Citizendia
Your Ad Here

Symptom/Sign: Chronic pain
Classifications and external resources
ICD-10 R52.1-R52.2
ICD-9

Chronic pain is defined as pain that persists longer than the temporal course of natural healing, associated with a particular type of injury or disease process. A symptom' (from Greek σύμπτωμα, "accident misfortune that which befalls" from συμπίπτω, "I befall" from A Sign is an indication of some fact or quality and a medical sign is an objective indication of some medical fact or quality that is detected by a Physician The International Statistical Classification of Diseases and Related Health Problems (most commonly known by the abbreviation ICD) provides codes to classify Diseases The International Statistical Classification of Diseases and Related Health Problems 10th Revision ( ICD -10) is a coding of diseases and signs symptoms abnormal findings R00-R69 - Symptoms and Signs (R00-R09 Circulatory and Respiratory systems ( Abnormalities of Heart beat R00-R69 - Symptoms and Signs (R00-R09 Circulatory and Respiratory systems ( Abnormalities of Heart beat The International Statistical Classification of Diseases and Related Health Problems (most commonly known by the abbreviation ICD) provides codes to classify Diseases The following is a list of codes for International Statistical Classification of Diseases and Related Health Problems. Pain, in the sense of physical pain, is a typical sensory experience that may be described as the unpleasant awareness of a noxious stimulus or bodily harm [1]

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. "[2] It is important to note that pain is subjective in nature and is defined by the person experiencing it, and the medical community's understanding of chronic pain now includes the impact that the mind has in processing and interpreting pain signals.

Contents

Functional anatomy

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 fibers converge into a region of the spinal cord referred to as the dorsal horn. The dorsal horn is the first relay station in pain signal transmission. The next element of pain transmission includes nerve fibers that then travel to the thalamus. From the thalamus the next order of neurons ascend to the limbic system and sensory cortex. This accounts for the affective elements and discriminative of pain respectively. [3][4]

Nociception

Main article: Nociception

Nociceptors convey information regarding damage or trauma from the body to the central nervous system, a process called nociception, where it is interpreted by the brain as pain. Nociception (synonym nociperception is defined as "the neural processes of encoding and processing Noxious stimuli. A nociceptor is a Sensory receptor that sends signals that cause the perception of Pain in response to a potentially damaging stimulus In Vertebrates the central nervous system ( CNS) is the part of the Nervous system which is enclosed in the Meninges. Nociception (synonym nociperception is defined as "the neural processes of encoding and processing Noxious stimuli. The brain is the center of the Nervous system in animals All Vertebrates and the majority of Invertebrates have a brain Pain, in the sense of physical pain, is a typical sensory experience that may be described as the unpleasant awareness of a noxious stimulus or bodily harm Nociception occurs in any tissue or organ in which pain signals arise secondary to a disease process or trauma. The nociception can also occur if there is dysfunction or damage to nerves themselves. [2]

Pathophysiology

Under 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 may generate nonnociceptive nerve fibers to respond to pain signals. Nonnociceptive nerve fibers may also be able to generate and transmit pain signals. In chronic pain this process is difficult to reverse or eradicate once established. [5]

Classification

Nociception (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]

Diagnoses

Pain may be a response to injury or any number of disease states that provoke nociception. Advances in imaging studies and electrophysiological studies allow us to gain a deeper insight into the characteristics and properties associated with the phenomenon of chronic pain. [6][7][8]

Related sequelae

Chronic pain may cause other symptoms or conditions, including depression and anxiety. It may also contribute to decreased physical activity given the apprehension of exacerbating pain. [9] Conversely it may itself have psychosomatic or psychogenic component to its cause. [10] Very little work has been done on the cognitive effects of chronic pain, with most of the publications focussing on the effects of cognition on pain but only 5% examining the effects of pain on cognition. Cognition is a concept used in different ways by different disciplines but is generally accepted to mean the process of awareness or thought [11]

