This study determined the influence of short term exposure to mechanical factors on regional musculoskeletal pain on full time newly employed workers (1081 subjects (median age 23, range 20-27) from 12 occupational groups and information collected by questionnaire.  

Subjects indicated on a blank body manikin any low back, shoulder, wrist or forearm or both, or knee pain which had occurred during the past month and had lasted more than 1 day.  Several specific manual handling activities were found to be associated with low back, shoulder, and knee pain. Carrying weights of more than 50 lbs (23 kg) on one shoulder was the factor which was most strongly associated with low back pain, shoulder pain, and knee pain , whereas forearm pain was most strongly associated with repetitive movements of the wrists.

By contrast very few postures were associated with regional pain, although bending forwards in an uncomfortable position for at least 15 minutes was associated with shoulder pain and kneeling for at least 15 minutes was associated with knee pain.   Exposure to mechanical factors was most strongly associated with pain at multiple sites rather than with pains in individual regions.  The conclusion was that even workers with only short term exposure to mechanical factors, musculoskeletal pain is increased. (Nahit ES, Macfarlane GJ, Pritchard CM, Cherry NM, Silman AJ: Short term influence of mechanical factors on regional musculoskeletal pain: a study of new workers from 12 occupational groups.Occupational & Environmental Medicine. 58(6):374-81, 2001). 

In this next study, the incidence of occupational injuries was related to several demographic factors, including low family income and rural residence, and several job characteristics, including working in a high-hazard occupation, job dissatisfaction, and exposure to six specific hazardous job activities: (1) performing lots of physical effort on the job, (2) lifting or carrying more than 10 lbs, (3) using stairs and inclines, (4) kneeling or crouching, (5) reaching, and (6) hearing special sounds.

These results suggest targeted prevention strategies for decreasing the incidence of work-related injuries and illnesses, such as worker self-assessment of the total physical effort demanded by a job and periodic monitoring of workforce job satisfaction. (Dembe AE, Erickson JB, Delbos R: Predictors of work-related injuries and illnesses: national survey findings. Journal of Occupational & Environmental Hygiene. 1(8):542-50, 2004). 

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These are the recommendations from the American Pain Society based on a systematic review that focused on evidence from randomized controlled trials on interventional treatments for low back pain: 

1. Provocative discography is not recommended for diagnosis in patients with chronic, nonradicular low-back pain.
2. Intensive interdisciplinary rehabilitation, which incorporates psychological interventions and exercise therapy, with cognitive/behavioral emphasis should be considered for patients with nonradicular low-back pain who do not respond to conventional, noninterdisciplinary therapies.
3. Facet joint corticosteroid injection, prolotherapy, and intradiscal corticosteroid injections should not be used for patients with persistent nonradicular low-back pain.
4. The risks and benefits of surgery should be discussed, and shared decision-making that includes a discussion of interdisciplinary rehabilitation as an option should be used for patients with nonradicular low-back pain, common degenerative spinal changes, and persistent and disabling symptoms.
5. There is not enough evidence to guide the use of vertebral disc replacement in patients with nonradicular low back pain, common degenerative spinal changes, and persistent and disabling symptoms.
6. The risks and benefits of epidural steroid injections should be discussed, and shared decision-making that includes a specific review of evidence of lack of long-term benefit should be used for patients with persistent radiculopathy due to herniated lumbar disc. Evidence for epidural steroid injection in spinal stenosis cases is sparse and shows no clear benefit, athough more trials are needed.
7. The risks and benefits of surgery should be discussed, and shared decision-making that includes a specific discussion about moderate benefits that decrease over time should be used for patients with persistent and disabling radiculopathy due to herniated lumbar disc or persistent and disabling leg pain due to spinal stenosis.
8. The risks and benefits of spinal cord stimulation should be discussed, and shared decision making that includes a reference to the high rate of complications following stimulator placement should be used for patients with persistent and disabling radicular pain following surgery for herniated disc and no evidence of a persistently compressed nerve root.

