Devices for the relief and evaluation of pain: preface and comments

Pain is the most popular complaint since the appearance of the human on earth, a very unpleasant feeling sometimes difficult to be treated. Therefore, we have many patients who complain of pain in our hospitals or clinics. When a patient with pain visits our institution, first of all, we must evaluate the grade of pain, and then start to treat the pain of the patient. Of course, we have many devices available to treat the patient with pain. In the following special articles, device for evaluation of pain, spinal stimulation device, device for electrical current therapy (ECT), LASER device for chronic and acute pain, epiduroscopy for lumbago, as well as disposable infusion pump for postoperative pain and cancer pain are described. The mechanism of pain may be understood by patients themselves. However, devices in these articles are very useful for the treatment of pain, especially intractable pain. I feel very happy if these articles contribute greatly for the treatment of patients with pain.     

Pelvic pain in urogynecology. Part II: treatment options in patients with lower urinary tract symptoms

Therapeutic options for chronic pelvic pain in women offer only a limited symptom relief. Especially in the patient with lower urinary tract symptoms (LUTS), where overlap of pain, storage and voiding symptoms is common, data on the efficacy of treatment of pain are limited. We conducted a literature review to detect articles which pertained to female patients with LUTS and pelvic pain and we included articles which evaluated the efficacy of the treatment of pelvic pain. Forty-one articles were detected, which included nerve stimulation (sacral and pudendal), intravesical instillations and injections, oral pharmacological treatments, periurethral injections as well as physical and manual therapy as treatment options. Only five controlled trials were found, which did not show superiority of the active treatment versus placebo. Although some treatment options show promising results in the treatment of pelvic pain in patients with LUTS, more randomised controlled trials are needed to confirm these results.     

Mechanisms underlying generation of cancer pain

As advances in cancer detection and treatment have increased the life expectancy of cancer patients, more attention to improving patient's quality of life (QOL) is needed. Among symptoms accompanying cancer, pain has strong impact on QOL. Most of cancer patients will experience moderate to severe pain and/or neuropathy during the course of their disease. Cancer pain can arise from different processes, either by direct tumor infiltration/involvement, or toxicity relating to chemotherapy used to treat cancer. The World Health Organization (WHO) has proposed a structured approach to drug selection for cancer pain, known as the "WHO analgesic ladder". However, several types of pain including bone cancer pain and chemotherapy-induced painful peripheral neuropathy are difficult to treat. The development of optimal analgesics for cancer pain has been hampered by the lack of understanding basic mechanisms that contribute to cancer pain. Recently, preclinical models of bone cancer pain and paclitaxel-induced painful peripheral neuropathy have been developed. These models have begun to provide insight into the mechanisms by which cancer pain is induced and how cancer pain-related sensory information is processed. In this paper, we review mechanism of cancer pain.     

乳腺癌术后疼痛及镇痛方法的研究进展

背景 乳腺癌为女性患者常见的一种恶性肿瘤,手术治疗是主要的治疗措施.乳腺癌术后疼痛具有独特的疾病特点,并且可以成为一种慢性疼痛长期影响患者的生活质量,一直是临床亟待解决的问题. 目的 阐述乳腺癌术后疼痛及镇痛方法的研究进展,为疼痛的预防和治疗提供参考. 内容 综述乳腺癌术后疼痛及其镇痛方法的研究现状. 趋向 进一步探讨乳腺癌术后疼痛综合征的治疗方法,以明确有效的防治措施.     

Emergency pain treatment--ambulatory intravenous morphine titration in a patient with cancer pain

Even when the guidelines for cancer pain management are followed, acute severe pain requiring immediate treatment will occur in some patients. Titration with intravenous morphine may provide fast and efficient pain relief and give an indication of the amount of opioid necessary for continuous treatment. In cooperation with a general practitioner we performed an intravenous morphine titration in a patient with severe cancer pain at home. Adequate analgesia was reached with 20 mg intravenous morphine. Blood pressure, cardiac frequency and oxygen saturation did not change. No side effects were reported during the titration, and the previous regimen with tramadol 150 mg per day was switched to slow release morphine 300 mg per day. This medication was prescribed by the general practitioner and provided good pain relief until the patient died two weeks later. We conclude that intravenous morphine titration may be performed even in cancer patients at home, adequate monitoring, however, should be available.     

