Paroxysmal head pain with backward radiation: will epicrania fugax go in the opposite direction?

Epicrania fugax (EF) has been recently described as a paroxysmal head pain starting in a focal cranial area of the posterior scalp and rapidly spreading forward to the ipsilateral eye or nose along a linear or zigzag trajectory. Here we report two patients presenting with the same clinical features, except for the starting site and the direction of the pain. Unilateral pain paroxysms occurred on either side of the head, with a quick backward radiation along a linear trajectory. The pain always stemmed from a particular point located at the fronto-parietal region, and reached the parieto-occipital region in several seconds. The symptoms did not fit any of the acknowledged headaches and neuralgias, and might correspond to a reverse variant of EF.     

Increased mechanosensivity of the greater occipital nerve in subjects with side-dominant head and neck pain – a diagnostic case-control study

Objectives: To investigate differences in pressure pain thresholds (PPTs) and longitudinal mechanosensitivity of the greater occipital nerve (GON) between patients with side-dominant head and neck pain (SDHNP) and healthy controls. Evaluation of neural sensitivity is not a standard procedure in the physical examination of headache patients but may influence treatment decisions.

Methods: Two blinded investigators evaluated PPTs on two different locations bilaterally over the GON as well as the occipitalis longsitting-slump (OLSS) in subjects with SDHNP (n = 38)) and healthy controls (n = 38).

Results: Pressure pain sensitivity of the GON was lower at the occiput in patients compared to controls (p = 0.001). Differences in pressure sensitivity of the GON at the nucheal line, or between the dominant headache side and the non-dominant side were not found (p > 0.05). The OLSS showed significant higher pain intensity in SDHNP (p < 0.001). In comparison to the non-dominant side, the dominant side was significantly more sensitive (p = 0.004).

Discussion: Palpation of the GON at the occiput and the OLSS may be potentially relevant tests in SDHNP. One explanation for an increased bilateral sensitivity may be sensitization mechanisms. Future research should investigate the efficacy of neurodynamic techniques directed at the GON.

Level of Evidence: 3b.     

Measuring pain in non-verbal critically ill patients: which pain instrument?

Pain is experienced by many critically ill patients. Although the patient’s self-report represents the gold-standard measure for pain, many patients are unable to communicate in the ICU. In this commentary, we discuss the study findings comparing three objective scales for the assessment of pain in non-verbal patients and the importance of the tool selection process.In the previous issue of Critical Care, Chanques and colleagues [1] evaluate the psychometric properties of three behavioral pain scales validated for use in non-communicative critically ill patients. The authors compare two scales recommended in the practice guidelines for pain management of adult ICU patients by the Society of Critical Care Medicine [2] - that is, the Behavioral Pain Scale (BPS) [3] and the Critical-Care Pain Observation Tool (CPOT) [4] - and a routine scale in use at the host institution, the Non-Verbal Pain Scale (NVPS) [5].Assessing pain in non-communicative adult patients in the ICU must rely on the observation of behavioral indicators of pain. Selection of pain assessment tools in clinical practice must be done with rigor. Indeed, an assessment tool can be shown to be valid only for a specific purpose and a given group of respondents and context of care. All steps of scale development are important. The first step, selection of items and scale scoring, can be done by using a combination of various strategies, including an in-depth literature review, consultation of end users (for example, ICU clinicians and patients), and direct clinical observation and other sources. Content validation is a method of examining the content and relevance of the items that are useful for selecting or revising them. Once developed, reliability and validity of the scale use must be tested with the targeted patient group [6]. Reliability refers to the overall reproducibility of scale scores. The examination of inter-rater reliability is crucial to determine whether two or more trained raters reach similar scores using the same scale for the same patient and at the same time. Validity refers to the interpretation of the pain scale scores and its ability to indicate that the individual is actually in pain. As behavioral pain scales aim to detect the presence of significant pain, the examination of criterion and discriminant validation is necessary. Criterion validation allows the comparison between behavioral scores and the gold standard (that is, the patient’s self-report of pain). Discriminant validation refers to the ability of the pain scale to discriminate between conditions or procedures known to be painful or not and its ability to detect significant changes over time (responsiveness). Because validation is an ongoing process, it is imperative that its use be evaluated by independent groups of caregivers who were not involved in its development, with various ICU patient groups or with a translated version of the scale. Finally, the ease of their implementation in ICU settings and the impact of their use on pain management practices and patient outcomes must be evaluated.Evaluation of the psychometric properties of behavioral pain scales in ICU patients unable to self-report has been recently performed [7,8]. Of the eight pain scales developed for adult ICU patients, the BPS and the CPOT were found to be the most valid and reliable. The present study [1] is the first to compare psychometric properties of these two pain scales in addition to the NVPS, at rest and during noxious (for example, turning and endotracheal suctioning) and non-noxious (for example, simple repositioning) procedures. Both the BPS and the CPOT showed the strongest psychometric properties in both intubated and non-intubated patients in comparison with the NVPS. These findings add arguments to the recommendations for the use of these two pain scales [2].What are the next steps in relation to pain assessment in the ICU? First, there is a clear need to better evaluate the impact of pain assessment and management on patient outcomes. Few studies have shown that evaluating pain was associated with positive outcomes such as a shorter duration of mechanical ventilation and ICU length of stay and reduced adverse events [9-11]. Whether better management in the ICU may lead to reducing long-term negative consequences such as chronic pain and symptoms of post-traumatic stress disorder remains largely unknown. Second, there is a need for valid physiologic measures of pain, especially in ICU patients too sedated or paralyzed in whom behavioral responses cannot be observed. The use of pupillary reflex dilation has shown some promising findings [12-14]. Meanwhile, the best alternative measure to assess pain in non-verbal patients remains the use of behavioral scales.Assessing pain in non-communicative ICU patients is challenging. The BPS and the CPOT have shown the strongest psychometric properties for this purpose. These scales should be incorporated into pain management protocols to target the desired levels of analgesia in order to optimize inter-professional practices and to achieve better patient outcomes.     

