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11/18/07 1:42 PMChronic pain - Wikipedia, the free encyclopedia
Page 1 of 7http://en.wikipedia.org/wiki/Chronic_pain
Name of Symptom/Sign:Chronic pain
Classifications and external resources
ICD-10 R52.1(http://www.who.int/classifications/apps/icd/icd10online/?gr50.htm+r521) -R52.2(http://www.who.int/classifications/apps/icd/icd10online/?gr50.htm+r522)
ICD-9
Chronic painFrom Wikipedia, the free encyclopedia
Chronic pain was originally defined aspain that has lasted 6 months or longer.More recently it has been defined as painthat persists longer than the temporal courseof natural healing, associated with aparticular type of injury or diseaseprocess.[1]
The International Association for the Studyof Pain defines pain as "an unpleasant sensory and emotional experience associated with actual or potentialtissue damage, or described in terms of such damage."[2] It is important to note that pain is subjective in natureand is defined by the person experiencing it, and the medical community's understanding of chronic pain nowincludes the impact that the mind has in processing and interpreting pain signals.
Contents1 Functional Anatomy2 Nociception3 The Pathophysiology of Chronic Pain4 Classification5 Diagnoses6 Chronic Pain Syndrome7 Management
7.1 Medications7.1.1 Opioids7.1.2 Non-steroidal anti-inflammatory drugs7.1.3 Antidepressants and Antiepileptic drugs
7.2 Interventional therapy7.3 Rehabilitation
8 Controversy9 References10 Footnotes11 See also12 External links
Functional Anatomy
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The anatomy of the nociceptive system can be grossly divided into the peripheral and central nervous system.The peripheral nervous system consists of small myelinated and unmyelinated nerve fibers. These nerve fibersconverge into a region of the spinal cord referred to as the dorsal horn. The dorsal horn is the first relay stationin pain signal transmission. The next element of pain transmission includes nerve fibers that then travel to thethalamus. From the thalamus the next order of neurons ascend to the limbic system and sensory cortex. Thisaccounts for the affective elements and discriminative of pain respectively.[3][4]
NociceptionThe experience of pain biologically is referred to as nociception. Nociception occurs in any tissue or organ inwhich pain signals arise secondary to a disease process or trauma. The nociception can also occur if there isdysfunction or damage to nerves themselves.[2]
The Pathophysiology of Chronic PainUnder persistent activation nociceptive transmission to the dorsal horn may induce a wind up phenomenon.This induces pathological changes that lower the threshold for pain signals to be transmitted. In addition it maygenerate nonnociceptive nerve fibers to respond to pain signals. Nonnociceptive nerve fibers may also be ableto generate and transmit pain signals. In chronic pain this process is difficult to reverse or eradicate onceestablished.[5]
ClassificationNociception (pain) may arise from injury or disease to visceral, somatic and neural structures in the body.More broadly pain is described as malignant or non-malignant in origin.[4]
DiagnosesPain may be a response to injury or any number of disease states that provoke nociception. Advances inimaging studies and electrophysiological studies allow us to gain a deeper insight into the characteristics andproperties associated with the phenomenon of chronic pain.[6][7][8]
Chronic Pain SyndromeChronic pain may generate other adversities including affective symptoms of depression and anxiety. It mayalso contribute to decreased physical activity given the apprehension of exacerbating pain.[9] Conversely itmay itself have psychosomatic or psychogenic component to its cause.[10]
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ManagementIt is rare to completely achieve absolute and sustained relief of pain. Thus, the clinical goal is painmanagement. Pain management is often multidisciplinary in nature. A recent journal article by Gatchell andOkifuji recognizes the importance of comprehensive pain programs(CPPs) in the management of chronic pain.They summarize their findings as follows: "CPPs offer the most efficacious and cost-effective treatment forpersons with chronic pain, relative to a host of widely used conventional medical treatment." [11][12]
Medications
"Because patients with chronic pain suffer many consequences of their illness, any treatment with the potentialto improve their symptoms should be prescribed and the results carefully studied." conclusion of the JohnsHopkins Arthritis Center (http://www.hopkins-arthritis.som.jhmi.edu/mngmnt/opioids.html) .
The New South Wales Government Health Department recommends (http://www.health.nsw.gov.au/public-health/psb/chronic_pain/pf_faq4.html#what_meds) a three stage approach in the treatment for chronic pain. Insummary (and stressing that all Chronic Pain should be treated under the advice of a fully qualified medicaldoctor):
paracetamol ( Tylenol etc ) OR an non steroidal anti-inflamatory (NSAID) like Naprosyn. For example1/3 of arthritis sufferers get good pain relief with extended release Panadol.
paracetamol AND a NSAID, OR paracetamol and codeine combined in one tablet. Often in combinationsmaller doses of each give much better results than a single drug alone.
opiate based pain killers. When the first line and second line medications do not provide adequate painrelief, the stronger opioids morphine and oxycodone are most commonly tried. Some opioids, such ashydromorphone, pethidine, and fentanyl, are not usually recommended for the treatment of chronic pain.
