Collaborative And Consultative Engagement

Eliciting and working with material of personal relevance to participants is of paramount importance. Staff should aim for an interactive collaborative and consultative engagement with patients to elicit patients' difficulties and struggles as the material for demonstrating applicability of pain management methods. This consultative style also maximizes involvement of patients in sharing solutions, with the benefits of easing the burden on the staff member, facilitating motivation, and...

Factor Iii Sudomotor Changes And Edema

Differential sweating between the affected and unaffected side is regarded as one of the diagnostic criteria for CRPS.26 Sweat production is a sympathetic cholinergic function, and variations occur in response to a wide variety of stimuli. Physiological variations are typically symmetric, and usually involve both hands and feet, as well as the head and trunk. These changes can occur apparently spontaneously or be induced by external or internal factors. These may include environmental...

Myofascial pain

Similar to FMS, MFP has many different labels. It has been cited under different headings over the years including fibrositis and myofibrositis when distinction between FMS was not so clear. MFP was first defined in the 1950s as was the trigger point'' which characterizes the condition.16 More research into its pathophysiology has led to clearer definition between MFP and FMS. However, research into this condition has been hampered by the lack of classification diagnostic criteria....

Treatment of pain in DSP and ATN

There are still only a small number of robust randomized controlled trials which specifically assessed peripheral neuropathic pain therapies in the context of HIV. Most include patients with both DSP and ATN as they are clinically indistinguishable. In the absence of trials specific to HIV, the practice has been to extrapolate from the wider body of evidence in the treatment of non-HIV peripheral neuropathic pain.28,29,30 Care must be taken to avoid drugs which exhibit significant known...

The Ethics Of Pain And Suffering Narrative Analysis

Man by his very nature,'' wrote Cicely Saunders in 1962, finds that he has to question the pain he endures and seek meaning in it.''82 For patients, the drive to find meaning in pain often takes the form of narrative - from extended personal stories to compressed beliefs. The belief that all pain and suffering is sent or sanctioned by God, for example, constitutes a compressed mininarrative that regularly occurs within larger accounts of divine providence throughout world religions. Although...

Atypical odontalgia

The IHS considers AO as a subgroup of persistent idio-pathic facial pain, i.e. persistent facial pain that does not have the characteristics of the cranial neuralgias and is not attributed to another disorder.''109 The IHS states that the term AO has been applied to a continuous pain in the teeth or in a tooth socket after extraction in the absence of any identifiable cause.''109 AO has also been called phantom tooth pain'' , or idiopathic toothache. As with AFP, no reliable data on incidence...

References

Headache Classification Committee of the International Headache Society. The International Classification of Headache Disorders. 2nd edn. Cephalalgia. 2004 24 1-150. 2. Russell M, Rasmussen BK, Brennum J etal. Presentation of a new instrument. The diagnostic headache diary. Cephalalgia. 1992 12 369-74. 3. Rasmussen BK, Jensen R, Schroll M, Olesen J. Epidemiology of headache in a general population - a prevalence study. Journal of Clinical Epidemiology. 1991 44 1147-57. 4. Gobel H,...

Neuralgic Amyotrophy

This may develop suddenly in an otherwise healthy individual or follow an infection, surgical procedure, childbirth, or an injection of vaccine or antibiotic. It usually begins as a severe pain around the shoulder on one side, followed by rapid development of weakness and atrophy. The muscles of C5 and C6 myotome are commonly involved, and the affected muscles may be very weak to the extent of being totally paralyzed. The pain is made worse by movement involving the affected muscles. It can be...

Key Learning Points

Chronic pain, impairment, and disability, rather than being actual entities, are constructs that can only be inferred in order to account for some form of behavior or phenomenon of interest. There is often a discordance or low degree of correlation among levels of chronic pain, impairment, and disability. What makes the operational definition and use of these three constructs difficult is that there are three broad categories of measures that can be used to operationally define them - physical,...

