CORE TOPICS IN PAIN Core Topics in Pain provides a comprehensive, easy-to-read introduction to this multi-faceted topic. It covers a wide range of issues from the underlying neurobiology, through pain assessment in animals and humans, diagnostic strate- gies, clinical presentations, pain syndromes, to the many treatment options (for example, physical therapies, drug ther- apies, psychosocial care) and the evidence base for each of these. Written and edited by experts of international renown, the many concise but comprehensive chapters provide the reader with an up-to-date guide to all aspects of pain. It is an essential book for anaesthetic trainees and is also an invaluable first reference for surgical and nursing staff, ICU professionals, operating department practitioners, physiotherapists, psychologists, healthcare managers and researchers with a need for an overview of the key aspects of the topic. CORE TOPICS IN PAIN Edited by Anita Holdcroft Department of Anaesthetics and Intensive Care Imperial College London Chelsea and Westminster Campus Fulham Road London SW10 9NH, UK Siân Jaggar The Royal Brompton Hospital Sydney Street London SW3 6NP, UK cambridge university press Cambridge, New York, Melbourne, Madrid, Cape Town, Singapore, São Paulo Cambridge University Press The Edinburgh Building, Cambridge cb2 2ru,UK First published in print format isbn-13 978-0-521-85778-9 isbn-13 978-0-511-13261-2 © Cambridge University Press 2005 2005 Informationonthistitle:www.cambrid g e.or g /9780521857789 This publication is in copyright. Subject to statutory exception and to the provision of relevant collective licensing agreements, no reproduction of any part may take place without the written permission of Cambridge University Press. isbn-10 0-511-13261-1 isbn-10 0-521-85778-3 Cambridge University Press has no responsibility for the persistence or accuracy of urls for external or third-party internet websites referred to in this publication, and does not guarantee that any content on such websites is, or will remain, accurate or appropriate. Published in the United States of America by Cambridge University Press, New York www.cambridge.org hardback eBook (NetLibrary) eBook (NetLibrary) hardback 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 [...]... 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... Reduced pain behaviour in models of chronic neuropathic and in ammatory pain Inhibition at the segmental level of the spinal cord and diffuse noxious inhibitory control The perception of pain in one part of the body can be reduced by application of a noxious stimulus to another body region The idea that pain inhibits pain has been used as the rationale behind therapeutic strategies employing counter... Interestingly, a more cognitively demanding task produces a greater reduction in perceived pain intensity Most levels of the CNS are thought to be involved in the attentional modulation of pain Activation in the PAG is significantly increased during a condition in which subjects are distracted from pain The level of PAG activity is predictive of the reduction in pain intensity produced by distraction Attention... amino butyric acid Guanylyl cyclase Guanosine diphosphate Glial derived nerve growth factor G-protein – through which many receptors link to intracellular events Guanosine triphosphate Hydrogen ions – important in ammatory mediator Histamine receptor type 1 Histamine receptor type 2 Interleukin 1␤ Interleukin 2 Inositol triphosphate – important intracellular messenger Inositol (1,4,5) triphosphate International... emission tomography Prostaglandin E2 – main pain producing prostanoid Phospholipase A2 – important intracellular messenger Protein kinase A – important intracellular messenger Protein kinase C Phospholipase C – important intracellular messenger Phospholipase A2 Another name for SNS (also known as Nav 1.8) Rostroventral medulla Sympathetic independent pain Sympathetic mediated pain Sensory nerve-specific sodium... activity in low-threshold, myelinated 1° afferents would decrease the response of DH projection neurones to nociceptive input (from unmyelinated afferents) Although there has been controversy over the exact neural substrates involved, the ‘gate control’ theory revolutionized thinking regarding pain mechanisms Pain is not the inevitable consequence of activation of a specific pain pathway beginning at... leads to increased excitability of projection neurones within the DH, C-fibre Modulation of pain processing at the level of the spinal cord The dorsal horn (DH) of the spinal cord is an important area for integration of multiple inputs, including primary (1°) sensory neurones and local interneurone networks, as well as descending control from supraspinal centres Pain can be modulated depending upon... theory of pain proposes that activity in low-threshold myelinated afferents can reduce the response of DH projection neurones to C-fibre nociceptor input An inhibitory interneurone is spontaneously active and normally inhibits the DH projection neurone reducing the intensity of pain This interneurone is activated by myelinated (A-fibre) low-threshold afferents (responding to innocuous pressure) and inhibited... 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 virtually 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... resulting in activation of descending pain- modulating pathways Other neurotransmitter systems are also involved 5-HT and norepinephrine are transmitters found in the projection neurones from the brain stem (RVM and pons) to DH Direct application of 5-HT or norepinephrine to the spinal cord results in analgesia, while destruction of these neurones blocks the action of systemically administered morphine . 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. CORE TOPICS IN PAIN Core Topics in Pain provides a comprehensive, easy-to-read introduction to this multi-faceted topic.