Current pain and headache reports
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Curr Pain Headache Rep · Jun 2001
ReviewFacilitating cancer pain control in the home: opioid-related issues.
The basic principles of pain management are the same whether the patient is in an acute care setting, their home, or a long-term care facility. Wherever the setting, pain management is part of the comprehensive care for the cancer patient. Successful therapy depends on a clear definition of treatment goals, an informed patient and family, collaboration and effective communication between the physician, home care nurse, patient and family, and ongoing monitoring to ensure effectiveness of pain relief measures. Careful discharge planning to ensure appropriate home care for the patient with pain and their family is critical.
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Most patients who have been diagnosed with cancer will experience pain at some point during the course of their disease. Often, opioid analgesics are not enough to completely alleviate the patient's pain and the selection of appropriate adjunct analgesic agents is critical. This article reviews the mechanisms of action and analgesic effects of several classes of antidepressants to enable the clinician to select the appropriate agent for the patient.
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Complex regional pain syndromes (CRPS) (formerly reflex sympathetic dystrophy and causalgia) are neuropathic pain conditions that are initiated by an extremity trauma or peripheral nerve lesion. Clinical definition and scientific understanding of CRPS are still evolving; however, both the clinical picture and therapeutic options are significantly influenced by a dysfunction of the sympathetic nervous system. Recent investigations suggest functional central abnormalities and a peripheral inflammatory component in the pathophysiology of CRPS. Interdisciplinary treatment includes physical, pharmacologic, and invasive interventional therapy, as well as stimulation techniques.
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Quantitative sensory testing (QST) refers to a group of protocols that allows for quantitative measures of somesthetic function. Several protocols evaluate perceptual threshold, whereas others evaluate perception of stimuli above threshold. Each protocol has its own advantages and disadvantages, but one must always weigh a trade-off between accuracy (with longer protocols) and expediency (with shorter protocols). ⋯ QST studies, using either neuropathic pain patients or healthy volunteers who have been rendered temporarily hyperalgesic, have demonstrated that pain abnormalities can be modality specific. The fact that various pain abnormalities can exist independently of each other suggests that (at least partially) different neuropathologic processes are responsible for each one. Current research suggests that both peripheral sensitization and central sensitization play a role in these abnormal pain conditions, and identification of precise neuropathologic mechanisms is under active investigation.
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Neurostimulation methods for control of chronic neuropathic pain have recently gained in popularity. The reasons for this are multifactorial. As opposed to nerve ablation, these methods are minimally invasive and reversible. ⋯ DBS is reserved for carefully selected patients in whom the other treatment modalities have failed. In a minority of patients the "tolerance" to neurostimulation develops after long-term use. Further research is needed to establish better outcome predictors to neurostimulation and possibly improve patient selection criteria.