Permanent End To Chronic Pain

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Classification of chronic pain and disability

Chronic low back pain is not the same as chronic pain-related disability. So it may be better to classify pain and functional outcomes over time. This takes us back to our classification of acute, recurrent, and chronic pain. The importance of chronic pain is not simply the duration of the pain but also its impact on the patient's life, von Korff's classification reflects the severity and impact of chronic pain and the importance of both pain and disability (McGorry et al 2000).

What are some of the types of patients with chronic pain

There is a spectrum of patients with chronic pain. At the positive end of the spectrum are patients who might be called adaptive copers or persons with chronic pain. They frequently have identifiable nociceptive or neuropathic stimuli. The psychological changes, when present, are generally consistent with and secondary to the levels of pain and impairment. Patients function at a reasonable level despite their pain. They are compliant with treatment, follow instructions, and tend to respond to medications and other treatments as would be expected. On the other end of the spectrum are those patients who are dysfunctional and might be called chronic pain patients. Their pain seems out of proportion to any identifiable stimulus. They have psychological and behavioral changes that interfere with their lives. They function at a level far lower than would be expected. They may be noncompliant with treatment recommendations, miss appointments, fail to follow directions, and respond poorly to...

Noninvasive Therapies For The Treatment Of Chronic Pain

The multiple treatment options for patients with chronic pain include noninvasive and less costly therapies as well as more invasive and more costly therapies. Generally speaking, when treating pain sufferers, the KISS principle should be invoked the least invasive therapies should be tried first before more invasive therapies are used. Exercise and behavior modification should be the first steps along the therapy continuum to pain control ( Fig. 292 ). Although exercise may be beneficial in the treatment of chronic low back pain secondary to low back disorders, the same cannot be said for acute low back pain. Exercise is not beneficial in all chronic pain problems.113 Mannion and colleagues143 looked at three forms of exercise used in the chronic low back pain patient population modern physical therapy, aerobics, and muscle strength training. All three forms of exercise were similar regarding improvement in activities of daily living and reductions in pain frequency and intensity....

Acute and chronic pain

Doctors traditionally classify low back pain as acute or chronic. Acute pain is usually defined as being less than 6 weeks' duration. Many patients have recurrent attacks, but these often continue to be like acute pain. In the past, the definition of chronic pain was more than 6 months, which stressed its intractable nature. But 6 months is probably too late to begin thinking about and dealing with chronic pain, and many workers now classify chronic pain as being of more than 3 months' duration. In terms of clinical progress and the risk of chronic pain and disability, 6 weeks may actually be a better cut-off. The key distinction is not the duration of the pain, but the persistence of chronic pain beyond expected recovery times and the intractable nature of chronic pain. There are marked clinical differences between acute and chronic pain, which too many doctors and therapists ignore at their patients' peril. Loeser once exclaimed that acute and chronic pain have nothing in common but...

Chronic pain interpretation of symptomatic responses

With chronic pain, peripheral tissue and central nervous system elements may be sensitised and deconditioned to normal movement the criteria of symptom response needs to be different. Under these circumstances normal mechanical stimuli can produce pain, repeated movements may have a 'wind up' effect on pain production, there may be a spread of painful areas, and there may be ectopic nociceptive signals (Dubner 1991 Johnson 1997). These changes make the interpretation of mechanically produced symptom responses difficult and invalidate diagnostic labels applied to particular responses (Zusman 1992, 1994) . Psychosocial elements that have been identified as factors in chronic spinal pain and disability are passive coping strategies, fear-avoidance behaviour, lack of self-efficacy and depression (Linton 2000). These characteristics may make patients overly anxious and fearful about pain responses, which they consequently exaggerate. These examples suggest that we should interpret the...

Invasive Therapies For The Control Of Chronic Pain

When more conservative, less invasive therapies fail to provide pain relief, the treating physician should offer more invasive therapies which, if performed correctly by well-trained physicians, may provide pain relief for the patient suffering from intractable, chronic pain. Interventional strategies used when less invasive therapies fail include anesthetic blocking techniques, continuous intraspinal analgesia, continuous plexus analgesia, implantable neuromodulatory techniques, and neurodestructive techniques.153 Local anesthetics are commonly used for the relief of pain in both acute and chronic states. However, under certain circumstances, a single bolus administration of a local anesthetic may not be sufficient to control pain. The use of continuous epidural infusions for the control of both acute and chronic pain has been well established.13 Pain states in which continuous epidural infusions may be indicated include uncontrolled neuropathic pain processes, failed neck and back...

The Development Of Chronic Pain And Disability

Of patients with non-specific low back pain. Most patients who present with an acute attack get better quite rapidly, no matter what we do. They need little more than analgesics, reassurance, and advice. We can rely on nature to cure them, and our job is only to assist and make sure we do not obstruct that process. The other 10-20 are at risk of developing chronic pain and disability. Once that occurs they present complex clinical and occupational problems for which we have no easy answer. By about 3 months the graph levels off. Any patient who is still off work is now chronic, with all the implications of that. Ordinary backache has become the source of major suffering and disability. These patients become trapped in a vicious circle of pain, disability, and failed treatment. It impacts on their whole lives, their family, and their work. This 10-15 minority has a disproportionate impact on health care use and social costs to society. Treatment is more difficult and has a lower...

Management of chronic pain

Recent advances in the understanding of the fundamental mechanisms involved in the transmission and modulation of noxious impulses have significantly extended the range of assessment tools and treatments clinicians offer to patients with pain. The majority of medical pain specialists in the UK are anaesthetists. Historically, anaesthetists have been responsible for the relief of pain in the perioperative period and have developed skills in percutaneous neural blockade. This expertise, developed originally for local anaesthetics, was then extended to neurolytic agents. Initially, pain clinics started as nerve-blocking clinics and most pain management clinics continue to be directed by anaesthetists. However, with increasing awareness of the complexity of the pain experience, there has been recognition that other health care professionals have a significant role in the management of patients with chronic pain. A multidisciplinary approach involving anaesthetists and other health care...

Quality Of Acute Pain Management In The Prevention Of Chronic Pain

As previously mentioned, there is increasing evidence that the quality of acute pain management is an important factor in the subsequent development or prevention of chronic pain after trauma. Melzack and colleagues1911 reported that patients with persistent postsurgical pain tended to be older individuals for whom lower doses of analgesics had been initially prescribed, resulting in ineffective analgesia in the early postoperative days. Pain persisted for a longer period in these individuals than in individuals for whom early analgesic therapy was more effective. Similarly, unrelieved preoperative pain may trigger central sensitization before surgical intervention, thereby thwarting preemptive analgesic efforts.1911 A critical time interval has been proposed during which effective acute pain management prevents delayed pain sequelae.193 This critical period of plasticity may be, in part, mediated by y-aminobutyric acid.193 Reorganization of central dendritic connections through...

Methodology Issues In Evaluating Chronic Pain

The primary problem in evaluating chronic pain is to define relevant outcome measures that can provide an estimate of success of treatment consistent with the therapeutic procedure. Caution needs to be exercised in collecting, analyzing, and interpreting outcome data because of two important conceptual concerns. First, there are no satisfactory objective indicators of pain that are universally applicable and acceptable. Second, every outcome is prone to some degree of error during design, collection, analysis, or interpretation. An attempt to define and apply quality control helps in obtaining dependable data. Other factors that need to be considered when evaluating outcomes include the demographic makeup, inpatient outpatient status, and the credibility of the treatment procedures in the patient population.133 Issues related to referral patterns, adherence to treatment, and attrition of the initial study group need attention. Reactivity, which is a measure of inherent subjectivity of...

Chronic Pain After Trauma

Pain persisting beyond the normal recovery period, and often greatly exceeding what might be anticipated relative to the residual pathology, can be considered chronic post-traumatic pain. Although it is widely assumed that psychological factors become increasingly important as acute pain becomes chronic, it is perhaps less well appreciated that a number of pathophysiologic changes also occur in both central and peripheral pain pathways. Consequently, the response of patients with chronic pain to various therapeutic interventions, including the response to local anesthetic blockade, often varies from what might be expected in the acute pain setting.163 163 Modification of the approach to treatment is required.

