Pain in hereditary neuromuscular disorders and myasthenia gravis: a national survey of frequency, characteristics, and impact.

The aim of our study was to evaluate pain frequency, intensity, and disability levels in a population with neuromuscular disorders (NMD). Of 862 questionnaires mailed to outpatients treated at 10 centers, 511 (300 men and 211 women) responded with answers suitable for analysis (response rate: 59.3%). Patients had Duchenne or Becker muscular dystrophy, type 1 myotonic muscular dystrophy, facioscapulohumeral muscular dystrophy, metabolic myopathy, or myasthenia gravis (MYA). The questionnaire packet included numeric scales for pain intensity and relief, the Brief Pain Inventory, the Saint Antoine Pain Questionnaire, and a scale to assess disability. More than two-thirds of the 331 patients (67.3%) suffered pain during the last three months. The mean number of days with pain was 18.4+/-15.1 days. The mean pain intensity was 4.8+/-2.5. Pain was usually diffuse (153 patients, 44%) and intermittent (228, 71%). Pain intensity varied by the NMD diagnosis; the most severe pain was observed in metabolic myopathy (13/27 patients suffered severe pain, 49%) and in MYA (16/42, 38%). Approximately three-quarters of patients had fewer than 10 days of inactivity due to pain during the last three months, and 98% had fewer than 30 days. Our study indicates that pain is frequent in hereditary muscle disorders and MYA. Mean intensity is moderate. Pain in NMD patients should be systematically assessed.

Differences in the sensations of cold on the anterior torso of control and spinal-cord-transected individuals.

Application of cold stimuli to the sentient portion of the anterior torso of 12 spinal-cord-transected individuals (patients) and to comparable sites of 11 control participants showed that thresholds are lower for women than for men and that the difference between the sexes is maintained following spinal-cord transection. Patients of both sexes were more sensitive to cold stimuli than were controls. Estimates of stimulus intensity showed that participants reliably distinguished the 3 cool stimuli but that control women offered significantly larger estimates than control men. Spinal-cord transection produced an increase in the intensity of the sensations in women and a reduction in men. The changes in sensory perception that follow spinal-cord injury extend throughout the somatosensory system and involve all modalities. These changes cannot be explained as a simple release from inhibition.

Effects of training on general practitioners' management of pain in osteoarthritis: a randomized multicenter study.

OBJECTIVE: To evaluate the effects of a short interactive training program for general practitioners (GP) on pain management in patients with osteoarthritis (OA). METHODS: A multicenter, parallel-group study. GP were randomized to receive training on relationships and communication, pain evaluation, prescription, and negotiation of a patient contract or to a control group receiving a presentation about obtaining consent in trials. Outcomes were patient assessments of pain and functional ability. We invited 1500 GP to take part in the study. Those who volunteered to receive the training recruited outpatients from May 2001 to April 2002. Patients participating in the evaluation of the effects of the general practitioners' training had lower limb OA and pain on motion [> or = 40 mm on a visual analog scale (VAS)] and had indications for treatment with acetaminophen. The primary endpoint: sum of patient pain relief based on the daily VAS self-evaluation during the 2 weeks of the trial. RESULTS: In total, 180 GP (84 trained, 96 nontrained) enrolled 842 patients (414 and 428, respectively). Mean baseline VAS pain was 63 +/- 14 mm. Patients in the trained-GP group had better overall pain relief (316 +/- 290 mm/day vs 265 +/- 243 mm; p < 0.0001), greater improvement in Lequesne and WOMAC scores (p < 0.0001), and better overall perception of treatment (p = 0.002). Acetaminophen use was slightly higher in the trained group; however, the difference in pain relief remained statistically significant (p = 0.0003) after adjustment for this difference. CONCLUSION: This is the first study to demonstrate a positive effect of physician training on patients with a painful condition.

Comparison of pain syndromes associated with nervous or somatic lesions and development of a new neuropathic pain diagnostic questionnaire (DN4).

