Pain

Heel pain

2011-05-28T14:24:00.000-07:00

HEEL PAIN
Plantar fascitis is an enthesitis at the insertion of the tendon into the calcaneum .It produces localized pain when standing and walking ,and tenderness in the mid line.It occurs alone or in seronegative spondarthritis.

Plantar spurs are traction lesions at the insertion of the plantar fascia in older people and are usually asymptomatic.They become painful after trauma.

Calcaneal bursitis is a pressure - induced ( adventitious ) bursa that produces diffuse pain and tenderness under the heel.Compression of the heel pad from the sides is painful ,which distinguishes it from plantar fascia pain.

Whatever the cause ,the pain is always worse in the morning as soon as weight is placed on the foot.

All of these lesions are treated with heel pads ,and reduce walking ,these are often self-limiting .A splint at night to hold the foot dorsiflexed and to stretch the plantar fascia is preferable to a local corticosteroid injection in plantar fasciitis . When an injection is necessary , a medial approach is used ,rather than through the heel pad ,under a posterior tibial nerve block.

Heel pain causes
-Plantar fascitis ___ below heel.
-Plantar spur ___ below
-Achilles tendonitis / bursitis ___behind heel.
-Sever's disease.
Arthritis of ankle / subtaloid joints.

PAIN BEHIND THE HEEL AND LEG

Sever's disease is a traction apophysitis of the Achilles tendon in young people ( cf.Osgood -Schlatter's disease) .
Achilles tendonitis is an enthesitis at the insertion of the tendon into the calcaneum.This is traumatic or it can complicate seronegative spondarthritis .Raising the shoe heel reduces pain.Occasionally a low-pressure corticosteroid injection near the enthesis is necessary.

Partial tear of the Achilles tendon causes a painful ,tender swelling a few centimetres above its insertion.Advise against walking barefoot and jumping .Therapeutic ultrasound is helpful.( Caution - a local injection may cause the tendon to rupture .)

Achilles bursitis lies clearly anterior to the tendon and can be safely injected with corticosteroid.

COMPARTMENT SYNDROMES

The muscles of the lower leg are enclosed in facial compartments ,with little room for expension to occur.Compartment syndromes can be acute and severe ,such as following exercise.

In the anterior tibial syndrome there is severe pain in the front of the shin ,occasionally with foot drop. Immediate surgical decompression to prevent muscle necrosis is sometimes required.

Chronic compartment syndrome produces pain in the lower leg that is aggravated by exercise and may therefore be mistaken for a vascular or neurological disorder.

Pain in the foot

2011-05-28T14:17:00.000-07:00

PAIN IN THE FOOT

The feet are subjected to extreme pressures by weight bearing and inappropriate shoes .They are commonly painful.Broad ,deep .thick -soled shoes are essential for sporting activities ,prolonged walking or standing ,and in people with congenitally flat or arthritic feet.

There are two common types of foot deformity :

Flat feet stress the ankle and throw the hind foot into a valgus ( everted ) position - a flat foot is rigid and inflexible.
High -arched feet place pressure on the lateral border and ball of the foot .

The foot is affected by a variety of inflammatory arthritic conditions.After the hand ,the foot joints are the most commonly affected by rheumatoid arthritis ,The diagnosis depends upon careful assessment of the distribution of the joints affected ,the pattern of other joint problems , or by finding the associated condition ( e.g psoriasis ).

PAIN IN THE FOOT CAUSES

Structural ( flat ( pronated ) or high arched ( supinated ).

Hallux valgus /rigidus ( +/- Osteoarthritis ).

Metatarsalgia.

Morton's neuroma.

Stress fracture.

Inflammatory arthritis.

-Acute ,monarticular -gout.

-chronic ,polyarticular -rhematoid arthritis.

-Chronic ,pauciarticular -seronegative spondarthritis.

Tarsal tunnel syndrome.

HALLUX VALGUS

The great toe migrates laterally .In the congenital form the first metatarsal is displaced medially ( metatarsus primus varus ) .The shape of modern shoes causes later onset of hallux valgus .It is a common complication of rheumatoid arthritis .

HALLUX RIGIDUS

Osteoarthritis of the first MTP joint in a normally aligned or valgus joint causes hallux rigidus - a stiff ,dorsiflexed and painful great toe .Careful choice of footwear and the help of a podiatrist suffice for most cases ,but some require surgery .

METATARSALGIA

This is common ,especially in women who wear high heels ,after trauma and in those with hammer toes.The balll of the foot is painful to walk and stand on .Callosities and pressure -inuced bursae develop under the metetarsal heads . Rheumatoid arthritis causes misalignment of the metatarsal bones and severe metatarsalgia.

TREATMENT is with podiatry and the wearing of appropriate shoes.Surgery is occasionally needed ,particularly in the rheumatoid forefoot.

Morton's metatarsalgia is due to a neuroma , usually between the third and fourth toes .It causes pain , burning and numbness in the adjacent surfaces of the affected toes when walking .It is helped by wearing wider , cushioned -soled shoes.

STRESS ( MARCH ) FRACTURES

These cause sudden ,severe weight -bearing pain in the distal shat of the fractured metatarsal bone .They occur after unaccustomed walking or with new shoes.There is local tenderness and swelling ,but initially X-rays are normal and diagnosis delayed.A radioisotope bone scan reveals the fracture earlier than X-rays .Reduced weight -bearing for a few weeks usually suffices.

TARSAL TUNNEL SYNDROME

This is an entrapment neuropathy of the posterior tibial nerves as it rounds the medial maleolus.It produces burning ,tingling and numbness of the toes ,sole and medial arch.The nerve is tender below the maleolus and ,when tapped ,produces a shock -like pain ( Tineli's sign ).A local steroid injection under the retinaculum ,between the medial maleolus and calcaneum ,is helpful.

Chest pains

2011-05-28T14:00:00.000-07:00

Chest pain can be a symptom of a number of severe conditions and is generally considered a medical emergency. Although it is clear that pain is non-cardiac origin, which is often a diagnosis of exclusion after excluding the most serious causes of pain.

SYMPTOMS AND SIGNS ACCORDING TO LIKELY ETIOLOGY

COSTOCHONDRAL OR CHEST WALL PAIN
Localized sharp/stabbing or persistent/dull pain ,reproduced by pressure over the painful area.

CERVICAL OR THORACIC SPINE DISEASE WITH NERVE ROOT COMPRESSION
Sharp pain,may be in radicular distribution ,exacerbated by movement of neck,back.

ESOPHAGEAL OR GASTRIC PAIN
Associated with dysphagia or gastric regurgitation,may be worsened by aspirin/alcohol ingestion/certain foods/supine position: often relieved by antacids.

BILIARY PAIN
Intolerance of fatty foods, right upper quadrant tenderness also present.

MYOCARDIAL ISCHEMIA
Precipitated by exertion or emotional arousal .ECG ( or holter monitor ) during pain shows ST segment shifts ,pain relieved quickly ( < 5 minutes ) by sublingual TNG

DIFFERENTIAL DIAGNOSIS OF ACUTE CHEST PAIN

1.

*DESCRIPTION OF PAIN
Oppressive,constrictive ,or squeezing ,may radiate to arms ,neck and back.

*BACKGROUND HISTORY
Less severe ,similar pain on exertion plus coronary risk factors.

*KEY PHYSICAL FINDINGS
Diaphoresis ,pallor S4 common .S3 less common.

*CONSIDER
Acute Myocardial Infarction.

*CONFIRMATORY TESTS
Serial ECGs ,Serial cardiac markers ( especially troponin ,CK )

2.
*DESCRIPTION OF PAIN
tearing or ripping may travel from anterior chest to mid back.

*BACKGROUND HISTORY
Hypertension or Marfan syndrome.

*KEY PHYSICAL FINDINGS
Weak,asymptomatic peripheral pulses ,possible diastoic murmur or aortic insufficiency.

*CONSIDER
Aortic Dissection

*CONFIRMATORY TESTS
CXR -Widened mediastinal silhoutte ,MRI .CT ,or transesophageal echogram ,intimal flap visualized.Aortic angiogram ,definitive diagnosis.

3.
*DESCRIPTION OF PAIN
Crushing ,sharp ,pleuritic ,relieved by sitting forward.

*BACKGROUND HISTORY
recent upper respiratory tract infection ,or other conditions which predispose to pericarditis.

*KEY PHYSICAL FINDINGS
Pericardial friction rub ( usually 3 component best heard by sitting patient forward )

*CONSIDER
Acute pericarditis

*CONFIRMATORY TESTS
ECG ,diffuse ST elevation and PR segment depression. Echogram ,pericardial effusion often visualized.

4.
*DESCRIPTION OF PAIN
Pleuritic ,sharp possibly accompanied by cough /hemoptysis

*BACKGROUND HISTORY
Recent surgery or other immobilization

*KEY PHYSICAL FINDINGS
Tachypnea ,possible pleural friction rub.

*CONSIDER
Pulmonary Embolism

*CONFIRMATORY TESTS
Arterial blood gas ,hypoxemia and respiratoy alkalosis ,Lung scan ,V/Q mismatch ,pulmonary angiogram ,arterial luminal filling defects.

5.
*DESCRIPTION OF PAIN
Very sharp, pleuritic

*BACKGROUND HISTORY
recent chest ,or history of chronic obstructive lung disease.

*KEY PHYSICAL FINDINGS
tachypnea ,breath sounds and hyperesonance over affected lung field

*CONSIDER
Acute Pneumothorax

*CONFIRMATORY TESTS
CXR ,radioluency within pleural space poss ,collapse of adjacent lung segment , If tension pneumothorax mediastinum is shifted to opposite side.

6.
*DESCRIPTION OF PAIN
Intense substernal and epigastric accompanied by vomiting and/or hemoptysis.

*BACKGROUND HISTORY
Recent recurrent vomiting /retching

*KEY PHYSICAL FINDINGS
Subcutaneous emphysema ,audible crepitus adjacent to the sternum.

*CONSIDER
Rupture of esophagus

*CONFIRMATORY TESTS
CXR pneumomediastinum .Esophageal endoscopy is diagnostic

DIFFERENTIAL DIAGNOSIS OF PATIENTS ADMITTED TO HOSPITAL WITH ACUTE CHEST PAIN RULED NOT MYOCARDIAL INFARCTION

Gastroesophageal Disease    42%
*Gastroesophageal reflux
*esophageal motility disorders
*Peptic ulcer
*Gallstones

Ischemic Heart Disease 31%
Chest Wall Syndrome 28%
Pericarditis 4%
Pleuritic/pneumonia 2%
Pulmonary embolism 2%
Lung cancer   1.5%
Aortic aneurysm 1%
Aortic stenosis 1%
Herpes zoster   1%

Chest pain

2011-05-28T13:02:00.000-07:00

CHEST PAIN

Pain in the chest is sometimes cause of Musculoskeletal conditions.An example is Tietze's disease.In this condition ,pain arises from the costochondral junctions.It is usually unilateral and affects one,two or three ribs. There is local tenderness ,which helps to make diagnosis.The condition is benign and self-limitin.It often responds well to anti-inflammatory drugs.Other causes of chst wall pain include rib fractures due to trauma or osteoporosis or a malignant deposit.

Chest pain may appear suddenly at any time. Try to ignore at first, but your chest pain has you scared and worried. Chest pain is one of the most common causes of application for emergency medical assistance. All medical emergency room doctors Every year evaluate and treat millions of people with chest pain.

There is little correlation between the severity of chest pain and the seriousness of its cause.

POSSIBLE SERIOUS CAUSES

The differential diagnosis of chest pain as (1).new ,acute ,and ongoing .(2).Recurrent,episodic and (3).persistent,sometimes for days.

MYOCARDIAL ISCHEMIA

*ANGINA PECTORIS

Substernal pressure,squeezing ,constriction ,with radiation typically to left arm; usually on exertion,especially after meals or with emotional arousal,

Characteristically relieved by rest and nitroglycerine.

*ACUTE MYOCARDIAL INFARCTION

Similar to angina but usually more severe ,of longer duration ( > or equal 30 min ) and not immediately relieved ,and hypoxemia.

