Likert Pain Scale Research Articles

Comparison of two hyaluronic acid formulations for safety and efficacy (chase) study of knee osteoarthritis: a multicenter, randomized, double-blind, 26 week non-inferiority trial comparing durolane® to artz®

Purpose: To compare efficacy and safety of intra-articular hyaluronic acid (HA) in two formulations: one 3.0ml injection of Durolane® vs five 2.5ml injections of ARTZ® for the treatment of knee osteoarthritis pain. Methods: Subjects (N=349) from the People’s Republic of China were randomized to treatment (Durolane=175, ARTZ=174). The Durolane group received 3.0ml at week 0 (baseline), with sham skin punctures at weeks 1, 2, 3, and 4. The ARTZ group received one 2.5ml injection at each of the same time points. The primary assessment was a Likert pain scale (Western Ontario and McMaster University scale, WOMAC). Secondary assessments included WOMAC scales of physical function and knee stiffness, and global self-evaluationat weeks 0, 6, 10, 14, 18, and 26. The primary analysis was non-inferiority of Durolane over 18 weeks, with secondary analysis over 26 weeks, with a priori non-inferiority defined as 8% of the respective scale. Only acetaminophen was permitted as rescue analgesia and all adverse events (AEs) were recorded. Results: Overall study retention was excellent; 332 (95.1%) subjects completed 18 weeks and 319 (91.4%) completed 26 weeks, with no significant retention difference between treatment arms. All variables met non-inferiority criteria over 18 and 26weeks and efficacy response was >90%. Treatment-related AEs were 9.8% (17/174) for Durolane and 13.1% (23/175) for ARTZ.

Rotigotine transdermal system and evaluation of pain in patients with Parkinson’s disease: a post hocanalysis of the RECOVER study

BackgroundPain is a troublesome non-motor symptom of Parkinson’s disease (PD). The RECOVER (Randomized Evaluation of the 24-hour Coverage: Efficacy of Rotigotine; Clintrials.gov: NCT00474058) study demonstrated significant improvements in early-morning motor function (UPDRS III) and sleep disturbances (PDSS-2) with rotigotine transdermal system. Improvements were also reported on a Likert pain scale (measuring any type of pain). This post hoc analysis of RECOVER further evaluates the effect of rotigotine on pain, and whether improvements in pain may be attributable to benefits in motor function or sleep disturbance.MethodsPD patients with unsatisfactory early-morning motor impairment were randomized to optimal-dose (up to 16 mg/24 h) rotigotine or placebo, maintained for 4 weeks. Pain was assessed in the early-morning using an 11-point Likert pain scale (rated average severity of pain (of any type) over the preceding 12 hours from 0 [no pain] to 10 [worst pain ever experienced]). Post hoc analyses for patients reporting ‘any’ pain (pain score ≥1) at baseline, and subgroups reporting ‘mild’ (score 1–3), and ‘moderate-to-severe’ pain (score ≥4) were performed. Likert pain scale change from baseline in rotigotine-treated patients was further analyzed based on a UPDRS III/PDSS-2 responder analysis (a responder defined as showing a ≥30% reduction in early morning UPDRS III total score or PDSS-2 total score). As post hoc analyses, all p values presented are exploratory.ResultsOf 267 patients with Likert pain data (178 rotigotine, 89 placebo), 187 (70%) reported ‘any’ pain; of these 87 (33%) reported ‘mild’, and 100 (37%) ‘moderate-to-severe’ pain. Change from baseline pain scores decreased with rotigotine compared with placebo in patients with ‘any’ pain (-0.88 [95% CI: -1.56, -0.19], p = 0.013), and in the subgroup with ‘moderate-to-severe’ pain (-1.38 [-2.44, -0.31], p = 0.012). UPDRS III or PDSS-2 responders showed greater improvement in pain than non-responders.ConclusionsThe results from this post hoc analysis of the RECOVER study suggest that pain was improved in patients with PD treated with rotigotine; this may be partly attributable to benefits in motor function and sleep disturbances. Prospective studies are warranted to investigate this potential benefit and the clinical relevance of these findings.

