Into the Island: A new technique of non-invasive cortical stimulation of the insula

Study aim. - We describe a new neuronavigation-guided technique to target the posterior-superior insula (PSI) using a cooled-double-cone coil for deep cortical stimulation. Introduction. - Despite the analgesic effects brought about by repetitive transcranial magnetic stimulation (TMS) to the primary motor and prefrontal cortices, a significant proportion of patients remain symptomatic. This encouraged the search for new targets that may provide stronger pain relief. There is growing evidence that the posterior insula is implicated in the integration of painful stimuli in different pain syndromes and in homeostatic thermal integration. Methods. - The primary motor cortex representation of the lower leg was used to calculate the motor threshold and thus, estimate the intensity of PSI stimulation. Results. - Seven healthy volunteers were stimulated at 10 Hz to the right PSI and showed subjective changes in cold perception. The technique was safe and well tolerated. Conclusions. - The right posterior-superior insula is worth being considered in future studies as a possible target for rTMS stimulation in chronic pain patients. (c) 2012 Elsevier Masson SAS. All rights reserved.

Postural adjustment after an unexpected perturbation in children with haemophilia

. Children with haemophilia often bleed inside joints and muscles, which may impair postural adjustments. These postural adjustments are necessary to control postural balance during daily activities. The inability to quickly recover postural balance could elevate the risk of bleeding. To determine whether children with haemophilia have impaired postural adjustment after an unexpected perturbation compared with healthy children. Twenty children with haemophilia comprised the haemophilic group (HG), and 20 healthy, age-paired children comprised the control group (CG). Subjects stood on a force plate, and 4% of the subjects body weight was applied via a pulley system to a belt around the subjects trunks. The centre of pressure (COP) displacement was measured after the weight was unexpectedly released to produce a controlled postural perturbation followed by postural adjustment to recover balance. The subjects postural adjustments in eight subsequent intervals of 1 s (t1t8), beginning with the moment of weight removal, were compared among intervals and between groups. The applied perturbation magnitudes were the same for both groups, and no difference was observed between the groups in t1. However, the COP displacement in t2 in the HG was significantly higher than in the CG. No differences were observed between the groups in the other intervals. Within-group analysis showed that the COP was higher in t2 than in t4 (P = 0.016), t5 (P = 0.001) and t8 (P = 0.050) in the HG. No differences were observed among intervals in the CG. Children with haemophilia demonstrated differences in postural adjustment while undergoing unexpected balance perturbations when compared with healthily children.

Preditores biopsicossociais de dor, incapacidade e depressão em pacientes brasileiros com dor crônica

JUSTIFICATIVA E OBJETIVOS: Esta pesquisa foi baseada na perspectiva biopsicossocial de dor crônica, que sugere a existência de interrelação dinâmica entre alterações biológicas, estado psicológico e contexto social, onde cada uma destas dimensões apresenta um papel diferenciado na dor crônica, incapacidade e ajuste emocional. Este estudo examinou a aplicabilidade de preditores de dor, incapacidade e sofrimento propostos pelos modelos biopsicossociais de dor em amostra de pacientes brasileiros com dor crônica. MÉTODO: Estudo de corte transversal realizado com amostra de conveniência de 311 participantes atendidos em diversos centros de dor localizados no Sul e Sudeste do Brasil. As análises estatísticas para examinar as propriedades dos testes e relações entre as variáveis incluíram teste t, Análise de Variância, correlações, regressão hierárquica múltipla e logística. Todas as análises estatísticas foram realizadas com o programa SPSS-14. RESULTADOS: Os fatores orgânicos, sócio-demográficos e cognitivos contribuíram para incapacidade, depressão, intensidade da dor e empregabilidade de forma diferenciada. Nessa amostra, grau de escolaridade, local da dor e autoeficácia contribuíram para incapacidade; pensamentos catastróficos foram o único preditor de depressão; gênero e autoeficácia contribuíram para a intensidade da dor; e idade, grau de escolaridade, incapacidade e autoeficácia foram fatores de risco para desemprego. CONCLUSÃO: As evidências descritas na literatura baseadas na perspectiva biopsicossocial, que enfatizam o papel distinto de fatores biopsicossociais na dor, incapacidade e sofrimento mental foram confirmadas nesse estudo.

