International Association For The Study Of Pain Research Articles

Pain treatment facilities: do we need quantity or quality?

Chronic pain patients referred to a pain treatment facility have no guarantee that they will receive a proper diagnostic procedure or treatment. To obtain information about organizational aspects of pain treatment facilities and the content of their daily pain practice, we performed a questionnaire survey. The aim of the study was to evaluate the amount of pain treatment facilities, the content of organized specialized pain care and adherence to the criteria of the internationally accepted guidelines for pain treatment services. The University Pain Centre Maastricht in the Department of Anaesthesiology and Pain Management at Maastricht University Medical Centre developed a questionnaire survey based on the Recommendations for Pain Treatment Services of the International Association for the Study of Pain (IASP). The questionnaire was sent to the medical boards of all hospitals in the Netherlands (n=94). The response rate was 86% (n=81). Of all hospitals, 88.9% (n=72) reported the provision of organized specialized pain care, which was provided by a pain management team in 86.1% (n=62) and by an individual specialist in 13.9% (n=10). Insight was obtained from pain treatment facilities in five different domains: the organizational structure of pain management, composition of the pain team, pain team practice, patient characteristics, and research and education facilities. Although 88.9% of all hospitals stated that organized specialized pain care was provided, only a few hospitals could adhere to the criteria for pain treatment services of the IASP. The outcome of the questionnaire survey may help to define quality improvement standards for pain treatment facilities.

Validation of the Greek Version of the DN4 Diagnostic Questionnaire for Neuropathic Pain.

The Douleur Neuropathique 4 questionnaire (DN4) was developed by the French Neuropathic Pain Group and is a simple and objective tool, primarily designed to screen for neuropathic pain. The aim of our study is to validate the DN4 in the Greek language. The study was set up as a prospective observational study. Two pain specialists independently examined patients and diagnosed them with neuropathic, nociceptive, or mixed pain, according to the International Association for the Study of Pain (IASP) definitions. A third and a fourth physician administered the DN4 questionnaire to the patients. Out of the 237 patients who met our inclusion criteria and had identical diagnoses regarding the type of pain, 123 were diagnosed with neuropathic, 59 with nociceptive, and 55 with mixed pain. Among patients with identical diagnoses of neuropathic or nociceptive pain, using a receiver operating characteristic (ROC) curve analysis, the area under the curve (AUC) was 0.92. A cutoff point of equal or greater than 4 resulted in a sensitivity of 93% and a specificity of 78%. Among patients suffering from pain with neuropathic element (neuropathic or mixed pain) or pain with no neuropathic element (nociceptive pain), using a ROC curve analysis, the AUC was 0.89. A cutoff point of equal or greater than 4 resulted in a sensitivity of 89% and a specificity of 78%. The Greek version of DN4 is a valid tool for discriminating between neuropathic and nociceptive pain conditions in daily practice.

Complex regional pain syndrome: recent updates

Complex regional pain syndrome (CRPS) may be defined as a painful and disabling disorder affecting one or more extremities showing signs of vasomotor (relating to the constriction and dilatation of blood vessels), sudomotor (stimulation of sweat glands), inflammatory, and trophic changes (changes brought about in tissues from interruption or destruction of nerve, blood supply or both) in the affected extremity. CRPS can occur after even trivial injury and, on occasion, can develop spontaneously. It was first described as a spectrum of symptoms during the American Civil War by Silas Weir Mitchell and colleagues in their book entitled Gunshot Wounds and Other Injuries of Nerves, and named it causalgia. The gamut of symptoms stretches from a self-limiting mild condition to a severe, debilitating condition affecting the quality of life and having a high impact on activity. Owing to the varied manifestation, the patient can present to any specialty be it orthopaedics, rheumatology, neurology, dermatology, or pain medicine. Pain is an early presenting feature and can be the most prominent of symptoms. A high index of suspicion is needed as early diagnosis and treatment may prevent the progression of symptoms and prevent disability. It has been known by many names in the past, including reflex sympathetic dystrophy, algodystrophy, algoneurodystrophy, Sudeck’s dystrophy, and causalgia. In 1994, the International Association for the Study of Pain (IASP) came up with a standardized set of criteria to diagnose CRPS. Until then, numerous different diagnostic and clinical criteria were used. As IASP criteria lacked specificity, a new set of diagnostic criteria were adapted at a closed conference of leading experts from around the world in the Fall of 2004 in Budapest, Hungary—these were called the ‘Budapest criteria’ (Table 1). The Budapest criteria were compared with the former IASP criteria and found to have a higher specificity while maintaining sensitivity, and were validated. Clinical presentation