Objective Sensory Evaluation of the Spread of Complex Regional Pain Syndrome

Background: The spread of complex regional pain syndrome (CRPS) has been well documented. Many severe refractory long-standing patients have total body pain (TBP) that evolved from a single extremity injury. Objective: The purpose of this study was to document by objective sensory threshold testing the extent of body area involvement in 20 long-standing patients with CRPS who have TBP. Study Design: A comparison of sensory threshold testing parameters between 20 longstanding refractory patients with CRPS who have TBP versus 10 healthy participants. Methods: Twenty patients with CRPS who stated that they suffered from total body pain were chosen from the Drexel University College of Medicine CRPS database. They were compared to 10 healthy participants that were age and gender matched to the patients with CRPS. The sensory parameters tested were: skin temperature; static and mechanical allodynia; thermal allodynia; mechanical hyperalgesia; after sensations following all sensory tests. The sites chosen for testing in the patients with CRPS were the most painful area in each of 8 body regions that comprised the total body area. Results: Five patients with CRPS had signs of CRPS over 100% of their body (20%). One patient had pain over 87% and another had pain over 90% of their body area. The average percentage of body involvement was 62% (range 37% – 100%). All patients with CRPS had at least one sensory parameter abnormality in all body regions. All patients with CRPS had lower pain thresholds for static allodynia in all body areas, while 50% demonstrated a lower threshold for dynamic allodynia in all body regions compared to the healthy participants. Cold allodynia had a higher median pain rating on the Likert pain scale in all body areas versus healthy participants except for the chest, abdomen, and back. Eighty-five percent of the patients with CRPS had a significantly lower pain threshold for mechanical hyperalgesia in all body areas compared to the healthy participants. After sensations occurred after all sensory parameters in the extremities in patients with CRPS. Limitations:The primary limitations of this study would be the variability of self-reported data (each subject’s assessment of pain/ discomfort to a tested parameter) and the challenge to uniformly administer each parameter’s assessment since simple tools and not precision instruments were used (with the exception of skin temperature). Conclusions: TBP and objective sensory loss occur in 20% of patients with refractory longstanding CRPS. Key words: CRPS, complex regional pain, static allodynia, dynamic allodynia, mechanoallodynia, thermal allodynia, allodynia, hyperalgesia, after sensation, total body pain, chronic pain.

SAT0415 Comparison of Radial Extracorporeal Shock Wave Therapy and Local Steroid Injection Treatment in Myofascial Pain Syndrome

BackgroundMPS which is characterized by trigger points in muscles is the most common cause of musculoskeletal disorders. Trigger points are commonly located in upper trapezius, scalenus, sternocleidomastoid, levator scapula and...

Pregabalin for the Treatment of Abdominal Adhesion Pain

Chronic pain related to postoperative abdominal adhesions is a common problem with no standard analgesic regimen currently established. In a double-blind, placebo-controlled trial, we examined the effects of pregabalin on pain modulation in patients with prior abdominal surgery and documented adhesion. The primary outcome measure was pain relief documented by a 2-point change on the Likert pain scale with a secondary pain measure of sleep interruption. A total of 18 women were randomized to receive either the drug (n = 11) or placebo (n = 7). Thirteen patients (eight pregabalin, five placebo) completed the blinded phase and 10 patients (seven pregabalin, three placebo) completed the open-label phase. Statistical analysis was performed in two settings: 1) Week 0 (as the baseline) through the end of Week 7 of the blinded fixed-dose phase; and 2) Week 7 (as the baseline) along With weeks 8 through 11 of the open-label phase. The pain score result from the blinded phase setting indicated that the amount of decrease was significantly greater in the drug group (P = 0.024), whereas the pain score result from the open-label setting indicated that the amount of decrease was significantly greater in the placebo group (P = 0.043). Only the sleep score result in the open-label setting was significantly greater in the placebo group (P = 0.024). We conclude that pregabalin significantly reduced patient-documented pain scores compared with placebo in our small cohort of patients with abdominal adhesion pain.

