The assessment of neuropathic pain in patients with prediabetes

AimsNeuropathic pain is associated with several clinical conditions, including anxiety, depression, sleep disorders, and decreased quality of life; however, less evaluated in prediabetes. This study aims to assess neuropathic pain through validated diagnostic tools in prediabetes.MethodsOne hundred and seventy-two patients with prediabetes and 170 controls were included in this cross-sectional study. The Leeds Assessment of Neuropathic Symptoms and Signs (LANSS) Pain Scale and Douleur Neuropathique 4 Questions (DN4) were used to evaluate neuropathic pain. The Visual Analog Scale (VAS) was used to estimate pain intensity.ResultsTwenty-three (13.4%) and 12 (7%) patients with prediabetes were diagnosed with neuropathic pain using DN4 and LANSS questionnaires, respectively. Neuropathic pain rates of the patients were higher than controls with two pain scales (p < 0.001). VAS scores were higher in prediabetes group than in controls (p = 0.021). LANSS, DN4, and VAS scores were positively correlated with HbA1c level (r = 0.184, p = 0.016; r = 0.180, p = 0.018; r = 0.188, p = 0.014, respectively). LANNS and DN4 scores were higher in female patients than in males (p < 0.001).ConclusionsNeuropathic pain was increased in prediabetes by DN4 and LANNS questionnaires. An appropriate diagnosis of neuropathic pain in prediabetes may prevent patients from different pain-related clinical conditions.     

Serum uric acid predicts changes in reports of non-gouty chronic pain: a prospective study among women with inflammatory and non-inflammatory pain

Widespread pain has earlier been associated with an increase in serum urate (SU). The aim of this study was to longitudinally study the relation between changes in pain reporting and the level of SU among women with chronic pain. Consecutive female patients (n = 124; aged 20–70 years), at rheumatology and rehabilitation practices, with chronic musculoskeletal pain of different origins were followed for 1 year with repeated blood samples and questionnaires. Complete data were obtained from 107 individuals. Factors that predicted an increase in pain extension during 12 months were studied in a logistic regression model. Changes in SU showed a significant correlation (r = 0.36) with changes in the number of reported pain locations. An initially high SU level (OR = 4.46), frequent use of alcohol (OR = 1.32) and a high number of pain locations (OR = 1.24) independently predicted an increase in pain extension during 12 months, whereas the use of steroids (OR = 0.21) in patients with inflammatory disorders resulted in a decreased number of reported pain locations. A relative increase in SU in combination with report of a high number of pain locations turned out to be a risk factor of increased pain extension in a cohort of women with chronic non-gouty pain followed during 1 year. The importance of SU in relation to chronic pain and its prognosis needs to be validated in larger studies.     

Pain patterns in chronic pancreatitis and chronic primary pain

BackgroundAbdominal pain is the most distressing symptom of chronic pancreatitis (CP), and current treatments show limited benefit. Pain phenotypes may be more useful than diagnostic categories when planning treatments, and the presence or absence of constant pain in CP may be a useful prognostic indicator.AimsThis cross-sectional study examined dimensions of pain in CP, compared pain in CP with chronic primary pain (CPP), and assessed whether constant pain in CP is associated with poorer outcomes.MethodsPatients with CP (N = 91) and CPP (N = 127) completed the Comprehensive Pancreatitis Assessment Tool. Differences in clinical characteristics and pain dimensions were assessed between a) CP and CPP and b) CP patients with constant versus intermittent pain. Latent class regression analysis was performed (N = 192) to group participants based on pain dimensions and clinical characteristics.ResultsCompared to CPP, CP patients had higher quality of life (p < 0.001), lower pain severity (p < 0.001), and were more likely to use strong opioids (p < 0.001). Within CP, constant pain was associated with a stronger response to pain triggers (p < 0.05), greater pain spread (p < 0.01), greater pain severity, more features of central sensitization, greater pain catastrophising, and lower quality of life compared to intermittent pain (all p values ≤ 0.001). Latent class regression analysis identified three groups, that mapped onto the following patient groups 1) combined CPP and CP-constant, 2) majority CPP, and 3) majority CP-intermittent.ConclusionsWithin CP, constant pain may represent a pain phenotype that corresponds with poorer outcomes. CP patients with constant pain show similarities to some patients with CPP, potentially indicating shared mechanisms.     

