User talk:WhatamIdoing/Sandbox
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| ICD-10 | R52 |
|---|---|
| ICD-9 | 338 |
| DiseasesDB | 9503 |
| MedlinePlus | 002164 |
| MeSH | D010146 |
Pain is a symptom that has many implications for the practice of medicine. It may signal hundreds of different medical conditions. Pain management is concerned with the relief of pain.
In medical terms, pain is the unpleasant sensory and emotional experience triggered by the perception of actual or potential tissue damage to their body, or any sensation that is described in those terms.[1] Medical diagnoses of pain are based entirely on patient's opinion.
Pain is a major symptom in many medical conditions, and it can significantly interfere with a person's quality of life and general functioning. In many cases, pain is self-limiting (stops without treatment) or responds to simple measures such as resting or taking a painkiller (analgesic). The study of pain has in recent years diverged into many different fields from pharmacology to psychology and neurobiology. It is also a separate sub-discipline in some specializations.
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[edit] Classification
It is common to characterize pain in various ways such as the duration, severity, type (dull, burning or stabbing), and location in body. It can also be classified by cause; for example, neuropathic pain is caused by damage to nerve fibres.
Acute pain, such as occurs with trauma, often has a reversible cause and may require only transient measures and correction of the underlying problem. In contrast, chronic pain often results from conditions that are difficult to diagnose and treat, and that may take a long time to reverse. Some examples include cancer, neuropathy, and referred pain. Often, pain pathways (nociceptors) are set up that continue to transmit the sensation of pain even though the underlying condition or injury that originally caused pain has been healed. In such situations, the pain itself is frequently managed separately from the underlying condition of which it is a symptom, or the goal of treatment is to manage the pain with no treatment of any underlying condition (e.g. if the underlying condition has resolved or if no identifiable source of the pain can be found).
Human pain receptors can sense mechanical forces of excessive pressure, stretching and splitting, noxious heat, noxious cold, noxious chemicals, and localised tissue inflammation. Pain can be perceived to originate from a very specific location, a general area, or no definable location, as in central pain. Mild pain is relieved by natural processes or painkillers, mild to moderate may require stronger painkillers and moderate to severe pain can require strong painkillers to provide relief, and agony can prevent a person from doing anything apart from responding to the pain, An ache is longer lasting or persistent pain usually associated with the hard tissue of the skeletal system or joints. Experience of pain can be temporary, being relieved shortly after a painful stimulus is removed, or, if damage has occurred, persist until healing has completed. Acute pain is the normal episodic response to a painful stimulus, but if pain is felt past the accepted normal healing period, or due to a disorder, it is called chronic pain.
[edit] Causes
Although rarely pain can be caused by mental disorder, most pain is caused by our biological pain sensing system (nociception).
[edit] Tissue damage
The most common cause of acute pain is direct damage to the part of the body that hurts.
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Please help improve this section by expanding it. Further information might be found on the talk page or at requests for expansion. |
- Shoulder pain
- Back pain
- etc.
[edit] Nerve damage
Actual damage to a pain nerve, rather than it's nociceptor, due to disease or trauma can cause a false signal being sent to the thalamus, regardless of stimulus this causes the brain to perceive painful stimuli even though there is no obvious or known physiologic cause for the pain. When the trauma is caused by the loss of a limb, or from which a person no longer receives physical signals it is known as phantom pain, this is experienced by most amputees and quadriplegics. Neuropathic pain is sometime called the disease of pain and meets the criteria to be classed as pain.
