Permanent End To Chronic Pain
Other patients with chronic abdominal pain will at some point in time require their use and the compassionate physician is often faced with no other alternative to relieve suffering. The key elements that make for comfortable and judicious use of these drugs is a solid patient-physician relationship, careful patient selection, and the adherence to a fairly rigid protocol for prescription that also includes certain expectations from the patient (eg, restriction of analgesic prescribing to a single physician, return to work, etc). When mild chronic pain necessitates analgesic use, weak opi-oids such as propoxyphene or codeine, are often used, even though they are probably no more potent than simple analgesics, such as acetaminophen alone. More severe pain requires stronger analgesics for short term use meperidine or morphine can be used. For patients requiring long term analgesics, sustained release preparations, such as transdermal fentanyl (Durgesic), are probably more useful. Agents...
Psychiatric treatments that may be required include more complex antidepressant drug regimens and specialist psychological interventions. Cognitive behaviour therapy has been shown to be effective in randomised controlled trials for a variety of functional syndromes (such as non-cardiac chest pain, irritable bowel, chronic pain, and chronic fatigue) and for patients with hypochondriasis.
Although pharmacologic therapy has a valuable role in these patients, it is also clear that a successful outcome requires taking into consideration several, equally important, factors. As explained previously, chronic pain cannot be viewed as a purely neurophysiologic phenomenon and has many other facets, the most important of which is the psychological dimension, consisting of cognitive, emotional and behavioral processes. The combination of these factors results in functional disability, a third dimension of chronic pain that is often ignored. Several psychological techniques have been used with good effect in the management of a variety of chronic pain syndromes, although specific evidence for their efficacy in chronic abdominal pain syndromes is generally lacking. Operant interventions focus on altering maladaptive pain behaviors, such as reduced activity levels, verbal pain behaviors and excessive use of medications. Cognitive behavioral therapy extends beyond this to also...
Nociception, or the process by which the nervous system detects tissue damage, is not synonymous with pain increased afferent signaling to the CNS by itself does not always make a patient with chronic pain seek medical attention. However, nociception can, and often does, lead to suffering, a negative response to the perceived threat to the physical and psychological integrity of the individual and made up of a combination of cognitive and emotional factors such as anxiety, fear and stress. This in turn can lead to certain patterns of illness behavior, which in turn determines the clinical presentation. Such behavior is a complex mixture of physiologic (eg, pain intensity severity or associated features), psychological (mental state, stress, mood, coping style, prior memories or experiences with pain, etc), and social factors (concurrent negative life events, attitudes, and behavior of family and friends, perceived benefits such as avoidance of unpleasant duties, etc). Thus individual...
A minority of patients become increasingly incapacitated and require more detailed management of what has become a chronic pain problem. Research has shown that the most important influences on the development of chronicity are psychological rather than biomechanical. The psychological factors are high levels of distress, misunderstandings about pain and its implications, and avoidance of activities associated with a fear of making pain worse.
The goals of a pylorus preserving Whipple procedure for chronic pancreatitis are twofold. The first goal is to remove the head of the pancreas, what Longmire referred to as the pacemaker of pancreatitis , which serves as the source of chronic pain. In properly selected patients, relief of pain will occur in almost every patient, 75 of whom will remain pain-free. In the remaining patients, pain relief will have been achieved that yields substantial improvement that allows the patient to reenter daily life patterns.
A clinical suspicion of adhesions is also often entertained by both physicians and patients with chronic abdominal pain even though the literature suggests that such a diagnosis is seldom validated. Adhesions are very common in women, even in the absence of prior surgery and are found in equal proportion in patients complaining of pelvic pain and those with other complaints. Indeed, laparoscopy for chronic pain seldom leads to a specific diagnosis and even less often to a change in management. In contrast to the above disorders, our experience suggests it is far more fruitful to carefully examine the abdominal wall in patients with chronic pain. This is an aspect that is frequently overlooked by gastroenterologists. Pain arising primarily in the abdominal wall can result from a poorly defined group of conditions whose pathophysiology remains obscure. The diagnosis is suggested when the pain is superficial, localized to a small area that is usually significantly tender, associated with...