Chou, Roger MD; Loeser, John D. MD; Owens, Douglas K. MD, MS; Rosenquist, Richard W. MD; Atlas, Steven J. MD, MPH; Baisden, Jamie MD, FACS; Carragee, Eugene J. MD; Grabois, Martin MD; Murphy, Donald R. DC, DACAN; Resnick, Daniel K. MD; Stanos, Steven P. DO; Shaffer, William O. MD; Wall, Eric M. MD, MPH; For the American Pain Society Low Back Pain Guideline Panel: Interventional Therapies, Surgery, and Interdisciplinary Rehabilitation for Low Back Pain: An Evidence-Based Clinical Practice Guideline From the American Pain Society.  Spine: 1 May 2009 - Volume 34 - Issue 10 - pp 1066-1077

A study in 2006 had shown that for non-intervential treatments show:

1. Acute Low Back Pain: NSAIDs, muscle relaxants, and advice to stay active are effective for short-term pain relief and long-term improvement of function.

2.  Chronic Low Back Pain: Interventions effective for short-term pain relief include antidepressants, COX2 inhibitors, back schools, progressive relaxation, cognitive-respondent treatment, exercise therapy, and intensive multidisciplinary treatment. 

However, many trials showed methodological weaknesses and the effects were compared to placebo, no treatment or waiting list controls, and do not have adequate sample size. (van Tulder MW, Koes B, Malmivaara A: Outcome of non-invasive treatment modalities on back pain: an evidence-based review.  European Spine Journal. 15 Suppl 1:S64-81, 2006).

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This study evaluated obesity as a marker for increased pain severity, disability, and psychologic distress in treatment-seeking, mixed chronic pain patients.  Three hundred seventy-two consecutive chronic pain patients seeking evaluation at a university pain clinic were divided into 3 weight categories, based on body mass index (BMI):

• normal (BMI < 25 kg/m2)
• overweight (BMI between 25 kg/m and 30 kg/m2)
• obese (BMI > or = 30 kg/m2).

 Patients completed questionnaires to identify

• pain severity
• disability
• depression
• anxiety
• quality of life.

 The findings showed: 

• Pain severity and days per week with pain were similar among the weight groups.
• Disability was related to increasing weight status, with increased BMI associated with more days per week with both reduced activity and complete disability.
• Depressive symptoms were also related to weight category, with an average Beck Depression Inventory score of 11.81 +/- 7.55 in normal, 12.88 +/- 11.64 in overweight, and 15.78 +/- 9.88 in obese patients.
• Anxiety scores were similar among the weight categories.
• Physical function domain of quality of life was also reduced in relation to weight.

 It was concluded that:  

• Weight is associated with co-morbid disability, depression, and reduced quality of life for physical function in chronic pain patients.
• Calculation of the BMI should become a routine part of the screening evaluation for chronic pain patients, with additional screening for disability and psychologic distress in patients with elevated BMIs.

(Marcus DA: Obesity and the impact of chronic pain. Clinical Journal of Pain. 20(3):186-91, 2004).

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Monday, May 04, 2009

 This multinational, Internet-based survey was designed to assess the prevalence, frequency, severity, and impact of opioid-induced bowel dysfunction in patients receiving opioid therapy for chronic pain and taking laxatives.

 At the time of the survey, 45% of 322 patients reported <3 bowel movements per week. The most prevalent opioid-induced side effects were constipation (81%) and straining to pass a bowel movement (58%). Those side effects considered most bothersome by patients were (in order of rank) constipation, straining, fatigue, small or hard bowel movements, and insomnia.

 Most of the OBD symptoms specified in the questionnaire were experienced by the majority of patients >or=4 times a week. Constipation was most often reported as severe. Most patients reported that their opioid-induced bowel dysfunction symptoms had at least a moderate negative impact on their overall quality of life and activities of daily living. A third of patients had missed, decreased or stopped using opioids in order to make it easier to have a bowel movement.

