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HAS BOTULINUM TOXIN A ROLE IN THE MANAGEMENT OF CHRONIC LOW BACK PAIN?

A Al-Kaisy. T Nurmikko, T Nash, Pain Research Inst, The Walton Centre for Neurology and Neurosurgery NHS Trust, Liverpool L 9 7LJ, UK

Introduction Patients with chronic low back pain frequently complain of muscle tenderness, stiffness and spasms We set out to investigate to what extent muscular mechanisms might explain the pain in these patients Because intramuscular botulinum toxin has been shown to reduce pain in conditions with muscle spasms, we decided to evaluate its efficacy in these patients

Methods This is a double-blind randomised cross-over study on the effect of Botulinum Toxin A versus placebo Following approval of the local ethics committee, 18 patients with chronic lower back pain without radiculopathy and with clinical evidence of paraspmal muscle spasms were selected Physical examination included assessment of tenderness and spasticity of the following muscles bilaterally. iliopsoas, quadratus lumborum, pinformis, and erector spmae as described by Travell and Simons (1) All patients underwent functional EMG of erector spmae muscles In addition they all received physiotherapeutic assessment and advice Injections of the study drug (200mU of BOTOX) or saline were performed at an interval of 16 weeks under fluoroscopic guidance, aimed at the muscles clinically involved. Outcome measures included VAS, McGill Pain Questionnaire, SF-36, Oswestry Disability Index, and Global Evaluation carried out by the physiotherapist

Results This is an ongoing study and the results will be presented at the meeting

Acknowledgments Supported in part by an unrestricted grant from Allergan UK

(1) Travell JG, Simons DG. Myofascial Pain and Dysfunction, Vol2

LOW BACK PAIN

All Amaout, Abdul Karim Mohammad, Damascus Pain Relief Unit, Dept Of Anesthesia, Univ Of Damascus, Almouassat Hospital, Damascus, Syria

Aim of Investigation To compare and choose the best method that we can use to analgise the low back pain, which can be caused by a multitude of disease processes

Methods The most common of them is muscular in origin, namely myofascial syndrome "trigger points" Common skeletal etiologies include degenerative disease of the vertebral column (osteoarthri-tis), disc diseases and, joint involvement (sacroihitis) Rheumatoid and other types of inflammatory arthritis can cause low back pain. Results: We have studied 235 patients complaining of low back pain from different causes We use in our treatment modalities consist of spray and stretch technique. Trigger point injections of local anesthetics, massage therapy, transcutaneous electrical nerve stimulation and, acupuncture

Conclusion Medical treatment of pain by use Trigger Points injection technique of local anesthesia show that the duration of pain relief obtained by these methods is about 87% and it lasts more than one year, whereas it was about 50% in the other methods of therapy.

Acknowledgments Thanks for Dr. M Mozaffar K MD, for his computer support, and Damascus Univ for financial support.

A RANDOMISED, DOUBLE BLIND, CROSSOVER STUDY COMPARING ORAL TRAMADOL WITH ORAL CO-PROXAMOL FOR THE TREATMENT OF CHRONIC BACK PAIN

TA Bamigbade*. C McCartney*, M. Paes*, R M Langford*, W J Gallagher* (SPON: J M.G. Foster), Dept of Anaesthesia and Pain Clinic, St. Bartholomew's Hospital, Smithfield, London EC1A7BE.UK.

Aim of Investigation Moderate strength analgesic drug combinations and non-steroidal anti-mflamatory drugs (NSAlDs) are used in the treatment of chronic back pain They are often only partially effective and the prolonged use ofNSAIDs is associated with significant adverse effects Tramadol is a synthetic opioid analgesic, which also modulates monoammergic mechanisms in the inhibitory pain pathways, resulting in a synergistic analgesic effect We investigate whether tramadol is a suitable treatment for chrome back pain, lacking typical opioid adverse effects

Methods Tramadol was compared to co-proxamol (dextropro-poxyphene 37.5mg, paracetamol 500mg per tablet) in 52 patients with chronic back pain, of lumbar facet joint origin, in a randomised, double blind, crossover study Patients received tramadol (maximum 400mg daily) or co-proxamol (maximum 8 tablets daily) followed 3 weeks later, by crossover to the alternate medication Efficacy analysis compared the averaged pain scores using Analysis of Variance The study had 90% power to detect a 0.31 point difference (on a 4 point pain intensity scale) between the treatments at the 5% level of significance

Results 33 of the 52 patients, contributed to the efficacy analysis We detected no difference, in the daily average worst pain experienced, between treatments 73% of the patients, when taking tramadol, experienced adverse effects compared to 48% when taking co-proxamol (P=0 07) 19% of patients, when taking tramadol, were withdrawn compared to 6% when taking co-proxamo! (P=0 082)

Conclusions Tramadol was no better than co-proxamol for relieving chronic back pain, whilst having more adverse effects Acknowledgments' Supported by Searle, division ofMonsanto pie

CHRONIC PAIN FOLLOWING LUMBAR SPINAL SURGERY IN 1000 PATIENTS

E Berger* (SPON J.Stratford), Div Neurosurgery, Sir Mortimer B Davis J. General Hospital, McGill Univ. C P 75, Station Cote St Luc, Montreal, QC R4V 1 H8 Canada

Aim of Investigation To investigate the relationship between post-op chronic pain, objective neuro-muscular findings and subjective pain perception

