Pelvic Pain: General

Successful injection for coccyx pain.
Foye PM, Buttaci CJ, Stitik TP, Yonclas PP
Am J Phys Med Rehabil. 2006 Sep;85(9):783-4.

Pain and neuromuscular disease: the results of a survey.
Tiffreau V, Viet G, Thevenon A
Am J Phys Med Rehabil. 2006 Sep;85(9):756-66.

OBJECTIVE: The objective of this study was to evaluate pain frequency, severity, location, treatment, and relief in a population of adult patients with neuromuscular disorders (NMD). DESIGN: The authors used a self-completion mail questionnaire from the Physical Medicine Clinic at the Lille University Medical Center (northern France). Two hundred eighty-one adults with a confirmed diagnosis of hereditary neuromuscular disease were mailed a questionnaire, which was returned by 125 subjects (response rate = 45%). The main outcome measures were mean motor deficiency scores (on the Brooke and Vignos scales), anxiety and depression scores, pain intensity (on a 0-10 numeric scale) and location, frequency of pain-aggravating situations, and pain treatment and relief. RESULTS: Seventy-three percent of respondents reported pain and 62% reported chronic pain (defined as pain for at least 3 mos). The mean pain intensity was 6.1/10 with 40% reporting severe pain (a score of > or = 7). Forty-six percent and 16% of subjects had a high risk for anxiety and depression, respectively. The most common pain-aggravating situations were "walking," "standing," and "muscle stretching." Walking was more frequently cited as a pain-aggravating situation by the chronic pain population than by the acute pain population. Seventy percent of patients with pain had received at least one analgesic drug. Massage was the most frequently prescribed physical treatment. CONCLUSIONS: Pain is a frequent symptom in adult patients with NMD and needs to be better characterized in this population. The use of painkillers and physical pain treatments did not seem to provide adequate relief for the patients studied here.

July

Pulsed radiofrequency for the treatment of ilioinguinal neuralgia after inguinal herniorrhaphy.
Rozen D, Ahn J
Mt Sinai J Med. 2006 Jul;73(4):716-8.

Background and Purpose: Ilioinguinal neuralgia secondary to inguinal hernia repair is frequently a chronic, debilitating pain. It is most often due to destruction or entrapment of nerve tissue from staples, sutures, or direct surgical trauma. Treatment modalities, including oral analgesics, nerve blocks, mesh excision, and surgical neurectomy, have varied success rates. Pulsed radiofrequency (PRF) has recently been described as a successful method of treating chronic groin pain. Unlike conventional radiofrequency, PRF is non-neurodestructive and therefore less painful and without the potential complications of neuritis-like reactions and neuroma formation. Although the mechanism is unknown, it appears that the interaction of an electromagnetic field and c-fos proteins may alter normal transmission of painful impulses. Our study examines five patients treated with PRF for ilioinguinal neuralgia secondary to inguinal herniorrhaphy. Method: Five patients were diagnosed with chronic ilioinguinal neuralgia secondary to inguinal hernia repair at our institution. Each patient was treated at vertebral T12, L1, and L2 with root PRF at 42 degrees C for 120 seconds per level. Results: Four out of five patients reported pain relief lasting from four to nine months on follow-up visits. Only one patient reported no pain relief whatsoever. Conclusion: Ilioinguinal neuralgia is challenging to treat. We have demonstrated the successful use of PRF for four out of five patients seen in our office.

Neuropathic pain: a practical guide for the clinician.
Gilron I, Watson CP, Cahill CM, Moulin DE
CMAJ. 2006 Aug 1;175(3):265-75.

Neuropathic pain, caused by various central and peripheral nerve disorders, is especially problematic because of its severity, chronicity and resistance to simple analgesics. The condition affects 2%-3% of the population, is costly to the health care system and is personally devastating to the people who experience it. The diagnosis of neuropathic pain is based primarily on history (e.g., underlying disorder and distinct pain qualities) and the findings on physical examination (e.g., pattern of sensory disturbance); however, several tests may sometimes be helpful. Important pathophysiologic mechanisms include sodium-and calcium-channel upregulation, spinal hyperexcitability, descending facilitation and aberrant sympathetic-somatic nervous system interactions. Treatments are generally palliative and include conservative nonpharmacologic therapies, drugs and more invasive interventions (e.g., spinal cord stimulation). Individualizing treatment requires consideration of the functional impact of the neuropathic pain (e.g., depression, disability) as well as ongoing evaluation, patient education, reassurance and specialty referral. We propose a primary care algorithm for treatments with the most favourable risk-benefit profile, including topical lidocaine, gabapentin, pregabalin, tricyclic antidepressants, mixed serotonin-norepinephrine reuptake inhibitors, tramadol and opioids. The field of neuropathic pain research and treatment is in the early stages of development, with many unmet goals. In coming years, several advances are expected in the basic and clinical sciences of neuropathic pain, which will provide new and improved therapies for patients who continue to experience this disabling condition.

June

Pyomyositis of the piriformis muscle in a juvenile.
Burton DJ, Enion D, Shaw DL
Ann R Coll Surg Engl. 2005 Jan;87(1):9-12.

The authors present a case of pyomyositis of the piriformis muscle. This case, the first in the English speaking literature of piriformis involvement in a juvenile, serves to illustrate the need for a high index of suspicion when treating children with symptoms related to impalpable pathology deep in the pelvis and the usefulness of MRI in early diagnosis and treatment before abscess formation. It also shows the potentially wide differential diagnosis in which the signs and symptoms may be misleading due to the close relationship of the pelvic muscles with the hip joint and adjacent viscera.

Central sensitisation in visceral pain disorders.
Moshiree B, Zhou Q, Price DD, Verne GN
Gut. 2006 Jul;55(7):905-8.

The concepts of visceral hyperalgesia and visceral hypersensitivity have been examined in a variety of functional gastrointestinal disorders (FGIDs). Although the pathophysiological mechanisms of pain and hypersensitivity in these disorders are still not well understood, exciting new developments in research have been made in the study of the brain-gut interactions involved in the FGIDs.

Comparison of clinical and evoked pain measures in fibromyalgia.
Harris RE, Gracely RH, McLean SA, Williams DA, Giesecke T, Petzke F, Sen A, Clauw DJ
J Pain. 2006 Jul;7(7):521-7.

Evoked pain measures such as tender point count and dolorimetry are often used to determine tenderness in studies of fibromyalgia (FM). However, these measures frequently do not improve in clinical trials and are known to be influenced by factors other than pain such as distress and expectancy. The purpose of this investigation was to determine whether evoked pain paradigms that present pressure stimuli in a random fashion (eg, Multiple Random Staircase [MRS]) would track with clinical pain improvement in patients with FM better than traditional measures. Sixty-five subjects enrolled in a randomized clinical trial of acupuncture were observed longitudinally. Clinical pain was measured on a 101-point numerical rating scale (NRS) and the Short Form McGill Pain Questionnaire (SF-MPQ), whereas evoked pressure sensitivity was assessed via manual tender point count, dolorimetry, and MRS methods. Improvements in clinical pain and evoked pain were assessed irrespective of group assignment. Improvement was seen in clinical pain during the course of the trial as measured by both NRS (P = .032) and SF-MPQ (P = .001). The MRS was the only evoked pain measure to improve correspondingly with treatment (MRS, P = .001; tender point count and dolorimeter, P > .05). MRS change scores were correlated with changes in NRS pain ratings (P = .003); however, this association was not stronger than tender point or dolorimetry correlations with clinical pain improvement (P > .05). Pain sensitivity as assessed by random paradigms was associated with improvements in clinical FM pain. Sophisticated pain testing paradigms might be responsive to change in clinical trials. PERSPECTIVE: Trials in fibromyalgia often use both clinical and experimental methods of pain assessment; however, these two outcomes are often poorly correlated. We explore the relationship between changes in clinical and experimental pain within FM patients. Pressure pain testing that applies stimuli in a random order is associated with improvements in clinical pain, but this association was not stronger than other experimental techniques.

