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Joint and muscle pain


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Markus Gehling. Henner Niebergall, Carl E Scheldt, Michael Tryba, Klaus Geiger, Dept of Anesthesiology, Intensive Care and Pain Therapy, Moenchebergstr. 41-43, D-34125 Kassel, Germany

Aim of Investigation To determine the frequency and seventy of chronic pain in patients after trauma and elective trauma surgery

Methods Approval by the Ethics Committee of our institution Prospective cohort study of 201 consecutive patients admitted for trauma surgery Measurement of chronic pain severity using an established questionnaire instrument seven months after surgery Chronic Pain Grading rates chronic pain seventy as follows Grade 0 = pain free, Grade I = low pain intensity and low pain-related disability. Grade II = high pain intensity and low pain-related disability, Grade III = high pain-related disability and moderately limiting, and Grade IV = high pain-related disability and severely limiting

Results Seven months after operation, 159 trauma patients (79%) were interviewed by telephone Prevalence of chronic pain seven months after surgery Grade 0 in n=61 patients (38 4%), Grade I in n=54 (34.0%), Grade II in n=12 (7 5%), Grade III in n=9 (5 7%) and Grade IV in n=23 (14 5%) subjects Conclusion In a previous study of chronic pain grading in 1016 normal subjects 4 5 % showed pain and disability corresponding with chronic pain grade III and IV in our study In our study, 20 2% of trauma patients showed increased chronic pain ratings seven months after trauma Persistent pain may increase the nsk to develop chronic pain


Jane Greening. Sean Smart*, Bruce Lynn, Rachel Leaiy*, Margaret Hall-Craggs* Dept of Physiology, Univ College London and Medical Imaging Unit, Univ College London Hospitals, London WC1E6BT,UK

Aim of Investigation. To investigate median nerve mobility in patients with chronic diffuse arm pain associated with repetitive hand and finger use (often termed RSI or CTD)

Methods. Subjects were female, age range 23 - 30 years Subjects were imaged lying supine in an open access MR scanner (OPEN Viva, 0.2 T, Siemens) with their wrist immobilised in splints in neutral, 30 flexion and 30 extension MRJ was performed on 8 contiguous 5mm slices aligned perpendicular to the nerve, using a T2 weighted fast spin echo

Results. During wnst extension the nerve was compressed in a saggital plane against the flexor retmaculum During wnst flexion, nerve movement in a lateral and postenor direction was observed in all control subjects, the median nerve becoming interposed between the tendons of flexor pollicis longus and superficialis. The patients did not demonstrate this degree of movement, the nerve remaining closely associated with the flexor retmaculum Conclusions. Patients with chronic diffuse forearm pain show greatly reduced mobility of the median nerve at the wnst This is likely to cause abnormal stress on the nerve dunng hand activities and in turn may cause abnormalities in nerve function that can contnbute to painful symptoms


I Ivanov,*Head of Transfusion Dept, R.Velcheva,M D *Head of hystocompatibility lab , G Stankova* Biochemist, Regional Blood Transfusion Centre, st "L Karavelov" 5, 4000-Plovdiv, BULGARIA

Aim of Investigation To registrate the pain relief in haemophilia patients with joint haemorrhagia after Koate-HP treatment

Methods Individual patient questionnaire form to mark the reactions and time when the pain relief appears

Results A group of 15 haemophilia patients who have been previously transfused cryoprecipitate, were again questioned for pain relief within Koate-HP infusion. The pain relief for two of the patients was marked after the second hour, four of them noted slight relief after the 8th hour, while for the rest -the pain relief was after the 10th hour

Conclusion. We make this announcement to state that after Koate-HP application no pain relief effect was registered in the first hour, as we have had during cryoprecipitate treatment, an important clinical symptom for the politraumatiezed haemophilia patient We believe our observations will be a challenge for investigators and up-to-date technologists as well


Helge Kasch5. Knstian Stengaard-Pedersen, Lars Arendt-Nielsen1, Troels Staehelm Jensen1Dept of Neurology, Aarhus Univ Hospital, Denmark Danish Pain Research Center, Aarhus Univ, Denmark 'Dept of Rheumatology, Aarhus Univ Hospital, Denmark Center for Sensory-Motor Interaction, Aalborg Univ, Denmark

