Der Schmerz
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The European Association for Palliative Care (EAPC) considers sedation to be an important and necessary therapy option in the care of selected palliative care patients with otherwise refractory distress. Prudent application of this approach requires due caution and good clinical practice. ⋯ Procedural guidelines are helpful to educate medical providers, set standards for best practice, promote optimal care and convey the important message to staff, patients and families that palliative sedation is an accepted, ethical practice when used in appropriate situations. EAPC aims to facilitate the development of such guidelines by presenting a 10-point framework that is based on the pre-existing guidelines and literature and extensive peer review.
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In 2009, the German version of ICD-10 (ICD-10 GM version 2009) introduced the diagnosis of "chronic pain disorder with somatic and psychological factors", because current ICD-10 diagnoses did not address the biopsychosocial character of chronic pain adequately. For most patients, a dichotomous classification into psychologically versus biomedically caused pain is inappropriate and does not reflect current knowledge on pain. The new code F45.41 addresses the relevance of psychological factors for chronic pain persistence and chronic pain treatment, even in those conditions with a clear biomedical cause at the beginning. ⋯ The distinction of this new diagnosis from other pain-associated diagnoses and recommendations for the coding of comorbid conditions are presented. The differentiation of everyday pain symptoms from pain disorders is outlined. Finally, contextual factors of the classification process, as well as problems in integrating this new diagnosis into diagnosis-related group (DRG) systems of financial reimbursement are discussed.
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Biofeedback is a direct feedback of a physiological function. The aim of biofeedback is to change the physiological function into a required direction. To manage this, the physiological function has to be fed back visually or acoustically and it has to be perceived consciously. ⋯ Biofeedback has proved to be successful in non-medical treatment of pain. According to more recent meta-analyses biofeedback reveals high evidence in the treatment of migraine or tension-type headache. In these headaches biofeedback procedures are considered highly effective.
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Neuropathic pain syndromes are characterised by the occurrence of spontaneous ongoing and stimulus-induced pain. Stimulus-induced pain (hyperalgesia and allodynia) may result from sensitisation processes in the peripheral (primary hyperalgesia) or central (secondary hyperalgesia) nervous system. The underlying pathophysiological mechanisms at the nociceptor itself and at spinal synapses have become better understood. ⋯ These mechanisms include reorganisation of cortical somatotopic maps in sensory or motor areas (highly relevant for phantom limb pain and CRPS), increased activity in primary nociceptive areas, recruitment of new cortical areas usually not activated by nociceptive stimuli and aberrant activity in brain areas normally involved in descending inhibitory pain networks. Moreover, there is evidence from PET studies for changes of excitatory and inhibitory transmitter systems. Finally, advanced methods of structural brain imaging (voxel-based morphometry, VBM) show significant structural changes suggesting that chronic pain syndromes may be associated with neurodegeneration.
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Neuroplasticity is the ability of the central nervous system to induce functional and microstructural changes in order to adapt to a new environment. However, so-called maladaptive neuroplasticity can also bring disadvantages, such as reduced inhibition of input signals, one of the suspected causes of chronic pain. With the method of repetitive transcranial magnetic stimulation (rTMS) a technique has been developed that makes it possible to study cortical excitability changes in the human brain non-invasively over a long time. ⋯ In phase II trials its efficacy has been demonstrated. Ongoing studies are focusing on management of the placebo effect; however, it is easier to control this effect in tDCS compared to rTMS. Phase III trials are currently in preparation.