Electroacupuncture at Sensitized Acupoints Relieves Somatic Referred Pain in Colitis Rats by Inhibiting Sympathetic-Sensory Coupling to Interfere with 5-HT Signaling Pathway / 中国结合医学杂志

OBJECTIVE@#To investigate whether electroacupuncture (EA) at sensitized acupoints could reduce sympathetic-sensory coupling (SSC) and neurogenic inflammatory response by interfering with 5-hydroxytryptamine (5-HT)ergic neural pathways to relieve colitis and somatic referred pain, and explore the underlying mechanisms.@*METHODS@#Rats were treated with 5% dextran sodium sulfate (DSS) solution for 7 days to establish a colitis model. Twelve rats were randomly divided into the control and model groups according to a random number table (n=6). According to the "Research on Rat Acupoint Atlas", sensitized acupoints and non-sensitized acupoints were determined. Rats were randomly divided into the control, model, Zusanli-EA (ST 36), Dachangshu-EA (BL 25), and Xinshu (BL 15) groups (n=6), as well as the control, model, EA, and EA + GR113808 (a 5-HT inhibitor) groups (n=6). The rats in the control group received no treatment. Acupuncture was administered on 2 days after modeling using the stimulation pavameters: 1 mA, 2 Hz, for 30 min, with sparse and dense waves, for 14 consecutive days. GR113808 was injected into the tail vein at 5 mg/kg before EA for 10 min for 7 consecutive days. Mechanical sensitivity was assessed with von Frey filaments. Body weight and disease activity index (DAI) scores of rats were determined. Hematoxylin and eosin staining was performed to observe colon histopathology. SSC was analyzed by immunofluorescence staining. Immunohistochemical staining was performed to detect 5-HT and substance P (SP) expressions. The calcitonin gene-related peptide (CGRP) in skin tissue and tyrosine hydroxylase (TH) protein levels in DRG were detected by Western blot. The levels of hyaluronic acid (HA), bradykinin (BK), prostaglandin I2 (PGI2) in skin tissue, 5-HT, tryptophan hydroxylase 1 (TPH1), serotonin transporters (SERT), 5-HT 3 receptor (5-HT3R), and 5-HT 4 receptor (5-HT4R) in colon tissue were measured by enzyme-linked immunosorbent assay (ELISA).@*RESULTS@#BL 25 and ST 36 acupoints were determined as sensitized acupoints, and BL 15 acupoint was used as a non-sensitized acupoint. EA at sensitized acupoints improved the DAI score, increased mechanical withdrawal thresholds, and alleviated colonic pathological damage of rats. EA at sensitized acupoints reduced SSC structures and decreased TH and CGRP expression levels (P<0.05). Furthermore, EA at sensitized acupoints reduced BK, PGI2, 5-HT, 5-HT3R and TPH1 levels, and increased HA, 5-HT4R and SERT levels in colitis rats (P<0.05). GR113808 treatment diminished the protective effect of EA at sensitized acupoints in colitis rats (P<0.05).@*CONCLUSION@#EA at sensitized acupoints alleviated DSS-induced somatic referred pain in colitis rats by interfering with 5-HTergic neural pathway, and reducing SSC inflammatory response.

Left Basilar Pneumonia Simulating Perforated Appendicitis with Peritonitis in a Child

We present an 8-year-old boy who presented with predominant abdominal symptoms initially to the referring hospital and the initial Chest radiograph being reported as normal. Inflammatory markers being sky high with abdominal symptoms and minimal Chest signs, he was referred to as an atypical case of Perforated Appendicitis. By the time patient was seen in the Tertiary University Teaching Hospital, he had developed classic clinical features of Left Basilar Pneumonia which was clearly evident on good quality repeat Chest radiograph and Ultrasound confirmed it and ruled out any abdominal pathology. The patient responded well to intravenous antibiotics followed by oral one with excellent recovery. Our case is a usual reminder of the fact that a patient is more likely to have a rare presentation of a common disease, than a common presentation of a rare one. Take a careful history and examine the child; consult the appropriate specialist resources and then, if necessary, extend your history and examination with review of available investigations especially being good at reading plain radiographs.

