Satiko Tomikawa Imamura

Impact of nervous system hyperalgesia on pain, disability, and quality of life in patients with knee osteoarthritis: a controlled analysis.

OBJECTIVE Refractory, disabling pain associated with knee osteoarthritis (OA) is usually treated with total knee replacement. However, pain in these patients might be associated with central nervous sensitization rather than peripheral inflammation and injury. We evaluated the presence of hyperalgesia in patients scheduled for a total knee replacement due to knee osteoarthritis with refractory pain, and we assessed the impact of pressure pain threshold measurements (PPT) on pain, disability, and quality of life of these patients. METHODS Sixty-two female patients were compared with 22 age-matched healthy controls without reported pain for the last year. PPT was measured at the lower extremities subcutaneous dermatomes, over the vastus medialis, adductor longus, rectus femoris, vastus lateralis, tibialis anterior, peroneus longus, iliacus, quadratus lumborum and popliteus muscles and at the supraspinous ligaments from L1-L5, over the L5-S1 and S1-S2 sacral areas and at the pes anserinus bursae and patellar tendon. RESULTS Patients with knee OA had significantly lower PPT over all evaluated structures versus healthy control subjects (P<0.001). Lower PPT values were correlated with higher pain intensity, higher disability scores, and with poorer quality of life, except for the role-emotional and general health status. Combined PPT values over the patellar tendon, at the S2 subcutaneous dermatome and at the adductor longus muscle were the best predictors for visual analog scale and Western Ontario and McMaster Universities Osteoarthritis Index pain scores. CONCLUSION Patients with pain due to osteoarthritis who were scheduled for total knee replacement showed hyperalgesia of nervous system origin that negatively impacted pain, knee functional capacity, and most aspects of quality of life.

A RANDOMIZED CONTROLLED TRIAL OF ACUPUNCTURE ADDED TO USUAL TREATMENT FOR FIBROMYALGIA

OBJECTIVE To evaluate the effectiveness of acupuncture for fibromyalgia. METHODS Fifty-eight women with fibromyalgia were allocated randomly to receive either acupuncture together with tricyclic antidepressants and exercise (n=34), or tricyclic antidepressants and exercise only (n=24). Patients rated their pain on a visual analogue scale. A blinded assessor evaluated both the mean pressure pain threshold value over all 18 fibromyalgia points and quality of life using SF-36. RESULTS At the end of 20 sessions, patients who received acupuncture were significantly better than the control group in all measures of pain and in 5 of the SF-36 subscales. After 6 months, the acupuncture group was significantly better than the control group in numbers of tender points, mean pressure pain threshold at the 18 tender points and 3 subscales of SF-36. After one year, the acupuncture group showed significance in one subscale of the SF-36; at 2 years there were no significant differences in any outcome measures. CONCLUSION Addition of acupuncture to usual treatments for fibromyalgia may be beneficial for pain and quality of life for 3 months after the end of treatment. Future research is needed to evaluate the specific effects of acupuncture for fibromyalgia.

Pedobarometric evaluation of the normal adult male foot.

Static and dynamic pedobarometric evaluations were performed on the feet of 100 normal adult white men aged from 20 to 49 years old (mean = 29.9±6.9), using version 3.848 of the F-SCAN system. All evaluations were performed using new pressure sensor insoles with standardized conditions. Maximum vertical forces and plantar peak pressure measurements were taken during 7.88 seconds each of walking in a straight line at subjects own pace and standing. Feet were separated based on their side and lower limb dominance. The means of three consecutive and three alternate tests provided quantitative data. Maximum static and vertical dynamic forces were found to be greater on the dominant side and were significantly correlated with body weight. There were significant differences between dominant and non-dominant sides in static plantar peak pressure evaluations at the forefoot and midfoot, and in the dynamic evaluations at the midfoot. There was a significant correlation between dynamic plantar peak pressures at the midfoot and body weight.