Cefaleia em pacientes com dor crônica entrevistados na Unidade de Dor do Hospital Central de Maputo, Moçambique

JUSTIFICATIVA E OBJETIVOS: Nos últimos anos, a abordagem da dor crônica em Maputo, capital de Moçambique, ganhou espaço, com a construção da Unidade de Dor do Hospital Central. No continente africano existem poucos estudos epidemiológicos sobre dor crônica. Em Moçambique, nenhum estudo prévio foi publicado. O objetivo deste estudo foi descrever e analisar as características da cefaleia em pacientes com dor crônica entrevistados no referido hospital. MÉTODO: Participantes com dor crônica de acordo com critérios da International Association for the Study of Pain (IASP), maiores de 18 anos, fluentes em português foram incluídos. Dados demográficos, características da dor crônica e presença de cefaleia foram investigados. RESULTADOS: Cento e dezoito pacientes foram avaliados. Destes, 79 (66,9%) eram mulheres e 39 (33,1%) eram homens, com média de idade de 52,4 anos. Presença de cefaleia foi frequente entre estes pacientes (53/ 44,9%) embora esta não fosse necessariamente sua dor principal. Cefaleia foi o principal segundo sítio de dor. Migrânea foi diagnóstico em 14 (11,9%) pacientes, cefaleia tensional em 28 (23,8%), cefaleia cervicogênica em 9 (7,6%). CONCLUSÃO: Os dados revelam que nos pacientes com dor crônica na Unidade de Dor do Hospital Central de Maputo há prevalência de cefaleias semelhante àquela descrita na população em geral por outros estudos.

Cognitive function in patients with chronic pain treated with opioids: characteristics and associated factors

Background The paucity of studies regarding cognitive function in patients with chronic pain, and growing evidence regarding the cognitive effects of pain and opioids on cognitive function prompted us to assess cognition via neuropsychological measurement in patients with chronic non-cancer pain treated with opioids. Methods In this cross-sectional study, 49 patients were assessed by Continuous Reaction Time, Finger Tapping, Digit Span, Trail Making Test-B and Mini-mental State Examination tests. Linear regressions were applied. Results Patients scored poorly in the Trail Making Test-B (mean?=?107.6?s, SD?=?61.0, cut-off?=?91?s); and adequately on all other tests. Several associations among independent variables and cognitive tests were observed. In the multiple regression analyses, the variables associated with statistically significant poor cognitive performance were female sex, higher age, lower annual income, lower schooling, anxiety, depression, tiredness, lower opioid dose, and more than 5?h of sleep the night before assessment (P?<?0.05). Conclusions Patients with chronic pain may have cognitive dysfunction related to some reversible factors, which can be optimized by therapeutic interventions.

Assessment of myocardial infarction by CT angiography and cardiovascular MRI in patients with cocaine-associated chest pain: a pilot study

Objectives: Cocaine is a commonly used illicit drug that leads to the most emergency department (ED) visits. Chest pain is the most common presentation, reported in 40% of patients. Our aim was to evaluate the incidence of previous myocardial infarction among young cocaine users (18-40 years) with cocaine-associated chest pain by the assessment of myocardial fibrosis by cardiovascular MRI. Second, we also intended to evaluate the coronary tree by CT angiography (CTA). Methods: 24 cocaine users (22 males) who frequently complained about cocaine-associated chest pain underwent CTA and cardiovascular MRI. Mean age of patients was 29.7 years and most of them (79%) had frequently used inhalatory cocaine. Results: The calcium score turned out to be positive in only one patient (Agatston=54). Among the coronary segments evaluated, only one patient had calcified plaques at the anterior descending coronary artery (proximal and medium segments). Assessment of regional ventricular function by the evaluation of 17 segments was normal in all patients. None of the patients showed myocardial delayed enhancement, indicative of myocardial fibrosis. CTA therefore confirmed the low cardiovascular risk of these patients, since most of them (96%) had no atherosclerosis detected by this examination. Only one patient (4%) had coronary atherosclerosis detected, without significant coronary stenosis. Conclusion: Cardiovascular MR did not detect the presence of delayed enhancement indicative of myocardial fibrosis among young cocaine users with low cardiovascular risk who had complained of cocaine-associated chest pain.