Ketamine and opioids

There is level I evidence from studies of acute postoperative pain that ketamine is opioid-sparing, without significantly reducing pain scores or the incidence of opioid-adverse events.77 However, ketamine is useful in the treatment of opioid nonresponsive (opioid tolerance or hyperalgesia) acute or cancer pain (as burst therapy), or in neuropathic, or visceral pain. The role of ketamine in pain management is as an antihyperalgesic, anti-allodynic, and tolerance-protective agent, rather than as...

Abbreviations

ABC American Botanical Council CBT ACC anterior cingulate cortex CCI ACE angiotensin-converting enzyme CCK ACOG American College of Obstetricians and CD ACR American College of Rheumatology CES ACTH adrenocortical trophic hormone CES-D ADL activities of daily living CFS AED antiepileptic drug CGRP AFP atypical facial pain CHF AHPA American Herbal Products Association CI AIDS acquired immunodeficiency syndrome CIN ALJ Administrative Law Judges CLBP AMA American Medical Association CMI AO...

Other Uses Of Topical Analgesics

Based upon the results of a number of small studies, mostly case reports, topical analgesics of various types including opioids may be very helpful in reducing the pain associated with pressure ulcers or dressing changes.80 I , 81 II , 82 II , 83 III , 84 II , 85 Patients undergoing any surgical procedure might benefit from the use of a topical analgesic to treat postoperative pain and reduce the need for systemic analgesics. Controlled studies have demon strated the benefit of EMLA cream in...

Voltagegated calcium channel blockers

Ziconotide is an antagonist at N-type voltage-sensitive calcium channels (VSCCs) found at presynaptic terminals in the dorsal horn of the spinal cord. The blockade produced by ziconotide is more specific for nociceptive than somatosensory transmission. There is increased expression of N-type VSCCs in chronic pain states which may explain its greater specificity for chronic rather than acute pain states. In contrast to opioids and local anesthetics, ziconotide is not associated with the...

Phantom sensation

Phantom sensation is experienced by almost everyone who undergoes limb amputation, but it rarely represents a clinical problem. Immediately after the amputation, the phantom limb often resembles the preamputation limb in shape, size, and volume.11,1922 2354 The sensation can be very vivid and often includes feelings of posture and movement. The phantom sensation may fade over time. Richardsen et al.26 prospectively studied phantom phenomena in 52 lower amputees. At six-months follow up,...

Computer models

Holsheimer et al.19 have performed computer modelling of electrode designs and suggested that optimal lead configuration is a transverse tripole with a central cathode with longer lateral anodes separated by 2.5-3 mm. A narrow bipole or tripole is optimal for dorsal column stimulation (Figures 20.2 and 20.3), as this keeps the stimulation over the posterior spinal cord better with anodal effects forcing the stimulus to penetrate more over the physiological midline. Many of the leads with large...

Prevalence

Several large surveys in the United States, Europe, and Australia have demonstrated the extent of CAM use by the public. According to the Centers for Disease Control and Prevention, in 2002 36 percent of US adults used some form of CAM therapy and if prayer was included, the number increased to 62 percent.5 Use of these therapies was most prominent for back problems, upper respiratory infections, and neck problems. In 2001, Millar6 reported that 17 percent of Canadians visited an alternative...

Persistent Somatoform Pain Disorder F454

The main complaint in this disorder is of persistent, severe, and distressing pain, which cannot be explained fully by any bodily process or physical disorder. Furthermore, this occurs in association with emotional conflict or psychosocial problems that are considered to be the main cause.9 In a different diagnostic classificatory schedule, DSM-IV,10 the diagnosis of pain disorder can be made as long as psychological factors are judged to have an important role in the onset, severity,...

