Tài liệu Core Topics in Pain ppt

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Contributors . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .ix
Preface . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .xi
Acknowledgements . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .xiii
Foreword . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .xv
General abbreviations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .xvii
Basic science abbreviations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .xix
PART 1BASIC SCIENCE 1
1.Overview ofpain pathways . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .3
S.I. Jaggar
2.Peripheral mechanisms . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .7
W. Cafferty
3.Central mechanisms . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .17
D. Bennett
4.Pharmacogenomics and pain . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .23
J. Riley, M. Maze & K. Welsh
5.Peripheral and central sensitization . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .29
K. Carpenter & A. Dickenson
6.Inflammation and pain . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .37
W.P. Farquhar-Smith & B.J. Kerr
7.Nerve damage and its relationship to neuropathic pain . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .43
N.B. Finnerup & T.S. Jensen
8.Receptor mechanisms . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .49
E.E. Johnson & D.G. Lambert
PART 2PAIN ASSESSMENT 63
Section 2aPain measurement . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .65
9.Measurement ofpain in animals . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .67
B.J. Kerr, P. Farquhar-Smith & P.H. Patterson
10.Pain measurement in humans . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .71
R.B. Fillingim
Section 2bDiagnostic strategies . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .79
11.Principles ofpain evaluation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .81
S.I. Jaggar & A. Holdcroft
12.Pain history . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .85
A. Holdcroft
13.Psychological assessment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .89
E. Keogh
CONTENTS
PART 3PAIN IN THE CLINICAL SETTING 95
Section 3aClinical presentations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .97
14.Epidemiology ofpain . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .99
W.A. Macrae
15.Pain progression . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .103
B.J. Collett
16.Analgesia in the intensive care unit . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .109
U. Waheed
17.The chronic pain patient . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .117
A. Howarth
18.Post-operative pain management in day case surgery . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .121
T. Schreyer & O.H.G. Wilder-Smith
Section 3bPain syndromes . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .127
19.Myofascial/musculoskeletal pain . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .129
G. Carli & G. Biasi
20.Neuropathic pain . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .137
M. Hanna, A. Holdcroft & S.I. Jaggar
21.Visceral nociception and pain . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .145
K.J. Berkley
22.The management oflow back pain . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .151
C. Price
23.Cancer pain . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .157
S. Lund & S. Cox
24.Post-operative pain . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .161
T. Kirwan
25.Complex regional pain syndrome . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .171
M.G. Serpell
26.Uncommon pain syndromes . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .177
A.P. Baranowski
27.Pain in children . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .183
R.F. Howard
28.Pain in the elderly . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .191
A. Holdcroft, M. Platt & S.I. Jaggar
29.Gender and pain . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .195
A. Baranowski & A. Holdcroft
PART 4THE ROLE OF EVIDENCE IN PAIN MANAGEMENT 201
30.Clinical trials for the evaluation ofanalgesic efficacy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .203
L.A. Skoglund
31.Evidence base for clinical practice . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .209
H.J. McQuay
PART 5TREATMENT OF PAIN 215
Section 5aGeneral Principles . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .217
32.Overview oftreatment ofchronic pain . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .219
C. Pither
vi CONTENTS
33.Multidisciplinary pain management . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .223
A. Howarth
Section 5bPhysical treatments . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .227
34.Physiotherapy management ofpain . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .229
M. Thacker & L. Gifford
35.Regional nerve blocks . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .235
A. Hartle & S.I. Jaggar
36.Principles oftranscutaneous electrical nerve stimulation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .241
A. Howarth
37.Acupuncture . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .247
J. Filshie & R. Zarnegar
38.Neurosurgery for the reliefofchronic pain . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .255
J.B. Miles
Section 5cPharmacology . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .261
