A. Beyer

Clinical and physiologic evaluation of stellate ganglion blockade for complex regional pain syndrome type I

Objective: The efficacy of peripheral sympathetic interruption after stellate ganglion blockade was assessed by a sympathetic function test. Results were compared with clinical signs such as temperature changes, pain reduction, and the development of Horner syndrome to evaluate the correlation with clinical investigations. Design: Stellate ganglion blockade with local anesthetics was carried out via an anterior paratracheal approach in 33 patients suffering from complex regional pain syndrome type I. Patients were examined before and after the procedure. For assessment of sympathetic nervous function, the vasoconstrictor response to sympathetic stimuli was assessed using laser Doppler flowmetry. Clinical parameters like surface temperature changes (thermography), pain relief (visual analogue scale), and Horner syndrome were monitored. Results: Twenty-three (70%) of 33 patients developed an increase in temperature difference between the treated hand and the contralateral hand of more than 1.5°C after the procedure, which is a clinical sign of sympathicolysis. In 48% (n = 11) of these patients, the sympathetic function test showed an undisturbed sympathetic nervous function. In 10 patients, no significant increase in temperature difference was observed. Although these patients presented with a normal sympathetic vasoconstrictor response, 4 felt pain relief of more than 50%, suggesting a placebo effect. Only 7 patients with pain relief revealed both clinical sympathicolysis and extinguished sympathetic nervous function and qualified for sympathetically maintained pain. Conclusions: Clinical investigation is not reliable in the assessment of stellate ganglion blockade. Proof of sympathetically maintained pain based on pain relief after stellate ganglion blockade is not conclusive.

Neurobiologische Grundlagen der Akupunkturanalgesie

Zusammenfassung.Fragestellung: Ziel dieser Übersichtsarbeit ist die Darstellung wesentlicher Erkenntnisse der Grundlagenforschung zum Wirkmechanismus der akupunkturinduzierten Analgesie (AA) auf der Grundlage der relevanten Literatur. Die Übertragbarkeit der Ergebnisse auf die Praxis und Theorie traditioneller Akupunktur werden kritisch diskutiert. Methode: Anhand einer umfassenden Literaturrecherche wurden relevante Arbeiten identifiziert, ausgewertet und zusammengefasst. Ergebnisse: Analgetische Wirkungen der Akupunktur wurden vielfach nachgewiesen. Biochemische, immunhistochemische, molekularbiologische und neurophysiologische Untersuchungen zeigen, dass kurzfristige Effekte der AA durch Aktivierung der endogenen opiatvermittelten Antinozizeption und deszendierender Schmerzhemmsysteme vermittelt werden. Potenzielle längerfristige Wirkungen sind mit den vorliegenden Ergebnissen nicht ausreichend erklärbar, jedoch existieren Hinweise auf spinale, neuromodulatorische Wirkungen und auf eine Beteiligung des limbischen Systems. Schlussfolgerung: Angesichts der Komplexität endogener Schmerzhemmsysteme und methodischer Einschränkungen existieren viele ungeklärte Fragen. Weitere Forschungsaktivitäten auf dem Gebiet erscheinen notwendig.Abstract.Aim: The aim of this review is to present the findings of basic research about mechanism of acupuncture-induced analgesia (AA) on the basis of the relevant literature. The transferability of the results into practice and theory of traditional acupuncture are critically discussed. Method: Extensive literature research was used to identify and summarize relevant studies. Results: AA has been proven by biochemical, immunohistochemical, molecular biological and neurophysiological investigations. It has been shown that short term AA is mediated by an activation of endogenous antinociceptive systems and descending inhibitory systems. Long term effects cannot be explained sufficiently by experimental results; however, they suggest an involvement of long term inhibitory synaptic modification at spinal cord neurons and clinical and radiological findings indicate limbic system modulation. Conclusion: Regarding the complexity of endogenous pain-inhibitory systems and the methodological shortcomings many questions remain unanswered. Further research activities are necessary in this field.

Intravenous titration with morphine for severe cancer pain: report of 28 cases.

BACKGROUND In a multicenter study, 28 patients with cancer pain and insufficient pain relief with analgesic treatment according to step II of the guidelines of the World Health Organization (WHO) were switched to oral slow-release morphine. METHODS Patients received intravenous morphine through a patient-controlled pump (PCA) for the first 24 hours (bolus = 1 mg, lockout interval = 5 minutes, maximum dose = 12 mg/hour). From day 2 patients were treated with oral slow-release morphine. Daily doses were calculated from the requirements of the day before. Breakthrough pain was treated with PCA until stable doses were reached (<2 boluses/day) and then with oral immediate-release morphine solution. Pain intensity was reported in a diary four times a day, in addition to mood, activity, and quality of sleep once daily. RESULTS Mean duration until adequate pain relief reported (<30 on a 101-step numerical scale; NRS) was 5 hours (range = 80-620 minutes). Mean pain intensity was reduced from 67 NRS to 22 NRS. Mean doses of oral morphine were 133 mg/day initially and then 154 mg/day on day 14. Serious adverse events such as respiratory depression were not observed. Two patients terminated the study due to progressive symptoms of gastrointestinal obstruction. Seventy-five percent of the patients evaluated the effectiveness of the analgesic regime as good. CONCLUSIONS Dose finding with intravenous PCA may be appropriate for a small minority of patients with severe pain. Higher treatment costs and the risk of complications are drawbacks of this method compared with conventional oral titration.

