Introduction to Clinical Pain Management Chronic Pain

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Chronic pain has traditionally had the negative connotation of psychogenic etiology and an arbitrary time domain. It has also been a pejorative term to the extent that chronic pain syndrome was deliberately omitted from the IASP Taxonomy of Chronic Pain Syndromes. This new volume gathers together the scientific and clinical evidence that confirms chronic pain as an identifiable syndrome, the final common path of many etiologies. Consistent with any clinical syndrome, there are common neurophysiological, neuroanatomical, and functional changes throughout the organism regardless of the precipitating factors. These changes are addressed in the early chapters of this volume. In addition, there is physical, psychological, and psychiatric deconditioning resulting from central and peripheral nervous system dysfunction. Socioeconomic impairment and reduction in quality of life almost invariably accompany these changes.

There has also been a recent paradigm shift from the curative medical model of pain in which symptoms are expected to resolve once the underlying pathologic process is treated medically or surgically to a model which emphasizes patient autonomy, symptom management, and functional restoration. This volume addresses this new model of chronic pain in those specific conditions where applicable. It also explores the conceptually distinct rehabilitation model, in which it is recognized that the underlying pathology may be incurable or untreatable. The goals now involve minimizing the adverse effects of the pain and maximizing function and quality of life.

Fundamental changes in practitioners' responsibilities to patients and society are occurring as a result of philosophical and legal advances related to chronic pain. Previously implied rights of patients now have been formalized in various intractable pain acts of several jurisdictions. The classical doctrine of primum non nocere (first do no harm) is being challenged ethically and legally under these circumstances. Experts in these fields explore these changing ethical and legal climates in early chapters.

This volume contains 46 chapters in three parts. The first part, General Considerations, comprises 14 chapters that cover subjects ranging from basic neurophysiology through clinical evaluation to the ethical, legal, and societal aspects of this disease as described above. Part II, entitled Management - therapies, contains 9 chapters that address pharmacological, psychological, behavioral, interventional (invasive) and alternative/complementary/placebo issues. Part III has 23 chapters that describe both specific and nonspecific pain syndromes and their management. The subjects discussed include general neuropathic pain syndromes, specific pain syndromes and regional pain (neck, back, joints, chest, abdomen, and pelvis), and issues related to pain at the extremes of age.

Chronic pain now covers a vast scientific and clinical arena, and has become a medical specialty in its own right. Scientific rationale and therapeutic options are much better described now than at any time in the past. This volume gathers the available evidence-based information on diagnosis and management in an accessible format without overwhelming detail. Where evidence-based data are not available, the authors provide thoughtful advice based on scientific experience and clinical wisdom. It is inevitable in a volume such as this that there will be omissions, for which we must accept responsibility. Nevertheless, we believe that this volume is an essential resource for all clinicians whose patients have chronic pain and scientists who challenge traditional assumptions.

Peter R Wilson, Paul J Watson, Jennifer A Haythornthwaite, and Troels S Jensen

Rochester, Leicester, Baltimore, and Aarhus

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