Impact of Nervous System Hyperalgesia on Pain, Disability, and Quality of Life in Patients With Knee Osteoarthritis: A Controlled Analysis

Objective. Refractory, disabling pain associated with knee osteoarthritis (OA) is usually treated with total knee replacement. However, pain in these patients might be associated with central nervous sensitization rather than peripheral inflammation and injury. We evaluated the presence of hyperalgesia in patients scheduled for a total knee replacement due to knee osteoarthritis with refractory pain, and we assessed the impact of pressure pain threshold measurements (PPT) on pain, disability, and quality of life of these patients. Methods. Sixty-two female patients were compared with 22 age-matched healthy controls without reported pain for the last year. PPT was measured at the lower extremities subcutaneous dermatomes, over the vastus medialis, adductor longus, rectus femoris, vastus lateralis, tibialis anterior, peroneus longus, iliacus, quadratus lumborum and popliteus muscles and at the supraspinous ligaments from L1-L5, over the L5-S1 and S1-S2 sacral areas and at the pes anserinus bursae and patellar tendon. Results. Patients with knee OA had significantly lower PPT over all evaluated structures versus healthy control subjects (P < 0.001). Lower PPT values were correlated with higher pain intensity, higher disability scores, and with poorer quality of life, except for the role-emotional and general health status. Combined PPT values over the patellar tendon, at the S2 subcutaneous dermatome and at the adductor longus muscle were the best predictors for visual analog scale and Western Ontario and McMaster Universities Osteoarthritis Index pain scores. Conclusion. Patients with pain due to osteoarthritis who were scheduled for total knee replacement showed hyperalgesia of nervous system origin that negatively impacted pain, knee functional capacity, and most aspects of quality of life.

Pain Relief and Functional Recovery in Patients with Complex Regional Pain Syndrome after Motor Cortex Stimulation

In addition to pain and neurovegetative symptoms, patients with severe forms of complex regional pain syndrome (CRPS) develop a broad range of symptoms, including sensory disturbances, motor impairment and dystonic posturing. While most patients respond to medical therapy, some are considered refractory and become surgical candidates. To date, the most commonly used surgical procedure for CRPS has been spinal cord stimulation. This therapy often leads to important analgesic effects, but no sensory or motor improvements. We report on 2 patients with pain related to CRPS and severe functional deficits treated with motor cortex stimulation (MCS) who not only had significant analgesic effects, but also improvements in sensory and motor symptoms. In the long term (27 and 36 months after surgery), visual analog scale pain scores were improved by 60-70% as compared to baseline. There was also a significant increase in the range of motion in the joints of the affected limbs and an improvement in allodynia, hyperpathia and hypoesthesia. Positron emission tomography scan in both subjects revealed that MCS influenced regions involved in the circuitry of pain. Copyright (C) 2011 S. Karger AG, Basel

Assessing the impact of upper blepharoplasty on quality of life with a standardized questionnaire (QBleflaro): a pilot study

BACKGROUND: There is scarce literature on assessing surgical results and the impact of upper blepharoplasty on quality of life of patients. OBJECTIVE: To evaluate the impact on quality of life of patients submitted to upper blepharoplasty. METHODS: A prospective study using a standardized questionnaire applied to adult women submitted to upper blepharoplasty and evaluated 90 days later to estimate the surgical impact on quality of life and complications. RESULTS: Forty-one healthy adult females (median age of 53 years) were evaluated from June 2005 to March 2006. The questionnaire showed high internal consistency. The quality of life element with greater impact on the first postoperative week was related to physical appearance perception and that of lesser impact was associated to relationship with relatives and close friends. Hypertrophic scar was the main late complication. Satisfaction levels with the surgery were significantly related with absence of undesirable effects (p<0.01). CONCLUSIONS: The authors suggest a consistent tool to evaluate the impact of this surgical procedure on quality of life of patients. High satisfaction levels with upper blepharoplasty stood out. Keywords: Blepharoplasty; Quality of life; Patient satisfaction

Relationship among eccentric hip and knee torques, symptom severity and functional capacity in females with patellofemoral pain syndrome