Concentration of cytokines in patients with osteoarthritis of the knee and fibromyalgia

Introduction Fibromyalgia and osteoarthritis may present a relationship with the concentration of cytokines. The aim of this study was to compare the serum concentrations of IL-12p70, tumor necrosis factor, IL-10, IL-6, IL-1β, and IL-8 in patients with knee osteoarthritis and fibromyalgia. Materials and methods The study included 53 women (71.2±7.6 years old) diagnosed with knee osteoarthritis with moderate-to-severe pain (visual analog scale >4) for at least 3 months. Sixty women (54.1±8.1 years old) diagnosed with fibromyalgia according to the American College of Rheumatology criteria and with moderate-to-severe pain (visual analog scale >4) also participated in this study. For the dosage of cytokines, blood was collected in the morning: 5 mL from the cubital vein. The material was centrifuged at 4°C, separated into 100 μL aliquots and stored at −80°C until processing. Serum concentrations of the studied cytokines were assessed using the BD Cytometric Bead Array method. Data were analyzed with Student’s t-test and the Mann–Whitney U test. Results We found higher levels of IL-6, IL-10, and IL-1β in fibromyalgia patients. After adjustment of age as a covariate, there was no statistically significant difference in the concentration of any cytokine between fibromyalgia and knee osteoarthritis patients. Conclusion Patients with knee osteoarthritis and fibromyalgia with the same duration and intensity of pain demonstrate similar concentrations of cytokines. Aging may play a role in cytokine profile, a finding not so extensively addressed in the literature and one that should be further investigated.

Poster 403 Guidelines on Neck Pain Rehabilitation: Non-Pharmacological Interventions

detection during needle positioning of transforaminal epidural steroid injections (TFESI) with dexamethasone and the occurrence of perineal pruritus. Design: A prospective, single-arm, observational epidemiological study. Setting: Spine center affiliated with a rehabilitation hospital. Participants: 150 consecutive subjects who underwent 284 TFESIs for management of radicular and axial spinal pain. Interventions: Cervical, lumbar and sacral TFESI with dexamethasone. Main Outcome Measures: Signs of vascular penetration during needle positioning at the neural foramen were observed using 4 different methods: the presence of blood at the needle hub after stylet removal (flash); blood aspiration; visualization of intravascular flow with contrast injection under live fluoroscopy; and visualization of intravascular flow using digital subtraction technology. Subsequently, the needle was repositioned and dexamethasone injection was performed after no sign of vascular penetration was noted. Within 5 minutes of the injection, the development of perineal pruritus was observed and correlated with any sign of vascular penetration during positioning. Results: Two hundred eighty four procedures were performed, 53 (18.66%) cervical, 144 (50.7%) lumbar and 87 (30.63%) sacral. Sixty eight procedures (23.94%) had signs of intravascular needle placement, and 216 procedures (76.06%) had no signs of vascular flow detection. For the subjects who had signs of vascular penetration during needle positioning, 10.29% had perineal pruritus, while for subjects who didn’t have any sign of vascular penetration only 1.39% had pruritus (P .0022) OR: 8.14 (CI: 2.04-32.45). Pruritus was observed in 2.08% of lumbar and 8.05% of sacral procedures OR 4.11 (CI: 1.03-16.34). In our sample no subjects who underwent cervical TFESI reported pruritis. Conclusions: The occurrence of signs of vascular penetration during needle introduction correlates with a higher chance of perineal pruritus after TFESI. This might be related to unrecognized intravascular injection leading to systemic absorption of dexamethasone.