EFFECTS OF MUSCULAR STRETCHING AND SEGMENTAL STABILIZATION ON FUNCTIONAL DISABILITY AND PAIN IN PATIENTS WITH CHRONIC LOW BACK PAIN: A RANDOMIZED, CONTROLLED TRIAL

Objective: The purpose of this study was to compare the effects of 2 exercise programs, segmental stabilization exercises (SSEs) and stretching of trunk and hamstrings muscles, on functional disability, pain, and activation of the transversus abdominis muscle (TrA), in individuals with chronic low back pain. Methods: A total of 30 participants were enrolled in this study and randomly assigned to 1 of 2 groups as a function of intervention. In the segmental stabilization group (SS), exercises focused on the TrA and lumbar multifidus muscles, whereas in the stretching group (ST), exercises focused on stretching the erector spinae, hamstrings, and triceps surae. Severity of pain (visual analog scale and McGill pain questionnaire) and functional disability (Oswestry disability questionnaire) and TrA muscle activation capacity (Pressure Biofeedback Unit, or PBU) were compared as a function of intervention. Interventions lasted 6 weeks, and sessions happened twice a week (30 minutes each). Analysis of variance was used for intergroup and intragroup comparisons. Results: As compared with baseline, both treatments were effective in relieving pain and improving disability (P < .001). Those in the SS group had significantly higher gains for all variables. The stretching group did not effectively activate the TrA (P = .94). Conclusion: Both techniques improved pain and reduced disability. In this study, SS was superior to muscular stretching for the measured variables associated with chronic low back pain. (J Manipulative Physiol Ther 2012;35:279-285)

Efficacy of graded activity versus supervised exercises in patients with chronic non-specific low back pain: protocol of a randomised controlled trial

Abstract Background Low back pain is a relevant public health problem, being an important cause of work absenteeism worldwide, as well as affecting the quality of life of sufferers and their individual functional performances. Supervised active physical routines and of cognitive-behavioral therapies are recommended for the treatment of chronic Low back pain, although evidence to support the effectiveness of different techniques is missing. Accordingly, the aim of this study is to contrast the effectiveness of two types of exercises, graded activity or supervised, in decreasing symptoms of chronic low back pain. Methods/design Sample will consist of 66 patients, blindly allocated into one of two groups: 1) Graded activity which, based on an operant approach, will use time-contingent methods aiming to increase participants’ activity levels; 2) Supervised exercise, where participants will be trained for strengthening, stretching, and motor control targeting different muscle groups. Interventions will last one hour, and will happen twice a week for 6 weeks. Outcomes (pain, disability, quality of life, global perceived effect, return to work, physical activity, physical capacity, and kinesiophobia) will be assessed at baseline, at treatment end, and three and six months after treatment end. Data collection will be conducted by an investigator blinded to treatment allocation. Discussion This project describes the randomisation method that will be used to compare the effectiveness of two different treatments for chronic low back pain: graded activity and supervised exercises. Since optimal approach for patients with chronic back pain have yet not been defined based on evidence, good quality studies on the subject are necessary. Trial registration NCT01719276

Pain and quality of life in patients undergoing radiotherapy for spinal metastatic disease treatment

Abstract Background Radiotherapy is an important tool in the control of pain in patients with spinal metastatic disease. We aimed to evaluate pain and of quality of life of patients with spinal metastatic disease undergoing radiotherapy with supportive treatment. Methods The study enrolled 30 patients. From January 2008 to January 2010, patients selection included those treated with a 20 Gy tumour dose in five fractions. Patients completed the visual analogue scale for pain assessment and the SF-36 questionnaire for quality of life assessment. Results The most frequent primary sites were breast, multiple myeloma, prostate and lymphoma. It was found that 14 spinal metastatic disease patients (46.66%) had restricted involvement of three or fewer vertebrae, while 16 patients (53.33%) had cases involving more than three vertebrae. The data from the visual analogue scale evaluation of pain showed that the average initial score was 5.7 points, the value 30 days after the end of radiotherapy was 4.60 points and the average value 6 months after treatment was 4.25 points. Notably, this final value was 25.43% lower than the value from the initial analysis. With regard to the quality of life evaluation, only the values for the functional capability and social aspects categories of the questionnaire showed significant improvement. Conclusion Radiotherapy with supportive treatment appears to be an important tool for the treatment of pain in patients with spinal metastatic disease.

