Showing papers in "The Clinical Journal of Pain in 1998"

Can we screen for problematic back pain? A screening questionnaire for predicting outcome in acute and subacute back pain.

Abstract: :Objectives:Because musculoskeletal pain is the second most frequent reason for seeking health care, the aims of this study were to determine the value of psychosocial variables in evaluating risk for developing chronic back pain problems and to develop a screening methodology to identify pa

Complex regional pain syndromes: Guidelines for therapy

Abstract: This report aims to present an orderly approach to the treatment of Chronic Regional Pain Syndrome (CRPS) types I and II through an algorithm. The central theme is functional restoration: a coordinated but progressive approach that introduces each of the treatment modalities needed to achieve both remission and rehabilitation. Reaching objective and measurable rehabilitation goals is an essential element. Specific exercise therapy to reestablish function after musculoskeletal injury is central to this functional restoration. Its application to CRPS is more contingent on varying rates of progress that characterize the restoration of function in patients with CRPS. Also, the various modalities that may be used, including analgesia by pharmacologic means or regional anesthesia or the use of neuromodulation, behavioral management, and the qualitatively different approaches that are unique to the management of children with CRPS, are provided only to facilitate functional improvement in a stepwise but methodical manner. Patients with CRPS need an individual approach that requires extreme flexibility. This distinguishes the management of these conditions from other well-described medical conditions having a known pathophysiology. In particular, the special biopsychosocial factors that are critical to achieving a successful outcome are emphasized. This algorithm is a departure from the contemporary heterogeneous approach to treatment of patients with CRPS. The underlying principles are motivation, mobilization, and desensitization facilitated by the relief of pain and the use of pharmacologic and interventional procedures to treat specific signs and symptoms. Self-management techniques are emphasized, and functional rehabilitation is the key to the success of this algorithm.

Self-reported sleep and mood disturbance in chronic pain patients.

Abstract: Objective: To evaluate the prevalence of self-reported sleep disturbance and its relationship to mood disturbance in chronic pain patients. Design and Setting: Survey of patients referred to a multidisciplinary outpatient pain clinic. Patients: The sample consisted of 105 consecutive patients (59 men and 46 women), with an average age of 41.5 (SD ± 13.4) years. Measures: Self-report measures of sleep disturbance and visual analog scales of mood disturbance (anxiety and depression) and pain experience (intensity and unpleasantness). Results: Patients were grouped according to whether they considered themselves "poor" (n = 68) or "good" (n = 37) sleepers. Poor sleepers reported more difficulties initiating and maintaining sleep and greater pain intensity and pain unpleasantness than did good sleepers. The two groups did not differ on measures of depressive or anxious mood. Conclusion: The results suggest that sleep disturbance is a prevalent complaint in chronic pain patients, but it is not always associated with an underlying mood disturbance.

Agreement Between Child and Parent Reports of Pain

Abstract: Objective: Parents are often the primary source of information regarding their children pain in both research and clinical practice. However, parent--child agreement on pain ratings has not been well established. The objective of the present study was to examine agreement between child- and parent-rated pain following minor surgery. Setting: Tertiary care children's hospital. Participants: A total of 110 children (56.4% male) aged 7-12 years undergoing surgery and their parents. Outcome Measures: Parents and children independently rated pain intensity by using a 7-point Faces Pain Scale on the day of the child's surgery and the following 2 days. Results: Correlations (both Pearson's and intraclass correlation coefficients) indicated a highly significant relationship between child and parent ratings. However, kappa statistics indicated only poor to fair agreement beyond chance. Parents tended to underestimate their children's pain on the day of surgery and the following day, but not on the second day following surgery. When children's and parents pain ratings for each of the 3 days were collapsed into a no-pain/low-pain group or a clinically significant pain group, kappa statistics indicated fair to good agreement, Parents demonstrated low levels of sensitivity in identifying when their children were experiencing clinically significant pain. Conclusions: Correlations between parent and child pain reports do not accurately represent the relationship between these ratings and in fact overestimate the strength of the relationship. Parents' underestimation of their child's pain may contribute to inadequate pain control.