Attention

Chronic pain impairs the ability to direct attention, in particular when compared to peers with low intensity or no chronic pain, people with high-intensity chronic pain have significantly reduced ability to perform attention-demanding tasks. Attention is the Cognitive process of selectively concentrating on one aspect of the environment while ignoring other things [12] The pain sensations appear to strongly capture the attention of people with chronic pain; tests assessing the ability to attend show poorer performance than peers who do not experience chronic pain on all tests demanding attention. In Psychology, sensation is the first stage in the biochemical and neurologic events that begins with the impinging of a stimulus upon the receptor cells of a [13] The exception is found with tasks that are highly demanding of attention, where performance between the two groups is equivalent. [13] In experimental testing, two-thirds of individuals with chronic pain demonstrate clinically significant impairment of attention, independent of age, education, medication and sleep disruption. Individuals with the highest levels of pain showed greatest disruption of memory traces, suggesting that pain diminishes working memory. Engrams are a Hypothetical means by which Memory traces are stored as biophysical or biochemical change in the Brain (and other Working memory (also referred to as Short term memory, depending on the specific theory is a theoretical construct within Cognitive psychology that refers to the [14]

Management

It is rare to completely achieve absolute and sustained relief of pain. Thus, the clinical goal is pain management. Pain management is often multidisciplinary in nature. A recent journal article by Gatchell and Okifuji 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 for persons with chronic pain, relative to a host of widely used conventional medical treatment. " [15][16]

Medications

In the treatment of chronic pain, whether due to malignant or benign processes, the three-step WHO Analgesic Ladder is often used. [1][2][3] This provides guidelines for stepping up the amount of analgesia and maintains a general basis that is used in a number of countries around the world to manage chronic pain conditions. The exact medications recommended will vary with the country and the individual treatment centre, but the following gives an example of the approach to treating chronic pain with medications. If, at any point, treatment fails to provide adequate pain relief, then the doctor and patient move onto the next step.

Mild pain

Paracetamol (acetaminophen), or a non steroidal anti-inflammatory drug such as ibuprofen

Mild to moderate pain

Paracetamol, an NSAID and/or paracetamol in a combination product with a weak opioid such as hydrocodone; used in combination, may provide greater relief than their separate use. Paracetamol ( INN) (ˌpærəˈsiːtəmɒl -ˈsɛtə- or acetaminophen ( USAN) is a widely-used Analgesic and Antipyretic Medication Non-steroidal anti-inflammatory drugs, usually abbreviated to NSAID s or NAID s, are drugs with Analgesic, Antipyretic and in higher Ibuprofen ( INN) (ˌaɪbjuːˈpɹəʊfɛn (from the now outdated nomenclature i so- bu tyl- pro panoic- phen olic acid is a Non-steroidal An opioid is a chemical Substance that has a Morphine -like action in the body Hydrocodone or dihydrocodeinone is a semi-synthetic Opioid derived from two of the naturally occurring Opiates Codeine and Thebaine

Moderate to severe pain

Morphine is the gold standard choice, followed by Oxycodone, Fentanyl in the form of a transdermal patch designed for chronic pain management, Diamorphine, hydromorphone or methadone are used less frequently. Medical uses Morphine can be used as an analgesic in hospital settings to relieve pain in Myocardial infarction pain in Oxycodone is an Opioid Analgesic Medication synthesized from Thebaine. Fentanyl is one of the most powerful Opioid Analgesics with a potency approximately 81 times that of Morphine. Heroin ( INN: diacetylmorphine, BAN: diamorphine) is a semi-synthetic opioid synthesized from Morphine, a derivative Hydromorphone, a more common synonym for dihydromorphinone hydrochloride (trade names Palladone IR, Palladone SR, Dilaudid and numerous others Methadone ( Dolophine Amidone Methadose Physeptone Heptadon and many others is a synthetic Opioid, used medically as an Analgesic, Antitussive

Pethidine is not recommended for chronic pain management due to its low potency, short duration of action, and toxicity associated with repeated use. Pethidine ( INN) or meperidine ( USAN) (commonly referred to as Demerol but also referred to as isonipecaine lidol pethanol piridosal Algil Alodan

Opioids

Opioid medications can provide a short, intermediate or long acting analgesia depending upon the specific properties of the medication and whether it is formulated as an extended release drug. An opioid is a chemical Substance that has a Morphine -like action in the body Opioid medications may be 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 long acting or extended release medication is often prescribed in conjunction with a shorter acting medication for break through pain (exacerbations).