Neck pain: rehabilitation

We started the preparation of this directive with the capacitation of the authors by means of the metodology employed by the Oxford Centre for Evidence Based Medicine, for the preparation of clinical directives by the Directives Program of the Brazilian Medical Association (Associação Médica Brasileira AMB). Next, we had five directive preparation meetings with the AMB Program’s coordinators. Articles from the MEDLINE (PubMed) databases, the Cochrane Database of Systematic Reviews, by means of the Health Virtual Library, with no time limitation. The search strategy adopted was based on (P.I.C.O.) structured questions (from the initials “Patient”; “Intervention”; “Control” and “Outcome”. The resulting search syntax for non-specific neck pain was: Question 1: neck pain AND (analgesics OR paracetamol OR acetaminophen OR dipyrone OR non narcotics OR analgesics OR opioid); Question 2: neck pain AND (muscle relaxants OR ciclobenzaprine OR carisoprodol); Question 3: neck pain AND (non-steroidal anti-inflammatory agents); Question 4: neck pain AND (physical modalities OR hyperthermia induced OR diathermy OR ultrasonic therapy OR electric stimulation OR ultrasound OR transcutaneous electric nerve stimulation OR TENS); Question 5: neck pain AND (exercise therapy OR physical activity); Question 6: (neck pain OR myofascial pain syndromes) AND (massage OR manual therapy); Question 7: (neck pain OR myofascial pain syndromes) AND (posture OR ergonomic OR ergometry); Question 8: neck pain AND (sleep OR posture); Question 9: (neck pain OR myofascial neck pain) AND (acupuncture therapy OR trigger points; Question 10: neck pain AND education; Question 11: neck pain AND (psychology OR interdisciplinary communication OR interprofessional relations OR cognitive behaviour therapy OR work style intervention); Question 12: neck pain AND (mechanical OR manipulation); Question 13: neck pain AND (nerve blocks OR local anesthetics); Question 14: (neck pain OR myofascial pain syndrome) AND botulinum Toxin; On all searches, we used Field: All Fields, Limits: no age limits, with metodological filter for study types: narrow. In this manner, we found 1495 articles. Next, based on the abstracts, we selected the ninety-one papers related to neck pain and its treatment. We classified the scientific evidence strength of these studies according to the Oxford Centre for Evidence Based Medicine guidelines. The randomized and controlled clinical essays were submitted to critical evaluation according to the Jadad scale, 1996. Finally, we selected the forty-seven references which, due to greater scientific evidence strength, consistence, and clinical relevance, gave support to the recommendations of this directive.

Abstract 18: Plantar fasciitis: a new treatment approach.1

Abstract Objective: To evaluate the efficacy of a new approach that shortens the duration of plantar fasciitis treatment. Design: Randomized controlled study. Setting: Outpatient clinic. Participants: 64 patients were randomly assigned to intensive conventional physical therapy (PT) (n=34) or needling and infiltration of the myofascial trigger points at the proximal portion of the medial gastrocnemius muscle (n=30). Interventions: Patients in the PT group received ultrasound and electric stimulation at the origin of the plantar fascia followed by stretching exercises of the gastrocnemius muscle. The other group was treated by needling and infiltration (1% lidocaine) of the taut band at the proximal portion of the medial gastrocnemius muscle of the involved limb(s). Injections were performed at weekly intervals. PT was administered for 3 consecutive days after the injections. Patients were instructed to perform stretching of the gastrocnemius muscles and of the plantar fascia at home twice a day. Main Outcome Measures: Visual analog scale and hindfoot functional test (American Orthopaedic Foot and Ankle Society Hindfoot Questionnaire) were performed before and after treatment by an independent evaluator. Duration of treatment was compared between the 2 groups. Results: Statistically significant reduction of pain and improvement in function were observed in both groups, without any differences between them. The time required to achieve the same improvement was significantly less (80%) in the injected group than in the control group ( P P Conclusions: Although treatment in both groups was equally successful, needling and infiltration of the medial gastrocnemius muscle provided faster pain relief and functional recovery in patients with plantar fasciitis.

Dor e fixadores externos: avaliação e tratamento

Pain is the most important cause of the delay in the gain of functional state in patients using externai fixators. The aim of this study is to evaluate the clinicai findings and the results of pain treatment in 20 patients, presenting pain with neuropathic characteristics during the use ofIlizarovs externai fixators in the lower limbs. Ali patients with deaferentiation symptoms were treated with central acting analgesics, antiinflamatory drugs and physical medicine modalities including ice packs, deep heat with ultrasound and neurostimulation of the peripheral neryous system. One patient recieved sympathetic block. Results de.m_oDs~rated symptomatic relief of neuropathic pain in 80,9% of patients which permitted the continuation of the use of the externai fixator, and an agressive rehabilitation approach aiming to increase of function during the orthopaedic treatment.