designed to investigate persistent pain as an outcome rather than the traditional outcomes of hernia recurrence, wound infection, or return to work. Guidance on laparoscopic and open hernia surgery published by the UK National Institute for Clinical...

Neuronal Plasticity

A characteristic feature of FMS is hyperalgesia (increased sensitivity to mechanical, thermal, and electrical stimuli) and allodynia (painful response to normally non-noxious stimuli). These are likely to be due to altered mechanisms within the CNS such as wind-up and central sensitiza-tion which have been demonstrated in FMS patients.49, 50 Altered pain processing has been illustrated by studies using functional magnetic resonance imaging (fMRI) where painful pressure stimuli result in...

Central poststroke pain

The median annual incidence of first stroke for all ages is 183 per 100,000 with the risk of stroke roughly doubling with each decade during adulthood.12 In the United States in 2007, the incidence of first stroke would be estimated at approximately 551,000 cases per year (based on 301 million US population). Stroke is the third leading cause of death in the United States and a leading cause of dis-ability.26 Based on the prevalence of stroke in the population (compared with that of SCI or MS),...

Dysesthetic Vulvodynia

Generally considered a diagnosis of exclusion, it presents commonly in perimenopausal and postmenopausal women as nonspecific superficial vulvar burning or perineal discomfort with intermittent, deep, aching pain. Patients deny entry dyspareunia. Physical examination is normal, with no tenderness on palpation. Pudendal nerve tenderness, hyperesthesiae, or hypoesthesiae in a saddle distribution extending from the mons pubis to the upper inner thighs and posteriorly across ischial tuberosities...

Focal Versus General Spasticity

In considering the management of spasticity and hence, as will be discussed, spasticity-associated pain, it is necessary to look at the clinical presentation of spasticity in terms of focal and general presentations. Focal or regional spasticity typically results from cerebral origin.7 This refers to spasticity primarily affecting one limb, e.g. upper limb with the flexion pronation adduction patterning described above or lower limb with the extension adduction patterning. However, flexion...

Pain after amputation

Pain after limb amputation was undoubtedly the first of all the postsurgical pain syndromes to be recognized. Silas Weir Mitchell described phantom limbs and pain syndromes caused by gunshot wounds following the American Civil War.36 Pain following limb amputation falls into two broad categories, phantom pain and stump pain (also called residual limb pain). Many lower limb amputees also report back pain.37 For a detailed review of phantom pain, see the excellent article by Nikolajsen and...

Diverticular disease

Diverticuli can occur throughout the gastrointestinal tract but prove to be most common in the colon where they exist as small sac-like herniations of mucosa through the muscular wall, typically at the site of penetrating blood vessels. Duodenal, jejuna, and ileal diverticuli can occur with Meckel's diverticulum forming a special congenital abnormality present in 2 percent of the population. Meckel's diverticuli are particularly notable since they may contain acid-producing gastric mucosa and...

Spielberger State Trait Anxiety Inventory

The Spielberger State-Trait Anxiety Inventory (STAI)28 is the most widely used measure of anxiety, a construct that is not used as extensively as depression is with chronic pain patients, but nevertheless a very important one with pain patients. The STAI is a 40-item inventory that assesses trait anxiety, a characterological, stable dimension of anxiety that is relatively consistent over time, as well as state anxiety, transitory feelings of anxiety usually in response to specific situations....

Chronic neck pain

For the treatment of chronic neck pain, the evidence is even more sparse than that for acute neck pain, and even less supportive of traditional approaches. There is no published evidence supporting the effectiveness of a collar, TENS, traction, trigger point therapy, or multimodal therapy for chronic neck pain.112 There is no published evidence of any drugs being effective. For acupuncture, the evidence is conflicting. While some studies have reported an effect greater than that of placebo,113...

