Permanent End To Chronic Pain
This is a 43-year-old male who had a medical history of chronic pain related to reflux sympathetic dystrophy and narcotic dependence. On the day of his demise, the decedent drove to a drive-thru prescription center at a major chain store, where he was to pick up a prescription for oxycodone. He never did pick up his medication, and one of the store employees found him unresponsive and slumped over the steering wheel in the store parking lot. An emergency medical team was unable to resuscitate him. The decedent had a medical history of peripheral neuropathy, reflux sympathetic dystrophy syndrome, anxiety, depression, and panic disorder. There was no suicidal ideation known however, there was worsening of depression, and the decedent became increasingly withdrawn. He had been taking narcotic painkillers for a very long time and required increasingly higher doses to ease his pain, according to one of his physicians. Information from the pharmacy showed that the decedent had multiple...
The multidisciplinary field of pain medicine applies the principles of anesthesi-ology outside of the operating room. Both acute and chronic pain is an extremely common complaint of patients. As such, there is a rapidly growing demand for specialists who can manage different pain syndromes. A typical patient is often an injured employee on workers' compensation. Anesthesiologists who specialize in pain management solely see patients in a clinic setting, such as a freestanding pain center. Here, the continuity of care lends itself to a more traditional doctor-patient relationship. They diagnose the etiology of pain syndromes and treat these problems with medication or procedural therapy (injections of local anesthetics, peripheral and central nerve blocks under fluoroscopy, implantation of spinal cord stimulators and intrathecal pumps, and transcutaneous nerve stimulation). In pain management, you can also earn certification in performing acupuncture.
Professional association for healthcare professionals interested in pain research and therapy. The group encourages research on pain mechanisms and syndromes, seeks to improve the well-being of patients with acute and chronic pain, and promotes education and training in the field. The organization also informs the public and develops an international databank, adoption of a uniform classification and, definition regarding pain and pain syndromes and creates a uniform records system on information relating to pain mechanisms. Founded in 1974, the group publishes a bimonthly newsletter, a monthly journal, and various other publications. For address, see Appendix II.
Although substance use disorders are mostly self-inflicted, they can be initiated or sustained through the well-intentioned treatment of a variety of common complaints (e.g., anxiety, headaches, insomnia, chronic pain). For most front-line practitioners, few days go by without repeated requests for more or stronger psychoactive medications. Once a substance use disorder has become established, it brings its own cargo of medical and psychiatric problems.
Patients with a high tolerance to alcohol, for example, readily develop similar tolerance to benzodiazepines, barbiturates, and anesthetic agents. A relationship exists between alcohol and opioids such that acetaldehyde, alcohols first metabolite, has been linked to increased production of endogenous opiates in the brain, which may explain the increased affinity for opioids observed among alcoholic persons and the frequency with which chronic pain patients develop alcoholism. Not all cross-tolerance is complete, however a fact with important implications for the treatment of withdrawal states.
Pain is the number one complaint of older Americans, and one in five older Americans takes a painkiller regularly. In 1998, the American Geriatrics Society (AGS) issued guidelines for the management of pain in older people. The AGS panel addressed the incorporation of several non-drug approaches in patients' treatment plans, including exercise.36 AGS panel members recommend that, whenever possible, patients use alternatives to aspirin, ibuprofen, and other NSAIDs because of the drugs' side effects, including stomach irritation and gastrointestinal bleeding. For older adults, acetaminophen is the first-line treatment for mild-to-moderate pain, according to the guidelines. More serious chronic pain conditions may require opioid drugs (narcotics), including codeine or morphine, for relief of pain.
Limb sensation can be accompanied by excruciating chronic pain in a part of the body that no longer exists.63 While information about location of a tactile stimulus could be coded and read out by stacks of topographic maps, it is important to emphasize that the lack of a precise somatotopic representation does not preclude information about stimulus location being extracted from populations of neurons located in a cortical area. For example, recent multi-electrode recordings in primates have revealed that information about stimulus location can be readily extracted, on a single-trial basis, from ensembles of neurons located in the secondary somatosen-sory cortex (SII) and area 2 of the parietal cortex, two regions in which one observes much less well-defined topographic maps than in the primary somatosensory (SI) cortex.92 Interestingly, due to a degree of overlap in the timing of SI, SII, and area 2 tactile responses, stimulus location could be derived almost simultaneously in all...
Local hypercontracted muscle fibers associated with trigger points are thought to limit local circulation, causing localized tissue hypoxia. This can lead to the release of substances that sensitize local nociceptors, creating the referred pain patterns characterized by trigger points. Histological examination of rabbit muscle identified with active trigger points found small C afferent nerve pain fibers in the immediate vicinity (18). These findings suggest myofascial pain from trigger points is mediated by not only local muscle hypercontractility, but also some component of hypersensitization of local nociceptors. BTX has been theorized to not only diminish muscle contraction, but also to inhibit the release of neuropeptides associated with myofascial pain. Indeed, in vitro studies of embryonic rat dorsal root ganglia neurons treated with BTX demonstrated decreased neuropeptide release (19,20). Furthermore, in vitro examination of rabbit ocular tissue treated by BTX-A revealed...
