Distraction Pain Research Articles

Abstract 1122‐000200: Chiropractor Manipulation Leading to Bilateral Vertebral Artery Dissection and Acute Ischemic Stroke

Introduction : Traumatic cervical artery dissection is one of the leading causes of stroke in patients under the age of 45. Recent chiropractic neck manipulation is associated with risk of vertebral artery dissection (VAD). The V3 segment of the vertebral artery is highly susceptible to the bending forces during forced manipulation leading to intimal damage. Methods : N/A Results : This is a case presentation of a 44 year old male who was transferred from another emergency department for left homonymous inferior quadrantanopia noted on an optometrist visit. He reported sudden onset left homonymous hemianopia after receiving a high velocity cervical spine adjustment at a chiropractor appointment for chronic neck pain a few days prior. CT angiogram of the head and neck revealed bilateral vertebral artery dissection at left V2 and right V3 segments. MRI brain confirmed an acute infract in the right medial occipital lobe. His right PCA stroke was likely embolic from the injured right V3 but possibly from the left V2 as well. As the patient reported progression from a homonymous hemianopia to a quadrantanopia, he likely had a migrating embolus. Conclusions : Arterial dissection accounts for about 2% of all ischemic strokes, but may be between 8–25% in patients less than 45 years old. VAD can result from trauma of varying severities ‐ from sports, motor vehicle accidents, and chiropractor neck manipulations to violent coughing/sneezing. It is estimated that 1 in 20,000 spinal manipulation results in vertebral artery aneurysm/dissection. In the United States, patients who have multiple chronic conditions are reporting higher use of complementary or alternative medicine, including chiropractic manipulation. Education about the association of VAD and chiropractor maneuvers can be beneficial to the public as these are preventable acute ischemic strokes. In addition, vertebral artery dissection symptoms can be subtle and patients presenting to chiropractors may have distracting pain masking their deficits. Evaluating for appropriateness of cervical manipulation in high‐risk patients and detecting early clinical signs of VAD by chiropractors can be beneficial in preventing acute ischemic strokes in young patients.

Clinical predictors of abnormal chest CT scan findings following blunt chest trauma: A cross-sectional study

PurposeSome surgeons believe that chest computed tomography (CT) scan should be used more prudently in management of blunt chest trauma patients. This study aimed to evaluate the clinical predictors of abnormal chest CT scan findings in trauma patients. MethodsThis cross-sectional study was conducted on blunt chest trauma patients aged ≥18 years who were referred to the emergency departments of two educational hospitals and underwent chest CT scan. These patients were enrolled in the study using a non-probability sampling method. The exclusion criteria included: class III or IV hemodynamic shock, need for immediate surgical or neurosurgical interventions, penetrating trauma, lack of required information, and pregnancy. Demographic factors, accident details, trauma mechanism, vital signs, and level of consciousness in predicting abnormal chest CT scan findings were evaluated. Analysis was performed using IBM SPSS statistics 21. ResultsA total of 977 patients (male 51.5%, female 48.5%) with the mean age of (41.71 ± 14.24) years, range 18–88 years were studied; 34.2% of them with high energy trauma mechanism. With 334 (34.2%) patients had abnormal findings on chest X-ray (CXR) and 332 (34.0%) cases had an abnormal findings on chest CT scan (agreement rate was 99.4%). There was a significant correlation between male gender (p < 0.0001), GCS<15 (p < 0.0001), high energy trauma mechanism (p < 0.0001), unstable hemodynamics (p < 0.01), and clinical signs and symptoms (p < 0.0001) with chest CT findings. Chest wall deformity (odds = 8; p < 0.0001), generalized tenderness (odds = 6.6, p < 0.0001), and decreased cardiac sound (odds = 3.8, p < 0.0001) were the important and independent clinical predictors of abnormal chest CT scan findings. ConclusionBased on the findings, chest wall deformity, generalized tenderness, decreased cardiac sound, distracting pain, chest wall tenderness, high energy trauma mechanism, male gender, respiratory rate > 20 breathes/min, decreased pulmonary sound, and chest wall crepitation were independent clinical predictors of abnormal chest CT scan findings following blunt trauma.

Diagnostic Value of Clinical Findings in Evaluation of Thoracolumbar Blunt Traumas.

