Pain

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Common pain conditions (acute and chronic)
Pain condition:	Links:
cancer pain	Treatment of cancer pain
chronic pancreatitis, duodenal ulcer, appendicitis	Digestive system and gastrointestinal disease
complex regional pain syndromes	Complex regional pain syndrome
diabetic neuropathy	Treatment of diabetic neuropathy
kidney stone colic	Abdominal pain
pain from arthritis, gout, foot pain, neck pain , knee pain, low back pain etc.	Arthritis and rheumatism
painful periods, pelvic pain, endometriosis etc.	Women's diseases
restless leg syndrome	Restless leg syndrome
sinusitis pain	Nose problems
trigeminal neuralgia pain	Trigeminal neuralgia

Contents 1 Pain 1.1 Symptoms 1.2 Diagnostic tests 1.3 Treatment 2 Restless leg syndrome 2.1 Diagnosis 2.2 Treatment 3 References

[edit] Pain

Pain conditons are very common in medicine. They can be divided into acute and chronic pain conditions.

Acute pain Acute pain is generated following surgery or when an acute traumatic injury happens. A soft tisue injury or a laceration of the skin irritates nerve endings that are buried in the tissue. The pain signals and neurotransmitters are different than in chronic pain. Acute pain is short lived, mostly only a few days and with remobilization and wound healing most of these conditions have resolved within 2 to 4 weeks (Ref. 1, p. 347).

Chronic pain is one of the most common symptoms that physicians are consulted about in their offices.

Chronic pain can have a multitude of causes. Typically it is caused from an underlying chronic condition such as rheumatoid arthritis, degenerative arthritis or fibromyalgia. One subtype of chronic pain is thought to be due to irritation of nerve fibers or pain receptors ("nociceptive pain"). Another chronic pain type is thought to originate from damage or dysfunction of a peripheral nerve or from CNS pathology, such as a stroke or injury of the spinal cord ("neuropathic pain"). The first type is felt as a pressure or as aching, the second type as deep burning or excruciatingly stabbing. An example for nociceptive pain would be cancer pain, for neuropathic pain would be pain from a stroke, diabetic neuropathy in a chronic foot ulcer, or phantom pain after an amputation (Ref. 1, p. 753).

[edit] Symptoms

When joints are involved in pain, there is usually associated joint swelling, stiffness and a lack of range of motion from the pain.

Depending on what underlying structure is involved (joint, bursa etc.) there is a difference in the clinical presentation and finding. The patient needs to keep track of the pattern of pain and perhaps keep a pain diary. It is a good idea to grade pain on a scale from 0 to 10 and communicate this to the physician when the history of the pain is discussed. What makes the pain better? What makes it worse? This will help the pain specialist to be able to deduct what type of pain he is trying to control.

[edit] Diagnostic tests

It is likely that the physician has already done some X-rays or other imaging studies such as MRI, CT scans or bone scans. Depending on the clinical impression there may or may not be a need to do more tests such as blood tests. A weakened grip can be measured using a Jamar dynanometer: 50 to 100 lbs. would be a normal range. In a patient with wrist pain due to a complex regional pain syndrome the best effort grip strength may only amount to 5 to 20 lbs. | height="581" bgcolor="#AEFFAE" align="center" valign="top" |

In the Table above a few common pain conditions are listed with links to where they are described in more detail. Under these links further diagnostic tests for these conditions can also be found.

[edit] Treatment

As the therapies in the various conditions vary according to the findings and to the underlying pathology, treatments will be reviewed in the chapters under these above links. However, generally speaking modern treatment of pain conditions consists of early reactivation after surgery.

Splinting is avoided whenever possible. We have learnt a lot from the subspecialty of sports medicine with regard to early diagnosis, aggressive rehabilitation, and if necessary possibly early minor corrective surgery. If surgery is required, anatomical abnormalities should be addressed with the minimum invasive procedure such as arthroscopic surgery to avoid extensive tissue damage and excessive pain. This gets the injured athlete through an injury a lot faster, with much less pain. Many other pain patients benefit from a similar approach, from stretching of injured tissues and early remobilization as soon after surgery as it is advisable. Often this is 2 or 3 days after the injury. Rest is avoided as much as possible. The links in the table above lead to other chapters where more therapeutic modalities are mentioned.

"Downtoning" pain is a new trend that is catching on in recent years. For prevention of pain syndromes surgeons will often premedicate the patient just prior to surgery with one dose of 1200 mg of gabapentin (= brandname: Neurontin), which was shown in a double blind study to reduce postoperative pain and pain pill use (Ref.2). This practice has been described in lumbar spine surgery (discectomies), abdominal hysterectomies and mastectomies. Gabapentin can also be used after surgery for a period of time to cut down pain medication and help with early remobilisation. Gabapentin also is useful in an adjunct to chronic pain management as is explained in the link above with regard to treatment of diabetic neuropathy, which is a pain condition particularly difficult to treat.

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[edit] Restless leg syndrome

Restless leg syndrome is a neurological disorder. It is not a behavior problem as it was thought of in the past by distraught parents and doctors. About 12 to 15 million Americans are suffering from this syndrome, where they have abnormal or unpleasant sensations under the skin and in the muscles of the lower legs, a burning, a feeling like insects are crawling or sharp knife-like pain. It is relieved somewhat by getting up and walking or running around, only to return very quickly when sitting down. Patients with this condition have also often sleep disturbances, which can be measured in the sleep laboratory.

[edit] Diagnosis

Sleep lab investigations are a good way to measure the severity of the restless leg syndrome condition and to evaulate the impact it has on the patient's sleep hygiene. It is known that sleep deprivation makes the symptoms worse and a reintroduction of a regulated sleep/wake rhythm improves the symptoms.

[edit] Treatment

Recently there have been reports of a very beneficial effect of gabapentin, an anti-epileptic drug. Gabapentin(brand name: Neurontin) releases GABA in some parts of the brain and inhibits the NMDA pain receptors. This link describes the use of it in the pain of complex regional pain syndrome. Dr. Stephen Clarke, Clinical Assistant Professor in the Div. of Neurology of the University of BC/Vancouver/Canada, reviewed the use of gabapentin at a conference in Vancouver/BC in November 2004 (Ref. 3). Dr. Clarke said that the use of gabapentin in restless leg syndrome is particularly satisfying as the patients who tend to not respond to all of the other medications respond in a high percentage of cases and this leads to a more normal life for them. It is a very safe medication as outlined under the complex regional pain syndrome link and the symptoms can be titrated by increasing the dose of the medication.

For more details on this see this National Institute of Neurological Disorders and Stroke link.

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[edit] References

1. Ruddy: Kelley's Textbook of Rheumatology, 6th ed., 2001, W. B. Saunders Company
2. The 50th Annual St. Paul's Hospital Continuing Medical Education Conference for Primary Physicians, Nov. 16 - 19, 2004
3. The 50th Annual St. Paul's Hospital Continuing Medical Education Conference for Primary Physicians, Nov. 16 - 19, 2004