Schmerz am Bewegungsorgan verstehen, untersuchen und diagnostizieren

Most patients who attend orthopedic trauma surgery practices present with pain of the musculoskeletal system which can significantly affect the quality of life. For most patients the reason for the pain is quite obvious and can be easily addressed; however, for other patients the mechanism responsible for the pain remains unclear. In these patients it is mandatory to have well founded knowledge about the origin of the pain, possible pathways of pain sensitization and chronification in order to ask the right questions during (pain) anamnesis and to perform an adequate clinical functional examination. This is the foundation to offer an effective treatment to patients or when necessary to initiate further diagnostic investigations in order to avoid pain chronification or to direct patients to a multimodal interdisciplinary approach when the pain is already chronic.     

Schmerztherapeutische Versorgungsstrategien

Acute pain is necessary for survival; it is, after all, a warning. Chronic pain, in contrast, has to be regarded as an illness; it affects about 20 million people in Germany and its treatment and later consequences involve substantial costs. After operations about 35% of patients experience chronic pain, and it has not proved possible to lower this rate even with minimally invasive procedures. Severe acute pain seems to have a significant factor in chronification, which is why it requires consistent and effective short-term treatment. Medicamentous analgesia and anaesthesia, with nerve blocks in the vicinity of the spinal cord or in peripheral regions, can be considered for this purpose. Since these measures can be associated with life-threatening complications in some circumstances, a clear and binding guideline on pain therapy should be required, as should an acute pain service that is available round the clock.     

Patienten mit vorbestehender Schmerzchronifizierung und/oder psychischen Auffälligkeiten

Existing pain chronification and psychological problems can affect the degree of perioperative pain and hence the postoperative outcome. Most elective surgery performed on the musculoskeletal system is indicated because of pain. To avoid perioperative complications it is therefore essential to identify patients with existing pain chronification before surgery is performed. Based on a systematic literature review, studies on orthopaedic surgery were filtered for existing pain chronification and checked in order to deduce clinically relevant and evidence-based recommendations. In summary, unproblematic pain is characterised by good organic explainability, lack of pain generalisation, no additional physical complaints, appropriate management of the physical damage encountered and suitable use of analgesics. In line with what is known about the mechanisms of pain chronification, patients with existing chronification usually display additional psychological problems. These psychological factors ought to be established prior to surgery. A preliminary non-surgical treatment could potentially also lead to a reassessment of the indication for surgery.     

How can I assess the back pain status in my patients? The Mainz chronic disease staging method and its prognostic value

Chronification of pain is not just a simple matter of duration, although many publications still pretend that this is so. Chronification is more a spread of pain on the physical level, on duration and even more on the psychological and social levels. We present different models to explain this process. Instruments to evaluate the amount of chronification are presented in comparison, on the one hand the graduation of chronic pain by von Korff, on the other hand the Mainz pain staging system (MPSS). Results of different inquiries have shown the correlation between chronicity of pain and measurements of quality of life and effectiveness of medical treatment. Also the MPSS has a prognostic value about the effect of further treatment. To get a differentiated view on the results of examinations and treatment outcome, an evaluation of the chronification process of the patient's pain is a necessity.     

Präoperative Schmerzen bei urologisch operativen Patienten

Background

The genesis of chronic pain in urology has so far been insufficiently investigated. No investigations have focused on the occurrence of preoperative pain. We developed an epidemiological questionnaire to analyze preoperative pain.

Methods

In this questionnaire, preoperative pain in all patients scheduled for urologic surgery (n=165) was analyzed. Acute and chronic pain was analyzed as main or adjoint pain, with the registration of severity, chronification states, and duration. We registered depression and anxiety, well-being, and somatic and psychological efficiency.

Results

Eighty percent of the patients reported pain within the previous 12 months. Acute preoperative pain was reported by 17% of the patients and chronic pain by 64%. Significant differences in quality of life were detected between patients with or without preoperative pain. Well-being was also significantly affected in patients having pain.

Conclusion

The pain severity and states of chronification not only explain a reduction in somatic and psychological well-being but also emphasize that preoperative pain should be identified thoroughly prior to surgery.     

Treatment of hand surgery patients in chronic pain

The treatment of hand surgery patients suffering from chronic pain requires an interdisciplinary procedure. An imbalance between nociception and antinociception can be seen as a reason for the chronification of pain. The complexity of the problem of chronic pain patients is marked by a wide variety of symptoms. Full diagnostic assessment to detect or to exclude other organic diseases is required. Rehabilitation to improve function and reduce pain intensity has priority. Our therapeutic strategy consists of intensive physiotherapy and analgesic drugs as well as a series of blockades with buprenorphine (Temgesic) of the ganglion stellatum (GLOA). This specific therapy achieved an improvement of the function of the upper extremity and a reduction of pain intensity. The majority of patients were satisfied with the outcome.     