Assessment Of Chronic Pain

In the early 1970s, chronic pain began to gain special attention as a discrete clinical syndrome that required and techniques led investigators to research and develop reliable and valid instruments for assessing chronic pain. For instance, an algometer was one of the many devices invented to measure chronic pain by comparing it with acute pain induced by a brief electric current applied to an arm tourniquet or tooth pulp.11 However, these early attempts of objectifying a complex, subjective experience such as pain in a single dimension failed to gain acceptance in the assessment of chronic pain. With time, as the multidimensional nature of chronic pain states was recognized, the need for the multitude of descriptors to capture the complex pain experience began to be fulfilled. Accordingly, several outcome measures emerged, although only a few of them have proven reliability and validity. A simple classification of outcomes that are routinely used in evaluation of chronic pain is...

Note for Chronic Pain Sufferers Who Dont Have Cancer

Although this book is about the pain and symptoms associated with cancer, much of the information presented is surprisingly relevant to people who don't have cancer but who suffer from unrelenting or progressive chronic pain. These materials include Chapters 3 and 4 on assessing pain and being an active health-care consumer, all of Part II that details medication use and much of Part III, including Chapter 12 on mind-body approaches to easing pain. Just as cancer pain is still often severely undertreated, so too is chronic non-cancer pain that accompanies trauma, degenerative, infectious diseases, and other medical disorders as well as chronic pain that simply cannot be explained. Sufferers are commonly disbelieved and untreated, leaving them feeling ridiculed, humiliated, depressed, and even suicidal. Often amplified by the absence of the drama associated with cancer, the barriers to good pain management (Chapters 1 and 2) are largely the same for chronic pain. Below are some of the...

Chronic pain states

Chronic pain is different in quality, as well as time, from acute pain. In the latter, biomechanical and biochemical factors may be the dominant influences on the pain experience and there is a more straightforward relationship between pain and nociception. With the passage of time neurophysiological, psychological and social factors may come to dominate the maintenance of pain and the link to the original tissue damage may become minimal (Unruh et al. 2002). This section briefly considers some of the reasons why a straightforward mechanical response may not be forthcoming in those who have developed 'chronic pain states'. However, it is emphasised that simply because patients have chronic or persistent pain does not necessarily mean theyhave a chronic pain state (Strong 2002). Many patients who have had long-term problems with neck pain benefit from a mechanical evaluation and respond positively there should be no time limit after which a mechanical evaluation is refused. Many...

Chronic pain

Chronic pain has traditionally been defined by pain duration for instance, symptoms that have persisted for more than three to six months. However, time scale alone is generally now considered to be an inadequate definition for chronic pain. Other factors are considered important in the chronic pain experience. Psychosocial and behavioural factors complicate the clinical problem and pain is disassociated from tissue damage. Patients may experience widespread pain, and the problem is more likely to prove difficult to treat. Symptoms may become complicated and persist due to non-mechanical problems. These are considered in more detail in Chapter 2, but in brief these consist of psychosocial or neurophysiological factors that act as barriers to resolution and obscure a mechanical problem. Psychosocial and cognitive factors are closely related to the development of chronic back disability. Depression, anxiety, passive coping, fear-avoidance and attitudes about pain are associated with...

Whos the Person Giving My Anesthesia Do Credentials Matter

Tion of the patient before, during, and after the surgical procedure. This is as important as the administration of the anesthetic itself. The anesthesiologist must decide if the patient is in their best medical condition for surgery because this profoundly influences outcome in patients with significant coexisting medical problems. The anesthesiologist also spends a considerable amount of time learning about the management of acute and chronic pain.

Table 51 International Association For The Study Of Pain Classification Of Pain Facilities

Focuses on the diagnosis and management of patients with chronic pain or may specialize in specific diagnoses or pain related to a specific region of the body Specializes in the multidisciplinary diagnosis and management of patients with chronic pain or may specialize in specific diagnoses or pain related to a specific region of the body Organization of healthcare professionals and basic scientists that includes research, teaching, and patient care in acute and chronic pain Scientific inquiry into the anatomy and physiology of pain perception increased, and with the discovery of opiate receptors in animal and human tissues, the actions of peptides on endogenous opioid receptors, the development of new therapies for the alleviation of pain, and the classification and description of chronic pain syndromes, some essential pieces were added that support modern pain therapy. 113 110 Adapted from Carr DB, Aronoff GM The future ofpain management. In Aronoff GM (ed) Evaluation and Treatment...

Physical performance measures

Simpler clinical test batteries can also directly observe the patient's capacity to perform everyday activities in a controlled setting. Harding et al (1994) developed such a battery for severely disabled patients with various chronic pain problems. Box 3.2 shows a simplified version they now use in routine clinical practice. They found the tests reliable and sensitive to change after a pain management program. Simmonds' group developed a similar but more comprehensive battery for patients with low back pain (Simmonds et al 1998, Novy et al 2002, Simmonds 2002). They again found it to be simple and easy to use, acceptable to patients, and reliable. On analysis, the tests fell into two groups. The larger and more powerful group assesses speed and coordination. The smaller assesses endurance, strength, and balance. Individual performance tests showed moderate Note These values are for chronic pain patients.

Therapeutic Interventions

Gather a history and current status of the client's chronic pain and substance abuse. 4. Discuss with the physician the use of medications to manage chronic pain and withdrawal from addictive substances. 5. Complete a thorough medication review by a physician who is a specialist in dealing with chronic pain and substance abuse. (8) 7. Administer to the client psychological instruments designed to objectively assess chronic pain (e.g., McGill Pain Questionnaire Short Form MPQ-SF , Psychosocial Pain Inventory PSPI ) give the client feedback regarding the results of the assessment. 11. Teach the client key concepts of rehabilitation versus biological healing, conservative versus aggressive medical interventions, acute versus chronic pain, benign versus non-benign pain, cure versus management, appropriate use of medication, role of exercise and self-regulation techniques. 12. Assign the client to read books about causes for and management of chronic pain process key concepts insights...

The lumbar sympathetic chain Commentary

The anatomy of this area is not detailed and so the viva is likely to move on quite quickly to clinical aspects of the subject. Lumbar sympathectomy is a procedure which is undertaken mainly by chronic pain specialists, and so you may well not have seen it done. The same may apply to psoas compartment (lumbar plexus) block, which you may also be invited to discuss. If you are struggling for facts then do not guess, but instead fall back on the anatomy. If you are able to show that you could work out a safe theoretical approach by virtue of your anatomical knowledge then you are likely to pass, even though the practical details may be incomplete.

Depression and Physical Symptom Perception

Although fewer studies have focused on pediatric than adult populations, similar associations have been described for children and adolescents (Apley 1967 Campo et al. 2002). In a cross-sectional study, Konijnenberg et al. (2006) examined psychiatric morbidity in children with medically unexplained chronic pain and pediatricians' abilities to identify psychological factors that might contribute to chronic pain symptoms using clinical judgment or a screening tool. In the study of 134 chronic pain patients ages 8-18 presenting in a university-based outpatient clinic, psychiatric morbidity was found in 60 , with 40 meeting criteria for an anxiety disorder and 35 for depressive disorders. The investigators found that clinical judgment and the screening tool were equally effective for identifying psychiatric disorders and allowing for interventions (Konijnenberg et al. 2006).

Depression and Functional Impairment

Similar to adult studies, studies of pediatric patients have found that depression has been associated with increased functional disability (Kashikar-Zuck et al. 2001, 2002 Katon 2003 Smith et al. 2003). Co-occurring depression and physical illnesses have been associated with disruptions of functioning at home, at school, and in recreational activities. In a study examining depression among youngsters with chronic pain, Kashikar-Zuck et al. (2001) found depression to be strongly associated with functional disability but not with pain severity. Adult studies have shown an association between the improvement of depressive symptoms and improvements on measures of functional impairment (Ormel et al. 1993).

Prevalence of mechanical syndromes in neck pain patients

Two surveys have been conducted of consecutive patients seen by McKenzie educational faculty (May 2004a, 2004b). In total, details of over one thousand patients were included in the two surveys from nearly eighty contributing faculty members, which included 256 patients with neck pain. The results were similar in the two studies, with most neck pain patients being classified as derangement (80 ), fewer numbers in other mechanical syndromes (8 , mostly dysfunction) and some classified as non-mechanical syndrome (12 ). The minority of patients not receiving mechanical classification were mostly classified as mechanically inconclusive (4 ), trauma (4 ) and chronic pain state (3 ).

Further direction the viva could take

You may then be asked how you might perform a block. Remember that the examiner's knowledge may be as theoretical as yours and that your collective experience may be small. You are unlikely to be picked up on small details as long as your overall account is plausible and safe. If your examiner does happen to work in chronic pain management they should not allow their specialist knowledge to influence the standard that is expected of you.