Opioid Tolerance And Opioidinduced Hyperalgesia

OT is a state of reduced opioid potency, reflecting down-regulation or desensitization of opioid-dependent, anti-nociceptive systems in the CNS. In contrast, OIH is a neuroadaptive state where opioid administration is associated with an increased response to painful stimuli (hyperalgesia), due to up-regulation or increased sensiti-zation of pronociceptive systems. These changes are reflected in a rightwards shift of the opioid dose-response curve in OT, in contrast to a downwards shift in OIH....

Notes on some terms relating to movement disorders

A number of descriptive terms are used to differentiate patterns of disordered muscle tone and movement, and may give rise to confusion among non-neurologists. Some of these terms, and their corresponding meanings, are listed below Spasticity is the type of muscle hypertonia seen following a lesion of the corticospinal tract. Resistance to passive movement of an affected limb is maximal at its outset and reduced once movement is initiated (clasp-knife effect). Tendon reflexes are increased. The...

Cell Death In The

Many forms of nerve injury can also produce death of sensory neurons.96 Apoptosis may be a result of mito-chondrial dysfunction97 and has been associated with a number of neuropathies.96,9899 Mitochondria-dependent apoptosis is activated by a number of factors including reactive oxygen species, ceramide, and nitric oxide,100 which have been implicated in the pathophysiology of neuropathies. These factors cause the release of cyto-chrome C from mitochondria leading to the formation of the...

The biopsychosocial approach to a diagnosis

It is essential that all reasonable attempts are made to establish a cause for the patient's pain behavior, including nociceptive, neuropathic, and psychological contributions. Pain behavior itself can obviously be modified by many other factors involving social and environmental influences. A demonstration of pathology commensurate with the degree of pain behavior is desirable. However, patients often have pathology which is difficult to interpret, e.g. degenerative changes on spinal...

Medial Branch Blocks

Cervical medial branch blocks can be used to test if a zygapophysial joint is the source of a patient's neck pain. They involve anesthetizing, under fluoroscopic control, the small nerves that innervate the target joint, each with no more than 0.3 mL of local anesthetic89 (Figure 36.5). Cervical medial branch joint blocks have face-validity, in that they selectively anesthetize the target nerves, and do not anesthetize any nearby structures that realistically might be the source of pain.90...

Chronic pancreatitis

Symptomatic pancreatitis can be associated with pancreatic cell death and or with ductal fibrosis and calcification. Acute pancreatitis, such as that induced by passage of a gallstone, is thought to be pathogenetically and morphologically different from chronic pancreatitis19 and generally resolves without permanent structural abnormalities. Chronic pancreatitis is associated with permanent abnormalities, but may present with an acute necrotic episode. Excessive alcohol consumption is the...

Spinal cord mechanisms

The sensory input from primary sensory neurons is transferred, via their central axons, to second-order neurons in the dorsal horn of the spinal cord. The synaptic contacts made between afferent central terminals and dorsal horn neurons are highly organized, both topographically and functionally to maintain accurate transfer of information regarding the peripheral noxious stimuli. Following peripheral nerve lesions, synaptic processing in the spinal cord can be subject to diverse forms of...

Rodent models of neuropathy

The most commonly used nerve injury models are the chronic constriction injury (CCI) of sciatic nerve,7 the partial sciatic nerve ligation (PNL) model,8 the spinal nerve ligation (SNL) transection model (Figure 1.2),9 and the spared nerve injury (SNI) model.6 All models are associated with the development of hypersensitivity to thermal (heat and cold), and mechanical stimuli which are used experimentally as correlates of hyperalgesia and allodynia symptoms in neuropathic pain patients.10...

Visceral Hypersensitivity Disorders

The observation that pathology and symptomatology may not correlate is readily apparent in numerous visceral pain disorders. Some disorders, such as chronic pancreatitis, have definable pathology, but alterations in pain appear out of proportion to objective radiographic or laboratory findings. Other disorders, such as irritable bowel syndrome, noncardiac chest pain, and postcholecystectomy syndrome, appear to have no grossly apparent histo-pathological basis for the discomfort and pain....