All of us have experienced acute pain, an unpleasant sensory and emotional experience that is associated with actual or potential tissue damage and which tells us that something is wrong with our body. This pain has a function because it allows for rapid identification of the site of origin of the underlying disease or injury and it allows for initiation of targeted therapy. On the contrary, chronic pain, one of the most common gastrointestinal (GI) conditions seen by primary care physicians and gastroenterologists, usually does not allow for rapid diagnosis of an underlying organic problem and is even less likely to lead to satisfactory therapy. Patients with chronic abdominal pain often have a track record of frequent emergency room visits and multiple physician examinations and of having been through a variety of diagnostic studies. Pain is a subjective experience there are no diagnostic tests that can determine the quality or intensity of an individual's pain. Regardless of...
Medical syndromes (such as fibromyalgia and chronic fatigue, chronic pain, and irritable bowel syndromes) highlight patterns of somatic symptoms, often in relation to particular bodily systems. Although they are useful in everyday medical practice, recent studies show there is substantial overlap between them.
Duration of pain is a more complex issue. For patients with chronic pain unlike acute pain, a multidisciplinary approach is essential. Precipitating, aggravating and relieving factors have not been shown to have an important diagnostic value. Difficult social or psychological conditions must be evaluated and in the case of failed-back, interdisciplinary evaluation may raise crucial pitfalls. Most chronic pain patients have to some extent psycho-social distress. This may be only an aggravating factor or a more causal disorder. If not all pain patients need a psychosocial evaluation, failed back patients are probably good candidates for such an approach. In these patients, suffering and distress may be severe, and social context is most of the time disturbed as a consequence of the disease and the loss of self-esteem (Guzman et al., 2001).
The relaxation response has been associated with improvements in many medical conditions including hypertension, cardiac arrhythmias, chronic pain, insomnia, side effects of cancer therapy, side effects of AIDS therapy, infertility, and preparation for surgery and X-ray procedures. It is also important to indicate that more recently, the overall implications of integrating relaxation response in routine clinical treatments has been examined. Some relevant examples will be discussed. The effect of a behavioral group intervention that included relaxation response training on chronic pain
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.
Large chisels struck with a mallet or pincer-cutters to amputate fingers, toes, hands and even attempts at higher levels produced guillotine amputations which healed badly, being akin to section at the demarcation line of gangrenous limbs. Trapped victims in extremis without assistance, obliged to undertake their own amputation, are also a special category who, when finally rescued, need surgical intervention to repair and improve what maybe an unsatisfactory amputation from the surgical aspect. In addition, there is a group of patients who insist on amputation, even without anaesthesia, usually because of chronic pain or debilitating infection, despite advice informing them of insufficient disability for the surgical risks involved, or that they were too ill, or had evidence of disease elsewhere despite this a number achieved their aim as Velpeau relates in a chapter on indications in 1840. He reported
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...
In a minority of patients the pain seems to be unconnected to any overt GI function such as eating or bowel movement and has been termed functional abdominal pain syndrome (FAPS). This and the more well studied syndromes described in the previous paragraph have much in common including a predominance of women, heavy use of medical resources, psychological disturbances and personality disorders, and dysfunctional relationships at work, with family, and in other social settings. Conceptually, some of these patients can be perceived as occupying an extreme end of the biopsychosocial continuum of chronic pain discussed above. Thus, if patients with painful pancreatitis represent an example of a disturbance primarily (but not exclusively) affecting nociceptive signaling, then patients with FAPS can be viewed as representing a dysfunction of perception, coping, or response strategies. In either case, the net result is a patient with a hard to manage illness behavior.