Differential blockade of nerve injury-induced shift in weight bearing and thermal and tactile hypersensitivity by milnacipran.
King T, Rao S, Vanderah T, Chen Q, Vardanyan A, Porreca F
J Pain. 2006 Jul;7(7):513-20.

Antidepressants such as tricyclic antidepressants have become used to treat a variety of chronic pain conditions. However, the side effects are dose-limiting in the treatment of chronic pain. Milnacipran is a norepinephrine/serotonin reuptake inhibitor that does not have the severe side effects associated with traditional tricyclic antidepressants. The effects of intrathecal and systemic administration of milnacipran on spinal nerve ligation (SNL)-induced thermal and mechanical hypersensitivity and shift in weight bearing were determined. Intrathecal administration of milnacipran was found to reverse both SNL-induced thermal and tactile (to von Frey filaments) hypersensitivity, as well as shift in weight bearing. Acute systemic administration of milnacipran also reversed nerve injury-induced thermal hypersensitivity for up to 5 hours but failed to reverse tactile hypersensitivity or shift in weight bearing. Of note, both intrathecal and subcutaneous administration of milnacipran induced thermal antinociception in both SNL and sham rats. Chronic (daily) systemic administration of milnacipran alleviated both thermal hypersensitivity and shift in weight bearing, with both acute and chronic effects observed on thermal hypersensitivity. However, chronic systemic milnacipran administration failed to alleviate tactile hypersensitivity to von Frey filaments. These results indicate that different mechanisms underlie shift in weight bearing, thermal hypersensitivity, and tactile hypersensitivity. PERSPECTIVE: These results indicate that the ability of milnacipran to relieve nerve injury-induced allodynia, hyperalgesia, and shift in weight bearing depends on the route of administration and the duration of treatment, with alleviation of SNL-induced tactile hypersensitivity and shift in weight bearing as a result of activity within the central-rather than the peripheral-nervous system.

Intensity dependence of auditory-evoked cortical potentials in fibromyalgia patients: a test of the generalized hypervigilance hypothesis.
Carrillo-de-la-Pena MT, Vallet M, Perez MI, Gomez-Perretta C
J Pain. 2006 Jul;7(7):480-7.

On the basis of recent evidence concerning the amplification of incoming stimulation in fibromyalgia (FM) patients, it has been proposed that a generalized hypervigilance of painful and nonpainful sensations may be at the root of this disorder. So far, research into this issue has been inconclusive, possibly owing to the lack of agreement as to the operational definition of "generalized hypervigilance" and to the lack of robust objective measures characterizing the sensory style of FM patients. In this study, we recorded auditory-evoked potentials (AEPs) elicited by tones of increasing intensity (60, 70, 80, 90, and 105 dB) in 27 female FM patients and 25 healthy controls. Fibromyalgia patients presented shorter N1 and P2 latencies and a stronger intensity dependence of their AEPs. Both results suggest that FM patients may be hypervigilant to sensory stimuli, especially when very loud tones are used. The most noteworthy difference between patients and control subjects is at the highest stimulus intensity, for which far more patients maintained increased N1-P2 amplitudes in relation to the 90-dB tones. The larger AEP amplitudes to the 105-dB tones suggest that defects in an inhibitory system protecting against overstimulation may be a crucial factor in the pathophysiology of FM. Because a stronger loudness dependence of AEPs has been related to weak serotonergic transmission, it is hypothesized that for many FM patients deficient inhibition of the response to noxious and intense auditory stimuli may be due to a serotonergic deficit. PERSPECTIVE: The study of auditory-evoked potentials in response to tones of increasing intensity in FM patients may help to clarify the pathophysiology of this disorder, especially regarding the role of inhibition deficits involving serotonergic dysfunction, and may be a useful tool to guide the pharmacologic treatment of FM patients.

Coping, pain severity, interference, and disability: the potential mediating and moderating roles of race and education.
Cano A, Mayo A, Ventimiglia M
J Pain. 2006 Jul;7(7):459-68.

Researchers have demonstrated that certain types of pain coping are correlated with less pain severity and disability and that there are differences between Caucasians and African-American pain patients in their use of specific coping strategies. However, the extent to which racial group differences exist in the associations between pain coping strategies and pain severity, interference, and disability is unclear. Furthermore, the role of education in these associations is uncertain. We recruited a diverse community sample of individuals with chronic pain and their spouses to examine this issue (N = 105). Participants completed the Coping Strategies Questionnaire, Multidimensional Pain Inventory, and Sickness Impact Profile. Results showed that African-American participants reported significantly more pain severity, interference, and disability and reported using diverting attention and prayer and hoping pain-coping strategies significantly more often than Caucasian participants; however, only the racial group difference in prayer and hoping remained when controlling for education. We also examined whether race and education interacted with coping strategies in relating to pain and disability. Significant three-way interactions were found for physical and psychosocial disability, suggesting that educational level should be included in analyses exploring racial group differences. The results suggest the need for pain treatments that take into account the educational and cultural context of pain. PERSPECTIVE: This article demonstrates that demographic variables such as race and education should be considered together when evaluating the effectiveness of coping with pain. The findings have the potential to enhance research and clinical practice with diverse groups.

Improvement in fibromyalgia symptoms with acupuncture: results of a randomized controlled trial.
Martin DP, Sletten CD, Williams BA, Berger IH
Mayo Clin Proc. 2006 Jun;81(6):749-57.

OBJECTIVE: To test the hypothesis that acupuncture improves symptoms of fibromyalgia. PATIENTS AND METHODS: We conducted a prospective, partially blinded, controlled, randomized clinical trial of patients receiving true acupuncture compared with a control group of patients who received simulated acupuncture. All patients met American College of Rheumatology criteria for fibromyalgia and had tried conservative symptomatic treatments other than acupuncture. We measured symptoms with the Fibromyalgia Impact Questionnaire (FIQ) and the Multidimensional Pain Inventory at baseline, immediately after treatment, and at 1 month and 7 months after treatment. The trial was conducted from May 28, 2002, to August 18, 2003. RESULTS: Fifty patients participated in the study: 25 in the acupuncture group and 25 in the control group. Total fibromyalgia symptoms, as measured by the FIQ, were significantly improved in the acupuncture group compared with the control group during the study period (P = .01). The largest difference in mean FIQ total scores was observed at 1 month (42.2 vs 34.8 in the control and acupuncture groups, respectively; P = .007). Fatigue and anxiety were the most significantly improved symptoms during the follow-up period. However, activity and physical function levels did not change. Acupuncture was well tolerated, with minimal adverse effects. CONCLUSION: This study paradigm allows for controlled and blinded clinical trials of acupuncture. We found that acupuncture significantly improved symptoms of fibromyalgia. Symptomatic improvement was not restricted to pain relief and was most significant for fatigue and anxiety.

Cystic endometriosis of the epididymis.
Giannarini G, Scott CA, Moro U, Grossetti B, Pomara G, Selli C
Urology. 2006 Jun 27;68(1):203.e1-203.e3.

Endometriosis of the male genitourinary tract is an exceedingly rare entity, with only 6 cases reported to date involving the bladder, prostate, lower abdominal wall, and paratesticular region. We present what we believe to be the first case of cystic endometriosis of the epididymis in a 27-year-old man with scrotal pain, describe its pathologic and immunohistochemical features, and discuss its pathogenesis.

A rare case of precoccygeal endometriosis.
Batt RE, Lele SB, Yeh J
Obstet Gynecol. 2006 Jul;108(1):213.

Superior Hypogastric Block: Transdiscal versus Classic Posterior Approach in Pelvic Cancer Pain.
Gamal G, Helaly M, Labib YM
Clin J Pain. 2006 Jul-Aug;22(6):544-7.