Aim of the Investigation. Soft-tissue injury in whiplash trauma may play a role for long lasting neck and jaw-muscle pain Pressure algometry in neck and jaw muscles was used to assess deep muscle pain after whiplash in a prospective study at regular intervals from trauma to six months after injury

Methods. 142 consecutive acute whiplash patients (M 67, F 75, Age 35 510.7) exposed to rear-end collision in motor vehicle accidents Patients with fractures, dislocation, unconsciousness, or amnesia were excluded from the study Whiplash patients were compared with 33 sex and age-matched controls exposed to acute, non-sport ankle distortion (M 14, F 19, Age. 32 89 9) Patients and controls were seen within 1 week, 1, 3, and 6 months after accident At every visit, pressure algometry (Somedic) was performed 3 times above each of 10 neck- and jaw-muscle spots and 3 times on a reference point (3rd left finger, PIP) Briefly, the al-gometer was placed nght-angled on the muscle Probe area one square centimeter, slope control desired rate of change of pressure at 20 kPa/s Individual regression lines for the sums of 30 pressure pain detection values (total PPDT) obtained at each visit were computed Patients and controls seen more than once were used for analysis. Total PPDT for day 90 was computed from individual line parameters, and unpaired t-test was applied on normally dis-tnbuted data

Results. Total pressure pain detection threshold was significantly lower in whiplash patients (P<0 05) than in controls Comparing matched patients and controls only, this was even more pronounced (P<0 002) There were no differences at control site (P>0.30) for the entire whiplash group, and for the matched patients and controls (P>0.06).

Conclusion: Cervical distortion patients (whiplash patients) have significantly decreased pain detection thresholds in the neck muscles and jaw muscles compared to another acute distortion condition. Pressure algometry can distinguish the differences in muscle-pain between whiplash patients and a control group.


Ann-Sofie Leffler*. Eva Kosek, Per Hansson, Neurogenic Pain Unit, Dept of Rehabilitation Medicine, Karolinska Instt/Hospital S-171 76 Stockholm, SWEDEN.

Aim of Investigation: To investigate the influence of pain intensity on sensibility to various somatosensory modalities in patients with subacute/chronic lateral epicondylalgia.

Methods: Thermal sensitivity (Thermotest), pressure pain sensitivity (pressure algometer) as well as low threshold mechanoreceptive function (von Frey) was assessed in the local pain area and the area of pain referral in 10 patients before and following pain provocation (weight lifting). A local anaesthetic was then injected into the most painful area and the quantitative sensory testing was repeated in the area of pain referral. The contralateral arm served as control and was treated and injected accordingly.

Results: There was no difference in sensibility between the affected and the unaffected arm in the local pain area during the whole experiment. In the area ofpain referral allodynia to warmth (p<0.04) was found during the whole experiment. Repeated wrist movements resulted in significantly increased pain intensity in the affected arm (p<0.001) but not contralaterally. In the affected arm sensibility to light touch decreased following pain provocation (p<0.03) but normalised following injection of local anaesthetic while no changes were seen contralaterally. Conclusions: The sensitivity to light touch in the area of pain referral was the only modality affected by the intensity of ongoing pain.


Ida Marini. Federico Vecchiet*, Ugo Capurso*, Dept of Oral Surgery, School of Dentistry, Univ of Bologna, Italy

Aim of Investigation: To show the relationship between the chronic pain in the cranio-cervico mandibular area and whiplash injury.

Methods: Forty-one patients (25 female and 16 male) with a mean age of 31.9 years, ranging from 16 to 65 years were examined. The symptoms had developed after a whiplash injury 8 months to 3 years previously. Patients were excluded if they had only clicking in the temporomandibular joint (TMJ) without pain or they had previous disc disease or facet joint denervation. Examination of the patients included the following: muscle and jaw palpation, registration of jaw sounds and jaw movements. Diagnosis was based on the Research Diagnostic Criteria for temporo-mandibular disorders (RDC/TMD). The clinical diagnoses were verified by tomography. Headache frequencies were also pointed out.

