Der Schmerz
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Numerous experimental studies have shown that systemic or regional administration of analgesics prior to a nociceptive stimulus results in a significant reduction of analgesic requirements compared with the administration of the same analgesic dose given after the nociceptive stimulus. This phenomenon is called "preemptive analgesia". Recently several clinical studies have been conducted to determine whether "preemptive analgesia" also occurs in humans. ⋯ Most studies have failed to show a significant reduction in postoperative analgesic requirements with preemptive analgesia. Even in studies with positive results the reduction in analgesic requirements was limited and without clinical relevance. Further studies should focus on the questions which analgesics and which administration routes might provide clinically significant "preemptive analgesia" and how long analgesia should be prolonged into the postoperative period.
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The analgesic effect of acupuncture in chronic gonarthrosis pain was studied in a placebocontrolled trial completed by 97 patients. Each patient was treated twice a week, receiving 10 acupuncture treatments in all. Before and after tee course of treatment all patients were examined by an unbiased independent examiner and the overall pain score was measured over 10 days using VAS scales; functional parameters (resilience) were measured with a modified Lysholm questionnaire. ⋯ After ten treatments the overall reduction in pain score was 47.5% in the verum group (follow-up 48.2%), and 26.1% in the placebo group (follow-up 26.1%). The results are statistically significant (P<0.05); they show that in gonarthrosis pain the analgesic effect of verum acupuncture exceeds that of placebo acupuncture. Measurement of the functional parameters according to the Lysholm score showed no significant change.
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Herpes zoster neuralgia and post-zoster neuralgia (PZN) are common disabling pain syndromes. While pain from acute herpes zoster is self-limited in most cases, as pain may disappear without treatment, post-zoster neuralgia is difficult to manage. Pathological findings in acute herpes zoster include infiltration of ganglia, demyelinization and loss of axons; yet the pathogenesis of pain remains largely unknown. ⋯ The same is true for specific zoster hyperimmunoglobulins and non-specific immunoglobulins; however, there are no definite results. In the future, controlled, double-blind studies on the effect of therapeutic measures in preventing postzosteric neuralgia need to be conducted. So far, the positive effect of sympathetic blocks in preventing the late pain complications of herpes zoster can only be suggested and recommended based on subjective experience.
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Pain and pain-related sympathoadrenergic reactions (hypertension, tachycardia) accompanied by nausea, vomiting and shivering are the most common side effects of recovery from anaesthesia. The alpha(2)agonist clonidine acts as a sedative, anxiolytic, antihypertensive, antiemetic, antisialogogue and decreases the incidence of shivering. Thus, we studied the effects of intraoperatively administered clonidine on the recovery period and the postoperative analgesic requirements in patients undergoing maxillofacial surgery. ⋯ Opiates are frequently used as analgesics after maxillofacial surgery, even though their most common side effect-respiratory depression, nausea and vomiting-are particularly dangerous in these patients because of the obstruction of the upper respiratory tract. Self-titration of the opiate dosage on demand can decrease the incidence of serious side effects. Clonidine administered intraoperatively caused a profound reduction in analgesic requirements in this study. Additional opiate administration in the postoperative period was unnecessary in nearly all clonidine-treated patients. The attenuating effect on sympathoadrenergic reactions leads to lowering of the rate-pressure product and may be of advantage for patients suffering from arterial hypertension, angina pectoris or bronchial asthma. The slower emergence from anaesthesia following clonidine administration is probably caused by double-blind study properties preventing full consideration of the decreased isoflurane requirements after clonidine.
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Quality assurance with regard to pain treatment is a major concern of the German section of the International Association for the Study of Pain (IASP). For this reason, efforts to reach a consensus on guidelines for diagnostic and therapeutic procedures have been intensified and include educational endeavours as a basis for state-of-the-art practice. The German IASP section has implemented a postgraduate educational programme on pain treatment for psychologists. ⋯ After completion of the training in psychotherapy, a certificate will be issued if the student fulfils the following requirements: (1) attendance at 150 classes on pain syndromes, their anatomical and physiological basis, and their medical treatment, psychological methods of pain assessment and treatment, and effective ingredients of psychological treatment for pain; (2) experience in the treatment of patients with chronic pain; and (3) submission of 10 reports on assessments and treatments of chronic pain patients under supervision. To ensure training on a regular basis, the educational programme is offered to members of the IASP jointly by the German IASP and the Academy of the German Psychological Association. A sequence of eight modules covering the curriculum is repeated at least every 2 years, thus permitting entry to the programme at any time.