Pain Syndrome Patients Research Articles

Невропатические болевые синдромы у больных с рассеянным склерозом: патогенез, диагностика, тактика ведения пациентов

Neuropathic pain syndromes (NPS), pathogenetically associated with the demyelinating process in the central nervous system and patient maladjustment, are commonly found in patients with multiple sclerosis (MS). Primarily, the diagnosis of NPS is based on a careful analysis of clinical symptoms, while the MRI data and neurophysiological methods are of auxiliary importance. Difficulties in the NPS treatment are due to the patterns of pathogenetic mechanisms that determine the chronic nature of NPS, as well as limited efficacy and common adverse events of the drug therapy. The review examines modern views concerning the main variants of NPS in MS (persistent extremity pain, trigeminal neuralgia, Lhermitte’s sign, painful tonic spasms), describes the patterns of pathogenesis and clinical manifestations of each syndrome, provides data on the information value of additional examination methods, analyzes existing methods to conservative therapy based on the randomized trials data. Particular attention is paid to the following points in patient management with NPS: setting adequate treatment goals, choosing medications, using rational combined pharmacotherapy and non-drug treatment methods, increasing patients’ adherence to therapy. KEYWORDS: multiple sclerosis, neuropathic pain syndromes, persistent extremity pain, trigeminal neuralgia, Lhermitte’s sign, painful tonic spasms, treatment tactics of neuropathic pain. FOR CITATION: Kiselev D.V., Spirin N.N., Baranova N.S., Karpova M.S. Neuropathic pain syndromes in patients with multiple sclerosis: pathogenesis, diagnosis, patient management. Russian Medical Inquiry. 2022;6(10):556–562 (in Russ.). DOI: 10.32364/2587-6821-2022- 6-10-556-562.

Features of the course of acute coronary syndrome in patients with diabetes

Acute coronary syndrome (ACS) remains a common cause of hospitalization for patients with diabetes mellitus (DM). Due to the frequent development of diabetic neuropathy, it is believed that this category of patients is characterized by a high frequency of atypical acute coronary syndrome, but data on this are quite contradictory. The objective. To determine the features of the clinical course and manifestations of pain syndrome in patients with ACS with accompanying diabetes. Materials and methods. The study involved 36 patients with diabetes (22 men and 14 women) aged 44-86 years, hospitalized urgently for ACS. Pain syndrome was assessed at the time of hospitalization and immediately after coronary artery revascularization according to the following criteria: visual analog scale (VAS), Numerical Rating Scale (NRS), clinical data, and biochemical markers. Results. The majority of patients (91.67%) at the time of hospitalization complained of chest pain, the rest were not bothered by any pain. During the survey, patients described pain as "burning" (30.56%), "squeezing" (30.56%), "squeezing" (25.0%), "tingling" (5.56%). There were also complaints of difficulty breathing (13.89%), shortness of breath (11.1%), palpitations (41.67%). The appearance of excessive sweating was noticed by 16.67% of patients. There was no statistically significant difference between the results of pain assessment by VAS and NRS (p> 0.1). The average value of glycemia at the time of hospitalization was 8.19 ± 3.45 mmol / l (men – 8.17 ± 3.61 mmol / l, women – 8.28 ± 3.13 mmol / l). Glycemia greater than 10.0 mmol / l was detected in 8 patients, which was 22.22% of all patients. This category of patients was dominated by patients with severe pain (62.5%). Conclusions. In patients with ACS and diabetes, the typical clinical picture of ACS prevailed (91.67% of patients) over the painless form. Prior to revascularization, moderate and severe pain occurred with equal frequency; there is no statistical difference between blood pressure, heart rate and glycemia (p> 0.1) in patients with severe and moderate pain. Hyperglycemia (≥10.0 mmol / l) was found in 22.22%, among this category of patients was dominated by patients with severe pain.

Topical therapy of acute nociceptive pain: results of an open randomized clinical trial of the domestic drug Alental cream

Evaluation of the therapeutic efficacy, safety and tolerability of the drug Alental cream for external use (VERTEX, LLS, Russia) compared with the original drug - Aertal cream for external use (Gedeon Richter, LLS, Hungary) for local therapy of acute nociceptive pain syndrome in patients who have suffered traumatic ankle injury. The study included 131 patients who had suffered an injury to the soft tissues of the ankle joint. The 1st comparison group received the drug Alental cream, the 2nd group - Aertal cream. The duration of therapy was 7 days. The effectiveness of the drugs was evaluated during treatment based on the dynamics of the intensity of pain syndrome and other symptoms of trauma, as well as the assessment of these changes by the doctor and the patient. The safety analysis included the registration of adverse events according to clinical and laboratory studies. Alental cream in terms of therapeutic efficacy was equivalent to the registered original preparation Aertal cream. The analysis of the assessment of the dynamics of clinical and laboratory parameters, the safety of treatment, including the frequency of adverse events, did not reveal significant differences between the two drugs. Alental cream can be used as a means for local therapy of acute nociceptive pain syndrome in traumatic soft tissue injuries.

