Pain Referral Research Articles

Chest Pain, Atherosclerotic Cardiovascular Disease Risk, and Cardiology Referral in Primary Care.

Background: The atherosclerotic cardiovascular disease (ASCVD) 10-year risk estimate is recommended by cardiologists for determining risk of a cardiac event. However, the majority of patients presenting to primary care with chest pain have noncardiac etiologies. Therefore, we determined if high versus low ASCVD risk was associated with primary care physicians’ referral to cardiology in patients with and without chest pain. Methods: Deidentified electronic health record (EHR) data was obtained from 5795 patients treated in academic primary care clinics from 2008 to 2015. Referral to cardiology was defined by an EHR code, chest pain was defined by ICD-9-CM code (786.5) and ASCVD was modeled as high versus low risk. Separate logistic regression models were computed to estimate the association between chest pain and referral to cardiology, ASCVD risk and referral, and both chest pain and ASCVD risk and referral with adjustment for potential confounding factors. Results: More patients with (n = 95, 7.8%) versus without (n = 75, 2.0%) chest pain were referred to cardiology (P < .0001). Separate unadjusted models revealed chest pain and high versus low ASCVD risk were significantly associated with referral (odds ratio [OR] = 4.20; 95% confidence interval [CI] 3.07-5.73 and OR = 1.41; 95% CI 1.04-1.91, respectively). After adjusting for ASCVD risk and confounders, chest pain but not high ASCVD risk remained significantly associated with referral (OR = 1.75; 95% CI 1.24-2.47 and OR = 1.15; 95% CI 0.72-1.82, respectively). Conclusions: In primary care patients presenting with chest pain, ASCVD risk scores are not associated with referral to cardiology. Overall, less than 8% of patients with chest pain were referred. While there is no evidence to indicate excessive referral to cardiology, we posit that implementing ASCVD risk tools in decision aids could contribute to referring those most in need of cardiology care.

Clinical versus radiological findings: A paradox in diagnosing minor hamstring injuries

Hamstring injuries occur commonly in athletes participating in sports that require sprinting/high velocity running, kicking a ball or agility. In the first instance, clinical assessment and management play a pivotal role in managing these injuries. Radiological investigations such as ultrasonography (US) and magnetic resonance imaging (MRI) are also recommended to confirm one or more parameters related to hamstring injury (the location, length, cross-sectional area, volume, edema, hemorrhage, etc.) and predicting return-to-play. However, hamstring injuries that are minor in nature, diagnosed clinically, may not be discernible on conventional US or MRI in some cases. Certain reasons for these paradoxical (clinical vs. radiological) findings may include pain referral to the posterior thigh from lumbosacral dysfunction or sciatic nerve pathoneurodynamics. Conversely, minor hamstring injuries might remain indiscernible within the threshold of conventional MRI sensitivity. To date, there is neither clear consensus on a standardized criteria nor strong evidence for using MRI to prognosticate return-to-play following hamstring injuries. This paper briefly discusses the controversy between contradicting clinical and radiological findings encountered by clinicians in the diagnosis of minor hamstring injuries. If posterior thigh pain appears with clinical signs and symptoms of a minor hamstring injury without pain referral from neighboring structures, but presents with negative findings on US or MRI, the diagnosis remains a challenge. However, such conditions are pragmatically treated as (nonstructural) hamstring injuries unless certain differential diagnoses can be established.

Managing Breast Pain - An Audit of Isolated Breast Pain Referrals

Managing Breast Pain - An Audit of Isolated Breast Pain Referrals

The Tri-Institutional Pain Registry-Analysis of Outpatient Pain Management at a Specialized Cancer Center.

