Permanent End To Chronic Pain

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Parental Chronic Pain and Its Impact on the Children

Direct evidence for any relationship between parental chronic pain and negative health consequences for children is, at best, tentative (Chun et al., 1993 Dura and Beck, 1988 Mikail and von Bayer, 1990 Raphael et al., 1990 Rickard, 1988 Roy et al., 1994). This body of literature is discussed briefly here. It is, however, noteworthy that it is almost impossible to draw any firm conclusions on the prevalence of psychological and health problems in the children of chronic pain sufferers. Some of these issues are further discussed in Chapter 8. Dura and Beck (1988) compared many aspect of family functioning of children living with chronic pain parents, diabetic, parents, and healthy parents. Children of mothers with chronic pain demonstrated some evidence of depression and psychological disturbance compared with the other two groups. A most important point of note was that all there groups of children scored well below the clinical range on the depression scale. Simply stated, all three...

Motivation For Cell Transplantation Therapies In Chronic Pain And

Chronic Pain Despite improvements (1) in surgical management, physical therapy, and the availability of pharmacological agents with a variety of delivery systems, many patients following peripheral and central neural injuries continue to suffer from intractable chronic pain (2). Although opioids are the most commonly used agent to control pain, only about 32 of patients receive any significant relief with long-term use (3). This often leads to untoward effects associated with tolerance, tolerability, drug diversion, and other side effects (4), including opioid-induced neurotoxicity. Nonopioid medications can attenuate some types of neuropathic pain but seldom remove the painful sensation completely (5). Recent attempts at classification of neuropathic, nociceptive, and other pain, aided by an IASP Taskforce (6), has helped the understanding of mechanisms and improvement of better treatments for chronic pain. Yet, with the frequency of inadequate or failed clinical trials, especially...

Parental Chronic Pain and Illness and Its Effect on Children

Depression and anxiety disorders are relatively common in the chronic pain population. The negative impact of parental, especially maternal, depression, has been shown to be psychologically harmful for children. In a review of the literature on maternal depression and its effects on children (Roy, 2001), I concluded that, in general terms, younger children are more at risk than older children, and that children of depressed parents are vulnerable to childhood and later depression as well as wide-ranging psychopathology and behavioral and social disturbances. The reasons for the vulnerability of the children are not always clear. It is conceivable that major mood disorders have a genetic basis, thus making the offspring susceptible. Parental bonding may be loosened the well-parent's attention may be diverted away from child care (our case illustrations will demonstrate this factor). Both of these factors have considerable power to create emotional disturbance in children. A few studies...

Partner Abuse and Chronic Pain

The relationship between abuse and pain has a time-honored link. Pain is used to convey anger, frustration, loss, and many other emotions. One aspect of the abuse-pain relationship that has received sustained attention from researchers and clinicians is the possible link between childhood abuse and adulthood chronic pain. This chapter focuses on the critical issue of partner abuse and pain. Home is not a safe haven for many women, but this issue has been grossly neglected in the family-pain literature. In this chapter we rectify this oversight by reviewing the literature on spousal abuse and its health (nonpsychiatric) consequences, with special attention to painful conditions, and by using case illustrations of women who were in abusive relationships at the point of referral to a pain clinic, which complicated their clinical presentation. Interventions with this type of patient are discussed.

Cannabis Use in Chronic Pain

Many patients self-report their use of cannabis for the relief of their chronic pain and a record of these has been kept recently. Two specific observations have been made. Firstly, a significant number of these patients have spinal pain as a result of trauma. The injuries have never been severe enough to cause neurological damage. However, all have experienced soft tissue damage and including one with a vertebral crush fracture. A common feature has been a combination of muscle spasm, excessive superficial spinal tenderness (hyperalgesia, allodynia) and lack of sleep.

The Impact of Chronic Pain on Marriage and Family

The global impact of chronic pain was borne out by a survey of 4611 individuals (Smith et al., 2001), in which 14.1 reported significant chronic pain and another 6.3 severe chronic pain. The presence of any significant and severe chronic pain had progressively more marked adverse effects on employment, daily activities, and all measured dimensions of general health. The scope of the pain problem is illustrated by a recent survey that reported that 43 of households have at least one family member with chronic pain (King, 2003). In a telephone survey of 2012 adult Canadians, chronic noncancer pain was reported by 29 of the respondents. Almost half were unable to attend social and family events, and the mean number of days absent from work in the past year due to chronic pain was 9.3 (Moulin et al., 2002). The impact of chronic pain on the general welfare of the family is substantial. A Dutch study revealed that as a result of chronic pain in a partner, spouses invested more time on...

Chronic Pain

There are a number of chronic pain syndromes commonly seen in pediatric offices and clinics. Chronic pain is traditionally defined as pain existing recurrently or consistently in the previous 3 months (8). The American Pain Society has added to that definition that chronic pain, in contrast to acute pain, rarely is accompanied by autonomic arousal (90). Chronic pain is a remarkably frequent occurrence in children and has an overall prevalence ranging between 15 and 25 . Girls tend to have more chronic pain than boys (30 vs 19 ). Chronic pain in childhood seems to peak between 12 and 15 years, but it is still significant in children as late as 16-18 years (91). Typical chronic problems are headache, abdominal pain, and limb pain. Of children who report chronic pain, 50 have pain in multiple sites, and the incidence of multiple pain sites increases with age. In children who have multiple pain sites, the most common combination is headache and abdominal pain, which occurs in 25 of all...

Pain from disease chronic

Sometimes pain from an acute disease situation can fail to be cured and enter into a long-term or chronic state. This is usually defined as pain that continues for more than three months. Pain from bones, joints and the lower back in particular are common types under this heading. It can be associated with an injury as perhaps in some low back pain, or in some cases of low back pain there may be no obvious damage (CSAG 1994). There may be general wear and tear linked with disease as in arthritic or rheumatic conditions. There may be disease of the nervous system itself causing chronic pain, and some headaches can be chronic (Schoenen et al. 1994). Neurogenic pain is associated with damage or disease of the nervous system and this can lead to a very severe burning kind of pain which is very difficult to treat. Types include causalgia, various neuralgias, and even phantom pain, although this latter is still a great mystery (Melzack and Wall 1996). The management of chronic pain often...

Motivational aspects of pain

The person experiencing pain is motivated to do something about it, if possible. The obvious example is to avoid or withdraw from the painful stimulus. Another approach is to determine to cope with it if it is impossible to avoid or withdraw. The person then uses a variety of coping strategies. For example, in a study of chronic pain

Frustration of need or motivation

This sense of being helpless or that the chronic pain situation is uncontrollable by the sufferer has a reciprocal effect on the motivation to cope, or to learn about the situation. It is a perception of the situation by the sufferer and the person will feel like withdrawing from the situation, and become listless and lethargic. There may be feelings of worthlessness and perhaps a sense of loss or bereavement. The symptoms do seem to be similar to those of depression, and the feelings of helplessness may be associated with those of depression. However, the main symptom experienced by the person with the chronic pain is one of not being in control, of being at the mercy

Motivation and control

The question of motivation is also related to a sense of self-efficacy (Bandura 1977), and feelings of being in control (Wallston 1989). The person in pain, particularly in chronic pain, may or may not feel in control of things. If the drive to cope with the painful experience is not successful, or is frustrated or means that the sufferer is dependent on others, then the sense of being in control may be lost. However, some people tend to respond to stress by feeling that they can deal with the situation, that they are responsible for their circumstances, that it is up to themselves to do something about things. There are others who tend to feel that they are not responsible, that others, more senior, more qualified, are in control and therefore they must wait until these powerful others 'in control' (and this may include beings such as 'God' or other supernatural entities or forces, even luck) do something about the situation. Chronic pain by definition is long term. It is...

The patients experiences Communication

In the chronic pain situation, the meaning of the pain for the sufferer has particular relevance to the social setting. In terms of pain behaviour, the sufferer will be entered into particular relationships with professionals, and his or her behaviour will reflect the patient's perception of these relationships and roles (Strauss et al. 1963 Goffman 1974, and for a critique, Brooking 1986). This perception of the relationships and roles can influence the beara-bility of the pain and even its perceived intensity.