Female chronic pelvic pain is common and complex

Chronic pelvic pain is simply long-term pain in the structures of natomic pelvis. This iswhere the simplicity stops. Since the female elvis contains organs and structures belonging to gynaecologial, gastrointestinal, urological andmusculoskeletal organ systems nyone or several of these organ systemsmay be involved in pelvic ain. Pain can be related to a specific diagnosis like endometriosis, nfection or tumour, but in other cases no specific pathology can e demonstrated. In some cases pain can be independent of the bvious pathology. The IASP (International Association for the Study of Pain) definiion of chronic pelvic pain is more limited stating that the pain has pparently gynaecological origin but for which no definitive lesion r cause can be found [1]. However, gynaecological disorders are ot the sole aetiologies behind chronic pelvic pain. Urinary and gasrointestinal aetiologies are common causes for chronic pelvic pain. n addition, patients with chronic pelvic pain often report concurent symptoms like irritable bowel syndrome or interstitial cystitis 2,3]. Large portions of patientswith chronic pelvic pain report pain n several areas, as well as chronic pain in other body parts [3–5]. hronic pelvic pain can be considered as a chronic pain syndrome long with chronic pain syndromes in other parts of the body with hanges in pain modulatory mechanisms. Due to localization of the pelvic pain delicate psychological ssues are involved and should be considered in research as well s in clinical management of the condition. Associated psychosoial problems cause further suffering and decrease in quality of life or these patients. On the other hand, psychological disturbances hould not be regarded as primary aetiological factors for chronic elvic pain.

Selected Reports From the 8th European Pain Congress; Pain in Europe VIII

ABSTRACTThe European Federation of IASP (International Association for the Study of Pain) Chapters (EFIC) held its 8th EFIC Congress in Florence, Italy, on October 9 to 12, 2013. Over 4000 clinicians and basic scientists attended the interdisciplinary congress. This report summarizes a range of selected presentations from the Congress. It is adapted from the authors’ abstracts of their work.

Prevalence of Neuropathic Pain According to the IASP Grading System in Patients with Chronic Non-Malignant Pain

The primary objective was to determine the prevalence of neuropathic pain according to the new International Association for the Study of Pain (IASP) grading system. The secondary objective was to compare the system classification of neuropathic pain with the classification of neuropathic pain according to a patient-administered screening questionnaire. A Multidisciplinary Pain Center. One hundred twenty patients with a variety of chronic pain conditions referred to a multidisciplinary pain center. Consecutively referred patients filled out the PainDETECT Questionnaire before the first consultation. During the first consultation, patients had pain history taken and bedside examination performed by a pain specialist. Patients were classified according to the score on the PainDETECT Questionnaire and graded according to the IASP grading system about the certainty of neuropathic pain. According to the IASP grading system, 22 patients (18.3%) classified as probable or definite neuropathic pain and 90 patients (75%) as unlikely neuropathic pain. According to the PainDETECT Questionnaire, 55 patients (45%) were classified as likely neuropathic pain and 13 patients (10.8%) as unlikely neuropathic pain. Eleven patients (20%) who were classified as neuropathic pain according to PainDETECT were also classified as probable or definite neuropathic pain by the new IASP grading system. According to the new IASP grading system, less than 20% of the patients referred to a multidisciplinary pain center fulfilled the criteria for neuropathic pain. The classification of neuropathic pain with the IASP system varies from the classification of neuropathic pain with the use of a self-administered screening questionnaire.