The Outpatient Pain Clinics at Memorial Sloan Kettering Cancer Center participated in developing a pain registry to gain insight on the referral and management of cancer pain as related to demographic information, cancer history, prescription records, and interventional pain procedures stored in the institutional database. Five cohorts (subsets of one another) were defined and compared to describe demographics and differences in management and outcomes by age, race, sex, and cancer type. Clinic patients were compared with the entire institution to determine factors associated with better pain relief and reduced side effects. A small percentage were referred to a pain specialist. A total of 1,043 patients completed 3,544 surveys. Compared with the institution, there were higher proportions of patients age 51 to 60 years, nonwhites, and patients with thoracic, abdominal, and head and neck cancers. Medical management controlled pain with three drug categories in 40% of visits. Short-acting opioids were the only category that statistically provided good pain relief with fewer side effects. Pain scores were improved with increasing opioid dose. Management differed by sex, age, and race; women consistently had lower doses of opioids, poorer pain control, more side effects, and were prescribed a greater variety of medications. A limited set of medications was required to manage most patients in the clinic, supporting the continued place of opioids and the World Health Organization analgesic ladder in managing cancer pain. Women may need a more nuanced approach for obtaining the best balance of pain relief and side effects.

The Clinical Features, Risk Factors, and Surgical Treatment of Cervicogenic Headache in Patients With Cervical Spine Disorders Requiring Surgery.

To clarify the clinical features and risk factors of cervicogenic headache (CEH; as diagnosed according to the International Classification of Headache Disorders-Third Edition beta) in patients with cervical spine disorders requiring surgery. CEH is caused by cervical spine disorders. The pathogenic mechanism of CEH is hypothesized to involve a convergence of the upper cervical afferents from the C1, C2, and C3 spinal nerves and the trigeminal afferents in the trigeminocervical nucleus of the upper cervical cord. According to this hypothesis, functional convergence of the upper cervical and trigeminal sensory pathways allows the bidirectional (afferent and efferent) referral of pain to the occipital, frontal, temporal, and/or orbital regions. Previous prospective studies have reported an 86-88% prevalence of headache in patients with cervical myelopathy or radiculopathy requiring anterior cervical surgery; however, these studies did not diagnose headache according to the International Classification of Headache Disorders criteria. Therefore, a better understanding of the prevalence rate, clinical features, risk factors, and treatment responsiveness of CEH in patients with cervical spine disorders requiring surgery is necessary. We performed a single hospital-based prospective cross-sectional study and enrolled 70 consecutive patients with cervical spine disorders such as cervical spondylotic myelopathy, ossification of the posterior longitudinal ligament, cervical spondylotic radiculopathy, and cervical spondylotic myeloradiculopathy who had been scheduled to undergo anterior cervical fusion or dorsal cervical laminoplasty between June 2014 and December 2015. Headache was diagnosed preoperatively according to the International Classification of Headache Disorders-Third Edition beta. The Japanese Orthopaedic Association Cervical Myelopathy Evaluation Questionnaire, Neck Disability Index, and a 0-100 mm visual analog scale (VAS) were used to evaluate clinical features, and scores were compared between baseline (ie, preoperatively) and 3, 6, and 12 months post-surgery. The prevalence of CEH in our population was 15/70 (21.4%, 95%CI: 11.8% to 31.0%). The main clinical features were dull and tightening/pressing headache sensations in the occipital region. Headache severity was mild (VAS, 32 ± 11 mm) and only one patient reported use of an oral analgesic. Compared to patients without CEH, patients with CEH had higher frequencies of neck pain (86.7% vs. 50.9%; P = .017), cervical range of motion limitation (ROM) (66.7% vs. 38.2%; P = .049), and higher Neck Disability Index scores (14 vs. 3; P < .001). Among the different cervical spine disorders, the prevalence of CEH was highest in cervical spondylotic myeloradiculopathy patients (60%), being ≤ 20% for all other disorders. Surgical treatments including cervical laminoplasty to relieve abnormal pressure on the spinal cord via a posterior approach, were associated with initial improvements in headache VAS that slightly diminished by 12 months post-surgery (P < .001). We report a lower prevalence of CEH in patients with cervical spinal disorders requiring surgery than that reported previously. The main clinical features of CEH were mild, dull, and tightening/pressing headache sensations in the occipital region. Potential risk factors for CEH included neck pain, limited cervical ROM, high Neck Disability Index score, and a diagnosis of cervical spondylotic myeloradiculopathy. The further accumulation of patients in a multi-institutional study may be required in order to discuss the diagnostic criteria and pathophysiology of this condition.

0608 ASSESSMENT OF OBSTRUCTIVE SLEEP APNEA IN PATIENTS WITHCHRONIC PAIN SYNDROME: HOW DOES PORTABLE RESPIRATORY RECORDING COMPARE TOPOLYSOMNOGRAPHY?