Objective: To determine the relationships between eccentric hip and knee torques, symptom severity and functional capacity in females with patellofemoral pain syndrome (PFPS). Design: Within-subject correlational study. Setting: University biomechanics laboratory. Participants: 10 females diagnosed with PFPS. Main outcome measures: Eccentric strength of the hip abductors and lateral rotators, and knee extensors were assessed using an isokinetic dynamometer. A 10-cm visual analog scale was used to determine usual knee pain in the last week. The Anterior Knee Pain Scale (AKPS) was used to determine the functional capacity of the patients. Results: The study found that the greater the eccentric knee extensor and hip lateral rotator torques, the higher the functional capacity of the patients (p = 0.02, r = 0.72; p = 0.02, r = 0.72). It was also shown that the greater hip lateral rotator torque, the less the usual pain reported in the last week (p = 0.004, r = -0.84). Despite the lack of statistical significance (p = 0.11), it was also found a modest negative relationship between the eccentric knee extensor torque and the usual pain reported in the last week (r = -0.56) that was considered clinically meaningful (d = 1.4). Conclusions: This study showed that eccentric knee extensor and hip lateral rotator torques were associated with functional capacity and pain level in females with PFPS. Further investigations should be carried out to verify the effects of an intervention program focused on the eccentric action of these muscles with respect to the symptoms in patients with PFPS. (C) 2011 Elsevier Ltd. All rights reserved.

Alpha lipoic acid in burning mouth syndrome - a randomized double-blind placebo-controlled trial

The burning mouth syndrome (BMS) is a chronic condition characterized by oral burning pain in the absence of clinical abnormalities and without established therapy. The purpose of this study was to evaluate the effectiveness of alpha lipoic acid (ALA) in the management of BMS symptoms through a randomized double-blind placebo-controlled trial. Thirty-eight patients (34 women and four men, median age 62.9 years, range 36-78) were included and 31 completed the study. The patients were randomized into two cycles of treatment: one with alpha lipoic acid and one with placebo both administered in identical capsules. These cycles were separated by a washout period of 20 days. The oral symptoms and the treatment response were assessed using a 100-mm visual analog scale before and after each cycle and the global perceived effect score, using a 5-point scale after each treatment cycle. The level of reduction on burning was significant for both treatments (paired t-test: P < 0.05; rp = 0.011; ral < 0.001). Considering the two cycles together, 22 patients reported at least some improvement after ALA use and 23 patients after placebo. Comparison of the oral assessment scores of the two cycles failed to demonstrate the effectiveness of ALA over placebo (t-test: P > 0.05; r = 0.75).

Low Intensity Laser Therapy in Temporomandibular Disorder: a Phase II Double-Blind Study

The purpose of this study was to evaluate the analgesic effect of Low Intensity Laser Therapy (LILT) and its influence on masticatory efficiency in patients with temporomandibular dysfunction (TMD). This study was performed using a random, placebo-controlled, and double-blind research design. Fourteen patients were selected and divided into two groups (active and placebo). Infrared laser (780 nm, 70 mw, 60s, 105J/cm(2)) was applied precisely and continuously into five points of the temporomandibular joint (TMJ) area: lateral point (LP), superior point (SP), anterior point (AP), posterior point (PP), and posterior-inferior point (PIP) of the condylar position. This was performed twice per week, for a total of eight sessions, To ensure a double-blind study, two identical probes supplied by the manufacturer were used: one for the active laser and one for the inactive placebo laser. They were marked with different letters (A and B) by a clinician who did not perform the applications. A Visual Analogue Scale (VAS) and a colorimetric capsule method were employed. Data were obtained three times: before treatment (Ev1), shortly after the eighth session (Ev2), and 30 days after the first application (Ev3). Statistical tests revealed significant differences at one percent (1%) likelihood, which implies that superiority of the active group offered considerable TMJ pain improvement. Both groups presented similar masticatory behavior, and no statistical differences were found. With regard to the evaluation session, Ev2 presented the lowest symptoms and highest masticatory efficiency throughout therapy. Therefore, low intensity laser application is effective in reducing TMD symptoms, and has influence over masticatory efficiency [Ev2 (0.2423) and Ev3 (0.2043), observed in the interaction Evaluations x Probes for effective dosage].

Paracetamol versus paracetamol-codeine in the treatment of post-operative dental pain: A randomized, double-blind, prospective trial