Influence of pain on social relationships

The pain will affect such people through the roles that are played by the person within these groups or with the particular people. The roles and relationships may have to be changed, such as with a husband or wife, or of an adult with an elderly parent. A relationship of dependency may change in respect to the degree of disability or incapacity created by the chronic pain. A child may be more dependent on a parent a parent may become dependent on an older child an older person may be dependent on an adult son or daughter and an adult son or daughter may become dependent again on an older parent. There will be emotional aspects to these changes also, with psychological distress, depression, and even anger and hostility being experienced or expressed. Work relationships and other social, community relationships may also be affected in terms of the roles held or the parts played in the various activities associated with these groups. Roy (1985) has given some excellent case examples of...

Social learning theory

Kelly (1955, 1991) built this model into a successful therapeutic process to help people cope with their relationships. Large and Strong (1997) have used Repertory Grid Technique to explore the meaning of coping for chronic pain patients, who found it a necessary evil (see Beail (1985) for examples including education and management).

Roles and pain behaviour

There are two main effects on role brought about by chronic pain. The main effects are of course in relation to those closest to the person in pain, and those for whom he or she plays an important role or spends a lot of time. These are effects on family structure and function, and effects on employment. The closest relationships are usually with the family (Roy 1992). However, some people can become very close to work mates or colleagues, as much time is spent with them and if working in stressful conditions, the degree of interdependence can be very great and, in particular, involve emotional dependence. This is often experienced at the time of retirement when the 'loss' of work and the relationships with mates or colleagues can be quite severe. If the loss is due to leaving work for reasons of illness and in particular chronic pain, then the fact that the pain has caused this loss can influence the attitude towards the pain. A sense of isolation can be very detrimental in the...

Socioeconomic aspects of pain

When one considers the number of people in chronic pain, the socioeconomic effects do not only involve the cost of compensation and benefit. There is also the lost productivity, in terms of work or of family support of work in terms of the effect on the family of the pain (Latham and Davis 1994). Estimates of the incidence of chronic pain in the USA for example include 23 million suffering from back ache and 24 million suffering from headache (Brena and Chapman 1983 Escobar 1985). Bonica (1974) estimated nearly 35 percent of Americans were affected by pain. Schmitt (198 5), estimated that 80 per cent of visits to physicians were for low back pain. Costs as high as 50 billion have been suggested (Schmitt 1985 Turk et al. It has been suggested that up to 45 million working days are lost because of back pain each year with treatment for this condition costing approximately 193 million each year (Rigge 1990 and more recently confirmed by Waddell 1996). Following a recent review of the...

Cognitive evaluation and pain

Ciccone and Grzesiak (1984) have identified eight types of schemata created or used by people with chronic pain. There is the awful nature of the experience being under external control mislabelling somatic sensations cognitive rehearsal the importance of self-efficacy immediate gains rather than those in the longer term poor opinion of self injustice. The creation or formulation of schemata depends very much on the situation as interpreted by the individual. Expectations are important (Anderson and Pennebaker 1980) in labelling the symptoms or feelings. Pain schemata can be more clear or memorable than others (Morley 1993), consisting of all sensory information including social factors and personal meaning (Katz and Melzack 1990). They are particularly vulnerable to the media, as are many illness representations. These may not be medical diagnoses, but they influence the behaviour (Leventhal et al. 1988).

Lifestyle

The person suffering from chronic pain has to face the prospect of long-term changes to their lifestyle, which may become very limited. This limitation may very well affect their partners or family who will also be influencing the sufferer's reaction to the pain. These psycho-social factors and also cultural factors may be very powerful indeed and treatments or interventions will be viewed through these influences. There may well be economic consequences to the chronic pain, in terms of lost or reduced opportunities to work. Issues of compensation and litigation may compound the issue (Skevington 1995 Melzack and Wall 1996). The sense of self-worth associated with being a productive independent person will be affected. Self-esteem or lack of it can be very influential in determining an individual's reaction to chronic pain. Ability or desire to cope constructively with the pain may be reduced if a sense of low esteem, depression, loss of

Conclusion

We are never dealing with Mr or Mrs Average. There are no standard reactions to a pain-producing experience. There may be certain principles that can be applied as we attempt to identify individual needs in people suffering from pain and as we attempt to help them gain relief. Indeed there can be tendencies to react in a particular way, as demonstrated by a qualitative study involving interviews with chronic pain patients (Carson and Mitchell 1998). Three themes were identified from the analysis. The first indicated that patients felt that the pain wore them down, but that they felt that they should get on with it and make do. The second theme dealt with the tendency to tell and yet also not to tell about the pain experience. The patients tended to reveal themselves differently to different people. The third theme was about the role that hope for relief plays in enabling the sufferers to carry on.

Positive emotions

The person with chronic pain will be particularly prone to depression (Romano and Turner 1985). Chronic pain has such a powerful effect on the whole person, that it can invade all aspects of his or her life and lifestyle. Such people may not be catastrophisers but they will be anticipating or reviewing the long-term implications of the pain, and its relative unmanageability. Their thinking will be dominated by the pain and its implications. This may lead to a sense of low esteem and worthlessness which can have a very marked effect on coping or a desire to participate in rehabilitation. There may also be a tendency to cognitive distortions, associated with the depression. There are unrealistic expectations or fears about the situation. The chronic pain sufferer may be concerned about future employment or social relationships or they may anticipate deterioration in family relationships as he or she anticipates becoming more and more of a burden to the rest of the family (Roy 1992)....

The meaning of pain

The second kind of meanings are biological. Here the meaning of warning is embodied in a current international definition of pain (IASP 1979). However, as we have noted above, some pains do not seem to be related to any symptom or sign of disease or injury. Alternatively, the pain may be much too late in the progress of a disease to be a warning. This is particularly the case in chronic pain. It is difficult to see the value of such pain, other than perhaps in terms of the philosophical or religious meanings. The third kind of meanings are the social meanings or consequences of pain. These

Use in Prevention and Therapy

Because thiamin deficiency can reduce pain tolerance, supplemental thiamin may ease chronic pain. Thiamin may be effective in peripheral neuropathy,5 particularly in inflammatory nerve disorders (such as trigeminal neuralgia). It may also be effective in diabetic neuropathy.

Case of Chronic Headache

Christy, age 40, sustained head and back injury in an automobile accident, which was the beginning of her descent into chronic pain and disability. Orthopaedic, neurological, and radiological examinations were essentially negative. Yet, she developed a migraine-type headache along with chronic back pain, which in a relatively short-time rendered her a virtual invalid. Our literature review, confined to mostly systemic family functioning, will show that there is much evidence of family disruption in the face of parental chronic illness. On the other hand, this body of literature falls somewhat short of defining the optimum functioning of these families. Families of chronically ill patients do not favorably compare with well families, and yet the benchmark of comparison for these families is invariably with well families. What could be construed as healthy functioning for the Christy family in view of the low probability of this family's returning to Mrs. Christy's premorbid level...

What Is an Appropriate Reaction

Davies is not complicated, and her response to the dramatic decline in the family fortune cannot be viewed as extraordinary. We often encounter this type of response in the spouses of our chronic pain patients. Spousal response is further complicated by the absence of any cogent medical explanation for the pain and disability. This has consequences for the marital relationship.

Why Is My Husband So Angry

Elmer is illustrative of some of the far-reaching consequences that a partner's chronic pain problem can have on the health and well-being of the spouse. Prior to the onset of backache, Mr. Elmer was apparently an easygoing man, his marriage was satisfactory, and he was on the whole a caring partner and a father. Then this patient went through what can only be described as a dramatic personality change following the onset of his back problem. He withdrew almost entirely from all family activities, and periodically engaged in verbally abusive behavior, mainly toward his wife and occasionally toward the children. His wife became very fearful of these outburst and lived in fear of him. The family was confronted with serious financial problems. Mrs. Elmer had to contend with her fear of these outbursts especially when directed at the children. When seen at the pain clinic, she had the appearance of a person under great stress. She looked emaciated, and reported that she...

Clinical Implications

Development of hyperalgesia is associated with a decrease of potassium currents. Considering the importance of these channels in determining the resting membrane potential and neuron excitability, activators of potassium channels or enhancers of their expression are potentially interesting targets for treatment of chronic pain syndromes. While limited experimental evidence supports this concept, the widespread expression of these channels and their complex pharmacological properties still require extensive preclinical studies before this approach can be tested in humans.

