Permanent End To Chronic Pain
Although there are many forms of psychological injury that can be the focus of a compensation claim (including chronic pain, cognitive impairment, postconcussive syndrome, depression), this review will focus onposttraumatic stress disorder (PTSD). This condition is diagnosed when the individual has (a) suffered a traumatic experience, and subsequently suffers (b) re-experiencing (e.g. flashbacks, nightmares), (c) avoidance (e.g. effortful avoidance of trauma-related thoughts, emotional numbing), and (d) hyperarousal (e.g. insomnia, irritability) symptoms. According to the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV American Psychiatric Association, 1994), PTSD has the distinctive feature of including a precipitating stressor as part of the disorder's definition. This establishes a straightforward connection between a triggering traumatic event and a variety of observed symptoms (Freckelton, 1997). Such a relationship enables PTSD to be susceptible to...
The evidence pertaining to symptom reporting decreasing after litigation resolution is very mixed. There is increasing research that PTSD symptoms persist after compensation has been settled (Brooks and McKinlay, 1992 Bryant and Harvey, in press-a Mayou, Bryant and Duthie, 1993 McFarlane, 1995), and this pattern of findings reflects evidence from studies ofback injury and chronic pain (Evans, 1984 Mendelson, 1995a). There is also evidence that symptom exaggeration is particularly prevalent in compensation-seeking individuals (Frueh, Smith and Barker, in press). There are insufficient prospective studies available that informs us about the modification of symptoms and impairment prior to and following resolution of compensation claims. The studies that are available are from very diverse jurisdictions with distinct compensation systems and provide little information concerning the mechanisms of change in any observed symptom change. The possibility that the stress associated with...
The most studied measure to index genuineness of clinical presentation is the MMPI MMPI-2 (Hathoway and McKinley, 1991). The MMPI-2 has an array of validity scales designed to index motivation underlying responses to items about psychopathology, including the F, Fb, L, K, Gough Dissimulation Index, Fp, S and Mp (for reviews, see Butcher and Miller, 1999 Greene, 1997 Pope, Butcher and Seelen, 2000). The ability of the MMPI-2 to discriminate between genuine and malingered presentations has been studied in a range of populations, including chronic pain, brain injury, and PTSD (Butcher and Miller, 1999). A number of studies have indicated the utility of the MMPI-2 to distinguish genuine from malingered PTSD (Fairbank et al., 1985). Even when malingerers are given information about PTSD,
Chronic pain, a common treatment target for behavioral medicine practitioners, provides a final example of the relevance of the neu-rocognitive examination to medical decision making. In their review of executive functions, self-regulation, and chronic pain, Solberg et al (2009) propose a model in which executive functions and associated decrements in self-regulation cause and maintain chronic pain disorders. Specifically, the cognitive, emotional, social, behavioral, and physiological challenges associated with chronic pain are more poorly managed in the context of poor executive function. Optimally designed chronic pain interventions may therefore require components aimed at improving executive functions and self-regulatory capacity, such as cognitive techniques and physical activity.
Dialectical behaviour therapy consists of four primary treatment stages with pre-commitment occurring prior to beginning each stage. Currently, the main body of research on DBT is on what is called Stage 1 DBT. The first stage of DBT is usually one year of treatment designed to get the client's behaviours under control. Clients in Stage 1 are usually engaging in severely out of control behaviours. They are suicidal, engaging or having the urges to engage in non-suicidal self-injurious behaviours, are substance abusing, binging and or purging, criminal behaviour, gambling, and engaging in out of control, impulsive behaviours. Once the clients' behaviours are under control, they move into Stage 2 of DBT. In Stage 2, the behaviours are under control, but the clients' level of misery is still extremely high. Usually, Stage 2 is some form of structure exposure based treatment, usually for trauma. Because the out of control behaviours that lead clients into Stage 1 DBT are usually to avoid...
A dying person should be assisted to live out his or her remaining days or weeks with minimal or no pain and remain, as fully as possible, normally alert. Among all the factors associated with dying, pain is probably the most dreaded and feared. Moreover, expectation and anticipation of pain is itself self-perpetuating pain. In most cases, the pain endured by a dying person serves no useful purpose. It does not serve as a warning or protective signal or as a diagnostic aid, as in the case of injury. Sometimes, pain associated with dying is categorized as long-term, chronic pain or as terminal pain. Professionals who care for terminally ill persons frequently describe the pain experienced by patients as ''total'' pain. The designation is intended to indicate not only that pain has multiple components, but that patients may feel that ''everything is wrong,'' meaning that one's whole being is consumed by pain.
