NYERI KRONIK

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R4
• The major function of the pain system is to protect the body from
injury
• Although inflammatory pain can play beneficial physiologic roles by
preventing further tissue injury during healing, and neuropathic pain
is associated with injury to the nervous system, dysfunctional pain
refers to pain without a benefit to the organism and without a
precipitant
PERIPHERAL SENSITIZATION
• Peripheral sensitization refers to a decrease in nociceptor threshold
an an increase in output, and many inflammatory mediators
pronmote such changes. The initial sensitization process occurs by
direct or indirect activation of the detectors that respond to noxious
stimuli and the transmitters that conduct the signal
• These modulatory effects occur early by mechanism such as
phosphorylation and ion channel insertion, and later through gene
modulation by transcription factors activated at the end of the various
pathways
CENTRAL SENSITIZATION
• One feature of central sensitization, or perhaps more accurately the process
that leads to central sensitization, is temporal windup, the progressive
increase in the response elicited by repeated identical stimuli.
• Repeated low frequency stimulation of c fiber stimulation leads to increase
action potential firing in the second order spinal cord neuron.
• This electrophysiological phenomenon correlates with development of pain
reported by patients upon repeated stimulation with what is initially an
innuoucous stimulus, but one that becomes noxious on repeated
stimulation and result in a prolonged pain following the end stimulation
FIBROMYALGIA
• Fibromyalgia (FM) is a multisymptomatic syndrome defined by the
core feature of chronic, widespread pain. FM is a common entity that
affects women more than men and increases steadily with age.
• FM usually is precipitated by trauma,stress,infections, or other factors
• It commonly accompanies a wide range of medical conditions,
including RA, low back pain, SLE, OA, inflammatory bowel
disease,headache,mood disorders
• Patients typically present with chronic, widespread stiffness and pain
that is described as a constant dull ache worsened by muscle
overactivity.
NEUROPATHIC PAIN SYNDROMES
• Neuropathic pain is a pathologic pain that results from sustained
transmission of pain signals in the absence of ongoing tissue injury or
activation of pain sensitive afferent peripheral nerves
• Neural injury or dysfunction at any point along the somatosensory
system from the peripheral nerve endings to the brain can cause
neuropathic pain
• Central sensitization,as outlined also plays a major role in neuropathic
pain
CHRONIC PAIN MANAGEMENT
 Patients with chronic pain multimodal (pharmacologic, behavioral,
physical modalities, & procedural) therapies  chosen based on the
underlying mechanism & the impact of the pain on function & suffering.
 Fear of reinjury, catastrophizing, and poor coping skills may undermine
the success of any mode of therapy.
 The success of opioid therapies in acute pain must be tempered by the
realization that for chronic pain treatment, opioid-induced hyperalgesia,
pharmacologic tolerance, drug diversion, patient outcomes, and legal
issues must be balanced appropriately for optimal care. Continuous
monitoring and attention to the physician-patient relationship is vital.
 Multiple new agents targeting ion channels and neurotransmitters are
being developed, with improving efficacy.
 New studies examining combination therapy (eg, an opioid plus
anticonvulsant agent) are likely to represent future practice because
of the complexity of pain treatment and the realization that one agent
is rarely sufficient.
 Several studies suggesting that physical modalities plus cognitive-
behavioral interventions are equivalent to large surgical procedures
are interesting.
• Combination Therapy
• Few trials  antinociceptive agents either from the same class (ie,
antiepileptic drugs) or from multiple classes (pairing opioids, antiepileptic
drugs, and antidepressant agents).
• A study by Gilron et al evaluated patients with diabetic neuropathy or
postherpetic neuralgia, comparing gabapentin, morphine, or the combination
of both drugs versus placebo reduction in mean daily pain from 5.72 at
baseline to 3.06 with the gabapentin morphine combination. The
combination was well tolerated but did produce higher frequencies of dry
mouth and constipation for gabapentin and morphine, respectively.
PAIN REHABILITATION STRATEGIES
• Psychologic management of pain
• Physical modalities and exercise
• Vocational rehabilitation
• Exercise
• Transcutaneous electrical nerve stimulation
• Ice and heat
• Iontophoresis
• Acupuncture

Longnecker, 2012
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