39.Routes, formulations and drug combinations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .263
L.A. Skoglund
40.Opioids and codeine . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .269
L. Bromley
41.Non-steroidal anti-inflammatory agents . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .277
J. Cashman & A. Holdcroft
42. Antidepressants, anticonvulsants, local anaesthetics, antiarrhythmics and
calcium channel antagonists . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .281
C.F. Stannard
43.Cannabinoids and other agents . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .287
S.I. Jaggar & A. Holdcroft
Section 5dPsychosocial . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .291
44.Psychological management ofchronic pain . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .293
T. Newton-John
45.Psychiatric disorders and pain . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .299
S. Tyrer & A. Wigham
46.Chronic pain and addiction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .305
D. Gourlay
47.The role ofthe family in children’s pain . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .311
A. Kent
48.Palliative care . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .317
S. Lund & S. Cox
PART 6SUMMARIES 323
49.Ethical standards and guidelines in pain management . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .325
A. Holdcroft
50.What is a clinical guideline? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .329
T. Kirwan
Glossary . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .335
Index . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .337
CONTENTS vii
Baranowski P. Andrew
Bennett Dave
Berkley J. Karen
Biasi Giovanni
Bromley Lesley
Cafferty Will
Carli Giancarlo
Carpenter Kate
Cashman Jeremy
Collett J. Beverly
Cox Sarah
Dickenson Anthony
Farquhar-Smith W. Paul
Fillingim B. Roger
Filshie Jacqueline
Finnerup B. Nanna
Gifford Louis
Gourlay Doug
Hanna Magdi
Hartle Andrew
Holdcroft Anita
Howard F. Richard
Howarth Amanda
Jaggar I Sian
Jensen S. Troels
Johnson E. Emma
Kent Alixe
Keogh Edmund
Kerr J. Bradley
Kirwan Trottie
Lund Samantha
Lambert G. David
Maze Mervyn
McQuay J. Henry
Macrae A. William
Miles B. John
Newton-John Toby
Patterson H. Paul
Pither Charles
Platt Michael
Price Cathy
Riley Julia
Schreyer T.
Serpell G. Mick
Skoglund Lassa
Stannard Cathy
Thacker Mick
Tyrer Stephen
Waheed Umeer
Welsh Ken
Wigham Ann
Wilder-Smith Oliver Hamilton Gottwaldt
Zarnegar Roxaneh
CONTRIBUTORS
The driving force for this book comes from our patients, rarely those who complied with our therapies, but par-
ticularly those who only partly responded, those who received complete pain relief as a marvel, and those who
were so consumed with anger that major barriers had to be broken down before healing could begin. In practic-
ing pain therapy questions inevitably arise for which we have no easy answers, but over time it is possible to plan
research to investigate and test theories. This book is written not to extol the science per se but rather to seek to
identify where further exploration is warranted, because we have no simple answers and the breadth of factors
that influence pain sensations and therapies is great.
The original publishers with whom we entered into a contract were Greenwich Medical, well known for their
concise cutting edge anaesthesia textbooks. We concurred with this format, expecting a low cost no frills approach.
Nevertheless we have attempted to provide the information needed to reach a postgraduate diploma standard. We
hope that the breadth of subjects distilled into this small volume will be a treasured resource for pain management
teams.
As far as possible we have attempted to format each chapter into an overall style. Some authors have resisted,
you the readers are our judges. Since writing or editing a book offers little recompense to those involved we hope
that the rewards are felt by your patients.
Anita Holdcroft and Siân Jaggar
PREFACE
We are indebted to Gavin Smith and Geoff Nuttall at Greenwich Medical for developing the ideas that we had
for this book and for almost publishing it. We are also grateful to our teachers and collaborators, many of whom
have distilled their expertise into this book. Of those we miss, Dr Frank Kurer and Professor Pat Wall are perhaps
the most recent but there are also the patients and experimental subjects who have taught us to ask questions and
seek answers.
ACKNOWLEDGEMENTS
An understanding of pain management should be an essential component of the training for all healthcare pro-
fessionals who deal with patients, irrespective of specialty. This includes doctors, nurses, dentists, physiothera-
pists and psychologists. All of them can contribute to a better outcome for patients who suffer pain.
There has been a huge explosion in our understanding of the basic mechanisms of pain and this is demonstrated
in the first few chapters of this book. Despite these advances in physiology, pharmacology, psychology and
related subjects, surveys repeatedly reveal that unrelieved pain remains a widespread problem. The challenges of
pain management encompass more than just postoperative pain and includes other types of acute pain (e.g.
trauma, burns, acute pancreatitis) as well as chronic pain and pain in patients with cancer. The range of topics
dealt with in this book bear testament to the ubiquity of pain and the way in which pain impinges itself into vir-
tually every realm of medical practice.