Results: 9% of the patients registered click and pain in TMJ and 60% of the cases had difficulty in opening the mouth. 92% of pain was found in the neck and 46% in the head. The patients gave 8 as the intensity of spontaneous pain using the visual analogue scale (VAS). Latent or active Trigger Points (TrPs) were found in 93% of the subjects. The involved muscles were: trapezius (98%), splenius (85%), stemocleido-mastoid (75%), masseter (52%) and temporal (5%). The radiological condilar position, according to Pullinger method, was: bilateral centred 41% (17); posterior and centred 37% (15); bilateral posterior 22% (9).

Conclusions: The incidence of clicking with TMJ pain in whiplash patients was low. All the patients had the TrP in the muscles of the neck and of the face. Their general muscle problems may affect posture, respiration pattern and general body function. Our results so far show that an early onset of treatment has the fastest and best results.


Sogorescu Eleonora. MD; Valcu Valeria, MD; Dumitrescu Eugenia, MD, Balneoclimatology and Medical Rehabilitation Clinic ofCalimanesti, Romania

Aim of Investigation: The severe functional prognosis ofcoxar-throsis, which sometimes leads to serious disabilities ("Kills the least, but invalidates the most") determines us to approach the methodology of treatment for this disease in balneary spas. The present paper proposes to follow the evolution of the pain parameter on coxarthrosis-affected, under the influence of the physio-kyneto-balneary treatment carried out in our spa on a 18-21 days' period.

Method: We conducted our study on a lot of 80 patients under the treatment in 1998; the appreciation of the pain parameter was made following the Bertrand rating (0 - painless; 1 - little pain; 2 - permanent pain, calmed down by resting- 3 - continuous pains, day and night). Here are the therapeutic means we used of: hygieno-dietetic regimen, drugs and physiotherapeutic treatment massage, kyneto-therapy in sulphurous water basin, kyneto-therapy indoors, procedures with a sedative effect.

Results: The pain parameter evaluated following the Bertrand rating proved an amelioration in 78% of the cases, as compared to the referential lot (that only followed the drug treatment), on which we obtained good results in 50% of the cases.

Conclusions: Coxarthrosis is a degenerative affection marked by its disabilitation character, thus representing one of the most difficult problems in the rheumatological practice. The pain control in cox-arthrosis makes possible the treatment of the disorders concerning the mobility and stability at hip level, thus assuring a good rehabilitation for the patients presenting this affection.


Michael JL Sullivan, Maurecn E. Sullivan & W. Stanish, Dept of Psychology, Dalhousie Univ, Halifax, Nova Scotia, B3H 4J1

Aim of Investigation: To compare the relative strength of psychological variables in predicting pain and disability in patients with whiplash injuries.

Methods: Participants were 73 (20 men, 53 women) consecutive referrals to the Atlantic Pain Clinic, a multidisciplinary treatment centre for the management of persistent pain disorders. All patients sustained injuries in rear-end motor vehicle accidents. All had a diagnosis of whiplash and all were involved in litigation. Patients completed measures of pain, disability, catastrophizing, state and trait anxiety, and depression.

Results: The results of regression analyses showed that psychological variables accounted for 20% of the variance in the prediction of pain severity. Psychological variables accounted for 43% of the variance in the prediction of perceived disability. Trait Anxiety was the best single predictor of pain, catastrophizing was the best single predictor of disability.

Conclusions: Increasingly, there are indications that predictors of pain may differ from predictors of disability. The results of the present research show that psychological factors accounted for more than twice the variance in disability ratings as compared to pain ratings. The results are consistent with views suggesting that intervention programs should target reductions in disability rather than reductions in pain.


Saranatra Waikakul, Dept ofOrthopaedic Surgery, Faculty of Medicine, Siriraj Hospital, Mahidol Univ, Bangkok, Thailand

Aim of Investigation: To find out prevalence and natural history of chronic pain after replantation in a prospective survey.

Method: All patients who had successful replantation and revascu-larization were evaluated about their chronic pain. Patients' biodata and characteristics of the injuries were recorded and correlation of these data to the severity and type of pain were analyzed. All patients were followed up at least 2 years. VAS was used to define pain severity.

Result: 39 of the 428 patients (9%) who underwent digital replantation and 20 of the 82 patients (24%) who underwent major limb replantation had moderate to severe chronic pain syndrome at the 6 month follow up. Surgical reconstruction of motor and sensory function could reduce pain significantly in most of the patients. At the 2 year follow up only 2 patients in the major limb replantation group had significant pain. However most of the patients who had pain had poor functional outcomes.