Effects of the ankle angle on the electromyographic activity of the trunk and lower extremities during isometric squat exercises

Background: Life in modern society has become convenient, but the lack of exercise due to a sedentary lifestyle has led to muscle weakness. The quadriceps femoris is essential for walking, standing, and using stairs in daily life. Muscle weakness can lead directly to impaired function. Squatting is the most representative exercise for effective muscle development and increasing the knee extensor strength. This study examined the effects of ankle angle during wall squats on the muscle activity of the vastus medialis oblique (VMO), vastus lateralis (VL), rectus femoris (RF), biceps femoris (BF), rectus abdominis (RA), and erector spinae (ES) to determine which ankle angle can better strengthen the vastus medialis oblique as a method of rehabilitation training after a knee joint injury. Methods: All subjects (n = 20) performed the following three types of wall squats randomly: (1) GWS (General Wall Squat), (2) WSD 10° (Wall Squat with dorsiflexion 10°), and (3) WSP 10° (Wall Squat with plantarflexion 10°). Each subject completed all three kinds of wall squatting exercises three different times, and the muscle activity data of the VMO, VL, RF, BL, RA, and ES were recorded. Results: Compared to GWS exercise, the VMO and RF muscle activity increased significantly under WSP 10° exercise (p < 0.05), whereas the VL, BF, RA, and ES activity did not increase significantly (p > 0.05). No significant change between WSD 10° and WSP 10° was observed (p > 0.05). Conclusions: WSP 10° can help increase the quadriceps muscle activity. Wall squat exercise with different ankle angles can be used for quadriceps muscle strengthening training for normal people and for recovery training for patellofemoral pain syndrome (PFPS) patients in the rehabilitation stage.

ОСОБЛИВОСТІ БОЛЬОВОГО СИНДРОМУ У ХВОРИХ НА КРИЛОПІДНЕБІННИЙ ГАНГЛІОНІТ

Relevance of the research. The features of complex anatomical and functional organization of the maxillofacial area, peripheral nervous system, as well as autonomic structures determine a variety of pathogenetic mechanisms of prosopalgia, among which the lesions of the pterygopalatine node are the most common. Despite the presence of a significant variety of clinical manifestations of pterygopalatine ganglionitis, the prevalence and variety of autonomic manifestations in this disease, the main complaint of patients is pain, the characteristics of which are quite different. The aim of our research was to study the nature of pain in patients with pterygopalatine ganglionitis. Material and methods of research. We examined 105 patients with pterygopalatine ganglionitis aged from 30 to 74 years. Patients were examined for the nature of pain and its intensity, the predominant time of onset and duration of pain attacks, the place of primary localization of pain and the area of its spread. A visual analog scale (VAS) was used to assess pain intensity. Based on the intensity of pain and depending on the severity of the disease, all patients were divided into three groups: mild, moderate and severe pterygopalatine ganglionitis. With a mild severity of pterygopalatine ganglionitis, the intensity of pain attacks is 4-5 points, lasting up to 30 minutes and with a frequency of 1-3 times a day with localization within one or two anatomical areas. With moderate severity, the intensity of pain attacks is 5-7 points, lasting from 30 minutes to 1-2 hours and with a frequency of 4-5 times a day with the gradual spread of pain from one area to half of the face. The severe course is characterized by pain attacks of 8-10 points, lasting for 2 hours or more and with a frequency of attacks from 4 to 6-10 per day. In addition, the pain, occurring in one anatomical area, gradually spread to half of the face, radiating to neighboring areas. Thus, analyzing the features of the pain syndrome in patients with pterygopalatine ganglionitis, we can conclude: 1. The intensity of pain, which was determined by VAS, increases depending on the severity of ganglionitis and ranges from 4.3 points in mild to 8.75 in severe ganglionitis. 2. The duration and frequency of pain attacks increase from 30 minutes with a frequency of 1-3 seizures per day in patients with mild pterygopalatine ganglionitis, to 2 or more hours and 4-10 seizures per day in patients with severe ganglionitis. 3. The localization of pain attacks extends from one anatomical area in mild ganglionitis to half of the face with the possibility of irradiation of pain in severe ganglionitis. 4. These clinical symptoms should be used in determining the severity of pterygopalatine ganglionitis and the choice of treatment tactics in the future.