Method A series of 600 patients with single operations, and 400 patients with multiple operations were examined clinically and radiologically 51 and 38 months following surgical intervention in work related accidents

Results In the group of 600 patients penradicular fibrosis was diagnosed preop in 0 67% and postop in 11% In the 400 patients with multiple operations, at the time of the second operation, the incidence of penradicular fibrosis had risen to 47%. In the 600 patient group with single operations 17 17% considered themselves improved, 31 67% remained unchanged and 51 33% considered themselves worse than pre-op 22 84% in the same group complained of chronic postop lumbar pain only while 59 32% complained of lumbar and unilateral leg, pain and 17 83% of lumbarand bilateral leg pain Four years after surgery one quarter only of the patients had returned to some kind of work

Conclusion. Proper patient selection and techniques to avoid pen-radicular fibrosis are necessary to prevent chronic post-operative pain

DOSE RESPONSE CHARACTERISTICS OF EPIDURAL STEROIDS

Alex Cahana MD, DAAPM, Benjamin Johnson MD, DABPMf, Dept of Anesthesiology, Sheba Medical Center, Tel-Hashomer, Israel 52621, f Director Pain Control Center, Vanderbilt Univ, Nashville, TN

Aim of Investigation The use ofepidural steroids for the treatment ofradicular low back pain is widespread, however optimal dosing has not been established The purpose of our study was to describe a dose response curve for Methylprednisolone (MP)

Methods Twenty patients with painful lumbar radiculopathy for 2-12 months were randomized to receive a single injection of 20, 40, 80, or 120mg MP Blood samples for plasma MP were obtained weekly on days 0-28 Back, sciatic pain (VAS), range of motion and neurological deficits were assessed blindly Patients filled Beck Depression Inventory (BDI), Speilberger State/Trait Anxiety Inventory (STAI), McGill Pain Questionnaire (MPQ) on each visit

Results Two patients were withdrawn as they failed to follow-up No correlation was found between epidural and plasma MP levels No difference in abnormalities on physical examination, VAS, MPQ, BDI and STAI scores were found between groups. VAS decreased from day 0 to 28 (10 ± 2 5 to 5 0 ± 3 0), and was inversely related to BDI, STAI in all groups

Conclusions We were unable to describe any correlation between epidural and plasma MP levels. We were unable to show a dose response curve and found that depression and anxiety were the only important determinants in clinical improvement regardless to the amount of MP administered We do not recommend measuring plasma MP for kinetic studies Selection of the epidural dose is probably inconsequential in the presence of severe depression or anxiety

MANAGEMENT OF SACROILIAC JOINT SYNDROME BY SUPPLEMENTING THE VISCOUS PROPERTIES OF SYNOVIAL FLUID

Octavio Calvillo, Una Srejic*, Adnan Dumitru* Center for Pain Medicine, Dept of Anesthesiology Baylor College of Medicine, Houston, Texas 77030

Aim of Investigation To investigate the effects of supplementing the viscoelastic properties ofsynovial fluid of the sacroiliac Joint [SIJ] in patients with sacroiliac joint syndrome [SIJS]

Methods We studied 12 patients with sacroiliac joint syndrome complaining of severe and incapacitating pain Ten patients had undergone lumbar fusion, the rest suffered from severe osteoarthn-tis of the spine The diagnosis was established by history and physical examination, and confirmed by injecting the SIJ with a local anesthetic under fluoroscopic guidance preceded by a positive arthrogram. All patients experienced analgesia after local anesthetic injection and received subsequently Ice ofhylan [8mg] into each Joint under fluoroscopic guidance preceded by a confirmatory arthrogram

Results All patients experienced pain relief [40-75%] in about 45-60 minutes, at 12 weeks post injection most patients experienced pain relief [60-75%] At 24 weeks seven of the 12 patients still experienced relief [40-60%].

Conclusions Viscosupplementation involves restoration of the rheological properties of the synovial fluid by injecting a viscoelastic substance into a joint The loss ofviscoelasticity of the synovial fluid in osteoarthntis results, at least partly, from a decrease in the quality of one of the major constituents ofsynovial fluid i e hyaluronan In osteoarthntis, there may be a decrease in the amount of hyaluronan, in addition there may be a decrease in the molecular weight of hyaluronan We are proposing that the pain m SIJS can be treated by supplementing the viscoelastic properties of synovial fluid in the SIJ by injecting hylan [a highly elastovis-cous solution of hyaluronan] The ideal treatment of SIJS remains to be discovered, however viscosupplementation is an option to be considered when other treatment modalities have failed in SIJS

CONVENTIONAL TREATMENT OF LOW BACK PAIN (LBP) AND ITS RELATIVE SUBJECTIVE TREATMENT SUCCESS (RSTS)

Joachim Chrubasik. Chnstian Conradt, Sigrun Chrubasik, Helmut Zappe, Sektion Allgemeinmedizin, Univ Hospital, Bergheimerstr. 147,69115 Heidelberg, FRG

Aim of Investigation To assess application and RSTS of conventional LBP treatment

Methods After Human Ethics Committee approval 315 patients (mean/± SD age 55/11 ys, size 168/13, weight 71/18) suffering from chronic LBP > 6 mos were asked which LBP treatment they had received in the past and if this treatment was effective Results Most popular treatments were heat application, gymnastics, and nonopioids followed by balneo-, electrical therapy and acupuncture Less popular were TENS and local anesthetic infiltrations and least popular nerve blocks, opioids and antidepressants (Fig) RSTS is also shown in the Fig