Adverse Events Associated With Fluoroscopically Guided Sacroiliac Joint Injections

To describe the type, incidence, and factors that contribute to adverse events associated with fluoroscopically guided intra-articular sacroiliac joint injections (IASIJ). A retrospective cohort study. Tertiary, academic, outpatient physical medicine and rehabilitation interventional spine clinic. English-speaking adults aged 18-90 years who underwent fluoroscopically guided IASIJ injections between March 8, 2004, and April 19, 2007. After IASIJ injections, 3 senior researchers recorded the presence and types of adverse events. The relationship of adverse events with age, gender, fluoroscopy time, vital signs, and trainee presence was analyzed with the Fisher exact or the Wilcoxon rank sum 2-sided tests. The frequency of immediate (during or immediately after the procedure) or delayed (within 24-72 hours after the procedure) adverse events. A total of 162 patients (133 women) underwent 191 procedures. The range of subject age was from 20 to 90 years (15.8 years, standard deviation [SD]). The range (SD) of the preprocedure 11-point Likert Pain Scale was from 1.0 to 10.0 (2.0) and for the postprocedure 11-point Likert Pain Scale was from 0.0 to 9.0 (2.5). Trainees were involved in 57% of the procedures. Reported immediate adverse events were vasovagal reaction (2.1% [n = 4]) and steroid-clogged needle (0.5% [n = 1]). Follow-up data were available for 132 of 191 procedures (69%). There were 32 adverse events reported at a mean follow-up interval of 2 days, of which, the most frequent adverse events were injection-site soreness (12.9% [n = 17]), pain exacerbation (5.3% [n = 7]), and facial flushing and/or sweating (2.3% [n = 3]). Delayed adverse events decreased with older age (P = .0029). The patients who underwent bilateral procedures experienced more delayed adverse events than the patients who underwent unilateral procedures (P = .024). Fluoroscopically guided IASIJ injection is associated with minimal adverse effects. The most common immediate adverse event was vasovagal reaction, and the most common delayed adverse event was injection-site soreness. Younger age is significantly related to reported delayed adverse events.

The utility of the Faces Pain Scale in the assessment of shoulder pain in Turkish stroke patients: its relation with quality of life and psychologic status

This study was planned to investigate the utility of the vertical Faces Pain Scale (FPS) in the assessment of pain in stroke patients using the shoulder pain model and to assess its utility in the Turkish patient population. The secondary aim was to analyze the association of FPS with the quality of life and depression in the study population.Thirty stroke patients (group I) and 30 controls (group II),all suffering from shoulder pain were included in the study.The patients with subacute shoulder pain and with no other known diseases and impairments were recruited as a control group. Shoulder pain was evaluated by the commonly used pain scales including the Visual Analogue Scale, Likert Pain Scale and 0–10 Numerical Rating Scale besides FPS. Depression was screened using Beck Depression Inventory (BDI) and quality of life was evaluated using Short Form-36 (SF-36). FPS showed good correlations with the other pain scales in both the groups(r= 0.950–0.972 and 0.674–0.926, respectively). In group I,there were significant correlations between FPS and physical functioning, pain and emotional role subscales of SF-36 (r= – 0.432, 0.707 and – 0.461, respectively).Although there was a low correlation between the FPS and BDI scores, it was not statistically significant. In group II,FPS showed significant correlations with the BDI scores and all subscales of SF-36 except social functioning and vitality (r= – 0.679 to 0.848). FPS had a high degree of convergent validity and can be used in the assessment of shoulder pain in stroke patients. It may be a good alternative for pain assessment especially in patients with speech disorders and illiterate patients.

Surgical algorithm for treatment of post‐traumatic trigeminal nerve pain

Acute postoperative pain following craniofacial or esthetic surgery, or trauma is readily treated with medicinal regimens. Facial pain persisting for more than six months is defined as chronic and must be distinguished from nontraumatic atypical facial pain or "tic-douloureaux." Our surgical experience managing chronic facial (trigeminal) pain is reviewed to provide insight into the success of our current algorithm for managing patients with chronic facial pain. We performed a retrospective review of nine consecutive patients operated for post-traumatic chronic trigeminal nerve pain. Most patients were women (mean age 41 years). Data evaluated included mechanism of nerve injury, physical exam, CT scans, computer-aided neurosensory testing, and diagnostic nerve blocks. Surgical management included hardware removal, neurolysis, and/or neuroma resection with nerve grafting when indicated. Primary outcome measurement included Likert pain scale score (range 0-10). Secondary outcome measurements included sensory exam, medication requirement, and return to work. Based on these outcome measures, results were defined as excellent, good, fair, or poor. Five of the nine patients had excellent outcomes, one was good, two were fair, and one was poor. The one patient with a poor result had temporary improvements, but later returned to baseline. No patient was made symptomatically worse or had operative complications. Successful treatment of chronic, post-traumatic trigeminal nerve pain can be expected using an algorithm that measures sensory function of the involved trigeminal nerve branch. Then either preserves that function through neurolysis or reconstruction with a nerve graft, or eliminates that function through neuroma resection.