Nevertheless, it has advantages in terms of reduced postoperative pain, lower wound morbidity, a more rapid return to normal activity, and less chronic pain and numbness than open repair. The benefits that are realized to the individual patients can be expanded into the societal advantages because these patients are returned to the work force more rapidly. Many surgeons are finding this technique more beneficial for the patients with bilateral and or recurrent hernias. These advantages need to be balanced against increased costs and a high recurrence rate in the learning curve period.
Acupuncture has been utilized for treatment and prevention of multiple health conditions, such as chronic pain, nausea and vomiting, obesity, substance abuse, and asthma. Stress response and cardiovascular effects of pain have reportedly been attenuated by nonpharmacological techniques such as acupuncture it modulates the body's pain system, increases the release of endogenous opioids (53), and or decreases postoperative pain (54). In a feline cardiovascular model, the utilization of electro-acupuncture induced improvements in regional cardiac wall motion activity during myocardial ischemia (55). Furthermore, acupressure applied to females undergoing elective cesarean section with spinal anesthesia displayed a reduction in nausea and vomiting (56).
There has been anecdotal evidence of improvement in patients treated with stimulation of the motor cortex for chronic pain (22,23). This has led to the suggestion that stimulation of the motor cortex might be an effective means of treating patients with tremor-dominant PD. A group in Italy has performed motor cortex stimulation for PD in three patients (24-26). They reported that a benefit comparable to STN DBS could be achieved with low-frequency not high-frequency stimulation. Advantages of this procedure might include safer placement, without the risk of deep hemorrhage, and perhaps greater efficacy.
Although the outcome of Gestalt therapy, at least in its pure form, has received rather less research attention, there is some evidence that this approach is as effective as behavioural and cognitive therapies (Beutler et al., 1991 Cross, Sheehan & Khan, 1982 Strumpfel & Goldman, 2002). There has also been exploration of the effectiveness of particular techniques derived from Gestalt therapy. Two-chair dialogue for conflict splits has been found to be more effective in some respects than empathic reflection and focusing (Greenberg & Dompierre, 1981 Greenberg & Higgins, 1980 Greenberg & Rice, 1981) and to result in greater reduction in indecision in clients with decisional conflicts than did behavioural problem solving (Clarke & Greenberg, 1986). Further studies have investigated the mechanism of change produced by the two-chair technique (Greenberg, 1984). Empty-chair dialogue for unfinished business has also been examined by Paivio and Greenberg (1995), who found it to be more...
Oral candidiasis is characterized by a recurrent, persistent, acute inflammatory reaction to Candida infection, which is limited to the uppermost epithelial layers of the oral mucosa. The inflammatory response to this pathogen elicits chronic pain and discomfort upon mastication, but it may also be responsible for activation of immunoef-
Pain as defined by the International Association for the Study of Pain is 'an unpleasant sensory and emotional experience associated with actual or potential tissue damage, or described in terms of such damage'. Nociception (perception of a painful stimulus) elicits physiological responses even in anaesthetized individuals and minimization of pain can improve clinical outcomes. An individual's response for months after injury may be determined by processes that occurred during the initial phases of the injury. Even brief intervals of acute pain can induce long-term neuronal remodelling and sensitization ('plasticity'), chronic pain and lasting psychological distress. Factors which influence postoperative pain include the
Some individuals worry, for example, that ''artificially'' extending human lives would cheapen our existence, whereas others point out that the modern medical enterprise has already drastically increased lifespans with no ill effects on society. Other subjects that the site has explored include the paucity of older people included in clinical trials the wisdom of using human growth hormone to combat symptoms of aging despite data suggesting that the substance curtails lifespan and how we might improve our flu-combating measures. It has discussed nanotech-nology, hormone replacement therapy, guidelines for keeping bones strong, and chronic pain, as well as age-related voice changes and hearing loss. SAGE Crossroads ponders such topics in News and Views articles as well as through Webcasts in which experts debate and discuss such matters.
The loss of minerals in the bones that accompanies aging reduces bone mass and increases the porosity and brittleness of bones. The result may be chronic pain in the joints of the lower spine and hips, a height reduction of several inches, other skeletal deformities (eg, dowager's hump), and an increased danger of fractures to the vertebrae, hips, ribs, and wrists. These are the symptoms of osteoporosis, a disorder that is four times more common among postmenopausal women than men in the same age range (45-50 years). Osteoporosis affects almost half of all women over 50, and as many as 90 of women over 70. It is more common among whites and Asians than among blacks and is also associated with chronic hyperthyroidism, long-term steroid therapy, and heredity.
