Permanent End To Chronic Pain
Chronic pain is best treated using multiple therapeutic modalities. These include physical therapy, psychologic support, pharmacologic management, and the rational use of more invasive procedures such as nerve blocks and implantable technologies. 3. In patients suffering from chronic pain, underlying psychologic psychiatric conditions should be addressed if any meaningful recovery is to be achieved. CHAPTER 78 CHRONIC PAIN MANAGEMENT SUGGESTED READINGS 1. Cameron T Safety and efficacy of spinal cord stimulation for the treatment of chronic pain a 20-year literature review. J Neurosurg 100(3 Suppl) 254-267, 2004.
When a chronic pain patient has suffered an injury or undergone surgery, the general rule is that the typical dose of oral opioids should be tripled for the first 1 to 2 days. In the preoperative preparation for a chronic pain patient, a one-time dose of gabapentin (900 to 1200 mg) or pregabalin (75 to 100 mg) coupled with a one-time dose of celecoxib (Celebrex) (200 mg) has been shown to improve pain control. After surgery gabapentin or pregabalin can be continued as a regular oral dose, and celecoxib should be continued at 100 mg bid for 5 days. Regional blocks should be used whenever possible and continued at least 24 hours after surgery if possible. A low-dose ketamine (0.05 to 0.2 mg kg hr) infusion during the operation helps with pain control and can be continued after surgery by combining ketamine with the opioid in a PCA infusion.
Voltage-gated calcium channels fluctuate between three primary functional states, which provide the opportunity for selective pharmacological intervention 10 . Initially, when the membrane is hyperpolarized, the channel is in the resting (closed) state. In response to the appropriate depolarized membrane potential, the channel may undergo a conforma-tional change to the activated state (open), permitting Ca + ions to enter the cell through the channel. Finally, the channel may enter an inactivated conformational state from either the activated or the resting state. In this inactivated state, the channel remains unresponsive to a depolarizing potential until it transitions to the closed state (recovers). Increased neuronal firing rates, such as those in chronic pain syndromes or epileptic episodes, are believed to drive a greater proportion of calcium channels into the inactivated state 11 . These distinct conformational states afford the possibility of discovering state-dependent...
There are three approved drugs, venlafaxine (16), duloxetine (17) and milnacipran (18), in the serotonin-norepinephrine reuptake inhibitor (SNRI) class. Whereas milnacipran blocks 5-HT and NE reuptake with almost equal potency, venlafaxine and duloxetine block 5-HT reuptake preferentially 39-41 . Clinical evidence shows that SNRIs have comparable efficacy in the treatment of MDD compared with antidepressants in the SSRI class. An advantage with SNRIs appears to be the ability of alleviating chronic pain associated with, and independent of depression 42-44 .
Among the various members of the TRP superfamily, the vanilloid-1 receptor (TRPV1) has emerged as a particularly attractive target for the treatment of acute and chronic pain. Regarded as a polymodal molecular integrator in nociception, TRPV1 is a nonselective cation channel localized on sensory neurons in C- and A8-fibers in sensory ganglia. It is gated by noxious heat, acidic pH, and capsaicin (1), the active component in hot chili peppers. Abundant evidence has demonstrated that TRPV1 is also modulated by numerous inflammatory mediators, including growth factors, neurotransmitters, peptides or small proteins, endogenous lipids, chemokines, and cytokines 9 . Activation of TRPV1 results in the release of molecules associated with pain transmission, such as calcitonin gene-related peptide (CGRP), substance P, and glutamate 10 . Mounting evidence for the existence of functional TRPV1 in both central and peripheral sensory neurons further implicates this receptor in pain perception and...
Brain electrical activity monitoring can be used to assess depth of anesthesia and includes two categories processed electroencephalogram (pEEG) and evoked responses (e.g., auditory). No single monitor can provide a fail-safe answer to the question of depth of anesthesia. pEEG waveform technology of differing formats can be used and has entered the market to a greater extent then evoked responses. The most familiar technology is known as the bispectral index (BIS). The purpose of any of these forms of EEG analysis is to estimate the degree of hypnosis that the patient is experiencing. Raw data, collected by electrodes placed on the forehead and temporal area, are processed by the computer module to create a dimensionless numeric representation of the degree of sedation. Lower numbers correspond to a greater depth, whereas higher numbers are found in awake or lightly sedated patients. The incidence of awareness in high-risk cases was reduced by approximately 82 (0.91 to 0.17 ) when...