Transdermal electroneurostimulation in patients with diabetic neuropathy

BACKGROUND: The dynamics of pain syndrome determined using various algic tests in the treatment of patients with diabetic neuropathic pain syndrome using tansdermal electroneurostimulation has been little studied.
 AIMS: To study the dynamics of projection zones of neuropathic pain syndrome in patients with diabetic polyneuropathy while using TENS.
 MATERIAL AND METHODS: 75 patients with diabetic polyneuropathy were examined. The control group (n=25; 33.3%) received a course of standard pharmacotherapy. The main group consisted of 2 groups. The first group (n=25; 33.3%) underwent a course of high-frequency low-amplitude (HL TENS) transdermal electroneurostimulation, and the second group (n=25; 33.3%) underwent a course of low-frequency high-amplitude (LH TENS) therapy. Pain syndrome was determined using a visual analogue scale (VAS) and a body diagram before, after treatment and in the long-term period.
 RESULTS: Using a visual analogue scale (VAS), the dynamics of pain syndrome after the use of LF TENS was lower than after the use of HFTENS by an average of 35% (p 0.05).
 The data obtained indicate that the regression of pain syndrome after physiotherapeutic treatment of TENS in patients from the main comparison groups exceeds similar indicators in patients from the control group by an average of 63% (p 0.05) both immediately after the course of exposure and in the distant the observation period by 23%. Against the background of TENS, the area of pain syndrome according to the body pattern significantly decreased by 53% after treatment (p 0.05) and by 65.6% in the long-term period (p 0.05), compared with a decrease in the area of pain syndrome in the control group.
 CONCLUSION: There were revealed significant differences between the quantitative and projection forms of pain measurement. The use of TENS enhances the analgesic effect of drug therapy in the treatment of diabetic neuropathic pain syndrome by 1.37 times while maintaining this effect without negative dynamics for 2 months after the end of the course of non-drug therapy. The developed technique for assessing pain syndrome using a body diagram in combination with a visual analogue scale (VAS) in patients with diabetic polyneuropathy provides a more reliable assessment of pain syndrome.

Prevalence of chronic pain syndrome in patients who have undergone hallux valgus percutaneous surgery: a comparison of sciatic-femoral and ankle regional ultrasound-guided nerve blocks

BackgroundChronic pain syndrome (CPS) is a common complication after operative procedures, and only a few studies have focused on the evaluation of CPS in foot-forefoot surgery and specifically on HV percutaneous correction. The objective of this study was to compare postoperative pain levels and incidence of CPS in two groups of patients having undergone femoral-sciatic nerve block or ankle block regional anaesthesia before hallux valgus (HV) percutaneous surgery and the association between postoperative pain levels and risk factors between these patient groups.MethodsA consecutive patient series was enrolled and evaluated prospectively at 7 days, 1, 3 and 6 months after surgery. The participants were divided into two groups according to the regional anaesthesia received, femoral-sciatic nerve block or ankle block, and their outcomes were compared. The parameters assessed were postoperative pain at rest and during movement by the numerical rating scale (NRS), patient satisfaction using the Visual Analogue Scale (VAS), quality of life and return to daily activities. Statistical analysis was performed.ResultsOne hundred fifty-five patients were assessed, 127 females and 28 males. Pain at rest (p < 0.0001) and during movement (p < 0.0001) significantly decreased during the follow-ups; at 6 months, 13 patients suffered from CPS. Over time, satisfaction remained stable (p > 0.05), quality of life significantly increased and patients returned to daily activities and work (p < 0.0001). No significant impact of type of anaesthesia could be detected. ASA 3 (p = 0.043) was associated to higher pain during movement; BMI (p = 0.005) and lumbago (p = 0.004) to lower satisfaction. No operative-anaesthetic complications were recorded. Postoperative pain at rest and during movement improved over time independently of the regional block used, with low incidence of CPS at last follow-up. Among risk factors, only a higher ASA was associated to higher pain during movement, while higher BMI and lumbago to lower satisfaction.ConclusionsBoth ultrasound-guided sciatic-femoral and ankle blocks were safe and effective in reducing postoperative pain with low incidence of CPS at last follow-up.Trial registrationClinical Trial NCT02886221. Registered 1 September 2016.

Cerebral Perfusion and Sensory Testing Results Differ in Interstitial Cystitis/Bladder Pain Syndrome Patients with and without Fibromyalgia: A Site-Specific MAPP Network Study.