Referred Somatic Hyperalgesia Mediates Cardiac Regulation by the Activation of Sympathetic Nerves in a Rat Model of Myocardial Ischemia / 神经科学通报·英文版

Myocardial ischemia (MI) causes somatic referred pain and sympathetic hyperactivity, and the role of sensory inputs from referred areas in cardiac function and sympathetic hyperactivity remain unclear. Here, in a rat model, we showed that MI not only led to referred mechanical hypersensitivity on the forelimbs and upper back, but also elicited sympathetic sprouting in the skin of the referred area and C8-T6 dorsal root ganglia, and increased cardiac sympathetic tone, indicating sympathetic-sensory coupling. Moreover, intensifying referred hyperalgesic inputs with noxious mechanical, thermal, and electro-stimulation (ES) of the forearm augmented sympathetic hyperactivity and regulated cardiac function, whereas deafferentation of the left brachial plexus diminished sympathoexcitation. Intradermal injection of the α2 adrenoceptor (α2AR) antagonist yohimbine and agonist dexmedetomidine in the forearm attenuated the cardiac adjustment by ES. Overall, these findings suggest that sensory inputs from the referred pain area contribute to cardiac functional adjustment via peripheral α2AR-mediated sympathetic-sensory coupling.

Essence of acupoints and meridians based on the studies of myofascial trigger points / 中国针灸

Based on the modern anatomy and physiology, the referred pain of myofascial trigger points of each muscle is integrated; compared with the twelve meridians as well as conception vessel and governor vessel, the similarity of their position and running course is observed. With the current research progress of myofascial trigger points and fasciology, based on the running course of referred pain of trigger points, combined with fascia mechanics, nerve and vascular, the location of acupoints and meridians, as well as the relationship between acupoints and meridians, are discussed.

Trigeminal Schwannoma simulating orofacial pain: differential diagnosis and treatment. Case report / Schwannoma trigeminal simulando dor orofacial: diagnóstico diferencial e tratamento. Relato de caso

ABSTRACT BACKGROUND AND OBJECTIVES: Orofacial pain is a major diagnostic challenge for the most experienced clinicians. Due to the complexity regarding the trigeminal-cervical joint, orofacial pain with the same etiology may present different symptoms, and pain with similar symptomatology may have different causes. The objective of this study was to alert health professionals about the importance of differential diagnosis in the hypothesis of trigeminal neuralgia, where the inclusion of the dentist in the medical-hospital team is of paramount importance in establishing the correct diagnosis. CASE REPORT: Twenty-nine-year-old female patient complained of electric shock and pulsatile orofacial pain that covered the third division of the fifth cranial nerve on the right side. Magnetic resonance imaging revealed the presence of trigeminal Schwannoma, causing neuralgia due to its neural compressive nature. Two different neurosurgery departments suggested tumor resection. However, after the evaluation by a third neurosurgery department, in which a dentist, specialized in orofacial pain was part of the team, the complete evaluation established the final diagnosis of right lower first molar odontalgia, with irreversible acute pulpitis as the cause of the symptoms and the expansive lesion was only a radiological finding. CONCLUSION: Interdisciplinary evaluation among physicians and dental surgeons is necessary to obtain the correct diagnosis when considering the hypothesis of trigeminal neuralgia.

RESUMO JUSTIFICATIVA E OBJETIVOS: As dores orofaciais representam grande desafio diagnóstico ao mais experiente clínico. Devido à complexidade do conjunto trigeminocervical, as dores orofaciais com a mesma etiologia podem apresentar sintomas diferentes, e dores com o mesmo sintoma podem ter etiologias diferentes. O objetivo foi alertar o profissional da saúde sobre a importância do diagnóstico diferencial quando aventada a hipótese diagnóstica de neuralgia trigeminal, e a presença do cirurgião-dentista na equipe médico-hospitalar é de suma importância para o estabelecimento do diagnóstico. RELATO DO CASO: Paciente do sexo feminino, 29 anos, apresentou dor orofacial em choque elétrico e pulsátil que percorria o trajeto da terceira divisão do V par craniano, do lado direito. A ressonância nuclear magnética evidenciou Schwannoma trigeminal, sendo diagnosticada neuralgia trigeminal secundária à essa lesão expansiva. Foi sugerida ressecção tumoral em dois serviços de neurocirurgia. Contudo, após a avaliação de um terceiro serviço de neurocirurgia, com a participação de cirurgião-dentista especialista em dor orofacial, foi estabelecido o diagnóstico de odontalgia do primeiro molar inferior direito, com pulpite aguda irreversível, sendo essa a causa do quadro sintomático, e a lesão expansiva, apenas um achado radiológico. CONCLUSÃO: A avaliação interdisciplinar entre médicos e cirurgiões-dentistas é necessária para o diagnóstico correto quando a hipótese diagnóstica for neuralgia trigeminal.