Anatomical Reorganization

Tactile mechanical allodynia is thought to be mediated by Ap-fiber afferents.146 However, the mechanisms by which this occurs are yet to be fully understood. Several studies using bulk labeling and single afferent fiber-filling techniques have demonstrated that following a peripheral nerve lesion, the central axons of injured Ap-fibers sprout from their normal termination sites in the deeper laminae of the dorsal horn (laminae II and IV) into lamina II of the dorsal horn, which is normally...

Problem Solving

Problem solving is often implicit in programs rather than taught as a separate component. It involves identification of the problem, generation of a range of possible solutions, prioritizing among those solutions according to opportunities, resources, and risks, and then attempting them. Many patients appear to use a narrow range of strategies, such as forcing themselves to persist when they meet an obstacle, which succeeds in some situations but rarely in chronic pain. Experimenting with...

Treatment Guidelines

In summary, the proportion of seropositive individuals in the population will decline as a result of childhood varicella vaccination. In time, this will reduce the incidence of HZ. Adult vaccination has been shown to be effective for the prevention of shingles and PHN.18 II In acute HZ, early antiviral therapy is recommended and pain treatment with strong opioids, tricyclic anti-depressants, or gabapentin should be considered in addition to conventional analgesics. The pharmacological...

Contributors

Praveen Anand ma md frcp Professor of Clinical Neurology Division of Neuroscience and Mental Health, Imperial College London, Hammersmith Hospital, London, UK School of Nursing and The Institute for Human Genetics University of California, San Francisco, CA, USA Professor of Neurology Albany Medical College Director Comprehensive Pain Program, Albany Medical College New York, USA Department of Clinical Oral Physiology, School of Dentistry Faculty of Health Sciences, University of Aarhus Aarhus,...

Residual limb pain

Not surprisingly, residual limb pain is common in the early postoperative period, but in most patients it subsides with healing. The prevalence of chronic residual limb pain is reported to vary between 5 and 100 percent Table 31.1 . Variations in the literature may reflect different methods of estimating pain and the fact that some amputees find it difficult to distinguish between residual limb and phantom pain. In a survey of 78 traumatic amputees, Pezzin et al.46 found that 14.1 percent...

Visceral Innervation

The reproductive organs have a dual innervation via the sympathetic thoracolumbar and parasympathetic sacral autonomic, with contributions from the somatic sensory nervous system.6, 7 The visceral afferent fibers travel the same route as their corresponding efferent autonomic fibers Table 41.1 . The afferent innervation of the upper vagina, cervix, uterus, proximal fallopian tubes, upper bladder, terminal ileum, and distal large bowel travels with the thoracolumbar sympathetics through the...

Wind uplike pain and aftersensations

Wind up-like pain or abnormal temporal summation, is the clinical equivalent to increasing neuronal activity following repetitive C-fiber stimulation of more than In humans, such pains may be evoked by either repetitive noxious or non-noxious stimulation from normal or hyperalgesic cutaneous areas, respectively. When repetitive low-threshold stimuli, which exclusively activate Ap-fibers, are applied at intervals of less than three seconds, they give rise to pain, which means that these stimuli...

Chronic pain after breast surgery

In the UK alone, 42,000 new patients are diagnosed with primary breast cancer each year and most undergo surgery, either mastectomy or breast conservation surgery with sentinel node sample or clearance. Chronic pain was initially reported in the 1970s as a rare consequence of breast cancer treatment.62 There are now many epi-demiological and clinical studies reporting the prevalence and characteristics of persistent pain which suggest that it occurs commonly, with subsequent impact upon quality...

Thoracoabdominal radiculopathy

This is usually seen in older patients with long-standing diabetes and may be associated with marked weight loss. Most patients describe girdle-like pain around the trunk that may be unilateral or bilateral. Abdominal wall weakness, cutaneous hyperesthesiae, or superficial sensory loss over the involved area may be seen on examination. EMG changes can be detected in paraspinal and abdominal wall muscles, in adjacent myotomes, and, on this basis, the lesion is presumed to be very proximal - in...