Transient osteoporosis associated with pregnancy: use of bisphosphonate in treating a lactating mother.

Transient osteoporosis is a rare condition causing regional pain, immobility and functional compromise. The authors present the case of a pregnant lady with multiple sites of transient osteoporosis, including a stress fracture, successfully treated with intravenous pamidronate and a physical rehabilitation programme. The authors discuss the mechanisms for the syndrome and its overlap with complex regional pain syndrome type I; as well as the implications of bisphosphonate administration to a nursing mother. The authors also highlight the advantages of MRI over standard radiography when investigating unexplained foot pain.

Contralateral hyperalgesia and allodynia following intradermal capsaicin injection in man.

OBJECTIVES: Contralateral responses to unilateral stimuli have been well described in animal models. These range from central sensitization to peripheral inflammatory responses. Our aim was to test for contralateral responses following unilateral intradermal capsaicin injection in man. METHODS: Three groups were investigated. A healthy volunteer group (1) was injected with capsaicin into the volar aspect of one forearm. A group of patients with RA (2) was also injected with capsaicin. A control group of healthy volunteers (3) was not injected with capsaicin. All groups were tested for hyperalgesia and allodynia every 10 min for 1 h following the injection using quantitative sensory testing. RESULTS: A total of 9/14 healthy volunteers (Group 1) and 10/14 patients with RA (Group 2) demonstrated contralateral sensitization that subsided within 1 h following intradermal capsaicin injection. A total of 2/23 control subjects (Group 3) demonstrated positive responses with the monofilaments. The frequency of the contralateral responses in the experimental groups compared with the control group is significant (P < 0.05). The peak hyperalgesia was relatively delayed contralaterally compared with the ipsilateral side (35 min vs 15 min). The area of sensitization, where present, was reduced compared with the ipsilateral side (5-50%). CONCLUSIONS: This is the first demonstration of a contralateral response following a unilateral stimulus in man. Bilateral neural pathways mediating contralateral responses may have a role in the pathophysiology of chronically painful or inflammatory diseases and a confounding influence on using the contralateral limb as a control experimentally. We did not find that a systemic inflammatory disease sensitized for this phenomenon.

Demystifying acupuncture.

Acupuncture refers to the insertion of fine needles into the body at specific points for a therapeutic effect. The term comes from the Latin words 'acus' (needle) and 'punctura' (to puncture). The technique has been practiced in the Far East for at least 3000 yrs but it is only in the last 30 yrs that interest has developed in the West underpinned by increasing scientific research. One of the main uses of acupuncture has been to treat musculoskeletal pain and this article will review the evidence base and outline the main theories of mechanisms of action.

Phantoms in rheumatology.

This paper examines rheumatology pain and how it may relate to amputee phantom limb pain (PLP), specifically as experienced in rheumatoid arthritis, fibromyalgia and complex regional pain syndrome (CRPS). Clinical findings, which suggest cortical sensory reorganization, are discussed and illustrated for each condition. It is proposed that this sensory reorganization generates pain and altered body image in rheumatology patients in the same manner as has previously been hypothesized for amputees with PLP; that is via a motor/sensory conflict. The correction of this conflict through the provision of appropriate visual sensory input, using a mirror, is tested in a population of patients with CRPS. Its analgesic efficacy is assessed in those with acute, intermediate and chronic disease. Finally, the hypothesis is taken to its natural conclusion whereby motor/sensory conflict is artificially generated in healthy volunteers and chronic pain patients to establish whether sensory disturbances can be created where no pain symptoms exists and exacerbated when it is already present. The findings of our studies support the hypothesis that a mismatch between motor output and sensory input creates sensory disturbances, including pain, in rheumatology patients and healthy volunteers. We propose the term 'ominory' to describe the central monitoring mechanism and the resultant sensory disturbances as a dissensory state.

Symmetry, T cells and neurogenic arthritis.

Symmetry in clinical disease occurs more commonly than expected by chance and is unexplained. In this paper we focus on symmetry in arthritis and describe the neurogenic hypothesis. Neuropeptides are anatomically relevant to systemic arthritis and have been shown to have modulating effects on both the immune and circulatory systems. Neural networks project bilaterally and are involved in the development and propagation of inflammatory disease. These putative pathological neuro-feedback loops may derive from the existence of biologically protective symmetrical mechanisms.