EAU guidelines on pain management

Pain is the most common symptom of any illness; the physician's therapeutic task is twofold: to discover and treat the cause of pain and the pain itself, whether or not the underlying cause is treatable, to provide relief and reduce the suffering caused by pain. Although we use the term of pain to define all sensations that hurt or are unpleasant, actually two quite different kinds of pain exist. The first (nociceptive) is associated with tissue damage or inflammation, the second (neuropathic) results from a lesion to the peripheral or central nervous systems. Pain can also be divided in acute and chronic. Caregivers are to face pain in two main settings: after surgery and in cancer patients. These tasks require a multidisciplinary team, able to properly assess and treat pain. Postoperative pain is to be treated early and aggressively. Several drug options are available, to be tailored on the surgical procedure and the patient. Pain in cancer patients consists of different aspects: it can be caused by the cancer itself or may be secondary to muscular spasm or cancer treatments. The management involves mainly pharmacotherapy, but also primary treatments as surgery, radiochemotherapy or even antibiotics can provide an adequate relief.Analgesics are to be employed according to an ascending scale, but other options can be combined to improve the outcome when a satisfactory balance between relief and side effects is not achieved; they include invasive techniques, physical and psychological therapy.The mainstay of pain management entails a interdisciplinary cooperation; it requires a full knowledge of the methods of evaluation and treatment of this condition.     

A proposed algorithm for the management of pain following spinal cord injury

STUDY DESIGN: Review. OBJECTIVES: To review published articles on the assessment, diagnosis and treatment of pain following spinal cord injury (SCI) and to synthesise evidence from these materials to formulate and propose a systematic approach to management. METHODS: Relevant articles regarding the treatment of pain were identified from electronic databases using the search terms (('spinal cord injury' or 'spinal cord injuries') and 'pain') and both ('treatment') and ('randomised controlled trials'). Relevant articles were also identified through citations in indexed journal publications and book chapters on this topic. RESULTS: Review of the literature indicates that there are a large variety of treatments used in the management of pain following SCI with a small number supported by strong evidence for effectiveness. A treatment algorithm is proposed based on identification of underlying pain contributors and application of appropriate treatment. CONCLUSION: Although there are relatively few studies clearly indicating efficacy in this population, an algorithm for the management of pain following SCI might assist to maximise our effectiveness in the treatment of this condition. It is recognised that choice of treatment is also determined by factors such as medication availability, cost and side effects as well as the preferences and characteristics of the person being treated. Nevertheless, an algorithm is proposed as a way to synthesise our current level of knowledge, identify gaps for further study and aid in the management of this difficult problem.     

A mechanism based understanding of cancer pain and development of novel strategies of cancer pain treatment

As advances in cancer detection and treatment have increased the life expectancy of cancer patients, more attention to improving patient quality of life is needed. The World Health Organization (WHO) has proposed a structured approach to drug selection for cancer pain, known as the "WHO analgesic ladder". This approach is capable of providing adequate relief to 70-90% of patients. However, the remaining 10-30% of patients are difficult to treat. The development of optimal analgesics for cancer pain has been hampered by the lack of understanding of basic mechanisms that contribute to cancer pain, which is due in part to the lack of appropriate animal models. Recently, preclinical models of bone cancer pain have been developed. These models have begun to provide insight into the mechanisms by which tumors cause pain and how cancer pain-related sensory information is processed. Once the mechanism by which cancer induces pain is elucidated, this would lead to the identification of molecular targets and the development of mechanism based therapies, which improve the quality of life of all those who suffer from cancer pain.     

The interdisciplinary management of cancer pain

For most patients, the most feared effect of cancer is the pain associated with the disease and its treatments. Poorly controlled pain in patients with cancer leads to suffering, poor nutrition, decreased compliance with treatment regimens, and increased mortality. Obviously, effective pain control is one of the pillars of effective global treatment of cancer in general. Historically, the treatment of pain in the cancer population was the responsibility of the medical oncologist, with escalating doses of opioids being the main form of therapy. Breakthroughs in diagnosis and treatment of cancer have led to patients living longer and potentially surviving this disease. Simple single-modal therapy with oral opioids fails to achieve adequate pain control in a significant percentage of patients. The interdisciplinary model for the management of cancer has long been a standard of practice, with collaboration among medical, radiation, and surgical oncologists. In this article, we describe an analogous approach to the management of cancer pain with collaboration among different specialties involved in the management of these patients.     

Epidural and intrathecal analgesia for cancer pain

The three-step analgesic ladder approach developed by the World Health Organization works well in treating the vast majority (70–90%) of patients suffering from pain related to cancer. In those patients who do not get pain relief by this three-step approach, intraspinal agents can be a fourth step in managing pain of malignant origin. Although morphine is the only opioid approved by the US Food and Drug Administration for intraspinal use, many different opioid analgesics are used intraspinally, including hydromorphone, fentanyl, sufentanil, meperidine and methadone in the treatment of cancer pain. Many non-opioid agents have also been used intraspinally either alone or in combination with opioids in the treatment of intractable cancer pain. This chapter summarizes the clinical use of these agents with some practical points.     