Conclusion: Chronic pain syndrome after replantation and revas-cularization is a rather common in major limb replantation and should be controlled to get good functional results.


I. Paturusi, C. Rasjad, A. Husain

Purpose: This study was intended to assess efficacy offisiotherapy compared to drug treatment on patients with knee osteoarthritis using Koshino Scores. In addition, incidence of osteoarthritis in different sex and relationship between osteoarthritis and age of patients were determined.

Material and Methods: This study was a non-randomly kuasi clinical trial. Subject were 20 patients above 50 years of age with signs and symptoms of osteoarthritis from General Hospital and private practices in Ujung Pandang. Patients were divided into two groups. The first group received NSAID (Non Steroid Anti Inflammatory Drug) while the second group was provided with NSAID and fisiotherapy. Koshino Scores was measured at baseline and after two, four and eight weeks of treatment. Score increment of 20 was good. Data was analyzed with Fischer's exact test. In addition, radiology examination was performed to determine femorotibial angle (FTA) and degree of joint injury according to Koshino grade.

Results: There were 7 males and 13 females participating in the study. Seventy percents of subjects were more than 60 years old. Weight and height evaluation showed a significant overweight. Radiology examination showed that Koshino grade I, II and III were 15%, 45%, and 40% respectively. In addition, FTA was 176.9 and 174.7 respectively for male and female. Results of Koshino Knee Score of the first group (NSAID) showed no significant increase of score at the second week (0%). However, significant increase of Koshino score was seen at the forth week (40%) and the eight week (50%). On the other hand, the Koshino score in the second group (NSAID + fisiotherapy) showed a significant increment at the second (40%), forth (90%), and eight (90%) week.

Discussion: The study showed that more cases were found in female compared to male with the average of age was above 60 years old. The sex ratio in this study was lower than that in Koshino study, but age average was similar. Also, thee result of femorotibial angle in female was smaller than that in male. It could also be concluded that fisiotherapy gave more benefit compared to drug treatment only. Fisiotherapy on knee osteoarthritis may limit degerative process.

Conclusion: We conclude that efficacy of knee fisiotherapy is better than drug therapy only. Osteoarthritis is more frequent in female and this may associate with overweight. Table 1. Comparisons of Koshino Score at the second, forth, and eight week of therapy

0 (0%)
4 (40%)
5 (50%)
NSAID + Fisiotherapy
4 (40%)
9 (90%)
9 (90%)


Michael J. Farrell. Joan McMeeken*, Stephen, J. Gibson, Robert D. Helme. National Ageing Research Inst, PO Box 31, Parkville, VIC, Australia 3052

Objective: Fluctuations in pain provide opportunities to examine the dynamic character ofhyperalgesia in clinical conditions. The objective of this study was to assess cutaneous thermal and mechanical pain thresholds (PT) over the thumb following pain provoked by movement in subjects with osteoarthritis of the hands (OA).

Method: Two groups ofOA subjects were recruited. One group had movement related pain (MP, n=12). The second group reported no pain in the preceding week (NP, n=12). Thermal (CO; laser) and mechanical (von Frey filaments) PT were measured over the dorsolatcral aspect of both thumbs, in both groups prior to, immediately following and 30 min after 5 min of self paced, resisted thumb movement.

Results: The NP group demonstrated stable PT across the 3 measurement periods. In the MP group mechanical PT over the moving thumb were lower immediately after movement and remained lower 30 min later. Thermal PT increased transiently in the non-moving hand in the MP group.

Conclusions: Movement pain is associated with increased mechanical sensitivity at a homotopic site and thermal hypoalgesia at a heterotopic site. Distant thermal hypoalgesia may reflect the influence ofDNIC. It is not readily apparent if movement pain related mechanical hyperalgesia is due to either peripheral or central sensitisation.


H Heim, Patricia Roche. A Wright, T Oei*, A Klestov**, Depts of Physiotherapy and Clinical Psychology, Univ of Queensland* and Rheumatology Dept, Royal Brisbane Hospital, Brisbane 4072, Queensland, Australia**

Aim of Investigation: To chart the course and nature of pain, and principle measures of disease and mental health status in outpatients with progressive rheumatoid arthritis (RA).