The sensitization phenomenon of acupoint and biological significances / 中国针灸

In the pathological conditions, the human body induces somatic sensory exchanges and takes neurogenic inflammatory reactions according to referred visceral organ. Acupoint possesses both diagnosing and treating functions according to the acupuncture theory. The sensitization of acupoint refers to a pathophysiological dynamic change which is manifested predominately as a neurogenic inflammatory reaction in the specific area(s) of the body surface under pathological conditions. Furthermore, the process of acupoint from "silent" (physiological status) to "active" (pathological status) is generally represented by the dynamic changes of acupoint location, size and physicochemical environment. These responses of acupoint sensitization simultaneously activate self-healing system in the body and eventually induce the curative effects.

Pain, click and crepitation as factors associated with temporomandibular dysfunction in Parkinson's disease / Dor, estalido e crepitação como fatores associados à disfunção temporomandibular na doença de Parkinson

ABSTRACT BACKGROUND AND OBJECTIVES: Parkinson's disease leads to mandibular movements that affect the masticatory cycle and induce orofacial pain, one of the main clinical alterations found in temporomandibular dysfunction. Thus, the present study aimed to analyze the possible factors associated with temporomandibular dysfunction and to verify the frequency of the dysfunction in this population. METHODS: This was a cross-sectional study in which the participants were evaluated using the Diagnostic Criteria for Temporomandibular Dysfunction research, used to classify the temporomandibular dysfunction and to obtain by physical examination and self-report the variables studied. RESULTS: A total of 139 people with Parkinson's disease were evaluated. Of these, 77 met the eligibility criteria, with 70% of the sample being male, with an average age of 62±9 years; Parkinson's disease diagnosis time of 6±4 years and with 71% of the sample in the moderate stage of Parkinson's disease. No significant associations were found between age, gender, time and stage of the disease with temporomandibular dysfunction. Of the variables analyzed, the significant results showed that the presence of pain (OR=10.92, 95% CI=2.25-59.93, p<0.001) has a greater chance of developing temporomandibular dysfunction, crepitation (Kappa=0.34, p<0.004) reflects moderate accuracy in the classification of temporomandibular joint disorder and the click (negative predictive value=77%, p<0.032) increases the probability of having temporomandibular dysfunction. CONCLUSION: Therefore, in this study, the frequency of the temporomandibular dysfunction was 30%, and it was observed that the factors associated with the dysfunction in people with Parkinson's disease were: pain, click, and crackle.

RESUMO JUSTIFICATIVA E OBJETIVOS: A doença de Parkinson leva a movimentos mandibulares que afetam o ciclo mastigatório e induzem a dor orofacial, uma das principais alterações clínicas encontradas na disfunção temporomandibular. Sendo assim, o presente estudo objetivou analisar os possíveis fatores associados à disfunção temporomandibular e verificar a frequência da disfunção nessa população. MÉTODOS: Trata-se de um estudo de corte transversal, no qual os participantes foram avaliados com o Critério de Diagnóstico para pesquisa em disfunção temporomandibular, utilizado para classificar a disfunção temporomandibular e obter, através do exame físico e autorrelato, as variáveis estudadas. RESULTADOS: Foram avaliadas 139 pessoas com doença de Parkinson. Dessas, 77 encontraram-se dentro dos critérios de elegibilidade, sendo que 70% da amostra era do sexo masculino, com média de idade de 62±9 anos, tempo de diagnóstico da doença de Parkinson de 6±4 anos e com 71% da amostra no estágio moderado. Não foram encontradas associações significativas entre a idade, sexo, tempo e estágio da doença com a disfunção temporomandibular. Das variáveis analisadas, os resultados significativos mostraram que a presença de dor (OR=10,92; IC95%=2,25-59,93; p<0,001) representa uma maior chance de desenvolver a disfunção temporomandibular, a crepitação (Kappa=0,34; p<0,004) reflete uma precisão moderada na classificação do transtorno da articulação temporomandibular e o estalido (valor preditivo negativo=77%; p<0,032) aumenta a probabilidade de ter a disfunção temporomandibular. CONCLUSÃO: Neste estudo, a frequência de disfunção temporomandibular foi de 30% e verificou-se que os fatores associados à disfunção em pessoas com doença de Parkinson foram dor, estalido e crepitação.