Pain as a Solution for Sexual Problems

Finally, the intriguing case of a young man who developed serious headaches soon after his marriage, which actively interfered with his sexual activities. He had a lifelong problem with intimacy and was somewhat overwhelmed by his newfound marital responsibilities. Pain for him served the purpose of buying time. Pain or, for that matter, any other symptom is used in complex and multiple ways in interpersonal relations. The meanings and functions of pain are not always evident, but in the cases presented here, the use of pain to avoid sexual relations, whether by the patient or the spouse, was unmistakable. Chronic pain inevitably creates a multitude of problems, but it is equally capable of resolving long-standing difficulties including those with the sexual relationship.

Gonadal Hormone Modulation Of Visceral Pain

The preponderance of evidence suggests that females are more sensitive to pain than males and several chronic pain syndromes including IBS, fibromyalgia, and temporomandibular disorders are more prevalent in women than in men (197-199). Furthermore, nociceptive thresholds are lowest and pain responses highest during periods of elevated estrogen (199-204), strongly suggesting that sex hormones modulate pain sensation.

Pain Behaviors and Marital Relations

All patients suffering from chronic pain conditions engage in pain behaviors. Coping with pain often translates into avoidance of certain activities and engaging in others. A not so far-fetched example would be a patient who avoids lifting any heavy or even not so heavy objects, and spends a great deal of time in inactivity. These pain behaviors are frequently encouraged by a caring partner and other family members. Engaging in pain behaviors and their reinforcement by a partner led to the development of psychological intervention that attempted both to eliminate pain behaviors engaged in by the patient and to discourage the partner from supporting or reinforcing such behaviors. There are only a few reports of interventions with spouses, and they are discussed in Chapter 10. Chronic pain, as noted earlier, does not leave too many aspects of marital and family relations untouched. Because of its intractability and uncertain etiology, chronic pain has its own peculiarities. Not...

The Various Aspects Of Pain

Suffering is a consequence of pain and of lack of understanding by patients of the meaning of the pain it comprises anxiety and fear (particularly in acute pain) and depression (particularly in chronic pain), which will be affected by patients' personalities, and their beliefs about the significance of the pain, e.g. whether merely a postponed holiday, or death, or a future of disability with loss of independence. Depression makes a major contribution to suffering it is treatable, as are the other affective concomitants of pain. Pain behaviour comprises consequences of the other three aspects (above) it includes behaviour that is interpreted by others as signifying pain in the victim, e.g. such immediate and obvious aspects as facial expression, restlessness, seeking isolation (or company), medicine-taking, as well as, in chronic pain, the development of querulousness, depression, despair and social withdrawal. It is thus useful to distinguish between acute pain (an event whose end...

Mechanisms Of Analgesia

In addition to these opioid mechanisms, non-opioid mediated pathways, e.g. serotonin, are important in pain. There is suggestion that opioid mechanisms are more important in acute severe pain, and nonopioid mechanisms in chronic pain, and that this may be relevant to choice of drugs.

Pain Measurement by Methods Other Than Self Report

One of the formal behavioral observation tools is the Gauvain-Piquard scale developed for the measurement of chronic pain in children 2-6 years old with cancer. Fifteen items have a 0-4 scale with nine items specific to pain assessment, six indicative of psychomotor retardation, and four relating to anxiety are included in the revised version. A score greater than 12 of a possible maximum score of 60 is indicative of pain (22).

What Happens to Communication

This little vignette captures a very common pattern of communication, or lack thereof, between a husband and wife who care deeply about each other. Both partners compromise their willingness to discuss their respective feelings lest they should hurt the other. The price for such collusion of silence can be high. Over time, the quality and quantity of communication deteriorate, with far-reaching consequences. Chronic pain impacts negatively on family communication for another complex reason. It is often the elusive and incomprehensible nature of chronic pain itself that militates against healthy family communication. Family members are often confused by the level of disability in the absence of any definite medical cause. They are confused and angered, but their emotions, by and large, remain unexpressed. Faulty communication under these circumstances is not hard to comprehend. A brief review of the research literature follows to highlight the extent of communication problems among...

For Cellbased Interventive Therapies

Other potential interventive agents for the treatment of pain are based on current and developing strategies elucidated from recent research, especially concerning central spinal sensitization and the spinal mechanisms thought to be the origins and ongoing causes of chronic pain (31), even when the injury is peripheral in location (32). For example, persistent small afferent input, as generated by tissue or nerve damage, results in a hyperalgesia at the site of injury and a tactile allodynia in areas adjacent to the site. Hyperalgesia is the result of sensitization of the peripheral terminal and a central (or spinal) facilitation evoked by persistent small afferent input. The allodynia reflects a central sensitization, with excitatory neurotransmitter (e.g., glutamate and substance P) release, initiating a cascade of downstream Thus far, the vast majority of cellular transplantation approaches for chronic pain management have utilized the cellular minipump method. However, it is...

Heat Allodynia and Hyperalgesia in Fibromyalgia Patients

For example, heat hyperalgesia has been shown to be a prevalent characteristic of fibro-myalgia (22-25). Fibromyalgia is a common disease, prevalent in approximately 2 to 10 of the general population and it occurs predominately in females (26). The pathogenesis of fibromyalgia is unknown, although abnormal concentration of central nervous system (CNS) neuropeptides and alterations of the hypothalamic-pituitary-adrenal axis have been described (27,28). Fibromyalgia is a chronic pain syndrome, characterized by generalized pain, tender points, disturbed sleep, and pronounced fatigue. Pain in fibromyalgia is consistently felt in the musculature and may be related to sensitization of CNS pain pathways. Fibromyalgia patients also have heat allodynia hyperalgesia when tested with ramp-and-hold skin temperatures, as shown in Figure 2 (3). However, unlike CRPS patients, fibromyalgia and IBS patients are more likely to have diffuse pain within many body areas. Thus, their heat hyperalgesia...

Who Does What An Exploration of Family Roles

Today, many families have two wage earners, and this has necessarily loosened some of the former rigidities of gender roles. Only two decades ago most respondents disapproved of women trying to combine work and family roles, even though a majority of women worked outside the home. By 1996, however, attitudes and behaviors were more concordant, with respondents expressing more approving views of women's dual role (Brewster andPadavic, 2000, p. 480). The general trend toward a more egalitarian gender ideology has continued between 1985 and 1996, albeit at a slower pace than in the previous decade. Gender issues are an important point in any consideration of role performance of persons with chronic pain or chronic disease, as gender has quite an impact on the way roles are maintained, compromised, or discarded. but especially for women. This indeed has multiple repercussions for people's roles and for how these roles may be affected by chronic pain disorder in one partner. Leventhal and...

Modulation of Pain by the Autonomic Nervous System

There has been increasing evidence to suggest that the ANS may modulate visceral sensory perception, and sympathetically mediated mechanisms are implicated in several chronic pain syndromes (57,58). In addition, there are animal and human data supporting a vagally mediated inhibition of visceral nociceptive sensory inputs (59,60). Iovino et al. used lower body negative pressure (LBNP) to experimentally activate the sympathetic nervous system by inducing venous pooling in the lower extremities, and to determine the effects on the

Modulation of Pain by Genotypic Profile

It has long been noted that some individuals are more sensitive to pain than others for a diverse range of noxious stimuli (84-86), some respond better to analgesics than others (87,88), and some individuals develop chronic pain syndromes after inflammation or injury whereas others do not. This variation is incompletely explained by environmental and cultural factors and research has therefore focused on the possible role of genetic factors. Inherited genetic variability, in the form of different DNA sequences in different individuals (their individual genotype), determines their individual biological traits (phenotype) via the pattern and quantities of proteins translated from active genes. Although environmental factors cannot alter the individual's genetic make-up, they can alter the pattern of transcription and translation resulting in altered protein expression, and ultimately cell function.

Christopher Eccleston Hannah Connell and Nicola Carmichael

We argue that an option for a residential treatment setting is sensible in developed health care economies. First, an analysis of the public health study of chronic pain finds that there is no good public health evidence base for any adolescent chronic pain intervention. Second, a conceptual analysis is undertaken for why removal of adolescents from their normal environments may offer a useful therapeutic option. Third, examples of current residential models, including summer camps and residential treatments, are given, and a more in-depth description is given of the Bath Pain Management Unit in the United Kingdom. Fourth, further discussion is provided on the barriers that often arise when stakeholders in children's pain services attempt to persuade each other of the importance or otherwise of intensive treatments. Finally, advice is given regarding how to develop and sustain an evidence-supported chronic pain management service for adolescents in chronic pain. Key Words Adolescence...