Most opioid treatment is oral (tablet, capsule or liquid), but suppositories and skin patches can be prescribed. A tablet is a mixture of active substances and Excipients usually in powder form pressed or compacted into a solid A suppository is a drug delivery system that is inserted either into the Rectum (rectal suppository Vagina (vaginal suppository or Urethra (urethral 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 pain is acute or chronic in origin. Opioids are efficacious analgesics in chronic malignant pain and modestly effective nonmalignant pain management. However, there are variable associated adverse effects, especially during the commencement or change in dosing and administration. When opioids are used for prolonged periods drug tolerance, chemical dependency and (rarely) addiction may occur. An opioid is a chemical Substance that has a Morphine -like action in the body Drug tolerance occurs when a subject's reaction to a Psychoactive drug (such as a painkiller or intoxicant decreases so that larger doses are required to achieve the same effect Physical dependence (or drug dependence) refers to a state resulting from habitual use of a drug where negative physical Withdrawal symptoms result from abrupt discontinuation The term " addiction " is used in many contexts to describe an obsession compulsion or excessive Physical dependence or psychological dependence such as Chemical dependency is ubiquitous among opioid therapy after continuous administration; however, drug tolerance is not well studied in patients on long term opioid therapy. Physical dependence (or drug dependence) refers to a state resulting from habitual use of a drug where negative physical Withdrawal symptoms result from abrupt discontinuation An opioid is a chemical Substance that has a Morphine -like action in the body Drug tolerance occurs when a subject's reaction to a Psychoactive drug (such as a painkiller or intoxicant decreases so that larger doses are required to achieve the same effect Addiction rarely occurs as a result of opioid prescription, but they are abused by some individuals, which can cause concern to health care providers. The term " addiction " is used in many contexts to describe an obsession compulsion or excessive Physical dependence or psychological dependence such as Diversion of opioid medications 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). Non-steroidal anti-inflammatory drugs, usually abbreviated to NSAID s or NAID s, are drugs with Analgesic, Antipyretic and in higher This class of medications does not include acetaminophen, which has minimal anti-inflammatory properties. Paracetamol ( INN) (ˌpærəˈsiːtəmɒl -ˈsɛtə- or acetaminophen ( USAN) is a widely-used Analgesic and Antipyretic Medication However, acetaminophen may be administered as a single medication or in combination with other analgesics (both NSAIDs and opioids). The alternatively prescribed NSAIDs such as ketoprofen and piroxicam, have limited benefit in chronic pain disorders and with long term use is associated with significant adverse effects. The use of selective NSAIDs designated as selective COX-2 inhibitors have significant cardiovascular and cerebrovascular risks which have limited their utilization. [17][18]

Antidepressants and antiepileptic drugs

Some antidepressant and antiepileptic drugs are used in chronic pain management and act primarily within the pain pathways of the central nervous system, though peripheral mechanisms have been attributed as well. An antidepressant is a Psychiatric medication used for alleviating major depression or Dysthymia ('milder' depression The anticonvulsants, also called antiepileptic drugs (abbreviated "AEDs" are a diverse group of pharmaceuticals used in the treatment of epileptic These mechanisms vary and in general are more effective in neuropathic pain disorders as well as complex regional pain syndrome. Neuropathy is a medical term usually short for Peripheral neuropathy. Complex Regional Pain Syndrome (CRPS is a chronic progressive disease characterized by severe pain swelling and changes in the skin [19] Drugs such as Gabapentin have been widely prescribed for the off-label use of pain control. Gabapentin (brand name Neurontin) is a medication originally developed for the treatment of Epilepsy. The list of side effects for these classes of drugs are typically much longer than opiate or NSAID treatments for chronic pain, and many antiepileptics cannot be suddenly stopped without the risk of seizure. An epileptic seizure is caused by excessive and/or hypersynchronous electrical Neuronal activity and is usually self-limiting

Other Adjuvant & Atypical Analgesic Agents

Other drugs are often used to help analgesics combat various types of pain and parts of the overall pain experience. In addition to gabapentin, the vast majority of which is used off-label for this purpose, orphenadrine, cyclobenzaprine, trazadone and other drugs with anticholinergic properties are useful in conjunction with opioids for neuropathic pain. Gabapentin (brand name Neurontin) is a medication originally developed for the treatment of Epilepsy. Orphenadrine (sold under the Brand names Norflex Mephenamin Disipal Banflex Flexon Biorphen Brocasipal and others is an Anticholinergic Drug of Cyclobenzaprine is a long-acting skeletal muscle relaxant. It is marketed as Flexeril (5 and 10 mg tablets and also as Fexmid (7 Trazodone (trade names Desyrel, Molipaxin, Trittico, Thombran, Trialodine, Trazorel) is a Psychoactive compound The latter three drugs are also muscle relaxants and are therefore particularly useful in painful musculoskeletal conditions. Clonidine has found use as an analgesic for this same purpose and all of the mentioned drugs potentiate the effects of opioids overall. Clonidine is a direct-acting α2 Adrenergic agonist prescribed historically as an Antihypertensive agent