Approaches to prevention and control

We must also recognize the importance of psychosocial as well as physical demands of work. Physical risk factors may be most important for the initial onset of back pain. But psychosocial issues are probably even more important for its impact and consequences, for management, and for chronic pain and disability. Addressing psychosocial aspects of work and providing support may be just as important as modifying the physical demands.

What should we tell patients

The review of individual risk factors suggests that most of us are going to get back pain at some time in our lives. It does not make much difference whether we are male or female, young or old, tall and thin, or small and fat. There is not a lot we can do about these personal characteristics in any event, but we do not need to worry about them. We may all be fated to have some back pain, but there is nothing in our genes that dictates it will inevitably lead to chronic pain and disability. Advice about work is a critical part of managing back pain, and that advice depends on whether work is a risk. Sadly, too much advice is based on old myths that current evidence shows are wrong. Many patients and health professionals are firmly convinced that heavy manual work must somehow cause back injury or degenerative changes. So further exposure might cause further damage and hinder recovery or lead to chronic pain and disability. Strong scientific evidence now explodes these myths.

Treatment of Pain and Pain Disability

Chronic pain can result in a sensitization of the nervous system, producing physiological and neuro-anatomical changes. Likewise, disuse or inactivity can lead to further pain and disability. Some patients with chronic pain develop severe impairment in their level of functioning. The term pain-associated disability syndrome has been used to describe a downward spiral of increasing disability and pain for which acute symptom-focused treatment is not sufficient to reverse the pain and disability trajectory (Bursch et al. 2003). For such patients, a rehabilitation model of treatment is important. In some ways, this model is parallel to the rehabilitation required after orthopedic surgery. For example, progress is initially measured by changes in functioning rather than by improvements in pain. For most, pain and or pain-related distress decreases once normal functioning is recovered. For children with pain-associated disability syndrome, normal functioning includes physical functioning...

What Practitioners Say It Does

The benefits of relaxation and stress reduction, in turn, can reduce levels of stress hormones, improve immune functioning, diminish chronic pain, improve mood, and even possibly enhance fertility. Quieting the conscious mind is believed also to allow the body's inner wisdom, or internal physician, to be heard. That is, meditation promotes the body's ability to heal itself.

Impairment And Disability

Assessment at one point in time is inevitably limited, because impairment and disability are not static or passive. Both can vary with time, disuse, and rehabilitation. We have not found any physical basis for permanent disability in ordinary backache, and physiologic impairments at least have the potential to recover. Psychological, behavioral, and social impairments may all be remediable. Functional limitation may persist as long as pain lasts, and there is good clinical and epidemiologic evidence to suggest that the chances of successful rehabilitation of chronic pain reduce over time (Ch. 7). But, in principle, this kind of impairment always has the potential to improve. Various groups have proved this, even in chronic low back cripples (Cox et al 1988, Watson 2001).

What It Can Do for You

The term placebo today has acquired something of a stigma. Many view placebos as ineffective, deceitful remedies. Yet many positive results have come from placebos, including abatement of chronic pain and other symptoms. The placebo effect is intriguing, as is the fact that the mind can produce a negative, nocebo response to an inactive or nonspecific drug.

Disability and Specific Mental Disorders

Somatoform disorders present a unique conundrum in disability claims, in that the impairment is purportedly due to physical symptoms but the underlying pathogenesis is substantially psychological. In some of these cases, such as chronic pain disorders, a peculiar disability issue has emerged. Although the disability is said to be caused by physical symptoms and is not, therefore, technically a mental health issue, a secondary psychological reaction is asserted as an independent impairment (Drukteinis 2000). So, for example, patients may claim disability due to back pain, but the medical evidence shows that a sedentary work capacity is still possible. Then, with what amounts to circular logic, patients say that it is their depression caused by an inability to work that makes them totally disabled. This scenario is often seen in situations where percentage ratings of permanent impairment are required as part of settlement negotiations.

Medial Elbow Tendinopathy

As with lateral elbow tendinopathy, plain radiographs are not needed to make an accurate diagnosis of medial elbow tendinopathy, but should be considered with a history of trauma, motion loss, locking, or chronic pain. Also similar to lateral epicondylitis, management of medial epicondylitis includes ice, medications, injections, and straps. However, cor-ticosteroid injections are not recommended because of possible ulnar nerve injury. In medial elbow tendinopathy, the most effective stretch is performed with the elbow extended and the wrist and fingers gently pulled into full extension. The forearm can be pronated or supinated. Strengthening focuses on wrist flexion and forearm pronation exercises.

Nonmalignant Pain

Those afflicted with persistent pain suffer both emotional and physiologic harm. The term chronic benign pain is, therefore, a misnomer chronic nonmalignant pain is the preferred terminology. Although it can be successfully argued that any debilitating painful condition is truly malignant, for the purpose of this discussion the term chronic nonmalignant pain is defined as persistent pain not associated with cancer. Certainly there are severe chronic pain states associated with advanced peripheral vascular disease, demyelinating diseases of the central nervous system (CNS), and other chronic debilitating conditions that deserve measures as heroic as those offered patients with malignancies. Tn these cases, the severity of the pain and resultant dysfunction may outweigh the potential risk of untoward side effects. Hippocrates asserted, Extreme remedies are very appropriate for extreme diseases.1 Yet even for these seemingly desperate scenarios, the...

General Principles Of Management

The treatment of chronic pain that persists because of deranged patterns of healing, the development of altered pain pathways, chronic ischemia, or the misuse or disuse of myofascial structures is far more complex than the treatment of acute pain syndromes. The contribution of psychological factors to the interpretation and outward expression of pain takes on added importance as resultant behavioral changes often contribute to the perpetuation of pain. Furthermore, the group of patients suffering from chronic pain is far from homogeneous. Instead, these patients represent a complex clinical syndrome manifesting varying degrees of psychosocial, physical, and vocational dysfunction. Obviously, no one approach can be expected to achieve the desired goals of reducing pain, improving the quality of life, and reducing dependency on the healthcare system. Successful intervention requires not only accurate medical diagnosis but also behavioral and functional considerations in concert with...

Impact of Inflammatory Bowel Disease on the Patient

An often unappreciated major complication of inflammatory bowel disease is substance abuse. As a result of chronic pain, as much as 5 of patients with inflammatory bowel disease are physically addicted to oral narcotics. Many more are psychologically dependent on their pain medication.

Pain and Psychosocial Adjustment

Because pain is a central feature of SCD, a key concern of patients, families, and medical professionals is pain management and coping. The reader is referred to Chapter 9 for a general review of pediatric pain and descriptions of intervention techniques. (For reviews related to pain management in SCD, see Chen et al. 2004 Swain et al. 2006.) In addition to the expected emotional and psychological distress associated with chronic pain, increased levels of pain and related hospitalizations in children with SCD have also been associated with increased rates of psychosocial difficulties, including high rates of school absenteeism and removal from the peer group. As discussed earlier, children with SCD are also at increased risk for psychological and emotional adjustment problems, including depression, anxiety, and social difficulties (Barbarin et al. 1994 Brown et al. 1993b Thompson et al. 1995). Therefore, interventions that aim to decrease pain and to increase effective coping are...

Overview Of Management

Outpatient chronic pain management programs include a team that can carry out behavioral modification, relaxation, and cognitive, physical, and occupational therapies to increase activity and reduce pain behavior. In addition, the team may adjust medications, deal with mood disorders, and provide education. Claims about the efficacy of pain treatments that have not been subjected to a clinical trial must be considered in relation to the nonspecific placebo effects provided by the team's interest, attention, and overall approach to the patient. Hands-on therapies such as soft tissue manipulations and ultrasound are less likely to affect neuropathic compared with muscu-loskeletal sources of pain. However, nocicep-tive pain from muscles and joints commonly accompanies neurologic diseases, causes disability, and degrades quality of life, and can exacerbate neuropathic sources of pain.

Treatment of Medication Overuse Headache

We suggest two basic treatment approaches, both of which provide the same principles of care (1) a simple outpatient protocol for patients who have inadvertently fallen into the cycle of medication overuse, or (2) a structured, multi-week, outpatient interdisciplinary chronic pain program that includes a physical therapy (PT) component, a medical component possibly including intravenous infusions, as well as a psychological treatment component.