Correlation Between Referred Pain Region and Sensitized Acupoints in Patients with Stable Angina Pectoris and Distribution of Sensitized Spots in Rats with Myocardial Ischemia / 针刺研究

OBJECTIVE: To observe the correlation between the referred pain regions of stable angina pectoris (SAP) and the acupoints in coronary heart disease (CHD) patients and to investigate the rule of regional sensitized point distribution in rats. METHODS: A total of 1 046 CHD patients with SAP from 8 hospitals in China were recruited in the present study. The tenderness was palpated along the left and right chest, back, shoulder, upper limb, etc. by a specially-assigned researcher in each hospital. Among them, 77 patients accepted pain threshold (PT) measurement by using a hand-held esthesiometer. In animal experiments, 14 SD rats were subjected to occlusion of the left anterior descending branch of the left coronary artery for 4 h for establishing myocardial ischemia (MI) model, and other 4 normal rats were used as the sham-operation control group. Four hours after MI, all the rats accepted tail venous injection of 5% Evans blue (50 mg/kg) for examining the distribution of the blue dye exudation spots at the body surface where the mechanical PT was also detected by a von Frey. RESULTS: In 1 046 CHD patients, 987 (94.36%) were found to have at least one tenderness spot. The tenderness spots were found at the left chest (87.47%), right chest (13.67%), left arm (ulnar side, 41.30%), right upper limb (4.68%), left shoulder back (30.21%), right shoulder back (7.07%), etc., accompanied with rash or pigmentation, subcutaneous induration, cord-like tissue contracture, skin sag, etc. The mechanical PT level was significantly lower at the tenderness spots of the left upper limb than at non-tender points of the right upper limb in CHD patients (P<0.001). Tenderness and cutaneous abnormal changes in angor pectoris patients distributed mostly on the left chest, back, shoulder and upper limb, and some also on the right. Tender points scattered on, near or outside acupoints. A similar distribution of the blue exudation spots and lower mechanical PT spots were found in MI rats, but not in sham-MI rats. CONCLUSION: In the case of MI, a regular "referred sensitization" response frequently occurs in the dermatomere area innervated by the corresponding segments (T 1－T 5) in both CHD patients and MI rats, which may be closely associated with the formation of acupoints in ancient China.

Understanding of the trigger points of myalgia: acupuncture and dry needling exploration and modern acupuncture mechanism / 中国针灸

The similarities and differences between trigger points of myalgia and acupoints were explored. Nodules could be detected by B-ultrasound at trigger points of myalgia, but not acupoints. In clinical symptoms, the referred pain pathway of trigger points of myalgia is similar with the pathway of acupuncture meridian. Therefore, the location of trigger points of myalgia should take referred pain as pathway, which is similar with locating acupoints as meridian. Acupuncture at trigger points of myalgia takes jumping feeling as criterion, while acupuncture at acupoints are mainly based on acid swelling and numbness. From clinical observation to basic experimental research, a lot of pathophysiological evidence is provided for trigger point of myalgia. It is believed that the trigger point of myalgia might be the precise acupoint in modern scientific research, and the meridian is the synthesis of the mechanics of nerve, blood vessel and fascia. Although acupuncture and dry needling are different in theory, but the scientific foundation of TCM and western medicine is coherent.

Bilateral testicular pain as an acute aortic dissection symptom / Dolor testicular bilateral como presentación de disección aórtica aguda

Abstract Acute aortic dissection is a serious cardiovascular event and the most common acute disease of the great vessels. According to the anatomical distribution of the compromised aorta, the Stanford Group classifies it into type A and type B. Its prognosis depends on its early identification and treatment, as the mortality rate in type A increases rapidly with each hour of delay of diagnosis. Clinical manifestations of aortic dissection may be varied, which makes its early diagnosis difficult. Regarding its diagnosis, genital pain is one of the rarest symptoms. In this paper, the case of a patient who initially attended a health care institution due to acute bilateral testicular pain and was eventually diagnosed with acute aortic dissection is presented.

