Modifikationen der Guanethidin-Blockade zur Diagnostik der sympathischen Reflexdystrophie (Morbus Sudeck)

Patients and methods

Forty-seven RSD patients were investigated. Among the typical triad of RSD symptoms, all patients showed distally generalized oedema of the affected extremity and complained of spontaneous pain. This pain showed an orthostatic component in all but two patients. The modifications of the IVRG-block were: (1) distal (in contrast to proximal) suprasystolic compression of the affected extremity before i.v. injection of guanethidine (GA); (2) reduction of the recommended dose of GA (10–30 mg) to 2.5 mg GA for each block; (3) no additional local anaesthetics, which are recommended for suppression of the typical pain following GA injection, since this pain allows identification of the distribution of the GA (complete? incomplete?) within the symptomatic area; (4) repeated subsequent injection of physiological saline to improve the distribution of GA within the symptomatic area.

Results

Injection of GA and repeated injections of saline (mean: 43 ml, range: 10–95 ml) elicited pain—lessening in intensity with repetition—in the same region as the spontaneous pain of RSD in all but the two patients mentioned above. Following the modified IVRG block, all but these two patients experienced significant pain reduction (Table 1). In total, 87% of all 47 patients under study were acutely (for at least 1 day) pain-free after the block.

Conclusions

The modified IVRG block seems to have a high diagnostic value with respect to the presence of a sympathetic contribution to the pain in RSD. As a reduced GA dose/block is used, this form of the block appears to be safer than other kinds of sympathetic blocks.     

Rückenbeschwerden und Wirbelsäulenform

Background

Despite controversial reports in the literature the use of video raster stereography and multivariate procedures leads to a reasonable model of spinal form parameters associated with lower back pain.

Patients and methods

A total of 201 male subjects (no pain: n=113, lower back pain: n=84, facet syndrome: n=4) were examined by means of video raster stereography in a controlled cross-sectional investigation.

Results

Multivariate factor and discriminant analyses revealed spinal form variables which showed significant differences (p<0.01) between pain-free volunteers and back pain patients (e.g. trunk imbalance, lumbar lordosis, trunk inclination). The spinal form in facet syndrome patients did not differ from lower back pain patients but showed specific lumbar curve patterns.

Conclusion

The physiological range of individual variations of spinal shape and individually exposed spinal form deviations associated with lower back pain syndromes hamper a simple differentiation of spinal form findings. Multivariate analyses are helpful to discriminate spinal form variations according to clinical disorders and video raster stereography appears to be useful in the quality management of exercise therapy.     

Contrast-enhanced ultrasonography with Sonazoid? for the evaluation of bowel ischemia

Purpose

To determine the usefulness of contrast-enhanced ultrasonography with the contrast agent Sonazoid? for the detection of bowel ischemia.

Methods

From March 2007 to February 2009, 65 patients (35 men and 30 women, mean age 70.4?±?16.1?years) were enrolled. Fifty-three patients complained of acute abdominal pain with small bowel dilatation (n?=?40) or reduced bowel peristalsis (n?=?13). Twelve patients were clinically suspected of having bowel ischemia. After Sonazoid? injection, bowel segments were scanned using harmonic imaging, and the signal intensities were classified as normal or diminished. The definitive diagnosis was confirmed by surgery in 30 patients, autopsy in 6, endoscopy in 3, angiography in 1, and clinical follow-up in 25.

Results

All 50 patients with normal signal intensities were confirmed not to have bowel ischemia. In the 15 patients with diminished signal intensities, 14 patients were confirmed to have bowel ischemia, resulting in an overall sensitivity of 100% [95% confidence interval (CI) 80.7–100%], a specificity of 98% [95% CI 89.5–99.9%], a positive predictive value of 93% (95% CI 68.1–99.8%), and a negative predictive value of 100% (95% CI 94.1–100%).

Conclusion

Contrast-enhanced ultrasonography with Sonazoid? is a highly sensitive and specific method for the diagnosis of bowel ischemia.     