OBJECTIVE: The classic posterior approach of superior hypogastric block has several technical difficulties. The transdiscal approach is a novel and easier approach for superior hypogastric which overcome these technical difficulties. METHODS: Thirty patients were randomly allocated to two groups: The transdiscal group and the classic group; visual analog scale pain scores, daily morphine consumption, duration of the procedure and side effects were recorded. RESULTS: The duration of the procedure was significantly decreased in the transdiscal group (24.4+/-5.6 min) compared to the classic group (57.9+/-9.8 min). There were no significant differences between the 2 groups in daily morphine consumption and VAS pain scores. There was no discitis, disc rupture, or herniation in the transdiscal group. CONCLUSION: The transdiscal approach for superior hypogastric plexus block in pelvic cancer pain is easier, safer, and more effective with less side effects than the classic approach.

Pharmacologic management of complex regional pain syndrome.
Rowbotham MC
Clin J Pain. 2006 Jun;22(5):425-9.

Few randomized controlled trials of oral pharmacotherapy have been performed in patients with complex regional pain syndrome (CRPS). The prevalence of CRPS is uncertain. Severe and advanced cases of CRPS are easily recognized but difficult to treat and constitute a minority compared with those who meet minimum criteria for the diagnosis. Unsettled disability or liability claims limit pharmaceutical industry interest in the disorder. Many studies are small or anecdotal, or are reported on only via posters at meetings. Targeting the process of bone resorption with bisphosphonate-type compounds such as calcitonin, clodronate, and alendronate has shown efficacy in three published randomized controlled trials. Intravenous phentolamine has been studied both alone and in comparison to intravenous regional blockade or stellate ganglion block. Steroids continue to be administered by multiple routes without large-scale placebo-controlled trials. Topical medications have received little attention. There has been considerable interest in the use of thalidomide and TNF-alpha blockers for CRPS, but no published controlled trials as of yet. Numerous other oral drugs, including muscle relaxants, benzodiazepines, antidepressants, anticonvulsants, and opioids, have been reported on anecdotally. Some therapies have been the subject of early controlled studies, without subsequent follow-up (eg, ketanserin) or without an analogous well-tolerated and equally effective oral treatment (eg, intravenous ketamine). Gabapentin, tricyclic antidepressants, and opioids have been proven effective for chronic pain in disorders other than CRPS. Each has shown a broad enough spectrum of analgesic activity to be cautiously recommended for treatment of CRPS until adequate randomized controlled trials settle the issue. The relative benefit of oral medications compared with the widely used treatments of intensive physical therapy, nerve blocks, sympathectomy, intraspinally administered drugs, and neuromodulatory therapies (eg, spinal cord stimulation) remains uncertain. In summary, treatment of CRPS has received insufficient study and remains largely empirical.

Treatment of complex regional pain syndrome: functional restoration.
Harden RN, Swan M, King A, Costa B, Barthel J
Clin J Pain. 2006 Jun;22(5):420-4.

In this review, the authors discuss the development of consensus-based treatment guidelines in 1997. They also synthesize the recommendations of a closed workshop held in Budapest in late 2004 that reexamined these treatment guidelines and made further and more detailed recommendations. They explore and develop the rationale for making functional restoration the pivotal treatment algorithm in the management of complex regional pain syndrome, around which all other treatments, such as psychotherapy, drugs, and interventions, revolve. The authors discuss in detail the process of functional restoration and the modalities appropriate to accomplishing that--specifically, the role of the occupational therapist, physical therapist, recreational therapist, and vocational rehabilitation specialist. Medications, interventions, and psychotherapy will be covered in other sections of this series.

Diagnosis of complex regional pain syndrome: signs, symptoms, and new empirically derived diagnostic criteria.
Harden RN, Bruehl SP
Clin J Pain. 2006 Jun;22(5):415-9.

This review will discuss the relevant history of the taxonomy and eventual development of diagnostic criteria of what is currently called complex regional pain syndrome. The authors will take their discussion through the early days (at which time the disorder was called reflex sympathetic dystrophy) through consensus-developing conferences to the current conceptualization of the criteria as published by the International Association for the Study of Pain's Task Force on Taxonomy in 1994. The authors will also mention the recent work of the closed workshop held in Budapest in 2004, where clinical and research criteria were proposed; these criteria were published in 2005. The review will also address issues of staging and subtyping the syndrome, as well as a discussion of the salient signs, symptoms, and tests appropriate for use in the diagnosis.

Pieces of the puzzle: management of complex regional pain syndrome.
Nelson DV
Clin J Pain. 2006 Jun;22(5):413-4.

May

Chronic pelvic pain and quality of life after laparoscopy.
Cox L, Ayers S, Nala K, Penny J
Eur J Obstet Gynecol Reprod Biol. 2006 May 26;.

OBJECTIVES: To examine the long-term relationship between chronic pelvic pain (CPP) and quality of life and see if this is affected by a negative laparoscopy result. STUDY DESIGN: A postal questionnaire survey of CPP and quality of life in 63 women who underwent a diagnostic laparoscopy 12-18 months previously. RESULTS: Women with CPP still reported pain 12-18 months after laparoscopy and a significantly poorer quality of life than UK norms for women of a similar age. Factor analysis showed that reports of pain symptoms clustered into two dimensions: (1) pain associated with menstruation and (2) pain associated with sexual intercourse and bladder and bowel function. Most dimensions of quality of life were significantly associated with pain. However, 'role limitation due to emotional problems' and 'mental health' were only associated with pain due to sexual intercourse and bladder and bowel function. Pain and quality of life were not affected by laparoscopy result or follow-up appointment. CONCLUSIONS: Women with CPP continue to have pain and a low quality of life 12-18 months after laparoscopy. Laparoscopy results and follow-up appointments do not appear to affect either pain symptoms or quality of life in the long term, although this may be confounded by women obtaining treatment elsewhere.

Long-term outcomes after surgical and nonsurgical management of chronic pelvic pain: One year after evaluation in a pelvic pain specialty clinic.
Lamvu G, Williams R, Zolnoun D, Wechter ME, Shortliffe A, Fulton G, Steege JF
Am J Obstet Gynecol. 2006 May 24;.

OBJECTIVE: The purpose of this study was to describe long-term outcomes for women with chronic pelvic pain (CPP) after evaluation in a CPP specialty clinic. STUDY DESIGN: This was a prospective observational cohort study of women treated for CPP at the UNC Pelvic Pain clinic between 1993 and 2000. The primary outcome was improvement in pain and the main exposure was treatment group: primarily medical (pharmacotherapy, psychotherapy, physical therapy, or combinations of the 3) or surgical (hysterectomy, resection or ablative procedures, oophrectomy, diagnostic surgery, pain mapping, vulvar or vestibular repair). Univariate, bivariate, and multivariable analyses were performed to look for relationships between background characteristics, treatment group, and improvement in pain. RESULTS: Of 370 participants; 189 had surgical treatment and 181 had medical treatment. One year after evaluation, 46% reported improvement in pain and 32% improvement in depression. Improvement in pain was similar in both treatment groups and odds of improvement were equal even after adjusting for background characteristics, psychosocial comorbidity, and previous treatments. CONCLUSION: One year after evaluation in a CPP specialty clinic, women experienced modest improvements in pain and depression after recommended surgical or nonsurgical treatment.

Pain intensity and pain affect in relation to white matter changes.
Oosterman JM, van Harten B, Weinstein HC, Scheltens P, Scherder EJ
Pain. 2006 May 31;.

Since aging is a risk factor for both dementia and the occurrence of painful conditions, with the number of aged people increasing in the next decades, an increase in the number of elderly people suffering from both conditions can be anticipated. Reliable pain assessment in this population is restricted by reduced communicative and cognitive capacity, with serious consequences for effective pain treatment. White matter changes are frequently observed in the various subtypes of dementia as well as in normal aging, and may play a crucial role in pain processing. In healthy elderly people, reliable pain assessment can be accomplished, which enables examining the relationship between pain experience and white matter changes. A normal structure and function of the white matter is extremely important for dorsolateral prefrontal cortex (DLPFC) functioning, which has recently been linked to pain inhibition. The present study focused on the relation between white matter changes and both pain intensity and pain affect in elderly people without dementia. The Coloured Analogue Scale (CAS) and the Number of Words Chosen-Affective (NWC-A) were applied to measure pain intensity and pain affect, respectively. The presence of white matter changes was significantly related to a higher score on the NWC-A but not the CAS score. These results suggest that pain experience may change as a result of aging and that white matter changes might be indicative for these alterations.