Patients with pre-existing chronic pain and/or psychological problems

Existing pain chronification and psychological problems can affect the degree of perioperative pain and hence the postoperative outcome. Most elective surgery performed on the musculoskeletal system is indicated because of pain. To avoid perioperative complications it is therefore essential to identify patients with existing pain chronification before surgery is performed. Based on a systematic literature review, studies on orthopaedic surgery were filtered for existing pain chronification and checked in order to deduce clinically relevant and evidence-based recommendations. In summary, unproblematic pain is characterised by good organic explainability, lack of pain generalisation, no additional physical complaints, appropriate management of the physical damage encountered and suitable use of analgesics. In line with what is known about the mechanisms of pain chronification, patients with existing chronification usually display additional psychological problems. These psychological factors ought to be established prior to surgery. A preliminary non-surgical treatment could potentially also lead to a reassessment of the indication for surgery.     

Pain treatment tomorrow

In the last few years global understanding of pain has improved due to current molecular biological studies. The identification of a large number of different proteins is an essential part of future therapies, since they, as enzymes, receptors or ion channels, are specific relays in the nociceptive system and therefore have key functions in pharmacotherapeutic therapy. Nature itself supplies a variety of substances which are of therapeutic value, some of which are already in scientific trial. In contrast, even today not all available pain therapy measures are in use in Germany, at least not in all areas. Especially the treatment of children is not state of the art. Thus a further increase of chronic pain patients is to be expected in the future. This development has to be stopped, not only for ethical reasons, but also to prove the economical value of adequate pain therapy. Qualified treatment of acute pain within well defined limits can help to avoid chronification and further costs. This will be the decisive argument with which to mobilize the necessary funds for the development of the pain treatment of the future.     

Einfluss pr?operativer Schmerzen auf die postoperative Schmerzchronifizierung

Background

We examined the influence of preoperative pain on postoperative pain chronification in urological patients.

Methods

Pain was determined before operation, immediately afterwards and 3 or 6?months post-surgically. Acute and chronic pain was analysed in detail with regard to severity, grade of chronification and pain intensity. We also assessed patients with the Hospital Anxiety and Depression Scale.

Results

Patients with preoperative pain reported postoperatively higher pain scores compared to patients without preoperative pain. Patients with higher Hospital Anxiety and Depression Scale scores reported higher pain scores for the first 7?days after the operation. Three months after surgery 51.2% of all patients and 6?months after surgery 1.2% of all patients reported about pain.

Conclusion

Our results give evidence to the fact that preexisting pain prior to surgery has an influence on the postoperative pain course. To avoid chronification adequate therapy of the preexisting pain should be carried out.     

Association of sleep quality and chronification of musculoskeletal pain in an older adult: A case report

BackgroundSleep disorders and chronic musculoskeletal pain are highly prevalent conditions that are often comorbid clinically. The role of sleep disorder on the chronification of musculoskeletal pain is well documented, although the mechanisms have not yet been fully established.ObjectivesHere we present a case study demonstrating the clinical comorbidity of sleep disorder with chronification of musculoskeletal pain in an older adult with clinical history of hypothyroidism. The aim of this case is to highlight important risk factors of age, gender and hypothyroidism, which the clinician should be aware of for their potential contributory role in the development of sleep disorder and chronification of musculoskeletal pain.Clinical featuresPatient presented with a flare-up of pain in right shoulder and neck that had been intermittently present for several years but of which the intensity had become increasingly worse over time. The patient was diagnosed with chronic right rotator cuff tendonitis and a grade III supraspinatus tear. Clinical history revealed that significant sleep disorder and hypothyroidism were also present in this case.Intervention and outcomesTreatment focused on relieving pain and restoring function to the right shoulder. Interventions including passive mobilization, manual ischemic trigger point therapy, and passive traction were applied. Patient also provided with diaphragmatic breathing exercises to help alleviate her sleep disorder. After 12 weeks patient reported decreased pain levels and improved ROM of the right shoulder. Patient also reported improved sleep, both in quality and quantity.ConclusionThis case demonstrates the importance of considering the association between sleep disorder and the chronification of musculoskeletal pain in older adults. This study highlights common potential risk factors of age, gender and hypothyroidism which may contribute to the development of these conditions in older patients.     