 These gastrointestinal symptoms add to the burden already experienced by chronic pain patients, negatively impacting quality of life and, in some cases, affecting opioid treatment itself. (Bell TJ, Panchal SJ, Miaskowski C, Bolge SC, Milanova T, Williamson R: The prevalence, severity, and impact of opioid-induced bowel dysfunction: results of a US and European Patient Survey (PROBE 1).  Pain Medicine. 10(1):35-42, 2009 Jan.

This following randomised, double-blinded study evaluated the analgesic efficacy of prolonged-release (PR) oral oxycodone when co-administered with PR oral naloxone, and its impact on opioid-induced constipation in patients with severe chronic pain. Another objective was to identify the optimal dose ratio of oxycodone and naloxone.

 A total of 202 patients with chronic pain (mainly non-cancer related, 2.5% of patients had cancer-related pain) under stable oral oxycodone therapy (40, 60 or 80 mg/day) were randomised to receive 10, 20, 40 mg/day naloxone or placebo. After a 4-week maintenance phase, patients received oxycodone only for 2 weeks. Pain intensity was evaluated using a numerical analogue scale and bowel function was assessed using the bowel function index.

 No loss of analgesic efficacy with naloxone was observed. Mean pain intensity scores on randomisation were comparable for placebo, 10mg, 20mg and 40 mg naloxone dose, and remained unchanged during treatment. Bowel function improved with increasing naloxone dose. Naloxone 20mg and 40 mg significantly improved bowel function at the end of the maintenance phase compared with placebo (p<0.05). Overall, the combination was well tolerated, with no unexpected adverse events. There was a trend towards an increased incidence of diarrhea with higher doses of naloxone. The 2:1 oxycodone/naloxone ratio was identified as the most suitable for further development.

 It was concluded that the co-administration of PR oral naloxone and PR oral oxycodone is associated with a significant improvement in bowel function compared with PR oral oxycodone alone, with no reduction in the analgesic efficacy of oxycodone. (Meissner, Winfried. Leyendecker, Petra. Mueller-Lissner, Stefan. Nadstawek, Joachim. Hopp, Michael. Ruckes, Christian. Wirz, Stefan. Fleischer, Wolfgang. Reimer, Karen: A randomised controlled trial with prolonged-release oral oxycodone and naloxone to prevent and reverse opioid-induced constipation. European Journal of Pain: Ejp. 13(1):56-64, 2009).

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Brain areas that are involved in cognition and mood also play a role in pain processing.  This present study examined the relationship between chronic pain and cognition (executive functions and memory), while controlling for mood, in cognitively intact older persons and in patients with early Alzheimer's disease who suffered from arthrosis/arthritis.  

Pain intensity and pain affect were assessed by the Colored Analogue Scale for Pain Intensity and for Pain Affect, the Faces Pain Scale (FPS) and the Number of Words Chosen-Affective. Level of depression and anxiety were evaluated by questionnaires. Executive functions and memory were assessed by neuropsychological tests.  

There were no significant correlations between specific cognitive functions, pain intensity and pain affect were lacking in the cognitively intact older persons. Cognition, in particular memory, appeared to be related to depressive symptoms. In contrast, a significant positive correlation was observed between executive functions, pain intensity and pain affect measured by the Faces Pain Scale in the Alzheimer's disease group.  It was concluded that although older persons with depression were excluded, in studies on pain and cognition one should control for the presence of depressive symptoms in older persons with and without dementia. (Scherder EJ, Eggermont L, Plooij B, Oudshoorn J, Vuijk PJ, Pickering G, Lautenbacher S, Achterberg W, Oosterman J: Relationship between chronic pain and cognition in cognitively intact older persons and in patients with Alzheimer's disease. The need to control for mood.  Gerontology. 54(1):50-8, 2008). 