Obstructive Sleep Apnea (OSA) is a common condition seen in veterans with Chronic Pain Syndrome (CPS). Portable respiratory recording (PRT) is cheaper and more readily available than polysomnography (PSG). The validity of PRT in the diagnosis of OSA in patients with CPS is not well characterized. Veterans with CPS admitted to a referral pain rehabilitation center underwent PSG along with supervised PRT in the sleep laboratory on presentation. Studies were scored independently by a blinded scorer using AASM scoring criteria, hypopneas were scored based on oxygen desaturation and arousal criteria in PSG while they were scored based on oxygen desaturation on PRT. Generated reports were compared for Apnea Hypopnea Index (AHI), Oxygen Saturation Nadir (OSN), Oxygen Desaturation Index (ODI), Time Supine (TS), and Mean Heart Rate (MHR) using mean, standard deviation and Parson Correlation Coefficient (PCC). Twenty-five veterans with CPS were enrolled (22 male, 3 females with an average BMI of 30.15). Average AHI was 23 +/-15 via PSG and 18.2 +/-16.5 via PRT, with PCC 0.69. Twenty three patients were found to have OSA based on PSG while nineteen patients were found to have OSA based on PRT. Ten patients had severe OSA based on PSG while four patients had severe OSA based on PRT. OSN was 86.1 +/- 22.8% via PSG and 85.8 +/-22.7% via PRT, PCC 0.54. ODI was 13.6 +/- 13.6 via PSG and 14.3 +/- 11.1 via PRT, PCC 0.82. TS was 192.7 +/- 109 min via PSG vs 223 +/- 124.4 min via PRT, PCC 0.81. MHR was 67.6 +/- 19.8 bpm via PSG vs 63.8 +/- 18.6 bpm via PRT, PCC 0.97. The results were not statistically significant. The sensitivity and severity characterization of PRT is suboptimal when compared to the PSG gold standard with chronic pain. Oximetry and positional measurements are similar between PRT and PSG. Further analysis of PRT sensitivity based on patient characteristics may help identify more suitable candidates for PRT testing. None.

Experimental pain in the groin may refer into the lower abdomen: Implications to clinical assessments.

To investigate the effects of experimental adductor pain on the pain referral pattern, mechanical sensitivity and muscle activity during common clinical tests. Repeated-measures design. In two separate sessions, 15 healthy males received a hypertonic (painful) and isotonic (control) saline injection to either the adductor longus (AL) tendon to produce experimental groin pain or into the rectus femoris (RF) tendon as a painful control. Pain intensity was recorded on a visual analogue scale (VAS) with pain distribution indicated on body maps. Pressure pain thresholds (PPT) were assessed bilaterally in the groin area. Electromyography (EMG) of relevant muscles was recorded during six provocation tests. PPT and EMG assessment were measured before, during and after experimental pain. Hypertonic saline induced higher VAS scores than isotonic saline (p<0.001), and a local pain distribution in 80% of participants. A proximal pain referral to the lower abdominal region in 33% (AL) and 7% (RF) of participants. Experimental pain (AL and RF) did not significantly alter PPT values or the EMG amplitude in groin or trunk muscles during provocation tests when forces were matched with baseline. This study demonstrates that AL tendon pain was distributed locally in the majority of participants but may refer to the lower abdomen. Experimental adductor pain did not significantly alter the mechanical sensitivity or muscle activity patterns.

Referred Pain Patterns of the Infraspinatus Muscle Elicited by Deep Dry Needling and Manual Palpation.