Conclusion Heat and balneotherapy as well as gymnastics are very promising to alleviate LBP (subjective success rates 70-80%) and seem to be as effective as oral nonopioids Further research is needed to compare treatment efficacy and to define the specific indications for their use

NUMBER OF PAIN-FREE PATIENTS: A USEFUL TOOL TO EVALUATE THE SUCCESS OF LOW BACK PAIN (LBP) TREATMENT

Sigrun Chrubasik. Christian Conradt, Helmut Zappe, Sektion Allgemeinmedizin, Univ Hospital, Bergheimerstr 147, 69115 Heidelberg, FRG

Aim of Investigation To assess the effectiveness of Harpagophytum extract (principal active constituent harpagoside, a cycio- and lipoxygenase inhibitor) in treatment of acute exacerbations of chronic LBP

Methods After Human Ethics Committee approval 197 patients (mean±SD age 56±11, weight 75'14, size 171 ±9) received randomly and double-blind either Harpagophytum extract with 50 mg (H;o) or 100 mg (Hioo) harpagoside/day or placebo (P) over 4 weeks Tramadol (T) was offered as rescue medication Patients were defined as pain-free when subjective pain (scale 0-4) and Tconsumption were zero on 5 days in week 4 (main cnteniim) The Arhus low back pain rating scale (AS) [a validated instrument (Pain 57 317-26, 1994)] was used as subsidiary measure. Relative differences from the AS starting indices (Ibefore - lend/Ibefore) were calculated For statistics, the Cochrane-Armitage test for trend was employed and, multiple regression analysis to identify con-founders

Results The number of pain-free patients was 3, 6 and 10 (p< 0 05) and AS relative change was 21%, 21% and 18% (ns) in groups P, hzoo and Hioo. respectively The component pain of AS was influenced by T consumption (p < 0 05).

Conclusion The number of pain-free patients is a reliable and independent tool to study the effectiveness ofLBP treatment Harpa-gophytum extract is a weak analgesic with a dose-dependent efficacy for acute exacerbations of chronic LBP Further studies are required to find the optimum Harpagophytum extract dose

POST-OPERATIVE PAIN IN SPINAL NEUROSURGERY

G. De Benedittis. R Campanella*, M Caroli*, M M Migliore*, F Tibeno* and R M Villani*, Pain Research & Treatment Unit, Inst ofNeurosurgery, Univ of Milan and Polichnico Hospital, 20121, Milan, Italy

Aim of InvestigationThe incidence, magnitude and duration of acute pain experienced by neurosurgical patients after various spinal operations are not known precisely, because of lack of well-designed clinical and epidemiological studies These important pain variables have been assessed in 51 consecutive patients (26 women, 25 men, 27-75 years, mean 45 9 years), who underwent vanous spinal neurosurgical procedures

Methods Indications for neurosurgery included (a) lumbar disk hemiation (70%),(b) cervical diskhemiation (10%), spinal stenosis (3%), (c) other (menmgiomas, cysts, etc ) (17%) The most important factors that influence the occurrence, intensity, quality and duration of post-operative pain included the following (a) the site, nature and duration of operation, the type of incision and the amount ofmtraoperative trauma, (b) the psychophysiologic make-up of the patient; (d) the presence ofsenous complications related to the operation and involving pain-sensitive structures, (e) the anesthetic management before, during and after the operation and (f) the quality of postoperative care

Results The incidence of post-operative pain for spinal surgery was significantly higher than reported after brain surgery (100% vs 60%) In 40% of the patients the intensity was moderate-to-severe Pain occurred most frequently in the first 48 hours following operation, but a significant number of patients had to endure pain for longer periods Relationships between type of surgery and excision, anesthetic management and post-operative care will be discussed Low back pain surgery was associated with significantly greater post-operative pain than cervical spinal surgery (p< 05) Sex, but not age, was significantly associated with the onset of pain, with males reporting a greater severity of post-operative pain Approx half of the patients operated-upon had a pathological MMPI profile. This psychological pattern predicted a significantly greater post-operative pain (p 05)

Conclusions Results of this pilot study indicate that post operative pain following spinal surgery is an important, although so far neglected, clinical problem, that deserves greater attention by surgical teams, in order to provide a better and more appropriate treatment

LOW BACK PAIN MANAGEMENT BY PHYSICAL THERAPY METHODS IN A DEVELOPING COUNTRY, INDIA

H N Debsarma. Dept. ofPMR, Inst of Neurological Sciences, Guwahati, India

Aims of Investigation An attempt has been made to compare the pain management in low back pain patients by two physical methods - deep heat modality viz Shortwave diathermy and superficial heat viz infrared therapy where comparative study of effectiveness of heat modalities is scant

Methods 14 males and 16 females, total 30 subjects with low back pain were taken in the study. Pain assessment of each subject was done at the start of the study Out of 30, a group of 15 each was treated for 10 days with same unit with deep heat - shortwave diathermy (SWD) continuously for 10 minutes and other group with superficial infrared (IR) heat therapy for 10 minutes Exercise therapy was suspended during the period At the end of the study evaluation of treatment efficacy to each subject was done by same method

Results Repeat comparable measure of pain by Visual Analogue scale (VAS 0-10) at the end of the study revealed significant response ofreliefofpam by SWD group than IR group A positive relationship was shown between the measure of pain intensity relief following deep heat modality

Conclusion This study showed that deep heat modality is more effective than superficial heat in pain management in LBP patients, however, infrared therapy may be more appropriate when deep heat is not possible or contramdicated

SPREAD OF EPIDURAL DOSE OF BUPIVACAINE AND STEROIDS IN FAILED BACK PROBLEM

Aly Essa*, Maged EI-Ansary. Avicenna Pain Relief Unit, Dept of Anesthetics, Faculty of Medicine, Al-Azhar Univ, Cairo, Egypt, PO Box274Dokki.