PULMONARY EMBOLISM

May be substenal or lateral ,pleuritic in nature ,and associated with hemoptysis ,tachycardia , and hypoxemia.

AORTIC DISSECTION

Very severe in center of chest ,a "ripping " quality ,radiates to back ,not affected by changes in position.May be associated with weak or absent peripheral pulses.

MEDIASTINAL EMPHYSEMA

Sharp,intense,localized to substernal region ,often associated with audible crepitus.

ACUTE PERICARDITIS

Usually steady ,crushing ,substernal,often has pleuritic comonent aggravated by cough,deep inspiration, supine positio,and relieved by sittingg upright ,one,two ,or three-component pericardial friction rub often audible.

PLEURISY

Due to nflammation,less commonly tumor and pneumothorax.Usually unilateral ,knifelike ,superficial,aggravated by cough and respiration.

LESS SERIOUS CAUSES

*COSTOCHONDRAL PAIN

In anterior chest ,usually sharply localized.may be brief and darting or a persistent dull ache.Can be reproduced by pressure on costochondral and /or chondrosternal junctions.In Tietze's syndrome ( costochondritis ) ,joints are swollen ,red , and tender.

*CHEST WALL PAIN

Due to strain of muscles or ligaments from excessive exercise or rib fracture from trauma,accompanied by local tenderness.

* ESOPHAGEAL PAIN

Deep thoraci discomfort; may be accompanied by dysphagia and regurgitation.

EMOTIONAL DISORDERS

Prolonged ache or dart like,grief,flashing pain.associated with fatigue,emotional strain.

OTHER CAUSES

(1) Cervical disk.(2) Osteoarthritis of cervical or thoracic spine. (3) Abdominal disorders ,peptic ulcer, hiatus hernia ,pancreatitis ,biliary colic . (4) Tracheobronchitis,pneumonia. (5) Disese of the breast ( inflammation ,tumor ). (6) Intercostal neuritis ( herpes zoster ).

Hips pain and treatment

2011-05-27T11:59:00.000-07:00

Hip pain , that occurs in and around the hips ,due to some causative problems in joint. This type of pain usually shows up within the hip or in part of groin. Hip pain can be caused by problems with muscles, ligaments, tendons and other structures that support the hip joint. problems with hip pain usually occur outside of the hip or thigh.Sometimes it can be caused by the disease in the body than others. This type of pain is called referred pain.This type of pain rarely an emergency, and the pain can be managed by self-care at home with some home remedies ,with restricted movements and by taking some analgesic cream massage.

HIP PAIN TREATMENT

SELF - CARE AT HOME

In the older age, the body usually covered less easy to tolerate. Falls can often cause bruising (or bruising) and inflammation of tissue that is damaged. That does not feel pain immediately, and within a few hours of the injured area may stiffen and begin to get angry. If the patient can stand and walk quite easily with some limp, so it is sensible to rest and ice, injured areas and initiating activities tolerated. Over-the-counter pain killers can be used. Usually pain and stiffness should be resolved within a few days. If pain persists or begins to worsen rather than improve, a medical assessment may be useful. Hip pain and tenderness, which are developed as excessive, but without a specific injury can be treated at home for rest and a gradual return to full activity. Although rest is important, it is also important to maintain range of motion, or should try to stretch your legs, hips and back and keep your body moving.

Care for pain in the hip that exists due to an underlying disease should be coordinated with the health care practitioner. Often, pain in the hip sporadically, depending on the control of the state of health.

MEDICAL CARE AND MEDICATION FOR HIP PAIN

The cause of hip pain guide treatment. Outside of medicine, treatment should be to maintain strength and range of motion of the hip. As with any illness or injury, the goal is to bring the patient to their normal level of functioning. A team approach involving the health care practitioner, physiotherapist or chiropractor treats can be considered.We can use ( analgesics) pain killers for hip pain.

The discomfort can often be treated with drugs against pain. Acetaminophen, ibuprofen and naproxen can all be used. Although these drugs do not require a prescription, each with its own potential side effects and whether there are underlying medical conditions present, it is useful to ask for help from a pharmacist or to inform your healthcare professional health that you take a new medication without a prescription.

Use of medication will depend on the prescription for the pain in the hip. Very often, the drugs are intended for the treatment of the underlying disease or damage that causes pain. Depending on the situation, small courses of drugs, or narcotic analgesics, with or without muscle relaxants may be used until the underlying problem is resolved.

Hip pain

2011-05-27T11:54:00.000-07:00

HIP PAIN

" Hip " refers to a wide area between the upper buttock ,trochanter and groin.It is useful to ask the patient to point to the site of pain and its field of radiation.Pain arising from the hip joint itself is felt in the groin ,lower buttock and anterior thigh and may radiate to the knee .Occasionally and inexplicably ,hip arthritis causes pain only in the knee .

Pain in the hip is not always felt directly on the hip. Instead, you can feel it in the mid-thigh or groin. Similarly, you feel pain in the hip may actually reflect a problem in the back, rather than pain in the hip.

The hip pain is a most common problem and it can be confusing because there are many reason .It is more important to accurately diagnose the cause of your symptoms so that appropriate treatment can be directed to the underlying problem.

If you have pain in the hip, some Common causes include:

PAIN IN THE HIP __ CAUSES .

HIP REGION PROBLEMS _________________ MAIN SITES OF PAIN

Osteoarthritis of hip . ____________________ Groin ,buttock ,front of thigh to knee.

Trochanteric bursitis. ____________________ Lateral thigh to knee.

Meralgia paraesthetica. ___________________ Anterolateral thigh to knee .

Referred from back. ____________________ Buttock.

Facial joint pain . _____________________ Buttock and posterior thigh .

Inflammatory arthritis . ____________________ Groin ,buttock ,front of thigh to knee.

Sacoillitis (AS ). ____________________ Buttock.

Avascular necrosis . ____________________ Groin ,buttock .

Polymyalgia rheumatica . ____________________ Buttocks ,lumbar spine .

OSTEOARTHRITIS ( OA )

Osteo-arthritis is the most common cause of hip joint in a person over the age of 50 years .It causes pain in the buttock and groin on standing and walking .Stiff hip movements cause difficulty in putting on a sock and may produce a limp.

TROCHANTERIC BURSITIS

This may be due to trauma or unaccustomed exercise ,but sometimes has an unknown cause.It occurs in inflammatory arthrithis.the pain over the trochanter is worse going up stairs and when abducting the hip ,and the trochanter is tender to lie on .A local corticosteroid injection onto the surface of the trochanter is helpful.

MERALGIA PARAESTHETICA

This cause numbness and burning dysaesthesia ( increased sensitivity to light touch ) over the anterolateral thigh and may be precipitated by a sudden increase in weight.

FRACTURE OF THE FEMORAL NECK

This usually occurs after a fall ,occasionally spontaneously .There is pain in the groin and thigh ,weight bearing is painful or impossible ,and the leg is shortened and externally rotated .Occasionally a fracture is not displaced and remain undetected .X-rays are diagnostic.Anyone with a hip fracture ,especially after minimal trauma ,should be reviewed for osteoporosis .

AVASCULAR NECROSIS ( OSTEONECROSIS ) OF THE FEMORAL HEAD

This is uncommon but occurs at any agr.There is severe hip pain .X-rays are diagnostic after a few weeks ,when a well -demarcated area of increased bone density is visible .In the femur this lies at the upper pole of the femoral head.The affected bone may collapse.Early ,the X-ray is normal but bone scintigraphy or MRI demonstrate the lesions.Risk factors include treatment with corticosteroids or heparin ,exposure to high barometric pressures ( diverse and tunnellers ) ,excessive alcohol consumption ,and sickle cell disease.

INFLAMMATORY ARTHRITIS OF THE HIP

This produce pain in the groin and stiffness ,which are worse in the morning .Rheumatoid arthritis ( RA) rarely presents with hip pain ,although the hip is involved eventually in severe RA .Ankylosing spondylitis and other seronegative spondarthritides cause inflammatory hip arthritis in younger people.

POLYMYALGIA RHEUMATICA

Bilateral hip ,buttock and thigh pain and stiffness that are worse in the morning in an elderly patient may be attributable to polymyalgia rheumatica .

Neurosurgery could be a part of pain management

2011-05-27T11:25:00.000-07:00

Pain is part of the body's defense system, producing a reflexive retraction from the agonized stimulus, and tendencies to protect the affected body part while it heals, and avoid that bruising situation in the future. It is an important part of animal life, vital to healthy survival.

People with congenital insensitivity to pain have reduced life expectancy. Idiopathic pain (pain that persists after the trauma or pathology has healed, or that arises without whatever manifest cause), may be an omission to the intent that pain is helpful to survival, although, such pain is psychogenic, enlisted as a protective amusement to keep dangerous emotions unconscious. It is not clear what the activity benefit of whatever extremity forms of pain (e.g. toothache) strength be, and the intensity of whatever forms of pain (for example as a result of injury to fingernails or toenails) seems to be out of all proportion to whatever activity benefits.

MANAGEMENT OF CHRONIC PAIN
Chronic discompose is gravely disabling and distressing and taxing to trait .Multidisciplinary discompose relief clinics are helpful in providing limited and supportive therapy.Pain control should ,however ,be part of all doctors skills.
A management organisation for intractable discompose ,when it is often difficult to find the fine cause has heptad components.

DIAGNOSTIC
Rigorous attention must be paid to the question of identification ,reviewing the history ( first assistance ), the investigations and radiology.A limited surgical approach may then become apparent ( e.g discompose in undiagnosed spinal stenosis trigeminus hurting ,glossopharyngeal hurting ,or discovery of syringomyelgia in intractable upper branch discompose ).

PSYCHOLOGICAL
Chronic discompose influences quality of life and lifestyle.Clinical depression is almost universally associated with chronic discompose event when the underlying pathology is benign .Perhaps paradoxically a relative minority of patients suffering discompose from secondary cancer are clinically depressed despite the gravity of their disease.Antidepressant drugs and modification of style are of help in improving the quality of life.Preservance and compliance with therapy is an invariable issue.

ANALGESICS

CO-ANALGESICS
Co-analgesics are drugs that have a primary use in conditions another than discompose but are also effective ,either lonely or when additional to customary analgesics.
Examples are non-steroidal anti-inflammatory drugs uesd in bone discompose or antidepressant antidepressants and anticonvulsants utilised in deafferentation pain.
Calcium-channel blockers ( nifedipine ) improve sympathetically mediated discompose ,as occurs in ,for example Raynaud's disease.Muscle relaxants , antibiotics and steroids by injection each relieve discompose when utilised in pertinent situations ( e.g nonindulgent spastically , infection and inflammatory arthropathy ,respectively ).

STIMULATION
Acupuncture,ice,heat ultrasound,massage ,transcutaneous electrical cheek stimulation ( TENS ) and spinal cord stimulation all achieve analgesia by a gating gist on large fat cheek fibres.

NERVE BLOCKS
Pain pathways can be closed either temporarily by local anaesthetic or permanently with phenol or with radiofrequency lesions.Examples are .

SOMATIC BLOCKS
(a) Peripheral cheek and plexus injections.
(b) Epidural and spinal analgesia.

SYMPATHETIC BLOCKS
(a) Sympathetic ganglia and cheek endings injections.
(b) Central epidural and spinal likable blockade.

NEUROSURGERY
Highly specialized and sometimes disputable techniques have a locate alongside pharmacalogical remedies.Examples are dorsal rhizotomy ,sympathectomy,cordotomy and neurostimulation.

Pain

2011-05-27T11:14:00.000-07:00

PEOPLE WITH CONGENITAL INSENSITIVITY TO PAIN HAVE REDUCED LIFE EXPECTANCY

PAIN

INTRODUCTION

Pain is an unpleasent and unique physical and psychological experience.Acute discompose serves a biological purpose (e.g retraction of a branch ) and causes likable hyperactivity .It is typically self-limiting,when healing is complete.Chronic discompose (e.g causalgia ) lasts many months ,far longer than the required for healing.