Psychische Veränderungen bei Patienten mit komplexem regionalem Schmerzsyndrom (CRPS)

Question

Do comorbid psychological disorders, dysfunctional pain processing, and psychosocial pain coping occur with complex regional pain syndrome (CRPS) and is a connection between clinical and psychological manifestations apparent?

Methods

In addition to securing information on case histories and performing clinical neurological examinations of chronic CRPS patients, the structured clinical interview (SCID), pain perception scale, and the Kiel Pain Inventory were employed.

Results

The structured clinical interview revealed evidence of a depressive episode in 65% of CRPS patients. Pain perception is similar to neuropathic pain syndromes and patient history revealed a slightly increased frequency of anxiety and affective disorders. Depressive syndrome occurred significantly more often in right-sided CRPS; otherwise, there were no significant correlations between medical history, clinical examination, and frequency of psychological disorders. However, CRPS patients with allodynia manifest clinical signs of special psychological distress.

Conclusion

In chronic CRPS depressive syndrome frequently develops and psychological treatment can be recommended.     

Kann es Rheuma sein

Background

An inflammatory rheumatic disease can underlie every form of joint and back pain. In the routine practice it is important to be able to confirm or reliably deny the suspicion of a rheumatic disease directly during the examination of a patient.

Methods

This cannot be achieved by the commonly used diagnostic tools of laboratory medical tests or imaging. The former have been shown to be insufficiently reliable for rheumatological diagnostics and the latter can be very useful in the form of magnetic resonance imaging (MRI) but is unsuitable for daily routine use. The clinical examination often results in very clear diagnostic indications, especially when a rheumatic disease is present.

Conclusion

The carefully carried out clarification of the question of the leading symptom of inflammatory joint pain allows a rapid and reliable diagnostic estimation of the suspicion of a rheumatic disease.     

Syndrome myofascial du muscle piriforme et sciatalgie persistante chez le lombalgique en rééducation

Background

Myofascial syndrome affecting the piriformis is quite common in rehabilitation patients with low back pain and may present as persistent sciatica.

Goals

Based upon a clinical case, define the symptomatology and treatment of myofascial piriformis muscle syndrome.

Results

Computerized tomography-controlled corticoid injections and specific rehabilitation relieve muscle contracture and pain, allowing the back pain program to be resumed.

Discussion

The physiotherapist’s knowledge of myofascial syndrome affecting the piriformis may help early diagnosis and treatment, thus avoiding unnecessary lumbar investigations.     

Chronischer Beckenbodenschmerz

Background

Chronic pelvic pain represents a multifactorial problem of unknown etiology. International standardized diagnostic and therapeutic approaches do not exist.

Methods

Medline and PubMed databases were searched for systematic reviews and guidelines for prevalence and therapy of chronic pelvic pain syndrome.

Results

Frequency, clinical picture, and treatment concepts for various forms of chronic pelvic pain are presented. If established treatments fail, then multimodal therapy concepts are recommended. Controlled studies, which fulfill evidence-based medicine criteria, are lacking.

Conclusion

The success of multimodal therapeutic approaches in other chronic pain diseases should lead to the development and verification of these for chronic pelvic pain.     

Operiert wird der Patient und nicht das Röntgenbild

Background

Disorders of segmental spine mobility are frequently associated with symptoms of nonspecific back pain.

Methods

Functional X-ray examination of the cervical and lumbar spine regions in lordotic and kyphotic positions (lordosis-kyphosis test) show exactly the type of intervertebral dysfunction.

Results

Together with the clinical findings the functional X-ray examination allows determination of appropriate interventions and optimal pain management.     

Epidurale Rückenmarkstimulation bei Postnukleotomiesyndrom

Background

Spinal cord stimulation (SCS) is an effective alternative treatment in patients with chronic neuropathic pain and mainly radicular distribution. The aim of this prospective study was to investigate changes in BOLD signal with fMRI during active SCS and to correlate the results with the clinical pain intensity, measured with a visual analogue scale (VAS).

Patients and methods

Three patients with failed back surgery syndrome were tested during the clinical trial of SCS. A first fMRI was performed with marked pain and a high VAS score. Before the second fMRI a therapeutic stimulation phase with pain reduction was carried out.