This study evaluated the validity of traditional pain behaviors (guarding, bracing, rubbing, grimacing, and sighing) in persons with and without cognitive impairment and chronic low back pain.   

Thirty-seven cognitively intact and 40 cognitively impaired participants with and without chronic low back pain were studied.  Forty-six of the participants were pain free, and 31 had chronic low back pain. Participants with chronic low back pain exhibited significantly higher levels of grimacing and guarding than pain-free participants. Intact subjects exhibited fewer guarding and rubbing behaviors but a higher number of bracing behaviors than cognitively impaired participants. 

These results support the utility of facial grimacing in assessing pain in patients with mild to moderate cognitive impairment and call into question the validity of guarding and rubbing in assessing pain in persons with mild to moderate cognitive impairment. (Shega JW, Rudy T, Keefe FJ, Perri LC, Mengin OT, Weiner DK: Validity of pain behaviors in persons with mild to moderate cognitive impairment. Journal of the American Geriatrics Society. 56(9):1631-7, 2008). 

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Many patients with chronic pain complain of coolness of their skin and here is the scientific basis for these complaints which involve skin circulation. 

This study investigated the effect of painful stimulation of latent myofascial trigger points (MTrPs) on skin blood flow and to evaluate the relative sensitivity of laser Doppler flowmetry and thermography in the measurement of skin blood flow. Painful stimulation was obtained by a bolus injection of glutamate (0.1mL, 0.5M) into a latent MTrP located in the right or left brachioradialis muscles. A bolus of glutamate injection into a non-MTrP served as control.

Pain intensity (visual analog scale was assessed after glutamate injection. Pressure pain threshold was recorded bilaterally in the brachioradialis muscle before and after glutamate-induced pain. Skin blood flow and surface skin temperature were measured bilaterally in the forearms before, during, and after glutamate-induced pain with laser Doppler flowmetry and thermography.  

The present study demonstrated an attenuated skin blood flow response after painful stimulation of latent MTrPs compared with non-MTrPs, suggesting increased sympathetic vasoconstriction activity at latent MTrPs. Additionally, laser Doppler flowmetry was more sensitive than thermography in the detection of the changes in skin blood flow after intramuscular nociceptive stimulation. (Zhang Y, Ge HY, Yue SW, Kimura Y, Arendt-Nielsen L: Attenuated skin blood flow response to nociceptive stimulation of latent myofascial trigger points. Archives of Physical Medicine & Rehabilitation. 90(2):325-32, 2009).

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A recent research shows that hot weather can give you a headache. On the other hand, air pollution appeared to have no effect on headache in a large, long-term case-crossover study.  Low barometric pressure was also linked to the risk of headache, but only for nonmigraine pain.  Mukamal KJ, et al "Weather and air pollution as triggers of severe headaches" Neurology 2009; 72: 922-927.

Here’s an article with an opposing view that showed that air pollution is associated with an increase in the number of emergency department visits for headache.

This study involved 10,497 emergency department visits for headache that occurred at a Montreal hospital between 1997 and 2002 to examine the associations between visits for headache and selected meteorological and air pollution factors.  

Statistically significant positive associations were observed between the number of emergency department visits for headache (ICD-9: 784) and the atmospheric pressure for all and for female visits for 1-day and 2-day lagged exposures. The percentage increase in daily ED female visits was 4.1%, 3.4%, and 2.2% for current day, 1-day and 2-day lagged exposure to SO(2), respectively, for an increase of an interquartile range (IQR) of 2.4 ppb.

The percentage increase was also statistically significant for current day and 1-day lagged exposure to NO(2) and CO for all and for female visits. Presented findings provide support for the hypothesis that emergency department visits for headache are correlated to weather conditions and ambient air pollution - to atmospheric pressure and exposure to SO(2), NO(2), CO, and PM(2.5).