Imipramine decreases oesophageal pain perception in human male volunteers

Department of Medicine, Suite 501, Pepper Pavilion, Allegheny University Hospitals, Graduate, One Graduate Plaza, 1800 Lombard Street, Philadelphia, Pennsylvania 19146, USA

Correspondence to: Dr D O Castell.

Accepted for publication 19 January 1998

Background—Visceral hyperalgesia is a hallmark of functional gastrointestinal disorders. Antidepressants improve symptoms in these patients, although their mode of action is unclear. Antidepressant, anticholinergic, and analgesic mechanisms have been proposed.
Aims—To investigate whether imipramine, which has a visceral analgesic effect, increases pain thresholds to experimental visceral pain.
Methods—Visceral perception for first sensation and pain was measured with intraoesophageal balloon distension in 15 male volunteers. The effect of imipramine was studied in a double blind, placebo controlled, crossover study. Imipramine was given in ascending doses for 12 days (25 mg days 1-3, 50 mg days 4-6, 75 mg days 7-12), with oesophageal perception studied on day 13. 
Results—Inflation volumes and intraballoon pressures at first sensation were not different between placebo and imipramine. Balloon inflation volume at pain threshold was higher on imipramine (p=0.015). Median intraballoon pressures were not different at pain threshold for placebo and imipramine. Oesophageal wall compliance was not affected by imipramine.
Conclusion—Increased pain thresholds on imipramine in this group of normal male volunteers in the absence of changes in oesophageal tone imply the presence of a visceral analgesic effect.
(GUT 1998;:807-813)

Keywords: antidepressants;  imipramine;  visceral hyperalgesia;  oesophageal balloon;  distension;  functional bowel syndromes

     

Improved functional outcome in patients with early rheumatoid arthritis treated with intramuscular gold: results of a five year prospective study

OBJECTIVE—To determine whether there is a relation between disease duration and functional outcome in patients with rheumatoid arthritis (RA) treated with intramuscular sodium aurothiomolate (gold) for five years.
METHODS—440 patients with RA were enrolled in a prospective trial of gold treatment. Initial demographic details were recorded. Disease activity was assessed at yearly intervals using a combination of clinical (pain score, Ritchie articular index, duration of morning stiffness) and laboratory (erythrocyte sedimentation rate, C reactive protein) parameters. Change in functional status was assessed using the health status questionnaire (HAQ). Patients were stratified according to disease duration at outset (group 1= 0-2 years n=106, group 2 = >2-5 years n=93, and group 3= >5 years n=235).
RESULTS—There were no significant differences between the groups at outset. A total of 160 patients completed five years of treatment (group 1 n=44 (42%), group 2 n=37 (40%), and group 3 n=79 (34%)). Patients in group 1 had a significantly lower HAQ from year 1 to year 5 with a mean improvement of 30% at the end of the study (p<0.001). Neither group 2 nor group 3 had a significant change in their HAQ at study end. There were significant improvements in all other variables (p<0.05) in each group apart from pain in group 2.
CONCLUSION—Patients with early RA have a larger reversible component to their HAQ. Only patients with disease duration of up to two years have a longlasting improvement in their functional ability after starting intramuscular gold treatment.

Keywords: gold; rheumatoid arthritis; function; HAQ     

Racial and Ethnic Variation in Pain Following Inpatient Palliative Care Consultations

Studies have documented high levels of pain in hospitalized individuals at the end of life, with minorities reporting higher levels of pain than whites. In response, inpatient palliative care (IPC) teams have grown rapidly to improve care of seriously ill individuals. Although research indicates that IPC teams effectively reduce and maintain control of pain, racial and ethnic differences in pain following IPC consultation remain unclear. This study investigated racial and ethnic pain differences after an IPC intervention in 385 seriously ill white, black, and Latino individuals aged 65 and older. Using the 11‐point Numeric Rating Scale for pain, individuals were asked to rate their pain intensity at four points during hospitalization (before IPC consultation, 2 and 24 hours after the consultation, and at hospital discharge). Results indicate that whites (F_{1.657, 173.998} = 16.528, P < .001), blacks (F_{1.800, 95.410} = 7.103, P = .002), and Latinos (F_{1.388, 73.584} = 10.902, P < .001) all experienced significant reductions in pain after the intervention. Adjusted multivariate models testing between‐group racial and ethnic differences revealed that Latinos were 62% more likely than whites to report experiencing pain at hospital discharge (relative risk = 0.38, 95% confidence interval = 0.15–0.97). Regardless of race or ethnicity, IPC effectively reduces and controls pain after consultation. Despite pain decreases, Latinos remain more likely than whites to report pain at follow‐up. Further research is needed to determine the mechanisms in operation and to better understand and address the needs of this population.     