Resumen La disección aórtica aguda es un evento cardiovascular catastrófico que corresponde a la más común de las enfermedades agudas de los grandes vasos. Según la distribución anatómica de la aorta comprometida, el grupo de Stanford la clasifica en dos tipos: A y B. Su pronóstico depende de la identificación y manejo tempranos, siendo la tasa de mortalidad rápidamente creciente en el tipo A con cada hora que se retrasa el diagnóstico. Las manifestaciones clínicas de la disección aórtica pueden ser múltiples, lo que dificulta su diagnóstico precoz. Dentro de las formas de presentación, una de las más infrecuentes es el dolor en los genitales. Se presenta el caso clínico de un paciente que consulta inicialmente por un dolor agudo testicular bilateral y que finalmente es diagnosticado con disección aórtica aguda.

Síndrome miofascial / Myofascial syndrome

El síndrome de dolor miofascial es un complejo de síntomas sensoriales, motores y autonómicos causados por puntos gatillo miofasciales y estos como puntos de exquisita sensibilidad e hiperirritabilidad localizados en una banda tensa palpable, en músculos o su fascia, que producen una respuesta de contracción local de las fibras musculares por un tipo específico de palpación y si es lo suficientemente hiperirritable, da lugar a dolor, sensibilidad y fenómenos autonómicos, así como la disfunción en zonas por lo general distantes de su sitio de origen. Con una alta prevalencia en la población general, y responsable de gran parte de discapacidades y disfunciones en ámbitos laborales y actividades de la vida cotidiana. Presenta factores precipitantes de índole mecánico, estructural, postural, nutricional y endocrino, e involucra una fisiopatología específica, con la participación de múltiples factores proinflamatorios y sustancias neuro-vasoactivas. Su diagnóstico es fundamentalmente clínico, y existen diversos tratamientos para evitar su cronicidad y avance, que usualmente involucra tratamientos accesibles y costoefectivos, los cuales pueden brindar al paciente una solución o manejo a un dolor crónico, muchas veces subdiagnosticado e infratratado, si el médico cuenta con los conocimiento adecuados sobreesta entidad.

Myofascial pain syndrome is compoused by sensory, motor and autonomic symptoms that are generated by myofascial trigger points that are exquisite in sensitivity and irritability. These trigger points are located in a palpable taut band in muscle or fascia, which produce a local twitch response of muscle fibers for a specific type of palpation and if there is enough hyperirritability results in pain, tenderness and autonomic phenomena and dysfunction that appears usually in distant areas from its site of origin. With a high prevalence in the general population, myofascial síndrome is responsible for disability and dysfunction in work areas and daily life activities. It presents precipitating factors, such mechanical, structural, postural, nutritional and endocrine, and involves a specific pathophysiology, involving multiple pro-inflammatory factors and neuro-vasoactive substances. Diagnosis is mainly clinical, and there are various treatments to prevent chronicity and development, which usually involves easy and económica access to treatments, which may give the patient a solution or managing a chronic pain, often underdiagnosed and undertreated, if it has adequate knowledge about this entity.

Diagnosis and treatment of abnormal dental pain

Most dental pain is caused by an organic problem such as dental caries, periodontitis, pulpitis, or trauma. Diagnosis and treatment of these symptoms are relatively straightforward. However, patients often also complain of abnormal dental pain that has a non-dental origin, whose diagnosis is challenging. Such abnormal dental pain can be categorized on the basis of its cause as referred pain, neuromodulatory pain, and neuropathic pain. When it is difficult to diagnose a patient's dental pain, these potential alternate causes should be considered. In this clinical review, we have presented a case of referred pain from the digastric muscle (Patient 1), of pulpectomized (Patient 2), and of pulpectomized pain (Patient 3) to illustrate referred, neuromodulatory, and neuropathic pain, respectively. The Patient 1 was advised muscle stretching and gentle massage of the trigger points, as well as pain relief using a nonsteroidal anti-inflammatory and the tricyclic antidepressant amitriptyline. The pain in Patient 2 was relieved completely by the tricyclic antidepressant amitriptyline. In Patient 3, the pain was controlled using either a continuous drip infusion of adenosine triphosphate or intravenous Mg2+ and lidocaine administered every 2 weeks. In each case of abnormal dental pain, the patient's diagnostic chart was used (Fig.2 and 3). Pain was satisfactorily relieved in all cases.