Results

With high pain levels SCS activated the cingulate gyrus, thalamus, prefrontal cortex, supplementary motor area and postcentral gyrus. After pain reduction, SCS did not elicit these activations in the second fMRI, using the same stimulation parameters.

Conclusions

In patients with chronic neuropathic pain and high VAS levels, SCS elicited BOLD activation in the cingulate gyrus, thalamus, prefrontal cortex, and primary and secondary somatosensory area. Pain reduction by SCS resulted in a reduction of functional activity in these areas as revealed by follow-up fMRI.     

Stress et douleurs viscérales: une revue

Aim

To review the various psychological theories of stress, to better understand how this takes place in the question of visceral pain, in particular, abdominal pain.

Procedure

Systematic review of significant articles on stress and visceral pain, in both the child and the adult.

Results

A great influence of the events suppliers of stress in the visceral pain is demonstrated. However, the link of causality cannot be demonstrated.

Conclusion

The clinical approach of visceral pain is complex. Therefore, it is open toward complementary therapeutic ways, which seem to bring satisfaction in many situations.     

Schmerztherapie in der Lehre

Background

The subject of pain and pain therapy is not mandatory in medical curricula in Germany. Therefore, the German Society for the Study of Pain (DGSS) has developed a core-curriculum for pain and suggested its implementation for all medical faculties.

Method

At the University of Witten/Herdecke this DGSS core curriculum was extended in terms of a ??pain week??, which comprised 22?h of seminars and clinical teaching and started in 2009. The knowledge gained by the students regarding the intended learning issues was measured by a pre-post self-assessment questionnaire.

Results

In almost every category the students reported significant knowledge gain. The learning issues were rated as relevant for the professional career.

Conclusion

The ??pain week?? is intended to be a constant part of the medical curriculum at the University of Witten/Herdecke in the future. It will be integrated into the new cross-sectional subject of palliative care and be assessed by examinations.     

Präoperative Schmerzschulung

Background

The present research was performed to investigate the influence of preoperative information on pain given by the nursing staff on postoperative pain perception in patients.

Methods

A randomized controlled interventional study was conducted in 93 patients undergoing cardiac surgery at the University Hospital Erlangen. One day before the surgery all participants were evaluated using the Eysenck Personality Questionnaire, patients of the treatment group were additionally trained by a member of the nursing staff in pain behaviour. After discharge from the intensive care unit the pain experience of the patients was evaluated using standardized questionnaires.

Results

Of the 93 patients, 73 finished the study protocol and were analyzed. The pain experience was not significantly different between the two study groups. Patients with increased levels of neuroticism (characterized by emotional lability) regardless of study group more frequently reported pain values above 3/10.

Conclusion

No significant modulation of postoperative pain experience was achieved by preoperative information on pain. However, it cannot be ruled out that this intervention, particularly in view of the reduction in anxiety, may form a significant element of perioperative pain management.     

Chronischer Schmerz

Background

Chronic pain is a widespread social problem. This paper reports on the care situation for patients with chronic pain in out-patient community settings in Austria.

Materials and methods

The study took the form of a telephone survey together with internet research. Every second out-patient pain service (from a total of 83) was contacted and 21 out of 42 agreed to participate.

Results

The number of community-based physicians with a certificate in pain therapy as well as the number of out-patient pain services showed considerable regional variation. Partial or full interdisciplinary teams are a feature of approximately 50% of out-patient pain units and 76% of such services use guidelines according to their own estimation. Pain perception tends to be measured using pain rating scales rather than pain questionnaires. A wide range of treatments is offered either directly or via referral.

Conclusions

Quality criteria relating to the structure of care established by the Austrian Society for Pain have only been partially implemented. Potential for improvement exists particularly with regards to the prevalence of pain-specific training, interdisciplinary teamwork and the measurement of outcomes.     