Coping with back pain

Most people with back pain, even chronic pain, cope with the pain, adjust, and continue to lead more or less normal liv es. Chronic pain is not synonymous with disability and depression. So how is it that some people cope with the pain successfully while others become disabled What are the different mental strategies they use to cope with the stress (Jensen et al 1991, Main & Spanswick 2000)

Pain Of Spinal Origin

The number of pain-sensitive structures now recognized as potential causes of persistent pain of spinal origin is increasing. The anulus of the intervertebral disc, the facet joint and capsule, the spinal nerve, the dorsal root ganglion (DRG), the dura, the posterior longitudinal ligament, and the paravertebral musculature, as well as the articulations at either end of the vertebral column, with the pelvis (sacroiliac joint, STJ) and the skull (OA joint), are common sites of chronic pain generation. College of Surgeons in 1997, are also important considerations in chronic pain situations.11 Pain of nonspinal origin mimicking spinal pain, undiagnosed malignancy in the spinal column or epidural space, and evidence of cauda equina syndrome are conditions requiring urgent medical intervention.

How beliefs affect health care

At the other end of the spectrum are patients to whom back pain is a serious problem that takes over their attention and their lives. Fear dominates their approach. They are convinced it is due to some serious disease, which no one has yet been able to identify. They are pessimistic about the future, believing they will continue to have back pain permanently and that sooner or later it will disable them. They feel it is all out of their control, and there is nothing they can do about it. It is up to health professionals to find out what is wrong and to cure them. Their beliefs are fixed and difficult to change. They do not accept reassurance easily, and may seek repeated reassurance or alternative opinions. They have low expectations of treatment and poorer outcomes. They may be depressed, which distorts their beliefs and coping strategies, and makes them even more hopeless and helpless. And harder to help. One of the most striking features of some patients with chronic pain is...

Pharmacokinetic Aspects of Intracerebroventricular and Intracerebral Drug Administration

Clinical examples of intrathecal small drug delivery are the icv administration of glycopeptide and aminoglycoside antibiotics in meningitis (5), the intraventricular treatment of meningeal metastasis (6), the intrathecal injection of baclofen for treatment of spasticity (7), and the infusion of opioids for severe chronic pain (8). These examples have in common that the drug targets in all instances are close to the ventricular surface. Superficial targets may also be accessible for some macromolecular drugs. In the case of nerve growth factor (NGF), specific receptors are expressed on axons running in the fimbria-fornix (9). Tracer pharmacokinetic studies showed that the direct tissue penetration of NGF after intraventricular injection is marginal and does not extend deeper than 1 -2 mm from the surface of the infused ventricle in rats (10) and beyond 2-3 mm in the primate brain (11). However, retrograde transport of labeled NGF to neuronal cell bodies in cholinergic basal forebrain...

Evidence Based Treatment Approaches

Based on current knowledge, the use of an SSRI such as fluoxetine or citalopram would likely represent the first line of psychopharmacological treatment for youth with IBD and an anxiety or depressive disorder. Meighen (2007) described the successful treatment of chronic pain and major depressive disorder in two adolescent girls with Crohn's disease using the selective serotonin-norepinephrine reuptake inhibitor duloxetine. A handful of case reports have associated the onset of IBD remission with initiation of treatment with the antidepressants bupropion (Kane et al. 2003) and phenelzine, a monoamine oxidase inhibitor (Kast 1998). Bupro-pion has been reported to lower levels of tumor necrosis factor-alpha, a circulating proinflammatory cytokine associated with gut mucosal erosions in Crohn's disease (Brustolim et al. 2006). Mirtaz-apine, another novel antidepressant, has been reported to increase levels of tumor necrosis factor-alpha, leading some to suggest that its use should be...

Indications for Surgical Intervention

There are several indications for surgical intervention for spinal infection. Open surgical biopsy to determine the bacteriologic diagnosis is recommended in patients with nondiagnostic cultures or closed biopsy. Patients in sepsis refractory to medical treatment may require abscess drainage or debridement of necrotic tissue to facilitate penetration of antimicrobial therapy to sites of active infection. Individuals presenting with acute neurological deficit resulting from spinal cord compression require emergent decompression. Delaying surgical intervention in neurologicalally compromised patients may be cautiously reserved in those who are too significantly medically compromised to undergo surgery, and those who present with over 72 hours of neurological deficit. Chronic pain and significant deformity are relative indications for surgical intervention.

Elliot S Krames Francis S Pecoraro

Melzack's and Wall's gate control theory3 led the way for a less empiric and more scientific approach to treating pain. In 1965, it was known that large-diameter nerve fibers inhibit nervous transmission and that small-diameter nerve fibers encourage nervous transmission. Melzack and Wall hypothesized that large-diameter fibers inhibit nerve transmission of small-diameter nerve fibers and that this control occurs at the spinal cord level. Additionally, this spinal locus of control, or modulation of noxious information, was influenced by descending input from the brain. This control from higher central neural centers is now called central control. Thus, central modulatory control incorporates higher cortical functions, such as those responsible for cognition, motivation, and emotion, on the modulation of pain.12 With the elucidation of the gate control theory, innovations in the treatment of chronic pain specifically neuropathic pain have evolved. Despite all the current advances in...

Malingered Conditions

Mental health clinicians should bear in mind the malingered conditions that they may encounter in forensic and nonforensic settings. Literature reviews demonstrate that malingered conditions include dissociative identity disorder (McConville and LeBourgeois 2008), psychosis (Greenfield 1987), suicidally (Rissmiller et al. 1999), and PTSD (Frueh et al. 1997). Malingered conditions that cross the spectrum of psychiatry and neurology that have been reported include acute dystonia (Rubinstein 1978), amnesia (Bolan et al. 2002), chronic pain (Greve et al. 2009), cognitive deficits (Iverson and Binder 2000 Sweet 1999), dementia (Gittelman 1998), seizure (DeToledo 2001), and sleep disorder (Mahowald et al. 1992). Additionally, there are now several case reports documenting malingering by proxy behaviors, in which caretakers induce or report illness in a dependent in order to reap some external incentive for example, disability payments or controlled substances for the presumed benefit of the...

Psychological Assessment and Structured Clinical Interviews

Traditionally, investigation of malingered cognitive deficits in both civil and criminal venues was the primary area of neuropsychological study (Slick et al. 1999 Sweet et al. 2008), but there is now expanding research related to chronic pain patients (Bianchini et al. 2005), Social Security disability ap

Underlying Moral Debates About Peoples Quality Of Life Suffering And The Bestinterests Standard

Typically, competent adults can decide what treatments are in their best interest, and what quality of life they wish to support. This is called the self-determination standard. When people are faced with a choice between prolonging life and preventing great suffering, they sometimes believe there are worse things than dying. Most of us would not want to endure a mindless existence of intense and chronic pain with no prospect of improvement. Some people leave advance directives about their desires in such circumstances or designate surrogates to make decisions for them if they become incompetent. Friends and family can help inform these decisions even when no advance directive has been left and no surrogate appointed. They can have a role in determining what they believe the person would have wanted given his or her values, thereby using the substituted judgment standard. treatment from an incompetent person when life has no other prospects but severe and chronic pain. The all other...

The Standard Is Not Objective

Second, objective and subjective can be understood differently. What is objective can mean what is intersub-jectively confirmable, and what is subjective is not. So understood, some statements about quality of life such as pain are objective. Most people who have been on a ventilator say that it is very unpleasant and being unable to move or speak would be a further burden. The fact that most people would not want for themselves a life of chronic pain and immobility, with no hope of improvement or personal interactions, gives objective confirmation to a judgment that some kinds of lives and experiences would be very painful. If most of us agree that something is painful, we have an objective ground for claiming that something is painful.

The Standard May Be Abused

Life they have in mind in deciding whether they should withhold or withdraw treatments. Critics are also correct that some people do not justify their claims that others will really suffer chronic pain without compensatory benefits. To determine if noncomparative quality-of-life judgments are especially open to abuse, they should be compared with other kinds of judgments of similar complexity. Critics show why these different kinds of quality-of-life judgments must be kept distinct, and that a good deal of abuse may come from failing to do this. Resource allocation issues are important, but they should not be snuck into noncomparative quality-of-life considerations.