A case-control study of risk factors in men with chronic pelvic pain syndrome.
Berger RE
J Urol. 2006 Jun;175(6):2122.

Use of telemedicine in chronic pain consultation: a pilot study.
Peng PW, Stafford MA, Wong DT, Salenieks ME
Clin J Pain. 2006 May;22(4):350-2.

OBJECTIVES: Telemedicine has been used extensively in various settings, including monitoring patient treatment response and counseling. However, there are few data on the application of telemedicine to chronic pain patients. The present study was the first pilot project to determine whether telemedicine technology for chronic pain consultation was feasible, cost-saving, and satisfactory to patients and pain physicians. METHODS: A prospective pilot study was conducted on chronic pain patients requiring follow-up consultations using telemedicine technology. Patients were interviewed by phone following the consultation. RESULTS: Eleven telemedicine anesthesia consultations involving eight patients (age 42+/-9 years; six men, two women) were performed. All were follow-up consultations. The average distance from patients' home to the clinic was 314+/-170 km. The reasons for consultation were for update of patient progress (10/11), medication change (6/11), and counseling (3/11). The time to complete the consultation was 24.5+/-9.5 minutes. The data for the time and the cost that the patient spent on the consultation are presented as median and 25% to 75% interquartile range. Patients having telemedicine consultations spent 0.9 hours (0.83-1) and Canadian dollar 3 (dollar 2-4) versus an estimate of 8 hours (6-8) and Canadian dollar 80 (dollar 46-260) for a conventional consultation (both P<0.005). Telemedicine consultation was found to be highly satisfactory to the patient and the consulting and attending anesthesiologists. CONCLUSIONS: This pilot study indicates that telemedicine follow-up consultations for chronic pain patients are feasible and cost-saving. Patients and anesthesiologists were highly satisfied with telemedicine consultation. Patients reported a significant saving in time and cost compared with a conventional consultation.

A new classification is needed for pelvic pain syndromes--are existing terminologies of spurious diagnostic authority bad for patients?
Abrams P, Baranowski A, Berger RE, Fall M, Hanno P, Wesselmann U
J Urol. 2006 Jun;175(6):1989-90.

Persistent postsurgical pain: risk factors and prevention.
Kehlet H, Jensen TS, Woolf CJ
Lancet. 2006 May 13;367(9522):1618-25.

Acute postoperative pain is followed by persistent pain in 10-50% of individuals after common operations, such as groin hernia repair, breast and thoracic surgery, leg amputation, and coronary artery bypass surgery. Since chronic pain can be severe in about 2-10% of these patients, persistent postsurgical pain represents a major, largely unrecognised clinical problem. Iatrogenic neuropathic pain is probably the most important cause of long-term postsurgical pain. Consequently, surgical techniques that avoid nerve damage should be applied whenever possible. Also, the effect of aggressive, early therapy for postoperative pain should be investigated, since the intensity of acute postoperative pain correlates with the risk of developing a persistent pain state. Finally, the role of genetic factors should be studied, since only a proportion of patients with intraoperative nerve damage develop chronic pain. Based on information about the molecular mechanisms that affect changes to the peripheral and central nervous system in neuropathic pain, several opportunities exist for multimodal pharmacological intervention. Here, we outline strategies for identification of patients at risk and for prevention and possible treatment of this important entity of chronic pain.

Psychiatric comorbidities in a community sample of women with fibromyalgia.
Raphael KG, Janal MN, Nayak S, Schwartz JE, Gallagher RM
Pain. 2006 May 12;.

Prior studies of careseeking fibromyalgia (FM) patients often report that they have an elevated risk of psychiatric disorders, but biased sampling may distort true risk. The current investigation utilizes state-of-the-art diagnostic procedures for both FM and psychiatric disorders to estimate prevalence rates of FM and the comorbidity of FM and specific psychiatric disorders in a diverse community sample of women. Participants were screened by telephone for FM and MDD, by randomly selecting telephone numbers from a list of households with women in the NY/NJ metropolitan area. Eligible women were invited to complete physical examinations for FM and clinician-administered psychiatric interviews. Data were weighted to adjust for sampling procedures and population demographics. The estimated overall prevalence of FM among women in the NY/NJ metropolitan area was 3.7% (95% CI=3.2, 4.4), with higher rates among racial minorities. Although risk of current MDD was nearly 3-fold higher in community women with than without FM, the groups had similar risk of lifetime MDD. Risk of lifetime anxiety disorders, particularly obsessive compulsive disorder and post-traumatic stress disorder, was approximately 5-fold higher among women with FM. Overall, this study found a community prevalence for FM among women that replicates prior North American studies, and revealed that FM may be even more prevalent among racial minority women. These community-based data also indicate that the relationship between MDD and FM may be more complicated than previously thought, and call for an increased focus on anxiety disorders in FM.

April

Treatment of non cardiac chest pain: a controlled trial of hypnotherapy.
Jones H, Cooper P, Miller V, Brooks N, Whorwell PJ
Gut. 2006 Apr 20;.

BACKGROUND: Non cardiac chest pain (NCCP) is an extremely debilitating condition of uncertain origin which is difficult to treat and consequently has a high psychological morbidity. Hypnotherapy has been shown to be effective in related conditions such as irritable bowel syndrome where its beneficial effects are long lasting. AIMS: This study aimed to assess the efficacy of hypnotherapy in a selected group of patients with angina- like chest pain in whom coronary angiography was normal and oesophageal reflux was not contributory. Patients & METHODS: 28 patients fulfilling the entry criteria were randomised to receive, after a four week baseline, either 12 sessions of hypnotherapy or supportive therapy plus placebo medication, over a seventeen week period. The primary outcome measure was a global assessment of chest pain improvement. Secondary variables were a change in scores for quality of life, pain severity, pain frequency, anxiety, and depression as well as any alteration in the use of medication. RESULTS: 12 of 15 (80%) hypnotherapy patients versus 3 of 13 (23%) controls experienced a global improvement in pain (p=0.008) which was associated with a significantly greater reduction in pain intensity (p=0.046) although not frequency. Hypnotherapy also resulted in a significantly greater improvement in overall wellbeing in addition to a reduction in medication usage. There were no differences favouring hypnotherapy with respect to anxiety or depression scores. CONCLUSION: Hypnotherapy appears to have utility in this highly selected group of NCCP patients and warrants further assessment in the broader context of this disorder.

Sex differences in adolescent chronic pain and pain-related coping.
Keogh E, Eccleston C
Pain. 2006 Apr 24;.

Sex differences exist in pain and the strategies used to cope with pain. Although it is has been proposed that such differences become apparent around puberty, somewhat surprisingly very little research has specifically investigated sex as a moderator of pain within adolescents. The primary aim of the current study was to investigate sex differences in pain and coping within a group of 46 male and 115 female adolescent chronic pain sufferers. All were aged between 11 and 19 years and had been referred to the Pain Management Unit at the Royal National Hospital for Rheumatic Diseases, United Kingdom. Patients completed a battery of measures including pain experiences and a pain coping questionnaire. No sex differences were found in pain chronicity, although males and females did differ in self-reported pain experiences (females reported higher pain). Sex differences were also found in coping behaviours. Females used more social support, positive statements and internalizing/catastrophizing, whereas males reported engaging in more behavioural distraction. Of these strategies internalizing/catastrophizing was found to mediate the relationship between sex and pain. This suggests that not only do sex differences exist in the pain experiences and pain-coping strategies of adolescents with chronic pain, but that internalizing/catastrophizing may be an important mechanism in understanding such differences. More research examining potential sex differences in children and adolescents is recommended.

