Lars Werhagen

Analysis of long-standing nociceptive and neuropathic pain in patients with post-polio syndrome

The purpose of this study was to analyze pain, both nociceptive and neuropathic, in patients with post-polio syndrome (PPS) and relate the pain to age at the initial polio infection, age at examination, to gender and disability. The study was conducted in a university hospital department. Patients with PPS were interviewed at their regular visits about pain, its character, intensity and localization. A clinical examination, including a thorough neurological examination, was performed. Data included age at time of polio infection, age at time of examination and gender. Pain intensity was measured with the VAS-scale and walking capability by the WISCI-scale. One hundred sixty-three (88 women, 75 men) patients were included in the study. Pain was present in 109 (67%). Pain was more frequently reported by women (82%) than by men (49%). 96 patients experienced nociceptive pain, 10 patients both neuropathic and nociceptive pain and three experienced pure neuropathic pain. Half of the patients with pain experienced pain in more than one body region. When neuropathic pain was present, another additional neurological disorder was diagnosed. Pain was more often found in younger patients (around 70%) than in older patients (around 50%). In summary pain is common in patients with PPS and most patients experienced nociceptive pain. Women have pain more often than men. Older patients experience pain more seldom than younger patients. Age at time of primary polio infection is important for the development of pain. When neuropathic pain is present, it is important to proceed with neurological examination to find an adequate diagnosis.

Spasticity and bone density after a spinal cord injury.

STUDY DESIGN Descriptive, cross-sectional study. OBJECTIVE To assess the relationship between spasticity and bone mineral density in the lower extremities in individuals with a motor complete spinal cord injury. METHODS Eighteen individuals, matched for time since injury, gender, and age, were included in the study. Nine men had severe spasticity, and 9 men had spasticity that was either mild or not present. Comparisons regarding bone mineral density were made using dual energy X-ray absorptiometry. Regions of interest measured were total leg, pelvis, femoral neck and total hip. Between-group differences regarding fat and lean tissue were analysed. RESULTS Background data, such as weight, height, standing and exercising habits, smoking and alcohol use, were similar in both groups. There was no difference between the groups regarding bone mineral density. All of the participants presented with osteoporosis or osteopaenia values at the hips. Participants with severe spasticity had larger muscle volume than those with none or mild spasticity. No correlations between bone mineral density and body composition with age or time since injury were seen. CONCLUSION No difference in bone mineral density dependent on spasticity was detected in this study, but all included participants showed osteopaenia or osteoporosis at the hip, but not in full body values. Individuals with severe spasticity had greater muscle mass compared with those with no or mild spasticity.

Effect of intravenous immunoglobulin on pain in patients with post-polio syndrome.

OBJECTIVE Pain is a common symptom that affects quality of life in patients with post-polio syndrome. An increase in cytokine in the cerebrospinal fluid suggests that inflammation is pathophysiologically important in post-polio syndrome. Intravenous immunoglobulin might therefore be a therapeutic option. The aim of this study was to analyse the effect of intravenous immunoglobulin treatment on pain in post-polio syndrome. METHODS An uncontrolled clinical study. Patients with post-polio syndrome and pain (n = 45) underwent a neurological examination and were interviewed about pain before and 6 months after treatment with intravenous immunoglobulin. Pain intensity was measured on a visual analogue scale. The pain was classified according to the International Association for the Study of Pain criteria as neuropathic when it occurred in an area with decreased sensibility, or nociceptive when signs of inflammation and/or painful joints movements were present. RESULTS After treatment 31/45 (69%) patients were improved, with a mean visual analogue scale decrease from 53 to 42 (p = 0.001). Eighteen patients (40%) had a decrease of 20 or more points on the visual analogue scale. The effect of treatment did not differ regarding age, gender and severity of disability. CONCLUSION Two-thirds of 45 patients with post-polio syndrome and pain reported a decrease on the visual analogue scale for pain after treatment with intravenous immunoglobulin, and 40% reported a decrease of 20 or more points on the visual analogue scale.

