Articles: chronic-pain.
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Within a prospective longitudinal study of 111 patients with acute radicular pain and lumbar disc prolapse who underwent conservative or surgical treatment, we examined the importance of specific pain coping strategies, which have received little attention in psychological pain research: appeals to "stick it out" on the cognitive level and endurance strategies on the behavioural level. Prior to treatment we conducted a psychological and neurological examination. The psychological tests included the Kiel Pain Inventory (KPI) and the Beck Depression Inventory (BDI). ⋯ Patients in group A were a specially high risk group: at the time of discharge they had no pain, but from the first week after discharge up to the 6-month follow up they had increasing pain. Additionally at the 6 month follow up they seemed less likely to return to work and 8 times more of them had applied for early retirement than in the groups of patients without psychological risk factors. The results suggested several suggestions for modification of medical and psychological therapy for chronic pain patients.
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Our knowledge of the risk factors involved in the process by which acute pain becomes chronic has improved. Psychological conceptualizations of chronic pain presently include (1) the pain-tension cycle, with special reference to a diathesis-stress model, (2) the operant conditioning model, and (3) the interrelationship between vulnerability to pain attacks on the one hand and body posture, gait and activities of daily living on the other. With reference to these conceptualizations and to psychological procedures for the enhancement of self-management strategies, a low back school was implemented at the worksite as a preventive measure. The target population is characterized by (1) rare but recurrent pain episodes, (2) mild pain that has had little impact on daily activities, and (3) pain contingent on particular activities or situations. LOW BACK SCHOOL: A low back school called "Turn your back on backache" consists of the following elements: (1) analysis of labour conditions and adaptation of the worksite to the person, (2) relaxation and stress management, (3) training of posture, gait, and activities of daily living, and (4) stretching and stengthening of the muscles involved. The programme comprises 12 2-h sessions and is conducted by a physiotherapist according to a manual, after an introduction to self-management procedures including behavioural training for working with groups. For homework, participants are asked to practise the exercises demonstrated. ⋯ (1) A back school training for the worksite results in a decreased frequency of back pain episodes and an increase in reported health status and wellbeing. (2) The effects of behavioural training of posture, gait, and activities of daily living in hospital staff are clearly demonstrated by observational methods. (3) Assuming that present posture, gait, and daily activities are interrelated with future pain conditions, an increase in the exercise of adequate behaviours indicates a preventive effect of the back school programme.
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Prolonged administration of morphine for the treatment of chronic pain causes constipation requiring the use of laxatives, which may result in electrolyte deficits. Morphine-induced constipation is due to the binding of the drug to opioid receptors in the gastrointestinal tract and the brain, where it mimics the actions of enkephalins. The effect on the gastrointestinal tract seems to be more intense than the central effect. ⋯ Provided that the anatomical organization of the haemorrhoidal veins in the rat is similar to that in man, slow-release naloxone will be carried by the matrix, to which it is absorbed further down in the gastrointestinal tract. It may thus even reach the rectum, from where, after having been absorbed, it bypasses the liver, enters the central nervous system and reduces the antinociceptive effect of morphine. In conclusion, it can be stated that oral administration of naloxone in combination with morphine may help to prevent constipation during the treatment of chronic pain.
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Despite regular administration of analgesics, a high percentage of patients with chronic malignant pain experience break-through cancer pain or incident pain. Such pain peaks in patients with chronic malignant pain require "rescue" medication in addition to basic analgesia with for example slow-release morphine or buprenorphine. For rescue medication a fast acting and powerful analgesic should be available to the patient. Recent studies have shown that intranasal fentanyl provides rapid onset of pain relief. ⋯ The patients received 2, 4, 6, 7 or 8 fentanyl boluses (totalling 0.054 mg, 0.108 mg, 0.162 mg, 0.189 mg or 0.216 mg, respectively). Rapid onset and marked reduction of pain intensity was achieved in all five patients. There were no clinically relevant changes in arterial haemoglobin oxygen saturation, heart rate, arterial blood pressure or respiratory rate. All five patients scored the pain relief obtained as good or very good. There were no reports of pain or burning sensations in the nose or other side-effects.
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The spectrum of perioperative pain treatment is discussed in the present review. The analgesic efficacy of various drugs and the dosage methods of administration and side effects reported for them in such reference works as the practical guide on the management of acute pain recently published by the International Association for the Study of Pain (IASP) are described. Effective postoperative analgesia can diminish stress reactions following surgery. ⋯ Investigations performed by the author of this review have shown that epidural infusion of highly diluted mixtures of bupivacaine/fentanyl is highly effective in the analgesic treatment of patients undergoing prostatectomy, providing excellent physical mobilization. The potential dangers of drug combinations and contraindications are also discussed. The concept of using balanced analgesia to induce additive or synergistic effects following the administration of analgesic drugs requires further clinical studies.