Effect of low-level laser therapy on pain levels in patients with temporomandibular disorders: a systematic review

Temporomandibular disorders (TMD) are characterized by the presence of temporomandibular joint (TMJ) and/or masticatory muscle pain and dysfunction. Low-level laser is presented as an adjuvant therapeutic modality for the treatment of TMD, especially when the presence of inflammatory pain is suspected. Objective: To systematically review studies that investigated the effect of low level laser therapy (LLLT) on the pain levels in individuals with TMD. Material and Methods: The databases Scopus, embase, ebsco and PubMed were reviewed from January/2003 to October/2010 with the following keywords: laser therapy, low-level laser therapy, temporomandibular joint disorders, temporomandibular joint dysfunction syndrome, temporomandibular joint, temporomandibular, facial pain and arthralgia, with the inclusion criteria for intervention studies in humans. exclusion criteria adopted were intervention studies in animals, studies that were not written in english, Spanish or Portuguese, theses, monographs, and abstracts presented in scientific events. Results: After a careful review, 14 studies fit the criteria for inclusion, of which, 12 used a placebo group. As for the protocol for laser application, the energy density used ranged from 0.9 to 105 J/cm², while the power density ranged from 9.8 to 500 mW. The number of sessions varied from 1 to 20 and the frequency of applications ranged from daily for 10 days to 1 time per week for 4 weeks. A reduction in pain levels was reported in 13 studies, with 9 of these occurring only in the experimental group, and 4 studies reporting pain relief for both the experimental group and for the placebo. Conclusion: Most papers showed that LLLT seemed to be effective in reducing pain from TMD. However, the heterogeneity of the standardization regarding the parameters of laser calls for caution in interpretation of these results. Thus, it is necessary to conduct further research in order to obtain a consensus regarding the best application protocol for pain relief in patients with TMD.

A comparative radiographic investigation of femoroacetabular impingement in young patients with and without hip pain

OBJECTIVE: To compare the existence of radiographic abnormalities in two groups of patients, those with and without hip pain. METHODS: A total 222 patients were evaluated between March 2007 and April 2009; 122 complained of groin pain, and 100 had no symptoms. The individuals in both groups underwent radiographic examinations of the hip using the following views: anteroposterior, Lequesne false profile, Dunn, Dunn 45º, and Ducroquet. RESULTS: A total of 1110 radiographs were evaluated. Female patients were prevalent in both groups (52% symptomatic, 58% asymptomatic). There were statistically significant differences between the groups in age (p<0.0001), weight (p = 0.002) and BMI (p = 0.006). The positive findings in the group with groin pain consisted of the presence of a bump on the femoral head in the anteroposterior view (p<0.0001) or in the Dunn 45º view (p = 0.008). The difference in the a angle in the anteroposterior, Dunn, Dunn 45º, and Ducroquet views for all of the cases studied was p,0.0001. The joint space measurement differed significantly between groups in the Lequesne view (p = 0.007). The Lequesne anteversion angle (ρ) and the femoral offset measurement also differed significantly (p = 0.005 and p = 0.0001, respectively). CONCLUSIONS: We conclude that the best views for diagnosing a femoroacetabular impingement are the anteroposterior pelvic orthostatic, the Dunn 45º, and the Ducroquet views. The following findings correlated with hip pain: a decrease in the femoral offset, an increase in the α angle, an increase in the Lequesne ρ angle, a decrease in the CE angle of Wiberg, a thinner articular space and the presence of a bump on the femoral head-neck transition.