To identify the most common referred pain (ReP) pattern of the infraspinatus myofascial trigger point (MTrP) and compare its coincidence with the original ReP pattern, to verify whether there are any significant differences by sex and types of technique and to determine the observed signs and symptoms evoked by deep dry needling (DDN) and manual palpation (MPal). A cohort study of patients randomized to two different examination methods (July and August 2016). Students and staff recruited from Miguel Hernandez University (Southeast Spain). One hundred thirty-three participants (70.7% women) with shoulder complaints were randomly assigned to either an MPal (n = 67) or DDN group (n = 66). The same physiotherapist carried out the techniques on all participants, and the same protocol was followed for both the DDN and MPal groups. The physiotherapist did not ask participants about their pain features or other relevant issues. Local twitch response (LTR) and ReP assessed through a visual analogue scale and features of ReP of the infraspinatus muscle. The areas with the highest percentage of ReP were the front (area 3; 27.1%) and back (area 11; 21.1%) of the arm, anterior (area 4; 36.1%) and posterior (area 12; 42.1%) shoulder, and infraspinatus muscle area. DDN proved to be significantly easier than MPal in evoking an LTR (p ≤ 0.001). There were significant differences between sexes in zone 2 (p = 0.041) and no statistically significant differences were found by technique. The ReP pattern of the infraspinatus muscle coincides with the original pattern described by Travell and Simons, although the neck area should be questioned. The study found no significant differences in the ReP pattern by sex and when comparing MPal with DDN of MTrP of the infraspinatus muscle. DDN proved to be significantly easier than MPal in evoking an LTR.

Ultrasound-detected pathologies cluster into groups with different clinical outcomes: data from 3000 community referrals for shoulder pain

BackgroundUltrasound is increasingly used to evaluate shoulder pain, but the benefits of this are unclear. In this study, we examined whether ultrasound-defined pathologies have implications for clinical outcomes.MethodsWe extracted reported pathologies from 3000 ultrasound scans of people with shoulder pain referred from primary care. In latent class analysis (LCA), we identified whether individual pathologies clustered in groups. Optimal group number was determined by the minimum Bayesian information criterion. A questionnaire was sent to all patients scanned over a 12-month period (n = 2322). Data collected included demographics, treatments received, current pain and function. The relationship between pathology-defined groups and clinical outcomes was examined.ResultsLCA revealed four groups: (1) bursitis with limited inflammation elsewhere (n = 1280), (2) bursitis with extensive inflammation (n = 595), (3) rotator cuff tears (n = 558) and (4) limited pathology (n = 567). A total of 777 subjects (33%) completed questionnaires. The median (IQR) duration post-ultrasound scan was 25 (22–29) months. Subsequent injections were most common in groups 1 and 2 (groups 1–4 76%, 67%, 48% and 61%, respectively); surgery was most common in group 3 (groups 1–4 23%, 21%, 28% and 16%, respectively). Shoulder Pain and Disability Index scores were highest in group 3 (median 48 and 30, respectively) and lowest in group 4 (median 32 and 9, respectively). Patients in group 4 who had surgery reported poor outcomes.ConclusionsIn a community-based population, we identified clusters of pathologies on the basis of ultrasound. Our retrospective data suggest that these groups have different treatment pathways and outcomes. This requires replication in a prospective study to determine the value of a pathology-based classification in people with shoulder pain.

Quality of Life in Patients with Coronary Artery Disease and Panic Disorder: A Comparative Study.

The quality of life (QOL) of patients with coronary artery disease (CAD) is known to be impaired. Non-cardiac chest pain referrals are often under-diagnosed and untreated, and there are hardly any studies comparing the QOL of CAD and panic disorder related (non-cardiac) chest pain referrals (PDRC). We assessed the psychiatric morbidity and QOL of patients newly diagnosed with CAD (n = 40) at baseline and six weeks post-treatment and compared their QOL with patients with PDRC (n = 40) and age- and gender-matched healthy controls (n = 57). Psychiatric morbidity in the CAD group was assessed using the General Health Questionnaire (GHQ12) item, Hamilton Anxiety Scores (HAM-A), and Hamilton Depression Scores (HAMD). QOL measures were determined by the World Health Organization QOL questionnaire (brief) and Seattle Angina Questionnaire. The CAD group was treated with anti-ischemic drugs (nitrates, betablockers), antiplatelet drugs (acetylsalicylsalicylic acid), anticoagulants (low molecular weight heparin, clopidogrel), and managed for risk factors. The PDRC group was treated with selective serotonin reuptake inhibitors and anxiolytics. Patients with panic disorder had a worse QOL than those with CAD and healthy controls in the physical domain and psychological domain (PDRC vs. CAD vs. healthy controls, p < 0.001). In the CAD group, smoking was associated with change in angina stability (p = 0.049) whereas other tobacco products were associated with change in angina frequency (p = 0.044). Psychiatric morbidity was present in 40.0% of patients with CAD. In the PDRC group, a significant correlation of HAM-A scores was noted in the physical (p = 0.000), psychological (p = 0.001), social (p = 0.006), and environment (p = 0.001) domains of QOL. Patients with panic disorder had a significant improvement in anxiety scores after treatment compared to baseline (HAM-A scores difference 21.0 [16.5-25.6]; p < 0.001). Patients in the PDRC group had a worse QOL than those in the CAD and healthy control groups. This highlights the need for careful diagnosis and prompt treatment of panic disorder in these patients to improve their QOL. Additionally, smoking, the use of other tobacco products, and hypercholesterolemia were associated with angina symptoms in patients with CAD.