Pain motivates us to withdraw from damaging or potentially damaging situations, protect the dilapidated embody part patch it heals, and avoid those situations in the future. It is initiated by stimulation of nociceptors in the peripheral nervous system, or by damage to or malfunction of the peripheral or central nervous systems. Most pain resolves promptly once the agonized input is removed and the embody has healed, but sometimes pain persists despite removal of the input and apparent healing of the body; and sometimes pain arises in the absence of any detectable stimulus, damage or pathology. Social support, cultural values, hypnotic suggestion, excitement in sport or war, distraction, and appraisal can every significantly modulate pain's intensity or unpleasantness.

ESSENTIAL PHYSIOLOGY OF PAIN

Pain perception is mediated by free nerve endings, the terminations of finely myelinated .A-delta and of non-myelinated C fibres.Chemicals related locally as a termination of injury either produce discompose by direct stimulation or by sensitizing the nerve endings.A-delta fibres provide uprise to perception of sharp,immediate discompose which is followed by slower-onset ,duller,more diffuse and prolonged discompose mediated by slower-conducting C fibres.

Sensory impulses start the cord via dorsal spinal roots.Within it, impulses ascend either in each dorsal (posterior ) column or in each spinothalamic tract.The cells of the grey matter in the spinal cord are arranged in laminae labelled I to X from dorsal to dorsoventral A fibres terminate in laminae I and V and touch second-order neurons which beam fibres to the contralateral lateral via the anterior commissure and up the anterolateral column in the direct spinothalamic tract C fibres mostly terminate in the center gelitinosa ( Laminae II and III ) .

A series of short fibres provide uprise to long axons which pass finished the anterior commissure to the contralateral lateral and up the spino-reticulo-traumatic tract.

The spinothalamic tracts circularize impulses which localizes pain.Thalamic pathways to and from the cortex mediate emotional components.

Sympathetic state increases discompose - for example increasing blood flow in a painful limb.

GATE THEORY OF PAIN

Gate theory proposes that the entry of receptive impulses is monitored by the cells of the substantia gelitinosa ,which acts as a regular determining whether or not sufficient state penetrates to fire secondary neurones in the dorsal horn.Each gate is influenced by descending state from the brain.This can override spinall cord restrictive mechanism and alter how far the gate is open.

ENDOGENOUS OPIATES

The endorphin family of peptides have opiod state and probably statement for the rattling real effects of placebo,stress reducers and accupuncture analgesia.They are neurotransmitters acting at restrictive synapses .

Lower back pains

2011-05-27T10:33:00.000-07:00

LOWER BACK PAIN

CAUSES

LUMBAR DISC DISEASE

Common cause of low backand leg pain,usually at L4-L5 or L5-S1 levels.Dermatoma sensory loss ,reduction or loss of deep tendon reflexes or myotomal pattern of weakness more informative than pain pattern for localization .Usually unilateral ,bilateral with large central disk herniations compressing multiple nerve roots__ may cause cauda equina syndrome .

Indication for lumbar disk surgery

(1) Progressive motor weakness from nerve root injury .
(2) Progressive motor impairment by EMG.
(3)Abnormal bowel or bladder function .
(4) Incapicitating nerve root pain despite conservative treatment for at least 4 weeks ,and (5)recurrent incapacitating pain despite conservative treatment .The latter two criteria are controversial.

SPINAL STENOSIS

A narrowed spinal caal producing neurogenic claudication i.e buttock ,and/or leg pain induced by walking or standing and relieved by sitting.Symptoms are usually bilateral.Unlike vascular claudication smptoms are provoked by standing without walking .Unlike lubar disk disease, ,symptoms are relieved by sitting.Focal neurogenic deficits common ,severe neurologic deficits ( paralysis ,incontinence ) rare.Stenosis results from acquired (75%) ,congenital ,or mixed acquired/congenital factors.Symptomatic treatment adequate for mild disease,surgery indicated when pain inerferes with activities of daily living or focal neurologic signs present.Surgery successful in 65-80%.25% develop recurrent stenosis within 5 yeas.

TRAUMA

Low back strain or sprain used to describe minor ,self-limited injuries associated with Low Back Pain.Vertebral fractures from trauma result in weging or compression of vertebral bodies.burst fractures involving anterior and posterior spine elements can occur.Neurlogic impairment common with vertebral fractures early surgical intervention indicated.Most common cause of non-traumatic fractureis osteoporosis,others are osteomalacia ,hyperthyroidism ,hyperthyroidism ,multiple myeloma ,or metastatic carcinoma ,glucocorticoid use may predispose vertebral body to fracture .Clinical context ,exam findings,and spine X-rays establish diagnosis.

SPONDYLOLISTHESIS

Slippage of anterior spine forward ,leaving posterior element behind .L4-L5 >L5-S1 levels, can produce LBP or radiculopathy /cauda equina syndrome.

OSTEOARTHRITIS

Back pain induced by spine movement .Increases with age radiologic findings do not correlate with severity of pain.Facet syndrome __ radicular symptoms and signs,nerve root compression by unilateral facet hypertrophy.Foraminotomy and facettectomy __ long-term pain relief in 80-90% .Loss of intervertebral disk height reduces vertical dimensions of intervertebral foramen,descending pedicle can compress the exiting nerve root.

VERTEBRAL METASTASES

Back pain most common neurologic symptoms in patients with systemic cancer.Metastatic carcinoma ,multiple myeloma and lymphomas frequently involve spine.Back pain may be presenting symptoms of cancer .pain typicaly unrelieved by rest .MRI or CT -myelography demonstrates vertebral body metastasis ,disk space is spared.

VERTEBRAL OSTEOMYELITIS

Back pain unrelieved by rest ,focal spine tender-ness,elevated ESR.Primay source of infection ( lung ,urinary tract ,or skin ) found in 40% .IV drug abuse a risk factor .Destruction of the vertebral bodies and disk space common.Lumbar spinal pidural abscess presents as back pain and fever ,exam may be normal or show radicular findings ,spinal cord involvement ,or cauda equina syndrome ,abscess extent best defined by MRI.

LUMBAR ARACHNOIDITIS

May follow inflammatory response to local tissue injury within subarachnoid space ,fibrosis results in clumping of nerve roots,best seen by MRI treatment is unsatisfactory.

IMMUNE DISORDERS

Ankylosing spondylitis ,rheumatoid arthritis ,Reiter's syndrome ,psoriatic arthritis ,and chronic inflammatory bowel disease.Ankylosing spondylitis __ typically male <40 years with nocturnal back pain.pain unrelieved by rest but improves with exercise.

OSTEOPOROSIS

Loss of bone substance resulting from hyperparathyroidism chronic glucocorticoid use ,immobilization,or other medical disorders.Sole manifestation may be pain exacerbated by movements.

VISCERAL DISEASES

Pelvis refers pain to sacral region .lower abdomen to lumbar region,upper abdomen to lower thoracic or upper lumbar region.Local signs are absent ,normal movements of yhe spine are painless.A contained rupture of abdominal aortic aneurysm may produce isolated back pain.

OTHER

Chronic LBP with no clear cause ,psychiatric disorders ,substance abuse may be associated.

Back pains

2011-05-27T10:23:00.000-07:00

CHRONIC BACK PAIN IS CAUSE OF 14% OF LONG TERM DISABILITY IN THE UK

BACK PAIN TYPES AND RISK FACTORS

Low back pain is a common symptom.It is often traumatic and work related ,although lifting apparatus and other mechanical devices are used to avoid it .Episodes are generally short lived and self limiting ,and patients attend a physiotherapist or osteopath more often than a doctor.Chronic back pain is the cause of 14% of long term disability in the UK .

FIVE TYPES OF LOW BACK PAIN

1. LOCAL PAIN

Caused by activation of pain -sensitive nerve endings near affected part of the spine (e.g tears ,stretching ).

2. PAIN REFFERED TO THE BACK

Abdominal or pelvic origin ,back pain unafected by spine movement.

3. PAIN OF SPINE ORIGIN

Restricted to the back or reffered to lower limbs.Disease of upper lumbar spine refer pain to upper lumbar region,groin ,or anterior thighs.Disease of lower lumbar spine refer pain to buttocks or posterior thighs.

4. RADICULAR PAIN

Radiates from spne to leg in specific nerve root territory.Coughing,sneezing ,lifting heavy objects or straining may eicit pain.

5. PAIN ASSOCIATED WITH MUSCLE SPASM

Diverse causes ,accompanied by taut paraspinal muscles.

RISK FACTORS FOR POSSIBLE SERIOUS CAUSES OF ACUTE LOW BACK PAIN

HISTORY

Pain worse at rest or at night _______ Age >50 years.

Prior history of cancer _______ Intravenous drug use.

History of chronic infection ( especially pulmonary ,urinary tract or skin) _____Rapidly progressive neurologic deficit

History of trauma

EXAMINATION

Unexplained fever.

Unexplained weight loss.

Straight leg raising sign.

Percussion tenderness ___ low spine or costovertebral angle.

Abdominal, rectal or pelvic mass.

Rapidly progressive focal neurologic deficit ( e.g sensory loss ,leg weakness ,asymmetric or absent leg reflexes ,abnormal bladder function )

LABORATORY STUDIES

Routine laboratory studies and lumbar spine X-rays ___rarely needed for acute low back pain but indicated when risk factors for serious underlying disease are present MRI ans CT -myelography are tests of choice for anatomic definition of spine disease .Electromyography ( EMG) and nerve conduction studies useful for functional assessment of peripheral nervous system.

VISCERAL CAUSES OF LOW BACK PAIN

Stomach ( posterior wall ) __ Gall bladder ___Gall stones.

Pancreatic__tumor ,cyst ,pancreatitis.

Retroperitoneal __hemmorrhage ,tumor ,pyelonephritis.

Vascular __ abdominal aortic aneurysm ,renal artery and vein thrombosis.

Colon __ colitis ,diverticulitis ,neoplasm.

uterosacral ligaments __ endometriosis ,carcinoma.

Uterine malposition.

Menstrual pain.

Neoplastic infiltration of nerves.

Radiation neurosis of tumor/nerves.

Prostate ___ carcinoma ,prostatitis.

Kidney __ renal stones, inflammatory disease , neoplasm ,infection.

Pain in the wrist - Carpal tunnel - Hand pain

2011-05-27T10:04:00.000-07:00

PAIN IN THE HAND AND WRIST

Hand pain is commonly caused by injury or repetitive work-related use .When associated with pins and needles or numbness it suggests a neurological cause arising at the wrist ,elbow or neck.Pain and stiffness that are worse in the morning are due to tenosynovitis or inflammatory arthritis.The distribution of hand pain often indicates the diagnosis.

TENOSYNOVITIS

The finger flexor tendons run through a series of synovial sheath and under loops which hold them in place.Inflammation occurs with repeated or unaccustomed use ,or in inflammatory arthritis when the thickened sheaths are palpable .

Flexor tenosynovitis cause finger pain when gripping and stiffness of the fingers in the morning.Occasionally a tendon causes a trigger ,when the finger remains flexed after gripping and has to be pulled straight.A tendon nodule is palpable ,usually in the palm.

Dorsal tenosynovitis is less common except in rheumatoid arthriris.The swelling is on the back of the hand and wrist.

De Quervain's tenosynovitis causes pain and swelling around the radial styloid where the abductor policis longus tendon is held in place by a retaining band.There is local tenderness ,and the pain at the styloid is worsened by flexing the thumb into the palm.

PAIN IN THE HAND AND WRIST - CAUSES

ALL AGES

Trauma / fractures.

Tenosynovitis.

- Flexor with /without triggering.

- Dorsal.

- De Quervain's.

Carpal tunnel syndrome.

Ganglion.

Inflammatory arthritis.

Raynaud's syndrome.

Chronic regional pain .

OLDR PATIENTS .

Nodal osteoarthritis .

- DIPs ( heberden's nodes ).

- PIPs ( Bouchard's nodes ).

- First carpometacarpal joint.

Trauma - scaphoid fracture .

Pseudogout.

Gout.

- Acute.

- Tophaceous.

TREATMENT

Therapeutic ultrasound helps some people.Usually corticosteroid is injected alogside the tendon under low pressure ( not into tendon itself ) .Occasionally surgery is needed.