Deep Brain Stimulation

In 1948, Pool performed a neurosurgical implant of a silver electrode in the caudate nucleus in an attempt to treat a woman with depression and anorexia (Pool, 1954). In subsequent years, developments occurred in treating neurological disorders such as chronic pain, refractory movement disorder, and epilepsy. The technological advancements in stereotactic neurosurgery and the need for reversible targeted lesions facilitated the emergence of deep brain stimulation (DBS) as an alternative to surgical lesions in the treatment of various neurological disorders (see below). As opposed to epidural and subdural surface electrodes, DBS involves the placement of multicontact electrodes in subcortical regions such as the thalamus, basal ganglia, or white matter tracts (Rezai et al., 1999). The surgeon drills burr holes under local anesthesia and places the electrodes, guided by precise landmarking. The subject is typically awake during the surgery and is also instrumental in guiding the final...

Psychosocial Adjustment

Children living with HIV commonly experience pain (Gaughan et al. 2002 Hirschfeld et al. 1996 Lolekha et al. 2004), including abdominal pain of unclear etiology, myositis, tension headaches, and neuropathic pain that is difficult to manage. Discomfort related to invasive procedures, toxicities and adverse drug reactions, invasive secondary infections, pancreatitis, and erosive esophagitis may be treated pharmacologically. Pain has been found to be associated with more severe immunosuppres-sion and increased likelihood of death (Gaughan et al. 2002). There are no published studies examining the relationship between chronic pain and psychological distress in HIV-infected children. Nevertheless, children fear pain, and pain is made worse by emotional distress, so attention at regular intervals to physical and emotional distress is warranted.

Unspecific low back pain

A thorough clinical examination is important to eliminate differential diagnoses and gain confidence. In patients with subacute or chronic pain, a CT scan and a clinical evaluation of inorganic signs are recommended if symptoms have lasted longer than 2-4 weeks (Fig. 6.5.28). Chronic pain. Information about the nature of the problem, emphasizing reduction of fear, will give the patient confidence to resume light activity. Guidelines recommending avoiding twisting and bending when lifting and excess carrying that involves prolonged isometric activity, and encouraging use of the thighs when lifting heavy objects can be given. The patient should be instructed to use the back and flex it 37 . Information may be reinforced at repeated appointments. It is documented that patients with chronic low back pain will benefit from exercise therapy. A recent study indicates that low-impact aerobics is the most cost-effective physiotherapy method 41 . A variety of other methods have also...

Hypoactive Sexual Desire Disorder

Female sexual desire is a complex interaction among biologic, psychological, social, interpersonal, and environmental components. Ovarian function, especially ovarian androgens, may play an important role. In women age 20 to 49, HSDD is almost threefold more likely in surgical postmeno-pausal women than premenopausal women. However, no significant difference in HSDD exists between naturally or surgical postmenopausal women over age 50 (Leiblum et al., 2006). Medical illnesses, such as thyroid disease, chronic pain conditions, urinary incontinence, and depression anxiety, may negatively impact sexual desire. Medications can affect sexual drive, especially selective serotonin reuptake inhibitor (SSRI) antidepressants, antihypertensives, antipsy-chotics, and narcotics. Fear of pregnancy or sexually transmitted infection and discord or communication difficulty in a couple's relationship may diminish sexual desire. The clinician must explore all aspects of the biopsychosocial model when...

Family Psychoeducational Approaches

Barlow and Ellard (2004) reviewed 12 psycho-educational intervention studies, including samples of children with asthma, chronic fatigue syndrome, diabetes, juvenile arthritis, and chronic pain. Overall, studies showed evidence of effectiveness on such variables such as self-efficacy, self-management of disease, family functioning, psychosocial well-being, reduced isolation, social competence, knowledge,

The complex regional pain syndrome Commentary

Complex regional pain syndrome (CRPS) Types I and II are important examples of neuropathic pain, which may affect a wide range of age groups. The condition is seen almost exclusively in the chronic pain management clinics and you may well have little direct experience of its main features and management. Neuropathic pain, however, complicates many disease states, is severe and difficult to treat, and remains incompletely understood. For this reason it continues to appear as a popular examination topic.

Future health care for back pain

We now have a much more solid evidence base for what does (and, equally important, what does not) work. I believe we are already seeing a revolution in the clinical management of acute back pain. We are still struggling to find a better answer for those patients who develop chronic pain and disability. And we are slow to accept that if we are going to put this new approach into practice we must also change the health care delivery system to make it possible.

Health care for ordinary backache

Inappropriate and even harmful investigations and treatment that are really designed for different problems. Even when such treatment is simply ineffective rather than directly harmful, it may cause more subtle harm. It perpetuates the focus on disease and on passive, mechanical treatment. It creates unrealistic expectations of symptomatic cure. Delays and protracted treatment also defer more effective management and lead directly to chronic pain and disability. In some cases it may have been better not to have that referral or treatment at all.

Principles of services for back pain

Primary care clinicians must also distinguish between what sometimes seem to be two very different groups of patients with non-specific back pain. Most patients seem to get better no matter what we do, and need little more than reassurance and advice. We need to identify as early as possible the few who are at risk of chronic pain and disability. Timing is vital. 1 know that I have repeated this ad nauseam about clinical management, but it is so fundamental that we must apply it one last time to health care delivery. Design of the system must also take account of the passage of time and the risks of chronic pain and disability. The natural history of back pain is of a persistent or recurrent problem, and recovery may not mean the complete absence of pain. The key issue is the duration of sickness absence. There are three stages (Fig. 21.1) in which health care needs are very different. For the 10 of patients who do not recover sufficient to return to ordinary activities and work...

A back pain rehabilitation service

Rehabilitation facilities should be available for all patients who are still off work after 3-6 weeks and at risk of chronic pain and disability. Physical therapy has a key role in rehabilitation. Referral patterns, physical therapy facilities, and organization should reflect this. At present, rehabilitation is often regarded as a tertiary service after medical treatment is complete or has failed. That must change.

Chronic Pediatric Pain

Perioperative use of regional anesthesia helps children to wean more quickly from mechanical ventilation, to suffer fewer complications, to leave the hospital sooner, and to incur fewer hospital expenses.1 However, we have been slow to apply regional techniques to the treatment of children with chronic pain. Reasons include basic differences between children and adults in the natural history of terminal illness and chronic nonmalignant pain, lack of familiarity with regional techniques, and fear that regional techniques may harm children. Any decision to try a regional technique is grounded in an assessment of risks and benefits. Several authors have suggested that the risk of interventional pain management in children is low, but few studies address the actual outcomes of these techniques. Not surprisingly, most outcome-based studies of interventional chronic pain treatment focus on adults. For example, one study of adults with chronic nonmalignant pain found less need for systemic...

Medical Management beyond Withdrawal

Methadone is a long-acting opiate receptor agonist with strong affinity for its receptor and can be dosed once daily for most opiate-dependent patients. Currently, methadone may be used for treating opiate dependence in hospitalized patients (i.e., for withdrawal) or in licensed methadone treatment facilities. Take-home doses are regulated and depend on length of time in treatment and treatment response, including good attendance, adherence to program rules, lack of diverting behaviors, and abstinence, as verified by drug test results. Generally one take-home dose a week is allowed from the outset (many programs are closed on Sundays). Progression to increased take-home doses is determined by state and federal regulations, with the more restrictive statute taking precedent. For family physicians with patients in methadone maintenance, knowing a patient's take-home schedule can provide insight into how well they are doing in treatment. Recent increases in overdose deaths involving...

Acromegaly Patient Encounter 1 Medical History Physical Examination and Diagnostic Tests

EB, a 48-year-old woman, presents to a new primary care clinic. EB's chief complaints are chronic pain of the knee and pins and needles and numbness in both hands. Over the past few years, she feels that her body has been changing. EB reports increased urinary frequency, excessive sweating, worsening headaches, an increase of two shoe sizes, and facial hair that she shaves once a week. She says that her hands have enlarged to the point that my wedding band won't fit anymore.

Probability of return to work

Probability Impact Healthcare

Both recovery from the acute attack and the development of chronic pain and disability are processes that take place over time. Health professionals are certainly aware of patients' clinical progress. However, this epidemiologic view stresses that the passage of time, in itself changes the patient's whole situation. This is so simple and so obvious that we often dismiss it as a truism, to our patients' peril. expected ' the health care they receive, and changes in their work situation. Those factors at onset that predict chronic pain and disability may differ from those at 3-4 weeks, or at 3 months. The influence of some factors may reduce over time, while other factors may become more important. For example, the type and circumstances of injury and severity of symptoms may be useful predictors of recovery in the early stages, but their effects diminish over the first few months. Conversely, the patient's psychological reaction to failure to recover as expected only develops with the...