Methods: 120 hospital outpatients with RA for 15.27 years on average, were assessed at baseline, five (N = 61), and six (N= 59) years later. The MPQ-PRJ was used to calculate the mean score of pain intensity and two group profiles of pain quality, the Category Utilisation Profile (CUP) and Average Rank Profile (ARP). Measures of disease and mental health were: ESR, haemoglobin level, grip strength, morning stiffness, joint tenderness, functional capacity, state anxiety, depression and learned helplessness. A 6-point scale rated antirheumatic drug therapy.

Results: At baseline, the mean PRI score of 18.10 (12.93) was portrayed with 3 subclasses of pressure, dullness, tenderness and the tiring, troublesome and nauseating qualities of joint pain. Mean scores on each measure of disease and mental health were in the DMARD medication. Repeated measures analysis showed no significant change in any of measures, nor in CUP/ARP profiles, over six years.

Conclusions: Under current antirheumatic drug therapy, the average level of joint pain, disease and negative mental health in outpatients remains moderate over a six year extension of chronic and active RA. The consistency of the results with a 1997 outcome study of RA suggests their value as comparative data for future studies of outcome in RA.


Thomas Hummel, Christine Schiessi2, Jorg Wendler3, and Gerd Kobal2, Dept. of ORL, Univ. of Dresden, 01307 Dresden, Germany; Dept. of Pharmacology, Dept. of Medicine 111, Univ. of ErIangen-Numberg, 91054 Eriangen, Germany

Aim of Investigation: Previous research indicated that patients with chronic inflammatory joint pain respond differently to repetitive painful stimulation. The present study investigated whether these changes are related to the peripheral or central nervous nociceptive system.

Methods: The pain model used is based on the nociceptive stimulation of the nasal mucosa with gaseous carbon dioxide; it allows the simultaneous recording of cortical chemo-somatosensory event-related potentials (CSSERP) and the negative mucosal potential from the surface of the nasal respiratory epithelium. Twelve patients with rheumatoid arthritis (RA) were compared to healthy controls matched for age and gender. Responses to both different intensities of painful stimuli and constant intensities of series of 4 stimuli were analysed.

Results: As in previous studies mentioned above, differences were only found when repetitive stimulation was performed. While the peripheral nociceptive response did not differ between groups, CSSERP amplitudes P1N1 and N1P2 were larger in RA patients. Conclusions: This indicates that chronic inflammatory joint pain produces central nervous changes of nociceptive processing. Acknowledgments: This research was supported by DFG grant SFB 353 (A7) and by grant P01 DC 00161 from the N1DCD, NIH, USA.


E.A. Mahmoud1. M.G. Abdel Motaal, M.M. Kamal, R. Bennett, P. Watson1, M. Al Janabi, A.K.P. Jones, Human Physiology and Pain Research Laboratory, Univ of Manchester, Rheumatic Diseases Centre, Clinical Sciences Building, Hope Hospital, Salford, M6 8HD, UK; Rheumatology and Rehabilitation Dept, Assiut Univ Hospital, Assiut, Egypt; Nuclear Medicine Dept, Hope Hospital, Salford, M6 8HD, UK; Behavioural Medicine Dept, Clinical Sciences Building, Hope Hospital, Salford, M6 8HD, UK; Nuclear Medicine Dept, King College Hospital, London.

Aim of Investigation: Pain is the most significant symptom in patients with RA and is most closely related to medication use. However, the precise relationship between pain and inflammation has not been defined. The aim of this project was to determine the relationship between pain experience, inflammation and different coping strategies and mood in patients with RA.

Methods: 20 patients with definite RA were recruited and assessed including: clinical assessment, ESR, CRP, Visual Analogue Scale (VAS) of global pain, both knees and wrists, depression, anxiety and coping strategy questionnaires. Labelled neutrophil scintigra-phy of White blood cell (WBC) (4 hours and 24 hours scans) of both knees and wrists was performed after injection of mixed WBC labelled with 99m technetium hexamethyl propylene amine oxime "9 tc" HMPAO" using the Gamma camera scmtigraphy. All the patients were assessed on 2 or 3 occasions over a one-year period.

Results: We have found that there is poor correlation between pain and WBC uptake of the joint (P>.05). Psychological factors including depression, anxiety and pain coping are more important in predicting pain (P<.05).