Putative analgesic activity of repeated oral doses of vitamin E in the treatment of rheumatoid arthritis. Results of a prospective placebo controlled double blind trial

OBJECTIVE—Vitamin E, the most potent naturally occurring lipid soluble antioxidant has been suggested to possess both anti-inflammatory and analgesic activity in humans. This double blind and randomised study used a broad spectrum of clinical and laboratory parameters to investigate whether there was any additional anti-inflammatory or analgesic effects, or both, of orally administered α-tocopherol in rheumatoid arthritis patients who were already receiving anti-rheumatic drugs.
METHODS—Forty two patients were enrolled and treated with α-tocopherol (n=20) at a dose of 600 mg twice a day (2 × 2 capsules) or with placebo (n=22) for 12 weeks. The following parameters were measured: (1) Three clinical indices of inflammation—the Ritchie articular index, the duration of morning stiffness, and the number of swollen joints; (2) three measures of pain—pain in the morning, pain in the evening, and pain after chosen activity; (3) haematological and biochemical measures of inflammatory activity; (4) assays for the oxidative modification of proteins and lipids.
RESULTS—All laboratory measures of inflammatory activity and oxidative modification were unchanged. Furthermore, the clinical indices of inflammation were not influenced by the treatment. However, the pain parameters were significantly decreased after vitamin E treatment when compared with placebo.
CONCLUSION—The results provide preliminary evidence that vitamin E may exert a small but significant analgesic activity independent of a peripheral anti-inflammatory effect, but which complements standard anti-inflammatory treatment.

     

Symptoms and visceral perception in severe functional and organic dyspepsia

^a CURE: Digestive Disease Research Center/Neuroenteric Disease Program, UCLA, Los Angeles, California, USA, ^b Department of Medicine, Vanderbilt University, Nashville, Tennessee

Correspondence to: Dr E A Mayer, Neuroenteric Disease Program, West LA VA Medical Center, CURE Bldg 115, Rm 223, 11301 Wilshire Blvd, Los Angeles, California 90073, USA.

Accepted for publication 31 October 1997

Background—Hypersensitivity of gastric afferent pathways may play an aetiological role in symptoms of functional dyspepsia.
Aims—To determine whether patients with severe organic dyspepsia (associated with tissue irritation/injury) and those with functional dyspepsia (no detectable tissue irritation) differ in their perception of gastric distension and whether this difference is reflected in differences in their gastrointestinal and psychological symptoms.
Methods—Perceptual thresholds, referral patterns, and gastrointestinal and psychological symptoms were compared in 23 patients with functional dyspepsia, 10 organic dyspeptics, and 15 healthy controls.
Results—Fifteen (65%) functional dyspeptics and no organic dyspeptics had reduced perceptual thresholds for fullness, discomfort, or pain (odds ratio (OR) 19.56, 95% confidence interval (CI) 1.95 to 476.09, p=0.0017). Either reduced perceptual thresholds or altered referral was found in 20 (87%) functional dyspeptics and four (20%) organic dyspeptics (OR 10.0, 95% CI 1.34 to 89.54, p=0.014). During sham distension fullness, discomfort and pain were reported by healthy controls, organic dyspeptics, and functional dyspeptics. A sham response of pain but no other sensation was more frequent among functional dyspeptics (43%) than healthy controls (7%) (OR 10.77, 95% CI 1.10 to 257.35, p=0.026). Gastrointestinal and psychological symptoms and gastric compliance were similar in the functional and organic groups.
Conclusions—Alterations in the perception of gastric distension distinguishes between functional and organic dyspepsia, while symptoms do not. A total of 87% of functional dyspeptics studied had evidence of altered visceral afferent function. In this study population, psychological abnormalities or changes in compliance did not explain the findings.
(GUT 1998;:814-822)

Keywords: dyspepsia;  hyperalgesia;  visceral afferents

     

Potential role of brain biomarkers in primary knee osteoarthritis patients using magnetic resonance spectroscopy