Opioids
Opioid medications provide short, intermediate and long acting analgesia depending upon the specificproperties of the medication and whether it is formulated as an extended release drug. Opioid medications maybe administered orally, by injection, via nasal mucosa or oral mucosa, rectal, transdermal, intravenously,epidurally and intrathecally. In chronic pain conditions that are opioid responsive a combination of a longacting or extended release medication is often prescribed in conjunction with a shorter acting medication forbreak through pain (exacerbations).
Most opioid treatment is oral (tablet, capsule or liquid), but suppositories and skin patches can be prescribed.An opioid injection is rarely needed for patients with chronic pain.
Although opioids are strong analgesics, they do not provide complete analgesia regardless of whether the painis acute or chronic in origin. Opioids are efficacious analgesics in chronic malignant pain and modestly
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is acute or chronic in origin. Opioids are efficacious analgesics in chronic malignant pain and modestlyeffective nonmalignant pain management. However, there are variable associated adverse effects, especiallyduring the commencement or change in dosing and administration. When opioids are used for prolongedperiods drug tolerance, chemical dependency and (rarely) addiction may occur. Chemical dependency isubiquitous among opioid therapy after continuous administration; however, drug tolerance is not well studiedin patients on long term opioid therapy. Addiction rarely occurs as a result of opioid prescription, but they areabused by some individuals, which can cause concern to health care providers. Diversion of opioidmedications is another concern for health care providers.
Non-steroidal anti-inflammatory drugs
The other major group of analgesics are Non-steroidal anti-inflammatory drugs (NSAID). This class ofmedications includes acetaminophen which may be administered as a single medication or in combinationwith other analgesics. The alternatively prescribed NSAIDs such as ketoprofen and piroxicam, have limitedbenefit in chronic pain disorders and with long term use is associated with significant adverse effects. The useof selective NSAIDs designated as selective COX-2 inhibitors have significant cardiovascular andcerebrovascular risks which have limited their utilization.[13][14]
Antidepressants and Antiepileptic drugs
Some antidepressant and antiepileptic drugs are used in chronic pain management and act primarily within thepain pathways of the central nervous system, though peripheral mechanisms have been attributed as well.These mechanisms vary and in general are more effective in neuropathic pain disorders as well as complexregional pain syndrome.[15] Drugs such as Gabapentin have been widely prescribed for the off-label use ofpain control. The list of side effects for these classes of drugs are typically much longer than opiate or NSAIDtreatments for chronic pain, and many antiepileptics cannot be suddenly stopped without the risk of seizure.
Interventional therapy
Injections, Neuromodulation and Neuroablative Therapy may be used to target either the tissue structures andorgan/systems responsible for persistent nociception or the nerves conveying nociception from the structuresimplicated as the source of chronic pain.[16][17][18][19][20]
Rehabilitation
Further information: Physical medicine and rehabilitation
As alluded to earlier there are other modalities used in the treatment of chronic pain. These include: physicalmodalities such as thermal agents and electrotherapy. Complementary and alternative medicine, therapeuticexercise and behavioral therapy are also utilized autonomously or in tandem with interventional techniques andconventional pharmacotherapy. This is most often structured in a multidisciplinary or interdisciplinaryprogram.[21]
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ControversyPain.com (http://www.pain.com) UN-INCB (http://www.incb.org)
Chronic pain patients are often misdiagnosed. Patients are often ignored, and their pain dismissed asimaginary. Patients, particularly the ones prescribed opioids, are often labeled as drug addicts. Furthermore,chronic pain patients in the United States and other countries, continue to encounter problems caused by theirgovernments' war on illegal drugs (examples include but are not limited to: red tape in applying for/renewal ofspecial prescription pads; government-mandated limits and excessive regulations for hospitals and drugstores;etc.).
ReferencesCarol A. Warfield: Principles & Practice of Pain Management 1st edition, McGraw-Hill Professional2004John D. Loeser: Bonica's Management of Pain 3rd edition, Lippincott Williams & Wilkins 2001
Footnotes1. ^ Shipton EA, Tait B (2005). "Flagging the pain: preventing the burden of chronic pain by identifying and treating
risk factors in acute pain". European journal of anaesthesiology 22 (6): 405-12. PMID 15991501. 2. ^ a b Merskey H (1994). "Logic, truth and language in concepts of pain". Quality of life research : an international
journal of quality of life aspects of treatment, care and rehabilitation 3 Suppl 1: S69-76. PMID 7866375. 3. ^ Romanelli P, Esposito V (2004). "The functional anatomy of neuropathic pain". Neurosurg. Clin. N. Am. 15 (3):
257-68. PMID 15246335. 4. ^ a b Vanderah TW (2007). "Pathophysiology of pain". Med. Clin. North Am. 91 (1): 1-12. PMID 17164100. 5. ^ Vadivelu N, Sinatra R (2005). "Recent advances in elucidating pain mechanisms". Current opinion in
anaesthesiology 18 (5): 540-7. PMID 16534290. 6. ^ Dunckley P, Wise RG, Fairhurst M, Hobden P, Aziz Q, Chang L, Tracey I (2005). "A comparison of visceral and
somatic pain processing in the human brainstem using functional magnetic resonance imaging". J. Neurosci. 25 (32):7333-41. PMID 16093383.