Analysis of peak magnitude and duration of analgesia produced by local anesthetics injected into sympathetic ganglia of complex regional pain syndrome patients

Abstract: :Objective:Pain-relieving effects of lidocaine/bupivicaine local anesthetic (LA) and saline (S) block of sympathetic ganglia (stellate block, 4 patients; lumbar sympathetic block, 3 patients) were compared in 7 complex regional pain syndrome (CRPS) patients on a double-blind crossover basis

Evaluation of the Faces Pain Scale for Use with the Elderly

Abstract: :Objective:The specific objective for this research was to determine initial psychometric properties of the Faces Pain Scale (FPS) as a measure of pain intensity for use with the elderly.Design:The study was descriptive correlational in nature, with nonrandom sampling. A total sample of

Assessment of pain during medical procedures: a comparison of three scales.

Abstract: :Objective:Pain assessment is crucial to pain research. Knowledge about the strengths and weaknesses of pain measures is important to the continued advancement of our understanding of pain. The purpose of the present study was to compare the validity and utility of three measures of pain int

Symptoms of spinal stenosis do not improve after epidural steroid injection

Abstract: :Objective:This study was carried out to evaluate the therapeutic effect of epidural steroid injection on pseudoclaudication in patients with lumbar degenerative spinal canal stenosis.Design:Fifty-three patients who complained of pseudoclaudication of less than 20 m in walking distance w

IASP Diagnostic Criteria for Complex Regional Pain Syndrome: A Preliminary Empirical Validation Study

Abstract: :Objective:To assess the ability of the International Association for the Study of Pain Complex Regional Pain Syndrome (CRPS) diagnostic criteria and associated features to discriminate between CRPS patients and patients with painful diabetic neuropathy.Design:Prospective assessment of s

Comparison of integrated group therapy and group relaxation training for fibromyalgia

Abstract: :Objective:The efficacy of an integrated, psychological treatment program was tested in a controlled study involving 27 patients with chronic musculoskeletal pain (fibromyalgia).Design:The experimental treatment program consisted of instruction in various selfhelp techniques(e.g., cognitive

Efficacy and technical complications of long-term continuous intraspinal infusions of opioid and/or bupivacaine in refractory nonmalignant pain: a comparison between the epidural and the intrathecal approach with externalized or implanted catheters and infusion pumps