Public Health Its for Our Own Good

For all centrally governed societies, population science is of tremendous importance. In theory, knowing the prevalence (the total number of cases present in a population in a given time) and the incidence (the number of new cases in a given time) should allow one to plan for the amount and type of resources needed to provide a viable response. In theory, if we know how many children have chronic pain within our population and how many are developing chronic pain, then we should be able to model how many will require health care provision. Similarly, if we have information on changes in incidence, then we can plan service delivery in the future. This is all relatively straightforward, then. But, how far is this realistic We do know how many children have chronic pain. Epidemiological studies have reported the prevalence of chronic severe pain as approx 25 , and relatively stable across a variety of developed health care economies. In a survey of 5424 Dutch children and adolescents, 54...

Leaders Experts and Enthusiasts

In the absence of a reliable population-based approach to chronic pain and because of the ostensibly silent problem of chronic pain in children and adolescents, the histories of new service development tend to have been idiosyncratic. We have seen a number of factors implicated in the development of new services. Perhaps the most commonly cited reason given is to respond to local need. However, treatments have also been developed to build and maintain the reputation of expert centers, to provide the base for research, for various organizational imperatives, such as the need to use (or lose) existing resources, because a wealthy or powerful donor required it, or maybe even simply to satisfy the empire-building tendencies of individuals. In some cases, local or national guidance has had an effect, but in many cases the roots of new pain services can be traced to individual or small group action. Chronic pain service developments are no different in this account from any other...

Evidence for Alterations in Descending Pain Modulation

Since the beginning of the 20th century it has been known that the brain can tonically inhibit spinal cord excitability, thereby regulating the amount of peripheral sensory information reaching the central nervous system. More recent evidence has demonstrated the activity of both pain-inhibitory and -facilitatory mechanisms that can tonically and phasically regulate spinal cord excitability (55,62,63). While top-down tonic pain-inhibitory modulation appears to predominate in healthy individuals, an upregulation of descending pain-facilitatory systems has been demonstrated in the maintenance of hyperalgesia in animal models of peripheral nerve injury (64). An alteration in the balance between inhibitory and facilitatory pain-modulatory systems has been proposed as a possible mechanism underlying chronic pain syndromes such as fibromyalgia (65) and IBS (66,67). Zambreanu et al. were the first to

What Happens to the Children

This chapter, a further elaboration of some of the issues discussed in Chapter 3, addresses the critical issue of the health and well-being of the children of chronic pain sufferers. To that end, we shall first revisit some of the literature discussed in Chapter 3, which shows that, in general, children are not unduly affected by a parental pain problem. This chapter also presents seven case illustrations four in which the children reacted badly and developed a variety of problems seemingly as a consequence of a parental chronic pain problem, and three in which the children showed minimal impact. The chapter then analyzes the reasons that might account for these different outcomes.

Initial Clinical Trials

Chronic Pain Numerous studies with rodent models of acute and chronic pain have suggested that adrenal chromaffin cells implanted into the intrathecal space, and in the periaqueductal gray, reliably produce significant analgesic effects (126,127). Although the majority of these studies have used unencapsulated cells, recent studies suggested that encapsulated cell implants also produce analgesia in rats. The analgesic effects of adrenal chromaffin cells in the rodent model have provided the rationale to pursue clinical trials in patients with chronic pain. Small open-label trials demonstrated that the implantation procedure was minimally invasive and well tolerated (128,129). Neuro-chemical and histological studies determined that the encapsulated cells survived and were biochemically functional for up to 1 yr. Because reductions in morphine intake were noted following implantation (suggesting efficacy), larger scale, randomized studies were initiated in a collaborative study between...

Visceral Hypersensitivity

Visceral hypersensitivity is thought to play an important role in the development of chronic pain in these patients however, what causes and maintains this hypersensitivity is still poorly understood. A review of the possible biological factors that may be involved in modulating visceral pain sensitivity will now be presented, following which evidence for their involvement in FGD will be discussed.

Clinical Use Of Agents

American Academy of Pain Medicine and the American Pain Society also advocate the prudent use of narcotic analgesics for the treatment of chronic pain (15,16). The widespread use of opioids in chronic, nonmalignant pain, however, is still somewhat controversial because of the lack of substantial evidence from long-term controlled studies demonstrating effectiveness in this setting (17). The clinical use of opioids in different types of pain and in different clinical settings has been reviewed in detail in a recent book (18). The World Health Organization (WHO) introduced a three-tiered approach for the treatment of cancer pain (19) that also serves as a model for the management of acute and chronic pain. In this model, the first tier consists of acetaminophen (APAP) or a nonsteroi-

Physical Health Consequences

Reports on chronic pain and spousal abuse are few, and most of them acknowledge that chronic pain is commonly observed in abused spouses and partners (Dienemann et al., 2000 Haber and Roos, 1985 Kendell-Tackett et al., 2003 Plichta, 2004 Rapkin et al., 1990 Woods, 2004). A few of these studies were designed specifically to determine if there is a direct relationship between abuse and pain. One of the early studies, Haber and Roos (1985), investigated 153 women attending a pain clinic 53 of these women reported abuse. Of these women, 78 were abused for the first time in their marriage. The mean duration of abuse was 12 years. In all cases pain problems followed incidents of abuse. This study was entirely based on patient interviews, and no standardized questionnaires were used. Yet the findings of this study cannot be dismissed, given the magnitude of the abuse uncovered. Dienemann and associates (2000) investigated partner abuse in 82 women with a diagnosis of depression. The subjects...

Psychophysical Studies Of Visceral Sensation

To determine whether uncontrolled clinical observations are indeed representative of responses evoked by visceral pain rather than a nonspecific characterization of chronic pain, psychophysical studies have been performed using controlled visceral and nonvisceral stimuli in both healthy subjects and those with clinical diagnoses of painful visceral disorders. Visceral stimuli have included chemical, electrical, thermal, and mechanical stimuli (15). Most studies have not attempted to compare responses to visceral stimuli with those evoked by cutaneous stimuli in a side-by-side comparison. An exception to this is a study by Strigo et al. (16), which directly compared sensations evoked by balloon distension of the esophagus with sensations evoked by thermal stimulation of the midchest skin. Using graded intensities of both distending and thermal stimuli, it was possible to match the intensity of evoked sensations produced at the two different sites. Consistent with clinical lore,...

The Residential Treatment Program for Adolescents

Given that centers of adolescent medicine are relatively rare, rarer still is the specialized center or treatment program for adolescents with chronic pain. There are good examples internationally of pediatric pain leaders winning and maintaining access to, or control over, general medical beds or delivering outpatient multidisciplinary pain management programs, but unusual is the dedicated residential program of treatments. A pioneer of this type of treatment program is David Sherry, a pediatric rheumatologist. Dr. Sherry and colleagues identified that the typical response of modern health care systems to an adolescent chronic pain problem was not achieving the desired outcome and in some cases may have contributed to suffering. He identified that a large number of children presented to outpatient pain or rheumatology clinics with complex regional pain syndrome type (CRPS)-1 (also known as reflex sympathetic dystrophy or algodystrophy). Adolescents typically present with a limb...

The Bath Pain Management Unit

The Bath Pain Management Unit is, organizationally, one-third of the Royal National Hospital for Rheumatic Diseases, National Health Service Trust. The small national hospital provides specialized services in chronic pain, rheumatic diseases, and neurorehabilitation. It is housed on the site of the original Roman In 1993, two senior rheumatologists identified that they needed to develop rehabilitation for adults with chronic pain and invited the first author to consult on its development. The Pain Management Unit (PMU) was developed to deliver specialist assessment of adults with chronic pain and a 3-week residential treatment program for adults with chronic pain (32). The PMU soon became self-governing and was organized, and remains organized, around a central principal encapsulated in its vision statement to enable people to reduce the impact of pain on their lives, and to influence society's attitude to pain. In 1998, a number of events collided with a serendipitous result. First,...