PurposeFibromyalgia is a common co-morbidity in patients with interstitial cystitis/bladder pain syndrome. Quantitative sensory testing measures and regional cerebral blood flow measures have been noted to differ from healthy controls in both subjects with fibromyalgia and those with interstitial cystitis when studied independently. The present study examined such measures in subjects with the diagnosis of interstitial cystitis both with and without the co-diagnosis of fibromyalgia to determine whether differences in these measures may be associated with co-morbidity.Patients and MethodsFemale subjects with the diagnosis of interstitial cystitis with (n = 15) and without (n = 19) the co-diagnosis of fibromyalgia as well as healthy control subjects (n = 41) underwent quantitative sensory testing. A subset of these patients (9 with and 9 without fibromyalgia) underwent brain perfusion studies using arterial spin labeled functional magnetic resonance imaging. An analysis was performed of absolute regional cerebral blood flow of regions-of-interest when experiencing a full bladder compared with an empty bladder.ResultsSubjects with both interstitial cystitis and fibromyalgia were more hypersensitive than those without fibromyalgia as well as healthy controls in most sensory measures except heat. Subjects with interstitial cystitis, but no fibromyalgia, differed from healthy controls only in toleration of the ischemic forearm task. Other co-morbidities were more common in those subjects with both interstitial cystitis and fibromyalgia. Bladder fullness was associated with significantly greater whole brain gray matter blood flow in subjects with interstitial cystitis and fibromyalgia when compared with that of subjects with interstitial cystitis without fibromyalgia. Examination of regional cerebral blood flow in individual regions-of-interest demonstrated statistically significant differences between the subjects with interstitial cystitis with and those without fibromyalgia bilaterally in the thalamus, amygdala and hippocampus, as well as the right prefrontal cortex and greater responsiveness to changes in bladder fullness in the insula.ConclusionQuantitative sensory testing and brain perfusion data support that there are two phenotypes of interstitial cystitis patients, which can be differentiated by a co-diagnosis of fibromyalgia. This may affect responsiveness to treatment and suggest the utility of stratifying interstitial cystitis patients according to their co-morbidities.

Больовий синдром у пацієнтів із вогнепальними пораненнями кінцівок та посттравматичними стресовими розладами

Під час бойових дій на Сході України кількість пацієнтів із вогнепальними пораненнями кінцівок становить близько 64 %. Лікування посттравматичних стресових розладів у даних пацієнтів у 82,1 % випадків не завершується позитивним результатом. Причиною таких результатів є висока інцидентність розвитку хронічного больового синдрому та збереження стійкості до лікування посттравматичних стресових розладів. У 30–40 % випадків лікування больового синдрому в пацієнтів із вогнепальними пораненнями та посттравматичними стресовими розладами не призводить до позитивного ефекту. У подальшому реконструктивні оперативні втручання необхідно виконувати 35–40 % поранених.

Idiopathic scoliosis. Mechanisms of development

Objective: One of the most complicated problems of Orthopaedics is the treatment of scoliosis. More than 90% of cases are attributable to Idiopathic deformation, the cause of which is unknown. We investigated the cause of pathogenesis of this disorder.&#x0D; Methods: At our institution more than 6900 patients aged 1-89 years have undergone inpatient and outpatient treatment in connection with spinal pain syndrome and different neurological disorders associated with idiopathic scoliosis. This study was undertaken between February 1996 and February 2010. All patients had a clinical, radiography and laboratory examinations.&#x0D; Results: The 29.6% of patients were aged 31-50 years old. 60% were men and 40% were women. While examining patients with scoliosis deformation, we noted symptoms of body asymmetry i.e. different volumes of the right and left halves of face body and limbs. These features were typical for all patients irrespective of sex, age, and ethnic origin. 83,2% of patients had underdevelopment of the left part of the body, and only 16,8% of the right side. Analysis of published work in anatomy, physiology, neurophysiology, vertebrology, done simultaneously with analysis of the clinical material, allowed us to make some conclusions.&#x0D; Conclusions: First asymmetrical structure of the human body is based on laws of nature and is linked with difference of sizes of brain’s hemispheres, particularly of the right and left gyrus centralis anterior which controls the muscle’s function and our movements. Second asymmetrical tension of Erector spinae muscles, leads to inclination of the pelvis on a side of weak muscles; thus initiating development of the lateral spine curves. Since such a situation is typical for all people, this deformation is known as functional scoliosis. Third, further development of the bodies of vertebrae, their arches, processes, intervertebral discs, ligaments, and other anatomical elements in position of the deviation leads to one sided underdevelopment of these structures. As a result the areas of instability appear in each segment of spine ( neck, chest, lumbar and sacral areas ). Fourth, the muscles in a growing body misbalance and on the ground of rotating movement, start rotatory dislocation of vertebrae in zones of instability in all parts of the spine. As a result torsion of the deformed wedge-shaped vertebrae leads to formation of the structural scoliosis. The rotation of the vertebrae, described above, does not depend on sex, age and ethnic origin of the patient and has a character of the natural development. Thus from our point of view, the term idiopathic scoliosis, must be changed to spinal muscle asymmetrical deformation of a reflex origin. Understanding of this rotation allowed us to establish an effective non-surgical method of treatment of scoliosis and spinal pain syndrome in patients of all ages.