A Case of Bruxism-Induced Otalgia

Here, the author presents a case of bruxism-induced otalgia in a 29-year-old female patient. The pain was sharp and penetrating in character. It was usually worse in the morning and frequently radiated to the right temporal area. She had received unsuccessful medical treatments for migraine headache. The otoendoscopic examination revealed a normal tympanic membrane. A thorough inspection of her teeth revealed excessive wear on the incisal edges, and the cause of her otalgia was identified as bruxism-related temporomandibular joint disorder. After the use of an occlusal splint and repeated botulinum toxin injections in the masseter and anterior temporalis muscles, along with good sleep hygiene, she experienced significant relief of pain and symptoms. The author suggests that multidisciplinary cooperation between ENT clinicians and dentists is necessary for the quick and accurate diagnosis and treatment of bruxism and the consequential referred otalgia.

Referred Pain to the Knee in Hip Diseases : A Case Series Study / The Japanese Journal of Rehabilitation Medicine

Patient 1, a 75-year-old woman with a past history of osteoarthritis of the right knee and Parkinson disease, had a subarachnoid hemorrhage. She complained of right knee pain during her rehabilitation. It turned out that she had sustained a right trochanteric fracture after falling out of bed in another hospital. Patient 2, an 86-year-old woman with a past history of rheumatoid arthritis, was treated with the Gamma nail technique for a left trochanteric fracture. She described experiencing pain in the region from the left knee to the lateral side of the left thigh during her rehabilitation, about two months after the hip operation. X-ray and computed tomography images showed varus displacement of the femoral head due to screw cut-out. In each of these cases, it took some time for us to detect the underlying hip diseases. The dermatome shows regions of the skin innervated by each single spinal segment. Similarly, the sclerotome shows regions of bone and periosteum innervated by each single spinal segment. According to Inman and Saunders's sclerotome, the proximal portion of the femur is mainly innervated by L3, L4 and L5. On the other hand, in dermatome perspective, L3, L4 and L5 innervate the knee and region around the knee. It means that hip diseases can cause referred pain to the knee.Untypical pain in distant regions from the hip joint makes it difficult to examine the hip joint and causes delay in an accurate diagnosis, as in the cases just described. Therefore, we should keep in mind that hip diseases can cause referred pain to the knee.

Frequency and Location of Referred Pain in Patients with Temporomandibular Disorder / Frecuencia y Ubicación del Dolor Referido en Pacientes con Trastornos Temporomandibulares

Based on the survey of records regarding the location and frequency of referred pain in patients with temporomandibular disorder when certain pre-established areas are palpated, we proposed an anatomical-topographical division of the head and neck to allow the standardization and reproducibility of locations of referred pain. Of the 835 charts reviewed, 419 (50.2%) patients had referred pain on palpation of the regions based on the Research Diagnostic Criteria for Temporomandibular Disorders (RDC/TMD) and palpation of the cervical regions, as often analyzed by the Cochran Q test. The concordance coefficient of Kendall examined the correlation between regions of referred pain concerning to palpated sites. The new regions were defined preauricular, facial lateral, temporoparietal, posterior head, posterior and lateral cervical, anterior cervical and calvaria. The region palpated that originated more referred pain was corresponding to the masseter muscle followed by the region of the sternocleidomastoid muscle, regardless of the side palpated. On palpation of the regions established by the RDC/TMD, the most frequent area of referred pain was the lateral facial region. On palpation of the neck, were the posterior and lateral cervical regions. The sites that originated more referred pain when palpated were the masseter, temporalis, sternocleidomastoid and trapezius muscles.