Safety and Efficacy Review: Lacosamide for the Treatment of Diabetic Neuropathic Pain

Objectives To provide background information on diabetic peripheral neuropathic pain (DPNP), current treatment options for DPNP, and information about lacosamide. To determine the safety and efficacy of lacosamide as a treatment option for DPNP. Methods A literature search was performed in order to describe DPNP, locate pertinent information about lacosamide, and determine the safety and efficacy of lacosamide for the treatment of DPNP in various trials. A search was also performed to review the effects of other medications on DPNP for the education of the reader as well as to make a comparison to lacosamide. Results DPNP is a common occurrence in patients with diabetes. Options for the treatment of DPNP include anti-depressants, anti-convulsants, opiates, and other alternative medications. One of the most recently studied drugs for DPNP is lacosamide, an anti-convulsant usually prescribed for the adjunct treatment of partial onset seizures. Three RCTs using lacosamide and an extension to one of the trials was found and reviewed. Rauck et al found that lacosamide titrated up to 400 mg divided twice daily to treat DPNP caused 60% of patients to have a significant decrease of 3.11 on the Likert Pain Scale as compared to 50.8% of patients in the placebo group having a decrease of 2.21 on the Likert Pain Scale from the beginning of treatment until conclusion of the trial. Shaibani et al performed an extension to the trial performed by Rauck et al and determined that the effects of lacosamide used for DPNP were maintained over a 2.5 year period. Wymer et al reproduced the results of the study done by Rauck et al by using 200 mg, 400 mg, and 600 mg of lacosamide divided twice daily and comparing them to placebo to see the difference in the Likert Pain Scale scores from the beginning of the trial to conclusion of the trial. The Likert Pain Scale differences were 1.8, 1.9, 2.5, and 2.0 for the placebo, 200 mg, 400 mg, and 600 mg dosage groups, respectively. In the 400 mg lacosamide daily group, 58% of subjects experienced a significant decrease in the Likert Pain Scale score. The 200 mg and 600 mg dosage groups showed no difference in the Likert Pain Scale scores. Ziegler et al studied the changes in pain scores from baseline to the last four weeks of maintenance therapy using lacosamide 400 mg and 600 mg versus placebo. No significant changes were seen in either group. The 400 mg and 600 mg groups lowered the pain scores -0.40 and -0.36 points below placebo, respectively. However, when broken into sections, the trial did show significant changes in pain scores. There were no significant differences in adverse effects across all trials using the 400 mg dose of lacosamide. No trials were found that compared lacosamide to any other drug for the treatment of DPNP. Conclusion Mixed results do show that lacosamide has the potential to effectively and safely lower pain scale scores in individuals with DPNP. However, due to a lack of consistent results and comparison studies with more established and accepted treatments, lacosamide cannot be recommended first line.

No Relation Between Pelvic Belt Tests and Abdominal Muscle Thickness Behavior in Athletes With Long-Standing Groin Pain. Measurements With Ultrasound

To investigate whether abdominal muscle thickness in athletes with long-standing adduction-related groin pain (LAGP) differs between subgroups with a positive or no response to a pelvic belt. The response to a pelvic belt is defined positive in case of a decrease > or = 1 on a Likert pain scale (0-10) during the squeeze test (SQT) or a decrease > or = 1 on the active straight leg raise (ASLR) test score (0-10). Cross-sectional study. Physical therapy practice. Fifty athletes with LAGP. Squeeze test and ASLR test. First, the effect of a pelvic belt on pain during the SQT and the ASLR test score was evaluated. Then, thickness of m. transversus abdominis (TA) and m. obliquus internus (OI) was measured using ultrasound during rest, ASLR left and right, and SQT. Of the 50 participants, 25 (50%) experienced a decrease in pain during the SQT when wearing a pelvic belt and 10 (20%) improved in ASLR performance with a pelvic belt. Thickness of TA and OI at rest (both cases P > .08) and relative thickness compared with rest during tasks (in all cases P > .12) revealed no significant difference when comparing the 2 subgroups based on the belt response during the SQT or ASLR. Using these methods, abdominal muscle thickness behavior in athletes with LAGP did not differ between the subgroups based on a positive or no response to a pelvic belt. However, the ultrasound method used may not have been sensitive enough to reveal differences between groups.