This section is focused on advances that have occurred in the medicinal chemistry of CB2 agonists since the publication of an earlier review 25 . With the recent entry of several CB2-selective agonists into the clinic, there has been an increase in the number of reports of novel selective agonists with demonstrable efficacy in both acute and chronic pain models. Pharmacophore-based de novo virtual screening methods 26 and high-throughput hit-based optimization have been the two main
The quality and distribution rather than the quantity of blood vessels appear to be important in maintaining the healthy joint. The questions here, rather than being what makes blood vessels grow, may be more appropriately put as what makes them grow in a particular direction, what makes them branch and anastomose, and what determines the particular distribution of arterioles, capillaries, and venules. In addition, the growth of fine unmyelinated sensory nerves along newly formed blood vessels in tissues that are normally avascular may contribute to the chronic pain of some inflammatory and angiogenic diseases such as arthritis and spondylosis 6, 17 .
Historically, there have been some links made between vulvodynia and sexual and physical abuse. Most relevant studies have failed to demonstrate this link (Edwards et al., 1997). Studies in which patients have more depressive symptoms and somatic complaints than controls do not differentiate between cause and effect (Lotery et al., 2004). James Aikens et al. (2003) showed that increased scores for somatic depressive symptoms were due to a lack of sexual interest and chronic pain, with no significant difference in cognitive affective symptoms or depressive history disorder.
Perhaps the most important final point to make in this chapter is that health is not simply a physical or biological matter. Psychological factors are heavily involved in it in all of its aspects. Stress, anxiety and emotion, in general, all have their effects on the immune system, health in general and in reactions to disease. Although this makes health a more complex matter than it was once thought to be, it also means that various psychosocial factors can be used in order to bring about positive changes to the health of individuals, from dealing with stress and the control of chronic pain through to increased chances of longevity.
Peripheral changes and is a feature that is commonly observed following surgery and other forms of trauma. Following injury, there is an increased responsiveness to normally innocuous mechanichal stimuli (allodynia) in a zone of ''secondary hyperalgesia'' in uninjured tissue surronding the site of injury. These changes are believed to be a result of processes that occur in the dorsal horn of the spinal cord following injury. This is the phenomenon of central sensitisation 5 . Several changes have been noted to occur in the dorsal horn with central sensitisation. Firstly, there is an expansion in receptive field size so that a spinal neuron will respond to stimuli that would normally be outside the region that respond to nociceptive stimuli. Secondly, there is an increase in the magnitude and duration of the response to stimuli that are above threshold in strength. Lastly, there is a reduction in threshold so that stimuli that are not normally noxious activate neurons that normally...
Analgesic pharmacotherapy is the mainstay of postoperative pain management. Although concurrent use of other interventions is valuable in many patients and essential in some, analgesic drugs are needed in almost every case. The guiding principle of analgesic management is the individ-ualization of therapy. Through a process of repeated evaluations, drug selection and administration is individualized so that a favourable balance between pain relief and adverse pharmacological effects is achieved and maintained (Table 1). An expert committee convened by the World Health Organization (WHO) has proposed a useful approach to drug selection for acute and chronic pain states, which has become known as the 'analgesic ladder' (World Health Organization 1986) (Fig. 5). The World Federation of Societies of Anaesthesiologist (WFSA) has been developed to treat acute and post-operative pain. Initially, pain can be expected to be severe and may need strong analgesics in combination with local...
Peripheral nerve blocks (PNBs) share many of their advantages with neuraxial (spinal and epidural) anesthetic and analgesic techniques, first of which is the lack of need for airway instrumentation. This feature makes PNBs useful in cases in which airway management will be difficult or in which the patient has borderline respiratory function. PNB allows for shorter discharge times in ambulatory settings because of the decreased incidence of nausea, vomiting, and severe pain. PNB may diminish or prevent the development of chronic pain syndromes because of the lack of central nervous system sensitization that occurs after acute injury. Finally, patients with PNB have minimal if any opioid requirements in the immediate postoperative phase.
Human Reproduction 14 1 186-9 International Association for the Study of Pain (1986) in RCOG (2005) Guideline no 41 Initial Management of Chronic Pain. RCOG, London 41 Initial Management of Chronic Pain. RCOG, London Sasieni P, Adams J, Cuzick J (2003) Benefits of cervical screening at different ages evidence from the UK audit of screening histories. British Journal of Cancer 89 (July) 88-93 in NHSCSP 2004
In addition to these pathological features within the gastrointestinal tract, Crohn's disease and ulcerative colitis are commonly associated with systemic, extra-intestinal features. Inflammation in the eye, both uveitis and episcleritis, are not uncommon in Crohn's disease patients. Arthritis is another complication and can result in chronic pain in large and small joints as well as the spine. There are also examples of blood diseases, such as hypercoagulability, and skin diseases, such as erythema nodosum due to inflammation in the subcutaneous tissue, in Crohn's disease patients. The biliary tract can also be involved in the form of primary scle-rosing cholangitis.