Few studies have directly compared the clinical features of neuropathic and non-neuropathic pains. For this purpose, the French Neuropathic Pain Group developed a clinician-administered questionnaire named DN4 consisting of both sensory descriptors and signs related to bedside sensory examination. This questionnaire was used in a prospective study of 160 patients presenting with pain associated with a definite neurological or somatic lesion. The most common aetiologies of nervous lesions (n=89) were traumatic nerve injury, post herpetic neuralgia and post stroke pain. Non-neurological lesions (n=71) were represented by osteoarthritis, inflammatory arthropathies and mechanical low back pain. Each patient was seen independently by two experts in order to confirm the diagnosis of neuropathic or non-neuropathic pain. The prevalence of pain descriptors and sensory dysfunctions were systematically compared in the two groups of patients. The analysis of the psychometric properties of the DN4 questionnaire included: face validity, inter-rater reliability, factor analysis and logistic regression to identify the discriminant properties of items or combinations of items for the diagnosis of neuropathic pain. We found that a relatively small number of items are sufficient to discriminate neuropathic pain. The 10-item questionnaire developed in the present study constitutes a new diagnostic instrument, which might be helpful both in clinical research and daily practice.

[2003 clinical practice guideline: Standards, Options and Recommendations for pain assessment in adult and children with cancer (summary report)]. / Recommandations pour la pratique clinique: Standards, Options et Recommandations pour l'évaluation de la douleur chez l'adulte et l'enfant atteints d'un cancer (mise à jour)--rapport abrégé.

CONTEXT: The "Standards, Options and Recommendations" (SOR) project, which started in 1993, is a collaboration between the French Federation of Cancer Centers (FNCLCC), the 20 French Regional Cancer Centers, and specialists from French public universities, general hospitals and private clinics. The main objective is the development of clinical practice guidelines to improve the quality of health care and the outcome of cancer patients. OBJECTIVE: To update clinical practice guidelines for the assessment of pain in adult or children with cancer in collaboration with the French society for pain study and treatment. METHOD: The methodology is based on a literature review and critical appraisal by a multidisciplinary group of experts who define the CPGs according to the definitions of the Standards, Options and Recommendations project. Once the guideline has been defined, the document is submitted for review by independent reviewers. RESULTS: This article is a summary version of the full document presenting the clinical practice guidelines with algorithms. The main recommendations concern the means used to evaluate pain and its consequences and their use in specific cases (acute or chronic pain, patients able to communicate or not, children under or over 6 years old). Others recommendations were also established concerning the evaluation ofpsychological, social and family context, the evaluation of pain in hospital or at home, in terminal phase patients and for the establishment of a therapeutic strategy and follow-up of patient with pain.

[For a coordination of the supportive care for people affected by severe illnesses: proposition of organization in the public and private health care centres]. / Coordination des soins de support pour les personnes atteintes de maladies graves: proposition d'organisation dans les etablissements de soins publics et privés.

The concept of continuous and global care is acknowledged today by all as inherent to modern medicine. A working group gathered to propose models for the coordination of supportive care for all severe illnesses in the various private and public health care centres. The supportive care are defined as: "all care and supports necessary for ill people, at the same time as specific treatments, along all severe illnesses". This definition is inspired by that of "supportive care" given in 1990 by the MASCC (Multinational Association for Supportive Care in Cancer): "The total medical, nursing and psychosocial help which the patients need besides the specific treatment". It integrates as much the field of cure with possible after-effects as that of palliative care, the definition of which is clarified (initial and terminal palliative phases). Such a coordination is justified by the pluridisciplinarity and hyperspecialisation of the professionals, by a poor communication between the teams, by the administrative difficulties encountered by the teams participating in the supportive care. The working group insists on the fact that the supportive care is not a new speciality. He proposes the creation of units. departments or pole of responsibility of supportive care with a "basic coordination" involving the activities of chronic pain, palliative care, psycho-oncology, and social care. This coordination can be extended, according to the "history" and missions of health care centres. Service done with the implementation of a "unique counter" for the patients and the teams is an important point. The structure has to comply with the terms and conditions of contract (Consultation, Unit or Centre of chronic pain, structures of palliative care, of psycho-oncology, of nutrition, of social care). A common technical organization is one of the interests. The structure has to set up strong links with the private practitioners, the networks, the home medical care (HAD) and the nurses services at home (SSIAD), when they exist, to guarantee the continuity of the supportive care under all its aspects and in order to take into account the preferences of the patients. According to Hospital 2007 propositions, the extended, flexible and general purpose Group of Sanitary Cooperation (GCS) meets the necessities inherent to the structures of supportive care within the territories of health because it can be established between one or several health care centres and the private health professionals, thus favouring the cooperation between public and private health care centres. PSPH and general medicine.