Compare the Effectiveness of Dry Needling Therapy Versus Cryotherapy on Patients with Upper Trapezius Trigger

Myofascial trigger point (MTrPs) are one of the most overlooked and ignored causes of acute and chronic pain and at the same time, constitute one of the most common musculoskeletal pain condition. All muscles can have MTrPs. It's a hyperirritable spot in a taut band of the skeletal muscle that is painful on contraction, stretching and elicits a referral pain distant from the point. Dry needling technique is an effective method for the treatment of MTrPs. It is an efficient technique which is reduced a trigger pain and irritability & low in risk of this treatment, more studies are required. The treatment which is available for trigger points are Cryotherapy/spray and stretch, massage, compression release, modalities-ultrasound, laser etc…dry needling, acupuncture, intramuscular manual therapy etc…This study helps the patient to choose the best available treatment option.

The Role of Testosterone Supplemental Therapy in Opioid-Induced Hypogonadism: A Retrospective Pilot Analysis.

Chronic opioid therapy for pain management is known to induce several endocrine changes. The authors examined the effect of testosterone supplemental therapy (TST) in patients with chronic, noncancer pain undergoing opioid therapy. It was hypothesized that treatment of opioid-induced hypogonadism (OIH) can reduce opioid requirements in patients suffering from chronic pain and approve their quality of life. Over 18 months period, patients with OIH were identified in a tertiary referral pain center, Numerical Rating Scale (NRS) pain scores and daily morphine equivalent dose (MED) were the primary outcomes measured. Data were collected and comparative analysis performed between men undergoing TST versus nontreatment group. Twenty-seven OIH patients (total testosterone <300 ng/dL) were identified during the study period. TST group consists of 11 patients, while non-TST group consists of 16 patients as control cohort. Mean patient age (55 and 54.4, p = .4) and basic metabolic index (28.5 and 31.9, p = .07) in TST and non-TST groups, respectively. Mean follow-up total testosterone (ng/dL) was significantly higher after TST compared with the non-TST group (497.5 vs. 242.4 ng/dL, p = .03). Median follow-up NRS was 0 and 2 in the TST and non-TST groups (p = .02). Mean MED (mg) decreased by 21 mg in TST group and increased by 2.5 mg in non-TST group (p < .05). This study reports that treatment of OIH with TST can reduce opioid requirements in men with chronic pain as quantified by MED. It also confirms previous reports on the potential effects of OIH and that TST is effective in correcting opioid-induced endocrine abnormalities.