Interventional therapy

Pulsed radiofrequency, neuromodulation, direct introduction of medication and nerve ablation may be used to target either the tissue structures and organ/systems responsible for persistent nociception or the nociceptors from the structures implicated as the source of chronic pain. Pulsed radiofrequency is a development of heat based radiofrequency denervation both procedures used in medicine to treat especially chronic Pain. In neuroscience neuromodulation is the process in which several classes of Neurotransmitters in the nervous system regulate diverse populations of Neurons (one Ablation is defined as the removal of material from the surface of an object by Vaporization, Chipping, or other erosive processes Nociception (synonym nociperception is defined as "the neural processes of encoding and processing Noxious stimuli. A nociceptor is a Sensory receptor that sends signals that cause the perception of Pain in response to a potentially damaging stimulus [20][21][22][23][24]

An intrathecal pump used to delivery very small quantities of medications directly to the spinal fluid. An intrathecal pump is a Medical device used to delivery very small quantities of medications directly to the Spinal fluid of a human being This is similar to epidural infusions used in labour and postoperatively. The major differences are that it is much more common for the drug to be delivered into the spinal fluid (intrathecal) rather than epidurally, and the pump can be fully implanted under the skin. This approach allows the drug to be delivered directly to the site of action, ie the spinal cord, and so allows a higher dose to be given with less systemic side effects. [25]

A spinal cord stimulator is an implantable medical device that creates electric impulses and applies them near the dorsal surface of the spinal cord provides a paresthesia ("tingling") sensation that alters the perception of pain by the patient. Spinal Cord Stimulator (SCS or Dorsal Column Stimulator (DCS is an implantable Medical device used to treat chronic pain of neurologic origin Paresthesia (pron /ˌpɛɹɪsˈθiʒə/ paraesthesia in British English, pron

Rehabilitation

Further information: Physical medicine and rehabilitation

As alluded to earlier there are other modalities used in the treatment of chronic pain. Physical medicine and rehabilitation (PM&R or physiatry, is a branch of Medicine dealing with functional restoration of a person affected by physical disability These include: physical modalities such as thermal agents and electrotherapy. Electrotherapy is the use of Electrical energy in the treatment of impairments of health and a conditions of abnormal functioning. Complementary and alternative medicine, therapeutic exercise and behavioral therapy are also utilized autonomously or in tandem with interventional techniques and conventional pharmacotherapy. This is most often structured in a multidisciplinary or interdisciplinary program. [26]

Behavioral therapy

Main article: Behavioral therapy
Main article: Applied behavior analysis

Applied behavior analysis treats pain as mixture of respondent and operant conditioning in which normal tissues learn to fire pain responses in the presence of specific environmental antecedents and consequences. Behaviour therapy is a form of Psychotherapy used to treat depression, Anxiety disorders, Phobias, and other forms of Psychopathology Applied behavior analysis ( ABA) is the science of applying experimentally derived principles of behavior to improve socially significant behavior Applied behavior analysis ( ABA) is the science of applying experimentally derived principles of behavior to improve socially significant behavior Tissue is a cellular organizational level intermediate between cells and a complete organism The model was first proposed by Fordyce in 1976. [27][28] There is mixed support for behavioral treatment of pain, with many studies reporting positive results,[29][30][31][32] though a review of studies in 2005 suggested that though behavioral can be an effective and economical means of treating chronic pain, a substantial portion of patients do not benefit from behavior therapy, that effects are rather modest, and there is little evidence to support different treatment modalities have different effects. [33]

Biofeedback

Main article: Biofeedback

Biofeedback based on behavioral principles has shown some success for chronic pain, demonstrating greater improvement in one study than peers undergoing cognitive-behavioral therapy and conservative medical treatment,[34] though a different study showed improvements over wait-list controls but no difference between biofeedback and cognitive-behavioral therapy. Biofeedback is a form of Alternative medicine that involves measuring a subject's quantifiable bodily functions such as Blood pressure, Heart rate, Biofeedback is a form of Alternative medicine that involves measuring a subject's quantifiable bodily functions such as Blood pressure, Heart rate, [35]