[edit] Associated nerve damage
Allodynia, a type of dysesthesia, is a condition where non painful stimulus, like light touch, can trigger pain. Mechanoreceptors can influence the output of nociceptors by making connections with the same interneurons, the activation of which can reduce or completely eliminate the sensation of pain. Another way to modulate the transmission of pain information is via descending fibers from the brain. These fibers act through different interneurons to block the transmission of information from the nociceptrors to secondary neurons.[2]
Both of these mechanisms for pain modulation have been implicated in the pathology of allodynia. Several studies suggest that injury to the spinal cord might lead to loss and re-organization of the nociceptrors, mechanoreceptors and interneurons, leading to the transmission of pain information by mechanoreceptors[3][4] A different study reports the appearance of descending fibers at the injury site.[5]These changes both ultimately affect the circuitry inside the spinal cord, and the altered balance of signals probably leads to the sensation of pain.
[edit] Increased sensitivity
Hyperalgesia can be localised or generalised, and can be caused by nociceptor damage or by the immune system response to certain poisons. This is induced by Platelet aggregating factor (PAF) which comes about in an inflammatory or an allergic response, and seems to occur via immune cells interacting with the peripheral nervous system and releasing pain-producing chemicals (cytokines and chemokines).[6]
Increased sensitivity can also be caused by persistent transmission of nociception to the dorsal horn, which may induce a wind up phenomenon. This induces pathological changes that lower the threshold for pain signals to be transmitted. In addition it may generate nonnociceptive nerve fibers to respond to pain signals. Nonnociceptive nerve fibers may also be able to generate and transmit pain signals.[7]
[edit] Brain damage
- Damage in the brain, in an area involved in nociception can cause central pain.
[edit] Misperception
- See also: BDSM
[edit] Mental disorder
- Rarely a mental disorder can cause psychogenic pain, which is indistinct from the sufferer to actual physical pain.
[edit] Pathophysiology
- Further information: Nociception
- Further information: Pain
[edit] Diagnosis
Pain itself is not diagnosed: it is a symptom reported by the patient. In this sense, pain is whatever the patient says that it is.[citation needed]
To establish a greater understanding of an individual's pain, health-care practitioners will typically try to establish certain characteristics of the pain, and by using the gestalt of these, the source or cause of the pain can often be established. The following characteristics are commonly used:
- Quality: The quality of the pain remains a key characteristic, and is often the first question a practitioner will ask. Typical descriptions of pain quality include sharp, stabbing, tearing, squeezing, cramping, burning, lancinating (electric-shock like), or heaviness. It may be experienced as throbbing, dull, nauseating, shooting or a combination of these. Indeed, individuals who are clearly in extreme distress such as from a myocardial infarction may not describe the sensation as pain, but instead as an extreme heaviness on the chest. Another individual with pain in the same region and with the same intensity may describe the pain as tearing which would lead the practitioner to consider aortic dissection. Inflammatory pain is commonly associated with some degree of itch sensation, leading to a chronic urge to rub or otherwise stimulate the affected area. The difference between these diagnoses and many others rests on the quality of the pain.
- Intensity: Pain may range in intensity from slight through severe to agonizing and can appear as constant or intermittent. The threshold of pain varies widely between individuals. Many attempts have been made to create a Pain scale that can be used to quantify pain. The purpose of these scales is to monitor an individual's pain over time, allowing care-givers to monitor response to therapy for example. Accurate quantification can also allow researchers to compare results between groups of patients. Pain may be quantified on a pain numeric rating scale (NRS) that ranges from 1-10 points; such as scale (using a cut point of 4 or more) for predicting pain that interferes with functioning has a sensitivity of 64% and a specificity of 83%.[8]
- Localization: Localization is the term used to decribe the subjective experience of pain being in a specific area or region of the body. Localization is not always accurate in defining the problematic area, although the region will often help narrow the diagnostic possibilities. Some pain sensations may be diffuse or referred. Referred pain usually happens when sensory fibres from the viscera enter the same segment of the spinal cord as somatic nerves i.e. those from superficial tissues. The sensory nerve from the viscera stimulates the nearby somatic nerve so that the pain localization in the brain is confused. A well-known example is when heart damage is perceived as pain the left shoulder or arm.[9] Localization results in specific pain being named as as neck pain, cutaneous pain, kidney pain, or the painful uterine contractions occurring during childbirth etc. This common usage is not consistent with the scientists' model of pain being a subjective experience. The types of pain that can be classified by localisation are:
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- Cutaneous pain: Caused by injury to the skin or superficial tissues. Cutaneous nociceptors terminate just below the skin, and due to the high concentration of nerve endings, produce a well-defined, localized pain of short duration. Examples of injuries that produce cutaneous pain include paper cuts, minor cuts, minor (first degree) burns and lacerations.