Bessere Verlaufsdokumentation bei Patienten mit lumboradikul?ren Schmerzsyndromen

Background

The purpose of the study was to present a reliable instrument with easy application to assess the outcome and improvement of therapy in patients with radicular symptoms of the lumbar spine.

Methods

Data from patients who underwent microdiscectomy because of lumbar radicular symptoms were collected and analyzed and interviews were performed using the well-known North American Spine Society (NASS) lumbar spine questionnaire (17?items) before and after the intervention. In addition patient data including comorbidities were collected. By calculating effect size (ES) and standardized response mean (SRM) for each item of the questionnaire, the questions with the highest change before and after the intervention could be selected.

Results

A total of 139 patients undergoing microdiscectomy for lumbar radicular symptoms due to a disc herniation were included in the analysis. Concerning the three dimensions pain, neurological symptoms and impairment of activities in daily life, the questions with best predictive value (high ES and SRM) were selected. According to their clinical relevance eight questions of the NASS questionnaire were finally selected for the short form.

Conclusion

This short, significant and easy to use questionnaire is in our opinion a useful instrument to assess the course of patients with radicular back pain and especially to measure and monitor the outcome of therapeutic interventions, in addition to conventional clinical diagnostics and examinations. This novel instrument could be a useful tool for improving quality assurance in conventional and interventional pain management of these patients.     

Simple and Cost Effective Clinical Methods for Measuring Neuromuscular Fade Responses with Emphasis on “Train of Four” Fade

Objective

To evaluate different pressure transducers, available in the operating room for pressure measurements, interfaced with common monitoring equipment, for quantitation of the train of four (TOF) fade during clinical neuromuscular block (NMB).

Method

We determined evoked pressure changes produced by the thumb in response to TOF stimuli. We studied the responses of: a) a membrane disc device, and b) modified pressure transducers which were placed directly under the distal phalanx of the thumb of the clenched hand. The responses were displayed/recorded on OR monitors. The optimal positioning of these thumb pressure sensing (TPS) devices and their sensitivity and accuracy during onset, spontaneous (partial) recovery and pharmacologic reversal of NMB, were determined in anesthetized patients during muscle relaxation (Vecuronium) and reversal (Neostigmine). Simultaneous comparisons were made on twenty eight patients between the TOF fade responses obtained by the TPS devices and by conventional electromyographic and/or mechanomyographic methods. Comparisons were made either between pairs of data (e.g. “t” test, correlation coefficients, measuring agreement) or between several “treatment” groups (ANOVA of repeated measures).

Results

Correlations between the results of the TPS devices and the other methods were the closest (r->0.8) at higher TOF (T4/T1) ratios (e.g. during reversal. Measuring agreement was satisfactory and no significant differences were detected between the regression data (e.g. slope, residuals, x-axis of the regression lines) of the T4/T1 ratios vs. time when comparing EMG and TPS data during reversal of NMB.

Conclusion

Measuring quantitatively the TOF fade by TPS devices is an economically feasible method for determining the adequacy of recovery from clinical non-depolarizing NMB.     

Langzeiteffekte interventioneller Behandlungen von chronischen Schmerzen des Bewegungssystems

Introduction

Interventional procedures are frequently used for treatment of musculoskeletal pain syndromes but current scientific evidence does not show successful outcome in chronic cases. In this study the effect of repeated interventional treatment on the long-term outcome of patients with chronic musculoskeletal pain was examined.

Materials and methods

In order to prepare for a retrospective outcome study (RCT) on proliferation therapy the clinical records of 38 patients who had been repeatedly treated (minimum 5 times) with an interventional treatment concept were examined.

Results

Patients were treated on average 10 times with approximately 107 single injections during each treatment cycle. In the long term the chronic pain syndrome showed a statistically significant deterioration with a generalization of the pain as well as an increase in pain medication, surgery and psychosocial impairment..

Discussion

Repeated treatment cycles of interventional pain therapy did not lead to an improvement in the treated pain syndromes and in the long term the pain syndromes deteriorated further. It seems likely that the interventional approach promoted this adverse development but the data of this study are not sufficient to conclusively prove this thesis.     