What decline in pain intensity is meaningful to patients with acute pain?

Despite widespread use of the 0-10 numeric rating scale (NRS) of pain intensity, relatively little is known about the meaning of decreases in pain intensity assessed by means of this scale to patients. We aimed to establish the meaning to patients of declines in pain intensity and percent pain reduction. Upon arrival to the postanesthesia care unit, postsurgical patients rated their baseline pain intensity on both a 0-10 NRS and on a 4-point verbal scale. Patients whose NRS was higher than 4/10 received intravenous opioids until their pain intensity declined to 4/10 or lower. During opioid titration, patients were asked every 10 min to rate pain intensity on a NRS and to indicate the degree of pain improvement on a 5-point Likert scale from 'no improvement' to 'complete pain relief'. Seven hundred adult patients were enrolled. For patients with moderate pain, a decrease of 1.3 units (20% reduction) corresponded to 'minimal' improvement, a decrease of 2.4 (35% reduction) to 'much' improvement, a decrease of 3.5 units (45% reduction) corresponded to 'very much' improvement. For patients with severe pain, the decrease in NRS pain score and the percentage of pain relief had to be larger to obtain similar degrees of pain relief. The change in pain intensity that is meaningful to patients increases as the severity of their baseline pain increases. The present findings are applicable in the clinical setting and research arena to assess treatment efficacy.     

Does midazolam enhance pain control in prehospital management of traumatic severe pain?

Purpose

Midazolam comedication with morphine is a routine practice in pre and postoperative patients but has not been evaluated in prehospital setting. We aimed to evaluate the comedication effect of midazolam in the prehospital traumatic adults.

Methods

A prehospital prospective randomized double-blind placebo-controlled trial of intravenous morphine 0.10 mg/kg and midazolam 0.04 mg/kg vs morphine 0.10 mg/kg and placebo. Pain assessment was done using a validated numeric rating scale (NRS). The primary end point was to achieve an efficient analgesic effect (NRS ≤ 3) 20 minutes after the baseline. The secondary end points were treatment safety, total morphine dose required until obtaining NRS ≤ 3, and efficient analgesic effect 30 minutes after the baseline.

Findings

Ninety-one patients were randomized into midazolam (n = 41) and placebo (n = 50) groups. No significant difference in proportion of patients with a pain score ≤ 3 was observed between midazolam (43.6%) and placebo (45.7%) after 20 minutes (P = .849).Secondary end points were similar in regard with proportion of patients with a pain score ≤ 3 at T30, the side effects and adverse events except for drowsiness in midazolam vs placebo, 43.6% vs 6.5% (P < .001). No significant difference in total morphine dose was observed, that is, midazolam (14.09 mg ± 6.64) vs placebo (15.53 mg ± 6.27) (P = .315).