See also


Conditions related to pain
Drugs
Other approaches in Physical medicine and rehabilitation (Physiatry)
Alternative therapies


Surgery

Footnotes

  1. ^ Shipton EA, Tait B (2005). Suffering, or pain, is an individual's basic Affective experience of unpleasantness and aversion associated with harm or threat of harm Pain, in the sense of physical pain, is a typical sensory experience that may be described as the unpleasant awareness of a noxious stimulus or bodily harm Arthritis (from Greek arthro-, joint + -itis, inflammation plural arthritides is a group of conditions involving damage to the Joints of the body Back pain (also known " dorsalgia " is Pain felt in the back that usually originates from the Muscles Nerves Bones Cancer (medical term Malignant Neoplasm) is a class of Diseases in which a group of cells display uncontrolled Complex Regional Pain Syndrome (CRPS is a chronic progressive disease characterized by severe pain swelling and changes in the skin Major depressive disorder, also known as major depression, unipolar depression, unipolar disorder, clinical depression, or simply depression Fibromyalgia (FM is a disorder classified by the presence of chronic widespread Pain and tactile Allodynia. A headache ( cephalalgia in medical terminology is a condition of pain in the Head; sometimes Neck or upper back pain may also be interpreted Sciatica is a set of symptoms including Pain that may be caused by general compression and/or irritation of one of five nerve roots that give rise to the Sciatic nerve The anticonvulsants, also called antiepileptic drugs (abbreviated "AEDs" are a diverse group of pharmaceuticals used in the treatment of epileptic Gabapentin (brand name Neurontin) is a medication originally developed for the treatment of Epilepsy. Pregabalin ( INN) (prɨˈgæbəlɨn is an Anticonvulsant drug used for Neuropathic pain and as an adjunct therapy for Partial seizures with or Levetiracetam ( INN) (lɛvɨtɪˈræsɨtæm Topiramate (brand name Topamax) is an Anticonvulsant drug produced by Ortho-McNeil Neurologics and Noramco Inc Lamotrigine (marketed as Lamictal (ləˈmɪktəl by GlaxoSmithKline, called Lamictin in South Africa, he למוג'ין ( Lamogine Zonisamide is a Sulfonamide Anticonvulsant approved for use as an adjunctive therapy in adults with partial-onset seizures History An antidepressant is a Psychiatric medication used for alleviating major depression or Dysthymia ('milder' depression A local anesthetic is a drug that causes reversible Local anesthesia and a loss of Nociception. Ketamine is a drug for use in human and veterinary medicine developed by Parke-Davis (today a part of Pfizer) in 1962 Paracetamol ( INN) (ˌpærəˈsiːtəmɒl -ˈsɛtə- or acetaminophen ( USAN) is a widely-used Analgesic and Antipyretic Medication Non-steroidal anti-inflammatory drugs, usually abbreviated to NSAID s or NAID s, are drugs with Analgesic, Antipyretic and in higher An opioid is a chemical Substance that has a Morphine -like action in the body Clonidine is a direct-acting α2 Adrenergic agonist prescribed historically as an Antihypertensive agent Ziconotide is a non- opioid, non- NSAID, non-local anesthetic used for the amelioration of Chronic pain. Physical medicine and rehabilitation (PM&R or physiatry, is a branch of Medicine dealing with functional restoration of a person affected by physical disability Cryotherapy is the use of cold in a variety of modalities to treat a medical condition "Hotbag" redirects here For the container used to keep pizzas warm see Pizza delivery. Occupational Therapy, often abbreviated "OT", is the "use of productive or creative activity in the treatment or rehabilitation of physically cognitively or History Antiquity In China, the practice of acupuncture can perhaps be traced as far back as Behaviour therapy is a form of Psychotherapy used to treat depression, Anxiety disorders, Phobias, and other forms of Psychopathology Chiropractic is a Health care profession that focuses on diagnosis treatment and prevention of mechanical disorders of the Musculoskeletal system, with special emphasis Prolotherapy ("Proliferative Injection Therapy" involves injecting an otherwise non- pharmacological and non- active irritant solution into the body Spinal Cord Stimulator (SCS or Dorsal Column Stimulator (DCS is an implantable Medical device used to treat chronic pain of neurologic origin "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. doi:10.1017/S0265021505000694. A digital object identifier ( DOI) is a permanent identifier given to an Electronic document. 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. doi:10.1016/j.nec.2004.02.010. A digital object identifier ( DOI) is a permanent identifier given to an Electronic document. PMID 15246335.  