Insufficient knowledge among physicians about pain assessment and management

Critics of medical education in the area of pain - its causes, assessment, and treatment - suggest that the typical medical school curriculum seems almost purpo sely designed to keep physicians in the dark about pain. In a 1989 interview, John J Bonica, generally regarded as the founder of the movement toward specialized pain clinics, observed, No medical school has a pain curriculum.''33 Over 15 years earlier, a study of hospital inpatients revealed significant undertreatment of pain based in...

Porphyria

Several related genetic disorders, all characterized by the increased formation of porphyrins or their precursors, are termed porphyria , (Box 40.1). Three subgroups have been identified which all have similar symptomatology intermittent acute porphyria (IAP), hereditary coproporphyria, and variegate porphyria. Of these, IAP is the most frequently encountered with attacks of colicky abdominal pain that are intermittent, may be associated with environmental exposures, and which can last for days...

Sodium Valproate And Divalproex

Sodium valproate and divalproex (a combination of sodium valproate and valproic acid in a molar ratio of 1 1) were reported to be effective in painful diabetic neuropathy in two small studies from a single center.83 II , 84 II Valproate at a dose of 1200 or 1000mg day was compared with placebo for one and three months, respectively. Significant improvement was claimed with a combined NNT for moderate or better pain relief of 1.5 (95 percent CI 1.2, 2.2).9 I However, one must raise concerns...

Etiology

The most common cause of musculoskeletal chest pain is costochondritis, with an incidence of up to 30 percent of all musculoskeletal chest pains,103'104 with inflammation of the costal cartilages and up to 42 percent of patients with recurrent costochondritis complaining of widespread pain.103 In a number of patients the chest pain still prevails once the clinical signs of costochondritis have subsided. The incidence of costochondritis has risen steadily in the last few years because of an...

Nerve conduction studies

Nerve conduction studies determine the velocity of conduction and magnitude of evoked action potentials in peripheral nerves. Slowing of conduction across a selected segment of the nerve indicates compression or focal damage to the nerve at that segment. Decreased amplitude indicates loss of nerve fibers. Electromyography selectively tests alpha motor neurons. Loss of motor neurons is indicated by denervation fibrillation potentials in the muscles innervated, or by the presence of large and...

Is opioid responsiveness different for nociceptive or neuropathic pain central or peripheral

Kalso et al.14 I provide some help here. They reviewed 15 randomized placebo controlled trials. Four looked at intravenous opioid testing and included 120 patients, the other 11 compared oral opioids with placebo in 1025 patients. The opioids tested were described as World Health Organization (WHO) step 3 analgesics, including fentanyl, hydromorphone, methadone, morphine, oxy-codone, and oxymorphone and a wide variety of nociceptive and neuropathic pain disorders were treated. Trials lasted...

Pain Intensity Difference Versus Pain Relief

Pain intensity scales may be categorical (e.g. none, mild, moderate, or severe), numerical rating (e.g. 11-point integer, 0-10), or numerical derived from a VAS. Pain relief scales are usually categorical (e.g. none, slight, moderate, good, or complete). Categorical data can often be converted directly to integers and analyzed as numerical data,81 differences are calculated by subtraction. Pain relief (PAR) may be more meaningful to patients however, they need to refer back to the initial pain...

Somatic Chest Pain Musculoskeletal

After coronary artery disease and gastroesophageal reflux, the next most common cause is musculoskeletal chest wall syndromes. Around 70 percent of these patients have chest wall tenderness on palpation that in up to 16 percent can resemble classical angina.101 The most common areas of musculoskeletal chest pain are sternum, xiphoid, left costosternal junctions, and left anterior chest wall.101 A musculoskeletal cause for a chest pain is suspected when the pain is specific of certain postures...

Chronic pain after hernia surgery

The epidemiology of chronic pain after inguinal hernia surgery is well documented. Indeed, the volume of literature reporting CPSP after hernia surgery has increased dramatically in the last two decades. Many studies have been specifically designed to investigate persistent pain as an outcome rather than the traditional outcomes of hernia recurrence, wound infection, or return to work. Guidance on laparoscopic and open hernia surgery published by the UK National Institute for Clinical...