Transcranial DC Stimulation Coupled With TENS for the Treatment of Chronic Pain A Preliminary Study

Objective: Based on evidence showing that electrical stimulation of the nervous system is an effective method to decrease chronic neurogenic pain, we aimed to investigate whether the combination of 2 methods of electrical stimulation-a method of peripheral stimulation [transcutaneous electrical nerve stimulation (TENS)] and a method of noninvasive brain stimulation (transcranial direct current stimulation (tDCS)]-induces greater pain reduction as compared with tDCS alone and sham stimulation. Methods: We performed a preliminary, randomized, sham-controlled, crossover, clinical study in which 8 patients were randomized to receive active tDCS/active TENS (""tDCS/TENS"" group), active tDCS/sham TENS (""tDCS"" group), and sham tDCS/sham TENS (""sham"" group) stimulation. Assessments were performed immediately before and after each condition by a blinded rater. Results: The results showed that there was a significant difference in pain reduction across the conditions Of stimulation (P = 0.006). Post hoc tests showed significant pain reduction as compared with baseline after the tDCS/TENS condition [reduction by 36.5% (+/- 10.7), P = 0.004] and the tDCS condition [reduction by 15.5% (+/- 4.9), P = 0.014], but not after sham stimulation (P = 0.35). In addition, tDCS/TENS induced greater pain reduction than tDCS (P = 0.02). Conclusions: The results of this pilot study suggest that the combination of TENS with tDCS has a superior effect compared with tDCS alone.

Temporomandibular disorders in headache patients

Objective: To identify the frequency of signs and symptoms of temporomandibular disorder (TMD) and its severity in individuals with headache. Study Design: 60 adults divided into three groups of 20 individuals: chronic daily headache (CDH), episodic headache (EH) and a control group without headache (WH). Headache diagnosis was performed according to the criteria of International Headache Society and the signs and symptoms of TMD were achieved by using a clinical exam and an anamnestic questionnaire. The severity of TMD was defined by the temporomandibular index (TMI). Results: The TMD signs and symptoms were always more frequent in individuals with headache, especially report of pain in TMJ area (CDH, n=16; EH, n=12; WH, n=6), pain to palpation on masseter (CDH, n=19; EH, n=16; WH, n=11) which are significantly more frequent in episodic and chronic daily headache. The mean values of temporomandibular and articular index (CDH patients) and muscular index (CDH and EH patients) were statistically higher than in patients of the control group, notably the articular (CDH=0.38; EH=0.25; WH=0.19) and muscular (CDH=0.46; EH=0.51; WH=0.26) indices. Conclusions: These findings allow us to speculate that masticatory and TMJ pain are more common in headache subjects. Besides, it seems that the TMD is more severe in headache patients.

Photodynamic therapy in actinic cheilitis: clinical and anatomopathological evaluation of 19 patients

BACKGROUND: Actinic cheilitis, a common disease caused by chronic solar exposure and tobacco use, is considered a premalignant lesion with potential to develop into squamous cell carcinoma. Some of the available treatments are invasive, have unaesthetic results and require multiple sessions. OBJECTIVE: To assess the efficacy of a therapy and its cosmetic results. METHODS: In this uncontrolled clinical trial a single photodynamic therapy (PDT) session using 16% methyl-aminolevulinate was performed on actinic cheilitis of the lower lip. A standardized questionnaire was applied in order to assess the clinical improvement from the patients' point of view and the satisfaction with the treatment. Anatomopathological evaluation was performed before the treatment and two months afterwards. RESULTS: The sample was composed of 19 patients (10 males and 9 females), phototypes I to III, with average age of 62 years. Main adverse effects were: sudden pain, scabs, herpes flare-up, and edema. The average score of pain during the procedure was 5,8+2,9. At the final assessment the patients reported improvement of 80% and satisfaction of 85% (p<0.01). Anatomopathological analysis showed a significant decrease of dysplasia (p=0.03) in spite of its presence in 84% of cases. There was no significant correlation between the level of dysplasia with either the subjective impression of clinical improvement (p=0.82) or with the patients' final satisfaction (p=0.96). CONCLUSION: PDT is effective in the treatment of actinic cheilitis, but it is associated with a significant level of pain. Due to the persistence of dysplasia, more research needs to be done in order to define the ideal number of sessions for the effective treatment of these lesions.