In healthy young subjects with no pre-existing chronic painful illness, the false positive rate is extremely low. Walsh et al. in 1990 reported in a study on 10 volunteers. 16.7 of them had minimal pain on injection, 6.7 moderate pain and 3.3 bad pain (Walsh, 1990). Further studies on older subjects suffering from chronic pain and on patients with significant psychometric features showed, as one would expect, higher false-positive rates. Carragee and al in 2000, conducted a prospective study including 30 patients. Little pain was elicited by low pressure injection of any anatomically normal disc. However, when discs although asymptomatic had fissuring of the annulus, the injection was painful. The main predictors of pain intensity were presence of chronic pain and abnormal psychometric scores (Carragee, 2000). As compared to the Walsh study, 40 of chronic pain group and 80 of the somatization group had at least one positive disc (Carragee, 2000). Future studies that focus on...
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.
As a modern medical specialty, anesthesiology includes the administration of surgical anesthesia, acute and chronic pain relief, postoperative care, the management of intensive care, respiratory intensive care, chronic pain management, resuscitation, and emergency medicine. Some departments of anesthesia have become departments of anesthesia and perioperative medicine. Nevertheless, even under optimum, fully modern conditions, the dangers of anesthesia should never be underestimated. In many cases, general anesthesia may be the most dangerous part of an operation. reasoned that there must be opiate receptors that play a role in the control of pain via some endogenous narcotic. Avram Goldstein (1919 ), one of the pioneers of this field, said that when thinking about the effects of morphine he asked himself ''why would God have made opiate receptors unless he had also made an endogenous morphine-like substance Just as enzymes and substrates fit together like locks and...
Management of pain and other symptoms At least 50 of patients undergoing dialysis experience pain, which is severe for nearly half of them. Pain is often intermittent but occurs over many years and the diverse causes lead to a high incidence of neuropathic pain. Numerous factors impede good pain control. A similar approach to that used to manage cancer pain can be taken with the WHO analgesic ladder, including adjuvants where indicated. Careful monitoring for toxicity is essential because of the retention of drugs or their metabolites in patients with renal failure. The active morphine metabolite, morphine 6 glucuronide, is retained in patients with ESRF and when morphine is taken for chronic pain its retention can lead to toxicity, including cognitive impairment and myoclonus. Alternative strong opioids such as oral hydromorphone and subcutaneous fentanyl or alfentanil and transdermal buprenorphine are being explored. Clearance of fentanyl may be altered in patients with ESRF, though...
Doctors' tasks include not only the traditional provision of diagnosis, investigation, prescriptions, and sickness certificates but also giving accurate advice, information, and reassurance. Primary care and emergency department doctors are potentially powerful therapeutic agents and can provide effective immediate care, but they may also unintentionally promote progression to chronic pain. The risk of chronicity is reduced by
Indwelling epidural and intrathecal access systems have been effectively used for some patients with intractable chronic pain and to deliver opiates and other drugs, such as clonidine and baclofen. A variety of electrical stimulation techniques, including peripheral (transcutaneous electrical nerve stimulation), spinal, and cerebral stimulations have been used for various somatic pain conditions, as well as for angina pectoris, with encouraging results. Acupressure is another alternative medicine technique that has been
Massive polycystic liver disease can cause chronic pain, early satiety, supine dyspnea, abdominal hernia, and, rarely, obstructive jaundice, or hepatic venous outflow obstruction. Therapeutic options include cyst sclerosis and fenestration, hepatic resection, and, ultimately, liver transplantation 25, 26 .
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).
In the context of clinically important pain, it is also important to understand the concept of sensitization. This refers to a phenomemon in which the gain of the entire noci-ceptive system is reset upwards by neuronal changes in either the periphery or within the central nervous system (CNS). Some form of sensitization invariably accompanies any kind of chronic pain, such as that seen with persistent inflammation. The net result is that noxious stimuli now elicit a pain response that is much greater when compared with the normal state, a phenomenon termed hyperalgesia.