Development and validation of the Neuropathic Pain Symptom Inventory.

This study describes the development and validation of the Neuropathic Pain Symptom Inventory (NPSI), a new self-questionnaire specifically designed to evaluate the different symptoms of neuropathic pain. Following a development phase and a pilot study, we generated a list of descriptors reflecting spontaneous ongoing or paroxysmal pain, evoked pain (i.e. mechanical and thermal allodynia/hyperalgesia) and dysesthesia/paresthesia. Each of these items was quantified on a (0-10) numerical scale. The validation procedure was performed in 176 consecutive patients with neuropathic pain of peripheral (n = 120) or central (n = 56) origin, recruited in five pain centers in France and Belgium. It included: (i) assessment of the test-retest reliability of each item, (ii) determination of the factorial structure of the questionnaire and analysis of convergent and divergent validities (i.e. construct validity), and (iii) evaluation of the ability of the NPSI to detect the effects of treatment (i.e. sensitivity to change). The final version of the NPSI includes 10 descriptors (plus two temporal items) that allow discrimination and quantification of five distinct clinically relevant dimensions of neuropathic pain syndromes and that are sensitive to treatment. The psychometric properties of the NPSI suggest that it might be used to characterize subgroups of neuropathic pain patients and verify whether they respond differentially to various pharmacological agents or other therapeutic interventions.

Clinical study of chronic pain in hereditary myopathies.

In the field of neuromuscular diseases, pain and its management remain imperfectly understood and described. We study 68 unselected, consecutive adult patients attending a multidisciplinary consultation for hereditary myopathy. Forty-six (67%) were suffering from chronic pain. Pain was assessed with self report questionnaire and a standardized clinical evaluation. Mean duration of the pain was 7.2+/-8.9 years, and multiple body sites were involved in 91% of cases. Usual pain intensity (Visual Analogue Scale 0-100) was moderate (39.5+/-26.2). For 42 patients (91%) the principal cause of the pain was of muscular origin, with frequent features of myofascial pain syndromes (MPS, 50%) and fibromyalgia (FMS, 26%). Pain was the major complaint for 6.3% of the patients. Pain management was essentially based on physiotherapy. Only a minority of patients (38%) has an appropriate drug treatment. Common analgesics appeared to be very effective in these patients.

Tramadol in post-herpetic neuralgia: a randomized, double-blind, placebo-controlled trial.