OSA Common in Veterans With Chronic Pain Syndrome

SESSION TITLE: Sleep Disorders 2 SESSION TYPE: Original Investigation Poster PRESENTED ON: Wednesday, October 26, 2016 at 01:30 PM - 02:30 PM PURPOSE: Obstructive Sleep Apnea (OSA) and Chronic Pain Syndrome (CPS) are both very common conditions and may occur frequently by chance alone. We studied the interaction between these disorders. METHODS: Veterans with CPS admitted to a referral pain rehabilitation center underwent polysomnography on presentation. Three groups of patients were compared: patients with CPS taking either opiates (O group), tramadol (T group) or none of these agents (C group). Demographics, Epworth Sleepiness Score (ESS) and sleep parameters were recorded and compared among these groups for statistical significance. RESULTS: Twenty-nine patients were studied and 90% of them had OSA with AHI >5; 48% were sleepy (ESS > 10) and 45% had OSA syndrome. Forty five percent of all patients were obese (BMI>30). Severe OSA was more common in the C group (7/14) than in the O group (3/12). The three patients in the T group had moderate or severe OSA. Obese patients in the O group had a lower AHI (11.4+/- 6.7) than obese patients in the C group (28.5 +/- 13.7), p 0.04. REM latency was longer in the T group (215 +/- 76 mins) than in the O group (105 +/- 74 mins; p 0.04). There was a trend towards a shorter REM latency in alert patients (ESS <11) in the C group (47 +/- 28 mins) compared to alert patients in the O group (99 +/- 51 mins), p 0.07. Sleepy patients in the C group tended to have a higher REM latency (170 +/- 128 mins) than alert patients (47+/- 28 mins), p 0.06. Obese sleepy patients in the C group had a shorter REM latency (59.3 +/- 9.5 min) than non-obese sleepy patients (192+/- 98 min), p 0.03. Obese sleepy patients in the C group tended to have less N3 sleep (15.4+/- 5.6%) than non-obese sleepy patients (24.4 +/-6.5%), p 0.06. Obese sleepy patients in the O group had a lower arousal index (9.7 +/- 0.8 events/hr) than non-obese sleepy patients (21.9+/- 2.3), p 0.001. Only one patient from all groups, who was taking opiates, had clinically significant central sleep apnea (central apnea index > obstructive apnea index > 5 events/hr). CONCLUSIONS: OSA is very common in veterans with CPS. Weight may modify the severity of OSA in this condition in an inverse fashion. Patients with CPS not treated with opiates may have a shorter REM latency, particularly if they are obese and alert. Somnolent patients with CPS may lose N3 sleep if they gain weight. However, if obese patients with CPS take opiates, they may have a lower arousal index than their non-obese counterparts. CLINICAL IMPLICATIONS: Veterans with CPS should be screened for OSA. The sleep architecture of patients with CPS and the natural history of OSA and CPS should be explored further. DISCLOSURE: The following authors have nothing to disclose: Karel Calero, Steven Sanders, Zachary Stachura, William Anderson No Product/Research Disclosure Information

Pain, Pressure Pain Threshold and Disability Following One Session of Dry Needling in Subjects with Active Trigger Points in the Upper Trapezius Muscle

Introduction: Myofascial pain syndrome is a common, non-articular musculoskeletal disorder characterized by local tenderness and referral pain due to the active trigger points in muscles. The aim of this study was to evaluate the effects of one session of dry needling in subjects with active trigger points in upper trapezius muscle. Materials and Methods: 23 subjects with active trigger points in upper trapezius muscle participated in the study. The pain intensity and Disability Index were measured using visual analogue scale (VAS) and Neck Disability Index questionnaire, respectively. All data were measured before and one week after the intervention. Using algometry, the pressure pain threshold was also measured immediately after the dry needling. Results: There were significant differences in mean pressure pain threshold among the three measurements (P < 0.001). The pressure pain threshold significantly decreased immediately after the intervention (P = 0.001); although it significantly increased a week later compared to before the intervention (P = 0.001). There was significant decrement in the mean Disability Index score and pain intensity after the intervention (P < 0.001). Conclusion: One week after one session of dry needling, disability, pain intensity and pressure pain threshold improved considerably in subjects suffering from active trigger points in upper trapezius muscle.

Referred leg pain originating from the sacroiliac joint: 6-month outcomes from the prospective randomized controlled iMIA trial.