An increase in levels of these factors is associated with an increase in the number of emergency department visits for headache. Szyszkowicz M: Air pollution and daily emergency department visits for headache in Montreal, Canada. Headache. 48(3):417-23, 2008 Mar.  

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Obstructive sleep apnea syndrome (OSAS) is a common disease characterized by repetitive partial or complete closure of the upper airway during sleep. Cardiovascular disturbances are the most important complications responsible for increased morbidity and mortality.

It is suggested that daytime somnolence, chronic fatigue, and nocturnal hypoxemia may further impair muscle function and decrease exercise fitness. The aim of this study was to evaluate cardiopulmonary response to exercise in OSAS patients. Hypertensive response to exercise was diagnosed in 39 of 111 patients (35%). Patients with severe sleep apnea were characterized by higher mean blood pressure at rest, at 25%, 50% of maximal work load, at peak exercise and at post-exercise recovery.

Several significant correlations between hemodynamic responses to exercise and sleep apnea severity were also noted. The conclusion was that exercise tolerance can be limited due to hypertensive response in about 20% of patients. Patients with severe OSAS have exaggerated hemodynamic response to exercise and delayed post-exercise blood pressure recovery.

Cardiopulmonary response to exercise seems to be related to sleep apnea severity. (Przybylowski T, Bielicki P, Kumor M, Hildebrand K, Maskey-Warzechowska M, Korczynski P, Chazan R: Exercise capacity in patients with obstructive sleep apnea syndrome. Journal of Physiology & Pharmacology. 58 Suppl 5(Pt 2):563-74, 2007 Nov.  

This following study assessed risk factors and correlates of snoring and observed apnea.  Parents and grandparents of students from 20 randomly selected primary schools in urban and rural areas of Kirikkale, Turkey were asked about respiratory diseases, psychological distress and sleep-related disorders, using the Respiratory Questionnaire, Hospital Anxiety and Depression (HAD) scale and Sleep Questionnaire, respectively, which were returned by their children.  

Out of 13,225 parents and grandparents of primary school students 12,270 returned the questionnaires, for an overall response rate of 92.7%. Snoring and the observed apnea were more prevalent among subjects from rural than those from urban areas. Exposure to biomass smoke and smoking were associated with an increased risk of snoring and observed apnea, after adjusting for gender, age, body mass index, income and education in the multivariate linear model.

In all subjects, increases in performance ability, daytime sleepiness, psychological distress and dyspnea scores observed in categories indicating increases in snoring intensity and observed apnea frequency constituted a trend but did always not reach statistical significance. Lastly, prevalence of traffic accidents, falling asleep at the wheel and morning headaches increased with the increments of snoring intensity and apnea frequency.  

It was concluded that exposure to biomass smoke in rural areas may account for the higher prevalence of snoring and observed apnea. Snoring intensity and observed apnea frequency may increase prevalence of traffic accidents along with many unfavorable symptoms. (Ekici M, Ekici A, Keles H, Akin A, Karlidag A, Tunckol M, Kocyigit P: Risk factors and correlates of snoring and observed apnea.  Sleep Medicine 9 (3):290-296, 2008).  

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To evaluate the effectiveness of recovery strategies on physical performance during a 3-day tournament style basketball competition, 29 male players (mean age 19.1 years, s= 2.1; height 1.84 m, s= 0.34; body mass 88.5 kg, s= 14.7) were assigned to one of three treatment groups: carbohydrate+stretching (7.7 g kg(-1) day(-1), s= 1.7; 'n = 9), cold water immersion (11 degrees C, 5 x 1; n = 10) or full leg compression garments (18 mmHg, approximately 18 h; n = 10).

Effects of the recovery strategies on pre-post tournament performance tests were expressed as the mean change (% +/- standard deviation of the change score). Changes and differences were standardized for accumulated game time, assessed against the smallest worthwhile change for each test, and reported qualitatively.