Patients certainly can develop wound problems such as hernias or chronic pain. They infrequently develop biliary strictures as a result of chronic inflammation, iatrogenic low-grade ischemia, or intrarterial chemotherapy. The clinician caring for these patients should be aware that the orientation of portal structures in the hilum is frequently rotated following a major resection and regeneration, as this knowledge can be helpful interpreting radiological studies.
The International Association for the Study of Pain defines pain as an unpleasant sensory and emotional experience associated with actual or potential tissue damage, or described in terms of such damage. Acute pain is associated with an identifiable cause (e.g., surgery, trauma, acute illness) and usually resolves with healing. Chronic pain is more difficult to define. It is believed that pain becomes chronic if it persists beyond 1 month of the usual course of an acute problem. However, other authors do not believe that duration should be identified as one of the distinguishing features of chronic pain and point to cognitive-behavioral aspects as essential criteria in any chronic pain syndrome.
Remifentanil is an ultrashort-acting opioid with a duration of 5 to 10 minutes and a context-sensitive half-time of 3 minutes. It contains an ester moiety and is metabolized by nonspecific plasma esterases. Although remifentanil is most commonly administered as a continuous infusion, it has been used as an intravenous bolus to facilitate intubation but with a significant incidence of bradycardia and chest-wall rigidity. Remifentanil has been shown to induce hyperalgesia and acute opioid tolerance, and its use should be questioned in patients with chronic pain syndromes.
Opioids - The broad spectrum analgesic efficacy of the opioids, like morphine, coupled with the fact that these agents do not show analgesic ceiling effects makes opioid compounds the mainstay in the control of moderate to severe pain (28). The analgesic actions of opioid drugs are mediated at multiple sites of action including peripheral sites, the spinal cord, and supraspinal sites such as the brainstem and midbrain (2). This multitude of opiate interactions also contributes to the side-effects associated with opioid analgesic therapy including dependence, tolerance, immunosuppression, respiratory depression and constipation (2, 29). Opioid dose titration can be achieved to manage some nociceptive conditions (29), however this strategy does not provide full efficacy in all chronic pain syndromes such as cancer and neuropathic pain (30). The cloning and characterization of the major opioid receptor subtypes (ji, OP1 5, OP2 and k, OP3) has stimulated significant basic and clinical...
Pain is the most common reason for physician visits. During the course of a year more than 100 million people in the U.S. alone will experience conditions associated with moderate to severe pain. Pain can serve a useful purpose by alerting sufferers to tissue damage and potentially dangerous underlying conditions, but unrelieved pain can disrupt normal function. In addition, millions suffer from neuropathic pain, a condition in which pain perception is distorted by nervous system damage, resulting in pain sensations that are more intense than is appropriate for the stimulus. The extreme condition is one in which chronic pain is experienced even in the absence of noxious stimulation.
Interference with the normal blood flow of delicate neural and epidural venous systems (Fig. 10) may cause venous stasis edema of the nerve root, neural fibrosis, and chronic pain (4,8). This phenomenon is usually observed in patients presenting with symptomatic disc herniation and spinal stenosis. Segmental arteries, branches from the aorta and the internal iliac artery, provide blood supply to the neural, osseous, and muscular structures of the spinal column. Branches from the lumbar arteries depart from the segmental arteries and enter the intervertebral foramen (radicular artery) with the exiting root to supply the medullary arteries of the spinal cord and the nerve roots.
Pain is defined by the International Association for the Study of Pain (1986) as 'an unpleasant sensory and emotional experience associated with actual or potential tissue damage, or described in terms of such damage'. The Royal College of Obstetrics and Gynaecology (2005) stipulate that acute pain reflects fresh tissue damage and resolves as the tissue heals. In chronic pain, additional factors are involved, and pain may continue long after the original tissue injury, or may exist in the absence of any such injury. Adequate time should be given for the initial assessment of women with pelvic pain, especially chronic pain. It has been shown that consultations that allow women to express their own ideas about their pain result in a better practitioner-patient (or therapeutic ) relationship, and therefore improved concordance with investigation and treatment (Selfe et al., 1998).
The magnitude of pain and the response to treatment can be monitored in several ways. A visual analog scale may be used in which the patient chooses a mark on a 10-cm line corresponding with the perceived amount of pain being experienced. Scales using color (from blue for minimal pain through violet hues to bright red for maximal pain) or numbers (from zero for no pain through ten for maximal pain) have been devised for adults (Figure 77-1). A scale of 10 faces, ranging from very happy to very sad, can be used in young children. The child points to the face matching the way he or she feels. Verbal descriptive scales such as the McGill Pain Questionnaire are useful both for clinical and research purposes. Functional ability is also a useful measure of pain. In some patients, especially those who also have chronic pain, assessing ability to perform regular functions such as activities of daily living, performing at work, or ability to participate in leisure activities may be more useful...
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Peace in Pain
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