OTHER CONDITIONS CAUSING PAIN

* CARPAL TUNNEL SYNDROME

This is due to thickened tendons or synovitis in the carpal tunnel .The history is usually typical and diagnostic with the patient waking with numbness ,tingling and pain in a median nerve distribution.The pain radiates to the forearm.The fingers feel swollen but usually are not .It is also seen during the last trimester of pregnancy.

Treatment is with a splint to hold the wrist in dorsiflexion overnight.This relieves the symptoms and is diagnostic ,used nightly for several weeks it may produce full recovery .If it does not ,a corticosteroid injection into the carpal tunnel helps in about 70% of cases ,although it may recur .Persistent symptoms or nerve damage requires nerve conduction studies and surgical decompression of the carpal tunnel.

* INFLAMMATORY ARTHRITIS

This may present with pain ,swelling and stiffness of the hands .In Rheumatoid arthritis the wrists ,proximal interphalangeal ( PIP ) joints and metacarpophalangeal (MCP ) joints are affected symmetrically.In psoriatic arthritis and Reiter's disease a finger may be swollen ( dactylitis ) or the distal interphalangeal ( DIP ) joints are affected asymmetrically.

* NODAL OSTEOARTHRITIS

This affects the DIP and less commonly PIP joints ,which are initially swollen and red.The inflammation and pain settle but bony swellings remain. There is often a strong family history and it rarely presents before 50 years of age .Reassurance and local treatment are all that is needed .

* FIRST CARPOMETACARPAL OSTEOARTHRITHIS

This causes pain at the base of the thumb when gripping or painless stiffness at the base of the thumb.

* SCAPHOID FRACTURES

These causes pain in the anatomical snuff box.They may not be seen immediately on X-ray ,Ultrasound scaphoid fractures evetually cause pain because of failed union.

* GANGLION

A ganglion is a jelly-filled ,often painless swelling caused by a partial tear of the joint capsule.The wrist is a common site.Treatment is not essential as many resolve or cause little trouble.They rarely respond to injection ,and surgical excision is possibly the best option.

DUPUYTREN'S CONTRACTURE

This is a painless palpable fibrosis of the palmar aponeurosos ,with fibroblasts invading the dermis .It causes puckering of the skin and gradual flexion of the affected fingers ,usually the ring and little fingers .It is more common in males .Caucasians ,in diabetes mellitus and in those who abuse alcohol .It is associated with Peyronie's disease of the penis - a painful inflammatory disorder of the corpora cavernosa ,leading eventually to painless fibrosis and angulation of the penis during erection .Plastic surgical release of the contracture is restricted to those with severe deformity of the fingers.

Fibromyalgia

2011-05-27T06:14:00.000-07:00

Middle class and middle age women are more prone for fibromyalgia widespread pain

CHRONIC WIDESPREAD PAIN ( FIBROMYALGIA OR FIBROSITIS SYNDROME )

Fibromyalgia is a useful diagnosis of exclusion although it is not universally accepted as a diagnosis.Patients value a name to explain symptoms previously dismissed or attributed simply to psychological or social problems.A typical features of fibromyalgia is tender trigger points.The tenderness is not all over a point which distinguishes it from anxiety states.The patient is usually a middle aged ,middle class woman who struggles on with her work and /or housework despite the pain .

Such individuals are difficult to live with and there is often family discord.Many patients have sleep disturbances ,so they awake unrefreshed and have poor concentration.The pain is a widespread ,unremitting ,aching discomfort.There are often other health problems.Such as chronic fatigue syndrome ,irritable bowel syndrome,premenstrual syndrome ,tension ,headache,anxiety and depression , doctors sometimes inappropriate label them 'heart sink ' patients.The patient's frustration is compounded by the fact that most tests are normal ,and they fear doctors believe it is all in their mind.

The controversial condition of unknown aetiology overlaps with chronic fatigue syndrome,with both conditions causing fatigue and sleep disturbance,Diffuse muscle and joint pains are more constant and severe in chronic widespread pain ,although the tender points previously consideed to be pathognomonic are now known to be ubiquitous ,associated with psychological distress,and of no diagnostic importance .Chronic widespread pain occurs most commonly in woman aged 40-65 years old,with a prevalence in the community of between 1 and 11% ,There are association with depressive and anxiety disorders,other functional disorders ,physical deconditioning and a possibly characteristic sleep disturbance

TREATMENT
The first principle is the identification and treatment of maintaining factors ( e.g dysfunction beliefs and behaviors ,mood and sleep disorders ).
Communication
Explanation of health ,including diagnosis and causes .
Education about management ( including self-help leaflets )
Stopping drugs 9e.g caffeine causing insomnia ,analgesics causing dependence )
Rehabilitative therapies.
Cognitive behavior therapy ( to challenge unhelpful beliefs and change coping strategies ).
Supervised and graded exercise therapy ( to reduce inactivity and improve fitness ).
Pharmacotherapies .
Specific antidepressants for mood disorders ,analgesia and sleep disturbamce.
Symptomatic medicines ( e.g appropriate analgesia ,taken only when necessary ).
Management consist of symptomatic analgesia ,reversing the sleep disturbance,and a physically oriented rehabilitation programme .A recent meta analysis suggests that tricyclic antidepressants that inhibit reuptake of both serotinin and norepinephrine ( noradrenaline ) have the greatest effect on sleep ,fatigue and pain.The doses used were too low for antidepressant efficacy and the drugs may work through their hypnotic and analgesic effects.

A sympathetic approach is appropriate ,with reassurance for the patient that fibromyalgia often improves and is not inevitably disabling.Encouragement should be given to undertake a graded aerobic exercise regimen.When depression is present ,it should be treated ,but potentially addictive anxiolytic agents are best avoided.A behavioral psychologist may persaude the person to pace their life more effectively and to cope better, although patients often resist reffered for psychological help.

DRUGS
Analgesics or NSAIDs help in some cases but are best used intermittently.
Low doses of sedative antidepressant drugs ,such as amitriptyline or dosulepin ( dothiepin ) help when taken a few hours before bedtime .It should be explained that these doses are analgesic and not antidepressant , and their side effects should be outlined.

Trigger point injections with local anaesthetic,corticosteroids or acupuncture are sometimes helpful.Oral corticosteroids ar not helpful.

Face pain

2011-05-27T05:47:00.000-07:00

FACE PAIN CAUSES AND TREATMENT

FACE PAIN

Most common cause of facial pain is dental : triggered by hot ,cold or sweet foods.Exposure to cold repeatedly induces dental pain .Trigeminal neuralgia consist of paroxysmal ,electric shock-like episodes of pain in the distribution of trigeminal nerve : occipital neuralgia presents as lancinating occipital pain.

The face is richly supplied with pain-senstive structures - the teeth ,gums ,sinuses ,temporomandibular joints , jaw and eyes .Disease of these causes facial pain.Facial pain is also caused by specific neurological coditions. such as ,

Trigeminal neuralgia ,trigeminal nerve lesions and postherpetis neuralgia.

TRIGEMINAL NEURALGIA ( TIC DOULOUREUX )

Frequent ,excruciating paroxysms of pain in lips ,gums ,cheek ,or chin ( rarely in opthalmic division of fifth nerve ) lasting seconds to minuts .Typically presents in middle or old age.Pain is often stimulated at trigger points.Sensory deficit cannot be demonstrated.Must be distinguished from other forms of facial pain arising from diseases of jaw ,teeth ,or sinuses.Rare causes are herpes zoster or a tumor.Onset in young adulthood raises the possibility of multiple sclerosis.

TREATMENT

Carbamazepine is effective in 50 - 75% of cases .Begin at 100 mg single daily dose taken with food and advance by 100 mg every 1-2 days until substantial ( 50%) pain relief occurs.Most patients require 200 mg qid : doses > 1200 mg daily usually provide no additional benefit.Follow complete blood count for rare complication of agranulocytosis .

For nonresponders ,phenytoin ( 300 -400 mg qd ) or baclofen ( 5-20 mg tid -qid ) can be tried .When medications fail ,surgical lesions ( heat or glycerol injection ) can be effective : in some centers , microvascular decompression recommended in a tortuous blood vessel found in posterior fossa near trigeminal nerve.

CLUSTER HEADACHE ( MIGRAINOUS NEURALGIA )

This condition ,distinct from migraine despite its name ,describes recurrent bouts of excruciating unilateral pain that wake the patients .Attacks cluster around one eye .It affects adults ,commencing in the third and fourth decades and is more common in men.Alcohol sometimes provokes an attack ,and also experimentally ,nitroglycerin .There are suggestions that there is a change in grey matter density on functional imaging in the posterior hypothalamus.The pain rises to a crescendo over half an hour and lasts for several hours.Vomiting occurs .One cheek and nostril feel congested .Transiet ipsilateral Horner's syndrome is common.

Despite very severe pain there are no serious sequelae.Attacks recur at intervals over several years but tend to disappear after 55.Analgesics are unhelpful.Triptans may abort an attack.Prophylactic migraine drugs are of little value.Lithium carbonate ( 400 - 1200 mg daily ) sometimes has a dramatic effect in preventing attacks: the drug level should be monitored .Inhalation of oxygen sometimes helps stop an attack.

PAROXYSMAL HEMICRANIA

Episodic paroxysmal hemicrania is a rare condition describing unilateral sudden brief ( < 20 minutes ) pain with characteristics of headaches.The pains may occur many times each day .Typically they respond to indomethacin.

ATYPICAL FACE PAIN

Facial pain for which no cause can be found is seen in the elderly ,mainly in women .It is believed to be a somatic equivalent of depression .Tricyclic antidepressants are sometimes helpful.

OTHER CAUSES OF FACE PAIN

Facial pain occurs in variants of migraine and in giant cell arteritis .

GIANT CELL ARTERITIS ( GCA , CRANIAL ARTERITIS ,TEMPORAL ARTERITIS )

This condition is a granulomatous arteritis of unknown aetiology occuring chiefly over the age of 60 .It affects extradural arteries .Other forms of arteritis ,such as systemic lupus erythematosus ( SLE ) and microscopic polyangitis ,can occasionally present with similar features .Giant cell arteritis is closely related to polymyalgia rheumatica and can coexist.

FACE PAIN IN GIANT CELL ARTERITIS

Pain in the face ,jaw and mouth is caused by inflammation of facial ,maxillary and lingual branches of the external carotid artery in Giant cell arteritis.Pain is characteristically worse on eating ( jaw claudication ) .Openin the mouth and protruding the tongue becomes difficult.A pain ful ischaemic tongue occurs rarely.

Neck pains - Shoulder pains

2011-05-27T05:19:00.000-07:00

Worry and stress also cause muscle tension and lead to chronic neck and shoulder pain

NECK AND SHOULDER PAIN

Worry and stress also cause muscle tension and lead to chronic neck pain,which is often burning in quality.Spondylosis seen on X-ray increases after the age of 40 years ,but it is not always causal ,as the pain often settles whilst the radiological changes persist.Spondylosis can ,however cause stiffness and increases the risk of mechanical or muscular neck pain .Muscle spasm can be palpable ,is tender and may lead to abnormal neck posture ( e.g acute torticollis ) . Muscular pattern neck pain is not localized but affects the trapezius muscle, the C7 spinous process ,the paracervical musculature or all three .It is also called shoulder girdle pain.Pain often radiates to the occiput but rarely beyond the tip of the shoulder .It is commonly associated with unilateral or bilateral tension headaches ,pain radiating over the head to the temple and eye ,described as like a pressure or tight band .These features are also seen in fibromyalgia.

ETIOLOGY

TRAUMA TO THE CERVICAL SPINE

Whiplash injury is due to tauma ( usually automobile accidents ) causing cervical musculoligamental sprain or strain due to hyperflexion or hyperextension.This diagnosis should not be applied to patients with fractures ,disk herniation ,head injury ,or altered consciousness.In one study ,18% of patients with hiplash injury had persistent injury-related symptoms 2 years after the car accident.