Abstract: OBJECTIVE To compare efficacies, failure rates, and technical complication rates of intraspinal treatments in patients with "refractory" nonmalignant pain conditions in relation to the approach (epidural/intrathecal), the drug (opioid/opioid-bupivacaine or bupivacaine), and the type of system used (externalized/internalized). In these comparisons, recent data from a companion paper (Nitescu et al., Clin J Pain 1998;14:17-28) were used as a reference to be compared with data from a literature review of different intraspinal treatment modalities in nonmalignant pain. DESIGN Prospective, cohort, nonrandomized, consecutive trial. SETTING Tertiary care center, institutional practice, hospitalized, and ambulatory care. PATIENTS Five groups according to treatment modality: (a) externalized, long-term intrathecal nylon catheters, connected to external, electronic infusion pumps (companion paper), n = 90; (b) internalized, long-term intrathecal catheters (Silastic) connected to implanted SynchroMed pumps, n = 330 (literature review); (c) externalized, "short-term" epidural catheters for "temporary" infusions, n = 565 (literature review); (d) externalized, long-term epidural catheters, n = 50 (literature review); (e) internalized, long-term epidural catheters, n = 111, connected to implanted systems: Port-A-Cath injection ports, n = 58; Infusaid pumps, n = 46; and SynchroMed pumps, n = 7 (literature review). INTERVENTIONS In reviewing the literature, we found 21 studies that reported on the intraspinal (epidural or intrathecal) administration of opioids with or without local anesthetics (usually bupivacaine). These studies were analyzed with respect to the rates of the variables satisfactory pain relief (efficacy), failures, and technical complications. A rate is the number of observations of a variable divided by the number of patients or the number of catheters or infusion systems, as logically indicated (e.g., the numbers of complications, such as epidural abscess and meningitis, were related to the number of patients and those of catheter occlusion or leakage to the number of the catheters). The variables were expressed as the means of the rates of a variable from studies belonging to various treatment modalities: approach (epidural vs. intrathecal), duration (short vs. long term), drugs administered intraspinally (opioid vs. opioid and/or local anesthetic), and type of infusion system (externalized vs. internalized). Further, the sums of all observations of one variable in different studies with various treatment modalities were related to the corresponding sums of the patients (alternatively, catheters or implanted devices). The proportions of these sums were tested for significance in relation to treatment modality. MAIN OUTCOME MEASURES Comparative rates of successful intraspinal treatment and its failures and complications. RESULTS (a) The intrathecal approach, compared with the epidural approach, was associated with higher rates of satisfactory pain relief for both externalized (86/90, 95% vs. 17/40, 42.5%, p < .0001) and internalized (295/336, 89% vs. 33/56, 59%, p < .0001) catheters; higher rates of treatment failures with externalized epidural catheters than with internalized intrathecal catheters (24/47, 51%, vs. 36/338, 11%, p < .0001); lower rates of treatment failures with internalized intrathecal catheters than with internalized epidural catheters (36/338, 11% vs. 29/76, 38%, p < .0001); higher rates of system replacement with internalized epidural catheters than with internalized intrathecal catheters (23/32, 72% vs. 6/49, 12%, p < .0001; higher rates of system removal with internalized epidural catheters than with internalized intrathecal catheters (22/49, 45% vs. 5/49, 10%, p < .001); higher rates of catheter-related complications with epidural than with intrathecal catheters (dislodgement 13/126, approximately 10% vs. 6/150, 4%, p < .05; leakage 5/51, approximately 10% vs. 1/116, 0.9%, p < .05; obstruction 2

Controlled trial of Japanese acupuncture for chronic myofascial neck pain: assessment of specific and nonspecific effects of treatment.

Abstract: :Objective:This article examines the specific and nonspecific effects of Japanese acupuncture on chronic myofascial neck pain in a randomized single-blind trial.Design:Forty-six patients were randomly assigned to receive relevant acupuncture, irrelevant acupuncture, or no-acupuncture control

Personality assessment of patients with complex regional pain syndrome type I.

Abstract: Objective: There is controversy regarding the importance of psychological/psychiatric factors in the development of the Complex Regional Pain Syndrome (CRPS). Our objective was to determine whether CRPS type I patients were psychiatrically different from other chronic pain patients, with particular attention to personality pathology. Design: A standardized clinical assessment of all major psychiatric categories, including personality disorders, was performed on 25 CRPS type I patients and a control group of 25 patients with chronic low back pain from disc-related radiculopathy. Measures: Both sections of the Structured Clinical Interview for the Diagnostic and Statistical Manual (3rd ed., rev.) and the visual analog scale. Results: Both groups were similar in terms of pain intensity and duration. Statistical analysis showed both groups to have a significant amount of major psychiatric comorbidity, in particular major depressive disorder, and a high incidence of personality disorders. Therefore, intense chronic pain was associated with significant psychiatric comorbidity in both groups and in similar proportions. Conclusion: The high incidence of personality pathology in both groups may represent an exaggeration of maladaptive personality traits and coping styles as a result of a chronic, intense, state of pain.

Stressful life events and psychological dysfunction in Complex Regional Pain Syndrome type I.