Conclusions: This preliminary data supports the concept that psychological factors may be more important in determining ongoing pain in RA, than inflammation driven nociceptive inputs. The physiological basis of this will be discussed. Acknowledgments: Supported by Univ of Manchester and Egyptian Mission Dept as a joint supervision grant.


Patricia Roche. A. Wright, T. Oei*, A. Klestov, H. Heim**, Depts of Physiotherapy and Clinical Psychology, Univ of Queensland*, and Rheumatology Dept, Royal Brisbane Hospital, Brisbane 4072, Queensland, Australia**.

Aim of Investigation: To predict baseline scores of pain intensity from measures of disease and mental health and a measure of disease duration and to determine the relative predictive ability of significant variables at baseline, to pain, five and six years later.

Methods: 120 hospital outpatients assessed for joint pain (MPQ-PR1), disease and mental health status, at baseline, five, and six years later,

Results: At baseline, hierarchical multiple regression revealed that the set of mental health measures (anxiety, depression and learned helplessness) in Step 1, the set of disease measures (disease activity, functional loss) in Step 2, and disease duration (Step 3), together accounted for 41% of variance in PRI 1 (p = 0.000). Mental health explained a significant 20% but only the Arthritis Helplessness Index was significantly and independently related to PRI 1. Disease measures together added a significant 18%. Grip strength, joint tenderness and Haemoglobin were each uniquely related to PRI 1. Disease duration added 2.4%. A Model retaining only those independent variables sharing unique variance with PRI 1 was used to predict PRI 2 (N = 61) and PRI 3 (N = 51). The measure of articular tenderness accounted entirely for the 27% variance explained in PRI 2 (after five years). None of the variables, individually, or in combination, related to PRI 3. Conclusions: Pain severity in progressive RA is partially explained by principle measures of disease severity, the sense of helplessness and disease duration. Joint tenderness is the most reliable predictor of subsequent pain over five years.


Noriko Satoh. Yoshihiro Ishihara Rehabilitation ofShizuokaken J.A. Nakaizu Supa Hospital, Nakaizut, Shizuoka, 410-2502, JAPAN

Aim of Investigation: The main treatment for rheumatoid arthritis of the shoulder joint is conservative therapy because this is a non-weight-bearing joint. Pain decreases the range of motion and then causes articulator contracture. Conservative therapy includes systematic and intraarticular administration ofNSAID's, kinesither-apy, and physiotherapy. In the present study, 1 gave phototherapy to outpatients with this disease and obtained satisfactory result.

Methods: The subjects were 44 outpatients who had RA with shoulder pain lasting for 6 weeks or more. Ages ranged between 38 and 79 (mean age 60.7). According to Steinbrocker's classification of RA, 24 and 20 patients were respectively in Class 2 Stage 2 and Class 2 Stage3. Phototherapy was given using the Super LIZER polarized light apparatus with a wavelength of600-830nm and an output of ISOOmW. It was delivered to the ipsilateral stellate ganglion region and the ipsilateral shoulder joint twice a week for 5 weeks After every session, the effect of the treatment was evaluated on the basis of symptoms, range of motion, and VAS score

Results Among the local symptoms, swelling of the shoulder joint resolved and pain on motion and joint effusion decreased Among the systemic symptoms, morning stiffness showed a mean decrease of 20 4 mm in the Class 2 Stage 2 group and 19.4 mm in the Class 2 Stage 3 group. Swelling of other joints resolved in 19 out of 24 patients from the Class 2 Stage 2 group and in 16 out of 20 patients from the Class 2 Stage 3 group The erythrocyte sedimentation rate decreased in 14 patients from the former group and in patients from the latter group The range of motion increased 34 6 0 9 after 10 sessions treatment in the Class 2 Stage 2 group, 27 9 9 9 degrees in Class 2 Stage 3 group The pain score decreased from 8 0 0 7 before treatment to 2 8 0 7 after treatment in Class 2 Stage 2 group, from 8207to4006m Class 2 Stage 3 group

Conclusions In animal studies, phototherapy was clearly more effective for Stembrocker Stage 2 RA accompanied by inflammation of the synovial membrane and extraarticular tissues than for Stage 3 and 4 In the present clinical study, its effectiveness was significantly higher in Stembrocker Stage 2 than in Stage 3 and 4 It appears that phototherapy should be started early after diagnosis This therapy should be given first as a nonmvasive "synovectomy " Although its effect is mild, it is useful not only for controlling pain but also for preventing articular destruction It may also be combined with other treatments