Conclusions

According to our study, midazolam does not enhance pain control as an adjunctive to morphine regimen in the management of trauma-induced pain in prehospital setting. However, such midazolam use seems to be associated with an increase in drowsiness.     

Does pain mediate the pain interference with sleep problem in chronic pain? Findings from studies for management of diabetic peripheral neuropathic pain with duloxetine

Although sleep problems are common in patients with chronic pain, it is unclear whether pain mediates (causes) impaired sleep. The relationship between pain and sleep has been difficult to investigate because of the potential confounds of depression and somnolence. This report used clinical trials data for duloxetine in the management of diabetic peripheral neuropathic pain (DPNP) to investigate the direction of this association. Data were pooled from three double-blind, randomized, placebo-controlled, 12-week trials of patients with DPNP without mood disorder (n = 1,139). DPNP patients reporting somnolence and those who were receiving sedating concomitant medications were removed from the analyses (n = 93). Efficacy measures included weekly mean scores for average daily pain severity, night pain severity, and pain interference with sleep. Duloxetine at 60 and 120 mg per day separated from placebo for average pain and night pain improvement as early as one week after treatment began, whereas sleep interference improvement separated from placebo at the three visits it was assessed (Weeks 4, 8, and 12). Change in sleep interference was moderately to strongly correlated (P < 0.001) with changes in average pain (r = 0.46) and nighttime pain severity (r = 0.53). These results confirm the association between the improvement in daily pain and nighttime pain, and improvement in sleep interference for a large population without depression or somnolence. Although this association cannot establish causality, these results provide some evidence for the possibility that pain may mediate the sleep problem associated with DPNP and perhaps chronic pain in general.     

Impaired trunk muscle function in sub-acute neck pain: etiologic in the subsequent development of low back pain?

Low back pain (LBP) and neck pain are associated with dysfunction of the trunk and neck muscles, respectively, and may involve common or similar mechanisms. In both cases, dysfunction may compromise spinal control. Anecdotally, neck pain patients commonly develop LBP. This study investigated the possibility that trunk muscle function is compromised in neck pain patients and that compromised trunk muscle function is associated with increased risk of LBP. Fifty-four neck pain patients and 52 controls were assessed on an abdominal drawing-in task (ADIT) and on self-report tests. Performance on the ADIT was able to detect neck pain patients with 85% sensitivity and 73% specificity. Catastrophizing and McGill pain questionnaire (affective) scores were higher in patients with an abnormal task response than in patients with an uncertain or normal response, although the self-report data did not predict task performance. Fifty subjects from each group were contactable by telephone at 2 years. They were asked whether they had experienced persistent or recurrent LBP since the assessment. Subjects (patients and controls) who obtained an abnormal response on the ADIT were 3 to 6 times more likely to develop persistent or recurrent LBP than those who obtained an uncertain or normal response. ADIT performance was the main predictor of development of LBP in patients. The results suggest that reduced voluntary trunk muscle control in neck pain patients is associated with an increased risk of developing LBP.     

Upper extremity pain in paraplegia北大核心CSCD

BACKGROUND AND OBJECTIVE As upper extremity (UE)function is critical to those with decreased function of the lower extremities,this study investigated the prevalence and patterns of pain in the UE among individuals with spinal cord injury (SCI). METHODS A university healthcare system database was searched for patients with accident related paraplegia,during a period spanning 17 years.Information regarding the level of injury was obtained.A questionnaire was sent with queries regarding medical status,demo- graphics and pain.The data were reviewed to determine relationships of pain with age,gender,time since injury,completeness of injury and neurologic level of injury (NLI).     

Can the LANSS scale be used to classify pain in chronic cancer pain trials?

Purpose

The Leeds Assessment of Neuropathic Symptoms and Signs (LANSS) scale was developed to differentiate pain of predominantly neuropathic or nociceptive origin. The aim of this study was to determine whether the LANSS scale was an appropriate tool to classify pain in a trial of patients with advanced cancer and chronic refractory pain.

Methods

Clinician assessment of pain type (neuropathic or nociceptive) was used to determine the sensitivity and specificity of LANSS scores in 112 trial participants. Those classified as "mixed" or of uncertain aetiology were excluded. We undertook several analyses in an attempt to improve the LANSS scale and better diagnose pain type for our specific dataset.