Entrapment of the radial sensory nerve (RSN) at the mid forearm is certainly less frequent than the compression neuropathies mentioned above. Nevertheless, it is a cause of chronic pain and discomfort in the radial forearm. Many patients with this entrapment are referred with a diagnosis of de Quervain's tendovaginitis. They should be carefully examined to exclude the diagnosis of RSN compression. Both conditions can exist at the same time. The RSN is usually compressed between the tendinous edges of the extensor carpi radialis longus and the brachioradialis between the mid- and distal third of the radial forearm. The aim of surgery is to release the fascia between these muscles. Conventional surgery with a 6-cm skin incision is effective.17
Hypnosis During hypnosis the subject passes into a trance. This is an altered state of consciousness in which the subject's attention is intensely focused while attention to other stimuli is reduced. It is not a deep sleep or unconsciousness. The subject is awake and can respond to the therapist. Perception, memory, behavior, and suggestibility are altered. In therapy the increased suggestibility can be used to influence behavior and feelings. Hypnotherapists claim benefit in chronic pain and
Day care patients frequently used phrases such as 'in the same boat' and 'kindred spirits' to express the subjective world-view they shared with one another, but not with other persons. In this respect, their experiences closely paralleled those of the patients studied by Jackson who attended a chronic pain clinic in the United States. Jackson's patients felt that they belonged to a 'pain-full world' (1994 218) which others 'could not possibly understand' (ibid.), and, consequently, that they were members of 'a very exclusive club' (1994 216).
The cause of chronic pain in the lateral elbow, somewhat misleadingly termed tennis elbow, is still unknown, which may be why a variety of surgical procedures have been described to treat it, including denervation,18 extensor tendon release,15 and decompression of the posterior interosseus nerve (PIN).16
Prior to leaving the practice, the patient entered into an IRB-approved research study on pharmacogenomic testing for chronic pain patients. As a result, the patient had a blood sample drawn for therapeutic drug management and genetic analysis of cytochrome P450 2D6 (CYP2D6) polymorphisms. The patient's steady-state serum concentration (Css) of tramadol and O-desmethyltramadol were 340 and 42 mg L, respectively. Tramadol is extensively metabolized to O-desmethyltramadol, an active metabolite, by CYP2D6.4 The patient was genotyped for the some of the most prevalent CYP2D6 polymorphisms (*3, 4, 5, 6, 7, and 8). According to the patient's genotype (*1 *5), he was heterozygous for CYP2D6*5 (the gene deletion), making him an intermediate metabolizer.
Another domain of orthoplastic surgery that has been unrealized is the need for orthoplastic surgery of the chest wall.50 Although soft tissue procedures are designed to treat mediastinitis and to help reconstruct the chest wall, structural instabilities, such as sternal nonunion and chronic pain based on sternal instability, can be treated with devices such as custom plates (Figure 1-10).
The majority of patients with alcoholic chronic pancreatitis are diagnosed between 35 and 40 years of age.15 Alcoholic chronic pancreatitis usually presents with an early phase of recurrent attacks of acute pancreatitis, followed by the late phase of the disease characterized by the development of chronic pain, pancreatic calcifications, and exocrine and later endocrine insufficiency. The pancreas demonstrates a large functional capacity so
Occipital neuralgia A chronic pain disorder caused by irritation or injury to the occipital nerve in the back of the scalp, triggering pain originating at the nape of the neck. The pain, often described as throbbing and migraine-like, spreads up and around the forehead and scalp.
Over the last several years, botulinum toxin type A (BTX-A) has been increasingly used in the treatment of various medical conditions. Increasing literature supports the role of BTX-A in the treatment of chronic pain syndromes. Blockade of acetylcholine release from the presynaptic membrane plays an important role in relief of muscles spasms and myofascial pain syndromes. However, some animal models suggest alternative mechanisms for the analgesic 4. Intramuscular injection of BTX-A reduces the discharge of intrafusal muscle fibers, which normally convey large non-nociceptive input (reporting muscle length) to the spinal cord (5). In chronic pain conditions (which may be the case in our subjects who all complained of symptoms for 6 months), reduction of this input theoretically can reduce the level of central sensitization. In animals, administration of BTX-A reduces the discharge of sympathetic neurons (17) and thus can reduce the role of the sympathetic system in pain maintenance.