K Stengaard-Pedersen. M Pfeiffer-Jenscn, A M Drewes, J Nielsen1, L Arendt-Nielsen2, and A V Olesen4, Dept of Rheumatology/Danish Pain Research Center, Univ Hospital of Aarhus, center for Sensory Motor Interaction, Univ ofAalborg, Dept of Internal Medicine M, Aalborg Hospital, "Dept of Biostatistics, Aarhus Univ, Denmark

Aim of Investigation Joint pain is the main complaint in rheuma-toid arthritis (RA) patients The aims were 1) to compare the ability of two different algometers ability to assess sore joints on the hand, and 2) to correlate the obtained pain detection thresholds (PDT's) to the traditional measures for pain and disease activity and the demographic data

Methods Forty-one patients with RA according to ACR criteria's were included Mean age 649 4 years Disease duration 14 5 10 years All patients were treated with DMARD's and/or glucocorti-coids All patients withdraw their analgesic intake 24 hours before the investigation Pressure algometry was performed using a hand-held device, as well as a computer-controlled pneumatic device (Aalborg Univ) Disease activity measures according to the American College of Rheumatology recommendations were obtained.

Results No difference was seen between the two methods in the sensitivity to assess joint pain, 2) a correlation was found between PDT's and total VAS, finger VAS, swollen/tender joint count (r between -0 364 and -0 473) There was no correlation between PDT's and acute phase proteins, x-ray, age and disease duration

Conclusions' A correlation between pressure pain threshold and traditional pain/disease activity measurements was found in patients with rheumatoid arthritis


Peter HTG Heuts. Onno P van Schayck, Rob A de Bie, Geert-Jan Dinant, Univ of Maastricht, Dept of General Practice, P OBox 616, 6200 MD Maastricht, The Netherlands

Aim of the investigation To find out whether promoting selfmanagement to patients with osteoarthntis (OA) of the hip and/or knee is effective in middle-aged patients (40-60 years) The aim of the presentation is to facilitate discussion about the important issue of monitoring treatment adherence

Methods In this presentation the design of the randomised clinical trial will be presented, with empasis on the method of enhancing treatment adherence

Results: From 77 practitioners collaborating in two morbidity registration networks of the Universities of Maastricht and Nijmegen an aselective sample of patients with hip and/or knee OA aged 40-60 years are being recruited Practices are randomly assigned to an experimental or control group in order to avoid contamination of experimental and control treatment within practices. During the training period (4 months) and the follow-up (24 months) questionnaires(patients, physicians and therapists) and telephone contacts are used for the promotion as well as the monitoring of treatment adherence.

Conclusions In setting up this clinical trial the use of questionnaires and telephone contacts to enhance and monitor treatment adherence is feasable, but further refinement and development seems worthwile.

Acknowledgments Supported by a grant of National League against Rheumatism, and partly by Ingelheim Boehnnger


Cheryl Bourguignon. School of Nursing, McLeod Hall, Univ of Virginia, Charlottesville, VA 22903 USA, Christine Miaskowski, Diana Taylor*, Kathryn Lee*, School of Nursing, Box 0610, Univ of California, San Francisco, CA 94143 USA

Aim of Investigation To investigate whether pain, fatigue, sleep, or inflammation change during the follicular or luteal phases of a menstrual cycle in premenopausal women with and without RA.

Methods The descriptive-comparative pilot study measured pain, fatigue, sleep, and inflammation in both phases of one menstrua] cycle Serum estradiol and progesterone verified menstrua] phase

Results With a small pilot study, we studied trends as well as statistically significant results The trend was that women with RA had more pain in both phases (p= 057, p= 055) than controls RA subjects tended toward greater pain in the luteal (p= 062) than follicular phase Women with RA had more fatigue (p= 028), increased sleepmess (p= 015), and reduced energy (p= 048) in the luteal than follicular phase Also in the luteal phase, they had less energy (p= 046) and more awakenings during sleep (p= 013) than controls Erythrocyte sedimentation rate and C-Reactive Protein tended to be higher for RA subjects than controls (p= 056- 065) but no differences emerged across phases Interleukin-6 exhibited small, non-significant differences between phases in RA subjects In the luteal phase, RA subjects tended to have lower cortisol levels (p= 053) than controls Also in the luteal phase, as cortisol decreased (r = - 6) and estradiol increased (r = 7), pain increased in women with RA

Conclusions In the luteal phase, women with RA tended toward more pain, less energy, poorer sleep, and decreased cortisol than controls Pain correlated with increased estradiol and decreased cortisol Thus, shifting hormone levels may affect RA symptoms in cycling women. Due to small sample size, this study must be replicated.