Neuronal Plasticity

A characteristic feature of FMS is hyperalgesia (increased sensitivity to mechanical, thermal, and electrical stimuli) and allodynia (painful response to normally non-noxious stimuli). These are likely to be due to altered mechanisms within the CNS such as wind-up and central sensitiza-tion which have been demonstrated in FMS patients.49, 50 Altered pain processing has been illustrated by studies using functional magnetic resonance imaging (fMRI) where painful pressure stimuli result in...

Central poststroke pain

The median annual incidence of first stroke for all ages is 183 per 100,000 with the risk of stroke roughly doubling with each decade during adulthood.12 In the United States in 2007, the incidence of first stroke would be estimated at approximately 551,000 cases per year (based on 301 million US population). Stroke is the third leading cause of death in the United States and a leading cause of dis-ability.26 Based on the prevalence of stroke in the population (compared with that of SCI or MS),...

Dysesthetic Vulvodynia

Generally considered a diagnosis of exclusion, it presents commonly in perimenopausal and postmenopausal women as nonspecific superficial vulvar burning or perineal discomfort with intermittent, deep, aching pain. Patients deny entry dyspareunia. Physical examination is normal, with no tenderness on palpation. Pudendal nerve tenderness, hyperesthesiae, or hypoesthesiae in a saddle distribution extending from the mons pubis to the upper inner thighs and posteriorly across ischial tuberosities...

Focal Versus General Spasticity

In considering the management of spasticity and hence, as will be discussed, spasticity-associated pain, it is necessary to look at the clinical presentation of spasticity in terms of focal and general presentations. Focal or regional spasticity typically results from cerebral origin.7 This refers to spasticity primarily affecting one limb, e.g. upper limb with the flexion pronation adduction patterning described above or lower limb with the extension adduction patterning. However, flexion...

Pain after amputation

Pain after limb amputation was undoubtedly the first of all the postsurgical pain syndromes to be recognized. Silas Weir Mitchell described phantom limbs and pain syndromes caused by gunshot wounds following the American Civil War.36 Pain following limb amputation falls into two broad categories, phantom pain and stump pain (also called residual limb pain). Many lower limb amputees also report back pain.37 For a detailed review of phantom pain, see the excellent article by Nikolajsen and...

Diverticular disease

Diverticuli can occur throughout the gastrointestinal tract but prove to be most common in the colon where they exist as small sac-like herniations of mucosa through the muscular wall, typically at the site of penetrating blood vessels. Duodenal, jejuna, and ileal diverticuli can occur with Meckel's diverticulum forming a special congenital abnormality present in 2 percent of the population. Meckel's diverticuli are particularly notable since they may contain acid-producing gastric mucosa and...

Spielberger State Trait Anxiety Inventory

The Spielberger State-Trait Anxiety Inventory (STAI)28 is the most widely used measure of anxiety, a construct that is not used as extensively as depression is with chronic pain patients, but nevertheless a very important one with pain patients. The STAI is a 40-item inventory that assesses trait anxiety, a characterological, stable dimension of anxiety that is relatively consistent over time, as well as state anxiety, transitory feelings of anxiety usually in response to specific situations....

Chronic neck pain

For the treatment of chronic neck pain, the evidence is even more sparse than that for acute neck pain, and even less supportive of traditional approaches. There is no published evidence supporting the effectiveness of a collar, TENS, traction, trigger point therapy, or multimodal therapy for chronic neck pain.112 There is no published evidence of any drugs being effective. For acupuncture, the evidence is conflicting. While some studies have reported an effect greater than that of placebo,113...

Opioid Tolerance And Opioidinduced Hyperalgesia

OT is a state of reduced opioid potency, reflecting down-regulation or desensitization of opioid-dependent, anti-nociceptive systems in the CNS. In contrast, OIH is a neuroadaptive state where opioid administration is associated with an increased response to painful stimuli (hyperalgesia), due to up-regulation or increased sensiti-zation of pronociceptive systems. These changes are reflected in a rightwards shift of the opioid dose-response curve in OT, in contrast to a downwards shift in OIH....