Neurophysiologische Aspekte von Schmerz und ihre Konsequenzen für den Anästhesisten

Nociception is a protective system of the body which prevents it from injury and tissue damage. Human beings respond to noxious stimuli by moving away. They learn by pain to avoid these situations in future. Shortly after major injury, there is a limited analgesic period allowing the body to flee the area of danger, later on, emerging pain compels the body to rest and supports recuperation. While acute pain has a certain meaning, chronic pain does not. It induces a comprehensive suffering including loss of initiative, appetite and vigilance. It reduces life-quality, often accompanied by depressive moods. Acute pain causes changes in the central nervous system leading to an increased sensitivity of nociception (hyperalgesia). During healing, the central processing of noxious stimuli is normalised taking minutes to weeks. Sometimes, unknown factors initiate chronification of pain. Changes on a molecular level in peripheral tissue as well as in the central nervous system induce ”cellular early genes” [24], a synthesis of c-fos, c-jun and other proteins favouring the chronification of pain. All efforts have to be made to depress or interrupt such a development. One of the first steps to pain prophylaxis in a hospital is an optimal surgical technique: incision, extension, limited tissue damage and minimal invasive surgery should guarantee the smallest impairment of the nociceptive system possible. However, nociceptive input is intense and of long duration and leads to central sensibilisation. Postoperative pain has lost its function as surgery anticipates healing. Pain induces a reduction of ventilation, circulation, digestion and increases the risk of other disorders. There is need of aggressive pain treatment for humanitarian reasons and for reasons of late sequelae like permanent pain and increased reduction of function [10]. This is of pivotal importance in patients with amputations or sympathetic reflex dystrophy (SRD). Antinociception is best provided by regional anaesthesia technique with a combination of local anaesthetics and opioids which results in better outcome [2, 12]. Hence, regional anaesthesia techniques are strongly indicated in those patients. Good antinociception may be even more important than it is assumed today. Anand [1] demonstrated a lower morbidity and mortality in 45 newborns undergoing cardiothoracic surgery, when general anaesthesia was performed with high-dose sufentanil versus halothane supplementary doses of morphine. Anaesthesiologists have to reconsider the quality of general anaesthesia: the antinociception of their regimen.     

Neuroplasticity and chronic pain

In the seventies and eighties spinal mechanisms inhibiting pain processing were discovered in animal studies leading to new therapeutic regimens such the use of spinal opioids. During the last decade additional studies revealed an increased sensibility of the spinal cord upon severe, long lasting pain perception, a mechanism called wind-up. Hyperalgesia is accompanied by persisting genetic changes of spinal cord cells, which may contribute to the chronification of pain. The severity and duration of acute pain apparently contributes to the possibility of chronic pain development. Although not all the consequences of these findings are clear, they may influence our way of performing anaesthesia and treating postoperative or acute pain situations, e.g. pain during herpes zoster or pain after trauma and amputation. In general, analgetic measures should be potent enough to prevent spinal sensiblisation, which can be best achieved with spinal blockade by local anesthetics. Another way of counteracting pain-induced spinal plasticity is by blocking or antagonizing its pathways with specific transmitters or their equivalents. All these spinally mediated regimens should be performed prior to later predominating mechanisms of supraspinal plasticity involving psychic changes due to persisting pain, which seem to evolve with delay to spinal processes.     

MicroRNA-based therapy in pain medicine: Current progress and future prospects

MicroRNAs (miRNAs) are small noncoding RNA molecules of 18–25 nucleotides in length that regulate gene expression involved in fundamental cell processes. The induction and chronification of pain is associated with many expressional changes in pain-related proteins. miRNA has the potential to regulate gene and protein expression associated with the induction and chronification of pain. Thus, miRNAs might have promise in therapy and as a diagnostic and prognostic biomarker in pain medicine. The application of miRNA has been an emerging field in pain research in recent years. Many studies focusing on the regulation of miRNAs under different tissue and nociceptive stimuli have been performed in recent years. In this review, we intend to introduce the most recent research in the field of miRNA related with pain medicine such as the expression and function of miRNA in different animal pain model, the challenge of application and delivery of miRNA in vivo, the potential toxic effects of miRNA and future problems in clinical application that need to be resolved. This review focuses on the results of miRNA in animal studies and the prospect for future success.     

What questions are appropriate for predicting the risk of chronic disease in patients suffering from acute low back pain?