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- Somatic pain: Originates from the neuromusculoskeletal system including muscles, ligaments, tendons, bones, blood vessels, and even nerves themselves. It is detected with somatic nociceptors. The scarcity of pain receptors in these areas produces a dull, poorly-localized pain of longer duration than cutaneous pain; examples include sprains and broken bones. Myofascial pain usually is caused by trigger points in muscles, tendons and fascia, and may be local or referred.
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- Visceral pain: Originates from body's viscera, or organs. Visceral nociceptors are located within body organs and internal cavities. The even greater scarcity of nociceptors in these areas produces pain that is usually more aching and of a longer duration than somatic pain. Visceral pain is extremely difficult to localize, and several injuries to visceral tissue exhibit "referred" pain, where the sensation is localized to an area completely unrelated to the site of injury. Myocardial ischaemia (the loss of blood flow to a part of the heart muscle tissue) is possibly the best known example of referred pain; the sensation can occur in the upper chest as a restricted feeling, or as an ache in the left shoulder, arm or even hand. The popularized term "brain freeze" is another example of referred pain, in which the vagus nerve is cooled by cold inside the throat. Referred pain can be explained by the findings that pain receptors in the viscera also excite spinal cord neurons that are excited by cutaneous tissue. Since the brain normally associates firing of these spinal cord neurons with stimulation of somatic tissues in skin or muscle, pain signals arising from the viscera are interpreted by the brain as originating from the skin. The theory that visceral and somatic pain receptors converge and form synapses on the same spinal cord pain-transmitting neurons is called "Ruch's Hypothesis".
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- Referred pain: Visceral pain sensation is often referred by the CNS to a dermatome, sclerotome or myotome region which may be far away from the originating source. This is explained, in part, due to a common embryological origin known as a somite in developing embryo. Examples of this include the heart which originates in the neck, thus producing the classical pain and arm pain experienced during acute cardiac pain.
- Radiation: Radiation of pain occurs when stimulus of a nerve at one site is perceived as pain in the sensory distribution of that nerve. Sciatica is the symptom of pain running down the back of the buttock, leg and bottom of foot that results from compression of a nerve root in the lumbar spine.
- Frequency and duration:
- Onset and offset:
- Exacerbating factors:
- Ameliorating factors:
[edit] Diagnosis in special populations
Most patients are able to verbally report and describe their pain. However, a patient who is very young or very disabled is unable to do this. In these cases, pain diagnoses are made by behavioral observations, such as grimacing, holding a body part stiffly, or retracting a body part that encounters an unpleasant sensation. Pain in these populations should not be disregarded.
[edit] Treatment and management
Pain management generally benefits from a multidisciplinary approach that includes pharmacologic measures (analgesics such as narcotics or NSAIDs and pain modifiers such as tricyclic antidepressants or anticonvulsants), non-pharmacologic measures (such as interventional procedures, physical therapy and physical exercise, application of ice and/or heat), and psychological measures (such as biofeedback and cognitive therapy).
[edit] Acute pain vs chronic pain
Pain management differs for acute and chronic pain. The distinction between these definitions is based on the nature of the pain rather than the duration of sensation.
