Permanent End To Chronic Pain
In order to investigate the molecular and cellular mechanisms for pain-related plasticity in the ACC, we decided to use genetic approaches together with integrative neuroscience techniques. First, we wanted to test if persistent pain may be enhanced by genetically enhanced NMDA receptor function, a key mechanism for triggering central plasticity in the brain4. Functional NMDA receptors contain heteromeric combinations of the NR1 subunit plus one or more of NR2A-D. While NR1 shows a widespread distribution in the brains, NR2 subunits exhibit regional distribution. In humans and rodents, NR2A and NR2B subunits predominate in forebrain structure. NR2A and NR2B subunits confer distinct properties to NMDA receptors heteromers containing NR1 plus NR2B mediate a current that decays three to four times more slowly than receptors composed of NR1 plus NR2A. Unlike other ionotropic channels, NMDA receptors are 5-10 times more permeable to Ca2+ than to Na+ or K+. NMDA receptor-mediated currents...
The distinctions between illness and disease for medical anthropologists illness is the patient's experience of symptoms in the context of family, work, and community disease is the practitioner's model of the pathological process. Help-seeking is usually orientated around the illness experience with respect to what is most at stake for the patient and significant others. Care can founder when the patient's primary concerns with the illness experience conflicts with or is entirely different from the physician's focus on disease. Thus, many patients with chronic pain experience interrogation of the disease process by the sceptical physician as delegitimizing their illness experience. This leads to high rates of dissatisfaction with care among this group of patients. Many so-called 'orphan diseases' chronic pain, chronic fatigue syndrome, etc. produce this result. When patients and families are from ethnic minority backgrounds, differences in cultural meanings and practices intensify...
We prefer an incision 2.5 cm from the midline at the coronal suture line on the side opposite the more severe pain. Placement closer to the midline was tried early on to allow laying the contacts in the PVG but in some patients subcortical produced leg weakness from traversing the subcortical white matter in the frontal lobe. Our target point ordinarily is 8 to 12 mm posterior to the intercommissural (AC-PC) midpoint and approximately 5 mm lateral to the midline, with the tip of the electrode on or 2 to 5 mm below the AC-PC line, with placement of the tip 1 to 2 mm from the edge of the third ventricle (Figure 6.8). We ordinarily insert a small-diameter exploring electrode and stimulate the area of interest to obtain the results of stimulation. Stimulation of this area usually begins at 250 microsecond pulses at 30 Hz and gradually increases to 8 volts or until side effects are encountered, or pain relief obtained. Side effects from stimulation can be used as an indication of a good...
Target and may result in neuroma formation. The afferent endings trapped within the nerve end are a source of spontaneous activity (e.g., Lisney and Devor, 1987) and are pathologically mechanosensitive (e.g., Welk et al., 1990). The latter is also a characteristic of demyelinating lesions (Smith and McDonald, 1980 Calvin et al., 1982). Neuromas in humans can be a source of chronic pain, and surgical excision runs the risk of further neuroma formation. The hyperexcitability and ectopic impulse generation at diseased terminals are plausibly related to the accumulation of Na+ channels, which has been demonstrated by using specific Na+ channel antibodies in peripheral nerve of fish, Apteronotus (Devor et al., 1989) and in rat (Devor et al., 1993). Consistent with Na+ -channel involvement, ectopic activity can be attenuated and inhibited by agents that block Na+ channels, such as the marine toxin tetrodotoxin (TTX) (Matzner and Devor, 1994). It is also silenced by low concentrations of...
Fentanyl transdermal patches are available for analgesia in chronic pain and for postsurgical patients. The use of the patch is contraindicated, however, for patients immediately after surgery because of the profound respiratory depression associated with its use. The patches must be removed and replaced every 3 days. The onset of action of transdermal fentanyl is slower than that of oral morphine. Thus, patients may require the use of oral analgesics until therapeutic levels of fentanyl are achieved. Fentanyl lozenges have been used to induce anesthesia in children and to reduce pain associated with diagnostic tests or cancer in adult patients. However, all of the adverse side effects associated with morphine are produced with far greater intensity, but shorter duration, by fentanyl in the patch, the lozenge, or IV administration. Given the abuse liability of fentanyl, controversy exists as to the ethics of marketing a lollipop lozenge form.