Central Post-stroke Pain and Pharmacological Treatment: Work in Progress

The International Association for the Study of Pain (IASP) defines central pain as “pain initiated or caused by a primary lesion or dysfunction of the central nervous system (CNS)” [1], at levels of spinal cord, brainstem or cerebral hemispheres. Central pain is less common in stroke than in other neurological diseases [2-4]. Central pain following stroke is a neuropathic chronic pain syndrome due to a post-stroke damage of CNS, resulting in anatomical, neurochemical, toxic, and inflammatory changes, causing an increase in neuronal excitability. Its frequency vary widely (8%–55%), reflecting small sample sizes, heterogeneous populations as well as differences in both study design, and chronic pain definition [3,5,6]. Central post-stroke pain can develops after both haemorrhagic and ischemic lesions occurring at any level of somato-sensory pathway of the brain, including medulla, thalamus, and cerebral cortex. Data from several studies indicate that the prevalence of central post-stroke pain is dependent on the location of the lesion, and occurrence is particularly high after lateral medullary infarction (or Wallenberg’s syndrome) or lesions in the ventroposterior thalamus [5]. Many of these patients will fulfil the diagnostic criteria for neuropathic pain, despite the pain being of nociceptive origin. In these cases, might be difficult to identify a central neuropathic element to the hemiplegic shoulder pain, spasticity, or other musculoskeletal pain and, in some cases, several pain types might be present in the same area of the body. The clinical manifestations of central post-stroke pain resemble those of other central and peripheral neuropathic pain syndromes [3,5]. There are no pathognomonic features or uniform signs with regard to onset, presentation, and intensity [5], and the characteristics and descriptions of central post-stroke pain vary substantially between patients. The presence of allodynia, hyperalgesia, or dysesthesia in response to the sensory examination is a predictor of central post-stroke pain [7]. The pathophysiology of central post-stroke pain is not well understood even if lack of central inhibition, imbalance of stimuli and central sensitization has been suggested. Moreover, a decrease of GABAergic inhibition has been observed at cortical, thalamic and spinal levels. Incomplete understanding of mechanisms underlying central post-stroke pain makes the development of targeted treatment demanding [3,5]. Moreover, the lack of published data from large and/or well-designed clinical trials involving patients with central post-stroke pain has created a situation where treatment guidelines are based upon “uncontrolled studies, clinical experience and expert opinion” [3].

Expanding the taxonomy of the diagnostic criteria for temporomandibular disorders

There is a need to expand the current temporomandibular disorders' (TMDs) classification to include less common but clinically important disorders. The immediate aim was to develop a consensus-based classification system and associated diagnostic criteria that have clinical and research utility for less common TMDs. The long-term aim was to establish a foundation, vis-à-vis this classification system, that will stimulate data collection, validity testing and further criteria refinement. A working group [members of the International RDC/TMD Consortium Network of the International Association for Dental Research (IADR), members of the Orofacial Pain Special Interest Group (SIG) of the International Association for the Study of Pain (IASP), and members from other professional societies] reviewed disorders for inclusion based on clinical significance, the availability of plausible diagnostic criteria and the ability to operationalise and study the criteria. The disorders were derived from the literature when possible and based on expert opinion as necessary. The expanded TMDs taxonomy was presented for feedback at international meetings. Of 56 disorders considered, 37 were included in the expanded taxonomy and were placed into the following four categories: temporomandibular joint disorders, masticatory muscle disorders, headache disorders and disorders affecting associated structures. Those excluded were extremely uncommon, lacking operationalised diagnostic criteria, not clearly related to TMDs, or not sufficiently distinct from disorders already included within the taxonomy. The expanded TMDs taxonomy offers an integrated approach to clinical diagnosis and provides a framework for further research to operationalise and test the proposed taxonomy and diagnostic criteria.

Treating Chronic Pain with CBT after a Stomach Cancer: What Strategies Can Be Used?

Dear Editor, We write to make some comments and pertinent observations regarding a recent case report. The International Association for the Study of Pain (IASP) [1] defines pain as “an unpleasant sensory and emotional experience associated with actual or potential tissue damage, or described in terms of such damage.” The IASP's definition highlights the multidimensional and subjective nature of pain, a complex experience that is unique to each individual. Operant behavior therapy for chronic pain is guided by the original operant conditioning principles proposed by Skinner [2] and refined by Fordyce [3] to be applicable to pain management. In this model, conditioned behaviors occur as a product of learning the consequences of engaging in the given behavior. Cognitive restructuring entails recognition of current maladaptive cognitions the patient is engaging in, challenging of the identified negative cognitions, and reformulation of thoughts to generate balanced, adaptive alternative thoughts. Research [4] has found cognitive behavioral therapy (CBT) to be an effective treatment for chronic pain and its sequelae as marked by significant changes in various domains when compared with wait-list control conditions. A meta-analysis [5] of 52 published studies compared CBT to habitual treatment control conditions and active control conditions at various …

Neuropathy, neuropathic pain, and sickle cell disease

Neuropathy, neuropathic pain, and sickle cell disease

Pain Management in Patients with Sickle Cell Disease – A Review

Pain is defined, by the International Association for the Study of Pain (IASP), as an ‘unpleasant sensitive and emotional experience, associated with or described in terms of tissue lesion’. It may be classified as acute or chronic when it becomes a symptom that worsens the quality of life, and thus loses its protective function. Pain may also be considered as chronic when it lasts over 3 to 6 months. Acute painful episodes, are the most common cause for patients with sickle cell disease (SCD) to seek medical attention. The causes of chronic pain are diverse in this population. In a sense, chronic sickle cell pain is a spin off the recurrent acute painful episodes. Pain management in patients with SCD presents unique challenges and opportunities.