History of Present Illness and Debilitating Symptoms

Pain is one of the most debilitating symptoms and has traditionally been underrecognized. Unrelieved pain is very common and is one of the most feared symptoms of illness. Surveys indicate that 20 to 30 of the U.S. population experiences acute or chronic pain, and it is the most common symptom experienced by hospitalized adults. More than 80 of patients with cancer and more than two thirds of patients dying of noncancer illnesses experience moderate to severe pain. There are approximately 75 million episodes of acute pain per year resulting from traumatic injuries and surgical procedures. Acute pain is caused by trauma or medical conditions, is usually brief, and abates with resolution of the injury. Chronic pain persists beyond the period of healing or is present for longer than 3 months.

Emotional Intensity Emotional Valence and Visual Perspective

Anism to avoid intrusive memories (Williams & Moulds, 2007). Moreover, chronic pain sufferers report less associated pain when remembering events from a third-person perspective compared to first-person (McNamara, Benson, McGenny, Brown, & Albert, 2005). Robinson and Swanson proposed that when switching from a third-person to first-person perspective, one attempts to reinstate the experiential code (associated with first-person perspective), but finding it unavailable will rely on the cognitive code (e.g., goals, beliefs) to reconstruct affective information. Consequently, affect intensity does not change, as the experiential code is no longer available. Conversely, switching from first-person to third-person perspective inhibits the experiential code, leaving the cognitive code to define the affective components of the event, resulting in the observed reduction of intensity. The model does not specify what occurs when the cognitive code is no longer available however, one might...

PCS Organic or functional

A wealth of literature also exists in describing the base rates at which the reporting of the clinical features associated with the PCS are noted in non-head-injured subjects. Gouvier, Uddo-Crane and Brown (1988), for example, have noted that no significant differences were found between the level of symptoms reported by a head injury group and uninjured controls. Both Iverson and McCracken (1997) and Gasquoine (2000) have noted that a similar level of symptom endorsement as that noted with PCS was also observed in a sample of patients suffering from chronic pain. Gasquoine suggested that the symptoms of PCS are not specific to concussion, but rather due to the effects of emotional distress more generally. Iverson and McCracken caution that levels of pain should be carefully considered in interpreting patients' physical, cognitive, and psychological complaints following head injury. Fox, Lees-Haley, Ernest, and Dolezal-Wood (1995) noted a similar coincidence of symptom reporting in...

Knee pain in adolescents

Knee pain in adolescents has many etiologies and the clinician must also rule out rare entities (e.g. tumor, referred pain) to establish a thorough diagnosis. Although meniscal injuries are less common in children than in adults, several recent reports indicate an increasing incidence of meniscal lesions in children and adolescents, especially those in competitive sports. De Inocencio i0i investigated the distribution of mus-culoskeletal pain in children. The knee was the most affected joint (33 ), followed by other joints (e.g. ankle, wrist, elbow, in 28 ), soft tissue pain (i8 ), heel pain (8 ), hip pain (6 ) and back pain (6 ). Symptoms were caused by trauma in 30 overuse syndromes in 28 (e.g. chondromalacia patellae, mechanical plantar fasciitis, overuse muscle pain) and normal skeletal growth variants (e.g. Osgood-Schlat-ter syndrome, hypermobility, Sever's disease) in i8 of patients. Sources of chronic pain about the knee may include tendinitis, apophysitis, patellofemoral...

Cost Of Chronic Unrelieved Pain

In the United States, the costs of unrelieved pain and disability arising from chronic pain are and will continue to be a major problem until appropriate, cost-effective algorithms for the management of chronic pain are created and implemented. Chronic unrelieved pain is not only a major drain on scarce healthcare resources but is the cause of untold suffering of millions of people worldwide. The direct, hard costs of unrelieved pain to patients and their families are loss of job, income, savings (and therefore security), and insurance. More intangible consequences of unrelieved pain include loss of self-esteem, depression, anger, frustration, and suffering. The end result of these direct and indirect costs of unrelieved pain is staggering to society and to the individuals who unfortunately suffer from it. Approximately 30 of the United States population, or approximately 70,000,000 persons, suffer from chronic pain. Given these alarming data, it is not difficult to imagine the impact...

Proximal Interphalangeal Joint Ligament Injuries

Digit Pip Dislocation Partial

Injuries are managed with buddy taping, early ROM, and a short period of protection in a dorsal blocking splint with the PIP joint in 30 degrees of flexion. The indication for surgical repair of the ligament is instability on active ROM, nonanatomic joint reduction, or chronic pain. Consideration may be given to surgical repair of significant injuries to the RCL of the index finger because of the restraints required for lateral pinch.

Table 261 Neurohumoral And Physiologic Responses To Trauma

Pain in trauma and burn victims indicated that these patients have a high incidence of moderate to severe pain.3 In reports of these studies, there was an inordinate concern for the hemodynamic changes and respiratory depression caused by analgesics.13 13 The results of these studies are surprising, because analgesic interventions have been shown to modify the stress response13 13 and to aid in early rehabilitation of the patient. The application of the ideal analgesic anesthetic regimen also reduces the incidence of chronic pain syndromes.181 The management of trauma patients during their period of rehabilitation involves treatment of contractures, spasticity, and pressure sores. Chronic pain may develop in the form of neuropathic pain, myofascial syndrome, complex regional pain syndromes, and phantom limb pain. The specific treatment of these syndromes is beyond the scope of this chapter. Analgesics include nonopioid drugs and opioid medications for acute pain. Tranquilizers are...

Fearavoidance beliefs

Fear Avoidance Model

Even if physical activity does aggravate pain, that is quite different from being the cause of the pain. Temporary aggravation may also be quite different from any long-term effect. To use the sports analogy again, training may cause temporary musculoskeletal aches but still lead to long-term benefit. Moreover, patients' perceptions of physical activity and its relation to pain are often inaccurate. Several studies have shown that patients with back pain overestimate the physical demands of their job compared with healthy fellow workers. Patients tend to overpre-dict the pain they will get on exercise. Treadmill endurance of patients with chronic low back pain is only 75 that of normal controls, even when this form of exercise does not increase their pain (Schmidt 1985). Both groups rate their exertion similarly, but the patients with back pain actually show lower levels of physiologic demand. They stop because they overestimate their exertion rather...

Drug Therapy The Cornerstone of Pain Treatment

Who Pain Ladder 2016

Pain medications are used commonly for acute or chronic pain for patients of all ages, including infants and the elderly, and will relieve pain in about 90 percent of cases. The World Health Organization (WHO) began a revolution in cancer pain therapies with its recommended ladder of medications for the appropriate sequence of therapies. It suggests that doctors treat mild cancer pain with mild painkillers and progress to more potent ones as needed, adding supplemental medications that can enhance pain relief or relieve medication-related side effects as necessary.

Psychological factors in illness behavior

Illness behavior is associated with chronic pain and disability, the amount of failed treatment, and problem patient status. These all lead to increased illness behavior, but the cause and effect relationship is not entirely clear. Illness behavior is not only the consequence of chronic pain and disability. It occurs at an earlier stage than we previously thought, and it may be involved in the process of developing chronic pain and disability. Patients who show marked illness behaviors have a lower success rate of any kind of treatment. Beliefs, distress, and illness behavior all get better or worse with the success or failure of physical treatment. This may become a vicious circle, which we will consider again from different perspectives in the following chapters. Illness behavior does not just happen it is learned. It is not fixed, but is a dynamic process over time, and health care may play a key role in its development. The information and advice we give may color patients'...

The clinical course of back pain

Probability of return to work 122 The development of chronic pain and disability 123 Identifying patients at risk of chronic pain and disability 126 Clinical factors 128 Psychosocial factors 130 Sociodemographic factors 130 The accuracy of screening 130 Conclusion 134 References 134 How do chronic pain and disability develop Can we predict which patients will do well and who is at risk of developing chronic pain and disability

Appendix 10a A Response To Critics

Some eminent pain specialists have attacked my interpretation of the non-organic signs as being contrary to modern neurophysiologic and clinical understanding of chronic pain. Dr Harold Merskey has been a constant critic throughout. Pat Wall profoundly disagreed and Fishbain et al (2003) recently published a zealous attack. CHRONIC PAIN_ The first criticism is that modern neurophysiologic and clinical understanding of chronic pain provides an alternative explanation for the non-organic signs (Merskey 1988, Margoles 1990, Fishbain et al 2003). 2. improved clinical diagnosis of the causes of chronic pain. Second, clinical studies show that patients with fibromyalgia, myofascial pain syndrome, and complex regional pain syndrome often have nonorganic signs. These findings are related to perceived pain and pain-associated phenomena. Recent advances in demonstrating pain generators, functional MRI (fMRI) changes, and pain imaging in the brain now provide a physical basis for chronic pain...

