下腰痛诊治过程中的临床思考

下腰痛是常见疾病,其病因复杂,治疗方法虽多,但并无特效疗法.因此,下腰痛的诊治比较棘手.本文回顾性分析2002年4月至2008年12月因下腰痛住院的936例患者的诊治过程,探讨如何在科学的临床思维指导下,综合运用各种诊断和治疗的方法,提高下腰痛的诊治水平.     

腰腿痛患者现病史的客观采集及其评价

腰腿痛患者的现病史采集比较困难,临床上经常引发混乱,甚至会被忽略。作者根据临床经验总结了一套相对系统和客观的分析思路。借此启发和提示临床医生临诊分析的主观能动性。作者还通过时现病史采集在医学发展史上的地位变化的回顾,提出了现代临床医学对患者症状特征进行归纳分析的重要性。     

Threat of pain influences social context effects on verbal pain report and facial expression

Current theoretical models of pain catastrophizing have diverging predictions regarding the role of social context and perceived threat on pain expression. The communal coping model of catastrophizing predicts that high pain catastrophizers display more pain expression in the presence of another, regardless of the threat value of the pain, while a cognitive appraisal model predicts high pain catastrophizers to express more pain when pain has increased threat value, regardless of social context. A 2 × 2 factorial design was used to test the validity of both predictions. Healthy participants with varying levels of pain catastrophizing were exposed to a cold pressor task, consisting of a 60 s immersion and 60 s recovery period. Interestingly, the immersion results revealed that beyond and independent from the effects of pain catastrophizing, the effect of threat on verbal pain report and facial expression was dependent on social context and vice versa. In a threatening context, perceived threat of pain mediated the inhibitory effect of social presence on pain expression, suggesting that the observer acted as a safety signal. In the recovery period, social presence enhanced facial expression, but only when no threat was induced. The results are discussed in terms of the dynamic interaction between social context and threat appraisals.     

PTSD and Emotional Distress Symptoms Measured After a Motor Vehicle Accident: Relationships with Pain Coping Profiles

This study explored differences among pain patients classified as Dysfunctional, Interpersonally Distressed, and Adaptive Copers on the Multidimensional Pain Inventory with respect to PTSD symptomatology, anxiety, and depression. Eighty-five patients with pain complaints who had experienced a serious motor vehicle accident were classified into these three pain coping categories and assessed using clinician and self-report measures. Results indicated that patients classified as Adaptive Copers (n = 24) showed less PTSD symptomatology, anxiety, and depressed mood, relative to individuals classified as Dysfunctional (n = 36) and as Interpersonally Distressed (n = 25), who did not differ on these dimensions. Emotional responses during the accident (fear, helplessness, danger, perceived control, and certainty that one would die) did not differentiate the groups. Pain profiles contributed to the prediction of self-reported PTSD symptoms, controlling for state anxiety. These data suggest that pain patients with both Dysfunctional and Interpersonally Distressed coping profiles are at elevated risk for a range of posttrauma problems following a serious motor vehicle accident.     

Is pain-related fear a predictor of somatosensory hypervigilance in chronic low back pain patients?

Pain-related fear has been found to be associated with increased disability and increased pain perception in patients with chronic low back pain. A possible mechanism by which pain-related fear could lead to increased pain perception is heightened attention to somatosensory sensations. In the present study, chronic pain patients reporting either a high or low level of pain related fear and control participants performed an auditory reaction time task, while occasionally non-painful electrical stimuli--accompanied by threatening instructions--were given to the arm or back. In the primary task condition, participants had to perform the auditory task while ignoring the electrical stimuli. Next, the task was presented under dual task conditions in which participants had to respond both to tones as well as to detection of electrical stimuli. It was hypothesized that for the primary task, high fearful patients would show greater disruption of performance on the auditory task than low fearful patients and controls when stimuli were presented to the back. For the dual task, slower reaction times for the auditory task, in combination with faster detection of electrical stimuli was expected. The hypotheses were not confirmed but patients scoring high on pain-related fear did show an overall increase in reaction time for all conditions of the primary task, with or without simultaneous stimulation. Regression analyses demonstrated that high pain-related fear was associated with increased reaction time to tones both in patients and healthy controls, and that within patients pain-related fear was a better predictor of reaction time to tones than present pain intensity. The findings may be interpreted as showing that patients with elevated levels of pain-related fear habitually attend to somatic sensations, giving less priority to other attention-demanding tasks.     