It has been demonstrated that relatively low doses of dynorphin produce analgesia, whereas higher doses produce hyperalgesia that persists for greater then 60 days after a single intrathecal injection. This protracted effect appears to be independent of activation of opioid receptors. In addition it has been shown that, under pathological conditions resulting from injury to peripheral nerves, the up-regulation of spinal dynorphin is accompanied by the development of chronic pain states. Thus, the development of chronic pain states can be blocked by anti-dynorphin antiserum (Lai et al. 2001). Thus, dynorphin can have both nociceptive and antinociceptive properties. It is thought that low levels of dynorphin, acting via k receptors, induce analgesia. Higher doses of dynorphin allows dynorphin to interact with multiple sites on the NMDA receptor complex and, thereby, to produce excitatory responses resulting in nociceptive and even toxic effects (Laughlin et al. 2001).
There is a paucity of literature regarding thoracic z-joint injections. Pain patterns were studied in normal volunteers in a preliminary investigation confirming that thoracic z-joints can cause both local and referred pain (33), and a referral pain diagram has been constructed based on these data from intra-articular injections. However, innervation to the z-joints in the thoracic spine is different than that anticipated for the cervical and lumbar spine. In an anatomic investigation, Chua and Bogduk (34) found that the medial branch upon leaving the inter-transverse space typically crossed the supralateral corners of the transverse processes and then passed medially and inferiorly across the posterior surfaces of the transverse processes, before dividing to innervate the multifidus muscles. Therefore the supralateral corners of the transverse processes may be more accurate target points if considering medial branch blocks for thoracic z-joints. A nonrandomized trial evaluating 40...
Patients receiving opioids for pain management become dependent. Furthermore, dependence is less likely if opioids are used judiciously. Acute pain can be controlled with opioids such as hydromorphone or oxy-codone, which have a rapid onset and short duration of action. In contrast, chronic pain is better treated with opioids such as methadone or morphine (e.g., Duramorph, MS Contin), which are less likely to produce euphoria because of their slow onset of action. Dependence in patients is most likely to occur in those with pain of unexplained or poorly defined etiology. Avoiding long-term use of opioids in this population reduces the risk of developing dependence. Development of dependence should not be a consideration in the management of terminal cancer pain.
In addition we have also demonstrated in mice that pregnanolone hemisuccinate prevents NMDA-induced convulsions, and is analgesic in the late phase of formalin-induced pain, an animal model for chronic neuropathic pain (111). These results suggest that in addition to neuroprotection pregnanolone hemisuccinate may potentially be useful in the treatment of seizure and chronic pain.
These are by far the most common mental disorders associated with pain in most settings. In the general population, 12 per cent of adults have experienced chronic widespread pain (defined according to the criteria of the American College of Rheumatologists) in the previous 3 months and their prevalence of mental disorders is three times that of the pain-free population. Most of these diagnoses are mood and anxiety disorders, with the former being more common in those with chronic pain. In pain clinic settings, the prevalence of mental disorders varies according to referral patterns, but about 30 to 40 per cent of patients have depressive disorders, and this is similar in those with and those without a relevant physical disorder. (3) Those without organic disorders tend to have lower ratings for both mood disorders and pain severity. Those with mood disorders report more severe pain. Diagnosis of mood and anxiety disorders is based on the usual standardized criteria, but may be...
The patient's pain beliefs and behaviours (described below) are key aspects of the mental state examination. Patients often attribute chronic pain to an organic disorder and offer diagnoses it is essential to review their medical records to assess the clinical findings and investigations and the extent to which they support any diagnosis which has been made.
Many standardized questionnaires have been developed for the assessment of patients with chronic pain. They can be valuable for identifying mechanisms that contribute to pain, planning treatment, and monitoring changes during and after treatment. The evaluation of pain and associated beliefs and behaviours require measures developed specifically for this purpose, and these are described below. The belief that chronic as well as acute pain signals an underlying physical disease, which requires and should respond to physical intervention, contributes to the widespread dissatisfaction often expressed by patients and their doctors. Inappropriate beliefs contribute to the development and maintenance of chronic pain and non-adherence to treatment and must therefore be assessed. Beliefs that are relevant to pain assessment fall into three groups (6)
Investigations into predisposing, precipitating, and maintaining causes of chronic pain show that in several respects the origins are similar to those of somatization and the somatoform disorders. The family histories of patients with chronic pain include an excess of mood disorders, pain and disability, substance abuse, and personality disorders. Engel(7) described the dynamics of 'the pain prone patient' involving abusive childhood experiences, and noted how pain can become a pathway for the expression of guilt and expiation. Recent research(8) has focused on childhood physical and sexual abuse, but it is not clear whether the relationship with pain is, at least to some extent, determined by selective reporting, or whether it is mediated by the presence of mental disorders. Pain is particularly likely to become chronic in those who have limited coping strategies, as indicated by premorbid personality traits, although this may not be evident until they are faced with negative life...