The efficacy and safety of sustained-release tramadol compared to placebo in the treatment of post-herpetic neuralgia were evaluated in a multicenter, randomized, double-blind, parallel-group study in 127 outpatients. Treatment was administrated for 6 weeks. The dose of tramadol could be increased from 100 mg/day to 400 mg/day (300 mg/day in patients more than 75 years old). Groups were compared on changes in pain intensity on a Visual Analogue Scale (VAS) between inclusion and the 6th week of treatment (covariance analysis as main analysis and repeated measures analysis as complementary analysis) in the per protocol (PP) population. The randomized population comprised 127 patients aged 35-85 years, mostly females (72.4%). Groups were comparable at inclusion both in the intent to treat (ITT) population (63 patients in the tramadol group and 62 patients in the placebo group) and in the PP population (53 patients in the tramadol group and 55 patients in the placebo group). Mean pain intensity on day 43 adjusted on day 1 (covariance analysis) was significantly lower in the tramadol group than in the placebo group in both the PP (P=0.0499), and the ITT (P=0.031) populations. The two groups significantly differed on change in pain intensity over time (repeated measures analysis) in the ITT population (P=0.012). The percentage of pain relief over the 6th week was significantly higher in the tramadol group than in the placebo group (P=0.017). During the 6th week, patients in the tramadol group required less rescue medication than patients in the placebo group (P=0.022). No significant difference was found between groups either in pain intensity on a 5-point Verbal Scale (VRS) or in quality of life measurements. Tramadol was administered at an average dosage of 275.5 (89.7) mg/day after a 1-week dose-adaptation period. Tramadol was well tolerated. No notable difference appeared between groups either in the percentage of patients with treatment-associated adverse events (TAAE) (29.7% in the tramadol group and 31.8% in the placebo group) or in the total number of TAAE (31 in the tramadol group and 28 in the placebo group).

Assessing the severity of migraine: development of the MIGSEV scale.

OBJECTIVES: To identify items that serve to assess the severity of migraine with a high level of clinical and psychometric relevance and to combine these into a unitary severity scale. BACKGROUND: Severity of migraine is an important determinant of patient quality of life and of health care resource utilization. Despite this, no validated method exists for measuring migraine severity. METHODS: After selection from the medical literature items of potential relevance to the severity of migraine, consensus meetings led to a choice of items which subsequently were refined further on the basis of patient interviews. The psychometric properties of those items then were assessed in a survey involving 287 migraineurs. The methods used to test reliability and validity included test-retest, calculation of Cronbach alpha coefficient, analysis of factorial structure using principal components analysis, a comparison of the agreement between doctors' and patients' assessments, and correlation with a validated quality-of-life questionnaire. The most pertinent items revealed by the factorial analysis were combined in a unitary scale. RESULTS: Seven items reflecting severity were identified by expert consensus. These were intensity of pain, tolerability, disability in daily activities, presence of nausea or vomiting, resistance to treatment, duration of attacks, and frequency of attacks. Principal components analysis identified 3 dimensions accounting for 65% of the overall variance related to intensity of attacks, resistance to treatment, and frequency of attacks. The internal consistency and the reproducibility of the items appeared quite satisfactory, and variations in these items were correlated with quality-of-life scores. The 4 items related to intensity of attacks were combined into a single scale with 3 response modalities. CONCLUSIONS: The 3 dimensions identified by this investigation appeared medically relevant and to have good psychometric properties. The items on the intensity dimension can be used to generate a simple scale for assessing migraine attack severity.

Differences in the sensations of warmth on the anterior torso of normal and spinal-cord transected individuals.

The threshold to warming was measured at 10 sites on the anterior torso between the umbilicus and the clavicle of normal and spinal-cord transected individuals. In normal individuals, thresholds were higher on the thorax than on the abdomen. Men had higher and more variable thresholds than women. Magnitude estimations of supra-threshold stimuli showed that men offer verbal estimates of warmth that are about half of the size of the estimates given by women to the same stimuli. The psychometric function shows that in women, the sensation of warmth grows more rapidly than in men after starting from a higher initial value. After spinal-cord injury, thresholds for detection of warming were elevated. This effect was most noticeable within 8 cm of the anesthetic zone, but farther away, thresholds were still elevated but uniform as a function of distance, being about 30% higher than in normal individuals. After spinal-cord injury, the psychometric functions show that small stimuli elicit relatively large sensations and that these sensations grow more slowly with increasing skin temperatures than for normal individuals. Thus, for small warm stimuli spinal-cord-injured patients (both men and women) have a response similar to normal women but the slope of the psychometric function is flat, being similar to the slope observed for normal men.

Using the dallas pain questionnaire to classify individuals with low back pain in a working population.