The first results from the randomized, controlled iFuse Implant System Minimally Invasive Arthrodesis (iMIA) trial showed that minimally invasive surgical management (MISM) of low back pain originating from the sacroiliac joint (SIJ) by placing transarticular triangular titanium implants reduced pain more effectively than conservative management (CM). We now conducted a separate analysis of the iMIA data to assess whether the referred leg pain (RLP) component of SIJ-associated pain may also be affected by MISM or CM. Data from 101 patients, recruited between June 2013 and May 2015 at nine European spine care centers, were included. Forty-nine patients were randomized to CM and 51 patients to MISM. RLP was defined as pain below the gluteal fold and assessed using the visual analogue scale (VAS). Changes in RLP over 6months were the primary endpoint. The prevalence of clinically significant RLP was 76.2%. Over 6months of follow-up, CM produced no significant change in RLP, which was 51.0 VAS points (interquartile range (IQR) 17.0-75.0) at baseline. In contrast, in the MISM cohort, we found a significant decrease in RLP from VAS 58.0 (IQR 24.5-80.0) at baseline to VAS 13.5 (IQR 0.0-39.3) after 6months (p < 0.01). Improvement of RLP was associated only with the type of treatment (OR 5.04, p < 0.01), but not with patient age, sex, or different patterns of pain referral. Our analysis shows that RLP is a frequent phenomenon in patients with SIJ-associated pain. At 6months of follow-up, MISM helped relieve RLP more effectively than CM. Clinical Trial Registration-URL: http://www.clinicaltrials.gov . Unique identifier: NCT01741025.

Distribution of hip pain in patients with idiopathic osteonecrosis of the femoral head

Objective: To determine the distribution of referred hip pain in patients with idiopathic osteonecrosis of the femoral head (ION).Methods: We prospectively documented 119 hips in 90 patients with ION (mean age 51 years). Patients identified the location of pain originating in their hip on a drawing of the body. Osteoarthritis of the hip (OA) was used as a historical cohort.Results: Referral of pain originating from the hip in patients with ION was 93% (111 hips) to the groin, 68% (81 hips) to the knee, 36% (43 hips) to the anterior thigh, 34% (40 hips) to the buttock, 18% (22 hips) to the lower leg, 9% (11 hips) to the greater trochanter, and 8% (9 hips) to the low back. About 97% (115 hips) of pain was located in the hip region (groin, buttock, and greater trochanter) and 77% (92 hips) showed referred pain (anterior thigh, knee, lower leg, and low back). Pain from ION was significantly more frequent in the knee and lower leg, but significantly less frequent in the lower back than pain from OA.Conclusion: We should be aware of ION masquerading as pain in the knee or anterior thigh.

Streamlining Chest Pain Referrals From the Emergency Department Reduces ‘Double Dipping’ in the Outpatient Cardiology Clinic

Each year, 500,000 patients present to Australian Hospital Emergency Departments (ED) with possible cardiac chest pain [[1]AIHW. Australian hospital statistics 2012-13. Health services series no. 54. Cat. no. HSE 145. Canberra: AIHW; 2014.Google Scholar]. The current Australian National Emergency Access Target (NEAT) is to discharge, admit or transfer patients presenting to emergency within four hours [[1]AIHW. Australian hospital statistics 2012-13. Health services series no. 54. Cat. no. HSE 145. Canberra: AIHW; 2014.Google Scholar]. Patients that present out of normal office hours, with no new ECG changes or biomarkers suggestive of myocardial infarction, are often discharged with a referral to the Cardiology Outpatient Clinic (COC) for follow-up consultation. Many of these patients require cardiac functional testing and often this first appointment with the Cardiologist is simply to order the test, with patients returning after the test for the results. This “double dipping” increases wait lists and creates a back log of referrals in the outpatient clinic. We sought to refer those suitable for functional testing direct from the ED to the cardiac investigation unit (CIU) prior to the COC in order to reduce the waiting list in these clinics. A two-month pilot study was initiated to begin on 1/12/15. A flow chart was devised to assist emergency physicians in selecting those patients suitable for functional testing. Chest pain referrals to the COC declined by 55% compared to the previous two months. A decrease in the waiting list was noticed from 200 patients to 140 post trial. A concomitant increase (29%) in the number of functional tests performed by the CIU was also observed. Preliminary data for the streamlining of these referrals looks promising in reducing wait times to access COC appointments.

The utility of a 'non-significant' coronary angiogram.