The treatment of chronic pain has presented a challenge to the ingenuity of health professionals, particularly because no single specialty or health profession has the range of skills that are required. The treatment of mental disorders,(4) such as depressive or anxiety disorders, is similar in most respects, whether or not pain is a prominent feature. The presence of pain may lead to additional problems due to somatization. In the presence of pain, mental disorders tend to be missed, and when recognized are treated inadequately. Depressive disorders with features indicating a good response to antidepressants should be treated with full therapeutic doses, but not with narcotics. Anxiolytic drugs, including benzodiazepines, which result in dependence should not be used in the treatment of these chronic disorders.
Psychological treatments(4) are derived from different theoretical formulations of the aetiology of pain. These include behavioural, cognitive, and psychodynamic approaches that have been developed specifically for the treatment of chronic pain. Other approaches include various forms of 'stress management' including relaxation techniques, biofeedback, and hypnosis. Psychological treatments are rarely used in isolation, either from each other or from additional interventions.
These seem mainly confined to malingering after injury. First, systems of litigation should be expedited. Prolonged cases certainly make for exaggeration of symptoms and disability. Second, some patients with chronic disability, irrespective of cause, do respond to rehabilitative treatment (e.g. chronic pain programmes), even at a late stage. If such programmes were easily and generally available at an earlier stage in the development of the disorder, symptoms and subsequent disability could certainly be prevented in some patients.
The probability that individuals will attend to somatic information will depend on the competition for attention from other sources of available stimuli. An illustration of this is the fact that symptoms perception is strongly influenced by environmental factors. When the environment is lacking in stimulation individuals tend to pay more attention to bodily symptoms. Conversely, when an individual's attention is drawn to the external environment, bodily symptoms are less likely to be noticed. This finding has wide day-to-day applications ranging from why people cough in the boring parts of movies to explain demographic differences in symptoms reports such as increased symptom reporting among the socially isolated and the unemployed.(37) It also has clinical applications in chronic pain and other chronic medical conditions where patients' isolation may exacerbate the condition by increasing preoccupation with symptoms.
In the consultation function psychiatrists wait to be asked for their opinion. However, the liaison function is more proactive and preventive, in that the consultant tries to establish a stable relationship with a department which sees a high prevalence of patients with psychiatric problems. This is effected through weekly staff meetings and often by additional staff training. The 'psychiatric-medical function' is an integrated service aimed at meeting the structural and organizational requirements of the target population. This is guided by nurse acuity levels. Staff are selected and trained to provide integrated care. Organizational prototypes of this function are the psychological-medicine units and the German psychosomatic wards.( ) Specific target populations include behaviourally disturbed patients, who are physically unwell and require complex medical care, complex somatizers, those with chronic pain, and specific patient populations from, for example, neurology or geriatric...
Medical management focuses on the treatment of intercurrent illnesses such as diabetes, cardiovascular and respiratory diseases, psychiatric disorders and on any factors that may impair recovery. Choice of medications will be important in view of the several pharmaceutical preparations that have been incriminated in delayed recovery 23 . Medical personnel need to be alert to late complications of head injury such as hydrocephalus and chronic pain syndromes, sympathetic dys-synergia following spinal cord injury and reflex sympathetic dystrophy following peripheral nerve damage and seek expert advice where necessary.
It is useful to distinguish between acute and chronic pain. Pain begins frequently as an acute experience but, for a variety of reasons some physical and often some psychological it becomes a long-term or chronic problem. According to the IASP classification of chronic pain, this term refers to any pain exceeding three months in duration. Central neuropathic pain, including pain associated with diseases of the spinal cord. Central post-stroke pain is the most frequently studied central neuropathic pain condition. It occurs in about 8 of patients who suffer an infarction of the brain. The incidence is higher for infarctions of the brainstem. Two thirds of patients with multiple sclerosis have chronic pain, half of which is central neuropathic pain (3).
Absence of a significant neurological deficit. A variety of non-operative treatment modalities have been used. Objective data regarding the merits of each modality are limited, due to the subjective nature of pain and its associated disability and the various pain generators underlying the symptoms. Immobilization, anti-inflammatories and the judicious use of analgesics are a logical first line of treatment for acute and chronic pain syndromes. Active physical therapy and exercise can be effective in selected cases of chronic axial pain, for reactivation after an acute episode of pain or pro-phylactically to diminish the likelihood of recurrent pain after an acute episode. Steroid injections can help reduce a focus of acute inflammation. The treatment does not directly treat the underlying cause of the pain and the effect is probably temporary. Its use and that of alternative therapies must be studied more closely to determine their usefulness in the treatment of spondylosis.