Notes on some terms relating to movement disorders

A number of descriptive terms are used to differentiate patterns of disordered muscle tone and movement, and may give rise to confusion among non-neurologists. Some of these terms, and their corresponding meanings, are listed below Spasticity is the type of muscle hypertonia seen following a lesion of the corticospinal tract. Resistance to passive movement of an affected limb is maximal at its outset and reduced once movement is initiated (clasp-knife effect). Tendon reflexes are increased. The...

Cell Death In The

Many forms of nerve injury can also produce death of sensory neurons.96 Apoptosis may be a result of mito-chondrial dysfunction97 and has been associated with a number of neuropathies.96,9899 Mitochondria-dependent apoptosis is activated by a number of factors including reactive oxygen species, ceramide, and nitric oxide,100 which have been implicated in the pathophysiology of neuropathies. These factors cause the release of cyto-chrome C from mitochondria leading to the formation of the...

The biopsychosocial approach to a diagnosis

It is essential that all reasonable attempts are made to establish a cause for the patient's pain behavior, including nociceptive, neuropathic, and psychological contributions. Pain behavior itself can obviously be modified by many other factors involving social and environmental influences. A demonstration of pathology commensurate with the degree of pain behavior is desirable. However, patients often have pathology which is difficult to interpret, e.g. degenerative changes on spinal...

Medial Branch Blocks

Cervical medial branch blocks can be used to test if a zygapophysial joint is the source of a patient's neck pain. They involve anesthetizing, under fluoroscopic control, the small nerves that innervate the target joint, each with no more than 0.3 mL of local anesthetic89 (Figure 36.5). Cervical medial branch joint blocks have face-validity, in that they selectively anesthetize the target nerves, and do not anesthetize any nearby structures that realistically might be the source of pain.90...

Chronic pancreatitis

Symptomatic pancreatitis can be associated with pancreatic cell death and or with ductal fibrosis and calcification. Acute pancreatitis, such as that induced by passage of a gallstone, is thought to be pathogenetically and morphologically different from chronic pancreatitis19 and generally resolves without permanent structural abnormalities. Chronic pancreatitis is associated with permanent abnormalities, but may present with an acute necrotic episode. Excessive alcohol consumption is the...

Spinal cord mechanisms

The sensory input from primary sensory neurons is transferred, via their central axons, to second-order neurons in the dorsal horn of the spinal cord. The synaptic contacts made between afferent central terminals and dorsal horn neurons are highly organized, both topographically and functionally to maintain accurate transfer of information regarding the peripheral noxious stimuli. Following peripheral nerve lesions, synaptic processing in the spinal cord can be subject to diverse forms of...

Rodent models of neuropathy

The most commonly used nerve injury models are the chronic constriction injury (CCI) of sciatic nerve,7 the partial sciatic nerve ligation (PNL) model,8 the spinal nerve ligation (SNL) transection model (Figure 1.2),9 and the spared nerve injury (SNI) model.6 All models are associated with the development of hypersensitivity to thermal (heat and cold), and mechanical stimuli which are used experimentally as correlates of hyperalgesia and allodynia symptoms in neuropathic pain patients.10...

Visceral Hypersensitivity Disorders

The observation that pathology and symptomatology may not correlate is readily apparent in numerous visceral pain disorders. Some disorders, such as chronic pancreatitis, have definable pathology, but alterations in pain appear out of proportion to objective radiographic or laboratory findings. Other disorders, such as irritable bowel syndrome, noncardiac chest pain, and postcholecystectomy syndrome, appear to have no grossly apparent histo-pathological basis for the discomfort and pain....