Coronary angiography is the gold standard for assessing coronary artery disease (CAD). In many patients with chest pain, no or mild CAD (< 50% stenosis) is found. It is uncertain whether this 'non-significant' result influences management and outcomes. We reviewed characteristics and outcomes in a contemporary cohort of chest pain referrals who had mild or absent CAD on coronary angiography. All patients undergoing coronary angiography at Auckland City Hospital during July 2010-October 2011 were reviewed (n = 2983). Of these, 12.3% (n = 366) underwent coronary angiography for evaluation of chest pain and were found to have absent or mild CAD. These patients were followed up for 2.3 ± 0.6 years. Mean age was 60.0 ± 12.3 years, 56.1% were female. The ECG was abnormal in 55.0% of patients. Stress testing for inducible ischaemia was undertaken in 40.7% of patients and was abnormal in 57.7%. Following angiography, 43.2% had no changes to cardiac medications. Additional drug therapy (aspirin, statin, beta-blockers, ACE-inhibitor) was commenced in around 14.2-22.1% of cases. These drugs were discontinued in 4.1-8.2% of patients. Rates of major adverse cardiovascular events and readmissions with chest pain were 0.3% (1) and 1.9% (7) respectively at 30 days, and 1.9% (7) and 6.0% (22) at 1 year. Although even non-obstructive atheroma may justify medical therapy to limit disease progression, our findings may suggest that in these cases, invasive coronary angiography, may not lead to the patient/physician reassurance justified by historical data.

Glenohumeral Joint Pain Referral Patterns: A Descriptive Study.

Pain diagrams are a useful tool to help physicians understand the varying presentation patterns of specific pain generators. This study is the first to describe the potential pain patterns of the glenohumeral joint (GHJ) based on responses to diagnostic image-guided GHJ injections. To determine potential GHJ pain referral patterns. 162 consecutive patients undergoing 168 GHJ injections recorded their preprocedure pain scores and drew accurate pain diagrams prior to undergoing fluoroscopically guided GHJ injections with local anesthetic. Postprocedure pain scores were recorded and those with complete relief were considered responders. Pain diagrams were overlaid via computer software to facilitate analysis and a composite pain map. A responder composite was also compared with a nonresponder composite. The GHJ was shown to cause pain in traditionally localized areas of the anterior and/or posterior shoulder and upper arm regions in 100% of patients who experienced complete pain relief after injection. Among 100% responders, 18% had neck pain and 6% had scapular pain. Pain was shown to radiate distally, with anterior forearm pain in 9%, posterior forearm pain in 8%, and hand pain in 9%. No patients with pain both in the medial neck and below the elbow were found to be 100% responders. Similarly, no patients were 100% responders if they had pain in the medial scapula and below the elbow, or medial scapula and medial neck. Anterior or posterior shoulder and upper arm pain, or a combination of the two, is the most common pain referral area from a symptomatic shoulder joint. Referral to the lateral neck, in combination with shoulder pain, was occasionally seen. Pain referral to the forearm and hand was less common. Rarely did a symptomatic shoulder joint refer pain to the scapula or to the medial neck.

Two-year follow-up of low-level laser therapy for elderly with painful adhesive capsulitis of the shoulder.

IntroductionThis paper reports on the medium-term mean 2-year prospective follow-up of a patient cohort of 35 unselected elderly patients with mean age of 65 years who visited our tertiary referral pain center for painful adhesive capsulitis of the shoulder managed with low-level laser therapy (LLLT).Materials and methodsAll patients in this prospective cohort study had documentation of the diagnosis by contrast-enhanced magnetic resonance imaging before study entry and all had failed to respond to a combination of conventional physical therapy and nonsteroidal anti-inflammatory medications for not fewer than 4 weeks. LLLT, at a wavelength of 810 nm emitted from a GaAIAs semiconductor laser device with 5.4 J per point and a power density of 20 mW/cm2, was employed to irradiate six predetermined anatomic points and two acupuncture points. The treatment regimen consisted of three sessions of treatment per week for 8 consecutive weeks. Each treatment session lasted 180 seconds. Serial clinical assessment was undertaken using the Constant–Murley shoulder score.ResultsA total of 50 painful shoulder joints were treated, as a number of elderly presented with bilateral symptoms. All but four painful shoulders showed significant improvement in Constant–Murley shoulder score at the end of 8-weeks’ LLLT treatment and, surprisingly, the improvement was found maintained at follow-up assessments at 1 year and 2 years.ConclusionWe conclude that LLLT is a viable option in the conservative treatment of shoulder pain arising from adhesive capsulitis of the shoulder in the elderly, with a positive clinical result of more than 90% and with clinical efficacy both in the short-term and the medium-term.