Vowles KE, Gross RT (2003) Work-related beliefs about injury and physical capacity for work in individuals with chronic pain. Pain 101(3) 291-298 7. Koho P, Aho S et al. (2001) Assessment of chronic pain behaviour reliability of the method and its relationship with perceived disability, physical impairment and function. J Rehabil Med 33(3) 128-132 8. Veldhuijzen DS, Kenemans JL et al. (2006) Processing capacity in chronic pain patients a visual event-related potentials study. Pain 121(1 2) 60-68 24. Tulgar M (1992) Advances in electrical nerve stimulation techniques to manage chronic pain an overview. Adv Ther 9(6) 366-372 28. Carter ML (2004) Spinal cord stimulation in chronic pain a review of the evidence. Anaesth Intensive Care 32(1) 11-21 36. Arnstein PM (1997) The neuroplastic phenomenon a physiologic link between chronic pain and learning. J Neurosci Nurs 29(3) 179-186
Is this episode similar to previous episodes If a patient describes the pain as being different, it should raise suspicion of a different etiology of the pain. Most patients with chronic pain, such as that caused by sickle cell crisis or disease, are able to recognize their typical painful episode. Breakthrough painful episodes in children with sickle cell disease are treated as acute pain. Because of the recurring and life-long nature of this pain, however, principles of chronic pain management are also necessary, such as behavioral-cognitive, psychological, and physical modalities.
And achieve a clear and quantitatively measurable clinical outcome in a reasonably short period of time. This is the prevention of shoulder subluxation in stroke patients by TES-induced muscle exercise. The most common residual defect of a stroke is paralysis of the contralateral arm, with atrophy of the affected muscles. The majority of these patients go on to develop chronic pain in the affected shoulder as the weight of the arm gradually stretches the flaccid muscles and pulls the humeral head out of its socket (the glenoid fossa).23 Conventional treatments with slings and painkillers is generally ineffective and tends to interfere with any rehabilitation effort. Electrical stimulation of the affected muscles via skin surface electrodes (so-called deep transcutaneous electrical neuromuscular stimulation) has been reported to prevent and reverse this problem,24 but each treatment session requires a trip to the clinic to apply the electrodes and adjust the stimulation parameters.
Patients who have an acute distal biceps tendon rupture often describe the sensation at the time of injury as tearing, ripping, popping, or electric. The sensation is usually sudden and dramatic. The pain is not excruciating, and it often subsides after several days. Chronic pain in the region of the distal biceps tendon suggests an incomplete or partial tear. Range of motion is normal following an acute distal biceps tendon rupture. Significant swelling and ecchymosis about the medial and anterior elbow regions are common (Fig. 9.1). Ecchymosis is due to the bleeding associated with the rupture from the radial tuberosity. Ecchymosis typically does not appear until 1 or 2 days after injury and begins to resolve within 1 or 2 weeks. It can vary from a small patch that forms in the region of the flexor-pronator origin to an area that extends from the distal third of the medial forearm to the middle portion of the medial upper arm.
Conventional analgesics play an important role in the management of pain, both acute and chronic, although they may not be the mainstay of treatment. As patients suffering from chronic pain are likely to be taking the prescribed drugs for months or years, some important factors must be considered before selecting the drug and its mode of delivery.
Vertebroplasty and kyphoplasty have been studied most extensively in the treatment of painful osteporotic VCFs and are now viable alternatives to conservative bracing or open surgical reduction and fixation. Patients with osteporotic VCFs have progressive kyphosis, chronic pain, and impaired ambulatory capacity, which can also lead to depression, malnutrition, and diminished pulmonary function (92). Osteoporotic VCFs are now the most common etiology of vertebral body fractures, with nearly 700,000 new VCFs sustained each year (93). Patients with these fractures rarely present with neurologic deficits, making percutaenous intervention feasible, provided the posterior elements and posterior cortical wall of the vertebral body are intact and no radiographic retropulsed bone in the spinal canal is evident.
To foster and encourage research of pain mechanisms and pain syndromes and to help improve the management of patients with acute and chronic pain by bringing together basic scientists, physicians and other health professionals of various disciplines and backgrounds who have an interest in pain research and management.
Unfortunately these classical signs are often unreliable. They sometimes occur in patients with organic disease such as acute stroke. (26) In a number of pain syndromes the existence of pain in one part of the body may elicit a regional effect that overlaps anatomical boundaries but nevertheless is still physiological. (27) In these syndromes non-anatomical distributions of pain and global impairment of sensation may be attributable to the effects of neuronal plasticity, usually in the spinal cord. Glove and stocking analgesia has long been known to be potentially attributable to organic causes such as peripheral neuropathy which require careful exclusion. Similarly, in regional pain syndromes the fact that a region of the body is affected and the patient might think, feel, or imagine that pain may be present is not proof of a hysterical symptom, since changes in adjoining nerves within the spinal cord may produce the same effect in response to a continued input of chronic pain....
