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Clinical Reasoning Typical cases are discussed there. The cases are brought by practioners.

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Old 14-08-2012, 11:32 PM   #1
gollygosh
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Default Itchy Joints?

The patient is a 32 year old woman. She has had back pain since she was involved in a school bus accident as a 15 year old. The bus was hit while she was leaning over the seat of the bus. The pain was immediate, in the mid- to low thoracic region, and according to the patient has changed since it started. "It is a 5, it is always a 5". In addition she has complaints of knee, and shoulder pain, and intermittent numbness in all extremities. She has been diagnosed with fibromyalgia, and gastroparesis. Imaging is negative. Motion is guarded, and about 50% of normal. Her rheumatologist has started her on meds(can't remember the name), and recently progressed the dose. Her orthopod has told her she is fat, and to put 5# ankle weights on, and walk around the house. He has also suggested that she discontinue all medications.(go Rambo) She is being seen by a counselor for PTSD-un -related to the bus injury

I've spoken to her about the nature of pain as protective. I've explained sensitization and told her at this it is safe to assume than her brain is "programmed for pain" we started with laterality training using magazine pictures with about 75 % compliance for daily 15 sessions. She is working on a graded exercise progression--actiivity of choice is T'ai Chi with the Wii. I've used DNM on the back with her experiencing warmth and the pain is still a 5. Today, she has a great new complaint. Her joints itch. I have never heard a patient complain of itchy joints before(this is not the tissue overlying the joints, this is in the joints)
I told her I could think of a couple possible explanations:

1. adverse reaction to medication; please call your physician.
2. maybe the brain is taking a new look at the body and is interpreted things differently.
3. circulatory changes--I remember my skin itching in association with cold, or cold water swims.
4. I also suggested that while she did need to follow-up with physician that this may be a way for the brain to reassess the situation, and perhaps begin down modulating.


Then I tried Simple Contact with my hands on her hips, and for the first time actually saw some ideomotion, with the patient experiencing WESS, back pain to 4, feet burning/numb. Shoulders numb, and itching in all of her joints. I pointed out to her that the change in back pain from a 5 to a 4 put a hole in the concept that "it is always a 5", and encouraged her to attached some hope to that change.

I 'd appreciate thoughts.

Geralyn
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Old 14-08-2012, 11:42 PM   #2
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I think you're on the right track.

Anecdotally, I've always associated "itching" with "improvement".
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Old 15-08-2012, 03:09 PM   #3
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Geralyn,
I have heard this complaint from others in your patients situation. Just recently, a physician I work with asked "how is it that my arthritic shoulder can itch so much?"
If I'm not mistaken there was an article about itch and chronic pain in IASP a few months ago. Apparently their website is down this AM so I can retrieve it now. It probably can best be accounted for with Craig's interoception model. I'll try to find the article later.
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Old 15-08-2012, 06:19 PM   #4
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Also, see Oaklander, Common Neuropathic Itch Syndromes, open access
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Old 16-08-2012, 12:24 AM   #5
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Geralyn,
I don't know what made think it was recent, but the article I referred to is Chronic itch and chronic pain: analogous mechanisms. Volume 131, issue 1 of PAIN.
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Old 16-08-2012, 12:30 AM   #6
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From an anecdotal point of view, temporary itching post-TKA/THA seems quite usual, which suggests part of the recovery phase is well underway.
Bee and wasp stings also itch like crazy in the recovery phase which is regarded as a positive sign.

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Old 16-08-2012, 12:38 AM   #7
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I checked out the article from both Diane, and Gil. Thank you. (I'm sorry I don't know how to link.)

What has me confused is that itch is a sensation on the skin. It is attributed to a special type of c fiber. My patient's complaint are of itching IN the joints. Would this be a synesthesia? I will see her next week, and hopefully I will be able to report progress, or perhaps she will have received valuable information from her physician.

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Old 16-08-2012, 02:48 AM   #8
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Sometimes itch, like pain, is not a sensation but a perception.
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“If you make people think they're thinking, they'll love you, but if you really make them think, they'll hate you." ~Don Marquis

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Old 16-08-2012, 03:30 AM   #9
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My experience is itching like you describe is along the line of what Gil is suggesting and that pain and itching is analogous and like Diane suggests, we are left with the same questions regarding itching as we are with pain. What is causing it, what does it signify and what, if anything can we do to resolve it?
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Old 07-12-2012, 04:34 PM   #10
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I am usually pretty good at remembering where things are on a large forum, but for now, I have been so busy with work and life that my brain is a little out of sync, so since I haven't found a "bookmark" button on the forum yet, I am just bumping this thread up, because I want to read it in more detail in a few days.

Hope ya'll don't mind.

Last edited by Curious One; 08-12-2012 at 04:50 PM. Reason: - typo
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Old 07-12-2012, 06:52 PM   #11
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The bookmark feature you are looking for would probably be the subscribe feature in thread tools.

The article about itch coupled opioid channels in the spine is in the pain research forum back this summer.

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Old 07-12-2012, 10:08 PM   #12
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From PRF and PubMed pdf available for free.
Quote:
Cell. 2011 Oct 14;147(2):447-58. doi: 10.1016/j.cell.2011.08.043.
Unidirectional cross-activation of GRPR by MOR1D uncouples itch and analgesia induced by opioids.
Liu XY, Liu ZC, Sun YG, Ross M, Kim S, Tsai FF, Li QF, Jeffry J, Kim JY, Loh HH, Chen ZF.
Source
Center for the Study of Itch, Washington University School of Medicine Pain Center, St. Louis, MO 63110, USA.

Abstract

Spinal opioid-induced itch, a prevalent side effect of pain management, has been proposed to result from pain inhibition. We now report that the μ-opioid receptor (MOR) isoform MOR1D is essential for morphine-induced scratching (MIS), whereas the isoform MOR1 is required only for morphine-induced analgesia (MIA). MOR1D heterodimerizes with gastrin-releasing peptide receptor (GRPR) in the spinal cord, relaying itch information. We show that morphine triggers internalization of both GRPR and MOR1D, whereas GRP specifically triggers GRPR internalization and morphine-independent scratching. Providing potential insight into opioid-induced itch prevention, we demonstrate that molecular and pharmacologic inhibition of PLCβ3 and IP3R3, downstream effectors of GRPR, specifically block MIS but not MIA. In addition, blocking MOR1D-GRPR association attenuates MIS but not MIA. Together, these data suggest that opioid-induced itch is an active process concomitant with but independent of opioid analgesia, occurring via the unidirectional cross-activation of GRPR signaling by MOR1D heterodimerization.
Copyright © 2011 Elsevier Inc. All rights reserved.
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