Basado en la encuesta de registros relativos a la ubicación y frecuencia de dolor referido en pacientes con trastorno temporomandibular al palpar ciertas áreas preestablecidas, propusimos una division topográfica anatómica de cabeza y cuello para permitir la estandarización y reproducibilidad de los lugares de dolor referido. Al examinar los gráficos de 835 sujetos, 419 un (50,2%) de los pacientes reportaron dolor referido a la palpación de las regiones sobre la base de los Criterios Diagnósticos para la Investigación de Trastornos Temporomandibulares (CDI/TTM) y palpación de la region cervical, con análisis de frecuencia con prueba de Cochran Q. El coeficiente de concordancia de Kendall examinó la correlación entre las regiones de dolor referido en relación a los sitios palpados. Las regiones nuevas fueron definidas como, pre-auricular, facial lateral, temporoparietal, cabeza posterior, posterior y lateral cervical, cervical anterior y bóveda craneal. La región de palpado en la cual se originó el dolor mencionado con mayor frecuencia, corresponde al músculo masetero, seguido por la región del músculo esternocleidomastoideo, independientemente del lado palpado. Durante la palpación de las regiones establecidas por los CDI/TTM, la zona más frecuente de dolor referido fue la región facial lateral. A la palpación del cuello, el dolor referido se reportó en la parte posterior y en las regiones cervicales laterales. Los sitios en los que se originó el mayor dolor referido a la palpación, fueron los músculos maseteros, músculos temporales, esternocleidomastoideo y trapecio.

Management of Patients with L2 Spinal Nerve Root Block Who Are Suffering from Low Back and Referred Pain

STUDY DESIGN: Prospective clinical study. OBJECTIVES: The aim of the study was to verify the effectiveness of L2 spinal nerve root block for patients who are suffering from low back pain and referred pain with compound causes. SUMMARY OF LITERATURE REVIEW: Most of low back pain and referred pain arises from discs, facet joints and sacroiliac joints. All structures above have the pain perception pathway through sympathetic nerves with a connection to L2 spinal nerves. MATERIALS AND METHODS: We selected patients with low back pain and referred pain for more than 2 weeks. Each 50 patients were randomly allocated to an experimental and a control group.The experimental group underwent a L2 spinal nerve root block with 2cc of 0.25% bupibacaine at the symptom dominant side. The control group underwent a skin infiltration with 2cc of 2% lidocaine only. The pain was assessed with a visual analogue scale (VAS) consisting of 100 points at 5minutes, day 1, day 3, day 5, day 7 and day 30 postprocedure. RESULTS: Both groups showed a significant improvement after the procedures(p=0.000). However, a greater improvement was shown in the experimental group(p=0.000). In the individual analysis, the experimental group had improved as time elapsed and the significancewas maintained until 30 days. However, in control group, the significance was lost at day 30. CONCLUSION: L2 spinal nerve root block is recognized to reduce the low back and referred pains which arise from compound causes in a degenerative spinal disease.

Los aportes de Henry Head a las basesneuroanatómicas y fisiológicas de la terapia de segmento / The contributions of Henry Head to neuroanatomical and physiological bases of therapy segment

Henry Head, neurólogo británico, ha pasado a la historia de la medicina occidental por su contribución a la creación de los mapas de dermatomas. Una modalidad terapéutica dentro de la medicina neuralterapéutica es la terapia de segmento y, dentro del estudio del marco de sustentación teórica y experimental de su utilidad se encuentra este artículo. Las hipótesis planteadas por Head en cuanto a la asociación e interrelación de sensibilidad cutánea y visceral, pueden constituirse en un aporte para las bases neuroanatómicas y fisiológicas de la neuralterapia y la medicina en general. Se realiza una revisión histórica de una parte de su trabajo menos difundida, dedicada al dolor referido en la enfermedad visceral y en los cambios mentales asociados a la misma...

Henry Head, a British neurologist, carved a name for himself in the Western Medicine Annals for his contribution to the creation of dermatome maps. Segment therapy stands as one of the therapeutic modalities making up neural-therapeutic medicine, and this paper is within the theoretical and experimental support frame of the study of its utilization. The hypotheses proposed by Head in terms of association and interrelation of cutaneous and visceral sensitivity can be deemed as a contribution to the neural-anatomic physiologic grounds for not only neural-therapy, but also general medicine. This paper constitutes a historic review of one of the least known parts of his work, devoted to visceral-disease-referred pain and visceral-disease-associated mental changes...

Referred Pain in Right Arm from Abdominal Wall Pseudoaneurysm

Pseudoaneurysm of the abdominal wall is a possible but very rare clinical entity. It is a known complication of surgery, trauma, or arterial puncture, but it is rarely spontaneous. Even though it can usually present with a wide range of local symptoms, it can cause referred pain via spinal cord, which is cross-excited with afferent sympathetic nervous system. We report a case of right arm pain which was referred from a small abdominal pseudoaneurysm like a referred pain from gall bladder. This rare entity should be considered in the differential for pain management in case that the pain does not resolve with medication or interventional pain management.