Nerve injury: an exceptional cause of pain after TVT.
Vervest HA, Bongers MY, van der Wurff AA
Int Urogynecol J Pelvic Floor Dysfunct. 2006 Apr 22;.

Persistent pain after a tension-free vaginal tape procedure is rare. Perforation or erosion of the tape into the bladder, urethra, or vagina; hematoma formation; and tape rejection are the most common causes. Less frequent causes are injury to the pelvic bone or to iliopectineal ligaments. In this case report, we present the passage of the tape through a nerve structure as the source of persistent and severe retropubic pain. Diagnostic procedures, such as cystoscopy, ultrasound, and MRI scanning, showed no abnormal findings. Treatment was initially conservative, but only locally injected analgesics and corticosteroids relieved the pain temporarily. Finally, surgical exploration revealed the inadvertent course of the tape through branches of the ilioinguinal/iliohypogastric nerve, which only became clear after pathological examination of the excised tape.

When Does Chronic Pain Become Intractable and When Is Pharmacological Management No Longer Appropriate? The Pain Specialist's Perspective.
Puig MM
J Pain Symptom Manage. 2006 Mar;31(4 Suppl):S1-2.

[Persistent abdominal pain.]
Coffin B, Sabate JM, Jouet P
Gastroenterol Clin Biol. 2006 Mar;30(3):392-8.

March

Ureteral endometriosis in patients after total abdominal hysterectomy: presentation and diagnosis: a case series.
Pugliese JM, Peterson AC, Philbrick JH Jr, Allen RC Jr
Urology. 2006 Mar;67(3):622.e13-5.

Although ureteral endometriosis is uncommon, it is a significant disease process that can cause irreversible renal damage because of delays in diagnosis. It is even more uncommon and therefore more likely to be left out of the differential diagnosis in postmenopausal women. This case series reviewed the clinical presentation and treatment of ureteral endometriosis, as well as the history and treatment of 3 postmenopausal women who presented with ureteral obstruction secondary to ureteral endometriomas.

Percutaneous-guided pain control: exploiting the neural basis of pain sensation.
Adolph MD, Benedetti C
Gastroenterol Clin North Am. 2006 Mar;35(1):167-88.

A prospective audit of 300 consecutive young women with an acute presentation of right iliac fossa pain.
Rennie AT, Tytherleigh MG, Theodoroupolou K, Farouk R
Ann R Coll Surg Engl. 2006 Mar;88(2):140-3.

INTRODUCTION: A prospective study of 300 women of child-bearing age presenting with right iliac fossa pain was carried out to determine what proportion had appendicitis and whether active observation resulted in a delay in diagnosis to the detriment of the patient.PATIENTS AND METHODS: Data were prospectively collected for 300 consecutive women of childbearing age referred with right iliac fossa pain to general surgeons at a district general hospital.RESULTS: After clinical assessment, 71 were discharged home immediately. Two others were found to be pregnant and 4 admitted to gynaecology. The remaining 223 women were admitted to the general surgical unit, 112 of whom underwent immediate appendicectomy. Of these, 97 had acute appendicitis. Two suffered deep infection and two had a superficial wound infection. A further decision to operate was made in 42 of 111 patients admitted for active observation, with 36 having acute appendicitis and 2 having a carcinoid tumour. Four had a wound infection. The average in-patient stay of those admitted for active observation and not operated on was 2 days (range, 1-4 days) compared with a length of stay of 2 days (range, 1-7 days) for those who underwent 'immediate' appendicectomy.CONCLUSIONS: Most women of child-bearing age who present with right iliac fossa pain do not have appendicitis. Those who do not have the classical features of appendicitis or peritonism can be safely managed by active observation.

The rectal administration of lignocaine gel and periprostatic lignocaine infiltration during transrectal ultrasound-guided prostate biopsy provides effective analgesia.
Siddiqui EJ, Ali S, Koneru S
Ann R Coll Surg Engl. 2006 Mar;88(2):218-21.

INTRODUCTION: Transrectal ultrasound guided prostate needle biopsy (TRUS) is the standard procedure to diagnose or exclude prostate cancer. This procedure can be associated with significant discomfort, both on insertion of the ultrasound probe as well as on taking the biopsy. We evaluated a new technique for pain relief during TRUS biopsy.PATIENTS AND METHODS: In Group 1 (n = 60), the biopsies were taken without any analgesia. In Group 2 (n = 60), 11 ml of Instillagel (2% lignocaine) was administered rectally prior to probe insertion and 5 ml of 1% lignocaine periprostatic injection was administered before taking the biopsy. The discomfort encountered during the procedure was graded by the patient on a scale ranging from no discomfort to mild, moderate and severe pain.RESULTS: In Group 2, there was a marked reduction in the pain experienced during the procedure. The Chi-squared test for trend showed a significant association between the rectal administration of local anaesthetic gel and reduction in pain on probe insertion (P = 0.0001). There was also a significant association between the use of periprostatic lignocaine injection and reduction in pain on taking the biopsy (P < 0.0001).CONCLUSIONS: The use of lignocaine gel prior to probe insertion and periprostatic infiltration of lignocaine before taking the needle biopsy significantly reduces the pain experienced by the patient during TRUS-guided prostate biopsy.

Endometriosis as a model for inflammation-hormone interactions in ovarian and breast cancers.
Ness RB, Modugno F
Eur J Cancer. 2006 Apr;42(6):691-703. Epub 2006 Mar 13.

Chronic inflammation has been implicated in a variety of cancers. In this review, we consider associations between endometriosis and cancers both local (ovarian) and distant (breast). We review the epidemiological data linking endometriosis to ovarian and breast cancers. We then consider evidence for a role for sex steroid hormones and for inflammation in the aetiology of each of these cancers. Finally, we consider that endometriosis may promote alterations in sex steroid hormones and inflammatory mediators. A possible explanation for the association between endometriosis and these reproductive cancers may then be local and systemic enhancement of aberrant inflammatory and hormonal mediators. If this hypothesis is true, endometriosis may need to be considered as a risk factor for ovarian and breast cancers, triggering increasingly intensive surveillance. Moreover, treatments for endometriosis may require consideration of the impact on long-term cancer risk.

Endorectal Ultrasonography in Predicting Rectal Wall Infiltration in Patients With Deep Pelvic Endometriosis: A Modern Tool for an Ancient Disease.
Bahr A, de Parades V, Gadonneix P, Etienney I, Salet-Lizee D, Villet R, Atienza P
Dis Colon Rectum. 2006 Apr 5;.

PURPOSE: This study evaluated the validity of endorectal ultrasonography in predicting rectal infiltration in patients with deep pelvic endometriosis. METHODS: Patients were recruited consecutively in the Department of Surgical Gynecology of Diaconesses Hospital from April 1996 to July 2003. Inclusion criteria were the suspicion of deep pelvic endometriosis on the basis of outpatient history and/or clinical symptoms with a mass palpable on bimanual examination that might infiltrate the rectal wall. There were no exclusion criteria. Endorectal ultrasonography wasperformed by the same investigator with a 7.5-MHz to 10-MHz rigid probe, producing a 360 degrees view of the rectal wall and adjacent areas. We used surgical and histopathologic findings as the "gold standard" to evaluate the validity of endorectal ultrasonography. RESULTS: This study was based on 37 patients (mean age, 35.8 (range, 26-46) years) who underwent surgery. The time between endorectal ultrasonography and surgery ranged from 4 to 529 (mean, 88.7) days. Eight patients had endometriosis nodules penetrating the rectal wall. Endorectal ultrasonography showed sensitivity, specificity, a positive predictive value, and a negative predictive value of 87.5, 97, 87.5, and 97 percent, respectively, in the diagnosis of infiltration of the rectal wall by endometriosis. CONCLUSIONS: Endorectal ultrasonography is a reliable technique for visualizing rectal infiltration in patients with deep pelvic endometriosis. It should be more widely used by gynecologists because knowing about rectal infiltration before surgery is fundamental to defining the best possible surgical approach.