Abstract: Objective: To determine to what extent stressful life events and psychological dysfunction play a role in the pathogenesis of Complex Regional Pain Syndrome type I (CRPS). Design: A comparative study between a CRPS group and a control group. Stressful life events and psychological dysfunction evaluation was performed with a life event rating list and the Symptom Checklist-90 (SCL-90). Setting: A university hospital. Subjects: The CRPS group consisted of 24 patients with a history of upper extremity CRPS of less than 3 months. The control group consisted of 42 hand pathology patients waiting for elective hand surgery within the next 24 hours. Main Outcome Measures: Stressful life event rating was measured using the Social Readjustment Rating Scale. Psychological dysfunction was measured using the SCL-90. Results: Stressful life events were experienced by 19 patients (79.2%) in the CRPS group and by 9 patients (21.4%) in the control group. This difference was significant. Testing of psychological dysfunction (SCL-90) in CRPS patients and the control group demonstrated some significant differences: male patients were more anxious than male controls; female patients were statistically more depressed, had feelings of inadequacy, and were emotionally less stable than female controls. In multivariate analysis, no significant differences were found across gender, age, or gender X group interactions. Of the SCL-90 dimensions, only insomnia correlated with the experienced stressful life events. Conclusion: Stressful life events are more common in the CRPS group, which indicates that there may be a multiconditional model of CRPS. The experience of stressful life events besides trauma or surgery are risk factors, not causes, in such a model.

Children's self-report of postoperative pain intensity and treatment threshold: determining the adequacy of medication

Abstract: Objective: Many studies have shown indirectly that children are undermedicated for postoperative pain. In this study, we used a pain self-report scale to examine this more directly. Methods: We performed a survey with 63 children who were postoperative from minor, uncomplicated surgery. Using the self-report scale, we determined the pain intensity at time of interview, the worst pain experienced postoperatively, and the intensity of pain that the subject felt to warrant pharmacologic intervention (the "treatment threshold"). A subgroup of 48 children was asked to indicate on the scale the intensities that represented mild, moderate, and severe pain. Results: Mean (SD) pain at time of interview was 1.9 (1.7) on the 0-6 scale. Mean worst postoperative pain was 3.8 (1.8). The mean for treatment threshold was 3.2 (1.8). We found gender differences in regard to the judgments about the intensities representing mild, moderate, and severe pain, with girls rating these lower than did boys. Twenty-five percent of subjects reported pain that was mild, 29% reported moderate pain, and 46% reported severe pain. Conclusions: We found that 51% of subjects were undermedicated for postoperative pain, being required to suffer pain that was above their treatment threshold. By determining each subject's treatment threshold and estimate of moderate pain, we have better defined the intensity at which pain becomes clinically significant.

A simultaneous comparison of three neonatal pain scales during common NICU procedures.

Abstract: Objective: This study evaluated neonatal pain scales during procedures commonly performed in a neonatal intensive care unit. Design: Evaluated were the Neonatal Infant Pain Scale (NIPS), the Comfort scale, and a new scale known as the Scale for Use in Newborns (SUN). Four procedures were scored: intubation, intravenous catheter insertion, endotracheal tube suctioning, and diaper changes. Scoring was done before, during, and after each procedure. Thirty-three patients were tested during 68 procedures with 1,428 scale scores. Results: All scales demonstrated significant changes. In before-versus-during for each procedure, the increase in pain scale score was significant for the NIPS, Comfort scale, and SUN. All three scales also demonstrated a return to baseline (before-vs.-after) for the four procedures, except for the Comfort scale, which remained elevated (p 2.5 kg on sedative or analgesic medications appeared to have procedure-related accentuation and sustained elevation in scale scores, whereas swaddling seemed to provide little added benefit. Conclusions: The pain scale scores identify changes in an infant's behavior/physiologic state. It is unclear whether these changes are totally "pain specific." In comparing the three scales, the SUN overall was a preferable tool because of its ease of use, scale symmetry, and scoring consistency.

Social context of pain in children with Juvenile Primary Fibromyalgia Syndrome: parental pain history and family environment.