CERVICAL DISK DISEASE

Herniation of a lower cervical disk is a common cause of neck ,shoulder ,arm,or hand pain.Neck pain ( worse with movements\ ),stiffness ,and limited range of neck motion are common.With nerve root compression ,pain may radiate into a shoulder or arm.Extension and latera rotation of neck narrows he intervertebral foramen and may reproduce radicular ymptoms ( Spurling's sign ).In young individuals ,acute radiculopathy from a ruptured disk is pften traumatic .Subacute radiculopathy is less likely to be related to a specific traumatic incident and may involve both disk disease and spondylosis.

CERVICAL SPONDYLOSIS

Osteoarthritis of the cervical spine may produce neck pain that radiates into the back of the head ,shoulders, or arms ,can also be source of hedaches in the posterior occipital region.A combined radiculopathy and myelopathy may occur.An electrical sensation elicited by neck flexion and raiating down the spine from the neck ( Lhermitte's symptoms ) usually indicates cervical or upper thoracic spinal cord involvement.MRI or CT -myelography can define the anatomic abnormalities,and EMG and nerve conduction studis can quality the severity and localize the levels of nerve root injury.

OTHER CAUSES OF NECK PAIN

Includes rheumatoid arthritis of the cervical apophyseal joints,ankylosing spondylitis ,herpes zoster ( shingles ),neoplasm metastatic to the cervical spine,infection ( osteomyelitis and epidural abscess ), nd metabolic bone disease.Neck pain may also be reffered from the heart with coronary artery ischemia ( cervical angina syndrome ).

THORACIC OUTLET

An anatomic region containing the first rib ,the subclavian artery and vein ,the brachial plexus ,the clavicle ,and the lung apex.Injury may result in posture -or task related pain around the shoulder and supraclavicular region.True neurogenic thoracic outlet syndrome results from compression of the lower trunk of the brachial plexus by an anomalus band of tissue ,tratment consists of surgical division of the band.Arterial thoracic outlet syndrome results from compression of the subclavian artery by a cervical rib ,treatment is with thrombolysis or anticoagulation ,and surgical excision of the cervical rib.Disputed thoracic outlet syndrome includes a large number of patients with chronic arm and shoulder pain of unclear cause ,surgery is controversial and treatment often unsuccessful.

BRACHIAL PLEXUS AND NERVES

Pain from injury to the brachial plexus or arm peripheral nerves can mimic pain of cervical spine origin.Neoplastic infiltration can produce this syndrome ,as can postradiation fibrosis ( pain less often present ). Acute brachial neuritis consist of acute onset of severe shoulder or scapular pain followed over days by weakness of proximal arm and shoulder girdle muscles innevated by the upper brachial plexus ,onset often preceded by an infection or immunization .Complete recovery occurs in 75% of patients after 2 years and in 89% after 3 years.

SHOULDER

If sign of radiculopathy are absent ,differential diagnosis includes mechanical shoulder pain ( tendonitis ,bursitis ,rotator cuff tear ,dislocation ,adhesive capsulitis and cuff impingement under the acromion ) and reffered pain ( subdiaphramatic irritation ,angina ,Pancoast tumor ).Mechanical pain is often worse at night ,associated with shoulder tenderness and aggravated by abduction ,internal rotation or extension of arm.

TREATMENT

Symptomatic treatment of neck pain includes analgesic medication and /or a soft cervical collar.Indications for cervical disk and lumbar disk surgery are similar ,however with cervical disease an aggressive approach is indicated if spinal cord injury is threatened.Surgery of cervical herniated disks consists of an anterior approach with diskectomy followed by anterior interbody fusion ,a simple posterior patial laminectomy with diskectomy is an acceptable alternative .The cumulative risk of subsequent radiculopathy or myelopathy at cervical segments adjacent to the fusion is 3% per year and 26% per decade.Nonprogressive cervical radiculopathy ( associated with a focal neurologic deficit ) due to a herniated cervical disk may be treated conservatively with a high rate of success.Cervical spondylosis with bony,compressive cervical radiculopathy is generally treated with surgical decompression to interrupt he progression of neurologic signs ,spondylotic myelopathy is managed with anterior decompression and fusion or laminectomy.

What is abdominal pain ?

2011-05-27T04:46:00.000-07:00

ABDOMINAL PAIN

UPPER ABDOMINAL PAIN

Epigastric pain is very common ,it is often a dull ache ,but sometimes sharp and severe .Its relationship to food intake should be ascertained .It is a common feature of peptic ulcer disease ,but also occurs in functional dyspepsia.

Right hypochondrial pain is usually from the gall bladder or biliary tract .Hepatic congestion ( e.g in hepatitis ) and sometimes peptic ulcer can present with pain in the right hypochondrium .Chronic ,often persistent ,pain in the right hypochondrium is a frequent symptoms in healthy females suffering from functional bowel disorders .This chronic pain is not due to gall bladder disease.

LOWER ABDOMINAL PAIN

Acute pain in the left iliac fossa is usually colonic in origin ( e.g acute diverticulitis ).Chronic pain is most commonly associated with functional bowel disorders.In females ,lower abdominal pain occurs in a number of gynaecological disorders and the differentiation from gastrointestinal disease is often difficult .

Persistent pain in the right iliac fossa over a long period is not due to chronic appendicitis.
Proctalgia is a severe pain deep in the rectum that comes on suddenly but lasts only for a short time.It is not due to organic disease.

ABDOMINAL WALL PAIN

Recurrent localized abdominal pain with local tenderness can very rarely arise from the abdominal wall itself.Causes are thought to include nerve entrapment ,external hernias and entrapment of internal viscera ( commonly omentum ) within traumatic ruptures of abdominal wall musculature.

Many reasons ranging from acute life-threatening emergencies to chronic diseases and functional disorders of the different parts of the body, may cause abdominal pain.Evaluation of abdominal pain requires immediate assessment of the likely reasons and early initiation of required treatment. A more comprehensive and more time for diagnosis can be followed in less serious situations.

PHYSICAL EXAMINATION

The general condition of the person should be noted.Does the patient look ill ? Large volumes of fluid may be lost from the vascular compartment into the peritoneal cavity or into the lumen of the bowel giving rise to hypovolemia i.e a pale cold skin, a weak rapid pulse and hypotension.

THE ABDOMEN

Inspection .Look for the presence of scars ,distension or masses.
Palpation .The abdomen should be examined gently for sites of tenderness and the presence or absence of guarding.Guarding is involuntary spasm of the abdominal walll and it indicates peritonitis.This can be localized to one area or it may be generalized ,involving the whole abdomen .
Bowel sounds .Increased high -pitch tinkling bowel sounds indicate fluid obstruction ,this occurs because of fluid movement within the large dilated bowel lumen.Absent bowel sounds suggest peritoneal involvement .In an obstructed patient ,absent bowel sound suggest strangulation or ischemia or ileus.It is essential that the hernial orifices be examined if intestinal obstruction is suspected.

PELVIC AND RECTAL EXAMINATION

Pelvic examination can be very helpful ,particularly in diagnosing gynaecological causes of an acute abdomen ( e.g a ruptured ectopic pregnancy ).Rectal examination is less helpful as localized tenderness may be due to any cause ,it may show blood on the finger stall.

SIGMOIDOSCOPY

If diarrhoea is present ,sigmoidoscopy is indicated to aid exclusion of infective ,inflammatory and ischemic causes of acute pain .A specimen of stool should be taken for stool culture for bacterial pathogens ( e.g campylobacter ,salmonella ,shigella ) when diarrhoea is present - stool should also be tested for Clostridium difficile toxin if antibiotic herapy precedes onset of diarrhoea and acute abdominal pain.

OTHER OBSERVATIONS

Mouth . The tongue is furred in some cases and a fetor is present.
Temperature. Fever is more common in acute inflammatory processes.
Urine. Examine for :

Blood - suggest urinary tract infection or renal colic.
Glucose and ketones - ketoacidosis can present with acute pain .
Protien and white cells - to exclude acte pyelonephritis.

Think of medical causes

INVESTIGATIONS

Blood count . A raised white cell occurs in inflammatory conditions.
Serum amylase. High levels ( more than five times normal ) indicate acute pancreatitis .Raised levels below this can occur in any acute abdomen and should not be considered dignostic of pancreatitis.
Serum electrolytes . These are not particularly helpful for diagnosis but useful for general evaluation of the patient.
Pregnancy. A urine dipstick is used with women of child bearing age.
X-rays. A chest x-ray is useful to detect air under the diaphragm owing to a perforatio .Dilated loops of owel or fluid levels are suggestive of obstruction ( supine abdominal X-ray ).
Ultrasound. This is useful in the diagnosis of acute cholangitis ,cholecystitis and aortic aneurysm and in expert hands is reliable in the diagnosis of acute appendicitis ,Gynaecological and other pelvic causes of pain can be detected.
CT scan. Spinal CT is the most accurate investigation in most acute emergencies.
Laparoscopy. This has gained increasing importance as a diagnostic tool prior to proceeding with surgery , particularly in men and women over the age of 50 years.In addition , therapeutic manoeuvers ,such as appendicectomy can be performed.

Abdominal pain

2011-05-27T04:31:00.000-07:00

Sudden onset of pain suggest a peroration ,rupture ,torsion and acute pancreatitis

ABDOMINAL PAIN

Pain is stimulated mainly by the stretching of smooth muscle or organ capsules .Severe acute abdominal pain can be due to a large number of gastrointestinal conditions ,and normally presents as an emergency.An acute abdomen can occasionally be due to referred pain from the chest ,as in pneumonia ,or to metabolic causes ,such as diabetic ketoacidosis .

In patients with abdominal pain the following should be ascertained :

The site ,intensity ,character ,duration and frquency of the pain .
The aggravating and relieving factors.
Associated symptoms ,including non gastrointestinal symptoms.

The onset ,site ,type and subsequent course of the pain should be determined as accurately as possible .In general ,the pain of an acute abdomen can either be constant ( usually owing to inflammation ) or colicky because of a blocked tube .The inflammatory nature of a constant pain wil be supported by a raised temperature ,tachycardia and /or a raised white cell count .If these are normal, then other causes ( e.g musculoskeletal ,aortic aneurysm ) or rare causes ( e.g porphyria ) should be considered .Colicky pain can be due to an obstruction of the gut ,biliary system ,urogenital system or the uterus .These will probably initially require conservative management along with analgesics .If a colicky pain becomes a constant pain,then inflammation of the organ may have supervened ( e.g strangulated hernia ,ascending cholangitis or salpingitis ).

A sudden onset of pain suggests:

A perforated ( e.g of a duodenal ulcer ) .
A rupture ( e.g of an aneurysm ) .
Torsion ( e.g of an ovarian cyst ).
Acute pancreatitis.

Back pain suggests :

Pancreatitis.
Rupture of an aortic aneurysm.
Renal tract disease.

Inflammatory conditions (e.g appendicitis ) produce a more gradual onset of pain .With peritonitis the pain is continuous and may be made worse by movement.

COMMON CAUSES OF ACUTE ABDOMINAL PAIN

Non-specific abdominal pain.
Acute appendicitis.
Renal colic.
Gynaecological disorders.
Intestinal obstruction.
Urinary tract infection.
Gall bladder disease.
Peritoneal ulcer/ dyspepsia.
Diverticular disease.

MEDICAL CAUSES OF ACUTE ABDOMEN.

REFERRED PAIN

Pneumonia.

Myocardial infarction.

FUNCTIONAL GASTROINTESTINAL DISORDERS

RENAL CAUSES

Pelviureteric colic.
Acute pyelonephritis.

METABOLIC CAUSES.

Diabetic mellitus.
Acute intermittent porphyria.
Lead poisoning.

HAEMATOLOGICAL CAUSES

Haemophilia and other bleeding disorders.
Henoch-Schonlein purpura.
Sickle cell crisis.
Polycythemia vera.

VASCULITIS

Embolic

Pain management

2011-05-27T01:45:00.000-07:00

PAIN MANAGEMENT ( MEDICATION )

Pain is a signal our body that something is wrong. It may be due to physical injury, a type of illness or emotional disturbances. Most of the types of physical pain can be treated with painkillers.

Both the area of injury and how the brain processes pain signals in the affected or injured area . Generally, medicines, and to try to stop the transmission of pain at the site of injury or affect the brain directly.