Amitriptyline vs. pregabalin in painful diabetic neuropathy: a randomized double blind clinical trial

To compare the efficacy and safety of pregabalin and amitriptyline in alleviating pain associated with diabetic peripheral neuropathy. A randomized, double-blind, crossover, active-control, clinical trial with variable dose titration was carried out (n = 51). Amitriptyline orally, at doses of 10, 25 and 50 mg at night-time and pregabalin orally, at doses of 75, 150 and 300 mg twice daily, by optional titration was used. Each drug treatment was of 5 weeks. There was a placebo washout period for 3 weeks between the two drugs. Assessment for pain relief, overall improvement and adverse events were carried out. Good, moderate and mild pain relief were noted in 21 (48%), 6 (13%) and 7 (15%) patients on pregabalin and 15 (34%), 5 (11%) and 12 (27%) patients on amitriptyline, respectively, by patient's global assessment of efficacy and safety. Patient and physician's global assessment, McGill pain questionnaire, Likert pain scale and Patient Global Impression of Change showed no significant difference between the treatments, although improvement with both treatments was seen from the first week. Of the 52 adverse events reported, 34 (65.4%) were with amitriptyline, drowsiness being the commonest [in 19 (43%) patients]. Pregabalin caused adverse events in 18 (25%), of which drowsiness was the most common in nine (20%) patients. The preferred pregabalin dose was 150 mg twice daily. As there are few differences between the two treatments in efficacy, pregabalin 150 mg twice daily might be the alternative choice as it is associated with fewer adverse effects in our population.

Low-Frequency Transcranial Magnetic Stimulation in Patients with Fibromyalgia and Major Depression

To study the efficacy of low-frequency transcranial magnetic stimulation in patients with fibromyalgia and major depression. Twenty-eight patients were randomly assigned to receive 20 sessions of real or sham transcranial magnetic stimulation of the right dorsolateral prefrontal cortex. The main stimulation parameters were 15 trains at 110% of the motor threshold for 60 seconds at a frequency of 1 Hz. Blinded external evaluators administered the fibromyalgia scales (FibroFatigue, Likert pain) and the depression scales (Hamilton Depression Rating Scale, Clinical Global Impression) during the study. Both treatment groups (real and sham) improved their scores in some of the scales (FibroFatigue and Clinical Global Impression), although there were no differences between them. No improvements were observed in the Likert Pain Scale in either of the groups. With the methodology used in this study, patients with fibromyalgia and major depression who received real magnetic stimulation did not present significant differences in symptoms with respect to those who received sham magnetic stimulation.

Randomized double‐blind study comparing the efficacy and safety of lamotrigine and amitriptyline in painful diabetic neuropathy

To compare the efficacy and safety of lamotrigine and amitriptyline in controlling chronic painful peripheral neuropathy in diabetic patients. A randomized, double-blind, crossover, active-control, clinical trial with variable dose titration was carried out (n = 53). Amitriptyline orally, at doses of 10, 25 and 50 mg at night-time, each dose for 2 weeks, and lamotrigine orally, at doses of 25, 50 and 100 mg twice daily, each dose for 2 weeks, by optional titration were used. There was a placebo washout period for 2 weeks between the two drugs. Assessment for pain relief, overall improvement and adverse events were carried out. Good, moderate and mild pain relief were noted in 19 (41%), six (13%) and seven (15%) patients on lamotrigine and 13 (28%), five (11%) and 15 (33%) patients on amitriptyline, respectively, by patient's global assessment of efficacy and safety. Patient and physicians global assessment, McGill pain questionnaire and Likert pain scale showed no significant difference between the treatments, although improvement with both treatments was seen from 2 weeks. Of the 44 adverse events reported, 33 (75%) were with amitriptyline, sedation being the commonest [in 19 (43%) patients]. Lamotrigine caused adverse events in 11 (25%), of which rash in three (7%) and elevations of creatinine in four (9%) were the most common. The preferred lamotrigine dose was 25 mg twice daily. As there are few differences between the two treatments in efficacy, lamotrigine 25 mg twice daily might be the first choice as it is associated with fewer adverse effects in our population.