Abstract: Objective: The purpose of this study was to describe parental pain history and the family environment as it relates to the functional status of children with Juvenile Primary Fibromyalgia Syndrome (JPFS) Design and Outcome Measures: Twenty-nine parents of children with JPFS completed a pain history questionnaire, Von Korff Chronic Pain Grading system, and the Family Environment Scale (FES) Twenty-one adolescents with JPFS completed the FES, the Visual Analogue Scale for Pain, the modified Fibromyalgia Impact Questionnaire for Children, the Arthritis Impact Measurement Scales, and the Symptom Checklist-90-Revised Correlational analyses were performed Results: Parents of children with JPFS reported multiple chronic pain conditions, including but not limited to fibromyalgia Parental pain history and the family environment correlated with the health status of adolescents with JPFS Children with JPFS perceived the family environment as significantly more cohesive than did their parents Greater incongruence between parent and child responses on the FES positively correlated with greater impairment Conclusions: These results suggest that family environment and parental pain history may be related to how children cope with JPFS Behavioral interventions targeting the family may improve the long-term functional status of children with JPFS

Review of the effectiveness of capsaicin for painful cutaneous disorders and neural dysfunction.

Abstract: :Background:Topical capsaicin is known to be a safe and effective pain management adjunct for rheumatoid arthritis, osteoarthritis, neuralgias, and diabetic neuropathy. However, studies and case reports in the literature have indicated that other conditions may also benefit from capsaici

Continuous infusion of opioid and bupivacaine by externalized intrathecal catheters in long-term treatment of "refractory" nonmalignant pain.

Abstract: OBJECTIVE To explore the possibility of obtaining pain relief by continuous intrathecal infusion of bupivacaine and opioid in patients with intractable nonmalignant pain. DESIGN Prospective, cohort, nonrandomized, consecutive trial. SETTING Tertiary care center, institutional practice, hospitalized, and ambulatory care. PATIENTS A total of 90 patients, 40 men and 50 women, 20 to 96 years old (median, 70 years), with various nonmalignant "refractory" pain conditions lasting for 0.3 to 50 years (median, 3 years) with nociceptive (n = 9), neurogenic/neuropathic (n = 17), and mixed pain (n = 64) were consecutively included in the study when (a) the pain dominated their lives totally, (b) other methods failed to provide acceptable pain relief, and (c) unacceptable side effects from opioids had occurred. Moribund patients and those with overt psychoses at the time of the assessment were excluded from the study. INTERVENTIONS (a) Insertion of externalized, tunnelled intrathecal catheters (101 in 90 patients). (b) Intrathecal infusion of opioid (morphine 0.5 mg/ml, or buprenorphine 0.015 mg/ml, and/or bupivacaine 4.75-5.0 mg/ml) from external electronic pumps was started in the operating room at a basic rate of 0.2 ml/hour, with optional bolus doses (0.1 ml 1-4 times/hour) by patient-controlled analgesia (PCA). Thereafter, the daily volumes were tailored to give the patients satisfactory to excellent (60-100%) pain relief, with acceptable side effects from the infused drugs, by increase or decrease of the basic rates and/or of the bolus doses, and their timing. (c) Supervision of the patients for 24 hours after catheterization in the postoperative ward. (d) Daily phone contact with the patients, their families, or the nurses in charge. (e) The patients had ad libitum access to nonopioid analgesics/sedatives and to opioids administered by various routes, until they obtained satisfactory pain and anxiolytic relief. MAIN OUTCOME MEASURES (a) Pain intensity (visual analog scores 0-10) and pain relief (0-100%). (b) Daily dosages (opioid administered by intrathecal and other routes, and intrathecal bupivacaine). (c) Scores (0-5) of nonopioid analgesics, gait and ambulation, duration of nocturnal sleep, and (d) rates of adverse effects. RESULTS During the intrathecal period [range, 3-1,706 days; median, 60 days; totaling 14,686 days, 7,460 (50% of which were spent at home)], 86 patients (approximately 95%) obtained acceptable (60-100%) pain relief. The nocturnal sleep duration increased from <4 to 7 hours (median values), nonopioid analgesic and sedative daily consumption became approximately two times lower, whereas the gait ability and ambulation patterns remained practically unchanged. Five patients still had ongoing treatment after durations of 30 to 1,707 (median, 206) days at the close of the study. In the remaining 85 patients, the intrathecal treatment was terminated because of patients' death (n = 23), replacement of the intrathecal treatment by dorsal column stimulation (n = 1), pain resolution (n = 32), refusal to continue the intrathecal treatment (n = 19), lack of cooperation due to delirium or to manipulation of the pump (n = 8), and loss of efficacy of the intrathecal treatment (n = 2). Thus, in the long run, the intrathecal treatment failed in 29 of the 85 patients with terminated treatment (34%). The principal side-effects and complications, except those attributed to the dural puncture, the equipment, and the long-term catheterization of the subarachnoid space, which are presented separately, were severe bradypnea (n = 1), transient paresthesiae (n = 26), short-lasting pareses (n = 16), temporary urine retention (n = 34), episodic orthostatic arterial hypotension (n = 11), and attempted suicide (n = 5, 3 of which were successful). No neurologic sequelae or death could be attributed to the intrathecal procedure. (ABSTRACT TRUNCATED)