Особенности болевого синдрома у пациентов с эпизодической и хронической головной болью напряжения

Актуальность. Головная боль напряжения (ГБН) — наиболее распространенный в популяции тип головной боли (ГБ). Некоторые исследования показали, что мышечное напряжение значительно возрастает с увеличением частоты ГБН, болезненность мышц может расти во время приступов ГБ. Высказано предположение, что непрерывный ноцицептивный вклад периферических миофасциальных структур может вызвать центральную сенсибилизации и, возможно, хронизацию ГБ. Целью исследования было изучение особенностей болевого синдрома у пациентов с эпизодической и хронической головной болью напряжения. Материалы и методы. Было обследовано 108 пациентов (55 мужчин, 53 женщины) с диагнозами «частая эпизодическая головная боль напряжения» (ЭГБН) (группа I, n = 64) и «хроническая головная боль напряжения» (ХГБН) (группа II, n = 44). Проводилось клинико­неврологическое обследование, пальпация перикраниальных и шейных мышц с обеих сторон с подсчетом числа болезненности перикраниальных мышц (ЧБПМ) и числа болезненности мышц шеи (ЧБМШ) для каждого пациента и их среднее значение в группе. Для оценки субъективной выраженности боли использовался метод визуальной аналоговой шкалы (ВАШ), для качественной характеристики боли — болевой опросник Мак­Гилла. Результаты. Пациенты обследованных групп по интенсивности ГБ по ВАШ существенно не отличались, показатель был в пределах умеренного с тенденцией к более выраженному в группе II. В обеих группах при пальпации перикраниальных и шейных мышц с обеих сторон болезненность при пальпации в основном была в пределах от слабой до умеренной, кроме трапециевидной и ременной мышц головы, где болезненность носила характер от умеренной до выраженной. В группе I по сравнению с группой II выявлено достоверное превышение показателя ЧБПМ и ЧБМШ слева, ЧБПМ справа и не отмечено различий между ЧБМШ групп I и II справа. У пациентов с ЭГБН выраженность мышечной болезненности снижалась с возрастом, были выше показатели, описывающие сенсорные и психоэмоциональные характеристики боли, выявлена положительная корреляционная связь между болезненностью перикраниальных мышц и интенсивностью и частотой ГБ в месяц. У пациентов с ХГБН обнаружены корреляционные связи между интенсивностью, средней продолжительностью ГБ в месяц и сенсорными и психоэмоциональными характеристиками боли, что может свидетельствовать о вовлечении центральных и периферических ноцицептивных механизмов в патогенез хронической ГБН. Выводы. Наличие мышечной болезненности, сенсорные и психоэмоциональные характеристики ГБ необходимо учитывать при планировании лечебных и реабилитационных стратегий, что будет препятствовать прогрессированию и хронизации ГБ и способствовать повышению качества жизни пациентов.

Professional Status of Persistent Spinal Pain Syndrome Patients after Spinal Surgery (PSPS-T2): What Really Matters? A Prospective Study Introducing the Concept of "Adapted Professional Activity" Inferred from Clinical, Psychological and Social Influence.

Persistent Spinal Pain Syndrome Type 2 (PSPS-T2) represents a main cause of work disruption. Beyond its societal consequences, occupational inactivity is responsible for a major decrease in physical/mental health in individuals but remains poorly analyzed. We designed a study to prospectively examine Professional Status (PS) evolution and its association with key bio-psychological markers. Data from 151 consecutively included working-age PSPS-T2 patients were analyzed to determine the proportion of professional inactivity and the relationships between PS and Social Gradient of Health (SGH), Numeric Pain Rating Scale (NPRS), EuroQol 5-Dimensional 5-Level (EQ-5D-5L), Oswestry Disability Index (ODI), Hospital Anxiety and Depression Scale (HADS), and Fear-Avoidance Belief Questionnaire work subscale (FABQ-W). Despite optimized medical management, 73.5% of PSPS-T2 patients remained inactive after 1 year of follow-up/p = 0.18. Inactive patients presented a low SGH/p = 0.002, higher NPRS/p = 0.048, lower EQ-5D-5L/p < 0.001, higher ODI/p = 0.018, higher HADS-D/p = 0.019 and higher FABQ-W/p < 0.001. No significant mediation effect of FABQ-W on SGH consequences regarding PS was observed in our structural model/p = 0.057. The link between unemployment and bio-psycho-social pain dimensions appears bidirectional and justifies intense collaboration with social workers. Optimizing therapeutical sequencing towards personalized professional plans implies restoring “Adapted Physical Function” as an initial goal, and tailoring an “Adapted Professional Activity”, matching with patient expectations and capabilities, as a final objective.