Necessity of imaging for symptom-free conscious patients presented to emergency department (ED) following traumatic thoracolumbar spine injuries has been a matter of debate. The present study was aimed to evaluate the diagnostic value of clinical findings in prediction of traumatic thoracolumbar injuries compared tocomputed tomography (CT) scan. The present diagnostic value study was carried out using non-random convenience sampling during the time between October 2013 and March 2014. All trauma patients > 15 years old underwent thoracolumbar CT scan were included. Correlation between clinical and CT findings was measured using SPSS 21.0 and screening performance characteristics of clinical findings in prediction of thoracolumbar fracture were calculated. 169 patients with mean age of 37.8 ± 17.3 years (rage: 15-86) were evaluated (69.8% male). All fracture patients had at least 1 positive finding in history and physical examination. The fracture was confirmed in only 24.6% of the patients with positive findings in history or physical examination. In 37.5% of patients the location of fracture, matched the area of positive physical examinations. Sensitivity, specificity, PPV, NPV, PLR, and NLR of clinical findings in comparison to thoracolumbar CT scan were 100 (95% CI: 89 - 100), 1.5 (95% CI: 0.2-6), 24.5 (95% CI: 18.3-31.9), 100 (95% CI: 19.7-100), 32.5 (95% CI: 24.6-43.03), and infinite, respectively. The results of the present study, show the excellent screening performance characteristics of clinical findings in prediction of traumatic thoracolumbar fracture (100% sensitivity). It could be concluded that in conscious patients with stable hemodynamic, who have no distracting pain and are not intoxicated, probability of thoracolumbar fracture is very low and near to zero in case of no positive clinical finding.

Does distracting pain justify performing brain computed tomography in multiple traumas with mild head injury?

Traumatic brain injury (TBI) is a significant health concern classified as mild, moderate, and severe. Although the indications to perform brain computed tomography (CT) are clear in moderate and severe cases, there still exists controversy in mild TBI (mTBI). We designed the study to evaluate the significance of distracting pain in patients with mTBI. The study population included patients with mild traumatic brain injury (GCS ≥13). Moderate and high risk factors including age <18months or ≥60years, moderate to severe or progressive headache, ≥2 episodes of vomiting, loss of consciousness (LOC), post-traumatic amnesia, seizure or prior antiepileptic use, alcohol intoxication, previous neurosurgical procedures, uncontrolled hypertension, anticoagulant use, presence of focal neurologic deficits, deformities in craniofacial region, and penetrating injuries were excluded. The patients were then grouped based on presence (DP+) or absence (DP-) of another organ fracture with severe pain (based on VAS). The primary outcome was any abnormal findings on brain CT scans; 330 patients were enrolled (184 DP+ and 146 DP-). Overall, two DP+ and one DP- patients had mild cerebral edema in brain CT (p > 0.99). No patients had any neurologic symptoms or signs in follow-up. Our results show that in the absence of any other risk factors, distracting pain from other organs (limbs, pelvis, and non-cervical spine) cannot be regarded as a brain CT indication in patients with mild TBI, as it is never associated with significant intracranial lesions.

Evaluation of Distracting Pain and Clinical Judgment in Cervical Spine Clearance of Trauma Patients

The concept of distracting pain (DP) is a controversial subjective confounder that often impedes the efficient and timely clearance of the cervical spine (C-spine). This study attempted to define DP more objectively and assess its true potential to mask the presence of C-spine injury. It also evaluated reliability and safety of clinical judgment in discounting the significance of pain peripheral to the neck (PP). This prospective study included patients with a Glasgow Coma Score ≥14 at a level I trauma center presenting in a C-spine collar. Demographics, mechanism of injury, severity and location of all pain, and C-spine imaging data were obtained. Patient and examiner perception of DP were ascertained using the Verbal Numerical Rating Scale (VNRS) along with the examiner's clinical opinion as to the presence of a fracture. A total of 160 patients were studied: 65 % male, mean age 39 years, and 44 % presenting after a motor vehicle crash. In all, 16 % complained of neck pain (NP) and 82 % of PP. There were 134 patients without NP, 110 of whom (82 %) had PP. The mean VNRS in patients with no NP was 4.2; in patients with NP it was 4.8. When examined, 14 patients without NP exhibited posterior cervical tenderness, one of whom had a fracture (7 %). Of the patients with PP, 10 % stated it was DP. The mean VNRS described as DP by all patients was 7.5 but by clinician 6.5. VNRS described as not DP was 4.8 for both patients and clinicians. Overall, 8 of the 160 patients (5 %) had confirmed C-spine injuries. Regardless of NP or PP and its potentially distracting nature, clinicians believed no fracture was present in 95 % of all cases. Clinical impression was 98 % accurate. For patients with NP, clinical impression had a 91 % negative predictive value (NPV) and a 100 % a positive predictive value (PPV). In those without NP, the NPV was 99 % and the PPV 25 %. The concept of DP is subjective and unreliable as a method to mitigate missed C-spine injuries. If it is to be considered for use, DP should be defined as VNRS ≥5. Reliance on clinical impressions regardless of the presence or absence of NP or PP, distracting or otherwise, is accurate and safe.