STUDY DESIGN: Individuals with low back pain were classified by cluster analysis of their responses to the Dallas Pain Questionnaire. These results enabled development of an alternative simple classification tool that yielded results close to those obtained by the cluster analysis. OBJECTIVES: To use the Dallas Pain Questionnaire to classify workers with low back pain, and to develop a practical classification tool for physicians. SUMMARY OF BACKGROUND DATA: The severity of low back pain is important information for patient management. Questionnaires exploring the multidimensional aspect of low back pain have been used to classify individuals with low back pain. The Dallas Pain Questionnaire is a short self-administered questionnaire that explores the functional and emotional aspects of chronic low back pain. It was tested in a population still at work using a simplified scoring system. METHODS: The study included 765 persons with low back pain still at work who completed the self-administered questionnaire. Of these patients, 732 could be classified by cluster analysis according to their answers to the Dallas Pain Questionnaire. A classification tool was developed to categorize them. Using external variables, the groups thus formed were compared. RESULTS: Respondents were classified into four classes: class 1 (minor disability), class 2 (intermediate disability), class 3 (disability for some physical activities), and class 4 (physical disability and emotional disturbance). External pain-related variables were clearly associated with increasing low back pain severity as measured by this classification tool. CONCLUSIONS: The Dallas Pain Questionnaire discriminated between different groups of persons with low back pain. The proposed classification uses a short, simple practical tool to assess different levels of low back pain.

Elementos para la evaluación del dolor en el paciente con cáncer / Elements for reevaluation of pain in cancer patients

El dolor asociado a cáncer requiere una evaluación integral del paciente y de su enfermedad, para establecer una adecuada terapéutica, así como tambíen, una reevaluación periódica en el caso en que se presenten diferentes tipos de dolor o cambios en la evolución del mismo. La evaluación clínica del paciente con dolor por cáncer comprende la identificación de las causas del dolor, el análisis del mecanismo implicado y la evaluación de la intensidad del dolor; ésta última se realiza mediante diversas técnicas disponibles, como escalas unidimensionales globales o métodos comportamentales, que permiten indicar la dimensión de la queja dolorosa, aunque no pueden presumir la causa o definir el componente orgánico y psicológico presente. Debido a que el paciente con dolor por cáncer presenta síntomas psicológicos como sentimientos de inutilidad, stress, incomprensión o pérdida de autoestima, el papel del medio familiar se constituye en un soporte para una mejor calidad de vida del paciente

Comparative study of the validity of four French McGill Pain Questionnaire (MPQ) versions.

Four different French versions of the McGill Pain Questionnaire (MPQ) have been published: 3 are MPQ translations in Canadian French and 1 (QDSA) is an MPQ reconstruction in (France) French. The aim of our work was to study the validity of these available questionnaires for use in France. The validity was evaluated by 44 French physicians. Various validity criteria were studied: item, dimension, subclass and pain descriptor intensity. A new French MPQ was also developed. Significant validity differences emerged between the different MPQ versions. This study confirms the satisfactory validity of the QDSA. The validity of the newly developed French MPQ was equal but not better than the QDSA. A 15-item short MPQ-QDSA version was also developed. For studies with patients from France, it is recommended that the QDSA or the short MPQ-QDSA versions be used.

Comparative effects of electroacupuncture and transcutaneous nerve stimulation on the human blink reflex.

The effects of low frequency (2 Hz) high intensity (10-12 mA) (electroacupuncture, EA) and of high frequency (100 Hz) low intensity (2 mA) (transcutaneous nerve stimulation, TNS) conditioning stimuli were studied on the nociceptive component (R2) of the blink reflex in normal volunteers. EA induced a progressive and moderate partially naloxone-reversible depression in the R2 response. In contrast, TNS induced a rapid and major depression in this reflex. In this latter case, naloxone failed to produce any reversal effect. These two patterns of data are discussed and further electrophysiological studies provide some evidence for two different mechanisms in the depressive effects of EA and TNS upon the nociceptive component of the blink reflex in man.