General physicians are experienced with treating acute pain, which usually is caused by soft tissue damage, infection and/or inflammation among other causes. It is usually treated simultaneously with pharmaceuticals or appropriate techniques for removing the cause and pharmaceuticals or appropriate techniques for controlling the pain sensation, commonly analgesics. Acute pain serves to alert after an injury or malfunction of the body. Failure to treat acute pain properly may lead to chronic pain.[10]
Specialists are usually needed for chronic pain management. Chronic pain may have no apparent cause or may be caused by a developing illness or imbalance. This disorder can trigger multiple psychological problems that are confounding, leading to various differential diagnoses. Sometimes chronic pain can have a psychosomatic or psychogenic cause.[11] Chronic pain is sometimes referred to as the "disease of pain"
[edit] Modalities
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Please help improve this section by expanding it. Further information might be found on the talk page or at requests for expansion. |
Acute pain is primarily relieved by correcting the cause. During the healing process, other treatments may be given to relieve the pain. There are also many possible treatments for chronic pain.
- Medication:
- Physical therapy:
- Nerve blocks: One of the pain management modalities are trigger point injections and nerve blocks utilizing long acting anesthetics and small doses of steroids.
[edit] Alternative medicine
A survey of American adults found pain was the most common reason that people use alternative medicine. Among American adults who used complementary and alternative medicine (CAM) in 2002, 16.8% used CAM to treat back pain; 6.6% for neck pain; 4.9% for arthritis; 4.9% for joint pain; 3.1% for headache; and 2.4% used CAM to treat recurring pain, with some using CAM to treat more than one condition.[12]
Hypnosis as well as diverse perceptional techniques provoking altered states of consciousness have proven to be of important help in the management of all types of pain.[13] Some kinds of physical manipulation or exercise are showing interesting results as well.[14]
Traditional Chinese medicine views pain as a 'blocked' qi, akin to electrical resistance, with treatments such as acupuncture claimed as more effective for nontraumatic pain than traumatic pain. Although the mechanism is not fully understood, acupuncture may stimulate the release of large quantities of endogenous opioids.[15] A 2004 NCCAM-funded study showed that acupuncture provides pain relief and improved function in patients with osteoarthritis of the knee, causing some managed care organizations to support acupuncture as adjunctive therapy for this purpose.[16] The National Institutes of Health's 1997 Consensus Statement on Acupunture notes that research has been mixed, partly due to difficulties with designing clinical studies with the proper controls.[17]
CAM may also involve the use of nutritional supplements in pain treatment. Options include curcumin, a polyphenol found in turmeric and a natural COX-2 inhibitor,[18] glucosamine, chondroitin, bromelain and omega-3 fatty acids. Glucosamine and chondroitin were found to be effective only in a minority of pain patients, those suffering from moderate to severe pain, but was otherwise equivalent to a placebo.[19]
[edit] Prognosis
The prognosis for relief of pain depends on the underlying cause. Some kinds of pain are easily resolved, and others are lifelong conditions.
[edit] Medical specialties
Pain management practitioners come from all fields of medicine. Most often, pain fellowship trained physicians are anesthesiologists, neurologists, physiatrists or psychiatrists. Some practitioners focus more on the pharmacologic management of the patient, while others are very proficient at the interventional management of pain. Interventional procedures - typically used for chronic back pain - include: epidural steroid injections, facet joint injections, neurolytic blocks, Spinal Cord Stimulators and intrathecal drug delivery system implants, etc. Over the last several years the number of interventional procedures done for pain has grown to a very large number.
As well as medical practitioners, the area of pain management may often benefit from the input of Physiotherapists, Chiropractors, Clinical Psychologists & Occupational therapists, amongst others. Together the multidisciplinary team can help create a package of care suitable to the patient.
[edit] See also
- Coccydynia
- Neuralgia
- Neuropathy
- Transcutaneous Electrical Nerve Stimulator
- Temporomandibular joint disorder
[edit] References
- ^ IASP Pain Terminology
- ^ Fitzpatrick, David; Purves, Dale; Augustine, George (2004). Neuroscience. Sunderland, Mass: Sinauer, 231-250. ISBN 0-87893-725-0.