Parent Pain Responses as Predictors of Daily Activities and Mood in Children with Juvenile Idiopathic Arthritis: The Utility of Electronic Diaries

The present study used electronic diaries to examine how parent responses to their child's pain predict daily adjustment of children with juvenile idiopathic arthritis (JIA). Nine school-aged children with JIA along with one of their parents completed thrice-daily assessments of pain-related variables, activity participation, and mood using handheld computers (Palm pilots) for 14 days, yielding a potential of 42 child and parent assessments for each dyad. Children provided information on current pain level, mood, and participation in social, physical, and school activities. Parents independently rated their own mood as well as their behavioral responses to their child's pain at the same time points using a separate handheld computer. Results of multilevel modeling analyses demonstrated that use of "protective" pain responses by parents significantly predicted decreases in child activity and positive mood, with an even stronger inverse relationship between protective pain response and positive mood observed in children with higher than average disease severity. Protective pain responses were not found to be significantly predictive of daily negative mood in children. The use of "distracting" responses by parents significantly predicted less child activity restrictions but only in children having higher disease severity. There also was an unexpected trend in which parent use of more distracting pain responses tended to be associated with lower child positive mood. These preliminary findings suggest the importance of the parent in influencing adjustment in children with JIA and lend support to the incorporation of parents into comprehensive pain management approaches. The potential benefits of using electronic daily diaries as a strategy to examine pain and adjustment in children with JIA pain are discussed.

The Effect of Distraction Induced by ReliefBand®on the Pain Threshold and Temporal Summation Threshold

Background: Pain is recognized as a cognitive phenomenon, which involves the processing of information. Given that human information processing is largely restricted to a number of simultaneous tasks, many interventions and techniques have been used to modify pain perception by distracting the cognitive processing of pain. This study tested the hypothesis that the pain threshold to electrical stimuli is increased as a result of distraction using a ReliefBand. Methods: Twenty volunteers were enrolled in this study. After attaching surface electrode to the medial plantar nerve territory of left foot, electrical stimuli were delivered to obtain baseline pain threshold and temporal summation threshold. After 15 minutes, while distracting with ReliefBand, the same parameters were obtained. Results: Pain threshold and temporal summation threshold before distraction were 7.9 2.2 mA and 7.0 2.1 mA respectively. During distraction pain threshold and temporal summation threshold were increased to 9.0 2.4 mA and 7.8 2.2 mA respectively. Conclusions: Pain and temporal summation threshold to electrical stimuli were increased during distraction with ReliefBand. Although we applied a technique with weak distracting ability, this distracted the processing of pain perception significantly. Further research about various distraction technique will be required.

Back Pain as a Distraction Pain Syndrome

One of the most intractable and expensive problems facing modern medicine today is chronic, nonspecific back pain. The current approach, which attributes the pain to structural problems, is invasive, expensive and not very effective. Based on this fact, along with a growing body of clinical and circumstantial evidence, we believe that it may be time for a paradigm shift in diagnosis and treatment, in which the problem is treated in an integrative fashion as more psychosomatic than structural. Although, in our conception, the pain is both real and ‘physical’, in the sense that it is experienced physically and may involve functional alterations in the affected tissues, we present a rationale that melds the purely ‘physical’ and purely ‘psychological’ conceptions of pain into an integrated model that is clinically significant. We believe that the ultimate reason for the persistence of the pain is in the mind/brain or subconscious. This creates or perpetuates the pain in order to distract attention from emotions that are too threatening for the individual to address consciously, such as anger, rage, grief or anxiety, hence the term ‘distraction pain syndrome’. We further suggest that a well controlled clinical trial, coupled with brain imaging studies, could corroborate or refute the promising results of the retrospective clinical studies we have conducted to date.

How distracting is distracting pain?

The study was to determine the effect of preexisting pain on the perception of a painful stimulus. We conducted a cross-section study at an urban ED using convenience sampling. Adult patients who had a 20-g IV catheter placed as part of their ED care were eligible for the study. Patients were excluded for the following reasons: more than one IV attempt, altered mental status, visual impairment, intoxication, or a physical abnormality at the IV site. Patients were asked to indicate on a 10-cm visual analog scale (VAS) the amount of pain they had at baseline immediately before IV placement. They were then asked to indicate on a separate VAS the amount of pain caused by the IV placement. Correlation between baseline pain and pain of the IV was assessed using Pearson's ρ. One hundred patients were enrolled in the study. The pain of IV placement did not differ significantly by gender, race, who placed the IV, or the location of the IV. The correlation between baseline pain and pain of the IV placement was poor (ρ =.14, confidence interval:−.06-.33). The response to a standardized painful stimulus among ED patients does not correlate highly with the severity of preexisting pain. (Am J Emerg Med 2003;21:43-44. Copyright 2003, Elsevier Science (USA). All rights reserved.)