Comparative estimation of a pain syndrome in patients after combined operations for coexistent pathology of anal channel and rectum with application of modern and standard surgical technologies

Objective. Comparative estimation of the pain syndrome in patients with concomitant pathology of anal channel and rectum after performance of combined operations, using modern high-frequency electro-surgical and radio-surgical apparatuses, as well as conventional scalpel.&#x0D; Materials and methods. The results of surgical treatment of 689 patients with concomitant pathology of anal channel and rectum, using apparatuses of a high-frequency electro-surgery and radio-wave surgery, were analyzed, using the pain syndrome estimation on 1-7th postoperative day. The patients were distributed into 4 investigation groups and a control group, consisting of 112 patients, operated on using metallic conventional surgical scalpel.&#x0D; Results. The pain syndrome on the first postoperative day was mostly expressed in patients of control group, for anesthesia they needed (4 ± 1) ml of 2% solution of promedol, while the patients of the first, third and fourth groups investigated, in which, accordingly, apparatus of radio-wave surgery «Surgitron» and high-frequency electro-surgical apparatuses «EFA» and «KLS Martin» were used, needed for anesthesia (2 ± 1) ml of 2% solution of promedol. While application of the electro-surgical high-frequency apparatus «ERBE ICC 200» the necessity for the 2% solution of promedol for anesthesia have constituted (3 ± 1) ml.&#x0D; Conclusion. Combined operations, using modern apparatuses of high-frequency electro-surgery and radio-wave surgery give significantly better results, than application of conventional surgical metallic scalpel, because it produces significantly reduced pain syndrome due to thin layer of coagulation necrosis, promoting formation of delicate elastic cicatrix and preventing development of cicatricial strictures of anal channel in postoperative period.

A Novel Multi-Dimensional Clinical Response Index Dedicated to Improving Global Assessment of Pain in Patients with Persistent Spinal Pain Syndrome after Spinal Surgery, Based on a Real-Life Prospective Multicentric Study (PREDIBACK) and Machine Learning Techniques.

The multidimensionality of chronic pain forces us to look beyond isolated assessment such as pain intensity, which does not consider multiple key parameters, particularly in post-operative Persistent Spinal Pain Syndrome (PSPS-T2) patients. Our ambition was to produce a novel Multi-dimensional Clinical Response Index (MCRI), including not only pain intensity but also functional capacity, anxiety-depression, quality of life and quantitative pain mapping, the objective being to achieve instantaneous assessment using machine learning techniques. Two hundred PSPS-T2 patients were enrolled in the real-life observational prospective PREDIBACK study with 12-month follow-up and received various treatments. From a multitude of questionnaires/scores, specific items were combined, as exploratory factor analyses helped to create a single composite MCRI; using pairwise correlations between measurements, it appeared to more accurately represent all pain dimensions than any previous classical score. It represented the best compromise among all existing indexes, showing the highest sensitivity/specificity related to Patient Global Impression of Change (PGIC). Novel composite indexes could help to refine pain assessment by informing the physician’s perception of patient condition on the basis of objective and holistic metrics, and also by providing new insights regarding therapy efficacy/patient outcome assessments, before ultimately being adapted to other pathologies.

Use of Hand Therapy After Distal Radius Fracture: A National Perspective

To assess whether certain distal radius fracture (DRF) patients, such as opioid users or complex regional pain syndrome (CRPS) patients, receive more hand therapy. Using the IBM MarketScan Research Databases from January 1, 2012, to December 31, 2016, we identified a cohort of DRF patients and created 4 subgroups of interest: frequent follow-up patients, persistent opioid users, prior opioid users, and patients with CRPS. We measured rates and demographic characteristics associated with therapy use in our populations of interest. In this cohort of 87,313 patients, 21% received hand therapy after primary DRF treatment. Patients with CRPS had a higher rate of therapy than non-CRPS patients (44% vs 21%, respectively). Frequent follow-up patients used more therapy than those with less follow-up (30% vs 17%, respectively). Persistent opioid users demonstrated slightly increased therapy use compared to the remaining population (25% vs 22%, respectively). Prior opioid users underwent less therapy than patients without prior opioid use (19% vs 22%, respectively). Female sex, residing in the Northeast, being on a preferred provider organization plan, and having more intense surgical treatments were associated with increased therapy use. This study showed variations in therapy use after DRF in subpopulations of interest. Patients with CRPS, persistent opioid use, and frequent follow-ups had higher rates of therapy. Patients with prior opioid use had lower rates of therapy. Therapy is more common in patients with DRF with CRPS, persistent opioid use, or more follow-up visits.