Amplification of Visceral Afferent Signals

There is growing evidence that visceral inflammation and injury can amplify activity in visceral pathways, as has been reported for postinfectious IBS (2) and other painful functional GI disorders (13). Possibly, either an increase in peripheral receptor sensitivity or an increase in the excitability of spinal or higher CNS pain regulatory systems may be responsible for producing a state of hyperalgesia (increased pain response to a noxious signal), allodynia (increased pain response to non-noxious or regulatory signals), and or chronic pain (14,15).

Psychological Distress and its Possible Role in Central Amplification of Pain

As noted, psychological disturbances are associated with greater pain severity and disability, and thus may serve as an amplifying factor to the pain experience, i.e., a CNS type of sensitization. So, while peripheral sensitization may influence the onset and short-term continuation of the pain, the CNS appears involved in the predisposition and perpetuation of pain, leading to the more severe chronic pain condition. As with case 2, L.J., this was evident by the lack of gut dysfunction associated with the pain and by the strong association of psychosocial disturbances and chronic pain behaviors. Empiric data support the idea that comorbid psychiatric diagnosis, major life stress, a history of sexual or physical abuse, poor social support, and maladaptive coping are associated with more severe and chronic abdominal pain and poorer health outcome (6,30-32). The relationship between psychosocial disturbances, emotional distress, and chronic pain may be mediated through impairment in the...

Interdisciplinary Team

The therapy team consists of a senior nurse, physiotherapist, occupational therapist, consultant pediatric rheumatologist, and consultant clinical psychologist. Research officers and students also work in support of programs. Assessment and access to the program are managed in a joint rheumatology psychology clinic. In the program, the team operates in a thematic interdisciplinary model in which skill sharing and task crossover are encouraged (within professional limits). The process is managed by the clinical psychologist. A larger backup team exists in the unit this team consists of other clinical staff working on adult programs, office staff working on maintaining communications or securing financial support for treatment, and research staff developing research on the measurement of chronic pain and on effective treatments for chronic pain.

Binary Concept Of Pain And Addiction

In reality, there is nothing about a real pain condition that is protective against having a concurrent substance-use disorder. Likewise, we now know that persons suffering from addictive disorders who are in methadone maintenance treatment (MMT) programs list severe chronic pain as a major problem (6). While there is no evidence in the literature to suggest that those patients without past histories or increased risk of substance-use disorders become addicted as a result of rational pharmacotherapy for the treatment of any condition, including pain, there is no credible evidence to the contrary (iatrogenic addiction''). Perhaps, a more relevant question to ask is whether rational pharmacotherapeutic management of acute or chronic pain can reactivate a previously dormant addictive disorder or express an as yet unidentified predisposition toward substance misuse or addiction. The answers to these questions clearly must be, Yes. Addiction is not an uncommon occurrence in the general...

Therapy Philosophy and Content

The core philosophy of the program is to promote developmentally appropriate behavior and normal health behavior despite chronic pain. For narrative purposes, the program is described as having three main themes. The third form of intervention is based on a mindfulness extension of traditional pain management relaxation. Again, for reasons that are beyond the limits of this chapter, relaxation has been largely replaced by mindfulness in this approach to chronic pain (38). By developing the skill of noticing but not reacting to the thoughts, physical sensations and emotions that are experienced moment by moment, cognitive vulnerability to stress, and emotional distress are reduced (39). The evidence base for relaxation in recurrent and acute childhood pain (particularly headache) is excellent for reducing the severity and frequency of episodes of pain (40). Mindfulness often has the side effect of relaxation, but it is more useful in chronic pain as a method for enabling people to...

Pain And Opioid Addictiona Continuum Approach

Case with opioids used for the treatment of chronic pain. Figure 1 shows diagrammatically this relationship. With chronic pain, appropriateness of ongoing opioid use may come into question, especially when there is little or no objective improvement in pain relief or function. In this case, the application of the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV) criteria for diagnosis of opioid dependence may lead to inappropriate diagnosis of addiction, potentially compromising patient care.

Behavioral Approach

In an extensive review of the literature, Newton-John (2002) made a number of valuable observations. Despite some limitations of the behavioral model, the research was broadly supportive of the operant behavioral paradigm on the spousal solicitous responses to pain behaviors. His conclusion was based on an analysis of 26 studies. The body of research, he noted, attested to the importance of the family, and the spouse in particular, in the etiology and maintenance of chronic pain disorders. However, he cautioned that the behavioral focus in patient-spouse research required expansion into broader domains. A relatively few reports on the efficacy of treatment designed to address the question of spousal role in the perpetuation of pain behavior have been reported in the literature. Moore and Chaney (1985) reported on an outpatient's couples group that was designed to investigate the effects of involving the spouses in a 16-hour cognitive-behavioral treatment program. Patients and spouses...

Basic Science Of Addiction

Tolerance is also a natural, expected physiologic response that can occur with exposure to certain classes of drugs, especially alcohol and opioids. Pharmacodynamic tolerance involves adaptations that occur at both the site of the drug action e.g., receptor, ion channel, and in related systems more distal to the site of the drug action. For example, pharmacody-namic tolerance to opioids is evident at both the level of the opioid receptor in the locus coeruleus (primary) and in the dopaminergic reward pathways afferent to the site of this discrete drug action (secondary) (15). Both persons addicted to heroin and chronic pain patients taking opioids can exhibit tolerance to certain effects of the drug.

Diagnostic and Statistical Manual of Mental DisordersIV

If one understands the correct definition of physical dependence, it is clear that the DSM-IV misuses the term dependence. By doing so, this has the effect of confusing a pain patient with one with the disease of addiction. Under the section Criteria for Substance Dependence,'' DSM-IV defines substance dependence as a maladaptive pattern of substance use, leading to clinically significant impairment or distress, as manifested by three (or more) of the following during the same 12-month period.'' It then lists seven criteria for determining if this disorder exists (Table 1) (21). Without differentiating between dependence and addiction, five of the seven criteria for substance-use disorder could apply either to a person with the disease of addiction or a chronic pain patient on opioids. (Table 2) Consequently, a pain patient on opioids may be misdiagnosed with the disease of addiction when he or she is physically dependent, which, as the definitions make clear, is a normal...

Universal Precautions In Pain Medicine

As we begin to gain an understanding of the prevalence of substance-use disorders within the chronic pain population, it has become clear that no one behavior is pathognomonic of addiction. With this in mind, the importance of carefully inquiring into drug and alcohol histories in all patients becomes evident. This information is vital to any clinician treating complex medical and psychological problems. Alcoholism, for example, is a disease that intrudes into many aspects of the care of affected patients seeking medical treatment. Unresponsive hypertension, intractable mood disorders, difficult interpersonal relations, and poor sleep are all part of the life of an untreated alcoholic. While the use of potent medications including opioids in such cases is likely to be more complicated than in a similar patient who is not afflicted with this disorder, the need for the treating health-care professional to explore issues related to drugs and alcohol is not because of a choice to...

Group Iii Specialty Referral

Group III represents the most complex and difficult population of patients to assess and treat. They are actively addicted and may be unable to see beyond their chronic pain condition. In the absence of concurrent assessment and treatment of the active addictive disorder, it is unlikely that even aggressive investigation and management of the pain complaint will lead to resolution of either the pain problem or the substance-use disorder. This group should be very tightly managed until they can be referred on to specialist assessment and care. While it is appropriate that the primary care practitioner manages the overall health of the patient, prescribing medications for pain may be inappropriate until the patient has sufficiently stabilized to qualify in Group II.

Federal Regulations For Prescribing A Scheduled Controlled Substance

One regulation governing the prescription of a controlled substance is that a lawful prescription must be issued for a legitimate medical purpose by an individual acting in the usual course of his her professional practice (21 CFR 1306.04). The clinician may administer, prescribe, or dispense a Schedule II controlled substance to a person with intractable pain, in which no relief or cure is possible or none has been found after a reasonable effort (21 CFR 1306.07). A chronic pain patient certainly falls into this classification. The clinician may treat acute chronic pain with a Schedule II controlled substances in a recovering narcotic-addicted patient (21 CFR 1306.07). Federal law or regulations do not restrict the prescribing, dispensing, or administering of a narcotic medication to a narcotic-addicted patient for the purpose of alleviating pain, if such prescribing is medically appropriate within standards set by the medical community

Focussing on symptoms and disengagement

Not only are disengagement coping strategies particularly maladaptive, but they also seem to distinguish CFS patients from others. Blakely and colleagues (1991) compared coping in CFS patients, chronic pain patients and healthy controls. The CFS group were significantly more likely than the others to use disengagement strategies in dealing with stressful situations.