The effects of drugs against pain are different for different people. In addition, pain tolerance varies greatly from person to person. For this reason, a drug is not suitable for everyone with the same injury. For example, some people are very satisfied with the medications prescribed by a sprained ankle, while others need a prescription pain reliever stronger. Drugs with proper pain depends on the person experiencing the pain, not in the condition that causes pain.

ANALGESICS ( PAIN KILLERS ) ANTI - INFLAMMATORY DRUGS FOR MUSCULOSKELETAL PROBLEMS

The key using drugs ,particularly in chronic disorders and the elderly ,is to balance risk and benefit and constantly to review their appropriateness.

SIMPLE AND COMPOUND ANALGESIC AGENTS

Simple agents such as paracetamol,aspirin ,or codeine compounds ( or combination preparation ) , used when necessary or regularly,relieve pain and improve function.Sleep may also be improved.Side effects are relatively ifrequent ,although drowsiness and constipation occur with codeine preparations, especially in the elderly.

Strong analgesics,such as dihydrocodeine or morphine drivatives,should be used only with severe pain.

NON-STEROIDAL ANTI-INFLAMMATORY DRUGS ( NSAIDs )

NSAIDs have anti-inflammatory and centrally acting analgesic properties.They inhibit cyclo-oxygenase (COX) ,a key enzyme in the formatin of prostaglandins, prostacyclins and thrombixanes .There are two specific cyclo-oxygenase enzymes : COX-1 ,the constitutive form,and COX-2 ,the form mainly induced by inflammation.Most of the older NSAIDs block both enzymes but with variable specificity : their therapeutic effects depends on blocking COX-2 and their side effects mainly on blocking COX-1.COX-1 is a constitutive enzyme present in many normal tissues.Inhibition of the enzyme by NSAIDs produce side effects caused,for example ,by the loss of gastric mucosal protection and a decrease in renal blood flow.

COX-2 is induced in response to pro-inflammatory cytokines and is not found in most normal tissues.It is associated with oedema and the nociceptive and pretic effects of inflammatio.COX-2 specific appears to be costitutive in the kidney ,COX-2 specicific NSAIDs are available.

USES

Short causes of NSAIds are used occasionally in osteoarthritis and spondylosis,even when there is minimal inflammatio .They are commonly used in musculoskeletal pain but simple analgesia is often more appropriate.In crystal synovitis .NSAIDs have a true anti-inflammatory effect.In chronic inflammatory synovitis ,NSAIDs do not alter the chronic inflammatory process,nor decrease the risk of joint damage ,but they do reduce pain and stiffness.Slow release preparation are useful for inflammatory arthritis and when more constant pain control is needed.NSAIDs gels have no proven role in chronic arthritis.

The use of NSAIDs in high doses rapidly reduces the pain and swelling.Initial doses,taken with food,are

NAPROXON: 750 mg immeditely ,then 500 mg every 8-12 hours.

DICLOFENAC: 750-100 mg immediately ,then 50 mg every 6-8 hours.

INDOMETHACIN: 75 mg immediately ,then 50 mg every 6-8 hours.

After 24-48 hours ,reduced doses are given for a further week

CAUTION: NSAIDs may cause renal impairment .In individuals with renal impairment or history of peptic ulceratio,alternative treatments include:

COLCHICINE: 1000 mg immediately ,then 500mg every 6-12 hours ,but this causes diarrhoea.

CORTICOSTEROIDS: intramuscular or intra-articular depot methylprednisolone.

ANALGESICS ( in order to potency )

Advice that they be taken only if needed .Maximum doses are indicated here.

PARACETAMOL 500-1000 mg 6 hourly

PARACETAMOL WITH CODIENE 1-2 tablets 6 hourly

PARACETAMOL WITH DEXTROPROPOXYPHENE 1-2 tablets every 6-8 hours

PARACETAMOL WITH DIHYDROCODIENE 1-2 tablets Every 6-8 hours

DIHYDROCODIENE 30-60 mg Every 6-8 hours

NON-STEROIDAL ANTI INFLAMMATORY DRUGS (NSAIDS)

Always to be taken with food.Use slow release preparations in inflammatory conditions or if more regular pain controls is needed .Examples

IBUPROFEN 200-400mg every 6-8 hours

IBUPROFEN SLOW RELEASE 600-8000 mg every 1-3 days

DICLOFENAC 25-50 mg 8 hourly

DICLOFENAC SLOW RELEASE 75-100 mg 1-2 daily

CELECOXIB* 200mg 1-2 daily.

ADVERSE EFFECTS

The most common side effects of standard ,COX non specific NSAIDs are indigestion or sin rashes. gastric erosions and peptic ulceration with perforation and bleeding also occur.Proton pump inhibitors are probably the best drugs to protect those at high risk from serious gastrointestinal events.H2 blockers nd prostaglandi -E2 analogues also help as gastro protective agents,The value of prostaglandin analogues is limited by their tendency to cause nausea and diarrhea.In the elderly,NSAIDs may cause gastric mucosal damage and gastrointestinal bleeding without warning symptoms,thereby causing significant morbidity and mrtality.They may also reduce renal function,especially in the elderly.COX -2 specific NSAIDs produce fewer gastrointestinal side efects (6% compared to 16% in one trial ) but role in arthritis is being evaluated .They are advised on health-economic grounds as first line treatment for ar risk patients and those over 65 years .Their higher cost is a disadvantage ,but may be offset if it proves safe to avoid the co-prescription of gastroprotective agents,even in individuals with previous peptic ulceration or other indicators of increased risk of ulceration,and if fewer major gastrointestinal complications requiring hospitalization result.

Chronic pain-A disabling pain for which no medical cause can be found

2011-05-27T00:49:00.000-07:00

The main sites of chronic pain syndromes are the head ,face ,neck ,lower back ,abdomen and genitalia.Quite often a minor abnormality will be found on in........

OTHER CHRONIC PAIN SYNDROME

A chronic pain syndrome is a condition of chronic disabling pain for which no medical cause can be found .The psychiatric classification would be a persistent somatoform pain disorder ,but this is unsatisfactory since the criteria include the stipulation that emotional factors must be the main cause ,and it is clinically difficult to be tat certain.The main sites of chronic pain syndromes are the head ,face ,neck ,lower back ,abdomen ,genitalia and all over ( CWP :fibromyalgia ) " Functional " low bac pain is the commonest ' physical ' reason for being off sick long-term in the UK .Quite often a minor abnormality will be found on investigation ( such as mild cervical spondylosis on the neck X-ray ,but this will not be severe enough to explain the severity of the pain and resultant disability .These pains are often unremitting and repond poorly to analgesics.Sleep disturbance is almost universal and co-morbid psychiatric disorders are found in a large minority.

AETIOLOGY

The perception of pain involves sensory ( nociceptives ) emotional and cognitive processing in the brain.Functional brain scans sugest that the brain may respond abnormality to pain in these conditions .This could be related to conditioned behavioral and physiological responses to the initial acute pain .The brain may then adapt to the prolonged stimulus of the pain by changing its central processing .Tprefrontal cortex, thalamus and cingulate gyrus seem to be particularly affected and some of these areas are involved in the emotional appreciation of pain in general .Thus it is possible to start to understand how beliefs ,emotions and behaviors might influence the perception of chronic pain.

MANAGEMENT

Management involves the identification and treatment of maintaining factors ( e.g dysfunctional beliefs and behaviors ,mood and sleep disorders ).
Communication
Explanation of ill-health ,including diagnosis and causes .
Education about management ( including self-help leaflets ).
Stopping drugs ( e.g caffeine causing insomnia ,analgesics causing dependence ).
Rehabilitative therapies.
Cognitive behavior therapy ( to challenge unhelpful beliefs and change coping strategies ).
Supervised and graded exercise therapy ( to reduce inactivity and improve fitness ).
Pharmaco therapies .
Specific antidepressants for mood disorders ,analgesia and sleep disturbance.
Symptomatic medicines ( e.g appropriate analgesia ,taken only when necessary ).

Since analgesics are rarely effective ,and can cause long-term harm, patients should be encouraged to gradually reduce their use .It is often helpful to involve the patient's immediate family or partner ,to ensure that the partner is also supported and not unconsciously discouraging progress.

Specific drug treatment are few .Nerve blocks are not usually effective.Anticonvulsants such as carbamazepine and gabapentine may be given a therapeutic trial if the pain is thought to be neuropathetic.

The antidepressants dosulepine ( dothiepin ) is an effective treatment in half of patients with atypical facial pain, and this effect seems to be independent of dosulepine's effect on mood.Another tricyclic antidepressant,amitriptyline,is more effective than a selective serotonin reuptake inhibitor ( SSRI ) in tension headaches ,which might be related to its independent analgesic effect.

Amitriptyline has the added bonus of increasing slow wave sleep ,which may be why it is more effective than Non Steroidal Anti Inflammatory Drugs in chronic widespread pain.

Tricyclic antidepressants that affect both serotonin and norepinephrine ( noradrenaline ) reuptake seem to be more effective than more selective norepinephrine reuptake inhibitors e.g in neuropathic pain.

There is some preliminary evidence that tricyclics are superior to Selective Serotonin Reuptake Inhibitors in chronic pain syndrome.

Pain in the shoulder it could be initial sign of rheumatoid arthritis

2011-05-26T23:53:00.000-07:00

PAIN IN THE SHOULDER

The shoulder is a shallow joint with a large range of movements .The humeral head is held in place by the rotator cuff ,which is part of the joint capsule.

It comprises the tendons of infraspinatus and teres minor posteriorly ,supraspinatus superiorly and teres major and subscapularis anteriorly .The rotator cuff ( particularly supraspinatus ) prevents the humeral head blocking against the acromion during abduction , the deltoid pulls up and the supraspinatus pulls in to produce a turning moment and permit the greater tuberosity to glide under the acromion without impingement.

Pain in the shoulder can sometimes be due to problems in the neck.Although the term FROZEN SHOULDER is commonly used for any painful stiff shoulder ,true frozen shoulder ( adhesive capsulitis ) is uncommon .

A painful ,stiff shoulder can result from rotator cuff lesions and is also seen following hemiplegia ,chest or breast surgery or myocardial infarction.Painful shoulders may also be the initial presentation of Rhematoid arthritis ,less commonly a seronegative spondarthritis ,and of polymyalgia rheumatica in the elderly.

DIFFERENTIAL DIAGNOSIS OF SHOULDER PAIN

Rotator cuff tendonitis pain is worse in night ad radiates to the upper arm.

Painful shoulders produce secondary muscular neck pain.

Muscular neck pain ( also known as shoulder girdle pain ) does not radiate to the upper arm.

Cervical nerve root painis usually associated with pins and needles or neurological signsin the arm.

ROTATOR CUFF ( SUPRASPINATUS ) TENDONITIS

This is a common cause of painful resriction of the shoulder at all ages .It follow trauma in 30% of cases and is bilateral in under 5% .The pain radiates to the upper arm and is made worse by arm abduction and elevation ,which are often limited.The pain is often worse during the middle of the range of abduction , reducing as the arm is raised fully and the painful part of the tendon rotates through to the proximal side of the acromion - a so - called painful arc syndrome.When examined from behind ,the scapula rotates earlier during elevation.Passive elevation reduces impingement and is less painful .Severe pain virtually immobilizes the joint ,although some rotation is retained ( cf ,adhesive capsulitis ) .There is also painful spasm of the trapezius .X-rays are necessary only when rotator cuff tendonitis is persistent or the diagnosis is uncertain.

TREATMENT

Analgesics or Nonsteroidal anti inflammatory drugs may suffice ,but severe pain responds to an injection of crticosteroid .Patients should be warned that 10% will develop worse pain for 24-48 hours after injection .Severiy per cent improve over 5-20 days and mobilize the joint themselves.Physiotherapy helps persistent stiffness but further injections may be needed.