Lacosamide in Painful Diabetic Peripheral Neuropathy

Peripheral diabetic neuropathy affects between 20% and 45% of patients with diabetes. To ascertain the effect of lacosamide on pain associated with peripheral diabetic neuropathy. One hundred nineteen patients with a 1 to 5-year history of pain attributed to diabetic neuropathy and a score of > or =4 on the Likert pain scale entered the multicenter, randomized, double-blind, placebo-controlled trial. Lacosamide (N=60) titrated from 100 to 400 mg/d or maximum tolerated dose and placebo (N=59) were the trial interventions. Primary efficacy criterion was change in pain score on the 11-point Likert pain scale. Secondary assessments included Short-Form McGill Pain and Short-Form-36 Quality of Life Questionnaires, sleep/activity interference, pain intensity, Patient and Clinical Global Impression of Change, and Profile of Mood. Patients receiving at least 1 dose of medication underwent safety evaluation. Ninety-four patients (lacosamide 46; placebo 48) completed the trial. Lacosamide had significantly (P=0.039) better pain relief versus placebo (primary outcome). Improvements were also seen in secondary outcome measures. Adverse events occurred in 52 lacosamide and 44 placebo patients. Common adverse events, occurring in > or =5% of patients, were headache (lacosamide 18%, placebo 22%), dizziness (lacosamide 15%, placebo 8%), and nausea (lacosamide 12%, placebo 7%). Five lacosamide and 3 placebo patients withdrew for adverse events. Lacosamide seems to attenuate pain in diabetic neuropathy in doses up to 400 mg/d and improves quality of life issues.

Ultrasound guided electrocoagulation in patients with chronic non-insertional Achilles tendinopathy: a pilot study

Background: High resolution colour Doppler ultrasound shows intratendinous Doppler activity in patients with chronic Achilles tendinopathy. Treatment of this neovascularisation with sclerosing therapy seems to relieve the pain. However, the...

Celecoxib reduces narcotic use and pain following augmentation mammaplasty

Narcotics have traditionally been used to control pain after augmentation mammaplasty, but they have adverse side effects, including addiction potential, clouded sensorium, nausea, and respiratory depression. Alternative strategies for managing postoperative pain are expensive, cumbersome, and also have their own risks. While long-term use of celecoxib has been associated with an increased risk of serious adverse cardiovascular effects, no problems have been reported with short-term use. The purpose of this study was to determine whether the addition of celecoxib, a selective nonsteroidal anti-inflammatory, to an analgesic regimen reduced narcotic use and pain following augmentation mammaplasty. One hundred patients underwent submuscular augmentation mammaplasty with smooth saline-filled mammary prostheses using an intravenous sedation technique. Group A (N = 50) used hydrocodone to manage postoperative pain. Group B (N = 50) used celecoxib 400 mg 1 to 2 hours before surgery and then daily in addition to hydrocodone postoperatively. Narcotic use, incidence of nausea, and complications were recorded. Pain was assessed daily with a Likert pain scale from 0 (no pain) to 10 (severe pain). Group A used 110 +/- 34 mg hydrocodone during the immediate 7-day postoperative period and reported an average pain scale score of 5.1. Group B, which used celecoxib, used 34 +/- 22 mg hydrocodone during the same period with an average pain scale score of 3.3. These differences were statistically significant (P < .05). Group B experienced 53% less nausea than Group A. There were no significant differences between the groups regarding age, implant size, or complications. Perioperative celecoxib administration in patients undergoing augmentation mammaplasty significantly reduced postoperative narcotic use, pain, and nausea. Its use should facilitate the patient's ability to resume everyday activities following surgery.

