Journal of Pain & Palliative Care Pharmacotherapy. 2014;28:54–55. ISSN: 1536-0288 print / 1536-0539 online DOI: 10.3109/15360288.2013.879248
EUROPEAN PERSPECTIVES ON PAIN AND PALLIATIVE CARE
Pain Management Discussion Forum Harald Breivik AB STRACT A case of a 51-year-old woman who presented with generalized body pain is discussed. The importance of a focused examination is described. The patient has tick-borne disease. Criteria for the examination are listed. This report is adapted from paineurope 2013; Issue 2, ©Haymarket Medical Publications Ltd., and is presented with permission. paineurope is provided as a service to pain management by Mundipharma International, Ltd., and is distributed free of charge to health care professionals in Europe. Archival issues can be accessed via the Web site: http://www.paineurope.com, at which European health professionals can register online to receive copies of the quarterly publication. KEYWORDS examination, focused, generalized pain, tick-born disease
• focused pain history, • physical examination, and • specific diagnostic studies (Table 1).
CLINICAL SCENARIO A 51-year-old lady presents with a 3-year history of increasing generalized, mostly musculoskeletal pain; fatigue; and bouts of low-grade fever. Her general practitioner (GP) has no clue as to what is causing this dramatic change in a previously always healthy, physically and socially active person. She is university educated and has a well-paid job, but has now been on extended sick leave for almost 2 years. Laboratory tests for rheumatological and autoimmune conditions are negative. Three of her four children (teenagers) have also developed similar, but less pronounced health problems.
Refer to the author’s 2008 paper published in the British Journal of Anaesthesia.1 The outcome of assessment by means of the focused pain history and examination was as follows:
• There was no indication of any risk factor for developing an idiopathic, generalized pain condition; the patient was a healthy, active, positive person before the pain developed. • Her family history is interesting in that three of her children developed similar pain problems at about the same time. • They had acquired a summer cabin on a part of the coast where tick-borne diseases have been diagnosed with increasing frequency lately. • Clinical and specific pain examinations revealed nothing extraordinary besides generalized tender muscles and joints. • There were indications of hypoesthesia for most sensory stimuli in the distal parts of her lower extremities and slight (questionable) hyperalgesia to pinprick as well as cold allodynia in the same locations. • Our patient had positive serological tests for the Borrelia spirochetes as well as for the intracellular bacterium Anaplasma phagocytophilum, a coinfection that can aggravate Lyme disease.
QUERY How would you go about diagnosing her pain condition? What about the therapy?
RESPONSE Assessing chronic pain should always be done in a systematic way that documents: Harald Breivik, MD, DMSc, FRCA, is Emeritus Professor of Anesthesiology, University of Oslo, Oslo, Norway. Address correspondence to: Dr. Harald Brievik, Division of Anesthesiology and Intensive Care, Rikshospitalet University Hospital, 0027 Oslo, Norway (E-mail: [email protected]).
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European Perspectives on Pain and Palliative Care TABLE 1.
Assessment of Chronic Pain1
Focused pain history
Physical examination
Specific diagnostic studies
General medical history. Specific pain history, clarifying: • Location. • Intensity. • Pain descriptors. • Temporal aspects. • Possible pathophysiological/ etiological issues. General physical examination. Neurological examination. Musculoskeletal system examination. Assessment of psychological factors. Specific pain evaluation. Quantitative sensory testing (QST). “Poor man’s sensory testing”: • Cold (20–25◦ C) water in a glass tube (for cold allodynia—A-delta and C-fibers). • Glass tube with 40◦ C warm water (for warm/heat allodynia—C-fibers). • Cotton wool and artist’s brush for dynamic mechanical allodynia. • Blunt needle for hyperalgesia and temporal summation of pain stimuli. Diagnostic nerve blocks, when appropriate. Pharmacological tests, when appropriate. Conventional radiography, CT, MRI, when appropriate.
The preliminary diagnosis was neuroborreliosis. Treatment for this disease is antibiotics. However, there are disagreements over the type of antibiotic(s), dosing, and for how long treatment is required.2
55
The ticks in question (Ixodes ricinus) are increasing in numbers and, as the climate warms, have migrated further north and higher up towards the mountainous areas of Norway. Tick-borne disease is an increasing health problem in most parts of Europe and in North America. Ixodes ricinus transmits bacteria (in Norway the most common are Borrelia burgdorferi sensu lato, Anaplasma phagocytophilum, Bartonella species, and Francisella tularensis), parasites (Babesia divergens/microti), and viruses (such as tick- borne encephalitis) to domestic animals, wild animals, and humans. Chronic Lyme disease can be an elusive diagnosis because the clinical picture varies considerably, and commonly used serological tests may not be sensitive enough. There is a heated debate going on between those who see chronic neuroborreliosis frequently, treat it vigorously with antibiotics for prolonged periods—and those who are convinced that it is a rare and insignificant health problem, cured by 2 weeks of oral tetracycline.2 Pain clinicians as well as general practitioners (GPs) should be aware of this. Declaration of interest: The author reports no conflicts of interest. The author alone is responsible for the content and writing of the paper.
REFERENCES [1] Breivik H, Borchgrevink PC, et al. Br J Anaesth. 2008;101:17–24. [2] Stricker R, Johnson L. FASEB J. 2011;25:4085–4087.