Complex regional pain syndrome I (CRPS I): prospective study and laboratory evaluation.

Abstract: Objective: To relate clinical features to autonomic laboratory indices used in the diagnosis of Complex Regional Pain Syndrome type I (CRPS I) (reflex sympathetic dystrophy) to generate improved diagnostic criteria. Description: CRPS I is a chronic pain syndrome, characterized by diffuse limb pain with allodynia and prominent vasomotor and sudomotor dysfunction. Methods: We conducted a prospective study on 102 patients referred for possible CRPS I. These patients completed a structured questionnaire and underwent neurologic examination, with special attention to the evaluation of clinical features of vasomotor, sudomotor, motor, and sensory, including pain, dysfunction. All patients were tested using a standard autonomic protocol that compared side-to-side skin temperature, resting sweat output, and quantitative sudomotor axon reflex test (QSART) measurements. Composite autonomic clinical (CRPS-Sx) and laboratory (CRPS-LAB) scores were defined. The clinical (subjective and objective) and the laboratory data were analyzed using Pearson's s correlation analysis and Bonferroni's probability value to assess concordance and their value in correctly diagnosing CRPS I. Results : All cases occurred after limb injury. One-third of cases did not fulfill out criteria of CRPS I. Highly significant correlations (p <.001) were found among certain clusters of symptoms and signs that shared unifying pathophysiologies. CRPS-Sx correlated with CRPS-LAB (p =.035). The indices that correlated most reliably with clinical data and with each other were RSO, QSART, and skin temperature reductions. Conclusion: Clinical and autonomic laboratory probability scores correlate in an internally consistent manner. Both CRPS-Sx and CRPS-LAB are sensitive and reliable tools to formulate a correct diagnosis of CRPS I and can be combined to provide an improved set of diagnostic criteria for CRPS I.

Comparison of the effects of perceived self-efficacy on coping with chronic cancer pain and coping with chronic low back pain.

Abstract: :Objective:The purposes of this study were to explore the differences between chronic cancer pain and chronic low back pain with respect to (a) the use of coping strategies to manage pain and (b) the relationship between self-efficacy for attenuating pain and pain outcomes.Design:Descriptive

Chest tube insertion: a prospective evaluation of pain management.