More versatile than reservoirs, implantable pumps have diverse applications in neurosurgery, particularly in the treatment of chronic pain (5,22). Intraspinal morphine, hydromorphone, bupivicane, and analgesic peptides have all been used to control patient pain in inpatient and outpatient settings (4,22). Implantable pumps have also been used for the treatment of spasticity with the intraspinal administration of baclofen (20,22,37). A more recent application of pump technology is in the treatment of Alzheimer's disease. Multicenter double-blind studies in Alzheimer's patients revealed a measurable improvement in behavior and neuropsychological test scores following bethanechol infusion (20,22). Finally, pumps have been used in the treatment of malignant glioma, in which postresection cavities have been targeted. Studies with methotrexate (19) achieved higher intratumoral concentrations than could be achieved with systemic administration (19,22). Side effects from intrathecal...
It was long suspected (e.g., Engle 1960), and is now widely documented by research findings from our laboratory and others that oral biology and systemic medicine are intimately intertwined. Certain prokaryotes that contribute the flora of the oral cavity are known to migrate into the cardiovascular system, to lodge in the aortic and the pulmonary valves, and to lead to severe cardiac malfunction and bacterial endocarditis. Serious tegumentary diseases, such as lichen planus, have their corresponding pathology in the oral mucosa (i.e., oral lichen planus, OLP, vide infra) (Chiappelli and Cajulis 2004). Several systemic neuroendocrine and immune responses to stress, to the allostatic response, and to bacteriokines, bacterial cytokine inducers that are produced by infectious pathogens and that contribute to the control of the pathological inflammatory response, are monitored in peripheral fluids (e.g., plasma, serum, urine), including total or parotid saliva. Case in point, the cold...
15.2.7 Examples of Importance of Pain Behaviour Especially in Chronic Pain 438 15.4.2 New Model to Explain Chronic Pain Neuromatrix Theory 443 15.5.4 Another Classification Suitable for Chronic Pain 450 188.8.131.52 Emory Pain Estimate Model 450 184.108.40.206 If Unchecked, Can Lead to Chronic Pain 453 15.7 Discussion of Acute vs Chronic Pain 471 15.7.2 Chronic Pain 477 220.127.116.11 Physiological Responses to Chronic Pain 477 18.104.22.168 Mechanism of Centralisation in Chronic Pain 477 22.214.171.124 Models That Can Be Used to Explain Chronic Pain 478
Pain, particularly if not reported by the patient because of limited communication in the intensive care setting, often leads to agitation and jeopardizes the patient's recovery. Insufficient amounts of analgesics may have been administered, for fear that the patient might become addicted. Addiction rarely develops unless the patient has a history of drug-seeking behavior or of chronic pain refractory to numerous interventions.
The expression of 'neuronal' proteins in the tumor may stimulate axonal outgrowth of free nerve endings, thereby enabling the tumor host to 'feel' the cancer as in NGF expression in pancreatic cancer or skeletal cancer which are frequently associated with chronic pain. Expression of 'neuronal' proteins in the nervous tissue on the other hand seems to play an important role in 'unwillingly' guiding tumor growth along nerve routes and may additionally stimulate tumor growth via paracrine mechanisms.
Anyone involved primarily in the management of chronic pain is aware that it may persist long after the initial tissue damage has healed. Pain reflects pathophysiological changes in the nervous system and they, together with changes that usually occur in patients' emotions and behaviour, have led to the conclusion that, in such cases, chronic pain is a specific health-care problem and a disease in its own right. This diagnostic category is not fully accepted among clinicians because many continue to believe that pain must be a symptom of an ongoing disease or injury. Current research reveals, however, that the pathophysiological changes mentioned persist when signs of the original cause for pain have disappeared. The signs and symptoms of chronic pain, once it has evolved into a disease, are listed in Box 3.7.1. The combination of these features of the condition reveal the potential for physical impairment, disability and handicap which collectively form the basis of significant...
Personality disorders have been considered as belonging to the spectrum of major psychiatric disorders. However, it must be remembered that external events, such as brain damage (organic personality disorders), or the psychological impact of a catastrophic event may also lead to personality changes. Severe psychiatric disorders may have a repercussion on the personality of the patient, and other illnesses may also have this effect. For example, chronic pain (of organic nature) can be accompanied by a profound personality change (algogenic psychosyndrome). Hypochondria or dissociative symptoms and traits may become relevant only after the patient has suffered an illness, or a problem related to diagnosis or treatment, or a problem involving the patient-physician relationship.