  4. ^ a b Vanderah TW (2007). "Pathophysiology of pain". Med. Clin. North Am. 91 (1): 1-12. doi:10.1016/j.mcna.2006.10.006. A digital object identifier ( DOI) is a permanent identifier given to an Electronic document. PMID 17164100.  
  5. ^ Vadivelu N, Sinatra R (2005). "Recent advances in elucidating pain mechanisms". Current opinion in anaesthesiology 18 (5): 540-7. doi:10.1097/01.aco.0000183109.27297.75. A digital object identifier ( DOI) is a permanent identifier given to an Electronic document. 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. doi:10.1523/JNEUROSCI.1100-05.2005. A digital object identifier ( DOI) is a permanent identifier given to an Electronic document. PMID 16093383.  
  7. ^ Geha PY, Apkarian AV (2005). "Brain imaging findings in neuropathic pain". Current pain and headache reports 9 (3): 184-8. doi:10.1007/s11916-005-0060-1. A digital object identifier ( DOI) is a permanent identifier given to an Electronic document. PMID 15907256.  
  8. ^ Turton AJ, McCabe CS, Harris N, Filipovic SR (2007). "Sensorimotor integration in Complex Regional Pain Syndrome: 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. doi:10.1016/j.mehy.2006.08.036. A digital object identifier ( DOI) is a permanent identifier given to an Electronic document. PMID 17071012.  
  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. ^ Kreitler S (2007). "Cognitive impairment in chronic pain" (pdf). Pain: Clinical Updates XV (4): 1-4. International Association for the Study of Pain. The International Association for the Study of Pain (IASP is an international professional organization promoting research education and policies for the knowledge and management of  
  12. ^ Eccleston C (1995). "Chronic pain and distraction: an experimental investigation into the role of sustained and shifting attention in the processing of chronic persistent pain". Behav Res Ther 33 (4): 391-405. doi:10.1016/0005-7967(94)00057-Q. A digital object identifier ( DOI) is a permanent identifier given to an Electronic document. PMID 7538753.  
  13. ^ a b Von Bueren Jarchow A; Radanov BP; Jäncke, L (2005). "Pain influences several levels of attention". Zeitschrift für Neuropsychologie 16 (4): 235-242. doi:10.1024/1016-264X.16.4.235. A digital object identifier ( DOI) is a permanent identifier given to an Electronic document.  
  14. ^ Dick BD, Rashiq S (2007). "Disruption of attention and working memory traces in individuals with chronic pain". Anesth. Analg. 104 (5): 1223-9, tables of contents. doi:10.1213/01.ane.0000263280.49786.f5. A digital object identifier ( DOI) is a permanent identifier given to an Electronic document. PMID 17456678.  
  15. ^ Henningsen P, Zipfel S, Herzog W (2007). "Management of functional somatic syndromes". Lancet 369 (9565): 946-55. doi:10.1016/S0140-6736(07)60159-7. A digital object identifier ( DOI) is a permanent identifier given to an Electronic document. PMID 17368156.  
  16. ^ Stanos S, Houle TT (2006). "Multidisciplinary and interdisciplinary management of chronic pain". Physical medicine and rehabilitation clinics of North America 17 (2): 435-50, vii. doi:10.1016/j.pmr.2005.12.004. A digital object identifier ( DOI) is a permanent identifier given to an Electronic document. PMID 16616276.  
  17. ^ Munir MA, Enany N, Zhang JM (2007). "Nonopioid analgesics". Med. Clin. North Am. 91 (1): 97-111. doi:10.1016/j.mcna.2006.10.011. A digital object identifier ( DOI) is a permanent identifier given to an Electronic document. PMID 17164106.  
  18. ^ Ballantyne JC (2006). "Opioids for chronic nonterminal pain". South. Med. J. 99 (11): 1245-55. PMID 17195420.  