CALCIFIC TENDONITIS AND BURSITIS

Calcium pyrophosphate deposits in the tendon are visible on x-ray ,but they are not always symptomatic.The pathgenesis is unclear ,although the part of the tendon affected is likely to be affected by relative ischemia.The deposit is ususlly just proximal to the greater tuberosity.It may lead to acute or chronic recurrent shoulder pain and restriction of movement .A local corticosteroid injection may help and ultrasound treatment may help to resolve the calcification .Aspiration of the deposit under x-ray control may be required for persistent pain .Rarely arthroscopic removal is necessary.Shedding of crystals into the subacromial bursa causes severe pain and shoulder restriction.The shoulder feels hot and is swollen ,and an x-ray will show a diffuse opacity in the bursa.The differential diagnosis of calcific bursitis is gout ,pseudogout or septic arthritis.Aspiration and injection with corticisteroid can help.

TORN ROTATOR CUFF

This is caused by trauma in the young but also occurs spontaneously in the elderly and in rheumatoid arthritis ( RA).It prevents active abduction of the arm , but patients learn to initiate elevation using the unaffected arm.Once elevated ,the arm can be held in place by the deltoid muscle.In younger people ,the tear is repaired surgically but this is rarely possible in the elderly or in rheumatoid arthritis.Repeated trauma of the cuff between humerus and acromion/acromioclavicular joint causes osteophyte and cyst formation.

Shoulder impingement syndrome causes pain and crepitus on abduction and rotation.

ADHESIVE CAPSULITIS ( TRUE " FROZEN SHOULDER " )

This is uncommon .Severe shoulder pain is associated with complete loss of all shoulder movements,including rotation.High doses of Non steroidal anti inflammatory drugs ( NSAIDs ) and intra-articular injections of corticisteroids are helpful.Once the pain settles ,a manipulation under anaesthetic is advisable.When untreated ,it removes in 1-2 years.

Back pain treatment - Pain in b/w ages 20-55 years is more likely to be mechanical

2011-05-26T11:55:00.000-07:00

Mechanical pain is managed with analgesia ,brief rest and physiotherapy

LOW BACK PAIN TREATMENT

Low back pain is a common symptom.It is often traumatic and work related ,although lifting apparatus and other mechanical devices are used to avoid it .Episodes are generally short lived and self limiting ,and patients attend a physiotherapist or osteopath more often than a doctor.Chronic back pain is the cause of 14% of long term disability in the UK .

MANAGEMENT OF BACK PAIN

Most back pain presenting to a primary care physician needs no investigation.

Pain between ages 20 and 55 years is likely to be mechanical and is managed with analgesia ,brief rest and physiotherapy.

Patients should stay active within the limits of their pain .

Early treatment of the acute episode ,advice and exercise programmes reduce long term problems and prevent chronic pain syndromes.

Physical manipulation of uncomplicated back pain produces short term relief and enjoys high patient satisfaction ratings.

Psychological and social factors may influence the time of presentation.

Appropriate early management reduces long-term disability.

ACUTE LOW BACK PAIN ( ALBP ) MANAGEMENT

Pain of 3 months duration ,full recovery occurs in 85%.Management controversial ,few well-controlled clinical trials exist.If risk factors are absent ,initial treatment is symptomatic and no diagnostic tests necessary.Spine infections ,fractures ,tumors or rapidly progressive neurologic deficits require urgent diagnostic evaluation.Patients with no risk factors and no improvement over 4 weeks are subdivided by the presence /absence of leg symptoms and managed accordingly.Clinical trials do not show benefit from bed rest >2 days.Possible benefits of early activity __ cardiovascula conditioning ,disk and cartilage nutrition.bone and muscle strength ,increased endorphin levels.Studies of traction or poture modification fall to show benefit .Proof lacking to support acupuncture ,ultrasound ,diathermy ,transcutaneous electrical nerve stimulation ,massage ,biofeedback or electrical stimulation.Self -application of ice or heat or use of shoe insoles is optional given low cost and risk ,benefit of exercises uncertain.A short course of spinal manipulation or physical therapy may lesson pain and improve function.Temporary suspension of activities known to increase mechanical stress on the spine ( heavy lifting ,straining at stool. prolonged sitting /bending /twisting ) may relieve symptoms .Value of education ( back school ) in long term prevention is unclear.

Pharmacologic treatment of Acute low back pain includes Non Steroidal Antiinflammatory drugs and acetoaminophen.Muscle relaxats ( cyclobenzaprine ,methocarbanol )provides short term benefit (4-7 days ),but drowsiness limits use .Opiods are not superior to Non Steroidal Anti inflammatory drugs or acetoaminophen for Acute Low Back Pain.Epidural anesthetic ,glucocorticoids ,opiods or tricyclic antidepressants are not indicated as initial treatment .

CHRONIC LOW BACK PAIN (CLBP) MANAGEMENT

Pain lasting >3months, differential diagnosis includes most conditions described above.Chronic low back pain causes can be lclarified by neuroimaging and EMG /nerve conduction studies,diagnosis of radiculopathy secure when results concordant with findings on neurologic exam .Management is complex and not amenable to a simple algorithmic approach .Treatment based upon identification of underlying cause ,when specific cause not found ,conservative management necessary.Pharmacologic and comfort measures similar to those described for acute low back pain.Exercise ( work hardening ) regimens effective in returning some patients to work ,diminishing pain ,and improving walking distances.

Hydrotherapy may be useful and some patients experience short term pain relief with percutaneous electrical nerve stimulation.Surgical intervent on based upon neuroimaging alone not recommended up to one third of asymptomatic young adults have a herniated lumbar disk by CT or MRI

Treatment for chronic regional pain syndrome - Reflex sympatetic dystrophy (RSD ) - Sudek’s atrophy

2011-05-26T07:16:00.000-07:00

Treatment for chronic regional pain syndrome - Reflex sympatetic dystrophy (RSD ) - Sudek’s atrophy

Management is difficult and the problem often very disabling.Early diagnosis,effective pain relief and general care of the patient are essential.

Physical therapy: Gradually increasing to use the program regarded as a painful limb or body part moving may help to restore range of motion and action.

Psychotherapy: CRPS often has profound psychological impact on people and their families. Those with CRPS may suffer from depression, anxiety or post-traumatic stress disorder, which increases the perception of pain and make rehabilitation more difficult.

Surgical sympathectomy: Surgical sympathectomy, a technology that destroys the nerves involved in CRPS, is controversial. Some experts believe it is unnecessary and makes CRPS worse, while others report a positive outcome.

Sympathectomy should be used only in patients whose pain is dramatically relieved (although temporarily), by a selective sympathetic blockade. spinal cord stimulation: to promote the placement of the electrodes adjacent to the spinal cord provides a pleasant tingling sensation in painful area. This technology can help many patients with their pain.

NSAIDs and corticosteroids are used in the early phase together with active exercise of the limb.Calcitonin may also help at this stage.If pain persists despite initial treatment ,a phentolamine test is used to test for evidence of sympathitically maintained pain (i.v infusion of up to 40mg with careful cardiac monitoring ) .If this is positive,a stellate ganglion block is used for upper limb and a sympathetic chain block for lower limb involvement.Guanethedine ( an alpha-blocking agent ) or lidocaine (lignocaine ) administered to the limb under tourniquet is also useful.Refferal to a pain management clinic is advisable.

The following measures can help reduce the risk of developing Complex Regional Pain Syndrome:

Use of vitamin C after a broken wrist. Studies have shown that people who use daily supplement of vitamin C after wrist fracture is a lower risk of complex regional pain syndrome, compared with those not taking vitamin C. Early mobilization after a stroke. Some studies show that people who get up and walk immediately after a stroke (early mobilization) to reduce the risk of complex regional pain syndrome.

The prognosis for Chronic Regional Pain Syndrome varies from person to person. spontaneous remission of symptoms occurs in some people. Others may have relentlessly pain and crippling, irreversible changes in spite of treatment. Some clinicians believe that early treatment is beneficial to limit the mess, but this belief has been justified by the evidence of clinical studies. Further research is needed to understand the aetiology of Chronic Regional Pain Syndrome, how it evolves, and the role of early treatment for better cure.

CHRONIC REGIONAL PAIN SYNDROME - REFLEX SYMPATHETIC DYSTROPHY ( RSD ) - SUDEK's ATROPHY

2011-05-26T07:10:00.000-07:00

CHRONIC REGIONAL PAIN SYNDROME TYPE I

REFLEX SYMPATHETIC DYSTROPHY ( RSD )

SUDEK's ATROPHY

This is defined as a complex disorder or group of disorders that may develop as a consequence of trauma affecting the limbs,with or without obvious nerve lesions (e.g strokes ),or without cause. It occured in 1.5% of sodiers injured in Vietnam.Its features are pain and other sensory abnormalities,including hyperesthesia,autonomic vasomotor dysfunction ,leading to abnormal blood flow and sweating and motor system abnormalities.

The complex regional pain syndrome occurs in two types with same signs and symptoms but different aetiologies:

Type I. Previously known as reflex sympathetic dystrophy syndrome, this type occurs after an disease or injury that did not rule directly damage the nerves in your affected limb. About 90 percent of people have type 1 complex regional pain syndrome .

Type 2. Once known as causalgia, this type occur in nerve injury differently. Many cases of complex regional pain syndrome occur after a trauma in an arm or a leg, a gunshot wound or shrapnel blast. Other major and minor injuries - such as surgery for heart attack, infections, fractures and sprains itself - can also lead to complex regional pain syndrome. Not well understood why these injuries or traumas can exaggerated complex regional pain syndrome.

This leads to structural changes of superficial and deep tissues ( trophic changes ).Not all components need be present.The sensory ,motor and sympathetic nerve changes are not restricted to the distribution of a single nerve and may be remote from and increased skin temperature - is difficult to diagnose but potentially reversible.After a period of weeks or months a second ,still painful,dystrophic phase develops,characterized by articular stiffness,cold skin and changes ,often with localized osteoporosis.A late phase involves continued pain,skin and muscle atrophy and muscle contractures,and is extremely disabling.

Chronic Regional Pain Syndrome can strike at any age, but the average age at diagnosis is 42. CRPS was diagnosed in children as young as two years old.It affects both men and women, but SDRC is three times more common among women than men. The number of reported cases of CRPS in adolescents and young adults is increasing. Researchers estimate that 5.2 percent of people with peripheral nerve injury, and 13-70 percent of people with hemiplegia (paralysis on one side of the body) will be affected by CRPS. It is also assumed that some people may be genetically predisposed to develop symptoms of Reflex Sympathetic Dystrophy / Chronic Regional Pain Srndrome, after a seemingly trivial injury has been sustained or significant.

Diagnosis is initially clinical - a high index of suspicion and recognizing the unusual distribtion of the pain.A three-phase bone scan shows diffuse or patchy increase in uptake in the affected limb in all three phases: early ( a few seconds - arterial );middle ( a few minutes - soft tissue ) ;and late ( several hours - mineral ).The bone phase abnormalities appear early and well before demineralization is seen on X-ray.There is never loss of joint space,which distinguishes the appearances from the periarticular osteoporosis of inflammatory joint disease.

There is no specific test available for the Chronic Regional Pain Syndrome, which is diagnosed primarily through observation of symptoms. However, thermography ,and sweat test, X-ray, electro-diagnostics and sympathetic blocks can be used to construct an image of the disease. The diagnosis is complicated by the fact that some patients improve without treatment. A delay in diagnosis and / or treatment of this syndrome can cause serious physical and psychological problems. Early treatment and quick recognition to provide the best chance of cure.

Joint pain swelling

2011-05-26T04:49:00.000-07:00

PAIN OR SWELLING OF JOINTS

Musculoskeletal complaints are extremely common in outpatient medical practice and are among the leading causes of disability and absenteeism from work. Pain in the joints must be evaluated in a uniform ,thorough ,and logical fashion to ensure the best chance of accurate diagnosis and to plan appropriate follow up testing and therapy. Joint pain and swelling may be manifestation of disorders affecting primarily the musculoskeletal system or may reflect systemic disease.

GOALS FOR THE INITIAL ASSESSMENT OF A MUSCULOSKELETAL COMPLAINT

1. Articular versus nonarticular .Is the pain located in a joint or in a periarticular structure such as soft tissue or muscle ?