Background: Codeine is frequently added to paracetamol to treat post-operative dento-alveolar pain; studies have shown effectiveness in relief of post-operative pain at high doses but at the expense of central nervous and gastrointestinal side effects. There has been no trial to compare the efficacy and safety of paracetamol 1000mg with paracetamol 1000mg combined with codeine 30mg. Method. A randomized, single centre, double-blind prospective parallel group trial was performed to compare paracetamol 1000mg with paracetamol 1000mg with codeine 30mg for the relief of pain following surgical removal of impacted third molars, and analysed on an intention-to-treat (ITT) basis. Eighty-two patients were assigned randomly to receive either drug for a maximum of three doses. Patients recorded their pain intensity one hour after surgery and hourly thereafter for 12 hours. Results: The average increase in pain intensity over 12 hours was significantly less in patients receiving paracetamol plus codeine than in those receiving paracetamol alone (p=0.03) -1.81cm/h compared with 0.45cm/h - a difference of 1.13cm/h (95 per cent Cl: 0.18 to 2.08). Of the patients who received the paracetamol codeine combination, 62 per cent used escape medication compared with 75 per cent of those on paracetamol alone (p=0.20). There was no significant difference between the two groups in the proportion of patients experiencing adverse events (P=0.5). Conclusion: A combination of 1000mg paracetamol and 30mg codeine was significantly more effective in controlling pain for 12 hours following third molar removal, with no significant difference of side effects during the 12 hour period studied.

Responses to a clinical test of mechanical provocation of nerve tissue in whiplash associated disorder

Involvement of nerve tissue may contribute to the persistence of pain following a whiplash injury. This study aimed to investigate responses to the brachial plexus provocation test (BPPT) in 156 subjects with chronic whiplash associated disorder (WAD) with and without associated arm pain and 95 asymptomatic control subjects. The range of elbow extension (ROM) and visual analogue scale (VAS) pain scores were measured. Subjects with chronic WAD demonstrated significantly less ROM and higher VAS scores with the BPPT than the asymptomatic subjects (P

Description of stable pain in rheumatoid arthritis: A 6 year study

Objective. To study pain quality and variability in patients with rheumatoid arthritis (RA). Methods. Pain, disease activity, and functional status Were assessed 3 times over 6 years in an initial cohort of 120 clinic patients with chronic pain from RA. A pain visual analog scale and the McGill Pain Questionnaire (MPQ) were used to record pain intensity and quality. RA disease activity and function were measured. Results. There was no statistically significant difference in any measure over the 3 assessments. RA pain intensity was moderate. The MPQ showed that sensory components of the pain were described in terms of pressure and constriction. Pain related affect was described with adjectives suggesting positive psychological adaptation to pain. Conclusion. The. results indicate a general profile of no change in pain sensation, affect, and emotional quality in clinic monitored patients with ongoing RA and ongoing, moderate levels of disease activity and function. The MPQ provides qualitative detail to patient's report of pain severity that could be a useful addition to longterm documentation of RA outcome. Regular MPQ documentation of current pain in outpatients could indicate whether any significant change in pain levels is reflected in altered word selection that reflects physiological or psychological change, and could assist clinicians to select the most appropriate form of therapy for RA pain.

Transitory increased blood pressure after upper airway surgery for snoring and sleep apnea correlates with the apnea-hypopnea respiratory disturbance index

A transitory increase in blood pressure (BP) is observed following upper airway surgery for obstructive sleep apnea syndrome but the mechanisms implicated are not yet well understood. The objective of the present study was to evaluate changes in BP and heart rate (HR) and putative factors after uvulopalatopharyngoplasty and septoplasty in normotensive snorers. Patients (N = 10) were instrumented for 24-h ambulatory BP monitoring, nocturnal respiratory monitoring and urinary catecholamine level evaluation one day before surgery and on the day of surgery. The influence of postsurgery pain was prevented by analgesic therapy as confirmed using a visual analog scale of pain. Compared with preoperative values, there was a significant (P < 0.05) increase in nighttime but not daytime systolic BP (119 ± 5 vs 107 ± 3 mmHg), diastolic BP (72 ± 4 vs 67 ± 2 mmHg), HR (67 ± 4 vs 57 ± 2 bpm), respiratory disturbance index (RDI) characterized by apnea-hypopnea (30 ± 10 vs 13 ± 4 events/h of sleep) and norepinephrine levels (22.0 ± 4.7 vs 11.0 ± 1.3 µg l-1 12 h-1) after surgery. A positive correlation was found between individual variations of BP and individual variations of RDI (r = 0.81, P < 0.01) but not between BP or RDI and catecholamines. The visual analog scale of pain showed similar stress levels on the day before and after surgery (6.0 ± 0.8 vs 5.0 ± 0.9 cm, respectively). These data strongly suggest that the cardiovascular changes observed in patients who underwent uvulopalatopharyngoplasty and septoplasty were due to the increased postoperative RDI.