AIM: The objective of the study was to develop a brief questionnaire to determine the risk of chronification for patients suffering from lumbar (low) back pain who are consulting a physician for the first or second time. METHOD: At the outset, and again after six months, a questionnaire with 167 valid items for chronification was distributed to patients in orthopedic offices. After six months, patients were contacted by mail to inquire whether they were still suffering from back pain. Based on outcome (persistence of back pain/absence of back pain) and by means of logistic regression analysis, those variables were determined that could predict actual chronification. RESULTS: The following items were predictive: "How strong was your back pain during the last week when it was most tolerable?" and "How much residual pain would you be willing to tolerate while still considering the therapy successful?" (Acceptance value, beta = 0.61), patient's educational level (beta = - 0.44), massage is experienced as bringing relief (beta = 0.44), 5 items of the Zung scale for depression (beta = 0.42), items of the scale for catastrophizing thoughts (beta = 0.41) and items of the scale for feelings of helplessness (beta = - 0.39) of the Kiel pain inventory; duration of the back pain for longer than 1 week (beta = 0.38), pain in other parts of the body (beta = 0.37); and female gender (beta = 0.25) CONCLUSION: Based on these questions, it was possible to predict the chronification of back pain with a probability of 78.05 %. A corresponding questionnaire and an evaluative table were developed.     

Effect of regional anesthesia on pain sensitization after surgery: New concepts

Severe postoperative pain and wound hyperalgesia, a clinical sign of central sensitization, are risk factors for the development of chronic postsurgical pain. This article describes the neuronal changes that surgical pain and possibly high opioid doses cause in the central nervous system. It also relates how regional anesthesia might oppose these changes and block both the pain sensitization and the pain chronification following surgery.     

The efficacy of a risk factor-based cognitive behavioral intervention and electromyographic biofeedback in patients with acute sciatic pain. An attempt to prevent chronicity

STUDY DESIGN: An investigation of the efficacy of an individually scheduled, risk factor-based cognitive behavioral therapy and a standardized electromyographic biofeedback intervention in the prevention of chronicity in patients with acute sciatica and psychosocial risk factors for chronicity. OBJECTIVES: To investigate the possibility of enhancing pain relief and preventing chronicity in patients with acute sciatica, based on a screening for psychosocial high-risk factors of chronification. SUMMARY OF BACKGROUND DATA: Psychological interventions were evaluated mainly in patients with chronic low back pain. Numerous randomized trials have demonstrated their efficacy, whereas the amount of pain relief was found to be marginal. METHODS: Subjective and behavioral outcome parameters were compared with the respective parameters in age-, gender-, and diagnosis-matched high- and low-risk patients. No additional behavioral treatment for in-patient medical therapy was offered to the patients. Outcome of these patients also was compared with that of a group of refusers of behavioral therapy. Psychological, functional, and behavioral variables were measured before and after treatment and at 3-, 6-, 12- and 18-month follow-up visits. Changes over time, group differences, and possible group x time interactions were analyzed by analysis of variance and nonparameteric comparisons. RESULTS: Data analysis showed a statistically and clinically significant, beneficial effect of both behavioral interventions. However, risk factor-based cognitive behavioral therapy was superior to electromyographic biofeedback intervention with respect to pain relief and application for early retirement. The cognitive behavioral therapy showed a similar good outcome (e.g., 90% showed a clinical significant pain reduction) as the low-risk patients (83% pain reduction). High risk patients and refusers of therapy showed a poor outcome in pain (33% and 20% pain reduction, respectively), disability, and work performance. CONCLUSIONS: Individually scheduled, risk factor-based cognitive behavior therapy could be a beneficial treatment modality, which can be offered, in addition to a medical treatment, to patients with acute sciatica and psychosocial high risk factors for chronicity. It may be an effective way to prevent chronification in these patients.     

Brain structural and psychometric alterations in chronic low back pain

Purpose

Chronic low back pain (CLBP) is one of the most important pain disorders with increasing social and economic implications. Given that CLBP is a multidimensional process associated with comorbidities such as anxiety and depression, treatment of chronic low back pain is still a challenge. Advancement of in vivo brain imaging technologies has revealed increasing insights into the etiology and pathogenesis of chronic pain; however, the exact mechanisms of chronification of LBP remain still unclear. The purpose of the present study was to analyse the neurostructural alterations in CLBP and to evaluate the role of comorbidities and their neurostructural underpinnings.