The cost of unrelieved pain can be measured in psychological, physiological and socio-economic terms.
Governments around the world are developing awareness that pain and disability can be very expensive and that
pain management strategies are sometimes very cost-effective. Despite this growing awareness there is a wide
variation in provision of pain management services even in countries with developed health services such as the
United Kingdom. The picture in parts of the developing world is sometimes much less rosy.
The advances in our understanding of pain mechanisms has lead to improved methods of management, either
by introducing new treatments or by allowing more efficient usage of older therapies. The multidisciplinary
approach remains a fundamental concept in the delivery of effective pain management.
Books such as this will be useful for trainees from many areas of medical practice. The Royal College of
Anaesthetists has defined competency-based outcomes for pain management at all levels of the anaesthetic train-
ing programme and there is provision for up to 12 months of full-time advanced training in pain management.
Many other professional groups are developing curricula for training in pain management. The International
Association for the Study of Pain (IASP) has been at the forefront in promoting education in pain management.
If you are interested in pain then please join IASP and also join the British Pain Society, a Chapter of IASP.
The provision of effective pain relief for all patients should be a prime objective of any healthcare service. This
book provides a comprehensive introduction to the ways of delivering that effective pain relief.
Dr Douglas Justins MB BS FRCA
Consultant in Pain Management and Anaesthesia
FOREWARD
AA Acupuncture analgesia
ACR American College of Rheumatology
AHCPR US Agency for Health Care Policy and Research
BMA British Medical Association
BPI Brief pain inventory
CBT Cognitive behavioural therapy
CEBM Centre for evidence-based medicine (Oxford)
CER Control event rate
CNS Central nervous system
CNCP Chronic non-cancer pain
COX Cyclo-oxygenase – there are at least two different isoforms
CRF Case report form
CRPS Complex regional pain syndrome
DCN Dorsal column nuclei
DDS Descriptor differential scales
DNIC Diffuse noxious inhibitor control
DREZ Dorsal root entry zone
DSM Diagnostic and statistical manual for mental disorders
EA Electroacupuncture
EER Experimental event rate
EMG Electromyogram
FMS Fibromyalgia syndrome
GP General practitioner
HIV Human immunodeficiency virus
IASP International Association for the Study of Pain
ICU Intensive care unit
IV Intravenous
JCAHO Joint Commission on Accreditation of Healthcare Organisations
LA Local anaesthetic
MA Manual acupuncture
MAOI Monoamine oxidase inhibitor
MDT Multidisciplinary teams
MPQ McGill pain questionnaire
MRI Magnetic resonance imaging
NCHSPCS National Council for Hospice and Specialist Palliative Care Services
NHMRC Australian National Health and Medical Research Council
NHS National Health Service
NHSE National Health Service Executive
NICE National Institute for Clinical Excellence
NNT Number needed to treat
NNH Number needed to harm
NSAID Non-steroidal anti-inflammatory drug
NCA Nurse controlled analgesia
NO Nitric oxide
NRS Numerical rating scale
OR Odds ratio
GENERAL ABBREVIATIONS
PCA Patient controlled analgesia
PDN Peripheral diabetic neuropathy
PET Positron emission tomography
PG Prostaglandin
PHN Post-herpetic neuralgia
PMP Pain management programme
RCS Royal College of Surgeons
RCT Randomised controlled trial
RSD Reflex sympathetic dystrophy
SC Spinal cord
SIP Sympathetic independent pain
SMP Sympathetic mediated pain
SN Solitary nucleus
SOP Special operating procedure
SR Systematic review
SSRI Selective serotonin reuptake inhibitors
TCA Tricyclic agents (note: two uses – see below)
TCA Traditional Chinese acupuncture (note: two uses – see above)
TENS Transcutaneous electrical nerve stimulation
TGN Trigeminal neuralgia
TP Trigger point
TeP Tender point
VAS Visual analogue scale
VRS Verbal rating scale
WHO World Health Organisation
xviii GENERAL ABBREVIATIONS