Evaluation of a program to reduce back pain in nursing personnel

OBJECTIVE: To evaluate the effectiveness of a program designed to reduce back pain in nursing aides. METHODS: Female nursing aides from a university hospital who had suffered episodes of back pain for at least six months were included in the study. Participants were randomly divided into a control group and an intervention group. The intervention program involved a set of exercises and an educational component stressing the ergonomic aspect, administered twice a week during working hours for four months. All subjects answered a structured questionnaire and the intensity of pain was assessed before and after the program using a visual analogue scale (VAS). Student's t-test or the Wilcoxon Rank Sum Test for independent samples, and Chi-square test or the Exact Fisher test for categorical analysis, were used. The McNemar test and the Wilcoxon matched pairs test were used to compare the periods before and after the program. RESULTS: There was a statistically significant decrease in the frequency of cervical pain in the last two months and in the last seven days in the intervention group. There was also a reduction in cervical pain intensity in the two periods (2 months, 7 days) and lumbar pain intensity in the last 7 days. CONCLUSIONS: The results suggest that a program of regular exercise with an emphasis on ergonomics can reduce musculoskeletal symptoms in nursing personnel.

Relatório de estágio: intervenção em fisioterapia na sindrome da cirurgia lombar falhada

Introdução: A síndrome da cirurgia lombar falhada (SCLF) caracteriza-se pela persistência ou recidiva da dor ou aparecimento de novos sintomas após discectomia, descompressão de canal estreito ou artrodese lombares. Objectivos: O objectivo deste estudo foi descrever a abordagem em fisioterapia de um caso com Síndrome da Cirurgia Lombar Falhada e avaliar os seus efeitos na funcionalidade e sintomatologia dolorosa neste indivíduo. Metodologia: A amostra foi constituída por um sujeito com 41 anos, trabalhador da construção civil, apresentando dor lombar com irradiação para o membro inferior, após ter sido submetido a discectomia lombar e artrodese, que realizou sessões de fisioterapia convencional antes e depois da cirurgia, e que apresentava sinais compatíveis com compressão radicular. A intensidade da dor foi medida através da escala visual analógica (EVA), as amplitudes com o goniómetro universal, a funcionalidade foi avaliada utilizando o Questionário de Incapacidade Roland-Morris (RMDQ), o estado psicológico foi avaliado através da “Escala de Desânimo Associado à Dor” e do “Inventário de Convicções e Percepções Relacionadas com a Dor”. Resultados: A dor era inicialmente em média de 5,5/10 EVA, sendo de 3,4/10 EVA no final do tratamento. Quanto à funcionalidade (RMDQ) esta variou de 14/24 no início para 17/24 no final. De uma forma geral, após a aplicação de técnicas para diminuir a tensão do piriforme, técnicas neuurodinâmicas e um programa de exercícios para melhoria do controlo motor, o paciente apresentou alívio das queixas de dor na nádega esquerda e anca, aumento da amplitude de rotação medial da coxo-femoral, ausência das parestesias na face plantar do pé esquerdo e melhoria das queixas de dor na face anterior e lateral da coxa. Verificamos que houve diminuição dos índices de dor e melhorias dos níveis de funcionalidade. Conclusão: Neste estudo de caso, foi salientado o processo de raciocínio clínico desenvolvido pelo fisioterapeuta: a interpretação dos dados da história e levantamento das primeiras hipóteses e a realização dos testes no exame objectivo, permitiram estabelecer um diagnóstico funcional e elaborar um plano de intervenção através do qual o utente recuperou parcialmente a sua funcionalidade e diminuiu os seus índices de dor.

Short- and medium-term effects of manual therapy on cervical active range of motion and pressure pain sensitivity in latent myofascial pain of the upper trapezius muscle: a randomized controlled trial

Objective: The purpose of this study was to investigate effects of different manual techniques on cervical ranges of 17 motion and pressure pain sensitivity in subjects with latent trigger point of the upper trapezius muscle. 18 Methods: One hundred seventeen volunteers, with a unilateral latent trigger point on upper trapezius due to computer 19 work, were randomly divided into 5 groups: ischemic compression (IC) group (n = 24); passive stretching group (n = 20 23); muscle energy technique group (n = 23); and 2 control groups, wait-and-see group (n = 25) and placebo group 21 (n = 22). Cervical spine range of movement was measured using a cervical range of motion instrument as well as 22 pressure pain sensitivity by means of an algometer and a visual analog scale. Outcomes were assessed pretreatment, 23 immediately, and 24 hours after the intervention and 1 week later by a blind researcher. A 4 × 5 mixed repeated- 24 measures analysis of variance was used to examine the effects of the intervention and Cohen d coefficient was used. 25 Results: A group-by-time interaction was detected in all variables (P b .01), except contralateral rotation. The 26 immediate effect sizes of the contralateral flexion, ipsilateral rotation, and pressure pain threshold were large for 3 27 experimental groups. Nevertheless, after 24 hours and 1 week, only IC group maintained the effect size. 28 Conclusions: Manual techniques on upper trapezius with latent trigger point seemed to improve the cervical range of 29 motion and the pressure pain sensitivity. These effects persist after 1 week in the IC group. (J Manipulative Physiol 301 Ther 2013;xx:1-10)