2. Inflammatory versus noninflammatory .Inflammatory disease is suggested by local signs of inflammation ( erythema ,warmth ,swelling ) ,systemic features ( morning stiffness ,fatigue ,fever ,weight loss ) ,or laboratory evidence of inflammation ( thrombocytosis ,elevated ESR or C-reactive protien ).

3. Acute ( < or equal 6 weeks ) versus chronic .

4. Localized versus systemic .

HISTORIC FEATURES

Age ,sex ,race and family history .
Symptom onset ( abrupt or indolent ) ,evolution ( chronic constant ,intermittent ,migratory ,dditive ) ,and duration ( acute versus chronic ).
Number and distribution of involved structures ,mono-articular ( one joint ) , oligoarticular ( 2-3 joints ) , polyarticular ( > joints ); symmetry .
Other articular features : morning stiffness ,effect of movement ,features that improve / worsen Sx .
Extra-articular Sx : e.g fever ,rash ,weight loss ,visual change ,dyspnea ,diarrhea ,dysuria ,numbness ,weakness.
Recent events : e.g trauma ,drug administration ,travel ,other illnesses.

PHYSICAL EXAMINATION

Complete examination is essential : particular attention to skin ,mucous membranes ,nails ( may reveal characteristic pitting in psoriasis ) ,eyes .Careful and thorough examination of involved and uninvolved joints and periarticular structurs : this should proceed in an organized fashion from head to foot or from extremities inward toward axial skeleton :

Special attention should be paid to identifying the presence or absence of

_ Warmth and / or erythema.

_ Swelling.

_ Synovial thickening.

_ Subluxation ,dislocation ,joint deformity.

_ Joint instability.

_ Limitation to active and passive range of motion.

_ Creptus.

_ Periarticular changes.

_ Muscular changes including weakness ,atrophy.

LABORATORY INVESTIGATIONS

Additional evaluation usually for monarticular ,traumatic ,inflammatory ,or chronic conditions or for conditions accompanied by neurologic changes or systemic manifestations.

_ For all evaluation : include Complete blood count ,Erythrocyte Sedimentation rate , or C-reactive protien.

_ Should be performed where there are suggestive clinical features ,rheumatoid factor ,ANA ,antineutrophilic cytoplasmic antibodies ( ANCA ) ,antistreptolysin O titer ,Lyme antibodies.

_ Where systemic disease is present or suspected : renal / hepatic function tests.

_ Uric acid :useful only when gout diagnosed and therapy contemplated.

_ CPK ,aldolase : consider with muscle pain ,weakness .

_ Synovial fluid aspiration and analysis ,always indicated for acute monarthritis or when infectious or crystal - induced arthropathy is suspected .Should be examined for (1) appearance ,viscosity .(2) cell count and differential ( suspect septic joint if White Blood Cells count > 50.000 ): (3) crystal using polarizing microscope : (4) Gram's stain ,cultures .

DIAGNOSTIC IMAGING

Plain radiographs should be considered for

_ Trauma.

_ Suspected chronic infection .

_ Progressive disability.

_ Monarticular involvement .

_ Baseline assessment of a chronic process.

_ When therapeutic alterations are considered.

Additional imaging procedurs ,including ultrasound ,radionuclide scintigraphy ,CT and MRI may be helpful in selected clinical settings.

SPECIAL CONSIDERATION IN THE ELDERLY PATIENT

The evaluationof joints and musculoskeletal disorders in the elderly patients presents a special challenge given the frequency insidous onset and chronincity of disease in this age group ,the confounding effect of other medical conditions ,and the increased variability of many diagnostic tests in the geriatric population .Although vertually all musculoskeletal conditions may afflict the elderly ,certain disorders are especially frequent .Special attention should be paid to identifying the potential rheumatic consequences of intercurrent medical conditions and therapies when evaluating the geriatric patients with musculoskeletal complaints .

Chronic pain work related upper limb syndrome

2011-05-26T04:24:00.000-07:00

CHRONIC ( WORK RELATED ) UPPER LIMB PAIN SYNDROME

This name is preferred to repetitive strain injury (RSI) .The predominant symptoms are pain in all or part of one or both arms.A specific lesions,such as tennis elbow or carpal tunnel syndrome ,or muscular -pattern neck pain often develop first ,and early recognition and treatment may prevent chronicity.After a variable period ,the pain becomes more diffuse and no longer simply work related ,and there is often severe distress.It is seen in keyboard workers and others who perform the same task without breaks for prolonged periods, and in musicians.When it arises at work ,it is often at a time of changing work practices ,shortage of staff or disharmony .Middle managers find it difficult to deal with and this compounds the stress.

It is seen throughout the developed world .It peaked in incidence in Australia in the 1970s and 1980s but has largely disappeared there ,apparently because of changes in work practices ,improvements in early medical management ,changes in workers compensation legislation ,and reduced media discussion of the problem.

Work related upper limb disorder (WRULD) is a general term that covers a variety of of musculoskeletal disorders which affect the shoulder, elbow, forearm, wrist or hand. This is not a specific condition, but a group of diseases. Previously the terms repetitive strain or stress injury (RSI) were frequently used.

There are also some specific conditions affecting the upper limbs which may be work-related if it can be shown they are due to occupational overuse. These conditions usually occur in working adults.

Some conditions are well defined with accepted diagnostic criteria, well defined risk factors and well established medical treatment.Some Other conditions, in which there is non-specific forearm or upper limb pain, are less well defined.

A large number of individuals with upper limb pain and dysfunction do not exhibit signs which are easily identifiable or in a good condition with a definitive diagnosis. these people may experience pain that is not localized to one region and the pain can go from one area to another and be of a very indefinite in nature. The Examination can often identify very little in the way of objective abnormality. The diagnosis is made after other specific conditions have been excluded.Forearm pain is Non-specific has been defined for purposes of research as ‘pain in the forearm in the absence of a specific diagnosis or pathology . It is one of the common complain of work related upper limb pain syndrome but estimates of its distribution vary widely. Other features which may be present include loss of function, weakness, cramp, muscle tenderness, burning and non-specific paraesthesia, and often a feeling of swelling.

Individuals who regularly use the computer is in danger, but professional sports is also aware of the risk of upper limb. Who spends time writing reports record is also aware of the risk of chronic( work related )upper limb pain syndrome . Even the usually pleasant to work in libraries can lead to shoulder pain. Small business owners, who may often have a tendency to do different activities, including lifting, moving and packing material can also they are at risk . Those who spend hours on the telephone all day can suffer, that's why call centers are now using headphones and microphones so there is no risk to human health cradling phone between shoulder and head for long periods. So there are many professions where Work Related Upper Limb pain syndrome are a risk. In fact, there are very few jobs and professions where there is very little risk or no risk of upper limb work related pain syndrome.

TREATMENT

If possible there should be a brief off work and a gradual return to activity once the pain has setteled .Cautious use of analgesia and NSAIDs ,with physiotherapy is helpful during the initial phase to prevent a vicious circle developing .

A review of working practices and the positioning of screen ,keyboard and chair essential ,as is support of the patient by their manager .Musicians are helped by expert advice on playing technique and should reduce playing times temporarily ,but not stop completely.

Headache - Causes of headaches and treatment of headaches

2011-05-23T13:57:00.000-07:00

HEADACHES CAUSES , TYPES AND TREATMENT

HEADACHES

Headaches is an almost universal experience ,and one of the most common symptoms in general and neurological practice .It varies from an infrequent and trivial nulsance to a symptoms of serious disease.

First step - distinguish serious from benign etiologies.Intensity of head pain rarely has diagnostic value :most patients who present to emergency ward with worst headache of their lives have migraine .Headache location can suggest involvement of local structures ( temporal pain in giant cell arteritis ,facial pain in sinusitus ).Rutured aneurysm ( instant onset ) ,cluster headache ( peak over 3-5 minutes ) ,and migraine ( onset over minutes to hours ) differ in times to peak intensity .Provocation by enviormental factors suggests a benign cause.

EVALUATION

Complete neurologic exam is essential first step.If exam is abnormal or if serious underlying cause is suspected for any reason ,an imaging study ( CT or MRI ) is indicated .Lumbar puncture is required when meninges ( stiff neck ,fever ) is a possibility.

MECHANISM

Pain receptors are located at the base of the brain in arteries and veins and throughout the meninges ,extracranial vessels ,muscles of the scalp ,neck and face ,paranasal sinuses ,eyes and teeth .Curiously ,brain itself is almost devoid of pain receptors.

Head pain is mediated by mechanical receptors ( e.g stretching of meninges ) and chemical receptors ( e.g 5-hydoxytryptamine and histamine stimulation ).

Nerve impuses travel centrally via the fifth and ninth cranial nerves and via upper cervical sensory roots.The majority of headaches are benign ,but the diagnostic isssue - and usual source of concern-is that some are caused by serious disease .

The following are some useful clinical pointers.

CHRONIC ( BENIGN ) AND RECURRENT HEADACHES

Almost all recurring headaches lasting hours or days - band like ,generalized head pains ,with a history going back for several years or months - are vaguely ascribed to muscle tension ,and/or migraine .Depression often accompanies them.In localized pain of short duration ,lasting some minutes or hours ,sinusitis ,glaucoma and migranous neuralgia shouls also be considered.Malignant hypertension ,with arterial damage and brain swelling ,occasionally causes headache.Headaches are not caused by high blood pressure alone .

Eyestrain from underlying refractive error is not itself a cause of headache ,though new prescription lenses sometimes provoke pain.

PRESSURE HEADACHES

Intracranial mass lesions displace and stretch the meninges and basal vessels .Pain is provoked when these structures are shifted either by a mass itself or by changes in cerebrospinal fluid ( CSF ) pressure , e.g coughing.Cerebral oedema around brain tumours causes further shift . These pressure headaches typically become worse on lying dpwn.Any headache , however mild ,that is present on waking and made worse by coughing , straining or sneezing may well be due to a mass lesions. Vomiting often accompanies pressure headaches .Such headaches are caused early ,over weeks by posterior focus masses , but over a longer timescale -months or even years - by hemisphere tumours.A rare cause of prostrating headache with lower limb weakness is an intraventricular tumours causing intermittent hydrocephalus .

HEADACHE OF SUBACUTE ONSET

The onset and progression of a headache over days or weeks with or without the features of a pressure headache should always raise the suspicion of an intracranal mass lesions or serious intracranial disease.Encephalitis ,viral meningitis and chronic meningitis should also be considered.

HEADACHES WITH SCALP TENDERNES

Patches of exquisite tenderness overling superficial scalp arteries are caused by giant cell arteritis ,which develops almost exclsively in patients aged over 50 years.

HEADACHE FOLLOWING HEAD INJURY

Subdural haematomas must be considered .However ,the vast majority of post-trauma headaches lasting days, weeks or months are not associated with any serious intracranial pathology.

A SINGLE EPISODE OF SEVERE HEADACHE

This common emergency is caused by one of the following :

Subarachnoid haemorrhage .

Migraine ,or other benign headaches.

Meningitis. ( occasionally ).

Particular attention should be paid to the suddenness of onset ( suggestive of a subarachnoid haemorrhage ) ,neck stiffness and vomiting ( any meningeal irritation ) ,or rash and fever ( bacterial meningitis ).

TENSION HEADACHE

The vast majority of chronic and recurrent headaches are believed to be due to neurovascular irritation and tension within scalp muscles .despite universal occurrence ,precise mechanism of common headache remain obscure .What is certain that most headaches are benign.Tight band sensations ,pressure behind the eyes , throbbing and bursting sensations are common.

There may be obvious precipitating factors such as ,worry ,noise ,concentrated visual efforts or fumes.

Depression is also a frequent underlying cause.Tension headaches are often attributed to cervical spondylosis , refractive erros or high blood pressure ,evidence for these associations is poor .Headaches also follow even minor head injuries.There are no abnormal physical signs other than tenderness and tension in the nuchal and scalp muscles.

MANAGEMENT

This involves :

Firm reassurance.

Avoiding cause .

Analgesics -limited amounts.

Physical treatment - massage ,ice packs , relaxation.

Antidepressants - when indicated.

Drugs for migraine .

Imaging is often needed for reassurance.