Copyright of Journal of Pain & Palliative Care Pharmacotherapy is the property of Taylor & Francis Ltd and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use.
EUROPEAN PERSPECTIVES ON PAIN AND PALLIATIVE CARE
Pain Management Discussion Forum Harald Breivik AB STRACT A case of a 51-year-old woman who presented with generalized body pain is discussed. The importance of a focused examination is described. The patient has tick-borne disease. Criteria for the examination are listed. This report is adapted from paineurope 2013; Issue 2, ©Haymarket Medical Publications Ltd., and is presented with permission. paineurope is provided as a service to pain management by Mundipharma International, Ltd., and is distributed free of charge to health care professionals in Europe. Archival issues can be accessed via the Web site: http://www.paineurope.com, at which European health professionals can register online to receive copies of the quarterly publication. KEYWORDS examination, focused, generalized pain, tick-born disease
• focused pain history, • physical examination, and • specific diagnostic studies (Table 1).
CLINICAL SCENARIO A 51-year-old lady presents with a 3-year history of increasing generalized, mostly musculoskeletal pain; fatigue; and bouts of low-grade fever. Her general practitioner (GP) has no clue as to what is causing this dramatic change in a previously always healthy, physically and socially active person. She is university educated and has a well-paid job, but has now been on extended sick leave for almost 2 years. Laboratory tests for rheumatological and autoimmune conditions are negative. Three of her four children (teenagers) have also developed similar, but less pronounced health problems.
Refer to the author’s 2008 paper published in the British Journal of Anaesthesia.1 The outcome of assessment by means of the focused pain history and examination was as follows:
• There was no indication of any risk factor for developing an idiopathic, generalized pain condition; the patient was a healthy, active, positive person before the pain developed. • Her family history is interesting in that three of her children developed similar pain problems at about the same time. • They had acquired a summer cabin on a part of the coast where tick-borne diseases have been diagnosed with increasing frequency lately. • Clinical and specific pain examinations revealed nothing extraordinary besides generalized tender muscles and joints. • There were indications of hypoesthesia for most sensory stimuli in the distal parts of her lower extremities and slight (questionable) hyperalgesia to pinprick as well as cold allodynia in the same locations. • Our patient had positive serological tests for the Borrelia spirochetes as well as for the intracellular bacterium Anaplasma phagocytophilum, a coinfection that can aggravate Lyme disease.
QUERY How would you go about diagnosing her pain condition? What about the therapy?
RESPONSE Assessing chronic pain should always be done in a systematic way that documents: Harald Breivik, MD, DMSc, FRCA, is Emeritus Professor of Anesthesiology, University of Oslo, Oslo, Norway. Address correspondence to: Dr. Harald Brievik, Division of Anesthesiology and Intensive Care, Rikshospitalet University Hospital, 0027 Oslo, Norway (E-mail: [email protected]).
54
European Perspectives on Pain and Palliative Care TABLE 1.
Assessment of Chronic Pain1
Focused pain history
Physical examination
Specific diagnostic studies
General medical history. Specific pain history, clarifying: • Location. • Intensity. • Pain descriptors. • Temporal aspects. • Possible pathophysiological/ etiological issues. General physical examination. Neurological examination. Musculoskeletal system examination. Assessment of psychological factors. Specific pain evaluation. Quantitative sensory testing (QST). “Poor man’s sensory testing”: • Cold (20–25◦ C) water in a glass tube (for cold allodynia—A-delta and C-fibers). • Glass tube with 40◦ C warm water (for warm/heat allodynia—C-fibers). • Cotton wool and artist’s brush for dynamic mechanical allodynia. • Blunt needle for hyperalgesia and temporal summation of pain stimuli. Diagnostic nerve blocks, when appropriate. Pharmacological tests, when appropriate. Conventional radiography, CT, MRI, when appropriate.
The preliminary diagnosis was neuroborreliosis. Treatment for this disease is antibiotics. However, there are disagreements over the type of antibiotic(s), dosing, and for how long treatment is required.2
55
The ticks in question (Ixodes ricinus) are increasing in numbers and, as the climate warms, have migrated further north and higher up towards the mountainous areas of Norway. Tick-borne disease is an increasing health problem in most parts of Europe and in North America. Ixodes ricinus transmits bacteria (in Norway the most common are Borrelia burgdorferi sensu lato, Anaplasma phagocytophilum, Bartonella species, and Francisella tularensis), parasites (Babesia divergens/microti), and viruses (such as tick- borne encephalitis) to domestic animals, wild animals, and humans. Chronic Lyme disease can be an elusive diagnosis because the clinical picture varies considerably, and commonly used serological tests may not be sensitive enough. There is a heated debate going on between those who see chronic neuroborreliosis frequently, treat it vigorously with antibiotics for prolonged periods—and those who are convinced that it is a rare and insignificant health problem, cured by 2 weeks of oral tetracycline.2 Pain clinicians as well as general practitioners (GPs) should be aware of this. Declaration of interest: The author reports no conflicts of interest. The author alone is responsible for the content and writing of the paper.
REFERENCES [1] Breivik H, Borchgrevink PC, et al. Br J Anaesth. 2008;101:17–24. [2] Stricker R, Johnson L. FASEB J. 2011;25:4085–4087.
Copyright of Journal of Pain & Palliative Care Pharmacotherapy is the property of Taylor & Francis Ltd and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use.