Longitudinal Assessment of Pain, Coping, and Daily Functioning in Children with Sickle Cell Disease Receiving Pain Management Skills Training

Objective. To conduct intensive pain management skills training (IST) in children with sickle cell disease (SCD) and their parents and to comprehensively evaluate pain, coping, and daily functioning in children pre, immediately post, and 3 months following treatment. Methods. Three children who received IST in nonpharmacological and pharmacological pain management strategies completed a Coping Strategies Questionnaire (CSQ) at pre, post, and follow-up assessments, and daily pain and activity diaries for 18 weeks, spanning from 1 week pretreatment to 11 weeks posttreatment. Results. From pre- to posttreatment, 1 child receiving IST indicated increased report of active coping attempts and all 3 children indicated decreased report of negative thinking on the CSQ. Participants in IST used coping skills on 90% of days with pain and reported the skills to be moderately helpful on the daily diaries. For daily activities such as eating dinner, playing with friends, and hours slept, children participated similarly on days with pain and days without pain during the posttreatment period. Given the small number of participants in this study, individual cases are discussed to highlight similarities and differences in how participants responded to the treatment and during the 3-month follow-up period. Conclusions. In this pilot study, each participant showed improvement in coping and daily functioning after completing the IST program. Individual differences in response to treatment indicate the need for more targeted intervention programs that incorporate pharmacological and nonpharmacological components. The results of this study highlight both the promise and the complications of conducting comprehensive pain intervention and functional outcome studies in children with SCD.     

Spatial and temporal characteristics of the spine muscles activation during walking in patients with lumbar instability due to degenerative lumbar disk disease: Evaluation in pre-surgical setting

Our purpose was to investigate the spatial and temporal profile of the paraspinal muscle activation during gait in a group of 13 patients with lumbar instability (LI) in a pre-surgical setting compared to the results with those from both 13 healthy controls (HC) and a sample of 7 patients with failed back surgery syndrome (FBSS), which represents a chronic untreatable condition, in which the spine muscles function is expected to be widely impaired.Spatiotemporal gait parameters, trunk kinematics, and muscle activation were measured through a motion analysis system integrated with a surface EMG device. The bilateral paraspinal muscles (longissimus) at L3-L4, L4-L5, and L5-S1 levels and lumbar iliocostalis muscles were evaluated.Statistical analysis revealed significant differences between groups in the step length, step width, and trunk bending and rotation. As regard the EMG analysis, significant differences were found in the cross-correlation, full-width percentage and center of activation values between groups, for all muscles investigated.Patients with LI, showed preserved trunk movements compared to HC but a series of EMG abnormalities of the spinal muscles, in terms of left-right symmetry, top-down synchronization, and spatiotemporal activation and modulation compared to the HC group. In patients with LI some of such EMG abnormalities regarded mainly the segment involved by the instability and were strictly correlated to the pain perception. Conversely, in patients with FBSS the EMG abnormalities regarded all the spinal muscles, irrespective to the segment involved, and were correlated to the disease’s severity. Furthermore, patients with FBSS showed reduced lateral bending and rotation of the trunk and a reduced gait performance and balance.Our methodological approach to analyze the functional status of patients with LI due to spine disease with surgical indications, even in more complex conditions such as deformities, could allow to evaluate the biomechanics of the spine in the preoperative conditions and, in the future, to verify whether and which surgical procedure may either preserve or improve the spine muscle function during gait.     

疼痛表达与中国人表达的躯体化

西方研究者认为中国人习惯用躯体化方式表达心理不适,不能区分身体疼痛和心理痛苦。通过回顾中文文本,认为在传统中国的语境中,身心互应的哲学观念使个体能够以一种隐性但自明的方式来表达自身情感。但在社会变迁的环境中,原有的社会关联多数都已崩解,个体开始使用躯体化以及疼痛作为索引,从而提供自我的某种参照。     

神经内分泌系统与多囊卵巢综合征

精神、心理因素会引起神经递质的改变,神经递质的变化又能引起促性腺激素的分泌异常,以神经递质作为桥梁,研究精神、心理因素与多囊卵巢综合征(PCOS)的关系。精神、心理因素使体内多巴胺、去甲肾上腺素、β-内啡肽及5-羟色胺的含量变化,从而影响促性腺激素释放激素及黄体生成素的水平。因此,精神、心理因素是PCOS的重要诱因,而PCOS又加重心理障碍。