Family Therapy Outcome

The literature on the merit of family therapy for health problems include studies on stroke (Clark et al., 2003), cancer (Keller and Jost, 2003 Sellers, 2000), diabetes (Hagglund et al., 1996 Satin et al., 1989), anorexia nervosa (Ball, 1999), and depression (Chase and Holmes, 1990 Clarkin et al., 1990 Lebow and Gurman, 1995 Stevenson, 1993 Waring et al., 1995). A comprehensive literature search failed to produce any controlled outcome study for family therapy and chronic pain disorders. However, there is one study that investigated the efficacy of couple therapy where both partners were victims of chronic pain (Boyd, 2001). The sample included five couples. Treatment outcome was analyzed from the participants' responses. This istudy is useful in understanding the emotional and relational needs when both partners are afflicted with chronic pain disorders. All the couples received eight sessions of therapy, and the outcome was generally positive. In an earlier study I reported on the...

Evidence Based Therapy

From a behavioral and cognitive model as from systemic one. This is a particularly critical observation. By broadening the base of family therapy, Carr (2000b) and others such as Pinsof and Wynn (1995) have systematically reported a high level of success with family therapy. Carr established evidence for the efficacy of family therapy with marital and family problems, psychosexual problems, anxiety disorders, mood disorders, psychotic disorders, alcohol abuse, chronic pain management, and family management of neurologically impaired adults. In his discussion on chronic pain management, he cited two references that may not be necessarily construed as family focused. Spousal behavioral reinforcement of pain behavior and its extinction is the focus of the work that Carr cites.

Some Further Thoughts

If this book has unifying theme, it is that in the face of enormous progress in biomedicine, the person behind the symptom or the syndrome tends to get lost. The person's social environment plays little or no part in major decision making, which can have serious consequences. A patient who suffers from cardiovascular disease and has bypass surgery is not likely to maximize the benefits of surgical intervention unless dramatic changes are also made in his lifestyle, ranging from trying to live in a low-stress environment to diet and exercise. In the context of chronic pain, a well-meaning spouse can undo much of the benefits that may accrue from treatment by reinforcing pain behaviors. Heightened tension in a family situation can have many consequences in the rehabilitation of such a patient. The family, even with all its problems, such as a high rate of divorce, still constitutes the most readily available source of support, and the value of social support in the recovery from illness...

Family Therapy Journals

The American Journal of Family Therapy had more articles on heath-related issues and family than any other journal including the medical and pain journals. However, not one article was in the category of chronic pain and family. Two nonempirical articles with some relevance had to do with psychotherapy with physically ill patients and clinical issues in treating somatoform disorders respectively (Navon, 2005 Walsh and Denton, 2005).

Sensory Neuron Specific Ca21 Channels

The contention that certain voltage-gated Ca2+ channels on sensory neurons are of relevance to visceral pain is based on the antinociceptive effect of gabapentin and pregabalin, two anti-convulsant drugs with high affinity for the a2d1 Ca2+ channel subunit in DRG neurons (197,202,203). Gabapentin and pregabalin are able to counteract the colonic hyperalgesia elicited by septic shock (204) and inflammation due to TNBSA (205). The writhing response to intraperitoneal injection of acetic acid is also inhibited by gabapentin (206). Since pregabalin does not alter the visceromotor response to distension of the normal colon (205), it is inferred that pregabalin-sensitive Ca2+ channels play a specific role in inflammation-evoked sensitization of GI afferents. Another Ca2+ channel targeted by analgesic drugs is the high voltage-gated N-type Ca2+ channel, which is of paramount importance for transmitter release. Inhibition of this channel by intrathecal administration of ziconotide affords...

And They All Lived Happily Ever After

All good fairytales end happily ever after, don't they Well, no, not always. Angela Carter reminded us that fairytales, even the ones with happy endings, always betray a hidden darker version of reality (45). Subtexts are nearly always also found that speak of secrets, shame, and lies of villains and weaklings dispatched without justice of hegemonic patriarchal morality banishing precocious attempts at usurpery and perhaps most pertinent to the current arguments, of grief and loss. Models of delivery of chronic pain management will come and go. In the absence of a strong public health argument for coordinated widespread treatment programs for adolescents with chronic pain, treatments will develop in isolated pockets, driven often by individuals, in temporarily supportive environments. What is missing, however, is any widespread change in the overall system to embrace these treatments as a standard or as a requirement. We are too often debating in response to the question should we...

Symptoms And Management

Most patients with cancer actually have several pains. Most have chronic pain with transient flares of acute pain.17 In approximately one-third, neuropathic pain will be prominent, though many will have a mixed pattern of neuropathic and nociceptive pain.18 Both the type of pain, pain intensity, and the temporal nature of pain govern the analgesic dosing strategy. Therapy needs to be individualized.19 20 Opioids should be used for moderate to severe pain.1920 Eighty percent of patients with severe pain will have pain controlled by morphine or other potent opioids. Opioid titration to response is a cardinal principle of treatment. An effective drug will be ineffective if underdosed potent opi-oids do not have a ceiling dose. Twenty percent of patients will require a complex approach to pain management of opioid (route) conversion, opioid rotation to an alternative opioid, opioid sparing (by adding an adjuvant analgesic), or maintenance of opioid dosing with simultaneous treatment of...

Family Reinforcement of Sick Behavior

No specific differences have been found between families of well children and those of children with chronic pain on family measures like marital satisfaction and cohesion (4). However, some clinical evidence suggests that these families may differ in areas not gaged by standardized instruments. Overprotectiveness and enmeshment are two of these areas. Walker suggested that social modeling of pain may contribute to recurrent pain episodes among children, particularly if the child vicariously observes a parent receiving attention from other family members if there are complaints of pain. Levy and coworkers noted that a child may learn pain behavior when caregivers seek extensive medical consultation for pain (16). Walker noted that caregivers of children with abdominal pain may view their children as vulnerable, and these caregivers may attempt to protect their children from potential health-related threats (4). This pattern may result in caregivers letting a child stay home from...

Conclusions and Future Directions

Much of what has been reviewed in this chapter points toward recommended changes in public policy for children who experience chronic pain and at the same time attend school. We anticipate that public policy ultimately will be expressed through federal and state legislation that it is hoped will dictate appropriate allocation of resources that allow for the incorporation of pediatric psychological and mental health services in schools. Many complex services will be needed for schools and the families served by them, including an increase in medical, educational, and psychological services. Perrin and Ireys observed that the organization of services for children with chronic illnesses is both diverse and fragmented (22). A first effort and necessary first step will be to integrate pediatric and psychological services across multiple locations, including schools and pediatric health care settings. staff services, adjunctive care for families, and transportation for caregivers) will also...

CAM Approaches for Pediatric Pain 21 Acupuncture

Kemper and colleagues (23), however, found that 67 of children referred to an acupuncturist for chronic pain problems (most commonly migraine headaches, endometriosis, and reflex sympathetic dystrophy) and 60 of their parents thought that acupuncture was a positive experience 70 of the children and 59 of the parents reported definite pain relief from the intervention. These findings support the feasibility and acceptability of acupuncture for pain relief in children. However, most of the patients in this study were adolescents (median age, 16 years), and only those patients who were referred and actually visited the acupuncturist were interviewed. No information was available regarding the percentage of referred patients who refused acupuncture or the reasons for their doing so. Thus, this study may have overestimated the acceptability of treatment. These researchers recommended further prospective investigations, particularly in younger samples. 2.1.1. Chronic Pain We evaluated the...

Prosthetic and Transformative Technology

Even videoconferencing with a patient in a distant hospital or doctor's office may be best thought of as a prosthesis to overcome distance. A pain team in a specialist center could interview an adolescent with chronic pain using videoconferencing. If the child is in a regional health center and accompanied by an advanced practice nurse or physician, the specialist could even conduct a distance physical examination. The specialist could examine lab results or an X-ray. The advantages of this type of approach are that the adolescent and family do not have to travel to the specialist center. In rural areas of Canada, patients might be several hundred kilometers from specialist care. If the family was in a northern area, it could mean a 3-day trip by air to visit a specialist center. Videoconferencing in this way does not fundamentally change the interaction there is nothing new about the interview. Although evaluations of videoconferencing in the delivery of pediatric pain management...