Acknowledgments. A UCSF School of Nursing T32 Grant from NINR supported the study.


Tess Cramond, James O'Callaghan2, **John Tuffley3, Bronwyn Williams4, *Peter Maclntyre5

Multidisciplinary Pain Centre, Royal Brisbane Hospital, Brisbane, Queensland, Australia. **Dept ofOrthopaedic Surgery, Royal Brisbane Hospital

Aim: To use intra-articular phenol for the treatment of chronic pain secondary to severe degenerative Joint disease in patients in whom joint replacement was contra-indicated

Method Phenol 10% in 60% meglumine lothalamate (Conray 280) was injected into the painful joint. The position of the needle and injection into the joint space was confirmed using an image intensi-fier.

Results. Three patients underwent intra-articular phenol injection They were all elderly and had multisystem diseases associated with advanced degeneration of one or more joints. None of the patients was suitable for joint replacement The pain was not relieved by appropriate conventional analgesics and prevented adequate nursing care. Three shoulders (one of the patients had bilateral shoulder disease) and one hip joint were injected. Each shoulder was injected with 5ml of Conray 280 mixed with 10ml of 0.5% bupivi-came The hip joint was injected with 10ml of Conray 280 All three patients obtained sustained pain relief which allowed the patients to receive full nursing care

Conclusions Phenol has a limited but important role in the management of pain In some patients not suitable for joint replacement it can be used mtraarticularly to provide effective, long-term anal-gesia for pain secondary to severe degenerative joint disease We believe this is the first reported use of phenol in the shoulder and hip joints.


Robert A. Boas. Dept. of Anaesthesia, Auckland Hospital Hon Assoc. Prof, Dept Pharmacology, Univ of Auckland, School of Medicine, Auckland, New Zealand.

Aim. To establish the nature, diagnostic distinctions and treatment outcomes, of a range of refractory anterior compartment knee pains.

Method: Data was obtained from a retrospective analysis of a sequential senes of 109 cases collected over 8 years

Results: Different groups were identified as follows

Patello-femoral pain. comprised 35% of cases, with diffuse, aching, constant pain, patellar tenderness and cutaneous hyperalge-sia about the front of the knee All had minor injury but 70% have a prior migraine, fibromyalgia, irritable bowel or other sensitisation pain disorder. Treatment for these was successful, using tncyclics, clonidine, oral analgesics, tens and rhythmical exercising. Femoral nerve blocks were needed for 20% of cases, but in all, 10% have needed repeat treatments.

Infra-patellar/saphenous nerve injury was seen in 18 of this senes, showing local irritation, usually within a scar Drug treatment to lessen secondary hyperalgesia preceded local/steroid block, 16 gaining complete cure.

Complex Regional Pain Syndrome occurred in 15% of post injury patients. Features included diffuse sharp/burning pain, hy-peralgesia/allodynia, colour/temp changes, swelling, weakness, wasting, textural skin changes, 5 hemorrhagic joint effusions, and infections which proceeded to amputation in two cases. Aggressive combined drug treatments, including gabapentm and sometimes opioids, were applied in conjunction with exercising, cognitive therapies and sensory stimulation as hyperalgesia regressed One third required femoral or epidural block to obtain pain suppression Four patients have not improved

Mechanical pain after trauma or surgery was the dominant cause of pain in twelve patients, but depression or abnormal illness behaviour were seen as compounding features Conservative cares generally gave 50% relief.

Mixed trauma/nerve injury causing long term sensitisation and functional loss was evident in another 10% who were difficult to treat Inflammatory arthropathy with pencapsular swelling, effusion and tenderness was a common feature Treatment was less successful than for other knee pains and may require more aggressive and combined treatments, including early joint replacement

9th WORLD CONGRESS ON PAIN, 1999, Vienna, Austria, p. 175 - 180


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