Core Elements of Integrative Medicine

Other options are considered in the Healing Foods Pyramid (Figure 11-6). While developing the best nutrition advice for the diverse people seen at the University of Michigan's Inte-grative Medicine Clinic, family physician Monica Myklebust found various recommendations for the prevention and treatment of obesity, mood disorders, heart disease, diabetes, chronic pain, and inflammation. The result of her work is a user-friendly tool that brings all of these data together. Omega-3 fatty acids, antioxidants, medicinal seasonings, soy, chocolate, and tea are all considered. For example, green tea offers a variety of health benefits, with emerging evidence for prevention of cancer, stroke, and cardiovascular disease (Schneider and Segre, 2009). Health concerns regarding the sources of U.S. food and recommendations for organic and wild food are discussed. The Healing Foods Pyramid is available as a web-based interactive version (www.med. umich.edu umim clinical pyramid). The top is left open...

Cutting the Wires Nerve Blocks and Neurosurgery Temporary Nerve Blocks

Nerve blocks can be as simple as the shot of novocaine dentists use to numb a tooth. By injecting a drug near the path of a nerve, you can block the transmission of painful signals before they reach the spinal cord and brain. Such blocks are used for minor surgery and sometimes for chronic pain, such as from a back injury. An epidural nerve block, used commonly for labor pain, provides more extensive pain relief because the anesthetic (numbing medicine) is injected into the epidural space, a compartment that surrounds the spinal cord. These local anesthetic blocks are considered temporary nerve blocks because numbness lasts for only several hours. For cancer pain, which often is progressive and unrelenting, temporary or local anesthetic blocks are usually used for secondary pain that is only indirectly related to the cancer itself or to diagnose or test the use of a more lasting nerve block, rather than for therapeutic use. Management of chronic pain that was present long before...

Denervation Of Cervical Facets C26

Attention must be paid to related pain conditions such as atypical facial pain, cervicogenic headaches, and cluster headaches. In these chronic pain syndromes, correct physical examination, imaging studies (including functional radiography), and differential diagnosis are essential because cervicogenic headache and cervical migraine respond to radiofrequency treatment, whereas tension headache and classic migraine do not.

How is the clinical syndrome of lumbar DDD characterized

Lumbar discography is utilized as a provocative test to assess patients with DDD. Although controversial, this test attempts to directly identify a cause and effect relationship between MRI findings of DDD and clinical symptoms. Findings that support a diagnosis of discogenic pain include concordant pain on injection of a specific disc level with absent or minimal pain on injection of adjacent control levels. Additional criteria for diagnosis include pain reproduction with a low pressure low volume injection and presence of abnormal disc morphology. Discography remains a controversial test in patients with abnormal psychometric profiles, chronic pain illness, worker's compensation claims, and secondary gain issues.

Patient Encounter 1 Part 2 Converting to Different Drugs and Adjusting Doses

Methadone is unique among the opiates as it has several mechanisms ( .-agonist, NMDA-receptor antagonist, and inhibition of reuptake of serotonin and norepinephrine) that make it an interesting choice for chronic pain. The long-half of methadone (30 hours) permits extended dosing intervals however, the potential for accumulation with repeated dosing often results in challenging dose conversion. Tramadol is a synthetic opioid with a dual mechanism of action ( -agonist and inhibition of serotonin and norepinephrine reuptake) and efficacy and safety similar to that of equianalgesic doses of codeine plus APAP. Tramadol has been evaluated in several types of neuropathic pain and might have a role in the treatment of chronic pain. Tramadol is associated with an increased risk of seizures in patients with a seizure disorder, those at risk for seizures, and those taking medications that can lower the seizure threshold. Doses greater than 500 mg have also been associated with...

What is the most important component of an exercise program for the treatment of low back pain due to lumbar DDD

The most important component of a low back exercise program is to address fear-avoidance behavior of the patient by reassuring the patient that it is safe to exercise despite the chronic pain he or she may experience. The appropriate exercise program is a supervised active physical therapy program that uses progressive, non-pain contingent exercise (i.e. the patient is encouraged to exercise despite their pain) to increase strength and endurance. Successful outcomes may be achieved with a variety of exercise programs including core strengthening, McKenzie therapy, Pilates, and aerobic conditioning. It is counterproductive to tell patients, Let pain be your guide. Patients with lumbar DDD must be reassured that they will not do any damage to their spine, even if exercise is painful.

Which patients are less than ideal candidates for surgical treatment for lumbar DDD

Surgical treatment is associated with poor outcomes in patients with unresolved secondary gain issues, worker's compensation claims, litigation, multiple emergency department visits, high levels of opioid usage, abnormal psychometrics, chronic pain illness, and exaggerated pain behaviors. Patients off work greater than 3 months tend to have worse results. To have any sense that surgery might benefit the patient, the surgeon must get to know the patient. Overreliance on MRI or discography data will lead to a high rate of clinical failures. Motivated patients without psychosocial overlay that fall within the narrow indications are likely to do well. Deviation from these strict criteria exposes the patient to significant operative risks with much less potential benefit.

Deep Brain Stimulation Today

Deepbrain Stimulation

A useful procedure used today in humans is called deep brain stimulation (DBS), which is not necessarily associated with drugs and pleasure. In this procedure, neurosurgeons implant electrodes into the brains of patients with a battery-powered generator that produces electrical pulses (see Figure 3-2). It has been found that stimulation of the electrodes can relieve symptoms of chronic pain, major depression, Parkinson's disease, and other disorders. Of course, it depends where the electrodes are implanted, and different sites are used for different disorders. This treatment is relatively new because the first use for DBS was approved by the FDA in only 1997. It is interesting that the mechanism of DBS is still not thoroughly understood. It won't surprise you to learn that DBS is being discussed as a treatment for addictive disorders. Promising results have been obtained in animal studies where DBS seems to reduce an animal's interest in self-administering drugs.

Clinical Applications Of Brachial Plexus Block

Approach The Brachial Plexus

More proximal surgical procedures usually use more proximal brachial plexus approaches (e.g., interscalene block for shoulder procedures). Clinical applications of interscalene block include all shoulder surgical procedures, including arthroscopic and open procedures,1201 management of frozen shoulder,123 repair of humeral fracture,1221 elbow procedures, carotid endarterectomy, vascular shunts, chronic pain syndromes, pain of the arm and forearm, and cancer pain management. Supraclavicular, 123 infraclavicular,123 and axillary123 blocks are used for elbow, forearm, and hand surgery.

Classification of WAD

This classification scheme has been found to have prognostic value, in that higher grades have been associated with poorer outcomes at six, twelve, eighteen and twenty-four months (Hartling et al. 2001). However, this classification scheme only gives an indication of severity and is unhelpful in prescribing management. As far as mechanical diagnosis and therapy is concerned, classification is determined by the mechanical evaluation. In the acute stage non-mechanical conditions may be common, no mechanically determined directional preference is detected and the patient is treated as for any traumaduring the inflammatory stage however, this frequently changes in the subsequent weeks. In the chronic stage multi-directional dysfunction, derangement or a chronic pain state may be present.

Pharmacologic Therapy

Opioids are considered the agents of choice for the treatment of severe acute pain and moderate-to-severe pain associated with cancer.45 For chronic pain, their use was once highly controversial, however, use of opioids in chronic pain is now gaining acceptance.46 Opioids are classified by their activity at the receptor site, usual pain intensity treated, and duration of action (short- vs. long-acting).

Clinical Presentation And Diagnosis Classification of Pain

Pain has always been described as a symptom. However, recent advances in the understanding of neural mechanisms have demonstrated that unrelieved pain might lead to changes in the nervous system known as neural plasticity. Because these changes reflect a process that influences a physiologic response, pain, particularly chronic pain, might be considered a disease unto itself. Pain can be divided into two broad categories, acute and chronic pain. Acute pain is also referred to as adaptive pain since it serves to protect the individual from fur ther injury or promote healing. However, chronic pain has been called maladaptive, a pathologic function of the nervous system or pain as a disease. Chronic Pain Chronic pain persists beyond the expected normal time for healing and serves no useful physiologic purpose. Chronic pain might be nociceptive, inflammatory, neuropathic, or functional in origin however, all forms share some common characteristics. Chronic pain can be intermittent or...