Does back pain prevalence really decrease with increasing age? A systematic review.
Dionne CE, Dunn KM, Croft PR
Age Ageing. 2006 Mar 17;.

BACKGROUND: It is believed that the prevalence of back pain decreases around the middle of the sixth decade. However, back pain is still among the most commonly reported symptoms in the elderly and osteoarthritis, disc degeneration, osteoporosis and spinal stenosis all increase with age. In light of this, it is difficult to understand why the prevalence of back pain would decrease with increasing age. OBJECTIVE: This study aimed at summarising the scientific evidence on the trends of back pain prevalence with age. METHODS: Population-based studies reporting the prevalence of back pain, including people aged 65 years and over, were systematically retrieved from several bibliographic databases. These were read and assessed by two reviewers, and papers retained ('good quality studies') were aggregated according to specific criteria. RESULTS: Good quality studies showed a large heterogeneity as to their methods and prevalence figures. No specific patterns were detected by country nor outcome measure. However, most studies that considered severe forms of back pain found an increase of prevalence with increasing age. The curvilinear association between age and back pain prevalence that is widely mentioned in the literature was found only for benign and mixed problems. CONCLUSIONS: The evidence concerning the association of back pain prevalence with age is more sparse than currently believed and this association seems to be modified by the severity of the problem. This knowledge could have important public health implications, as the proportion of older people will increase considerably in the coming years in most industrialised societies.

Chronic pain couples: Perceived marital interactions and pain behaviours.
Newton-John TR, Williams AC
Pain. 2006 Mar 22;.

Patient adjustment to chronic pain is well known to be influenced by the spouse and his or her response to patient expressions of pain. However, these responses do not occur in a vacuum, and the aim of the present study was to investigate patient-spouse interactions in chronic pain in detail. Ninety-five patient-spouse dyads completed questionnaires relating to mood, marital satisfaction and communication, and 80 couples also took part in semi-structured interviews. Data were analysed using quantitative and qualitative methods. Results showed that spouses of chronic pain patients reported engaging in a far wider repertoire of responses to pain behaviours than has been recognised to date. New response categories of 'hostile-solicitous' and 'observe only' were identified. Patients generally interpreted solicitous responses less favourably than spouse responses which encouraged task persistence. Male spouses identified fewer pain-related situations than female spouses but were more likely to report responding solicitously to patient pain behaviours. Marital satisfaction was significantly higher in patients who rated themselves as talking more frequently about their pain. Spouse perceived frequency of pain talk was not related to spouse marital satisfaction. There were no gender differences in marital satisfaction. The results of this study challenge some of the assumptions that have been held regarding chronic pain patient-spouse interactions.

The utility of the pelvic pain urgency/frequency questionnaire in a urogynecology population.
Gogia L, Smith K, Kleeman S
Obstet Gynecol. 2006 Apr;107(4 Suppl):75S.

February

Women presenting with lower abdominal pain: a missed opportunity for chlamydia screening?
Lloyd TD, Malin G, Pugsley H, Garcea A, Garcea G, Dennison A, Berry DP, Kelly MJ
Surgeon. 2006 Feb;4(1):15-9.

INTRODUCTION: Many young women presenting with lower abdominal pain are referred to general surgeons with possible appendicitis. For some of these patients there will be a gynaecological cause for their pain. There has been a steady increase in the incidence of Chlamydia infections and pelvic inflammatory disease (PID) among the general population. Therefore, are general surgeons considering this as a diagnosis for lower abdominal pain in women? METHODS: One hundred and ninety three women who had been admitted with lower abdominal pain to a single hospital between 1999 and 2001 were identified using computerised records and the notes were examined. One hundred and eighty six women were included in the audit. Investigations and treatments instigated for these patients were then carefully recorded. RESULTS: Seventy-four patients underwent appendicectomy, of which 59 were histologically confirmed. Eighty-nine patients (47.8%) of admissions had no final diagnosis and were not screened for Chlamydia trachomatis. Sexual history was recorded in only 51% of admissions. Vaginal swabs were sent in only 7.3% of admissions. CONCLUSION: Current guidelines for Chlamydia trachomatis screening produced by the Chief Medical Officer (CMO) include screening in women presenting with lower abdominal pain as well as those with post-coital or intermenstrual bleeding. Most women who present with classical symptoms of PID will present to gynaecological specialities for further management. However, a significant number of women presenting atypically will be referred to surgeons to exclude gastrointestinal causes for their lower abdominal pain. These women could and probably should be screened for Chlamydia trachomatis.

Sex differences and hormonal influences on response to cold pressor pain in humans.
Kowalczyk WJ, Evans SM, Bisaga AM, Sullivan MA, Comer SD
J Pain. 2006 Mar;7(3):151-60.

Although most studies show that women have higher subjective pain ratings in response to painful stimuli, there is less consistency across studies with regard to the influence of gonadal hormones on pain responsivity. The present study evaluated sex differences in response to cold pressor pain in normally menstruating women (NMW), women maintained on oral contraceptives (OCW), and men. Testing occurred during 5 phases of the menstrual cycle. All participants completed 10 sessions (2 sessions per phase). During the cold pressor test, participants immersed the forearm into water maintained at 4 degrees C, and pain threshold and tolerance were measured. Subjective ratings of pain, physiologic indices, and plasma levels of estradiol and progesterone were also assessed. Both estradiol and progesterone levels varied as a function of menstrual cycle phase in NMW and were significantly higher in NMW compared with OCW and men. There were no significant differences in pain threshold or tolerance for any of the groups as a function of menstrual cycle phase. There were no significant differences in pain tolerance between groups. However, pain threshold was higher in NMW compared with OCW and men. When the data were reanalyzed across consecutive sessions, a significant sex-by-day interaction was observed for both threshold and tolerance. Specifically, pain threshold and tolerance were similar for NMW, OCW, and men, but these latencies changed at different rates across session days. Pain threshold remained relatively constant for both OCW and men, but it increased across days for NMW. Pain tolerance remained stable across sessions in OCW, a slow consistent increase was observed for men, whereas a sharper increase, followed by an asymptote, was observed for NMW. These results suggest that circulating gonadal hormones might mediate adaptation to cold pressor pain. PERSPECTIVE: The present study supports the notion that differences in pain perception between the sexes and among menstrual cycle phases are subtle. However, normally menstruating women exhibited an increase in pain tolerance and threshold over repeated stimulation, whereas men exhibited a shallow increase in pain threshold only, suggesting a sex difference in the adaptation to painful stimuli in men and women.

Effects of guided imagery on outcomes of pain, functional status, and self-efficacy in persons diagnosed with fibromyalgia.
Menzies V, Taylor AG, Bourguignon C
J Altern Complement Med. 2006 Jan-Feb;12(1):23-30.

Objectives: (1) To investigate the effects of a 6-week intervention of guided imagery on pain level, functional status, and self-efficacy in persons with fibromyalgia (FM); and (2) to explore the dose-response effect of imagery use on outcomes. Design: Longitudinal, prospective, two-group, randomized, controlled clinical trial. Setting and subjects: The sample included 48 persons with FM recruited from physicians' offices and clinics in the mid-Atlantic region. Intervention: Participants randomized to Guided Imagery (GI) plus Usual Care intervention group received a set of three audiotaped guided imagery scripts and were instructed to use at least one tape daily for 6 weeks and report weekly frequency of use (dosage). Participants assigned to the Usual Care alone group submitted weekly report forms on usual care. Measures: All participants completed the Short-Form McGill Pain Questionnaire (SF-MPQ), Arthritis Self- Efficacy Scale (ASES), and Fibromyalgia Impact Questionnaire (FIQ), at baseline, 6, and 10 weeks, and submitted frequency of use report forms. Results: FIQ scores decreased over time in the GI group compared to the Usual Care group (p = 0.03). Ratings of self-efficacy for managing pain (p = 0.03) and other symptoms of FM also increased significantly over time (p= <0.01) in the GI group compared to the Usual Care group. Pain as measured by the SF-MPQ did not change over time or by group. Imagery dosage was not significant. Conclusions: This study demonstrated the effectiveness of guided imagery in improving functional status and sense of self-efficacy for managing pain and other symptoms of FM. However, participants' reports of pain did not change. Further studies investigating the effects of mind-body interventions as adjunctive self-care modalities are warranted in the fibromyalgia patient population.