Psychological Factors Associated with Idiopathic Arm Pain

<h3>Introduction</h3> Psychological and personality factors may be as important as, or more important than, pathological processes in the experience of pain. This is especially true in those who have a vague or uncertain pain source. The authors tested the hypothesis that patients who had pain with a discrete and easily identified cause would differ from patients who had vague, diffuse pain with no clear source (idiopathic pain) when evaluated with use of validated measures of several psychological factors, including pain, anxiety, catastrophizing, a tendency for somatic complaints, body consciousness, and locus of control. Patients were seen for a single routine office evaluation by one of three hand surgeons and then classified into one of three groups based on the clinical impression. One group was the discrete pain cohort group comprising those who had a single, discrete, identifiable cause of upper limb pain. Another was the idiopathic pain cohort group comprising those who had vague, diffuse complaints. The third group included patients who did not fall into either group and were excluded from the study. There were 56 discrete pain patients and 51 with idiopathic pain. There was no significant difference between the groups with regard to employment status. The idiopathic pain cohort had significantly more single individuals, and the discrete pain cohort had significantly more married individuals. Psychiatric comorbidity was present in 27.5% of the idiopathic pain cohort and in 12.5% of the discrete pain cohort. Measurements included a 10-point Likert pain scale, the Pain Anxiety Symptoms Scale, the Pain Catastrophizing Scale, the Wahler Physical Inventory, the Body Consciousness Questionnaire, and the Multidimensional Health Locus of Control Scale. <h3>Results</h3> Patients with idiopathic pain had more extreme complaints about pain than patients with discrete pain. They had significantly more pain with repeated movement and at rest. Patients with idiopathic pain had greater anxiety about their pain than those with discrete pain. They also had less-adaptive personality traits and demonstrated significantly greater helplessness than those with discrete pain. <h3>Discussion</h3> This study demonstrated several differences in the psychological characteristics of patients with idiopathic versus discrete pain. Patients with idiopathic arm pain reported their pain as more severe; exhibited higher levels of cognitive anxiety and fear of pain; demonstrated more helplessness, magnification, and overall catastrophic coping mechanisms for dealing with pain, and showed a tendency for increased somatic complaining. The strongest single factor in the study was related to catastrophizing. This is defined as the tendency to react to pain by perceiving progressively worse and worse outcomes related to a specific worry. Also, while it may be suggested that idiopathic arm pain may be a somatic representation of psychological distress, or may represent a heightened sensitivity to bodily sensations, a major factor in the present study of idiopathic arm pain was the poor coping mechanisms of the patients. Treatment of idiopathic arm pain can be very frustrating for the patient, the doctor, and the therapist. Physicians should be aware that psychological factors limiting appropriate coping mechanisms may be the reason that the patient is seeking help. Physicians may unknowingly encourage illness behaviors by the way they react to their patients. An honest assessment of the uncertainty of the diagnosis and the influence of psychological factors may help the patient address the necessary issues.

Piriformis syndrome: Diagnosis, treatment, and outcome—a 10-year study

Fishman LM, Dombi GW, Michaelsen C, Ringel S, Rozbruch J, Rosner B, Weber C. Piriformis syndrome: diagnosis, treatment, and outcome—a 10-year study. Arch Phys Med Rehabil 2002;83:295-301. Objectives: To validate an operational definition of piriformis syndrome based on prolongation of the H-reflex with hip flexion, adduction, and internal rotation (FAIR) and to assess efficacy of conservative therapy and surgery to relieve symptoms and reduce disability. Design: Before-after trial of cohorts identified by operational definition. Setting: Outpatient departments of 2 hospitals and 4 physicians' offices. Surgery performed at 3 hospitals. Patients: Consecutive sample of 918 patients (1014 legs) with follow-up on 733. Intervention: Patients with significant (3 standard deviations [SDs]) FAIR tests received injection, physical therapy, and serially reported pain and disability assessments. Forty-three patients (6.47%) had surgery. Main Outcome Measures: Likert pain scale. Subjective estimates of disablement in activities of daily living and instrumental activities of daily living. Results: At 3 SDs, the FAIR test had sensitivity and specificity of.881 and.832, respectively. Seventy-nine percent (514/655) of FAIR test positive (FTP) patients improved 50% or more from injection and physical therapy at a mean follow-up of 10.2 months. Average improvement was 71.1%. Of 385 FTP patients with disability data, mean disability fell from 35.37% prestudy (SD =.2275) to 12.96% poststudy (SD =.1752), a 62.8% improvement. Twenty-eight surgical FTP patients (68.8%) showed 50% or greater improvement; mean improvement was 68% at a mean follow-up of 16 months. Surgery reduced the mean FAIR test to 1.35 ± 2.17 months postoperatively. FTP patients generally improved 10% to 15% more than others after conservative treatment. Conclusions: The FAIR test correlates well with a working definition of piriformis syndrome and is a better predictor of successful physical therapy and surgery than the working definition. The FAIR test, coupled with injection and physical therapy and/or surgery, appears to be effective means to diagnose and treat piriformis syndrome. © 2002 by the American Congress of Rehabilitation Medicine and the American Academy of Physical Medicine and Rehabilitation