BackgroundPain in osteoarthritis (OA) primarily results from tissue damage but its' intensity does not essentially parallel the extent of joint destruction or presence of active inflammation, thus suggesting the likely involvement of a central component. The mid-anterior cingulate cortex (mACC) has an important role in pain perception, intensity and progression. In OA, low mACC γ-aminobutyric acid (GABA) was associated with high pain suggesting a role of prefrontal disinhibition. Aim of the work: To investigate the role of mACC (GABA) levels in chronic knee OA (KOA) pain and determine if magnetic resonance spectroscopy (MRS) brain neurotransmitters can serve as potential biomarkers. Patients and methods: Forty-five patients with primary KOA (M/F:33/12; age:57 ± 6 years) along with 15 matched controls were recruited. Pain was assessed using Visual Analogue Scale (VAS), Pain Catastrophizing Scale (PCS) and Western Ontario McMaster Osteoarthritis (WOMAC) questionnaire. mACC (GABA) was assessed and brain MRS neurotransmitters analysed including glutamate (Glx); N-acetylaspartate (NAA), total choline (tCho) and myo-inositol. Results: MRS analysis demonstrated no metabolite differences between controls and KOA patients in GABA, Glx, NAA and tCho. Myo-inositol:Glx ratio was significantly higher in patients (1.47 ± 0.37 vs 1.1 ± 0.29; p < 0.001). mACC (GABA) negatively correlated with VAS (r = −0.86, p < 0001), PCS (r = −0.94, p < 0001) and WOMAC (r = −0.96, p < 0001) in KOA patients. Myo-inositol:Glx significantly correlated with the age (r = 0.31, p < 0.038), disease duration (r = 0.61, p < 0.0001), VAS (r = 0.4, p < 0.02), PCS (r = 0.48, p < 0.001) and WOMAC (r = 0.53, p < 0.0001). Conclusions: This work confirms the importance of mACC in central sensitization of pain and highlights a promising role of the inflammatory neurotransmitter GABA and myo-inositol:Glx ratio as mechanistic biomarkers of chronic KOA pain.     

An Evidence‐Based Program to Improve Analgesic Practice and Pain Outcomes in Residential Aged Care Facilities

Pain is common in individuals living in residential aged care facilities (RACFs), and a number of obstacles have been identified as recurring barriers to adequate pain management. To address this, the Australian Pain Society developed 27 recommendations for comprehensive good practice in the identification, assessment, and management of pain. This study reviewed preexisting pain management practice at five Australian RACFs and identified changes needed to implement the recommendations and then implemented an evidence‐based program that aimed to facilitate better pain management. The program involved staff training and education and revised in‐house pain‐management procedures. Reviews occurred before and after the program and included the assessment of 282 residents for analgesic use and pain status. Analgesic use improved after the program (P < .001), with a decrease in residents receiving no analgesics (from 15% to 6%) and an increase in residents receiving around‐the‐clock plus as‐needed analgesics (from 24% to 43%). There were improvements in pain relief for residents with scores indicative of pain, with Abbey pain scale (P = .005), Pain Assessment in Advanced Dementia Scale (P = .001), and Non‐communicative Patient's Pain Assessment Instrument scale (P < .001) scores all improving. Although physical function declined as expected, Medical Outcomes Study 36‐item Short‐Form Survey bodily pain scores also showed improvement (P = .001). Better evidence‐based practice and outcomes in RACFs can be achieved with appropriate training and education. Investing resources in the aged care workforce using this program improved analgesic practice and pain relief in participating sites. Further attention to the continued targeted pain management training of aged care staff is likely to improve pain‐focused care for residents.     

Anxiety is associated with impaired tolerance of colonoscopy preparation in inflammatory bowel disease and controls

Background and aimPain and nausea are often reported during bowel cleansing (BC) for ileocolonoscopy (IC). We aimed to explore putative mechanisms associated with impaired tolerance to BC.MethodsA 1:1 (100 IBD and 100 controls) sex and age matched case–control study was performed. Patients completed the hospital anxiety and depression scale (HADS-A/HADS-D), visceral sensitivity index (VSI) and state-trait anxiety inventory, state scale (STAI-S), in addition to self-assessment of BC and abdominal pain and nausea ratings during BC. Endoscopists reported the Mayo score, Harvey Bradshaw index (HBI), simple endoscopic score for Crohn's disease, and Boston bowel preparation scale (BBPS).ResultsHigher VSI and depression scores were observed in IBD patients. VSI (P < 0.0001) and age (P = 0.008) showed a positive and negative association with abdominal pain during BC, respectively. HADS-A (P = 0.009) and female sex (P = 0.02) were positively associated with nausea during BC, while age (P = 0.02) showed a negative association. Disease activity was not associated with worse BBPS or nausea during BC, while a higher HBI was associated with more pain during BC (P = 0.0006). Nausea (P = 0.007) and abdominal pain (P = 0.003) during BC, and less previous ICs (P = 0.03) were independently associated with anxiety prior to IC (STAI-S). Significant correlations were found between VSI and STAI-S and disease activity.ConclusionHigher gastrointestinal-specific anxiety and co-morbid anxiety are associated with increased pain and nausea during BC, respectively. Pain and nausea during BC were in turn associated with higher anxiety levels at the moment of IC, potentially creating a “vicious circle”. Measures taken to reduce anxiety could improve BC and IC tolerance.     