Aim of Investigation To know the actual spread ofbupivacame and steroids after long standing fixation ofepidural catheters with port in patients suffering from failed back problem.

Methods A group of 10, patients with arachnoiditis and suffering from intolerable low back and radicular pains, were selected All the patients had an epidural catheter and subcutaneous port was fixed on the anterior chest wall Injection of 10 ml ofbupivacame (0 25%) was given every 2 weeks and methylprednisolone 40 mg was added once a month After 6-18 months a volume of 10 ml of radio opaque contrast medium was injected and the spread of the fluid was monitored with serial X-ray films

Results Most of the lumbar epidural catheters showed cephalic spread Caudal injection proved escape of the drug through the anterior sacral foramina Long standing catheters fixed more than one year showed new epidural adhesions which resulted in catheter outward migration

Conclusion New adhesions may result from long standing catheters or irritation by the drugs injected (preservatives) Epidural injections ofbupivacame and steroids were proved to give limited effect in failed back syndrome Cases with good response were those in which the drug could reach the site of arachnoiditis Neu-rolysis by hyalunnidase E or hypertonic saline were of limited effect

PATIENTS WITH LOW BACK PAIN; A 12 YEAR FOLLOW-UP STUDY

Evans PJD, Bolcina A L , Dept of Pain Management, Channg Cross Hospital, London W6 8RF UK Aims

The purpose of this observational study was to evaluate the progress of patients with low back pain, who were originally referred to the Channg Cross Pam Management Centre, and seen there during the period 1985 - 1986

Methods and Study Population Subjects were recruited from the original cohort who participated in a study of personality structure and psychological features in patients with low-back pain This study, which was published in 1991' compared the results ofvan-ous psychological tests to each other, and to clinical and sociode-mographic information derived from these patients It also assessed the value of the MMPI, a long and complex series of questions, intended to investigate personality structure The intention of this present study was to make a similar assessment of patients using some of the original questionnaires and tests Disability Index/ Inappropriate symptoms, objective physical signs, previous In addition, a basic history sheet was used which was based on the original, with modifications to enable comparisons of each patient between the two time points The MMPI was not repeated in the follow-up study

Results Patients in the original study cohort were contacted, where possible, using addresses and/or telephone numbers as listed on the hospital computerised information system Of the original sample of 82, 3 had deceased, and 37 were no longer traceable This left just over 50% of the original cohort who we were able to contact Of these, 9 declined to participate in the follow-up study (3 gave specific reasons of poor health), leaving 32 of the original 82 study patients (39%) who we were able to include in this follow-up study Results have as yet to be analysed It is intended to use similar statistical tests as were used in the original publication, as well as tests appropnate to between-group comparisons for the various patient characteristics and test results at the two time-points

References: Main CJ, Evans PJD, Whitehead RC, "An investigation of personality structure and other psychological features in patients presenting with low-back pain a cntique of the MMPI", in Proceedings of the VIth World Congress on Pain, Eds. Bond MR, Charlton JE, WoolfCJ, Elsevier Science Publishers 1991

COMPARISON OF POSTPARTUM BACK PAIN WITH THAT OF PATIENTS REFERRED TO A BACK PAIN CLINIC

Frank AO. Sharma V*, Romney M*', Frank AD*, McAuley JH2, De Souza LH*, Loughnan B*', 'Depts of Rehabilitation, Obstetrics and Anaesthetics, Northwick Park Hospital & Inst of Medical Research, Harrow, HA1 3UJ, UK, Dept of Health Studies, Brunei Univ, Islewonh TW7 5DU, UK

Aim of InvestigationTo identify the features of back pain experienced by pnmipara (group 1) 7-14 months after delivery in terms of pain distribution, and to determine if it has a specific clinical profile or is of a generalised musculo-ligamental nature Methods. 104 pnmiparous women (group 1) were compared with 55 age-matched women examined by the same investigator in a rheumatological back clinic (group 2) Site and referral pattern of pain; Quebec Task Force (QTF) Group, straight leg raise test and the Roland and Moms disability questionnaire were assessed Analysis compared the two groups

Results Three subjects in group 1 were clinically depressed and excluded. Low back pain was experienced significantly more by group 2 (p=0.04), thoracic pain was experienced significantly more by group 1 (p=0.025), and neck/shoulder pain was experienced in 59% in group 1 Pain referred into buttock or leg (QTF groups 2 or lower) was significantly greater in group 2 (p<0001) The lowest SLR was significantly less (p<0 001) and more asymmetncal (p=0 004) in group 2. The mean Roland score was 4 7 in group 1 and 7 2 in group 2 (p<0 0001)