Peripheral nerve blocks are used frequently in the management of the chronic pain patient with varying success. Nerve blocks may be used as a diagnostic tool, but can be employed to provide symptomatic relief on a temporary or more permanent basis. Injection of local anesthetic around a nerve can often provide relief in chronic pain patients that is beyond the normal expected duration of the blockade. The blocks may be repeated over the course of weeks or months. If good results are obtained, more destructive methods can be used to provide more lasting results. However, a good result with local anesthetic does not always mean a successful block by more permanent means.
In 1970, based on these studies, Akil and I began a systematic acute stimulation study of sites in the periventricular (PVG) and periaqueductal (PAG) areas in humans to determine sites to be used for pain relief. These acute stimulation studies were carried out in five patients as a prelude to placing stereotaxic lesions in the centrum median for chronic pain. The results led us to believe that the entire area along the wall of the third ventricle, extending from a centimeter above the intercommissural line caudally into the area of the raphae nuclei, could be used for electrical stimulation analgesia in the human (41) (Figure 6.1). We chose a site in the periventricular area for chronic studies because of the minimal side-effects in this area, in contrast to stimulation at sites farther caudal in the brainstem (41, 42). Our chronic studies began in 1971 with the cooperation of Medtronic, Inc., Minneapolis, MN, which provided modified their induction spinal cord stimulation system for...
It has also been discovered that the immune system has memory and can learn, which means that there is intelligence in every cell and that individuals can influence that intelligence by conscious effort. Studies have shown that attitude, emotions, thoughts, stress, depression, lifestyle, as well as food, exercise, and environment, can have a direct affect on health conditions from chronic pain and coronary heart disease to cancer and AIDS.
If history and physical exam do not lead to a specific diagnosis for chest pain, it is unlikely that laboratory tests will be helpful. Laboratory studies usually confirm previously known disorders or abnormal findings that are suspected clinically. These studies are probably unnecessary in children with chronic pain, normal physical exam, and no history to indicate cardiac or pulmonary disease (Table I-8).
In addition to the cognitive examination, a physical examination should be conducted in all patients with AD, although this might not be most effectively and conveniently performed at the initial assessment. Physical illness, including chronic pain, infection, cardiac insufficiency, or anaemia are all common in the elderly and can both complicate the diagnosis of AD and increase confusion in those known to have AD.
Pain and Paroxysmal Symptoms It is disappointing how many patients are told that pain is not usually a feature of MS. Unfortunately, it will be a feature for almost every patient at some time during the course of the disease. Pain can be classified into two broad categories paroxysmal pain and chronic pain. Chronic pain is highly prevalent in those with well-established disease and is multi-factorial. It may result from poor posture, spasticity, contractures, lumbar pain, or persistent dysesthesia.
Techniques such as fMRI and TMS, which do not require craniotomy, will be essential for the further development of less invasive techniques for treating neurosurgical disease. For instance, in order to perform endovascular, radio-surgical, or focused ultrasound procedures safely in the vicinity of eloquent cortex, an accurate preprocedure map is necessary. Therefore, the development of diagnostic brain mapping techniques should proceed in parallel to the development of new therapeutic techniques. Certainly, we can anticipate that the combination of more refined understanding of individual functional anatomy and less invasive techniques will open up entirely new avenues of neurosurgical treatment. One intriguing possibility is the use of imaging techniques to target the site of functional neurosurgical procedures. For example, the ongoing investigations into the neural basis of chronic pain may allow the further refinement of neurosurgical procedures for the treatment of pain. Already,...
Neurostimulation began shortly after Melzack and Wall6 proposed the gate control theory in 1965. This theory proposed that painful peripheral stimuli carried by C-fibers and lightly myelinated A-delta fibers terminated at the substantia gelatinosa of the dorsal horn (the gate). Large myelinated A-beta fibers responsible for touch and vibratory sensation also terminated at the gate in the dorsal horn. It was hypothesized that their input could be manipulated to close the gate to the transmission of painful stimuli. As an application of the gate control theory, Shealy2 implanted the first spinal cord stimulator device for the treatment of chronic pain. This technique was noted to control pain, and it has undergone
Appropriate patients for neurostimulation implants must meet the following criterion the patient has a diagnosis amenable to this therapy (i.e., neuropathic pain syndromes), the patient has failed conservative therapy, significant psychological issues have been ruled out, and a trial has demonstrated pain relief.10 However, pure neuropathic pain syndromes are relatively less common than the mixed nocice-ptive neuropathic disorders, including failed back surgery syndrome (FBSS) (Figure 7.6a, b). Also, many patients with chronic pain will have some depressive symptomatology, but psychological screening can be extremely helpful to avoid implanting patients with major psychological disorders. An interesting study by Olson and colleagues11 revealed a high correlation between many items on a complex psychological testing battery and favorable response to trial stimulation. This is to say, an overall mood state is an important predictor of outcomes.