Radiographic patterns and response to corticosteroid hip injection

OBJECTIVES—A prospective, open study of corticosteroid hip injection (CHI) was performed to determine if different radiological patterns of arthritis vary in their response.
METHODS—Forty five patients (15 with rheumatoid arthritis, 27 with osteoarthritis, and three with anklyosing spondylitis) underwent hip injection with 80 mg methyl- prednisolone and lignocaine under x ray control. Outcome was assessed at two, 12, and 26 weeks for pain, range of hip movement, and graded functional questionnaire. Patients estimated their pain in four components, night pain, rest pain, weight bearing, and referred pain, each measured by 10 cm visual analogue score and summed to give a total score out of 40 cm. Hip radiographs were evaluated blindly for pattern and severity of arthritis, as well as for progression between 0 and 26 weeks.
RESULTS—Median total pain score decreased from 29 cm at baseline to 22 cm at two weeks (p=0.0001), 24 cm at 12 weeks (p=0.03), but had returned nearly to baseline by 26 weeks (25 cm, p=0.3). Greatest improvement was seen for night pain. Mean range of internal rotation increased from 16 to 28 degrees at two weeks (p=0.03) and 23 degrees at 12 weeks (p=0.06). Functional ability did not change. Hips with an atrophic pattern of arthritis on plain radiography gained negligible pain relief at two weeks compared with hips with a hypertrophic or mixed bone response (p=0.04). The degree of pain relief was similar in patients with OA and RA, and was not influenced by radiographic severity or by the direction of migration of the femoral head.
CONCLUSION—Pain and internal rotation improve for up to 12 weeks after CHI. CHI offers a useful and safe therapeutic option for patients with hip arthritis, with the exception of those with a purely atrophic radiological pattern.

     

Pain in women with knee and/or hip osteoarthritis is related to systemic inflammation and to adipose tissue dysfunction: Cross-sectional results of the KHOALA cohort

BackgroundConsidering the role of metabolic diseases in osteoarthritis (OA), we investigated whether biomarkers of adipose tissue dysfunction could be associated with OA-related pain.DesignWe cross-sectionally analyzed patients with knee and/or hip OA at inclusion in the KHOALA cohort. We used visual analogic scale (VAS) for pain, the Western Ontario and McMaster Universities Arthritis Index (WOMAC) and Osteoarthritis Knee and Hip Quality of Life (OAKHQOL) pain subscores. At inclusion, we measured ultra-sensitive CRP (usCRP), leptin and adiponectin for calculation of leptin:adiponectin ratio (LAR), a marker of adipose tissue dysfunction associated with central adiposity, high-molecular-weight adiponectin, visfatin and apolipoproteins. Univariate and multivariable analyses using stepwise linear regression models were performed to search for correlation between pain assessments and these biomarkers, with systematic adjustment on age.ResultsIn 596 women with hip and/or knee OA, multivariable analyses indicated that higher pain intensity was associated with higher LAR (VAS pain: β=0.49; p = 0.0001, OAKHQOL pain: β=-0.46; p = 0.0002, WOMAC pain: β=0.30; p = 0.001) in the whole group as well as in hip or knee OA patients considered separately. Pain intensity correlated also with usCRP level (VAS pain: β= 0.27; p = 0.02, OAKHQOL pain: β =-0.30; p = 0.01) and Kellgren-Lawrence score. In 267 men, no correlation between biomarkers and pain was found.ConclusionSerum LAR and usCRP level are associated with pain level, independently of radiographic structural severity in women with hip and/or knee OA, emphasizing the role of adipose tissue dysfunction and of meta-inflammation in pain experience in the female population.