Conclusion Postpartum back pain is more diffuse and less likely to refer into the legs than back pain seen in a rheumatological clinic Postpartum back patients are significantly less disabled, with a Roland score commensurate with patients experiencing back pain in the community. Most post-partum back pain is likely to reflect musculo-ligamental pain

Acknowledgments North West Thames Regional Health Authority and Brunei Univ for financial support

PSYCHOLOGICAL ASSESSMENT AS PREDICTOR OF OUTCOME IN DISK SURGERY

Galilea E . Rebolledo P , Gonzalez M , Carbonell C , Vaienzuela P, (SPON AS Martin), Hospital del Trabajador, Santiago, Chile

Aim of Investigation Besides the organic aspects, psychosocial factors seems to be significantly involved in the success or failure of surgery The purpose of this study was to determine the value of psychological variables for predictors of outcome at 6 months in hemiated lumbar disk patients

Method Sixty nine work-injury patients with hemiated lumbar disk, underwent a semi-structured psychological interview and completed Goldberg Health Questionnaire-30 (GHQ-30) before the surgery between April 1997-Apnl 1998 in our institution Follow up was done reviewing clinical records at six month of surgery Diagnostic assessment includes 5 factors Psychophatology, Personality Traits, Psychosocial Stressors, Illness Behavior and Patient-Doctor Relationship We considered as good outcome when the patient return to work before sixty days after surgery Predictive relationship were sougth between psychosocial factors and good outcome

Results Age average was 39,8 years (23-66), educational level was 11,2 years (3-16) and 86% were married 52% were blue collar workers and 37% were white collar workers In accordance with the diagnostic assesment and outcome we obtained- Psychophatology patient with emocional disorders presented worse outcome in 30% of the cases respect those with good outcome (p<0,05) Patient with worse outcome obtained high score in GHQ-30 (9 points) The group with good outcome obtained 5 point on average (p<0,05) (cut off 7/8 points)- Psychosocial Stressors patients with low motivation to return to work, show worse outcome (44% of the cases) (p<0,05)-Illness Behavior 32% ptients with maladaptative illness behavior show worse outcome This diffrence was not statiscally significant -Personality traits and patiet-doctor relationship's variables, were not statistically significant in both group

Conclusions Emotional disorders, Low motivation to return to work and Maladaptative illness behavior were predictor of worse outcome in this study at 6 months follow up We will review clinical data and to compare this variables in one year follow up

ROLE OF IMMUNOLOGICAL AND ENDOCRINE DYSFUNCTIONS IN THE CHRONIFICATION OF PAIN: EVIDENCE IN PATIENTS SUFFERING FROM ONGOING SCIATIC PAIN FOLLOWING DISCECTOMY

Andrea Geiss, Renate Engel, Clemens Kirschbaum, D H Hell-hammer, Femand Anton, 'Center for Psychobiological and Psychosomatic Research, Univ of Trier, D-54290 Trier, Germany, Centre de Recherche Public de la Sante, Luxembourg

Aim of Investigation The aim of the present study was to replicate and extend previous findings (Neurosci Lett, 237, 65-68, 1997) indicating an attenuated responsiveness of the HPA axis and an enhanced IL-6 secretion in patients suffering from prolonged sciatic pain

Methods 10 patients suffering from ongoing sciatic pain following surgery were compared with 10 patients displaying low postoperative complaints and 9 healthy, pain-free volunteers regarding im-munological and endocrine parameters. Each subject participated in four sessions With respect to the endocrine parameters subjects were instructed to collect saliva samples between 0800 h and 2200h in intervals of2h throughout day 1 as well as in response to a low dose ofDEX (0 5 mg) (Dexamethasone-Suppression-Test) throughout day 4 Moreover, 5 saliva samples were also obtained in intervals of 15 minutes after waking up at 0700h Plasma 11 -6 concentrations were measured before and in response to the determination of mechanical pain thresholds (PT) on day 2 Further- more, we collected additional blood samples for in vitro determination of the dose-response curves ofLPS -induced TNFa- and IL-6 secretion in the presence of different doses ofDEX (lO'^-lO"6 M) on day 3.

Results Patients with ongoing pain exhibited a blunted increase of the cortisol secretion in response to awakening. The dysfunctional reactivity of the HPA axis was in addition characterized by a prolonged suppression of the cortisol secretion in response to DEX. Preliminary evaluation of the in vitro data also indicates that patients with ongoing complaints may display a relative gtucocorti-coid resistance as revealed by a higher dose of DEX needed to produce a 50% inhibition ofLPS-induced IL-6 cytokme production.

Conclusions Chronic pain syndromes might be related to dysfunctional interactions between neural, endocrine and immune systems. Further studies aimed at elucidating the mechanisms underlying the identified dysfunctions have to be performed.

BRAIN BIOCHEMICAL ABNORMALITIES IN CHRONIC BACK PAIN: AN IN VIVO HYDROGEN MAGNETIC RESONANCE SPECTROSCOPY (HMRS) STUDY

I.D. Grachev*. L. Zych*, S. Huckms*, B.E. Frednckson*, C.J. Hodge, A.V. Apkanan, Depts of Neurosurgery and Orthopedic Surgery, SUNY Health Science Center at Syracuse, NY, 13210, USA

Aim Our recent functional imaging studies show that the conical responses to painful stimuli are different between chronic pain patients and normal subjects. We hypothesized that these cortical activation differences may underlie biochemical abnormalities. To our knowledge, this is the first study of the regional brain biochemistry of chronic pain. Brain biochemistry was compared between chronic low back pain patients and normal subjects, using the'H MRS method.