There has been one recent prospective, randomized study. North et al.22 selected fifty patients as candidates for repeat laminectomy. All patients had undergone previous surgery and were excluded from randomization if they presented with severe spinal canal stenosis, extremely large disc fragments, a major neurological deficit such as foot drop, or radiographic evidence of gross instability. In addition, patients were excluded for untreated dependency on narcotic analgesics or benzodiazepines, major psychiatric comorbidity, the presence of any significant or disabling chronic pain problem, or a chief complaint of low back pain exceeding lower extremity pain. Crossover between groups was permitted. The six-month follow-up report included twenty-seven patients. At this point, they became eligible for crossover. Of the fifteen patients who had undergone reoperation, 67 (ten patients) crossed over to SCS. Of the twelve patients who had undergone SCS, 17 (two patients) opted for crossover...
Treatment of chronic pain by epidural spinal cord stimulation a 10-year experience. J. Neurosurg., 5 402-407, 1991. 26. North, R. and Wetzel, T. Spinal cord stimulation for chronic pain of spinal origin. Spine, 22 2584-2591, 2002. 35. Kumar, K., Malik, S., and Demeria, D. Treatment of chronic pain with spinal cord stimulation versus alternative therapies cost-effectiveness analysis. Neurosurgery, 51(1) 106-115, 2002.
These trials showed that DBS for pain could be effective, but suggested a very low percentage (13.5 to 17.8 ) of patients could be proven to have clinically significant pain relief at long-term follow-up (Coffey, 2001). The lesson learned from this study was that future trials of analgesic devices follow structured protocols for patient selection and utilize uniform implantation and treatment paradigms. It is imperative that MCS be subjected to this type of scrutiny prior to its widespread adoption as a potential standard therapy for chronic pain. current status. Pain, 104(3) 431-435. Brown, J.A. and Pilitsis, J.G. (2005). Motor cortex stimulation for central and neuropathic facial pain a prospective study of 10 patients and observations of enhanced sensory and motor function during stimulation. Neurosurgery, 56(2) 290-297 discussion 290-297. Burchiel, K.J. (2001). Deep brain stimulation for chronic pain the results of two multi-center trials and Coffey, R.J....
Chronic pain - benign origin, e.g. postherpetic neuralgia 2. In chronic pain of benign origin, narcotics and sedatives must be avoided. In these patients, depression usually plays a role and the clinician must not underestimate the value of antidepressants. 3. In chronic pain from terminal malignancy, patients often require strong narcotics -morphine, heroin. Frequent administration of small doses provides the greatest effect.
Pre-emptive analgesia refers to interventions aimed at preventing the development of central sensitization, resulting in reduced requirement for analgesia and a lower incidence of chronic pain syndromes. This is of clinical relevance, as approximately 70 per cent of patients attending our pain center have chronic pain arising from an acute noxious event. Acute and chronic pain models reveal a greater effect from local or systemic analgesia administered before rather than after a noxious stimulus, but the clinical evidence is not so clear cut. Methodological reasons may account for this.
Patients become inattentive to the painful stimuli, less anxious, and more relaxed. Disruption of normal REM sleep occurs with opioid administration. In addition, opioids depress polysynaptic responses but can increase monosynaptic responses and lead to convulsant effects in high doses. In patients with chronic pain, the euphoric effect of opioids, mediated by the -receptor, is usually blunted. Some patients feel a dysphoric effect upon the administration of opioids, which is most likely mediated by the a-receptor.
Dezocine is indicated as an analgesic for moderate to severe pain. In addition, it shows promise in chronic pain states, such as with victims of severe burns. Contraindications and adverse effects of the drug are similar to those described for morphine. No tendency toward abuse has been demonstrated thus far.
The outcome of psychological and psychiatric treatment has been studied extensively, (119 but is difficult to evaluate because reports differ with regard to the characteristics of patients and disorders, inclusion criteria, assessments, and treatments as well as details of treatment delivery, attrition rates, choice of control groups, and the duration of follow-up. Many patients with chronic pain are unwilling to accept treatment and others are considered unsuitable. Nevertheless, psychological and rehabilitation treatments can have a sustained effect, based on the range of assessments that have been described. Some preliminary studies indicate that they can be cost effective, with reductions in direct health costs and possibly in benefit payments. The outcome of patients with different mental disorders has not been assessed systematically. Patients involved in seeking compensation tend to have a poorer outcome, even after litigation has been concluded, but they can also benefit from...
