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Chronic pain (3 Types (Central pain (typically occurs shortly after the…
Chronic pain
3 Types
Nociceptive pain
2 Types
somatic pain
(pain from the joints, bones, muscles, and other soft tissues). Characterized by
more localized, dull, aching, throbbing, or squeezing pain
visceral pain
(pain from the internal organs)
Pain that is detected by specialized
sensory nerves
called
nociceptors
. These nerves are located throughout the soft tissues, such as in muscles and skin, as well as the internal organs
Neuropathic pain
typically follows the distribution of the nerve (or nerve root) that is damaged, but it can be bilateral and more diffuse, as in peripheral neuropathies
may be localized, such as in postherpetic neuralgia, or more widespread, such as in diabetic peripheral neuropathy
described as burning, stinging, tingling, or shooting pain
Physical findings typically reveal pain, numbness, or
allodynia (sensitivity to non-noxious stimuli)
in the nerve distribution.
caused by injury or dysfunction of the nervous system
Central pain
typically occurs shortly after the causative injury or damage, but it may be delayed by months or even years, especially if it is related to stroke
this syndrome can be caused by multiple sclerosis, tumors, epilepsy, brain or spinal cord trauma, or Parkinson disease
damage to or dysfunction of the central nervous system, which includes the brain, brainstem, and spinal cord
pain is
usually constant, with bursts of more severe pain
, often exacerbated by cough, temperature changes, movement, or emotions
often associated with
allodynia and/or hyperalgesia (oversensitivity to noxious stimuli)
the most prominent being
burning
. In addition to burning, sensations of numbness, pressure, lacerating pain, aching pain, “
pins and needles
,” and episodic brief bursts of sharp pain
Fibromyalgia
is thought to be one example of this type of central pain process.
Nonpharmacologic Therapy
Exercise program
ice and heat therapy, transcutaneous electric nerve stimulation (TENS), massage, acupuncture, and chiropractic manipulation
Cognitive-behavioral therapy (CBT)
include cognitive restructuring, problem solving, relaxation techniques, and mindfulness-based stress reduction, help mitigate maladaptive behavior patterns, such as catastrophizing, fear avoidance, and overgeneralizing
Pharmacologic Therapy
For neuropathic pain
Localized
localized symptoms can be treated with
topical agents
, such as
capsaicin cream
or a
lidocaine patch or cream
Both topical capsaicin and lidocaine have been shown to be effective for
diabetic neuropathy and postherpetic neuralgia
Systemic
anticonvulsant
drugs
gabapentin
and
pregabalin
are considered first-line agents for systemic therapy
Carbamazepine
has demonstrated efficacy for
trigeminal neuralgia
, but evidence for effectiveness in other neuropathic syndromes is lacking
The
serotonin-norepinephrine reuptake inhibitors
duloxetine
and
venlafaxine
have demonstrated efficacy in treating
diabetic neuropathy
For nociceptive pain
Acetaminophen is usually the first-line agent
Ideally, NSAIDs would be used for periodic flares and not on a continuous basis
Central pain syndromes
Tricyclic antidepressants, serotonin-norepinephrine reuptake inhibitors, gabapentin, and pregabalin are all reasonable options.
Definition
pain, with or without a clear precipitant, that has
persisted beyond 3 months
Red flag” symptoms
such as
nocturnal worsening of pain
(often seen in
cancer
), fever, or weight loss, should spur further investigation