Methods Localized in vivo HMRS was used to measure relative concentrations ofN-Acetyl aspartate (NAA), Creatine (Cr), Cho-line (Cho), Glutamate (Glu), Glutamine (Gin), y-Ammobutyric acid (GABA), Inositol (Ins), Glucose (Glc) and Lactate (Lac) within a 8mm brain's voxel. These measurements were performed in seven brain regions: thalamus, and cingulate, insula, sensorimotor, lateral prefrontal, orbital frontal, and visual cortices in the left hemisphere of right handed chronic back pain patients (n=5) and normal volunteers (n=19).

Results Chronic back pain patients demonstrated a significant decrease ofGlu/Cr, GIn/Cr, GABA/Cr, GABA+Glu/Cr, Cho/Cr and Glc/Cr ratios in the prefrontal cortex, and an increase of Glc/Cr, Ins/Cr, Glc/NAA and InsWAA ratios in the thalamus (Single-Factor ANOVA, patients vs. normals, p-values ranged between 0.01 and 0.0001). Most other brain regions showed no differences in metabolite concentrations between chronic back pain and control groups (P>0.05).

Conclusions 1) Chronic back pain seems to be related with abnormal biochemistry of the brain. 2) These abnormalities are region specific, are seen mainly in the lateral prefrontal cortex and the thalamus, where metabolite concentrations change in opposite directions. 3) The in-vivo 'H MRS is sensitive enough to detect pain related biochemical differences, and may be useful in assessing pain-states.

Acknowledgments Supported by NIH/NINDS RO 1 NS35115 and Dept ofNeurosurgery.

RELATIONSHIP OF PAIN WITH POSTOPERATIVE CT FINDINGS AND CLINICAL OUTCOME IN PATIENTS OPERATED ON FOR LUMBAR STENOSIS

A. Hemo, O. Airaksinen. T. Saari. Dept of Phys and Rehab Medicine, Univ Hospital, Kuopio, Finland.

Aim of Investigation To investigate the relationship of pain will CT-fmdings, subjective disability and walking capacity after surgery for lumbar spinal stenosis (LSS).

Methods The operated region was examined by CT which were classified into four stenosis groups: no stenosis (NoSte), central (CenSte), lateral (LatSte), and central-lateral (CenLat). The patient's subjective disability was based on the Oswestry questionnaire (Osw), and walking capacity was evaluated on a treadmill (Im/s, max 900 m). The severity of pain in the back and legs before and after the treadmill test was assessed using VAS. Accord ing to pain patients were classified into four groups: no pain at a] Painl(n=22); no pain before walking, but after walking in back a legs: Pain2 (n=18); pain only in back: Pain3 (n=24) and the rest. patients: Pain4 (n=l 18), altogether 182 patients.

 
Pain1
Pain2
Pain3
Pain4
 
NoSte (%)
33
33
37
36
 
CenSte (%)
18
11
29
22
 
LatSte (%)
32
28
13
17
 
CenLat (%)
18
28
21
25
 
Mean Osw
10
22
30
38
(p=0.0000)
Mean walk.
825
759
654
505
(p=0.0002)

Conclusions Pain influenced strongly on the patient's subjective disability and walking capacity, but the distribution ofCT findings was quite similar between the pain groups.

RELIABILITY OF ISOKINETIC TRUNK MUSCLE STRENGTH TEST, ASTRAND'S TEST AND PAIN ASSESSMENT IN PATIENTS WITH CHRONIC LOW BACK PAIN

A Keller*. J. Hellesnes*, J. I. Brox* (SPON: M, F. Wmnem), Dept of Physical Medicine and Rehabilitation, Ullevaal Univ Hospital, N-0407 Oslo, Noway.

Aim of the Study To determine the reproducibility of trunk muscle strength test by the Cybcx TEF isokmetic dynamometer in patients with chronic low back pain, and to make a comparison with the reproducibility of the Astrand's ergometnc bicycle test and pain assessment.

Methods Measurements were performed in 24 patients (9 men and 15 women) with chronic low back pain. All tests were carried out at 3 separate session on the same time of the day and with the same experienced examiner. The number of days between the sessions was 5-10 days. Trunk extension strength (total work) was measured at 3 angular velocities, 60°/sec, 120°/sec and 150°/sec. Pain on exertion was scored on a visual analogue scale after each session. The Astrand's test consisted of 6 min. exercise on an er-gometric bicycle while measuring the pulse in steady state. Results: There were significant differences in total work at the 3 time points for all 3 velocities (all p < 0.05, Fnedman's test). Post-hoc tests (Wilcoxon signed rank test) revealed a significant difference between tests 1 & 2, but not between tests 2 & 3. There was no significant difference between time points for Astrand's test or pain. The medians of the coefficients of variation (CV) and the critical differences (CD) for paired measurements (tests 1 & 2 and tests 2 & 3, respectively) are given in the table. Paired measurements for the muscle strength test were not carried out for tests 1 & 2 because there was significant difference in total work between these tests.