Does psychiatric treatment help patients with intractable chronic pain?
Kerns JW, White A, Nashelsky J, Sherman S
J Fam Pract. 2006 Mar;55(3):235-6.

Tricyclic antidepressants and intensive multidisciplinary programs are moderately effective for reducing chronic back pain; tricyclics are also effective for diabetic neuropathy and irritable bowel syndrome (strength of recommendation [SOR]: A, meta-analyses and multiple small randomized controlled trials). Cognitive therapies are modestly effective for reducing pain in the following: chronic back pain, other chronic musculoskeletal disorders including rheumatoid arthritis (SOR: B, multiple meta-analyses with significant heterogeneity), and for chronic cancer pain (SOR: B, 1 meta-analysis of various quality studies).

Predictors of adherence to treatment in women with fibromyalgia.
Dobkin PL, Sita A, Sewitch MJ
Clin J Pain. 2006 Mar-Apr;22(3):286-94.

OBJECTIVES: The goal of this study was to identify predictors of general and medication adherence in women with fibromyalgia (FM). METHODS: Participants were 142 women recruited from tertiary care hospitals or the community and 10 rheumatologists. Participants' demographic, clinical, and psychosocial characteristics, as well as patient-physician discordance, were assessed at the index visit. Adherence was assessed 6 months later. Multivariable generalized estimating equations were used to identify predictors of general adherence and adherence to medication. RESULTS: The average age of participants was 50.9 years (SD=10.2) and the median duration of FM was 32 months. Participants reported extensive use of health services and medications. The mean score for general adherence was 61.0 (SD=22.4; range 0-100) and 52.9% of the cohort reported at least one form of behavior reflecting nonadherence to medications. More general adherence was significantly predicted by lower patient-physician discordance on patient well-being and lower patient psychological distress. Medication adherence was significantly predicted by higher affective pain and lower patient psychological distress. CONCLUSIONS: Adherence is influenced by both clinical (patient-physician discordance and pain) and psychological (distress) factors in women with FM. Improvements in these domains may improve adherence in FM.

A randomized, double-masked, placebo-controlled pilot trial of extended IV lidocaine infusion for relief of ongoing neuropathic pain.
Tremont-Lukats IW, Hutson PR, Backonja MM
Clin J Pain. 2006 Mar-Apr;22(3):266-71.

OBJECTIVES: To determine the dose-response effect and safety of IV lidocaine at different dose infusion rates on spontaneous ongoing neuropathic pain. METHODS: In this double-masked, placebo-controlled, parallel study conducted in an outpatient clinical research center, patients with peripheral neuropathic pain received a 6-hour infusion of three doses (1, 3, and 5 mg/kg) of lidocaine or placebo. The main outcome measure was relief of pain intensity (percentage pain intensity difference [PID %]). Other measures were responder rate, adverse events, and correlation between lidocaine levels and PID %. RESULTS: There was a significant difference in the median PID % between the group treated with lidocaine 5 mg/kg/h (-34.60) and the placebo group (-11.96, P=0.012). Such effect began 4 hours after the onset of treatment and lasted until the end of the study. Lidocaine at lower infusion rates was no better than placebo in relieving pain. A modest but significant correlation was found between methylethylglycinexylidide (MEGX) levels and pain relief (R=0.60). There were no serious adverse events, but in two patients lidocaine was stopped prematurely. CONCLUSIONS: Lidocaine at 5 mg/kg/h was more effective than placebo at relieving neuropathic pain. The effect started 4 hours after the onset of treatment and continued for at least 4 hours after the end of the infusion. Additional research is needed using higher infusion rates with larger sample sizes to confirm these results and to explore the role of MEGX in the relief of neuropathic pain.

The role of helplessness, fear of pain, and passive pain-coping in chronic pain patients.
Samwel HJ, Evers AW, Crul BJ, Kraaimaat FW
Clin J Pain. 2006 Mar-Apr;22(3):245-51.

OBJECTIVES: The goal of this study was to examine the relative contribution of helplessness, fear of pain, and passive pain-coping to pain level, disability, and depression in chronic pain patients attending an interdisciplinary pain center. METHODS: One hundred sixty-nine chronic pain patients who had entered treatment at an interdisciplinary pain center completed various questionnaires and a pain diary. RESULTS: Helplessness, fear of pain, and passive pain-coping strategies were all related to the pain level, disability, and depression. When comparing the contribution of the predictors in multiple regression analyses, helplessness was the only significant predictor for pain level. Helplessness and the passive behavioral pain-coping strategies of resting significantly predicted disability. The passive cognitive pain-coping strategy of worrying significantly predicted depression. CONCLUSIONS: These findings indicate a role for helplessness and passive pain-coping in chronic pain patients and suggest that both may be relevant in the treatment of pain level, disability, and/or depression.

Complex regional pain syndromes: the influence of cutaneous and deep somatic sympathetic innervation on pain.
Schattschneider J, Binder A, Siebrecht D, Wasner G, Baron R
Clin J Pain. 2006 Mar-Apr;22(3):240-4.

OBJECTIVES: Complex regional pain syndromes (CRPS) can be relieved by sympathetic blockade. Different sympathetic efferent output channels innervate distinct effector organs (ie, cutaneous vasoconstrictor, muscle vasoconstrictor. and sudomotor neurons, as well as neurons innervating deep somatic tissues like bone, joints, and tendons). The aim of the present study was to elucidate in CRPS patients the sympathetically maintained pain (SMP) component that exclusively depends on cutaneous sympathetic activity compared with the SMP depending on the sympathetic innervation of deep somatic tissues. METHODS: The sympathetic outflow to the painful skin was modulated selectively in awake humans. High and low cutaneous vasoconstrictor activity was produced in 12 CRPS type 1 patients by whole-body cooling and warming (thermal suit). Spontaneous pain was quantified during high and low cutaneous vasoconstrictor activity. By comparing the cutaneous SMP component with the change in pain that was achieved by modulation of the entire sympathetic outflow (sympathetic ganglion block), the SMP component originating in deep somatic structures was estimated. RESULTS: The relief of spontaneous pain after sympathetic blockade was more pronounced than changes in spontaneous pain that could be induced by selective sympathetic cutaneous modulation. The entire SMP component (cutaneous and deep) changes considerably over time. It is most prominent in the acute stages of CRPS. CONCLUSIONS: Sympathetic afferent coupling takes place in the skin and in the deep somatic tissues, but especially in the acute stages of CRPS, the pain component that is influenced by the sympathetic innervation of deep somatic structures is more important than the cutaneous activation. The entire sympathetic maintained pain component is not constant in the course of the disease but decreases over time.

Inflammatory mediators are altered in the acute phase of posttraumatic complex regional pain syndrome.
Schinkel C, Gaertner A, Zaspel J, Zedler S, Faist E, Schuermann M
Clin J Pain. 2006 Mar-Apr;22(3):235-9.