Schmerzempfindung bei Jugendlichen mit chronischen funktionellen Schmerzen

Background

Pain perception is a central aspect of the multidimensional model of chronic pain. Up to now, validated measurement tools are lacking in the German language for measuring pain perception in adolescents. The aim of this study was to examine and adapt the well-established Pain Perception Scale for Adults by Geissner (SES) for use in adolescents with chronic pain to provide a measure for clinical diagnosis and evaluation of treatment effects.

Material and methods

Principal component, reliability and item analyses were conducted on a sample with 139 adolescents. To test validity, age and sex effects, correlations with pain-related constructs, differences between treatment groups (inpatients vs outpatients) and concordance between adolescents and their parents were analysed.

Results

Findings support a two-factor solution with one affective and one sensory factor; three additional sensory items were included in the final version. The scales show good internal consistency. Consistent with hypotheses, we found significant correlations with pain characteristics, emotional and cognitive variables as well as pain-related disability. Inpatients and outpatients show a significant difference in affective pain perception. Concordance between parents and adolescents was high.

Conclusion

With this questionnaire there is now a validated German assessment tool to measure pain perception in adolescents with chronic pain (Pain Perception Scale for Adolescents, SES-J). Due to its practicability it is suitable for clinical application.     

Mittelfristige Effekte einer multimodalen Behandlung bei Patienten mit Fibromyalgiesyndrom

Objective

Fibromyalgia shows a chronic course of the disease in most cases. Multimodal therapy has short-term effects but only intensive forms of therapy attain long-term effects. As part of an inpatient rehabilitation program a multimodal pain treatment including cognitive-behavioral therapy was conducted in order to evaluate medium-term effects.

Method

The German pain questionnaire (DSF), the hospital anxiety and depression scale (HADS-D), the chronic pain questionnaire (FESV), the short form questionnaire on indicators of rehabilitation status (IRES-24) and the self-efficacy scale (ASES-D) were distributed to 166?fibromyalgia patients (intervention group n=116; control group n=50) before and after rehabilitation as well as 6?months after treatment.

Results

The intervention group showed better results regarding symptoms (pain intensity, anxiety, depression), state of health (somatic health, psychological well-being, functioning in everyday life) and self-efficacy.

Conclusions

Based on the positive medium-term effects on functioning in everyday life and self-efficacy there is evidence that patients benefit from multimodal rehabilitation programs including integrative patient education.     

Advanced prostate cancer as a cause of oncogenic osteomalacia: an underdiagnosed condition

Purpose

Tumor-induced osteomalacia (TIO) is a paraneoplastic bone mineral disturbance related to fibroblast growth factor 23 (FGF23) overproduction by the tumor, usually from mesenchymal origin. Such condition leads to high phosphate renal wasting and, consequently, to cumbersome symptoms as weakness, bone pain, and fractures.

Method

Case report.

Result

We report a case of an advanced castration-refractory prostate cancer patient, which developed severe hypophosphatemia with elevated phosphate excretion fraction. TIO was suspected, and increased levels of FGF23 reinforced such diagnosis. The patient died 4?months after being diagnosed with TIO.

Conclusion

This case suggests that TIO has a dismal prognosis in prostate cancer patients. The clinical oncology community must be aware about such disturbance that can be present in those patients with weakness, bone pain, and hypophosphatemia.     

Schmerz und Lebensqualität nach Nephrektomie bei Lebendspendern

Background

This survey focusesed on chronic postoperative pain and impairment of quality of life after living donor nephrectomy.

Methods

Out of a total of 82 donors 58 (71%) were examined using the Chronic Pain Grade (CPG) by von Korff and Short-Form 12 (SF-12).

Results

Of the donors 34% suffered from chronic postoperative pain 22 months (range 9-57 months) after nephrectomy and in 55% of these cases the pain interfered with daily life activities. The quality of life was almost comparable with those of the average German population, but was reduced by chronic postoperative pain particularly with respect to the mental state.

Conclusion

Measures have to be taken to prevent chronic postoperative pain and donors should be encouraged to express their pain to ensure an adequate pain therapy.