Abstract: Objective: To evaluate pain associated with chest tube insertion in a group of patients with malignant pleural effusions Design: Prospective case series Setting: Acute care cancer center in an academic institution Patients: Fifty-two patients with symptomatic malignant pleural effusions Twenty-six evaluated by conventional approach to chest tube insertion (group 1), 26 evaluated after institution of a new chest tube protocol (group 2) Interventions: A new protocol was designed to improve pain control during chest tube insertion The protocol included improved housestaff and nursing education, premedication, proper insertion techniques, and more liberal and precise delivery of local anesthetic Outcome Measures: Both groups were evaluated by a verbal self-report scale (1-10) to assess pain and anxiety Results: The mean pain rating in group 1 was 62 (± 076) compared with 37 (± 56) in group 2 (p < 001) In group 1, pain or anxiety was 9 or 10 in 12 of 26 on a scale of 1 to 10, compared with 2 of 26 in group 2 (p < 0001) Anxiety rating was 45 (± 072) in group 1 compared with 15 (± 054) in group 2 (p < 001) Conclusions: Chest tube insertion was associated with an unacceptably high level of pain and anxiety in our hospital A new protocol, including housestaff education and changes in nursing policies, technical aspects, local anesthetic dose and delivery, and pre-medication, allowed us to approach the goal of a painless chest tube insertion

Homeopathic Arnica 30x is ineffective for muscle soreness after long-distance running: a randomized, double-blind, placebo-controlled trial.

Abstract: :Objective:To determine whether homeopathic Arnica 30× can reduce muscle soreness following long-distance running more than a placebo.Design:Randomized, double-blind placebo-controlled trial.Setting:Long-distance runs taking place in the community.Subjects:A total of 519 runners anticipating

Central nervous system abnormalities in complex regional pain syndrome (CRPS): clinical and quantitative evidence of medullary dysfunction.

Abstract: Objective Sensory and motor abnormalities are common among patients with complex regional pain syndrome (CRPS). The purpose of the present study was to define and characterize these abnormalities and to develop a hypothesis regarding the area of the central nervous system from which they derive. Design Data were acquired from study subjects using clinical examination and quantitative assessment of neurological function. Subjects were divided into four groups. CRPS patients were differentiated into two groups based on the presence or absence of sensory deficit on the face to clinical examination. The other two groups were composed of patients with other chronic pain syndromes and normal individuals without chronic pain or disability. Clinical and quantitative data were compared between groups. Patients One hundred forty-five CRPS patients, 69 patients with other pain conditions, and 26 normal individuals were studied. Results A high incidence of trigeminal hypoesthesia was observed in CRPS patients. CRPS patients with trigeminal hypoesthesia manifested bilateral deficits of sensory function, with a predominant hemilateral pattern. These patients also manifested bilateral motor weakness with a more prominent hemiparetic pattern. Both sensory and motor deficits were greatest ipsilateral to the painful side of the body. These features differed significantly from those of CRPS patients lacking clinical trigeminal deficit, other pain patients, and normals. A lower cranial nerve abnormality (sternocleidomastoid weakness) and a myelopathic feature (Hoffman's reflex) were more common in CRPS patients with trigeminal hypoesthesia. Conclusions Nearly half of CRPS patients had abnormalities of spinothalamic, trigeminothalamic, and corticospinal function that may represent dysfunction of the medulla. One-third of the remaining CRPS patients had neuroimaging evidence of spinal cord or brain pathology. The majority of CRPS patients in this study have measurable abnormalities of the sensory and motor systems or neuroimaging evidence of spinal cord or brain dysfunction.

Long-term transcutaneous electrical nerve stimulation (TENS) use: impact on medication utilization and physical therapy costs.