 
60°/sec
120°/sec
150°/sec
Astrand's test
Pain
Tests
2&3
2&3
2&3
1 &2
2 & 3
1 &2
2&3
CV (%)
6.5
8.4
8.2
8.3
5.9
7.2
6.6
D (%)
24.6
42.9
59.8
30.5
26.3
61.5
77.3

The CV for tests 2 & 3 of the muscle strength test at 60°/sec did not differ significantly from the CV for tests 2 & 3 ofAstrand's test and pain, but this was not the case for the two other angular velocities The CD at 60°/sec was of the same magnitude as the CD for Astrand's test, but lower than those for the two other velocities and pain

Conclusion. There seems to be a learning effect between 1 st and 2nd isokmetic test, but reproducibility at 60°/sec is comparable to Astrand's test We recommend that isokinetic test is carried out twice at 60°/sec and that the evaluation is based on the 2nd test

QUALITY OF LIFE, SELF-EFFICACY AND COGNITIVE PREDICTORS OF CHRONIC LOW BACK PAIN AND PEPTIC ULCER

Anand Kumar and Preeti Gupta, Dept of Psychology, M G Kashi Vidyapith Univ , Varanasi, G B Pant Hospital, New Delhi, India

Aim of Investigation Knowledge of quality of life, self-efficacy and cognitive predictors of chronic low back pain (CLBP) and peptic ulcer may definitely provide a significant approach to pain specialists for management and treatment of such patients This study explored the quality of life and self-efficacy of CLBP and peptic ulcer patients and association of cognitive factors with onset of these disorders

Methods 200 CLBP and 200 peptic ulcer patients (18-42 yrs , mean 28 36) were selected for this study who did not had any psychiatric or intemistic problems A control group of 200 normals, selected for this study, had never experienced any psychiatric or intemistic problems WHO Quality of Life Scale, Self-Efficacy Scale, Locus of Control Scale, Optimism Scale and Alienation Scale were administered to these groups individually

Results CLBP patients had several indices of lower quality of life, low level of self-efficacy, internal locus of control and passimism as compared to peptic ulcer patients, who manifested higher degree of alienation as compared to CLBP patients

Conclusions Cognitive factors are positively associated with onset of CLBP and peptic ulcer. CLBP patients need more attention because their impaired quality of life Findings may be utilised by the pain specialists for effective cognitive behavioral treatment of CLBP and peptic ulcer

THE RELATION BETWEEN GAIT COORDINATION AND ACTUAL PAIN IN SUBJECTS WITH NONSPECIFIC LOW BACK PAIN

Ciaudme J C. Lamoth. Onno G Meijer*, Robert C. Wagenaar'*, Paul I.J M. Wuisman* Faculty of Human Movement Science, Vrijc Umv, van der Boechorststraat 7, 1081 BT Amsterdam, The Netherlands Dept. of Physical Therapy, Sargent College of Health and Rehabilitation Sciences, Boston Univ, USA

Aim of Investigation To investigate the relation between coordination patterns of trunk rotation during gait and pain intensity in non-specific low back pain patients

Methods Transversal rotations of pelvis and thoracic movements of 10 patients with non-specific low back pain and 10 healthy subjects, were recorded during walking at a treadmill with different speeds. Relative phase between thorax and pelvis was calculated Patients rated the intensity of actual pain on a VAS

Results Patients walked slower compared to healthy subjects In healthy subjects, the coordination between pelvis and thorax changed from an in-phase to an out-of-phase pattern with increasing speed In contrast, out-of-phase coordination between pelvic and thoracic rotations at higher speeds was absent or diminished in patients. Patients who could not walk fast had low variability The difference in coordination between patients and healthy subjects was significant (p<0 01) A negative correlation (r=-0 803) was found between actual pain intensity and mean relative phase The more pain subjects had, the less counterrotation was found

Conclusion Most patients do not allow for counterrotation between pelvis and thorax when trying to increase walking speed This is related to self-reported pain-intensity The low variability of coordination in the most severe cases suggests an increased stiff-ness of the trunk, maybe by way of protective guarding or splinting to reduce or avoid pain In a following study, the relation between pain-related fear and gait coordination will be investigated Acknowledgments Supported in part by NWO Program Grant (#9904-65-090), and the Dutch Society of Exercise Therapists Mensendieck

EFFICACY OF MONODISCIPLINARY OUTPATIENT MANAGEMENT FOR LOW BACK PAIN

Eberhard Lang. Renate Eisele, Sdbine Kastner, Eberhard Heenng, Klaus Liebig, Neurological and Orthopaedic Dept, Unix ofErlan-gen-Numberg, D-91054 Eriangen, Germany

Aim of Investigation To investigate the actual efficacy of outpatient treatment for low back patients in middle franconia, a bavar-ian greater district with 1,6 Mio inhabitants

Methods All physicians of middle franconia (2100) involved in outpatient management were asked to include consecutively patients m the study which suffer from low back pain of at least 4 weeks duration without decreasing intensity Before and after a 6 months interval patients documented the following outcome data in a questionnaire- pain intensity on a visual analogue scale, pain dependent disability by means of Brief Pain Inventory, pain dynamic (intermittent, constant with fluctuating and non-fluctuating intensity) and days of inability to work within 3 months before start and end of the interval Physicians staged chronification of patients according to Gerbershagen [Internist 27 459-469(1986)] Treatment of patients was not standardized and included the natural spectrum of non-surgical therapies for low back pain except mul-timodal pain therapy programs