Pharmacoeconomic analysis of the application of strong opioids for the treatment of chronic pain syndrome in patients with pancreatic cancer

Objective: to evaluate the clinical and economic feasibility of opioid therapy based on the analysis of its cost and effectiveness in patients with chronic pain syndrome in pancreatic cancer.Material and methods. An observational prospective study in parallel groups of patients with chronic pain syndrome associated with pancreatic cancer was carried out. The analysis of cost minimization and cost-effectiveness was applied, as well as pharmacoeconomic modeling, which included the construction of a decision tree in patients receiving morphine sulfate (n=45) and fentanyl TTS (n=45) for pain relief. The sensitivity of the obtained data was assessed using one-way analysis.Results. It was shown that the treatment of chronic pain syndrome in patients with pancreatic cancer with opioid analgesics as part of combined treatment is the least expensive in the morphine sulfate group (incremental cost-effectiveness ratio 144.93). Based on the results of modeling, the prognostic factors of influence on the cost of analgesic therapy were determined: the cost of combined analgesic therapy, the cost of treatment of adverse reactions, and the cost-effectiveness ratio.Conclusion. Analgesic therapy of chronic pain syndrome with morphine sulfate in patients with pancreatic cancer is pharmacoeconomically feasible.

Влияние уровня противовоспалительного гормона кортизола в сыворотке крови на частоту возникновения хронического болевого синдрома у больных после торакотомии в зависимости от использованных методов послеоперационного обезболивания

Актуальность. При торакотомии повреждение тканей сопровождается повышением в крови маркеров воспаления, которые влияют на развитие хронического болевого синдрома. Цель исследования: изучить влияние различных методов послеоперационного обезболивания на состояние гормонов гипофизарно-надпочечниковой системы (гормонов стресса) и иммуноцитокиновый статус у больных после торакотомии. Материалы и методы. 85 больных после торакотомии были распределены на три группы. Обезболивание проводили с помощью пролонгированной паравертебральной аналгезии (ПВА) (n = 19) и пролонгированной эпидуральной аналгезии (ЭДА) (n = 36) 0,2% раствором ропивакаина, в контрольной группе (n = 30) — внутривенной контролируемой пациентом аналгезией (КПА) раствором морфина. В течение трех суток после операции исследовали уровни глюкозы крови, инсулина, интерлейкина (IL)-6, кортизола, фибриногена и С-реактивного протеина. Для оценки влияния различных методов обезболивания на формирование хронической боли проводили опрос больных через 6 месяцев после торакотомии. Результаты. У больных всех исследуемых групп в течение 72 часов послеоперационного периода сохранялась нормогликемия. Максимальный рост уровня инсулина наблюдался в контрольной группе на третьи сутки послеоперационного периода и составлял 62,54 ± ± 5,56 мкМЕ/мл. В опытных группах уровень инсулина также повысился, но был значительно ниже контрольной группы. Максимальный подъем уровня IL-6 наблюдался в первые сутки послеоперационного периода во всех трех группах и был следующим: в контрольной группе — 81,63 ± 38,40 пг/мл, в группе ЭДА — 70,69 ± 27,29 пг/мл, в группе ПВА — 80,12 ± 25,14 пг/мл. На третьи сутки уровень IL-6 снижался и был примерно одинаковым во всех группах. Максимальное увеличение С-реактивного протеина наблюдалось в контрольной группе — с 0,05 ± 0,02 мг/дл до 1,53 ± 0,60 мг/дл. В группе ЭДА — с 0,38 ± ± 0,23 мг/дл до 2,34 ± 0,84 мг/дл, в группе ПВА — с 0,32 ± ± 0,16 мг/дл до 2,14 ± 0,95 мг/дл. Уровень кортизола в группе ПВА через 24 часа после операции увеличился с 16,80 ± 2,33 мкг/дл до 27,78 ± 7,92 мкг/дл. В других исследуемых группах уровень кортизола оставался практически неизменным. Через 72 часа послеоперационного периода наиболее выраженная противовоспалительная реакция сохранялась в группе ПВА, где уровень кортизола составил 25,95 ± 7,87 мкг/дл (в контрольной группе — 23,64 ± 3,01 мкг/дл; в группе ЭДА — 23,26 ± 3,06 мкг/дл). В контрольной группе хроническая боль развилась через 6 мес. у 8 больных (53 %); в группе ЭДА — у 5 больных (33,3 %); в группе ПВА — у 3 больных (20 %). Выводы. Во всех группах наблюдались стабильные показатели гликемии. Уровень инсулина в контрольной группе был значительно выше. Применение ПВА и ЭДА обеспечивало лучшее стресс-протективное действие, но приоритет оставался за ЭДА. Динамика уровня кортизола показала, что наиболее выраженная системная противовоспалительная реакция наблюдалась в группе ПВА. Отмечена заметная связь между частотой возникновения хронического болевого синдрома, качеством обезболивания и уровнем кортизола плазмы крови в раннем послеоперационном периоде.

