The Clinical journal of pain
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The seven botulinum neurotoxin serotypes share less than 50% sequence homology and are immunologically distinct. The neurotoxins inhibit release of the neurotransmitter acetylcholine from the axon terminals of motor neurons, preganglionic sympathetic and parasympathetic neurons, and postganglionic parasympathetic nerves by a multi-step mechanism that differs slightly, but significantly, for each serotype. ⋯ The resulting muscle paralysis has provided the basis for therapeutic use of botulinum toxin types A and B in a variety of focal dystonias. The safety of the botulinum toxins, when administered focally, has permitted their widespread use in a number of other painful conditions.
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The immune system is unable to determine whether material it encounters is deleterious, benign, or even beneficial to the organism. This presents a significant challenge when protein-based biological therapies, such as botulinum toxin, are administered to patients. Many factors combine to influence the likelihood and the magnitude of an immune response if a response is elicited. ⋯ The majority of anti-toxin antibodies do not affect its function. Finally, although crossreactivity has been reported among the seven botulinum toxin serotypes, non-neutralizing antibodies are present that recognize regions of similarity among the serotypes. No cross-neutralizing antibodies have been described in patients administered any of the toxin serotypes.
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Randomized Controlled Trial Clinical Trial
Effects of a controlled exercise trial on pain in nursing home residents.
To report preliminary data relevant to the effects of an exercise and toileting intervention on pain among incontinent nursing home (NH) residents. ⋯ No significant changes in pain reports were attributable to exercise despite significant improvements in physical performance. In fact, there was a tendency for pain reports to increase with exercise. These preliminary findings suggest that exercise alone may be ineffective for pain management among incontinent NH residents. Care providers should consider that exercise to improve physical function may increase pain symptoms, requiring preemptive analgesia, other pain control strategies, or modified exercise techniques for this frail segment of the NH population.
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Chronic pain is a prevalent and costly problem. This review addresses the question of the clinical effectiveness and cost-effectiveness of the most common treatments for patients with chronic pain. ⋯ There are limitations to the success of all the available treatments. The author urges caution in interpreting the results, particularly in comparisons between treatments and across studies, because there are broad differences in the pain syndromes and inclusion criteria used, the drug dosages, comparability of treatments, the definition of "chronic" used, the outcome criteria selected to determine success, and societal differences. None of the currently available treatments eliminates pain for the majority of patients. Pain rehabilitation programs provide comparable reduction in pain to alternative pain treatment modalities, but with significantly better outcomes for medication use, health care utilization, functional activities, return to work, closure of disability claims, and with substantially fewer iatrogenic consequences and adverse events. Surgery, spinal cord stimulators, and IDDSs appear to have substantial benefits on some outcome criteria for carefully selected patients. These modalities are, however, expensive. Pain rehabilitation programs are significantly more cost effective than implantation of spinal cord stimulators, IDDSs, conservative care, and surgery, even for selected patients. Research is needed to identify which patients are most likely to benefit from the available treatments and to study combinations of the available treatments since none of them appear capable of eliminating pain or significantly improving functional outcomes for all treated.
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Spasticity is an abnormal increase in muscle contraction often caused by damage to central motor pathways that control voluntary movement. During clinical examination, spasticity manifests as an increase in stretch reflexes, producing tendon jerks and resistance appearing as muscle tone. There are many causes of spasticity, including demyelination from multiple sclerosis, congenital damage from diseases such as cerebral palsy, trauma to the brain or spinal cord, hemorrhage or infarction, and other pathologic conditions that interrupt neural pathways. ⋯ Botulinum toxin therapy may be particularly useful for patients with spasticity due to stroke, whose treatment can be tailored based on recovery of function over time. In addition, botulinum toxin therapy is safe for pediatric patients, including children with cerebral palsy, who may not be able to tolerate the cognitive side effects of oral medications. Results of studies evaluating botulinum toxin for the treatment of spasticity due to various causes are presented here.