7. ^ Geha PY, Apkarian AV (2005). "Brain imaging findings in neuropathic pain". Current pain and headache reports 9(3): 184-8. PMID 15907256.
8. ^ Turton AJ, McCabe CS, Harris N, Filipovic SR (2007). "Sensorimotor integration in Complex Regional PainSyndrome: a transcranial magnetic stimulation study". Pain 127 (3): 270-5. PMID 17011705.
9. ^ Pruimboom L, van Dam AC (2007). "Chronic pain: a non-use disease". Med. Hypotheses 68 (3): 506-11. PMID17071012.
10. ^ Sarno, John et al. (2006). The Divided Mind: The Epidemic of Mindbody Disorders. New York: ReganBooks, 11-18. ISBN 0-06-085178-3.
11. ^ Henningsen P, Zipfel S, Herzog W (2007). "Management of functional somatic syndromes". Lancet 369 (9565):946-55. PMID 17368156.
12. ^ Stanos S, Houle TT (2006). "Multidisciplinary and interdisciplinary management of chronic pain". Physicalmedicine and rehabilitation clinics of North America 17 (2): 435-50, vii. PMID 16616276.
13. ^ Munir MA, Enany N, Zhang JM (2007). "Nonopioid analgesics". Med. Clin. North Am. 91 (1): 97-111. PMID17164106.
14. ^ Ballantyne JC (2006). "Opioids for chronic nonterminal pain". South. Med. J. 99 (11): 1245-55. PMID 17195420.
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15. ^ Jackson KC (2006). "Pharmacotherapy for neuropathic pain". Pain practice : the official journal of World Instituteof Pain 6 (1): 27-33. PMID 17309706.
16. ^ Varrassi G, Paladini A, Marinangeli F, Racz G (2006). "Neural modulation by blocks and infusions". Painpractice : the official journal of World Institute of Pain 6 (1): 34-8. PMID 17309707.
17. ^ Meglio M (2004). "Spinal cord stimulation in chronic pain management". Neurosurg. Clin. N. Am. 15 (3): 297-306.PMID 15246338.
18. ^ Rasche D, Ruppolt M, Stippich C, Unterberg A, Tronnier VM (2006). "Motor cortex stimulation for long-term reliefof chronic neuropathic pain: a 10 year experience". Pain 121 (1-2): 43-52. PMID 16480828.
19. ^ Boswell MV, Trescot AM, Datta S, Schultz DM, Hansen HC, Abdi S, Sehgal N, Shah RV, Singh V, BenyaminRM, Patel VB, Buenaventura RM, Colson JD, Cordner HJ, Epter RS, Jasper JF, Dunbar EE, Atluri SL, Bowman RC,Deer TR, Swicegood JR, Staats PS, Smith HS, Burton AW, Kloth DS, Giordano J, Manchikanti L (2007)."Interventional techniques: evidence-based practice guidelines in the management of chronic spinal pain" (PDF). Painphysician 10 (1): 7-111. PMID 17256025.
20. ^ Romanelli P, Esposito V, Adler J (2004). "Ablative procedures for chronic pain". Neurosurg. Clin. N. Am. 15 (3):335-42. PMID 15246341.
21. ^ Geertzen JH, Van Wilgen CP, Schrier E, Dijkstra PU (2006). "Chronic pain in rehabilitation medicine". Disabilityand rehabilitation 28 (6): 363-7. PMID 16492632.
See also
Suffering
Conditions related to pain
ArthritisBack painCancerComplex Regional PainSyndromeClinical depressionFibromyalgiaHeadacheSciatica
Drugs
AnalgesiaAntiepileptics
GabapentinPregabalinLevetiracetamTopiramateLamotrigineZonisamide
AntidepressantsLocal anesthetics
Other approaches in Physical medicine and rehabilitation(Physiatry)
CryotherapyExerciseHot packOccupational therapyPhysical therapyTENS
Alternative therapies
AcupunctureBehavioral therapyChiropracticMassage therapyProlotherapy
Surgery
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Local anestheticsKetamine
NSAIDsOpioidsOther agents:
ClonidineZiconotide
Spinal cord stimulation
External linksStopPain.org (http://www.stoppain.org/)American Chronic Pain Association (http://www.theacpa.org/)Pain.com (http://www.pain.com/)Patient consumer web page sponsored by the APS (http://www.ampainsoc.org/people/)American Pain Foundation (http://www.painfoundation.org/)International Association for the Study of Pain- IASP (http://www.iasp-pain.org/)
Retrieved from "http://en.wikipedia.org/wiki/Chronic_pain"
Categories: All articles with unsourced statements | Articles with unsourced statements since June 2007 |Nociception | Pain
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