Results

There was strong association between the LANSS score and a diagnosis of neuropathic versus nociceptive pain, p?<?0.001. When the clinical assessment was compared with the LANSS scale, the overall accuracy was 94 % (79/84). The 5 false negatives and no false positives resulted in a sensitivity of 0.86 (0.70, 0.95), specificity of 1 (0.93, 1), positive predictive value of 1 (0.88, 1) and negative predictive value of 0.91 (0.80, 0.97). The negative likelihood ratio was 0.14 (0, 0.32). The scale had good discriminant and construct validity. Reliability was assessed via internal consistency with Cronbach's α?=?0.76, similar to that of the original validation study (α?=?0.74). None of the new scales developed was better at differentiating pain type.

Conclusions

The LANSS scale predicted well for pain type in a cancer population and is a useful tool for classifying pain in cancer pain trials.     

Is temporomandibular pain in chronic whiplash-associated disorders part of a more widespread pain syndrome?

OBJECTIVES: The prevalence of temporomandibular disorders in patients with chronic whiplash-associated disorder is a controversial issue that may be influenced by the widespread pain character and psychologic distress frequently observed in patients with chronic pain. The aim of this study was to determine the prevalence of temporomandibular disorder pain, widespread pain, and psychologic distress in persons with chronic whiplash-associated disorder pain, using a controlled, single blind study design. The prevalence of temporomandibular disorder pain in the chronic whiplash-associated disorder pain group was compared with 2 control groups: a chronic neck pain group and a no neck pain group. METHODS: From 65 persons, a standardized oral history was taken, a physical examination of the neck and the masticatory system was performed, widespread pain was investigated by tender point palpation, and psychologic distress was measured with a questionnaire (SCL-90). Because the recognition of temporomandibular disorder pain and neck pain remains a matter of debate, 3 well-defined classification systems were used: one based on the oral history, a second on a combination of oral history and pain on active movements and palpation, and a third one based on a combination of oral history and function tests. RESULTS: Irrespective of the classification system used, the chronic whiplash-associated disorder pain group more often suffered from temporomandibular disorder pain (0.001相似文献   

Do within-session changes in pain intensity and range of motion predict between-session changes in patients with low back pain?

Physiotherapists commonly use post-treatment changes in a patient's pain intensity and range of motion to guide treatment selection and predict possible longer-term outcomes. This study tested the validity of this practice by evaluating the predictive value of within-session changes in pain intensity and range of motion in 53 patients with low back pain. Pain intensity and range of motion measurements of spinal flexion, extension, lateral flexion, and straight-leg-raise were taken by the patient's therapist before and after one treatment session, and were repeated by a blinded therapist at the beginning of the patient's subsequent treatment session. Regression analysis revealed that the strength of association between within-session and between-session changes ranged from r = 0.35 to r = 0.80 for range of motion measurements, and from r = 0.24 to r = 0.47 for pain intensity. Odds ratios for pain and range of motion ranged from 3.5 (95% CI 0.9 to 14.6) to 37.0 (95% CI 4.1 to 330), indicating greater odds of improving between-session if improvement was obtained within-session. These results provide preliminary support for the practice of using within-session changes in pain intensity and range of motion to guide treatment selection when treating impairments in patients with low back pain.     

What is a meaningful pain reduction in patients with complex regional pain syndrome type 1?

OBJECTIVE: To investigate the degree of pain reduction in patients with complex regional pain syndrome type 1 (CRPS 1) that can be defined as "successful." DESIGN: All patients rated their pain on a visual analog scale (VAS; 0-10) before treatment and on three occasions after treatment, at 6 months, 1 year, and 2 years. Patients also rated a Global Perceived Effect (GPE) for their pain relief at the same time periods. The GPE items were classified as "successful" or "unsuccessful." The mean absolute and relative pain reduction (using the VAS) was calculated for both "successful" and "unsuccessful" GPE classifications for each time period. Sensitivity and specificity analyses were performed. PATIENTS: Sixty-one patients with CRPS 1. RESULTS: The patients defined a relative pain reduction of 58% (SD, 23.4) or more as "successful," whereas in "successful" and "unsuccessful" patient groups the pain was reduced significantly on the VAS. Furthermore, sensitivity and specificity analyses showed that a cut-off point of 50% relative pain reduction and a 3-cm absolute pain reduction on the VAS have the highest likelihood that patients will report their treatment "successful" on the GPE. CONCLUSIONS: Relative pain reduction of 50% or more and an absolute pain reduction of at least 3 cm on the VAS are accurate in predicting a successful pain reduction after a given treatment.