Impingement syndrome in the shoulder has generally been considered to be a clinical condition of mechanical origin. However, anomalies exist between the pathology in the subacromial space and the degree of pain experienced. These may be explained by variations in the processing of nociceptive inputs between different patients. We investigated the evidence for augmented pain transmission (central sensitisation) in patients with impingement, and the relationship between pre-operative
The aim of this study was to determine if positive Waddell signs
were related to patients’ demographics or to perception of their
quality of life. This prospective cross-sectional study included 479 adult patients
with back pain from a university spine centre. Each completed SF-12
and Oswestry Disability Index (ODI) questionnaires and underwent
standard spinal examinations to elicit Waddell signs. The relationship
between Waddell signs and age, gender, ODI, Mental Component Score
(MCS), and Physical Component Score (PCS) scores was determined.Aims
Patients and Methods
We suggest that different mechanisms underlie joint pain at rest and on movement in osteoarthritis and that separate assessment of these two features with a visual analogue scale (VAS) offers better information about the likely effect of a total knee replacement (TKR) on pain. The risk of persistent pain after TKR may relate to the degree of
Background. To investigate whether the interaction between pre-operative widespread hyperalgesia and radiographic osteoarthritis (OA) was associated with pain severity before and after total hip replacement (THR) and total knee replacement (TKR). Methods. Data were analysed from 232 patients receiving THR and 241 receiving TKR. Pain was assessed pre-operatively and at 12 months post-operatively using the WOMAC Pain Scale. Widespread hyperalgesia was assessed through forearm pressure pain thresholds (PPTs) measured using an algometer. The severity of radiographic OA was evaluated using the Kellgren and Lawrence scheme. Statistical analysis was conducted using linear regression and multilevel models, and adjusted for confounding variables. Results. Pre-operative. In knee patients, there was weak evidence that the effect of PPTs on pain severity was greater in patients with more severe OA compared to patients with less severe OA (Grade 3 OA: ß=0.96 vs Grade 4 OA: ß=4.03). However, in hip patients, the effect of PPTs on pain severity did not differ with the extent of radiographic OA (Grade 3 OA: ß=3.95 vs Grade 4 OA: ß=3.67). Post-operative. Patients undergoing TKR with less severe OA who had lower PPTs (greater widespread hyperalgesia) benefitted less from surgery than patients with higher PPTs (Grade 3 OA: ß=2.28). Conversely, patients undergoing THR with more severe OA who had lower PPTs benefited more from surgery than patients with higher PPTs (Grade 4 OA: ß=−2.92). Conclusion.
Introduction: Although the primary aim of Total Knee Replacement (TKR) is to relieve chronic joint pain, 10–20% of patients experience unexplained chronic pain after surgery. One possible cause of this pain is
Perioperative pain involves both neurogenic and inflammatory mediators. The neurogenic component is produced by the intense stimulation of the surgical procedure itself. However, inflammatory mediators resulting from tissue damage and the release of certain cytokines provoke the inflammatory response. Both the neurogenic and inflammatory elements create central nervous system (CNS) excitability. While conventional pain management responds to pain as it occurs, rather than anticipating it, a more appropriate protocol may involve pre-emptive administration of analgesic medication. By beginning this administration prior to surgery and continuing it throughout the rehabilitation process, CNS pharmacological agents are utilised to achieve the following goals: 1.) decrease the neurogenic component at the wound site; 2.) depress afferent pathways; and 3.) decrease
The patient with a painful arthritic knee awaiting
total knee arthroplasty (TKA) requires a multidisciplinary approach.
Optimal control of acute post-operative pain and the prevention
of chronic persistent pain remains a challenge. The aim of this
paper is to evaluate whether stratification of patients can help
identify those who are at particular risk for severe acute or chronic
pain. . Intense acute post-operative pain, which is itself a risk factor
for chronic pain, is more common in younger, obese female patients
and those suffering from
Background: Post-operative analgesia using parenteral opioids or epidural analgesia can be associated with troublesome side effects. Locally administered pre-emptive analgesia is effective, reduces
The majority of patients with osteoarthritis present to orthopaedic surgeons seeking relief of pain and associated restoration of function. Although our understanding of the physiology of pain has improved greatly over the last 25 years there remain a number of unexplained pain-related observations in patients with osteoarthritis. The understanding of pain in osteoarthritis, its modulation and treatment is central to orthopaedic clinical practice and in this annotation we explore some of the current concepts applicable. We also introduce the concept of the ‘phantom joint’ as a cause for persistent pain after joint replacement.
A rat model of lumbar root constriction with an additional sympathectomy in some animals was used to assess whether the sympathetic nerves influenced radicular pain. Behavioural tests were undertaken before and after the operation. On the 28th post-operative day, both dorsal root ganglia and the spinal roots of L4 and L5 were removed, frozen and sectioned on a cryostat (8 μm to 10 μm). Immunostaining was then performed with antibodies to tyrosine hydroxylase (TH) according to the Avidin Biotin Complex method. In order to quantify the presence of sympathetic nerve fibres, we counted TH-immunoreactive fibres in the dorsal root ganglia using a light microscope equipped with a micrometer graticule (10 x 10 squares, 500 mm x 500 mm). We counted the squares of the graticule which contained TH-immunoreactive fibres for each of five randomly-selected sections of the dorsal root ganglia. The root constriction group showed mechanical allodynia and thermal hyperalgesia. In this group, TH-immunoreactive fibres were abundant in the ipsilateral dorsal root ganglia at L5 and L4 compared with the opposite side. In the sympathectomy group, mechanical hypersensitivity was attenuated significantly. We consider that the sympathetic nervous system plays an important role in the generation of radicular pain.
We describe 261 peripheral nerve injuries sustained
in war by 100 consecutive service men and women injured in Iraq
and Afghanistan. Their mean age was 26.5 years (18.1 to 42.6), the
median interval between injury and first review was 4.2 months (mean
8.4 months (0.36 to 48.49)) and median follow-up was 28.4 months
(mean 20.5 months (1.3 to 64.2)). The nerve lesions were predominantly
focal prolonged conduction block/neurapraxia in 116 (45%), axonotmesis
in 92 (35%) and neurotmesis in 53 (20%) and were evenly distributed
between the upper and the lower limbs. Explosions accounted for
164 (63%): 213 (82%) nerve injuries were associated with open wounds.
Two or more main nerves were injured in 70 patients. The ulnar,
common peroneal and tibial nerves were most commonly injured. In
69 patients there was a vascular injury, fracture, or both at the
level of the nerve lesion. Major tissue loss was present in 50 patients:
amputation of at least one limb was needed in 18. A total of 36 patients
continued in severe neuropathic pain. This paper outlines the methods used in the assessment of these
injuries and provides information about the depth and distribution
of the nerve lesions, their associated injuries and neuropathic
pain syndromes.
The outcomes of 261 nerve injuries in 100 patients
were graded good in 173 cases (66%), fair in 70 (26.8%) and poor in
18 (6.9%) at the final review (median 28.4 months (1.3 to 64.2)).
The initial grades for the 42 sutures and graft were 11 good, 14
fair and 17 poor. After subsequent revision repairs in seven, neurolyses
in 11 and free vascularised fasciocutaneous flaps in 11, the final
grades were 15 good, 18 fair and nine poor. Pain was relieved in
30 of 36 patients by nerve repair, revision of repair or neurolysis,
and flaps when indicated. The difference in outcome between penetrating
missile wounds and those caused by explosions was not statistically
significant; in the latter group the onset of recovery from focal
conduction block was delayed (mean 4.7 months (2.5 to 10.2)