[Patients with chronic pain syndromes. Impact of an individual outpatient therapy program on pain and health-related quality of life].

BACKGROUND The study was performed to reveal the effect of an individualized personal outpatient therapy program, based on a multidisciplinary assessment, on pain and health-related quality of life in patients with chronic pain. METHODS Fifty patients were prospectively evaluated before and 3 months after establishment of an individualized outpatient therapy program. Health-related quality of life, pain and pain-related disability, depression and motivation to adopt self-management of chronic pain were assessed. Therapy adherence was tested with a structured interview. RESULTS Only marginal improvements were observed in terms of pain and health-related quality of life. Therapy adherence varied between the different therapies. CONCLUSIONS An individualized personal outpatient therapy program has only marginal effects on pain and health-related quality of life in patients with chronic pain.

Diagnostische Kriterien und neue Klassifikation des Halswirbelsäulensyndroms

ZusammenfassungFragestellung. Die Beschwerden des Halsbereichs, die in der Regel unter der Sammeldiagnose “Halswirbelsäulensyndrom” (HWS-Syndrom) subsumiert werden, wurden anhand einer empirisch entwickelten Klassifikation in 5 Syndromsubgruppen gegliedert. Die syndromspezifischen Diagnosekriterien wurden auf statistisch signifikante Assoziationen zu den jeweiligen HWS-Syndrom-Subgruppen untersucht. Methode. Innerhalb des Erhebungszeitraums von 2 Jahren wurden alle ambulanten Patienten der Klinik mit der Diagnose “HWS-Syndrom” in die Studie aufgenommen. Die statistischen Analysen erfolgten mittels univariater deskriptiver Analysen, bivariater Variablenvorauswahl und logistischer Regressionsmodelle. Ergebnisse. 332 der 653 Patienten mit der Zuweisungsdiagnose “HWS-Syndrom” konnten in die Studie eingeschlossen und entsprechend der diagnostischen Kriterien einer der 5 HWS-Syndrom-Subgruppen zugeordnet werden. Die statistische Analyse ergab bei 17 von insgesamt 35 untersuchten diagnostischen Kriterien eine signifikante Assoziation zu einer der 5 HWS-Syndrom-Subgruppen. Schlussfolgerung. Die statistischen Analysen zeigten, dass zwischen einer Reihe von Untersuchungsvariablen und den 5 HWS-Syndrom-Subgruppen signifikante Zusammenhänge bestehen. Die identifizierten Prädiktoren stellen die für ein bestimmtes HWS-Syndrom charakteristischen, syndromassoziierten diagnostischen Kriterien dar.AbstractObjectives. Pain and functional disorders of the neck are widely diagnosed as “cervical spine syndrome”. As this diagnosis is not able to sufficiently specify the different symptoms, a new classification with five pain syndromes, created empirically, was developed. The aim of this study is to evaluate the predictive values of the diagnostic criteria respectively clinical findings of patients diagnosed with cervical spine syndrome. Methods. Within the two year time frame of the study all patients diagnosed with “cervical spine syndrome”, which presented themselves at the clinic, were included. The statistic analysis was performed in multiple steps: univariate analyses, bivariate variable screening and the use of the logistic regression model. Results. Within two years 653 patients previously diagnosed as suffering from cervical spine syndrome presented at the clinic; 332 of them were included in the study. According to the diagnostic criteria they were attached to one of the five pain syndromes. The statistical analysis showed in 17 of 35 evaluated diagnostic criteria a significant association to one of the five subgroups of the cervical spine syndrome. Conclusion. The statistical analyses revealed significant associations between diagnostic criteria which were assessed by clinical examination and the five subgroups of the cervical spine syndrome. The identified predictors represent the typical syndrome-associated diagnostic criteria of a certain syndrome-subgroup.

Patienten mit chronischen Schmerzsyndromen

BACKGROUND The study was performed to reveal the effect of an individualized personal outpatient therapy program, based on a multidisciplinary assessment, on pain and health-related quality of life in patients with chronic pain. METHODS Fifty patients were prospectively evaluated before and 3 months after establishment of an individualized outpatient therapy program. Health-related quality of life, pain and pain-related disability, depression and motivation to adopt self-management of chronic pain were assessed. Therapy adherence was tested with a structured interview. RESULTS Only marginal improvements were observed in terms of pain and health-related quality of life. Therapy adherence varied between the different therapies. CONCLUSIONS An individualized personal outpatient therapy program has only marginal effects on pain and health-related quality of life in patients with chronic pain.

Patienten mit chronischen Schmerzsyndromen@@@Patients with chronic pain syndromes: Einfluss einer ambulanten individuellen Therapie auf Schmerzen und gesundheitsbezogene Lebensqualität@@@Impact of an individual outpatient therapy program on pain and health-related quality of life

BACKGROUND The study was performed to reveal the effect of an individualized personal outpatient therapy program, based on a multidisciplinary assessment, on pain and health-related quality of life in patients with chronic pain. METHODS Fifty patients were prospectively evaluated before and 3 months after establishment of an individualized outpatient therapy program. Health-related quality of life, pain and pain-related disability, depression and motivation to adopt self-management of chronic pain were assessed. Therapy adherence was tested with a structured interview. RESULTS Only marginal improvements were observed in terms of pain and health-related quality of life. Therapy adherence varied between the different therapies. CONCLUSIONS An individualized personal outpatient therapy program has only marginal effects on pain and health-related quality of life in patients with chronic pain.