Articles: chronic.
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Epidural or intrathecal opiate analgesia, combined with bupivacain by means of an implanted pump, represents a possibility for providing good pain management for cancer patients as well as other chronic pain patients. Several indications, for implantation of a percutanously refillable pump are demonstrated in 27 patients. Twenty-four patients were treated with epidural and 3 with intrathecal catheters. ⋯ In the course of 2 years there has been no significant increase in the daily dose of buprenorphin given epidurally to patients with chronic pain. There were no addiction problems with opiates given epidurally or intrathecally by means of implanted pumps. Because of a 13% complication rate, pumps and epidural or intrathecal catheters should only be implanted by an experienced team.
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Psychodynamic concepts postulate a psychogenesis of physical pain proposing several assumptions about the conversion of mental suffering into physical pain. Behavioural concepts, on the other hand, emphasize psychological conditions as risk factors for chronicity and describe psychological reactions to chronic pain. Patients with painful diseases and inadequate coping strategies very often display symptoms of anger, anxiety, or depression. ⋯ Subjects included in the study were given diagnoses of low back pain, tension headache, rheumatoid arthritis, and ankylosing spondylitis. Treatment effects in different diagnostic groups were compared to each other, supporting the assumption that pain reduction is greatest in low back pain and least in ankylosing spondylitis. Subjects with inflammatory rheumatic diseases showed some improvement in self-reported physical complaints and in their feelings of well-being.
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Oral medication is the simplest way in treatment of chronic pain. For cancer pain oral analgesics are efficacious in more than 90% of the patients. When a causal therapy of pain (e.g. chemotherapy, operation) fails an analgesic ladder with oral analgesics is instituted. ⋯ In any state of pain the response to the different groups of drugs should be evaluated first. Then a stepwise pharmacological approach should be performed. In most cases pain can be treated effectively by oral drugs.
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Present-day hypotheses about the origin of pain in deep tissues are based on the idea that pain is anindependent sensation with its own specialized apparatus of sensors, conduction pathways and centers. The sensors are callednociceptors ornocisensors, and the neuronal structures they activate are thenociceptive system. Accordingly, the reception, conduction and central nervous processing of noxious signals together are termednociception. ⋯ Finally an account is presented of pain produced by excitation of the nociceptive system proximal to the nociceptors. These pain states include pain resulting from pathophysiological impulse generation in nociceptive fibers (neuralgia orneuralgic pain) which usually projects into the region containing the sensory endings of these fibers (projected pain). Furthermore, brief descriptions of pain due to spinal root compression and ofcentral pain arising from various sites of the central nervous system are given.
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Pain is the leading symptom of inflammatory joint diseases. It is immediately caused by the release of prostaglandins (and potentially leukotrienes) from cells of the inflamed tissues, which sensitizes the pain receptors. The synthesis of these mediators depends on the activation of infiltrated inflammatory cells, as well as recruitment of tissue born cells, predominantly by the inflammatory cytokines Interleukin-1 (IL-1) or tumor necrosis factor (TNF). ⋯ Anti-inflammatory drugs as the glucocorticoids predominantly decrease the synthesis of cytokines, and thereby the stimuli leading to prostaglandin synthesis. Together with a decrease of the synthesis of arachidonate metabolizing enzymes this leads to correction of pain. Although not directly analgetic, immunosuppressive drugs, too, by decreasing the immune reaction dependent inflammation, contribute to pain relief.