Results 35 physicians participated on the study. Pre-post-data of 157 patients (43 ± 12 y) could be analysed Mean daily pain intensity and pain dependent disability improved by 30% and more of baseline value in 29% of patients Improvement of pain dynamic by one step occured in 21% of patients Days with inability to work within 3 months did not change significantly between time before (31 ± 38 days) and after treatment (30 ± 39 days) Chronification stage before treatment (1 20%, II 57%, III 23%) improved after treatment by one stage in 27% of patients Kind of treatment did not significantly influence any outcome parameter (ANOVA)

Conclusions Since less than one third of patients improved better than a possible placebo effect it is concluded that monodisciplinary treatment procedures of theses chronic low back patients were not sufficient Furthermore, positive outcomes did not depend on kind of treatment procedure It is assumed that even after moderate chronification of pain (stage II of Gerbershagen) multimodal pain therapy programs have to be used for adacquate pain relief acknowledgments Supported by BMG grant (GMKPO 1004995)

BEHAVIORAL CHARACTERISTICS OF A SUBGROUP OF CHRONIC LOW BACK PAIN PATIENTS WITH PAIN COMPLAINTS SENSITIVE TO DAILY MOOD

C. Lassalle. E Logak*, F Valentmi*, 0 Bayle*, C Vmgtnnier*, S M Consoli*, Pain Clinic and Dpt ofConsultation-Liaison Psychiatry, Broussais Hospital, Pans, 75014, France

Aim of Investigation Associations between chronic pain and depressive mood are well known, but the arguments for an etiological link from pain to depression or the reverse, are controversial.

Methods Clinical, psychosocial data, as well as data derived from a 2-weeks diary were collected from 35 chronic pain (mainly low back pain) patients attending a pain clinic (31 females and 4 males aged respectively 53 7±17 8 & 66 0±2 9) The pain diary allowed to assess once a day different pain, emotional and behavioral char actenstics and a global index of daily pain was computed from intensity and duration cues Several correlation coefficients were then computed for each patient either for simultaneous or for lag-time measures

Results Alexithymia was found in 20% and depression in 51% of this population (depression HAD-score ^8) Histograms of lag time correlation coefficients between pain and psychological van ables on the whole population showed neither a significant pain effect on mood or behavior nor a reverse effect, but in 39% of the population the correlation coefficient between day s mood and next days pain was >.Q 20 This subgroup of“ depression induced pain ”was charactenzed by a younger age lower baseline depression scores (p 0 04) and higher extent and quality of social support (Sarason scale) (p 0 02 & 0 04) The mean correlation coefficient between daily pain and daily perceived social support was negative for these patients (higher support-lower pain mean r - -0 18 p-0 03) contrary to the remaining population (mean r ~ 0 07 NS)

Conclusion Such results indicate that among patients suffering from chronic pain can be identified a subgroup with complaints sensitive to depressive mood which constitute an effective corn munication way with social network

THE IMPACT OF THERAPEUTIC EXERCISE ON THE DIFFERENCES IN PERCEPTION OF PAIN BETWEEN ACUTE AND CHRONIC LOW BACK PAIN

Marc McRae* and Robert Teasell Dept of Physical Medicine and Rehabilitation Univ of Western Ontario London Ontario, Canada N6A 5A5

Aim of Investigation Is the pain body diagram sensitive to differ ences between acute and chronic low back pain (LBP) patients in relation to other subjective scales of pain and disability

Methods Fifty-eight acute LBP patients (symptoms of less than 6 months) and 44 chronic LBP (symptoms greater than 6 months) attended a physiotherapy clinic for a therapeutic exercise program two to three times a week for a maximum of 6 weeks All patients completed a pain body diagram, a disability questionnaire (Quebec Back Pain Disability Scale) and a subjective pain seventy likert scale upon admission and discharge

Results Pnor to therapy the chronic LBP patients perceived their pain as being distributed over a larger portion of their body when compared to acute LBP patients (p<0 001) As well chronic LBP patients subjective expenence of pain and disability did not sig nificantly correlate with their perceived total body area score of pain extent (r = 0 20 and 0 23 respectively) However at the conclusion of therapy the pain body diagram correlated significantly with pain and disability for the chronic LBP patients (r - 0 57 and 0 50 respectively p<0001) For the acute LBP patients the pain body diagram was significantly correlated with their subjective experience of pain and disability at both the beginning (r 0 29 and 0 30, p< 0 05) and end of therapy (r = 0 27 and 0 27 p< 0 05)

Conclusion Pnor to completing the exercise therapy program chronic LBP patients tended to either over or under represent the extent of pain on their pain body diagram relative to the level of pain and disability expressed through the pain likert and disability scales However at the conclusion of therapy the chronic LBP patients appeared more like their acute LBP counterparts in that the perceived extent of their LBP as measured by the pain body diagram correlated with their pain severity and disability It appears that over time the chronic LBP patients over or under represents their perceived pain extent relative to their perceived pain severity and disability This may be due to different personality styles within this population (magnifiers versus mmimizers) The exercise therapy program appears to have made the chronic LBP pa tients more aware of the actual extent of their LBP

9th WORLD CONGRESS ON PAIN, 1999, Vienna, Austria, p. 181 - 187

   

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