Cedure is well tolerated with temporary results that are quite impressive but its role at this time should probably be limited to treating flares of chronic pain in patients with otherwise limited options. This is discussed in the chapter on chronic abdominal pain (see Chapter 41).
Tricyclic antidepressants such as amitryptyline (Elavil) are commonly used in chronic pain. This class of drugs has the added benefit of causing sedation as a side effect. However, they should be used at lowest possible doses to avoid early morning sedation and are best given before bedtime. Selective serotonin reuptake inhibitors, such as fluoxetine (Prozac), paroxetine (Paxil), and sertraline (Zoloft), do not show direct analgesic effects, but can be helpful when depression or anxiety contribute to the abdominal pain. Clonidine (Catapres), a central a-adrenergic agent, can help wean a child from opiods when they have been used for an extended time for pain control. Clonidine comes in a topical patch-delivery system and can be quite sedating.
- Posterior approaches Decompression adds instability, as the facet joints, disc, and supporting ligaments are left intact fusion of the involved segment is generally unnecessary, as is postoperative immobilization. Extensive laminectomies carry the risk of reverse lordosis, or swan neck deformity . Chronic pain with or without myelopathy may result.
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.
The following three pathophysiologic mechanisms may explain the pain in chronic pancreatitis (1) acute pancreatic inflammation, (2) increased intrapancreatic pressure, and (3) alterations in pancreatic nerves. Pancreatic enzyme therapy, CCK antagonists and octreotide decrease pancreatic secretion thus decreasing intrapancreatic pressure in both large and small ducts, as well as the pancreatic gland itself. Endoscopic procedures attempt to decrease the pain by decreasing pressure through improved drainage. There is a separate chapter on endoscopic treatment (see Chapter 138). Surgery affords decompression of the major pancreatic duct and is successful in some patients. There is also a chapter on surgical treatment (see Chapter 137, Chronic Pancreatitis Surgical Considerations ). Celiac plexus block and thoras-copic splanchnicectomy interrupt neural transmission of pain signals. There is also a chapter on chronic pain management (see Chapter 41, Chronic Abdominal Pain ).
For more-chronic conditions such as dry gangrene and persistent fracture non-union with chronic pain, purulent discharge, loss of weight, sleeplessness and immobility, it is apparent courage of a different kind is manifest. We have already recorded the remarkable determination of a boy, aged about 9, with severe chronic leg complications after crushing by a cartwheel a year previously. Reduced to a skeleton with 11 discharging fistulae and his health fading fast, he insisted on removal of his useless limb, saying to the surgeon
The ilioinguinal nerve may be damaged in lower quadrant surgical procedures, e.g., appendectomy, resulting in a weakness of the affected abdominal muscles, and predisposition to herniation. Similarly, the course of the ilioinguinal nerve and its genital branches varies considerably, rendering them prone to injury in the repair of an inguinal hernia. A direct inguinal hernia may also develop as a result of damage to the ilioinguinal nerve and subsequent wearing down of the abdominal muscles. Entrapment 15 of the ilioinguinal nerve within the inguinal ligament (ilioinguinal syndrome) may produce debilitating chronic pain in the cutaneous area of its distribution.
Our expanded view of the limbic system now includes its extension to this prefrontal cortex, specifically the orbital and medial portions of the frontal lobe this has been called the limbic forebrain. Widespread areas of the limbic system and association cortex of the frontal lobe, particularly the medial and orbital portions, are involved with human reactions to pain, particularly to chronic pain, as well as the human experiences of grief and reactions to the tragedies of life.
Chronic pancreatitis as a result of the conditioning therapy or prolonged steroid use may occur late in the posttransplantation period. Affected individuals may present with abdominal pain and or steatorrhea. Such patients are managed similarly to standard chronic pancreatitis patients. Therapy includes pancreatic enzymes to improve malabsorption or to reduce chronic pain and endoscopic retrograde cholangiography to alleviate pancreatic duct obstruction.
Peace in Pain
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