- ^ Wasner G, Naleschinski D, Baron R (2007). "A role for peripheral afferents in the pathophysiology and treatment of at-level neuropathic pain in spinal cord injury? A case report". Pain 131 (1-2): 219-25. doi:. PMID 17509762.
- ^ Yezierski RP, Liu S, Ruenes GL, Kajander KJ, Brewer KL (1998). "Excitotoxic spinal cord injury: behavioral and morphological characteristics of a central pain model". Pain 75 (1): 141-55. PMID 9539683.
- ^ Kalous A, Osborne PB, Keast JR (2007). "Acute and chronic changes in dorsal horn innervation by primary afferents and descending supraspinal pathways after spinal cord injury". J. Comp. Neurol. 504 (3): 238-53. doi:. PMID 17640046.
- ^ Marchand, F., Perretti, M., & McMahon, S. B. (2005). Role of the immune system in chronic pain. Nature Reviews Neuroscience, 6, 521-532.
- ^ Vadivelu N, Sinatra R (2005). "Recent advances in elucidating pain mechanisms". Current opinion in anaesthesiology 18 (5): 540-7. PMID 16534290.
- ^ Krebs, Carey, and Weinberger, “Accuracy of the Pain Numeric Rating Scale as a Screening Test in Primary Care,” Journal of General Internal Medicine 22, no. 10 (October 21, 2007): 1453-1458, doi:10.1007/s11606-007-0321-2 (accessed September 28, 2007).
- ^ Ann Waugh, Allison Grant (001). Anatomy and Physiology in Health and Illness. Edinburgh: Churchill Livingstone, pp 174-175. ISBN 0443-06468 7.
- ^ Dahl JB, Moiniche S (2004). "Pre-emptive analgesia". Br Med Bull 71: 13-27. PMID 15596866.
- ^ Sarno, John E., MD, et al., The Divided Mind: The Epidemic of Mindbody Disorders 2006 (ISBN 0-06-085178-3)
- ^ Barnes, P (2004-05-27), CDC Advance Data Report #343. Complementary and Alternative Medicine Use Among Adults: United States, 2002, U.S. National Center for Complementary and Alternative Medicine; news release.
- ^ Robert Ornstein PhD, David Sobel MD (1988). The Healing Brain. New York: Simon & Schuster Inc, pp 98-99. ISBN -671-66236-8.
- ^ Douglas E DeGood, Donald C Manning MD, Susan J Middaugh (1997). The headache & Neck Pain Workbook. Oakland, California: New Harbinger Publications. ISBN 1-57224-086-5.
- ^ Sapolsky, Robert M. (1998). Why zebras don't get ulcers: An updated guide to stress, stress-related diseases, and coping. New York: W.H. Freeman and CO. ISBN 0-585-36037-5.
- ^ Berman BM, Lao L, Langenberg P, Lee WL, Gilpin AM, Hochberg MC (2004). "Effectiveness of acupuncture as adjunctive therapy in osteoarthritis of the knee: a randomized, controlled trial". Ann. Intern. Med. 141 (12): 901-10. PMID 15611487.
- ^ Ramsay; et al. (1997-11-5). The National Institutes of Health (NIH) Consensus Development Program: Acupuncture. Retrieved on 2008-03-29.
- ^ Sharma S, Kulkarni SK, Agrewala JN, Chopra K (2006). "Curcumin attenuates thermal hyperalgesia in a diabetic mouse model of neuropathic pain". Eur. J. Pharmacol. 536 (3): 256-61. doi:. PMID 16584726.
- ^ Clegg DO, Reda DJ, Harris CL, et al (2006). "Glucosamine, chondroitin sulfate, and the two in combination for painful knee osteoarthritis". N. Engl. J. Med. 354 (8): 795-808. doi:. PMID 16495392.
[edit] External links
- WhatamIdoing/Sandbox at the Open Directory Project
- Acute Pain Medicine: Scientific Evidence (2nd ed) (2007 updated version)
- Pain Management Resources: PainEdu
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