Diffculties and ways to overcome them in selection of therapy for pain syndromes in patients with diabetes mellitus

Diabetes mellitus (DM) causes damage to various body systems, including the peripheral nervous system. The main variants of peripheral nerve damage in diabetes mellitus are considered. Information on the development of this kind of lesion, in particular, on the formation of neuropathic pain syndrome, is given. The therapeutic possibilities of drugs from various pharmacological groups for the treatment of patients with neurological complications of diabetes are analyzed.

Effects of tibiofemoral mobilization in patients of Patellofemoral pain syndrome.

To determine the effects of tibiofemoral joint mobilisation on pain and range of motion in patients with patellofemoral pain syndrome. The randomised control trial was conducted at the Lady Reading Hospital and Hayatabad Medical Complex, Peshawar, Pakistan, from July to December 2019, and comprised patellofemoral pain syndrome patients of either gender aged 25-35 years with anterior knee pain for at least one month. The subjects were randomly allocated control group A and experimental group B. Group A received 6 stretching and strengthening exercises of hip and knee muscles with hot pack, while group B additionally received tibiofemoral joint mobilisation. There were 3 sessions per week over 4 weeks for both the groups. Numeric pain rating scale, Kujala scale, algometer and goniometer were used to assess pain and range of motion at baseline and at the end of the last session. Data was analysed using SPSS 20. Of the 60 individuals initially assessed, 52(86.6%) were enrolled; 26(50%) in each of the two groups. The overall mean age of the sample was 29.63±3.25 years. The experimental group B showed significant improvement in pain, range of motion and pressure pain threshold (p<0.05) compared to the control group A. Group B also showed significant improvement in terms of functional activities (p<0.05). Except patellar instability and weight-bearing activities, the groups showed no significant difference (p>0.05). Tibiofemoral joint mobilisations with hip and knee stretching and strengthening exercises were found to be more effective in reducing pain, and increasing range of motion as well as pressure pain threshold. Identifier: NCT04225000:https://clinicaltrials.gov/ct2/show/NCT04225000.

Kinematics and muscle activation in subacromial pain syndrome patients and asymptomatic controls

BackgroundConflicting theories exist about the underlying cause of chronic subacromial pain in the middle-aged population. We aim to improve our understanding of kinematics and muscle activation in subacromial pain syndrome to provide insight in its pathophysiology. MethodsIn a cross-sectional comparison of 40 patients with subacromial pain syndrome and 30 asymptomatic controls, three-dimensional shoulder kinematics and electromyography-based co-contraction in 10 shoulder muscles were independently recorded. Glenohumeral and scapulothoracic kinematics were evaluated during abduction and forward flexion. Co-contraction was expressed as an activation ratio, specifying the relative agonistic and antagonistic muscle activity in each muscle. FindingsDuring abduction and forward flexion, the contribution of glenohumeral motion to elevation and glenohumeral external rotation was lower in subacromial pain syndrome (at 1200 abduction: −9°, 95% CI -14°- -3°; and − 8°, 95% CI -13°--3°, respectively), and was compensated by more scapulothoracic motion. The pectoralis major's activation ratio was significantly lower (Z-score: -2.657, P = 0.008) and teres major's activation ratio significantly higher (Z-score: -4.088, P < 0.001) in patients with subacromial pain syndrome compared to the control group. InterpretationReduced glenohumeral elevation and external rotation in subacromial pain syndrome coincided with less teres major antagonistic activity during elevation. These biomechanical findings provide a scientific basis for intervention studies directed at stretching exercises to reduce glenohumeral stiffness in the treatment of subacromial pain syndrome, and teres major strengthening to improve humeral head depressor function.