Epidemiology And Etiology Prevalence of Pain

Most people experience pain at some time in their lives, and pain is a symptom of a variety of diseases. For some, pain might be mild to moderate, intermittent, easily managed, and have minimal effect on daily activities. For others, pain might be chronic, severe or disabling, all consuming, and treatment resistant. Thus, identifying the exact prevalence of pain is a difficult task. According to the American Pain Foundation, more than 76 million people in the United States suffer from chronic pain, and an additional 25 million experience acute pain from injury or surgery. About 26 of the adults, mostly women and the elderly, experience chronic pain such as back pain, headache, and joint pain. and chronic pain and about 50 to 70 of those in active treatment will experience significant pain.6

Physician beliefs and patient satisfaction

Chiropractors at that time were much more confident about their training and their ability to help patients with back pain (Cherkin et al 1988). They were more comfortable and less frustrated by spinal pain, which is just as well as it is two-thirds of their practice Despite the philosophic basis of chiropractic medicine, the chiropractors in this study firmly believed that back pain depends on physical factors that they can and should diagnose. Family doctors (MDs) were less certain about the physical basis of back pain and their ability to assess it. Medical doctors and physical therapists placed more emphasis on the role of psychosocial factors in chronic pain and disability. Most practitioners agreed that job factors are also important, although DOs and DCs rated them less highly.

Primary Care of SUD Patients

Treatment for asthma, hypertension, chronic pain, and diabetes is complicated by the concomitant SUD. Patient adherence to treatment regimens is often compromised by the SUD, with getting high and minimizing withdrawal symptoms becoming the focus of their activities. Regular and nutritious meals may be difficult to access or may not be a priority for SUD patients, along with hygienic activities. Sleep disorders are common and can exacerbate health problems and their management. SUD patients' ability to store their medications safely and securely can be compromised by homelessness, diversion, and unsafe living environment.

Clinical Manifestations

Pelvic Inflammatory Disease (PID) Perhaps the major modern concern about gonorrhea is its potential for destruction of female reproductive organs. The gonococcus may spread upward from the cervix to inflame the uterine lining of the fallopian tubes (salpingitis) and ultimately cause peritonitis. Once established, PID becomes chronic, of long duration, and with serious consequences. Approximately 20 percent of women will have a recurrence after treatment for a primary episode of gonococcal PID. The syndrome of chronic pain, lower abdominal discomfort, and dyspareunia reflects insidious scarring and closure of the fallopian tubes, which may cause ectopic pregnancy and lead ultimately to involuntary infertility. Studies in Sweden indicate that the risk of sterility is 12 to 16 percent after a single episode of salpingitis and rises to 60 percent after three episodes.

Peripheral Nerve Blockade

Peripheral nerve blockade is an essential tool in the management of acute and chronic pain. It is useful in the treatment of procedure-related pain (e.g., laceration repair, fracture reduction, IV catheter insertion), traumatic pain (e.g., postoperative pain, femur fracture), and in the diagnosis and management of complex regional pain syndromes (e.g., sympathetic nerve blocks). Additionally, regional anesthetic techniques are very useful when general anesthesia or systemic analgesics cannot be easily used because of their potential to exacerbate a patient's underlying medical condition. For example, nerve blocks may offer the best analgesic alternative for patients with neuromuscular, metabolic, cardiac, or chronic lung disease because regional blockade provides intense (total) analgesia and produces minimal changes in cardiac and pulmonary physiology. Thus, these blocks can provide intense, unparalleled analgesia in patients with minimal reserve who cannot tolerate opioid-induced...

Sympathetic Blockade For Neuropathic Pain

Rapid advances are being made in our understanding of chronic pain mechanisms and novel molecular targets such as the vanilloid receptor and neuron-specific ion channels have been identified. Unfortunately, these advances have not yet led to new therapeutic approaches in the management of patients with intractable chronic pain. Leading investigators in the field are proposing a new approach a mechanism-based pain treatment. For example, knowledge of the different subtypes of sodium channels and their role in neuropathic pain states may lead to more selective channel blockers than the presently available local anesthetics. Such developments raise the possibility of blocking pain signals without affecting normal sensations. A plea is being made for an attempt to classify patients based on their pain mechanisms, using quantitative sensory tests, and to examine the efficacy of therapies, including nerve blocks, on the different aspects of the clinical presentation (e.g., ongoing pain and...

Neuropathic Pain In The P Sto P E Rat Iv E Peri O D

The possibility of the development of neuropathic pain should be borne in mind after surgery, as it is often missed in patients with acute pain and may require specific therapy (see Ch. 61 for the management of chronic pain). A useful definition of neuropathic pain is 'pain associated with injury, disease or surgical section of the peripheral or central nervous system'. One diagnostic clue after surgery is an unexpected increase in opioid consumption, as neuropathic pain often responds poorly to opioids. Features suggestive of neuropathic pain include

Applications Of Computergraphic Facial Reconstruction

Its physical appearance and its perception by others act together powerfully to set us a real challenge in identifying an individual. This is particularly so when we try to reconstruct a face from a skull of unknown provenance. We start with the not insignificant difficulty of trying to achieve a recognition from an acquaintance of the deceased, when we have no idea who the person was to begin with or how they were remembered during life - were they happy and smiling, sad or angry Did they have a condition which in some way characterized their facial appearance - we know that chronic pain or severe mental disorders such as schizophrenia can significantly alter facial affect in a person. Nevertheless, despite these obstacles, identifying an individual from their facial appearance remains a fascinating challenge for us worthy of serious academic study and development.

Distinguishing chemical and mechanical pain

As the cause of pain is an important determinant of the appropriateness of mechanical therapy, it is vital to distinguish between mechanical and chemical sources ofnociception (McKenzie 1981, 1990). We can begin to distinguish between these types of pain by certain factors gained during the history-taking and largely confirm this impression during the physical examination. A key characteristic that indicates the possibility of pain of chemical origin is constant pain. Not all constant pain is inflammatory in nature, but chemical pain is always constant. The term 'constant pain' indicates that the patient is never without an ache or discomfort from the moment they wake until the moment they fall asleep. The ache may be exacerbated by movements and be less at times, but the dull, relentless ache never goes entirely. Constant pain may result from chemical or mechanical causes, or be due to the changes associated with chronic pain.

Procedures For Pain Relief

Monitoring of chronic pain requires pain relief but also the patient's well-being, functional restoration, work-status restoration, and global outcome. These considerations may be very complex, because each case may be managed with multimodal analgesia techniques1 3 ( Table 12-5 ).

P Prithvi Raj Molly Johnston

Room Requirement For Nerve Block

When first seen at the nerve block facility, the acute or chronic pain patient has already been examined by many professionals in various hospitals and has undergone various tests and procedures. This experience makes the patient fearful and apprehensive of seeing another new set of medical professionals. Nerve blocks are often foreign to patients and can be a source of apprehension. The patient must be reassured that nerve blocks are a standard form of anesthesia for surgery and for therapy in chronic patients and are performed by experts. It is the responsibility of both the physician and the nurse to inform the patient of the purpose of the procedure, how it is done, the expected outcome, and the side effects and risks. Unless the procedure is urgent, this explanation is given on the visit before the procedure. To reinforce the verbal explanation, the patient receives a simple written explanation of the procedure. Patients who are to have a procedure for chronic pain are told to...

Neuropathic Versus Nociceptive Pain

One offshoot of the introduction of the gate control theory was awareness that most of the experimental data drawn upon to support the hypothesis were based on observations of normal animals. There was major concern that the observations might have little, if any, relevance to chronic painful conditions that exist in humans. This concern provided a stimulus for the production of animal models of chronic pain. One of the more prominent methods for producing such models involved damaging nerves by placing a ligature around a nerve bundle. This technique established the use of the terms neuropathic pain to denote pain induced by nerve injury and nociceptive pain to denote pain initiated by nociceptor stimulation. Likewise, investigations using animal models in conjunction with studies and observations involving human patients laid the foundation for a proposal that pain can be categorized as a normal sensation, as a symptom, or as a disease (Fig. 9-10 (Figure Not Available) ). As a...

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