Accumulated fatigue was evident over the tournament with small to moderate impairments in performance tests. Sprint and agility performance decreased by 0.7% (s = 1.3) and 2.0% (s = 1.9) respectively. Vertical jump decreased substantially after the first day for all treatments, and remained suppressed post-tournament. Cold water immersion was substantially better in maintaining 20-m acceleration with only a 0.5% (s = 1.4) reduction in 20-m time after 3 days compared with a 3.2% (s = 1.6) reduction for compression. Cold water immersion (-1.4%, s = 1.7) and compression (-1.5%, s = 1.7) showed similar substantial benefits in maintaining line-drill performance over the tournament, whereas carbohydrate+stretching elicited a 0.4% (s =1.8) reduction.

Sit-and-reach flexibility decreased for all groups, although cold water immersion resulted in the smallest reduction in flexibility. Basketball tournament play elicited small to moderate impairments in physical test performance. In conclusion, cold water immersion appears to promote better restoration of physical performance measures than carbohydrate + stretching routines and compression garments. (Montgomery PG, Pyne DB, Hopkins WG, Dorman JC, Cook K, Minahan CL: The effect of recovery strategies on physical performance and cumulative fatigue in competitive basketball. Journal of Sports Sciences. 26(11):1135-45, 2008 Sep. 

This following study examined the effectiveness of two different types of self-talk on the performance of a basketball-shooting task. 60 physical education and sports sciences students were organized into one control and two treatment groups which used self-talk.

During the experiment, the control group performed with the general instructions, whereas the self-talk groups used the cue-words "relax" and "fast," respectively, Analysis showed that only the participants of the self-talk group who used the word "relax" improved their performance significantly as compared to the other two groups. It appears that self-talk can positively affect performance if its content is appropriate for the task performed. (Theodorakis Y, Chroni S, Laparidis K, Bebetsos V, Douma I: Self-talk in a basketball-shooting task. Perceptual & Motor Skills. 92(1):309-15, 2001 Feb). 

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Bell's palsy is an idiopathic neuropathy of cranial nerve VII, and the incidence ranges from 15 to 40 per 100,000. The majority of patients recover, but up to 16 percent of patients have significant sequelae.  

The phenomenon of the "late recovered" Bell's palsy has the following specific features and has not formerly been described: (1) tightening of the facial muscles, with a deepening nasolabial fold and reduced palpebral fissure; (2) blepharospasm; and (3) incomplete recovery of peripheral VIIth nerve branches, with ipsilateral forehead paralysis, reduced depressor anguli oris function, and poor excursion of the angle of the mouth on smiling.  

Nonsurgical treatment involved four monthly botulinum toxin injections. Patients had injections to paralyze the ipsilateral orbicularis oculi, contralateral forehead rhytides, and depressor anguli oris and to treat blepharospasm and muscle tightness. The effectiveness of the botulinum toxin injections on facial symmetry and patient appreciation of this were assessed by measuring brow height and teeth exposure before and 3 weeks after injection.  

Twenty-three patients were followed up for a mean period of 37 months. The difference in brow height and teeth exposure after injection was less than preinjection measurements, but this did not reach statistical significance.

Patient self-assessments showed improvements in their appreciation of the facial symmetry, ability to go out in public, and feelings of self-worth (visual analogue scale).  Surgical treatment options include ipsilateral brow lift, division of the contralateral frontal branch, contralateral tarsorrhaphy to equalize the palpebral fissures, and bilateral upper blepharoplasty.  

The true benefit of botulinum toxin injections was more apparent during facial animation and not when the face was static. The patients greatly appreciated the improvement in facial symmetry. Various treatment options are available to improve the quality of life for patients with late recovered Bell's palsy. (Bulstrode NW, Harrison DH: The phenomenon of the late recovered Bell's palsy: treatment options to improve facial symmetry. Plastic & Reconstructive Surgery. 115(6):1466-71, 2005 May). 

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