Despite the relative proximity of skilled nursing and rehabilitation services, the institutionalized senior continues to be at increased risk for chronic pain (27). Although this problem has received little attention, it is anticipated that the judicious use of physical modalities and exercise, as outlined in this chapter, not only would aid in the prevention of chronic illnesses and impairment, but also would decrease the need for pharmacological intervention.
Electrophysiological research on fibromyalgia has examined sleep, pain processing, general health, and cognitive function. The diagnosis of fibromyalgia is based on diffuse pain in four body quadrants with tenderness upon palpation at certain musculoskeletal points (Landis et al, 2004). Patients often complain of sleep problems such as experiencing non-restorative, restless sleep. A small literature suggests that alpha wave sleep enduring throughout the sleep cycle may characterize chronic pain conditions, particularly fibromyalgia (Rains and Penzien, 2003). Instead of falling into a deep sleep, fibromyal-gia patients may remain in a stage predominated by alpha waves, a waveform typically associated with drowsy wakefulness. Recent research has not strongly supported this observation. In a study of patients undergoing polysomnography to diagnose probable sleep disorders, a subset of patients who had abnormal alpha wave activity were identified (Rains and Penzien, 2003). Less than 40 of...
Peripheral neuropathic chronic pain is a severe and debilitating pathological condition which affects many millions of people. Neuropathic pain is a consequence of either neurotropic infections (most notably HIV) or injuries of peripheral nerves, which may occur following trauma, nerve compression or diabetes. The mechanisms of neuropathic pain are poorly understood and existing therapy is often ineffective. Very recently the role of glial cells, particularly microglia and to a lesser extent astroglia, as primary mediators of chronic pain, has begun to be considered and gained substantial experimental support. It is now firmly established that injury to peripheral nerve causes rapid and significant activation of microglia in the dorsal horn of the spinal cord on the side of the peripheral nerve entry (Figure 10.8). The activated microglial cells in spinal cord express pain related signalling molecules - P2X4 purinoreceptors and p38 mitogen-activated protein kinase (p38 MAPK). The...
Another area for improvement for patients is, surprisingly, reporting of pain. Patients often do not report pain or will use other terms to designate functional difficulties rather than the cause (i.e., pain). This may be related to a belief that chronic pain cannot be controlled, that it is normal to have pain as one gets older, or that the physician cannot do anything about it (16). There is also a concern that the physician and staff do not have time to treat or report pain (15).
A host of comorbid conditions can make it more difficult for patients to complain of pain. Beside the obvious diseases (such as strokes) that prevent effective communication, there are psychological barriers as well. Probably most common among seniors is depression. Although this may be recognized, patients and health care professionals may attribute the depression to the chronic pain. Although depression is more common in people with chronic pain, it is a mistake to think that simply treating the pain will be enough to resolve both pain and depression. Studies indicate that, without active treatment of depression, pain control is unlikely to be successful (26). Because some medications for depression have also been used to control pain and there is a desire to minimize the number of medications, choosing an antidepressant that also helps with pain control makes sense.
To disseminate information on pain, many resources must be used. The government should collaborate with private organizations. Partners would include such organizations as the American Cancer Society, the American Chronic Pain Association, and other nationally and internationally recognized organizations that focus on pain relief. Also, local and statewide organizations should be identified to help promote a culturally sensitive educational media campaign to promote pain assessment and management. Communication within different health care systems regarding compliance and adherence to standards for pain management should also be a focus for change.
Millon's normal personality styles and dimensions have assessed their internal consistency, temporal stability, convergent and discriminant validity, factor structure, and comparability to PDs. Many subject populations have been sampled, including non-help-seeking adolescents, college students, noncollege adults, and the elderly psychiatric patients medical patients with a variety of diagnoses including cancer and chronic pain employees in a variety of occupations including law enforcement military personnel military veterans and prisoners. Included in the psychometric review are findings from the MAPI, MBHI, MBMD, MIPS MIPS-R, and PACL. The recently developed MIDC (Immelman, 1999, in press) is unique in allowing indirect ratings of individuals (e.g., political figures) through work samples and written records. Because it is essentially a qualitative measure of personality, traditional research methods and criteria do not apply. See Immelman (1999, 2005) for...
Preservative-free morphine is the only analgesic approved for the intrathecal treatment of chronic pain by the US Food and Drug Administration (FDA). Thus, morphine is the agent most widely used intrathecally, but it might not be suitable for long-term use because patients may become tolerant of the effects of the drug and require escalated doses, which in turn could increase side effects to intolerable levels.
Peace in Pain
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