A prospective study of pain and psychological functioning following traumatic spinal cord injury

Study design:Longitudinal study.Objectives:To study prospectively pain characteristics, change in pain over time and the associations between pain and psychological functioning in adults with traumatic spinal cord injury (SCI).Setting:Neurosurgical departments, SCI rehabilitation centres and the community.Methods:Adults with traumatic SCI admitted over a 3-year period to two neurosurgical departments underwent clinical examination and questionnaires within 3 months after injury (baseline) and at 6, 12 and 42 months following SCI. Pain intensity and interference within the last 7 days, a global quality of life (QoL) item, the 5-item Mental Health Index and the 6-item Catastrophizing scale were used.Results:Ninety individuals were recruited, of which 81 completed a telephone interview on average 3.5 (s.d., 0.6) years after the SCI. Pain was present in 75% at 3.5 years. Baseline pain catastrophizing scores did not predict pain intensity at 3.5 years. Both psychological functioning and QoL increased over time. QoL scores increased less in participants who reported an increase in pain intensity from baseline to the 3.5-year follow-up, and the change in QoL score correlated with the change in pain interference. Neuropathic pain had an onset within the first 12 months and tended to become persistent, whereas musculoskeletal pain more often had a late onset or resolved in cases of early onset.Conclusions:A large proportion of SCI participants continue to experience pain many years after SCI. Teaching individuals with SCI skills to minimise pain’s impact on function as soon as possible following injury may prove beneficial.

PAIN, ESPECIALLY NEUROPATHIC PAIN, IN ADULTS WITH SPINA BIFIDA, AND ITS RELATION TO AGE, NEUROLOGICAL LEVEL, COMPLETENESS, GENDER AND HYDROCEPHALUS

STUDY DESIGN Cohort study. OBJECTIVE To investigate the prevalence of neuropathic pain in adults with spina bifida, to study the relationship between neuropathic pain, age at examination, gender, completeness of injury, neurological level and presence of hydrocephalus. METHODS A total of 110 patients with spina bifida who visited the spinal cord injury outpatient clinic Spinalis were included. At the yearly check-up they underwent examination by a physiotherapist and a neurologist and were interviewed about pain character, temporal profile and localization. The patients were divided into 2 groups; spina bifida with (n = 57) and without hydrocephalus (n = 53). Pain was classified as neuropathic when it was in an area of decreased sensibility and had no correlation to movement and/or inflammatory signs. Results were analysed by chi2 analysis and Fishers exact test. RESULTS Twenty-two patients (20%) experienced nociceptive pain. Neuropathic pain was present in 11/110 (10%) patients, of these 62% experienced below level neuropathic pain. Neuropathic pain was present in 13% of male patients and 7% of female patients, 12% of patients with a lumbar level and 10% of patients with a thoracic level. Neuropathic pain was present in 9% of patients with a complete spinal cord injury, 14% of those with an incomplete spinal cord injury, 1,7% with hydrocephalus and 19% without hydrocephalus. CONCLUSION The results suggest that neuropathic pain is present in spina bifida. Careful analysis and classification of a patients pain is clinically important. Neuropathic pain is more common in patients without hydrocephalus and in older patients. Presence of neuropathic pain was not related to gender, completeness of injury, or neurological level.

Post-polio syndrome, spinal cord injury and statin myopathy: double trouble or incorrect diagnosis? Two case reports.

OBJECTIVE To discuss the importance of a thorough clinical examination and evaluation of symptoms in upper and lower motor neurone lesions. DESIGN Case report. METHODS Post-polio outpatient clinic, Danderyds University Hospital, Stockholm, Sweden. We describe here two patients with a past history of poliomyelitis, who were experiencing increasing muscular weakness. Clinical evaluation led to diagnoses of spinal cord injury and statin myopathy, respectively. CONCLUSION In order to make a correct diagnosis it is essential to distinguish between lower and upper motor neurone lesions. In the case of a lower motor neurone disorder a neurophysiological examination is necessary for a correct diagnosis, and is a prerequisite for adequate treatment and rehabilitation.

Immunoglobulin treatment in post-polio syndrome: Identification of responders and non-responders.

OBJECTIVE To define and characterize responders and non-responders in a group of 124 patients with post-polio syndrome who received a single treatment with intravenous immunoglobulin. DESIGN Open trial, prospective follow-up study. METHODS Clinical examination and data from medical records. Short Form 36 (SF-36), Physical Activity Scale for the Elderly (PASE) and visual analogue scale (VAS) measured quality of life, physical activity and intensity of pain, respectively. Data were obtained before treatment and at 6-month follow-up. RESULTS Two responder groups were identified with the outcome SF-36 Vitality and 3 with Bodily pain, respectively. Forty-five percent were positive-responders, identified before treatment by reduced physical function, muscle atrophy in the lower extremities, higher levels of fatigue and pain, and a VAS pain score above 20. Negative-responders were identified by good physical function and mental health, lesser muscle atrophy in the lower extremities, and low levels of fatigue and pain. CONCLUSION Intravenous immunoglobulin is a biological intervention, and therefore it is important to be able to identify responders and non-responders. In order to maximize a positive outcome it is suggested that patients with a high level of fatigue and/or pain and reduced physical function are selected.