Abstract: Objective A study was conducted to assess a variety of treatment outcomes in long-term users of transcutaneous electrical nerve stimulation (TENS) who suffer from chronic pain. Key components of the study examined the effects of long-term TENS therapy on pain-related medications and physical/occupational therapy (PT/OT) use. Design From a population of 2,(X)3 chronic pain patients (CPPs) who acquired a TENS device (Epix XL, Empi, Inc., St. Paul, MN, U.S.A.) for pain management, a randomly selected sample of 376 patients who used TENS were interviewed by telephone by an independent research firm. The survey assessed a variety of outcome variables including changes in medication use, number of pain-related medications, and use of PT/OT prior to TENS and after a minimum 6 months of TENS treatment. The data were subjected to a paired t test analysis. A cost simulation model was then applied to the medication and PT/OT data. Results The mean duration of pain, for which TENS was prescribed, was 40 +/- 60 months. As compared with the period prior to TENS use, this long-term TENS user group reported a statistically significant reduction in the following types of pain medications: opiate analgesics, tranquilizers, muscle relaxants, nonsteroidal anti-inflammatory drugs (NSAIDs), and steroids. PT/OT use was also significantly reduced. Cost simulations of pain medications and PT/OT are presented. Conclusions Long-term use of TENS is associated with a significant reduction in the utilization of pain medication and PT/OT. In this study population, cost simulations of medication and PT/OT indicate that with long-term TENS use, costs can be reduced up to 55% for medications and up to 69% for PT/OT. The potential for TENS associated improvement, combined with reduced medication-related complications and costs, are important points that clinicians should consider when constructing a treatment plan for chronic pain patients. Finally, cost simulation techniques provide a useful tool for assessing outcomes in pain treatment and research.

Percutaneous electrical nerve stimulation (PENS): a complementary therapy for the management of pain secondary to bony metastasis.

Abstract: Objective: To evaluate the use of a novel nonpharmacologic analgesic therapy known as percutaneous electrical nerve stimulation (PENS) in the management of opioid-resistant cancer pain. Design: PENS therapy was administered to three cancer patients on three or more occasion using acupuncturelike needle probes that were stimulated for 30 minutes at frequencies of 4-100 Hz. Results: Two of the three patients achieved good to excellent pain relief that lasted 24-72 hours after each treatment session. Conclusion: PENS therapy is a useful supplement to opioid analgesics for the management of pain secondary to bony metastasis in terminal cancer patients.

Oral methadone for the treatment of severe pain in hospitalized children: a report of five cases.

Abstract: OBJECTIVE Pain relief is still inadequate in many hospitalized patients, especially children in whom suboptimal use of analgesic drugs is still common. In the past 2 years, oral methadone has been used extensively in our institution for treating children with persistent pain from cancer, burns, or trauma who were capable of oral intake and whose pain was not relieved by nonopioid medications. SETTING Tertiary university hospital. PATIENTS Of the 70 children treated thus far with oral methadone, five are described in the present report. MAIN OUTCOME MEASURE Pain relief, acceptability, and side effects of oral methadone in children with pain. RESULTS Treatment with oral methadone (0.1% in 10% glucose, dose range of 0.2-0.6 mg/kg/day) for time periods of up to 6 weeks resulted in a rapid onset and stable pain relief, with no major side effects. No adverse responses were encountered after discontinuation of treatment. In three of the children, a parent-controlled analgesia regimen was successfully employed. CONCLUSIONS Oral methadone can be recommended for babies and children who have severe pain that is not alleviated by nonopioid medications and who are capable of oral intake.

Stiff upper lip: coping strategies of World War II veterans with phantom limb pain.

Abstract: Objective: Study of coping with phantom pain in nonclinical war veteran amputees. Design: Semistructured interview with amputees in their home setting. Setting: Residential home for war veteran amputees or respondents' own homes. Patients: Amputee veterans of World War II with phantom pain. Outcome Measures: Pain (McGill Pain Questionnaire) and pain history, coping (daily coping; Stone and Neale, J Pers Soc Psychol 1984;46:892-906), size of social network, and quality of war memories. Results: No differences in pain or coping were associated with place of residence (and prevalence of cues) or social networks; war memories appeared not to be associated with availability of cues, whether media coverage or other amputees. There was some association between the emotional tone of war memories and pain intensity. Veteran amputees were in general accepting of high levels of pain and made little use of medical resources, relating that to past experience of their pain being dismissed. Conclusion: Coping with phantom pain in war veteran amputees is predominantly silent acceptance of the pain, with little use of social support however available, and rare recourse to medical help, based on past unhelpful experience. Pain and mood appeared to be unrelated to specific war cues, but higher pain scores were reported by those with unhappier war memories.