Best practice & research. Clinical rheumatology
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Many soft tissue complaints are associated with the development of neuropathic pain. This pain is produced by pathophysiological processes that are different to the processes involved in the generation of the inflammatory or nociceptive pain more commonly encountered in soft tissue disorders. One of the consequences of this is that neuropathic pain can often be less responsive to standard analgesic therapies. ⋯ This chapter aims to outline some of the clinical features associated with neuropathic pain, the aetiological factors leading to its development and the evidence base (or lack) behind current treatment strategies. It will try to provide a rational approach to the management of neuropathic pain in patients with soft tissue disorders, particularly focusing on pharmacological management. Neuropathic pain is the focus of much current research activity, particularly pharmacological research, and this chapter will attempt to identify gaps in our clinical knowledge and highlight opportunities for further research.
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Low back pain is an extremely common patient complaint. Most cases resolve fairly quickly after the acute episode. However, a small but significant number of patients develop chronic low back pain; a persistent disabling condition. ⋯ Currently, it is difficult to find clinical guidelines on how best to manage chronic low back pain, and it remains a substantial treatment challenge for both physicians and patients. The causes, risk factors, prognosis and treatment strategies for chronic low back pain will be discussed in this chapter. The evidence regarding different pharmacological and non-pharmacological treatment modalities will be reviewed and a logical, focused treatment strategy will be outlined.
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Best Pract Res Clin Rheumatol · Jun 2006
ReviewAnkylosing spondylitis and symptom-modifying vs disease-modifying therapy.
The main objectives of medical therapy in ankylosing spondylitis (AS) are to relieve pain, stiffness and fatigue and to prevent structural damage. The Assessment in Ankylosing Spondylitis Working Group has proposed different domains with specific instruments to assess the efficacy of therapeutic agents classified as symptom-modifying and disease-controlling antirheumatic drugs. Non-steroidal antiinflammatory drugs (NSAIDs) are still the first-line treatment in the management of AS, and they are effective in controlling symptoms such as pain and stiffness and maintaining mobility in many patients. ⋯ Small studies have reported favourable results with intravenous methylprednisolone pulse therapy, but the effect is temporary. Pamidronate and thalidomide have been used in some preliminary trials but need further studies to assess their potential role in treating AS patients resistant or intolerant to other forms of treatment. Treatment with tumour necrosis factor blockers is not discussed in this review.
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In this review, we outline a rational approach to the complex problem of chronic idiopathic pain syndromes. We focus principally on musculoskeletal pain disorders and emphasize the differences between adults and children. ⋯ The evidence base for the interventions reviewed include both 'medical' and 'non-medical' approaches. Practical problems and issues are dealt with throughout the review in order to construct a pragmatic approach that the authors intend to be of everyday use to the clinician and allied health professionals.
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Best Pract Res Clin Rheumatol · Feb 2006
ReviewAcetaminophen or NSAIDs for the treatment of osteoarthritis.
Although non-pharmacological interventions are the cornerstone of osteoarthritis management, analgesics are an important component of treatment during the symptomatic periods of the disease. In this respect, current practice guidelines advocate the use of a simple analgesic, acetaminophen, or a non-steroidal anti-inflammatory drug (NSAID), given either systemically or topically as first-line or second-line drug therapies. The present paper aims first to assess the evidence for the efficacy and safety of these medications. Given the increasing importance of patient involvement in decision-making, the following key practical issue regarding acetaminophen and NSAIDs will then be addressed: 'which drug do patients prefer?' Regarding NSAIDs, a further question concerns the place for non-selective agents and cyclo-oxygenase-2 (COX-2) selective inhibitors (coxibs) in the light of new warnings and contraindications concerning coxibs in patients with increased risk of cardiovascular thrombotic events.