OBJECTIVES: Complex regional pain syndrome type 1 (CRPS 1) is a disorder that can affect an extremity after minor trauma or surgery. The pathogenesis of this syndrome is unclear. It has clinical signs of severe local inflammation as a result of an exaggerated inflammatory response, but neurogenic dysregulation also may contribute to it. METHODS: For further insights into the pathogenesis of CRPS 1, the authors investigated inflammatory and neurogenic mediators-C-reactive protein (CRP), interleukin-6 (IL-6), interleukin-8 (IL-8), soluble tumor necrosis factor receptor I/II (sTNFR I/II), sE-selectin, sL-selectin, sP-selectin, substance P, neuropeptide Y, and calcitonin gene-related peptide-in venous blood from both the healthy arm and the arm with acute CRPS I from 25 patients and from 30 healthy volunteers. RESULTS: Levels of IL-8 and sTNFR I/II were significantly elevated in patients, whereas all soluble forms of selectins were significantly suppressed. There was no significant difference in white blood cell count (WBC), CRP, and IL-6. Substance P was significantly elevated in patients. The other two neuropeptides were unchanged. None of the parameters studied showed any differences between the CRPS I-affected arm and the normal arm. CONCLUSIONS: Elevated IL-8 and sTNFR I/II levels indicate an association between CRPS I and an inflammatory process. Normal WBC, CRP, and IL-6 give evidence for localized inflammation. The hypothesis of neurogenic-induced inflammation mediated by neuropeptides is supported by elevated substance P levels.

Factors predisposing women to chronic pelvic pain: systematic review.
Latthe P, Mignini L, Gray R, Hills R, Khan K
BMJ. 2006 Feb 16;.

OBJECTIVE: To evaluate factors predisposing women to chronic and recurrent pelvic pain.Design, data sources, and methods Systematic review of relevant studies without language restrictions identified through Medline, Embase, PsycINFO, Cochrane Library. SCISEARCH, conference papers, and bibliographies of retrieved primary and review articles. Two reviewers independently extracted data on study characteristics, quality, and results. Exposure to risk factors was compared between women with and without pelvic pain. Results were pooled within subgroups defined by type of pain and risk factors. RESULTS: There were 122 studies (in 111 articles) of which 63 (in 64 286 women) evaluated 54 risk factors for dysmenorrhoea, 19 (in 18 601 women) evaluated 14 risk factors for dyspareunia, and 40 (in 12 040 women) evaluated 48 factors for non-cyclical pelvic pain. Age <30 years, low body mass index, smoking, earlier menarche (<12 years), longer cycles, heavy menstrual flow, nulliparity, premenstrual syndrome, sterilisation, clinically suspected pelvic inflammatory disease, sexual abuse, and psychological symptoms were associated with dysmenorrhoea. Younger age at first childbirth, exercise, and oral contraceptives were negatively associated with dysmenorrhoea. Menopause, pelvic inflammatory disease, sexual abuse, anxiety, and depression were associated with dyspareunia. Drug or alcohol abuse, miscarriage, heavy menstrual flow, pelvic inflammatory disease, previous caesarean section, pelvic pathology, abuse, and psychological comorbidity were associated with an increased risk of non-cyclical pelvic pain. CONCLUSION: Several gynaecological and psychosocial factors are strongly associated with chronic pelvic pain. Randomised controlled trials of interventions targeting these potentially modifiable factors are needed to assess their clinical relevance in chronic pelvic pain.

January

Mastalgia: a review of management.
Olawaiye A, Withiam-Leitch M, Danakas G, Kahn K
J Reprod Med. 2005 Dec;50(12):933-9.

Mastalgia affects up to two-thirds of women at some time during their reproductive lives. It is usually benign, but thefear of underlying breast cancer is why many women present for evaluation. Mastalgia can be associated with premenstrual syndrome, fibrocystic breast disease, psychologic disturbance and, rarely, breast cancer. Occasionally, extramammary conditions, like Tietzie syndrome, present as mastalgia. A thorough clinical evaluation is required to assess the cause. The majority of women can be reassured after a clinical evaluation. Approximately 15% require pain-relieving therapy. Mechanical breast support; a low-fat, high-carbohydrate diet; and topical nonsteroidal antiinflammatory agents are reasonable first-line treatments. Hormonal agents, such as bromocriptine, tamoxifen and danazol, have all demonstrated efficacy in the treatment of mastalgia. Side effects, however, limit their extensive use. Danazol is the only FDA-approved hormonal treatment and is best used in cyclic form to limit the adverse effects. Lisuride maleate is a new agent recently studied for the treatment of mastalgia. Initial data on this medication are encouraging. Sixty percent of cyclic mastalgia recurs after treatment. Noncyclic mastalgia responds poorly to treatment but resolves spontaneously in up to 50% of cases.

Relations between pregnancy-related low back pain, pelvic floor activity and pelvic floor dysfunction.
Pool-Goudzwaard AL, Slieker ten Hove MC, Vierhout ME, Mulder PH, Pool JJ, Snijders CJ, Stoeckart R
Int Urogynecol J Pelvic Floor Dysfunct. 2005 Nov-Dec;16(6):468-74. Epub 2005 Apr 1.

To assess the occurrence of pelvic floor dysfunction (PFD) in pregnancy- related low back and pelvic pain (PLBP) patients, a cross-sectional study was performed, comprising 77 subjects. Each subject underwent physical assessment, and filled in the Urogenital Distress Inventory completed with gynaecological questions. Differences in the presence of PFD between PLBP patients and healthy controls as well as differences in pelvic floor muscle activity were tested for significance. Interaction by age and vaginal delivery were tested. PFD occurred in 52% of all PLBP patients, significantly more than in the healthy control group. In PLBP patients a significantly increased activity of the pelvic floor muscles could be demonstrated with respect to healthy controls. The occurrence of PFD and PLBP was influenced by a confounding effect of age. Clinicians should be aware of the relation between PLBP and PFD and hence address both problems at the same time.

High incidence of chronic pain following surgery for pelvic fracture.
Meyhoff CS, Thomsen CH, Rasmussen LS, Nielsen PR
Clin J Pain. 2006 Feb;22(2):167-72.

OBJECTIVES: To determine the incidence of chronic pain after surgery for pelvic fracture using a strict definition and measures of intensity and health-related quality of life. METHODS: In April 2004, a questionnaire was sent to 221 patients who underwent surgery for pelvic fracture in the period 1996 to 2000. Chronic pain was defined as pain at present that related back to the pelvic fracture and was not a consequence of other disease. Health-related quality of life was measured using the 15D questionnaire. RESULTS: The response rate was 72.9% after a median follow-up of 5.6 years. Chronic pain was seen in 48.4% (95% confidence interval, 40.7%-56.2%). These patients had a combination of somatic nociceptive, visceral nociceptive, and neuropathic pain and had significantly lower health-related quality of life. Also, the use of opioids (14.1% vs. 4.8%) and nonsteroidal anti-inflammatories/paracetamol (57.7% vs. 21.7%), the request for financial compensation (75.6% vs. 45.8%), and complications related to leg function (62.8% vs. 20.5%) were significantly higher in the group with chronic pain than in the group without chronic pain. CONCLUSIONS: Chronic pain after pelvic fracture is a major problem that affects a patient's quality of life. The use of analgesics was higher in these patients, and they had more complications. Chronic pain after surgery for pelvic fracture deserves more attention.

Use of a mechanical massage technique in the treatment of fibromyalgia: a preliminary study.
Gordon C, Emiliozzi C, Zartarian M
Arch Phys Med Rehabil. 2006 Jan;87(1):145-7.

OBJECTIVE: To investigate how a mechanical massage technique (LPG technique) could contribute to the treatment of fibromyalgia. DESIGN: Feasibility study. SETTING: A single center. PARTICIPANTS: Ten women having a preexisting diagnosis of fibromyalgia based on American College of Rheumatology criteria were enrolled. INTERVENTION: Subjects received a total of 15 sessions of mechanical massage administered by a physical therapist once a week. MAIN OUTCOME MEASURES: The Fibromyalgia Impact Questionnaire and a physical examination scoring tender points (number, pain intensity). Evaluations were conducted at the screening visit, after 7 sessions (V7), and after completion of 15 sessions (V15). RESULTS: Most of the parameters (pain intensity, physical function, number of tender points) showed a significant improvement at V15 compared with screening. CONCLUSIONS: The findings suggest the possibility that the studied intervention might be associated with positive outcomes in women with fibromyalgia, and support the need for a controlled clinical trial to determine its efficacy.

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