Anatomical Reorganization

Tactile mechanical allodynia is thought to be mediated by Ap-fiber afferents.146 However, the mechanisms by which this occurs are yet to be fully understood. Several studies using bulk labeling and single afferent fiber-filling techniques have demonstrated that following a peripheral nerve lesion, the central axons of injured Ap-fibers sprout from their normal termination sites in the deeper laminae of the dorsal horn (laminae II and IV) into lamina II of the dorsal horn, which is normally...

Problem Solving

Problem solving is often implicit in programs rather than taught as a separate component. It involves identification of the problem, generation of a range of possible solutions, prioritizing among those solutions according to opportunities, resources, and risks, and then attempting them. Many patients appear to use a narrow range of strategies, such as forcing themselves to persist when they meet an obstacle, which succeeds in some situations but rarely in chronic pain. Experimenting with...

Treatment Guidelines

In summary, the proportion of seropositive individuals in the population will decline as a result of childhood varicella vaccination. In time, this will reduce the incidence of HZ. Adult vaccination has been shown to be effective for the prevention of shingles and PHN.18 II In acute HZ, early antiviral therapy is recommended and pain treatment with strong opioids, tricyclic anti-depressants, or gabapentin should be considered in addition to conventional analgesics. The pharmacological...

Contributors

Praveen Anand ma md frcp Professor of Clinical Neurology Division of Neuroscience and Mental Health, Imperial College London, Hammersmith Hospital, London, UK School of Nursing and The Institute for Human Genetics University of California, San Francisco, CA, USA Professor of Neurology Albany Medical College Director Comprehensive Pain Program, Albany Medical College New York, USA Department of Clinical Oral Physiology, School of Dentistry Faculty of Health Sciences, University of Aarhus Aarhus,...

Residual limb pain

Not surprisingly, residual limb pain is common in the early postoperative period, but in most patients it subsides with healing. The prevalence of chronic residual limb pain is reported to vary between 5 and 100 percent Table 31.1 . Variations in the literature may reflect different methods of estimating pain and the fact that some amputees find it difficult to distinguish between residual limb and phantom pain. In a survey of 78 traumatic amputees, Pezzin et al.46 found that 14.1 percent...

Visceral Innervation

The reproductive organs have a dual innervation via the sympathetic thoracolumbar and parasympathetic sacral autonomic, with contributions from the somatic sensory nervous system.6, 7 The visceral afferent fibers travel the same route as their corresponding efferent autonomic fibers Table 41.1 . The afferent innervation of the upper vagina, cervix, uterus, proximal fallopian tubes, upper bladder, terminal ileum, and distal large bowel travels with the thoracolumbar sympathetics through the...

Wind uplike pain and aftersensations

Wind up-like pain or abnormal temporal summation, is the clinical equivalent to increasing neuronal activity following repetitive C-fiber stimulation of more than In humans, such pains may be evoked by either repetitive noxious or non-noxious stimulation from normal or hyperalgesic cutaneous areas, respectively. When repetitive low-threshold stimuli, which exclusively activate Ap-fibers, are applied at intervals of less than three seconds, they give rise to pain, which means that these stimuli...

Chronic pain after breast surgery

In the UK alone, 42,000 new patients are diagnosed with primary breast cancer each year and most undergo surgery, either mastectomy or breast conservation surgery with sentinel node sample or clearance. Chronic pain was initially reported in the 1970s as a rare consequence of breast cancer treatment.62 There are now many epi-demiological and clinical studies reporting the prevalence and characteristics of persistent pain which suggest that it occurs commonly, with subsequent impact upon quality...

Thoracoabdominal radiculopathy

This is usually seen in older patients with long-standing diabetes and may be associated with marked weight loss. Most patients describe girdle-like pain around the trunk that may be unilateral or bilateral. Abdominal wall weakness, cutaneous hyperesthesiae, or superficial sensory loss over the involved area may be seen on examination. EMG changes can be detected in paraspinal and abdominal wall muscles, in adjacent myotomes, and, on this basis, the lesion is presumed to be very proximal - in...