Methods

In the present study we investigated a well-characterized group of 14 patients with CLBP and 14 healthy controls applying structural MRI and psychometric measures. Using an improved algorithm for brain normalization (DARTEL) we performed a voxel-based morphometry (VBM) approach. Correlation analyses were performed to evaluate the role of anxiety and depression in neurostructural alterations observed in CLBP.

Results

The psychometric measures revealed significantly higher scores on depression and anxiety in the patient population. VBM analysis showed significant decreases in grey matter density in areas associated with pain processing and modulation, i.e. the dorsolateral prefrontal cortex, the thalamus and the middle cingulate cortex. With respect to anxiety and depression scores, we did not observe any correlations to the structural data.

Conclusions

In the present study we found compelling evidence for alterations of grey matter architecture in CLBP in brain regions playing a major role in pain modulation and control. Our results fit the hypothesis of a “brain signature” in chronic pain conditions. The results of the psychometric assessment underline the importance of an interdisciplinary therapeutic approach including orthopedic, neurological and psychological evaluation and treatment.     

Dolor inguinal crónico posquirúrgico. Una revisión narrativa

Inguinodynia or chronic postoperative inguinal pain is a growing problem between patients who undergo surgical repair of an inguinal hernia. The change in results measurement proposed by many authors towards Patient Reported Outcome Measurement has underlined the importance of chronic postoperative inguinal pain, because of the great limitations in everyday life and the huge socioeconomic impact that it causes. In this article a narrative review of the available literature in PUBMED, EMBASE and Cochrane Library is performed and the most relevant aspects about epidemiology, etiology prevention, diagnosis and treatment of chronic postoperative inguinal pain are discussed. A new management algorithm is also proposed. The variability in its incidence and clinical presentation makes diagnosis of chronic postoperative inguinal pain a very challenging issue. There is no standardized therapy and an adequate etiological diagnosis is key point for a successful treatment. There are many treatment options that have to be sequentially used and adjusted to each patient and their clinical features.     

Chronic pain: not only a matter of time

The term "chronic" is often used in daily clinical practice to indicate a type of pain that lasts over time and is accompanied by diagnostic and therapeutic difficulties. The common feeling is that in this category are actually collected many different clinical cases with the unique characteristic that the pain lasts a long time. It follows that treatment failures are common and patients roam from doctor to doctor in search of an effective care program. At the same time the health spending for the treatment of these patients is becoming increasingly high. In clinical practice we meet many patients with obscure pain syndromes which are classified as "chronic" and untreatable only because persist for long time and that obtain a complete pain relief after a right diagnosis and a specific treatment. In this review the Authors want to argue that the term chronic should not be used only when the pain persists for some time or just when signs and symptoms of mechanisms in the central nervous systems are present. The authors suggest that there is a clear difference between acute and chronic pain but also that in chronic pain patients there are three different painful conditions: 1) patients with a chronic disease (or sequelae) and with chronic pain in which the pain mechanisms are closely related to the underlying chronic disease (e.g., rheumatoid arthritis) or to previous injury that has generated other unsolvable mechanisms (e.g., deafferentation pain after plexus avulsion); 2) patients with a chronic disease and chronic pain in which new mechanisms overlap those related to the underlying disease; 3) patients with chronic pain in whom the correlation between pain and the initial tissue injury is lost and the persistence of pain is due to new developed mechanisms. According to this classification we can distinguish patients with "painful chronic disease" by patients with "independent chronic pain". In these latter cases the complexity of the clinical picture is to be found in a maladaptative response to pain, in emergence of central nervous system mechanisms and in behavioral changes that, in turn, can cause long-term social, psychological and physical sequelae. Differences among patients in developing chronic pain can be related to differences in the ability of the brain to continuously adapt its functional and structural organization. It is obvious that the care plan for these complex patients is profoundly different from that needed for patients with pain linked to a chronic disease or stabilized pain mechanisms. The purpose of the present article is to provide a review of the most noteworthy developments in this field and to propose some observations that may help to understand this pain condition and the patients.     

Posttraumatische Schmerzsyndrome der unteren Extremität

Acute posttraumatic pain results from injuries to the lower extremity. Such acute pain can be the initial step in the development of chronic pain. The main aim of treatment for pain is to prevent pain from becoming chronic, or in the case of pain that is already chronic, to counteract the processes leading to its perpetuation. This goal cannot be achieved without interdisciplinary teamwork. Only an interdisciplinary approach can make it possible to treat chronic pain within its biopsychosocial modes of development and ultimately to achieve social and economic reintegration of the patient.