Chest Pain: The Only Symptom of Gastric Ulcer / General Medicine

A 51-year-old woman presented with a 3-month history of left-sided chest pain. The pain was colicky, without associated tenderness, and involved the T5-8 thoracic dermatomes. We suspected referred pain from peptic ulcer, and upper gastrointestinal endoscopy revealed multiple ulcers in the middle-third of the gastric lesser curvature. As the patient was on non-steroidal anti-inflammatory drug (NSAID) treatment for tension headaches, NSAID-induced peptic ulcer was diagnosed. Proton-pump inhibitor (PPI) treatment resulted in prompt pain relief. There are few reports of chest pain as the sole presenting symptom of peptic ulcer. Nevertheless, although rare, peptic ulcer should also be considered in the differential diagnosis of chest pain.

Estudo da relação entre hiperatividade dos músculos esfenomandibulares e sintomatologia visual / Relationship between sphenomandibular muscle hyperactivity and visual symptoms

This was an observational, descriptive study developed after an anatomical investigation of cadavers to identify the sphenomandibular muscle as an independent entity. The objective here was to perform a clinical and interpretative evaluation of the physiological relationships between the functions of the sphenomandibular muscle and various symptoms, thereby associating temporomandibular disorders with ocular pain. Ten anatomical sets (five cadavers) in the Department of Anatomy of the Medicine School of the Catholic University of Goiás were examined. This study was conducted between April, 2006 and December, 2008. Patients (181 subjects) suffering from temporomandibular disorder were treated in the Federal University of Goiás Dental School. Two groups were compared: Group I consisted of 58 patients with temporomandibular disorder, referred ocular pain, and hyperactivity of the sphenomandibular muscles; Group II was comprised of 45 patients with temporomandibular disorder, ocular pain, but no hyperactivity of the sphenomandibular muscles. After a clinical exam, treatments were conducted with semi-yearly follow-up exams for 2 years. Responses to the treatment were evaluated by questionnaires thereby quantifying existing levels of ocular pain. Pain was eliminated in 46 of the 58 patients in Group I (79.31%) and 8 of the 45 patients in Group II (17.77%). Our evaluation affirms that the sphenomandibular muscle, independent of the temporal muscle, has an intimate relationship with the orbit. The clinical exam allowed an evaluation of the sphenomandibular muscles in temporomandibular disorder episodes. The hyperactivity of the sphenomandibular muscle is thus significantly related to the presence of ocular-referred pain (p<0.05).

Estudo observacional e descritivo desenvolvido após estudo anatômico feito em cadáveres para a identificação do músculo esfenomandibular como entidade independente. Pretendeuse uma avaliação clínica interpretativa das relações fisiológicas entre as funções do músculo esfenomandibular e a sintomatologia que envolve desordem temporomandibular com dor ocular. Foram examinados 10 conjuntos anatômicos (cinco cadáveres) no Departamento de Anatomia da Faculdade de Medicina da Pontifícia Universidade Católica de Goiás. Além disso, foram tratados e acompanhados 181 pacientes atendidos no Ambulatório da Faculdade de Odontologia da Universidade Federal de Goiás, portadores de Desordem Temporomandibular. O trabalho foi desenvolvido entre abril de 2006 e dezembro de 2008. Foram comparados: o Grupo I, de 58 pacientes que apresentavam desordem temporomandibular, dor ocular reflexa e hiperatividade dos músculos esfenomandibulares; e o Grupo II, composto de 45 pacientes que apresentavam a desordem, dor ocular e não apresentavam hiperatividade dos músculos esfenomandibulares. O tratamento foi realizado após exame clínico com acompanhamento durante 2 anos, em avaliações semestrais. A resposta ao tratamento foi avaliada mediante questionário de opinião que estratifica o nível da dor ocular. A dor foi eliminada em 46 dos 58 pacientes do Grupo I (79,31%) e em 8 dos 45 pacientes do Grupo II (17,77%). O resultado da avaliação permite afi rmar que o músculo esfenomandibular, músculo independente do temporal, está em íntima relação com a órbita. O exame clínico permitiu a avaliação da hiperatividade dos músculos esfenomandibulares nos episódios de desordens temporomandibulares. A hiperatividade dos músculos esfenomandibulares está significativamente associada à presença de dor ocular reflexa (p < 0,05).