Differential diagnosis of facial pain and guidelines for management

The diagnosis and management of facial pain below the eye can be very different dependant on whether the patient visits a dentist or medical practitioner. A structure for accurate diagnosis is proposed beginning with a very careful history. The commonest acute causes of pain are dental and these are well managed by dentists. Chronic facial pain can be unilateral or bilateral and continuous or episodic. The commonest non-dental pains are temporomandibular disorders (TMDs), especially musculoskeletal involving the muscles of mastication either unilaterally or bilaterally; they may be associated with other chronic pains. A very wide range of treatments are used but early diagnosis, reassurance and some simple physiotherapy is often effective in those with good coping strategies. Dentists will often make splints to wear at night. Neuropathic pain is usually unilateral and of the episodic type; the most easily recognized is trigeminal neuralgia. This severe electric shock like pain, provoked by light touch, responds best to carbamazepine, and neurosurgery in poorly controlled patients. Trauma, either major or because of dental procedures, results in neuropathic pain and these are then managed as for any other neuropathic pain. Red flags include giant cell arteritis which much be distinguished from temporomandibular disorders (TMD), especially in >50 yr olds, and cancer which can present as a progressive neuropathic pain. Burning mouth syndrome is rarely recognized as a neuropathic pain as it occurs principally in peri-menopausal women and is thought to be psychological. Chronic facial pain patients are best managed by a multidisciplinary team.

Antioxidant profile in patients with complex regional pain syndrome type I

Complex regional pain syndrome (CRPS) type I is one of the most important problems with regard to physical medicine and rehabilitation. CRPS may cause not only higher therapeutic costs but also greater work time loss. The mechanism and pathogenesis of CRPS still remains unknown. Some findings indicating oxidative stress have been reported. This study was carried out to determine the role of oxidative stress in patients with CRPS. Twenty patients (13 women and seven men) with CRPS and 20 age- and sex-matched healthy controls were enrolled in this study. Complex regional pain syndrome was diagnosed according to the modified International Association for the Study of Pain (IASP) criteria. We evaluated demographic, clinical and laboratory characteristics of the patients. Antioxidant enzymatic activities consisting of serum superoxide dismutase (SOD), glutathion peroxidase (GPX) and glutathione S-transferase (GST) activities were measured using appropriate methods and compared with healthy controls. The mean age of the patients was 39.5years and the mean duration of symptoms was 5.5months. Complex regional pain syndrome devoleped after a traumatic event in 90% of patients. In 10% of patients there were no traumatic events. SOD, GPX and GST levels were significantly higher in patients with CRPS than healthy controls (P=0.012, P=0.036 and P=0.016, respectively). Our findings suggest a possible role of oxidative stress in the pathogenesis of CRPS.

The Importance of Putting Pain on the Curricula in Medical Schools in Europe

ABSTRACTPain continues to be underdiagnosed and undertreated in Europe. A lack of training in pain medicine among clinicians has been identified as a barrier to optimal pain management. Except for clinicians entering specialized training in pain medicine or a related field, inadequate or nonexistent pain management training is the norm in Europe. A multidisciplinary group of experts, including representatives from the European Federation of IASP (International Association for the Study of Pain) Chapters (EFIC), is launching a pan-European initiative aimed at raising the profile and importance of undergraduate pain education.

Nociception and autonomic nervous system

The International Association for the Study of Pain (IASP) defines pain as "an unpleasant sensory and emotional experience associated with actual or potential tissue damage, or described in terms of such damage". Pain may also be experienced in absence of noxious stimuli and together with temperature and other bodily feelings constitute the interoception redefined as the sense of the physiological condition of the entire body, not just the viscera. The main characteristic of these feelings is the affective aspect. Emotion, motivation, and consequent behavior connected with these feelings characterize their homeostatic role. This implies an interaction between neural structures involved in pain sensation and autonomic control. The aim of this review is to focus on pain perception, mainly on pain matrix structures' connections with the autonomic nervous system.