  19. ^ Jackson KC (2006). "Pharmacotherapy for neuropathic pain". Pain practice : the official journal of World Institute of Pain 6 (1): 27-33. PMID 17309706.  
  20. ^ Varrassi G, Paladini A, Marinangeli F, Racz G (2006). "Neural modulation by blocks and infusions". Pain practice : the official journal of World Institute of Pain 6 (1): 34-8. PMID 17309707.  
  21. ^ Meglio M (2004). "Spinal cord stimulation in chronic pain management". Neurosurg. Clin. N. Am. 15 (3): 297-306. doi:10.1016/j.nec.2004.02.012. A digital object identifier ( DOI) is a permanent identifier given to an Electronic document. PMID 15246338.  
  22. ^ Rasche D, Ruppolt M, Stippich C, Unterberg A, Tronnier VM (2006). "Motor cortex stimulation for long-term relief of chronic neuropathic pain: a 10 year experience". Pain 121 (1-2): 43-52. doi:10.1016/j.pain.2005.12.006. A digital object identifier ( DOI) is a permanent identifier given to an Electronic document. PMID 16480828.  
  23. ^ Boswell MV, Trescot AM, Datta S, Schultz DM, Hansen HC, Abdi S, Sehgal N, Shah RV, Singh V, Benyamin RM, 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). Pain physician 10 (1): 7-111. PMID 17256025.  
  24. ^ Romanelli P, Esposito V, Adler J (2004). "Ablative procedures for chronic pain". Neurosurg. Clin. N. Am. 15 (3): 335-42. doi:10.1016/j.nec.2004.02.009. A digital object identifier ( DOI) is a permanent identifier given to an Electronic document. PMID 15246341.  
  25. ^ Ferrante FM, Lu L, Jamison SB, Datta S (1991). "Patient-controlled epidural analgesia: demand dosing". Anesth. Analg. 73 (5): 547–52. doi:10.1213/00000539-199111000-00006. A digital object identifier ( DOI) is a permanent identifier given to an Electronic document. PMID 1952133.  
  26. ^ Geertzen JH, Van Wilgen CP, Schrier E, Dijkstra PU (2006). "Chronic pain in rehabilitation medicine". Disability and rehabilitation 28 (6): 363-7. PMID 16492632.  
  27. ^ Fordyce, Wilbert E (1976). Behavioral methods for chronic pain and illness. St. Louis: Mosby. ISBN 0-8016-1621-2.  
  28. ^ Fordyce, W. E. (1988). "Pain and suffering. A reappraisal. ". Am Psychol 43 (4): 276-83. doi:10.1037/0003-066X.43.4.276. A digital object identifier ( DOI) is a permanent identifier given to an Electronic document.  
  29. ^ Romano, J. M. ; Jensen, M. P. ; Turner, J. A. ; Good, A. B. ; Hops, H. (2000). "Chronic pain patient-partner interactions: Further support for a behavioral model of chronic pain". Behavior Therapy 31 (3): 415-440. doi:10.1016/S0005-7894(00)80023-4. A digital object identifier ( DOI) is a permanent identifier given to an Electronic document.  
  30. ^ Sanders, S. H. ; Chattanooga, T. (2006). "Behavioral Conceptualization and Treatment for Chronic Pain". A Context for Science with a Commitment to Behavior Change 7 (2).  
  31. ^ Turner JA, Clancy S (1988). "Comparison of operant behavioral and cognitive-behavioral group treatment for chronic low back pain". J Consult Clin Psychol 56 (2): 261-6. PMID 2967314.  
  32. ^ Turner JA, Clancy S, McQuade KJ, Cardenas DD (1990). "Effectiveness of behavioral therapy for chronic low back pain: a component analysis". J Consult Clin Psychol 58 (5): 573-9. PMID 2147702.  
  33. ^ Vlaeyen JW, Morley S (2005). "Cognitive-behavioral treatments for chronic pain: what works for whom?". Clin J Pain 21 (1): 1-8. PMID 15599126.  
  34. ^ Flor, H; Birbaumer N (1993). "Comparison of the efficacy of cicctromyographic biofeedback, cognitive behavior therapy, and conservative medical treatment for chronic skeletal pain". Journal of Consulting and Clinical Psychology 61 (4): 653-658.  
  35. ^ Newton-John TR, Spence SH, Schotte D (1995). "Cognitive-behavioural therapy versus EMG biofeedback in the treatment of chronic low back pain". Behav Res Ther 33 (6): 691-7. doi:10.1016/0005-7967(95)00008-L. A digital object identifier ( DOI) is a permanent identifier given to an Electronic document. PMID 7654161.  

External links

© 2009 citizendia.org; parts available under the terms of GNU Free Documentation License, from http://en.wikipedia.org
 Dapyx Software network: MP3 Explorer | Ebook Manager | Zenithic