Physiotherapists also contribute, with hands-on measures to improve spasticity and control of balance. They are involved in the management of chronic pain situations and work towards improvement in overall general fitness. They also recommend the use of devices such as orthoses to assist in mobility and weight bearing and overcoming limb deformities due to abnormal posturing. In this regard, they liaise closely with the technicians who make such devices.
Pain has physical and psychological dimensions, both of which may be measured they form an important aspect of the diagnosis of painful disorders and are essential for the correct application of treatment and its assessment. Pain is a subjective experience but physiological changes that accompany it may be measured they include changes in heart rate, muscle tension, skin conductivity and electrical and metabolic activity in the brain. These measures are most consistent in acute rather than chronic pain and they are used primarily in laboratory studies. Clinically, pain assessment includes a full history of the development, nature, intensity, location and duration of pain. In addition to clinical examination, self-report measures of pain are often used.
Narcotic agonists are medications that relieve pain. These are safe and effective when properly administered. These medications are opioid based and are used to treat acute or chronic pain from trauma, tumor growth, and from surgical procedures. They are also used to treat pain caused by the progression of diseases or complications from other conditions.
Patients who are in chronic pain should keep a pain diary. A pain diary helps the healthcare professional develop a pain management plan. The patient is asked to keep a timed record of the pain experience to include when the pain starts, what starts it, how bad it is, what relieves the pain, and any other factors that may explain how the patient is responding to the pain. This record can help the healthcare provider and the patient plan effective pain management.
A parametric study using multielectrode recordings. J. Neurophysiol., 90(5) 3024-3039. Cameron, T. (2004). Safety and efficacy of spinal cord stimulation for the treatment of chronic pain a 20-year literature review. J. Neurosurg., 100(3 Suppl.) 254-267. Coffey, R.J. (2001). Deep brain stimulation for chronic pain results of two multicenter trials and a
Many patients with chronic pain do not respond or respond inadequately to conventional analgesia, but do gain relief from the following groups of drugs, either alone or in combination with conventional analgesics. These drugs act by altering the activity of monoamines at a synaptic level. Tricyclics prevent the uptake of NA and serotonin, whereas the MAOIs prevent their breakdown. The newer anti-depressants are selective serotonin uptake inhibitors. Of all the antidepres-sants, most experience has come from using amitriptyline, which has been shown to be of benefit in certain chronic pain syndromes, e.g. post-herpetic neuralgia, and anecdotal evidence supports its more widespread use in this field. Although the newer agents are being used, less is known about their clinical effect. Much smaller doses are used to treat chronic pain than those needed to treat depressive illness. It is common practise to start at the smallest dose, e.g. amitriptyline 10 mg nocte, and increase slowly, by...
The complex array of multiple system responses explains how peripheral inflammation can result in a state of both peripheral and central hyperexcitability, i.e., wind-up and central sensitisation, mediated by PGs and other endogenous products such as oxygen free radicals, all conditioning and or predisposing to persistent chronic pain states. Experimental states of central sensitisation, presenting changes similar to those associated with clinical chronic pain, can be obtained through repetitive electrical stimulation, at critical high frequency (greater than 3 Hz), of nociceptive C-fibres of dorsal horn neurons, which induces a slow temporal summation of evoked responses, progressively increasing in frequency, magnitude and duration (wind-up). Evidence has accumulated in recent years to indicate that prolonged after-responses and slow temporal summation are mediated by the co-release of glutamate and substance P and their respective activation of NMDA and neurokinin 1 and 2...
The previously mentioned survey suggests that groin problems are extremely common in highperformance athletes. Roughly half the patients recover from acute injuries without significant sequelae. The remaining half of the patients can be divided into two groups, one in which the chronic pain is minor and the other group in which the pain is severe enough to require significant medical or surgical attention.30
The use of BoNT A has been increasingly reported in many conditions of pathological pain, including migraine and other headache disorders (Aoki 2003 Binder and Blitzer 2003), musculoskeletal pain, such as myofascial pain, low back pain, and other chronic pain syndromes (Luvisetto et al. 2007 Reilich et al. 2004 Sycha et al. 2004).
Chronic pain may require changes in mental and emotional attitude and lifestyle. An osteopathic method called counterstrain may be helpful in correcting nerve patterns.30 Drinking lots of water for back pain is beneficial because dehydration, which occurs even though not thirsty, allows acidic wastes to build up in muscles, causing pain. Avoid animal fat in the diet as it contains substances that are inflammatory.
Antidepressants have been effective in various pain syndromes.(51) Since there is a wide range of the medical conditions producing pain, the results have been quite variable. In general the antidepressants have been able to reduce many of the painful symptoms as well as be effective in treating the secondary depression associated with chronic pain. However, they do not demonstrate the clear analgesic effect of drugs such as opioids.
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