Evaluation of ultrasound, ultrasonophoresis and homeopathic mesotherapy on Cellulite treatment

Introduction: Cellulite is a complex architectural disorder with multifactorial etiologies that is prevalent in 98% of the women (1). Nowadays several aesthetic treatments are being used: surgical, cosmetic, physical, mechanical, and thermal. (2) Most treatments lack a substantial proof of efficacy. Objective: The purpose of this study was to test and evaluate the efficacy of Ultrasound, Homeopathic Ultrasonophoresis, and Homeopathic Mesotherapy versus control in cellulite in a population of women from ESTSP. Methods: Female volunteers (n=23), Caucasian, aged between 18-31 years, with BMI 19-27 kg/m2 with clinical cellulite gradation on the Cellulite Grading Scale of 1 to 4 were included in a control controlled study. Subjects were assigned in four different groups: Group I (Control, n=6), Group II (Ultrasound, (n=5), Group III (Homeopathic Ultrasonophoresis, n=6), Group IV (Homeopathic Mesotherapy, n=6). Groups II to IV were treated 3 times per week, for a total of 10 sessions. Cellulite gradation was evaluated at the beginning and the end of the trial by means of clinical photography, using a Canon IXUS 65 (6 mega pixels). For homeopathic treatments Dr. Reckeweg® Rekin® 59, 13 and 42 – Dietmed were used. The rating of perceived pain during Homeopathic Mesotherapy was evaluated by a visual analogic scale (VAS). The equipment Sonopuls 692, Enraf-Nonius was used for Ultrasound and Ultrasonophoresis treatments. Results:The higher number of participants with improvement in cellulite graduation occurred in group II (80%), followed group III (50%) and by group IV (33%). The group in which more changes in cellulite gradation occurred was group II, 20% of the individuals improved their score in 2 points. Results were statistically different between Group I and Group II, p=0,015. During the treatments of homeopathic mesotherapy the pain diminished 1 value in VAS scale. Discussion and Conclusion: Although all the three interventions groups were effective in the improvement of cellulite, as expected from previous works described in the literature, (2) only the ultrasound group was statistically different from control. These preliminary results point to the need of a new study using a higher number of participants and the same methodology.

Do Spirituality and Faith Make a Difference? Report from the Southern European Psycho-Oncology Study Group

OBJECTIVE: In the last decade, some attention has been given to spirituality and faith and their role in cancer patients' coping. Few data are available about spirituality among cancer patients in Southern European countries, which have a big tradition of spirituality, namely, the Catholic religion. As part of a more general investigation (Southern European Psycho-Oncology Study--SEPOS), the aim of this study was to examine the effect of spirituality in molding psychosocial implications in Southern European cancer patients. METHOD: A convenience sample of 323 outpatients with a diagnosis of cancer between 6 to 18 months, a good performance status (Karnofsky Performance Status > 80), and no cognitive deficits or central nervous system (CNS) involvement by disease were approached in university and affiliated cancer centers in Italy, Spain, Portugal, and Switzerland (Italian speaking area). Each patient was evaluated for spirituality (Visual Analog Scale 0-10), psychological morbidity (Hospital Anxiety and Depression Scale--HADS), coping strategies (Mini-Mental Adjustment to Cancer--Mini-MAC) and concerns about illness (Cancer Worries Inventory--CWI). RESULTS. The majority of patients (79.3%) referred to being supported by their spirituality/faith throughout their illness. Significant differences were found between the spirituality and non-spirituality groups (p ≤ 0.01) in terms of education, coping styles, and psychological morbidity. Spirituality was significantly correlated with fighting spirit (r = -0.27), fatalism (r = 0.50), and avoidance (r = 0.23) coping styles and negatively correlated with education (r = -0.25), depression (r = -0.22) and HAD total (r = -0.17). SIGNIFICANCE OF RESULTS: Spirituality is frequent among Southern European cancer patients with lower education and seems to play some protective role towards psychological morbidity, specifically depression. Further studies should examine this trend in Southern European cancer patients.