Transmitters that are released nonsynaptically diffuse through the ECS and bind to extrasynaptic, usually high-affinity, binding sites located on neurons, axons, and glial cells. This type of extrasynaptic transmission is also called volume transmission (VT) (neuroactive substances move through the volume of the ECS) (3,4,21-23). Populations of neurons can interact both by synapses and by the diffusion of ions and neu-rotransmitters in the ECS. Diffusion is therefore the underlying mechanism of VT. Diffusion parameters are changing throughout life, e.g., during development and aging, during repeated or prolonged neuronal activity, and in and after pathological states. This mode of communication by diffusion, and without synapses, is therefore very plastic, and provides a mechanism of long-range information processing in functions such as vigilance, sleep, chronic pain, hunger, depression, LTP, LTD, memory forma
Vulvodynia patients often have other medical complaints in addition to their vulvar symptoms. In a study of 301 vulvodynia patients at the University of British Columbia's Vulvar Disease Clinic, 55 indicated they had a suspected second chronic pain condition, including low-back pain, irritable bowel syndrome, migraine headaches, chronic fatigue syndrome, and fibromyalgia (39). That same study also reported a high proportion of patients with a history of yeast infections, a finding later supported by Harlow et al. (16). The
Staying up late of your own free will is one thing. But what if you're trying to get a good night's sleep and can't Insomnia takes different forms. Onset insomnia refers to difficulty establishing sleep common causes include anxiety and racing thoughts. Middle insomnia refers to middle-of-the-night awakening and an inability to return to sleep within a reasonable time. This type of problem is typical of people experiencing chronic pain, which may rouse them from the midst of slumber. Early morning awakening is frequently associated with depression. Whatever form insomnia takes, the net effect is the same insufficient restorative sleep leading to daytime fatigue.
In the general outpatient clinic, headaches are the main complaint evaluated by neurologists. Over 45 million people suffer from chronic headaches. This fellowship allows the clinician to gain further skill in treating chronic pain syndromes, including headaches. Some programs provide training in interventional pain techniques, similar to those learned by anesthesiologists. These procedures include epidural injections, trigger point injections, denervation procedures, and others. Many hospitals offer special headache clinics staffed by neurologists.
Headache is a leading cause of disability among patients in the United States. Chronic pain and associated symptoms significantly interfere with interpersonal relations, professional duties, and overall quality of life. Patients suffering from chronic headaches have an increased risk of developing psychiatric disorders, particularly affective disorders such as depression. The treating physician has the unique opportunity to diagnose and treat headache disorders, and ease patient suffering. A detailed examination with appropriate diagnostic testing often allows the physician to classify the specific disorder and initiate an effective therapeutic plan.
Following injury, the nervous system undergoes a tremendous reorganization. This phenomenon is known as plasticity. For example, the spinal cord is rewired following trauma as nerve cell axons make new contacts, a phenomenon known as sprouting. This in turn disrupts the cells' supply of trophic factors. Scientists can now identify and study the changes that occur during the processing of pain. For example, using a technique called polymerase chain reaction, abbreviated PCR, scientists can study the genes that are induced by injury and persistent pain. There is evidence that the proteins that are ultimately synthesized by these genes may be targets for new therapies. The dramatic changes that occur with injury and persistent pain underscore that chronic pain should be considered a disease of the nervous system, not just prolonged acute pain or a symptom of an injury. Thus, scientists hope that therapies directed at preventing the long-term changes that occur in the nervous system will...
Fellowships focusing on treating patients with chronic pain syndromes are primarily sponsored by the American Board of Anesthesiology, although there are a few PM&R-based programs. The daily activities include pain clinic, in which a fellow manages a patient base either medically or via interventional techniques. Some of the simpler procedures include epidurals, facet joint and target point injections, and fluoroscopically guided steroid injections. With its emphasis on procedures, pain medicine has become a lucrative area of expertise due to high reimbursements. Interventional pain man-the patient from traditional physical med-
Furthermore, a significant correlation between NGF mRNA levels and pancreatic fibrosis and acinar cell damage and between TrkA mRNA and pain intensity has been observed.179 These findings suggest that nerve changes in CP might be influenced by activation of the NGF TrkA pathway through paracrine mechanisms. NGF released from degenerating acinar cells, dedifferentiating acinar cells, and metaplastic ductal cells might interact with TrkA located in the perineu-rium of pancreatic nerves. The presence of NGF and TrkA in intrapan-creatic ganglia cells suggests that the NGF TrkA pathway is also activated in intrinsic neural structures. These observations are of clinical interest because changes in neural morphology are associated with pain in CP. However, the interaction of NGF and TrkA in CP might not be limited to influencing nerve growth, but may be more directly tied to pain generation. For example, NGF might directly influence chronic pain by the...
Pronator syndrome resembles carpal tunnel syndrome in that numbness occurs in the same digits, weakness may develop in the thenar muscles, and pain is reported in the wrist and forearm. Paresthesia of the median-innervated fingers without physical signs of carpal tunnel or chronic pain in the proximal palmar region of the forearm resistant to conservative treatment should be considered to be the result of compression of the median nerve in the pronator tunnel. The potential sites of compression, however, are not only in the pronator muscle therefore, it would be more adequate to term this condition proximal median nerve compression.
Peace in Pain
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