The Clinical journal of pain
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This paper provides a philosophical, historical, and clinical analysis of exaggerated pain behavior, focusing on the nature of the standards used to judge behavior as exaggerated. Malingering is understood as a special case of exaggerated pain behavior. Drawing upon the work of philosopher Ludwig Wittgenstein and psychiatrist-anthropologist Horacio Fabrega, I argue that these standards are primarily moral rather than scientific in nature. ⋯ The highly variable relation between clinical pain and tissue damage, as well as the common problem of medically unexplained physical symptoms in primary care, pose serious challenges to this strategy of illness behavior validation. It will remain necessary to triage suffering presented to health care providers into that which should be addressed in the medical setting and that which is better addressed elsewhere. But we need to discard pseudoscientific reliance on medical tests and develop new standards that are openly acknowledged to be moral and social in nature.
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Malingering is not a diagnosis. It is a behavior for which there are no established diagnostic criteria. Guidelines have been published according to which malingering might be suspected, but those guidelines do not discriminate between patients who are malingering and ones with genuine sources of chronic pain. ⋯ Negative responses do not exclude a genuine complaint of pain, for patients may have a source of pain that is not amenable to testing with diagnostic blocks. Diagnostic blocks have proved particularly useful in the investigation of spinal pain for which the cause is not evident on conventional medical imaging. They can also confirm or refute purported mechanisms of certain clinical features in complex regional pain syndromes.
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Comparative Study
Cost benefit analysis of neurostimulation for chronic pain.
To assess the healthcare utilization of patients with intractable chronic neuropathic pain treated with spinal cord stimulation and peripheral nerve stimulation and to provide a cost-benefit analysis. ⋯ The reduced demand for healthcare resources by patients receiving neurostimulation suggests that peripheral nerve stimulation and spinal cord stimulation treatment, although associated with relatively high initial costs, demonstrates substantial long-term economic benefits. Thus, neurostimulation should be considered as a viable option for the early treatment of patients with intractable chronic neuropathic pain.
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Comparative Study
Blood supply and oxidative metabolism in muscle biopsies of female cleaners with and without myalgia.
Pathomechanisms of work-related myalgia are poorly understood. Myalgia is thought to be caused by excitation of nociceptors present in the muscular tissue but not in the muscle fiber itself. Muscle contraction in combination with hypoxia is known to excite nociceptors. Morphologic analysis can contribute to the knowledge of the excitation of nociceptors. This study thoroughly examines the morphology of the trapezius muscle's capillary supply and signs of disturbed oxidative metabolism to understand their role in work-related myalgia. ⋯ This work indicates that the capillary supply of trapezius is affected in work-related trapezius myalgia. More studies are needed to understand possible mechanisms that would explain the occurrence of moth-eaten fibers.