Spousal Distress and

Spousal distress due to medical and psychiatric disorder in the partner is relatively common. All the major investigations pertaining to distress in the spouses of chronic pain patients so testify. Distress among many of the partners of chronic pain patients is commonly observed. Male as well as female spouses are adversely affected. The reasons for anxiety and depression in the spouses are perhaps not unduly complex. At its simplest, most of the spouses are forced into assuming greater levels of responsibility and, not infrequently, having to deal with unpredictability during intense periods of pain in their partners. Not uncommonly, quite a few spouses also develop an attitude that their partners are uninterested in sex, and in any event, sex with a sick person is undesirable. The spouse's perception that sex has a low priority for the patient may not be a major factor contributing to the deterioration in sexual activities. But it certainly is a contributory factor. Anger with the...

Principles of Pediatric Pain Management

Third, give analgesics by pain intensity. Mild-to-moderate pain should be managed with nonsteroidal anti-inflammatory drugs (NSAIDs) and oral weak opioids. Severe pain is managed by oral strong opioids or intravenous opioids and regional blockade techniques. Transdermal systems of opioids have little application in acute pain but are continued if the patient with chronic pain receiving this technique is admitted for acute exacerbation of pain.

Premorbid Sexual Problems

For many of the couples, sexual problems do not begin with the onset of chronic pain. Many marriages are strife-ridden before the onset of pain, and it may be reasonable to assume that intimate and satisfactory sexual relations in these couples are a casualty of faulty and unsatisfactory relationships rather than of pain. One patient with a long history of headaches always regarded her husband as distant and uninvolved. He spent a great deal of time on the road, due to business. The sexual relationship between these two individuals was intermittent and never very satisfactory. Therefore it was hardly surprising that following the onset of her pain problem the sexual activities came to a complete halt.

Clinical Approach Partner Abuse

Some signs and symptoms may be less obvious and may require numerous encounters until the finding of family violence is made. Victims of abuse may present to doctors frequently for health complaints or have physical symptoms that cannot otherwise be explained. Chronic pain, frequently abdominal or pelvic pain, is commonly a sign of a history of abuse. The development of substance abuse or eating disorders may prompt inquiry into family violence as well.

Is This Paternalism or Abuse

Jacky, in her forties, presented with a very complicated medical history. Her multiple pain problems, of many years' duration, was increasingly unresponsive to medical ministrations. Jacky was born with a congenital hip problem and had bilateral prosthetic replacement. She did not have this correction until the fourth year of her life, which left her with difficulty in walking and chronic pain. She had corrective surgery, but later as an adult she fractured her hip and had to have another replacement surgery. She had unrelenting pain in her entire lower back region.

Newly Married Couple

The presenting problem is a difficult area in relation to couple or family therapy with chronic pain sufferers. At the center of this issue is the presence of an unresolved medical problem and the patient's and indeed family member's capacity for attributing all their difficulties to the presence of chronic pain. Take the pain away and all will be well. Mr. and Mrs. Erikson were no exceptions. They announced that if only the headache could be eliminated, there would be no problem. However, the reality often is, and it is in this case, that pain was intractable and nonresponsive to medical ministrations.

The Health of the Partners Spouses and the Children

Tower and Kasl (1996), in a cross-sectional study, showed that depressive symptoms in one older spouse affected the other, and that marital closeness increased the effect. Independent interviews in 1982, 1985, and 1988 with spouse pairs who participated in the Established Populations for the Epidemiologic Study of the Elderly showed that changes in depressive symptoms in an older spouse contributed to changes in the depressive symptoms in the other. These findings were stronger when a couple was close. This study is of great clinical significance, as it demonstrates that marital closeness along with depression in one partner makes the other partner vulnerable for depression. Given that depressive symptoms are pervasive in the chronic pain population, it is reasonable to hypothesize that depressive symptoms in their spouses would be high. Taking care of a chronically ill person can be onerous or even perilous. Yet all the factors that determine the degree of vulnerability for the...

Further Thoughts on Mrs Christy and Her Family

We adopt an eclectic, albeit systemic, family therapy approach in discussing Mrs. Christy's case. First and foremost, family is an organization with hierarchy, roles, rules, styles of communication, affectional bonds, and mutual obligations. The executive function of the Christy family, the domain of the two parents, was seriously challenged with the onset of Mrs. Christy's chronic pain problems. Normally, with Mr. Christy's regular absence from home, a good deal of the executive functions were carried out by Mrs. Christy. Her inability to satisfactorily attend to the multifarious needs of this family, from decision making on a whole host of matters ranging from preparation of food, to paying bills, to attending to her children's needs, came under strain. From a structural point of view, every subsystem of the Christy family changed for the worse. The relationship between the parents, between the parents and the children, and between the children had to undergo some major changes in...

Pain Intervention 101 Techniques

NSAIDs are important to acute and chronic pain management (Table 3). The NSAIDs, when used in conjunction with opioids, are valuable in the improvement of postoperative pain by causing the opioid-sparing effects and greater reduction in pain scores (127-129). The risk of perioperative bleeding does not appear

Brenda C McClain

Some view acute, in-hospital pain management as within the purview of a said specialty. However, hospital-based pain care for children is more than associated symptom management of a given disease. This chapter demonstrates the complexity of pediatric in-hospital pain management and indicates acute pain syndromes as major components of the specialty of pain medicine. The practice of hospital-based pediatric pain care requires a vast knowledge base that also encompasses the philosophies and skills of chronic pain medicine. The essentials of neurobiology, pharmacology, and practice principles of hospital-based pain care for children are the focus of this chapter. The aim of this chapter is to present the complexity of hospital-based pain concerns for children. The fund of knowledge required to manage the spectrum of pain that one encounters in hospital-based care supports the need to recognize acute pain as an integral component of the specialty of pain medicine. Currently,...

Discussion of Cases

The first two cases were selected because they represented the most common kind of health problems encountered by the spouses of chronic pain patients. The question of burden in the chronic pain population is generally associated with more responsibilities for the well partner, accentuated by financial problems. Anxiety and depression are the most common reactions noted in the partners of chronic pain patients. The case of Mrs. Falconer is complex, as it seems to suggest that her illness resolved a long-standing marital conflict, although there was a major shift of responsibilities from the patient to the well spouse without any ill effect. Whatever additional burden Mr. Falconer had to assume due to his wife's chronic condition, her illness apparently removed their differences, and that was enough compensation for Mr. Falconer.

Lead Extraction

Leads when lead can be separated from infected area Occult infection with no clear source but pacer system suspected Chronic pain at pocket or lead insertion sites unresponsive to other management Lead failure or design flaw that may pose a future risk to the patient Lead that interferes with treatment of a malignancy Leads preventing vascular access for new implantable device Nonfunctional lead in a young patient

Types Of Pain

Neuropathic pain follows damage to the nervous system. Acute pain without nociceptive (afferent) input (some neuralgias) is less susceptible to drugs unless consciousness is also depressed, and any frequently recurrent acute pain, e.g. trigeminal neuralgia, poses management problems that are more akin to chronic pain. Chronic pain is transmitted principally by slow conducting type C fibres (but to a lesser extent by fast conducting A-delta fibres). It is better regarded as a syndrome8 rather than as a symptom (see above) for it is a collection of disparate pains of long duration, often sharing common emotional and behavioural aspects. It presents a depressing future to the victim who sees no prospect of release from suffering, and poses for that reason long-term management problems that differ from acute pain. Suffering and affective disorders can be of overriding importance and the consequences of poor management may be prolonged and serious for the patient. Analgesics alone are...

Methadone

Methadone is a synthetic drug structurally and pharmacologically similar to morphine it acts mainly at the p-receptor. Methadone is largely metabolised to products that are excreted in the urine (tV2 8 h). The principal feature of methadone is its duration of action. Analgesia may last for as long as 24 h. If used for chronic pain in palliative care (12-hourly) an opioid of short t should be provided for breakthrough pain rather than an extra dose of methadone. Use. Diamorphine is used medicinally for acute pain, e.g. myocardial infarction and chronic pain, e.g. in palliative care. Diamorphine provides a more rapid onset of pain relief than morphine because it is more lipid soluble and enters the brain more readily. Its duration of action is about the same and it may cause less nausea and hypotension. Diamorphine is more soluble than morphine to a useful degree.33 This, together with its greater potency (greater efficacy in relation to weight and therefore requiring a smaller volume)...