An Update of the Systematic Appraisal of the Accuracy and Utility of Lumbar Discography in Chronic Low Back Pain

Background: The intervertebral disc has been implicated as a major cause of chronic lumbar spinal pain based on clinical, basic science, and epidemiological research. There is, however, a lack of consensus regarding the diagnosis and treatment of intervertebral disc disorders. Based on controlled evaluations, lumbar intervertebral discs have been shown to be the source of chronic back pain without disc herniation in 26% to 39% of patients. Lumbar provocation discography, which includes disc stimulation and morphological evaluation, is often used to distinguish a painful disc from other potential sources of pain. Despite the extensive literature, intense debate continues about lumbar discography as a diagnostic tool. Study Design: A systematic review of the diagnostic accuracy of lumbar provocation and analgesic discography literature. Objective: To systematically assess and re-evaluate the diagnostic accuracy of lumbar discography. Methods: The available literature on lumbar discography was reviewed. A methodological quality assessment of included studies was performed using the Quality Appraisal of Reliability Studies (QAREL) checklist. Only diagnostic accuracy studies meeting at least 50% of the designated inclusion criteria were included in the analysis. However, studies scoring less than 50% are presented descriptively and critically analyzed. The level of evidence was classified as good, fair, and limited or poor based on the quality of evidence developed by the U.S. Preventive Services Task Force (USPSTF). Data sources included relevant literature identified through searches of PubMed and EMBASE from 1966 to September 2012, and manual searches of the bibliographies of known primary and review articles. Results: Over 160 studies were considered for inclusion. Of these, 33 studies compared discography with other diagnostic tests, 30 studies assessed the diagnostic accuracy of discography, 22 studies assessed surgical outcomes for discogenic pain, and 3 studies assessed the prevalence of lumbar discogenic pain. The quality of the overall evidence supporting provocation discography based on the above studies appears to be fair. The prevalence of internal disc disruption is estimated to be 39% to 42%, whereas the prevalence of discogenic pain without assessing internal disc disruption is 26%. Conclusion: This systematic review illustrates that lumbar provocation discography performed according to the International Association for the Study of Pain (IASP) criteria may be a useful tool for evaluating chronic lumbar discogenic pain. Key words: Lumbar intervertebral disc, lumbar discography, provocation discography, analgesic discography, diagnostic accuracy

Don't Blame It on the Weather!

In his recent “Perspective” ⇓, Mark Lema does an excellent job of addressing the growing difficulties in providing high-quality pain care in the United States and those confronting the international movement, which aims for the universal recognition of pain relief as a fundamental human right. The latter campaign was officially launched on October 11, 2004 (“Global Day against Pain”) by the International Association for the Study of Pain (IASP) and the European Federation of IASP Chapters with the World Health Organization at a joint meeting in Geneva. Its basic premise is that inappropriate treatment of pain is unethical and “susceptible to both legal and professional action” ⇓. More recently, as part of the 13th World Congress on Pain in Montreal, the International Pain Summit, hosted by the IASP in September 2010, the summit delegates from 129 countries supported a “Declaration that Access to Pain Management is a Fundamental …

Visceral pain: the importance of pain management services.

Visceral pain: the importance of pain management services.

Neuropathic pain needs systematic classification

Neuropathic pain needs systematic classification

El laberinto del dolor y la necesidad de impulsar la investigación básica

The International Association for the Study of Pain (IASP),defines pain as “an unpleasant sensory and emotional expe-rience associated with actual or potential tissue damage, ordescribed in terms of such damage” [1,2]. Chronic pain is con-sidered as a disease and a public health problem worldwide.Pain is the most frequent reason for medical visits, in partic-ular among the elderly, with significant repercussions for thequality of life of the people who suffer from it. According tothe aphorism by Hippocrates, medicine does not always cure,but it must try to provide relief – from what – from pain. TheWorld Health Organization predicts that deaths due to cancer(the second leading cause of death in the world) will dou-ble by 2030; and every year there are 5.5 million people withend-stage cancer in whom pain management is inadequate[3].In thisnewcenturyintheUnitedStates,Congressdeclaredthe country’s purpose of designating the first decade asthe “10 years of pain research and control”[4]. Assessingpain as a vital sign (the fifth vital sign) and establishing a