Pentazocine

Pentazocine is given to relieve moderate to severe pain, and also for chronic pain, for its liability to induce dependence is less than morphine. Its dysphoric effect limits its usefulness. with an analgesic efficacy similar to that of codeine. It is used to relieve moderate acute and chronic pain on its own or as a compound tablet (co-dydramol dihydrocodeine 10 mg plus paracetamol 500 mg). Dihydrocodeine causes histamine release and should not be used in patients with hyper-reactive airways. Meptazinol is a high-efficacy partial agonist it also has central cholinergic activity which add to its analgesic effect. It is used to relieve acute or chronic pain of moderate intensity, e.g. postoperatively and in obstetrics. Meptazinol does not cause euphoria and withdrawal effects seem not to occur when it is discontinued. It appears not to induce a withdrawal syndrome in opioid-dependent subjets. Tramadol is an opioid with additional actions the basis of its analgesic effects appears...

Case Illustrations

Yost discussed at the end of Chapter 5. This case encapsulates some of the key problems of communication in chronic pain families. To recapitulate, Mr. Yost, a man in his late forties with a long history of multiple pain problems, married with two children, complained that his wife was very critical of the medication, mostly narcotic analgesics, that was prescribed for pain control. His wife, a health-care professional, had considerable doubts about the severity of his pain. The fact that Mr. Yost could work for many hours a day and never missed work contributed to her doubts. In contrast to what happened with these two fathers, it is even more problematic, for purely practical reasons, for some mothers with chronic pain problems to remove themselves from the family situation. Even working mothers are responsible for child rearing and doing household chores. These essential tasks are not easily

Days

Recovery of thermal hyperalgesia and tactile allodynia after subarchnoid grafts of human neuronal cell lines in the excitotoxic model of SCI pain. Adult male Wistar Furth rats were spinally injected with quisqualic acid (QUIS), an excitoxic agent, in a rat model of SCI and chronic pain (239-242). Animals were left untreated or were injected with either NT2.17 GABA or NT2.19 5HT cells (1 x 106 cells injection) into the subarchnoid space at 2 wk (14 d) after QUIS. Animals were tested before the SCI (baseline) and weekly following QUIS and cell grafts for hypersensitivity to thermal (A) or tactile (B) stimuli in hindpaws below the SCI. The transplant was done at 2 wk after the original excitotoxic SCI. (Figure 2 continued) All animals were examined for chronic pain behaviors in both the contralateral and ipsilateral hindpaws. Both ipsilateral and contralateral hindpaws recovered near-normal sensory responses to thermal stimuli after grafting either the GABAergic NT2.17 or...

Background

Understanding the mechanisms leading to the development and maintenance of visceral pain requires an appreciation of the neuroanatomical structures and neurophysiological processes involved, and these have been previously described. It is important to appreciate that the complex physiological processes involved in pain transmission from the gut to the brain are highly dynamic and subject to change depending on the stresses imposed by the internal or external environment. As a result, pain transmission is modifiable, and as will be discussed, this may be relevant to the symptoms of chronic pain in FGD patients.

Living With Reality

First, we review the epidemiology of chronic pain within a public health perspective. Second, we review the reasons given for treating people away from home the different models of care that have been attempted or are in progress are introduced. Third, we place residential treatment settings under closer scrutiny. Experience from our own setting in Bath, England, will be used as a case study to exemplify some of the issues discussed. Within this example, we

Pathophysiology

What is the physiological basis to justify this conceptual model Chronic pain is a multidimensional (sensory, emotional, and cognitive) experience, best explained by abnormalities in the neurophysiological functioning at the afferent, spinal, and central nervous system (CNS) levels (7). Chronic pain is distinct from acute pain arising from peripheral visceral injury or disease, because structural abnormalities, motility disturbances, and tissue damage leading to increased afferent visceral stimuli are not prominent and may not even be present. As pain becomes more chronic, the CNS becomes the primary modulator of the pain experience and can even amplify incoming regulatory (i.e., non-nociceptive) visceral afferent signals to the point of conscious awareness and distress. The discussion below provides a plausible explanation for amplification of chronic pain from both peripheral and central sources (3).

The Systems Approach

This section discusses couple therapy with chronic pain sufferers and their partners. As a rule, couple therapy is initiated by the therapist, which usually takes a good deal of the time, because such a suggestion often meets with varying levels of resistance from the patient. Nevertheless, couple therapy can yield benefits. There is little debate in the psychotherapy literature that the success of therapy largely depends on the couple's being motivated. This is an important point, as some of our patients or their partners engage in therapy with some reservation. They do not come to a pain clinic for psychological or marital help. We will explore the application and process of couple therapy with two couples at different family stages (1) a newly married couple without children, where one partner has serious problems with headaches and (2) an older retired couple (the Friesens see Chapter 7), where one partner has multiple health problems. Problem-centered systems family therapy...

Mild Symptoms

Chronic pain behavior activities, have little or no psychosocial difficulties (although they may experience symptom exacerbation with stress) or chronic pain behaviors, and are not high health-care utilizers. Like case 1, they commonly have IBS, dyspepsia, or other functional GI disorders where the pain is associated with altered GI motility or sensitivity indicating a greater peripheral (i.e., gut related) contribution to the condition. Treatment involves education, reassurance, and dietary lifestyle changes (Fig. 1) or possibly pharmacological treatments (e.g., antidiarrheals and anti-cholinergics) targeted to gut function.

Severe Symptoms

J.L. (case 2) represents the small proportion of patients with severe and refractory symptoms. They are most frequently seen in referral centers. The pain may be constant or frequently recurrent, and is not associated with GI dysfunction. There is usually marked impairment of function (disability is not uncommon), chronic pain behaviors, comorbid psychiatric diagnoses (e.g., depression, anxiety disorders, somatization, or Axis II diagnoses), associated psychosocial difficulties (e.g., major losses or deprivation and sexual physical abuse), maladaptive coping (e.g., catastrophizing), and high health-care use. Here, antidepressant medication and possibly mental health or pain center referral are needed along with an ongoing relationship with the primary care physician to provide psychosocial support through brief, regular visits (49).

Summary

PCFST was used to assess and treat them. The applicability of this model was very clear with the young couple, but less so with the elderly couple. Nevertheless, both couples benefited from this intervention. The success of these cases must not be exaggerated, as there are no control outcome studies on the efficacy of couple therapy with chronic pain sufferers. Many couples refuse to engage in this therapy, and others drop out early. Yet others go though the process without showing any benefit. These issues are pointed out not to discourage therapists from trying to engage couples in therapy, but to show that there are limitations imposed by the nature of the setting (pain clinic), the complexity of the problems (chronicity and disability), and a lack of motivation (medical orientation of the patients and family members). Still, when couples do engage in this endeavor, many succeed in improving their relationship and overall couple functioning despite their ongoing struggle with...

Animal studies

In a recent report, Chichewizc and Welch (1999) found that A9-THC (20mg kg) and morphine (20 mg kg) induced analgesia in both vehicle treated and morphine tolerant mice. In both groups, analgesia was equally effective indicating that analgesia produced by the combination is not hampered by existing morphine treatment (no cross tolerance to the combination). Mice were tested with A9-THC (20 mg kg) and morphine (20 mg kg) twice daily for 6.5 days and tested for tolerance and on day 8, A9-THC tolerance was observed, but morphine tolerance did not occur. These results suggest low-dose combinations of A9-THC and morphine might prevent morphine tolerance. The authors conclude that combinations of these drugs may be useful in chronic pain patients over morphine administration alone.

Therapy Process

The therapy operates by a standard process of change that is used as a model by the team to monitor therapy progress. For week 1, the process involves adaptation to the new environment, learning of new understandings of chronic pain, experimentation with different ways of thinking about thinking, behaving in pain, focusing on the relationships with significant others, and exposure to painful exercise within a graded activity and reinforcement program.

Peace in Pain

Peace in Pain

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