Medial thalamotomy using stereotactic radiosurgery for intractable pain: a systematic review

Medial thalamotomy using stereotactic radiosurgery (SRS) is a potential treatment for intractable pain. However, the ideal treatment parameters and expected outcomes from this procedure remain unclear. The aim of this systematic review is to provide further insights on medial thalamotomy using SRS, specifically for intractable pain. A systematic review was performed to identify all clinical articles discussing medial thalamotomy using SRS for intractable pain. Only studies in which SRS was used to target the medial thalamus for pain were included. For centers with multiple publications, care was taken to avoid recounting individual patients. The literature review revealed six studies describing outcomes of medial thalamotomy using SRS for a total of 125 patients (118 included in the outcome analysis). Fifty-two patients were treated for cancer pain across three studies, whereas five studies included 73 patients who were treated for nonmalignant pain. The individual studies demonstrated initial meaningful pain reduction in 43.3–100% of patients, with an aggregate initial meaningful pain reduction in 65 patients (55%) following SRS medial thalamotomy. This effect persisted in 45 patients (38%) at the last follow-up. Adverse events were observed in six patients (5%), which were related to radiation in five patients (4%). Medial thalamotomy using SRS is effective for select patients with treatment-resistant pain and is remarkably safe when modern radiation delivery platforms are used. More posteriorly placed lesions within the medial thalamus were associated with better pain relief. More studies are warranted to shed light on differences in patient responses.

     

Social pain

This chapter focuses on what social pain is and how it should be managed. In order to understand social pain in a cancer patient, it is necessary to recognize the change in the patient's daily life after the diagnosis of cancer. Because the degree of suffering and the relationships with family members and the people he or she worked with differ from patient to patient, it is important to note that the context of social pain is different in each patient. Five points shown below are essential in managing social pain. 1. Economical suffering may be alleviated by utilization of the social security system while taking into account each patient's standard of living. 2. Burdens on family members should be lessened, such as by not having them stay at the patient's bedside every day and letting them go home occasionally. 3. The normal patterns of communication, support, and conflict in the family should be identified, and the extent to which they have been disrupted by the illness should be assessed. 4. It is important to understand the ethnic, cultural, and religious background of the patient and the potential impact of their influence on the individual and the illness. 5. Practical or emotional unfinished business that the patient has needs to be identified, and efforts should be made to support fulfillment.     

Citation classics in main pain research journals

The number of citations of an article in scientific journals reflects its impact on a specific biomedical field and its recognition in the scientific community. In the present study, we identified and analyzed the characteristics of the 100 most frequently cited articles published between 1970 and 2010 in journals pertaining to pain research and related fields. These articles were identified using the database of the Science Citation Index (1970 to present). The most cited article received 3,017 citations and the least cited article received 302 citations, with a mean of 585 citations per article. These citation classics were published in six high-impact journals, led by Pain (84 articles). Of the 100 articles, 39 were observational studies, 25 were review articles, and 20 concerned basic science. The articles originated from 14 countries, with the United States contributing 47 articles; 67 institutions produced these 100 top-cited articles, led by National Institutes of Health of the United States (8 articles) and University College London (6 articles); 18 persons authored 2 or more of the top-cited articles. This analysis of the top citation classics allows for the recognition of major advances in pain research and gives a historical perspective on the scientific progress of this specialty.     

Pain management in a patient with intractable spinal cord injury pain: a case report and literature review

Chronic pain is one of the more disturbing sequelae of spinal cord injury, often interfering with the basic activities, effective rehabilitation, and quality of life of the patient. Pain in the cord-injured patient is often recalcitrant to treatment. This dilemma is amplified by the limited availability of effective pharmacological and nonpharmacological treatment options. We identified relevant articles regarding pain after spinal cord injury from the Medline database from 1975 to 2005 using the search terms "spinal cord injury" or "spinal cord injuries" and "pain" or "spasticity or "muscle spasms." We also searched by hand the review articles in a recently published book from the International Association for the Study of Pain Press on spinal cord injury pain, and identified relevant articles through reference lists. We present a patient with intractable spinal cord injury pain who was successfully treated with a pain management plan that addressed the various aspects of spinal cord injury pain. The evidence for treatment options is reviewed.     

Virtual reality for the treatment of neuropathic pain in people with spinal cord injuries: A scoping review

Context: Virtual and augmented imagery are emerging technologies with potential to reduce the severity and impact of neuropathic pain in people with spinal cord injury (SCI).Objective: We aimed to identify and discuss studies using virtual and augmented reality applications for the management of neuropathic pain in people with spinal cord injury.Methods (data sources, data extraction): A systematic literature search was conducted using PRISMA scoping review guidelines. Articles were searched in PubMed, Embase and Web of Science databases using search terms relating to SCI, virtual and augmented reality and neuropathic pain. With no strong evidence for visual imagery in the treatment of pain in SCI patients, we selected exploratory, feasibility and more rigorous methodologies such as randomized controlled trials and case-control studies. We only selected studies evaluating the effects of visual imagery on neuropathic pain at or below the spinal cord injury level.Results: Of 60 articles located, we included nine articles involving 207 participants. All studies were exploratory using head-mounted devices or 3D and 2D screens with virtual walking or limb movement imagery. Outcomes included pain sensitivity, motor function and body ownership. Eight of the nine studies reported significant reductions in neuropathic pain intensity. However, given small sample sizes in all studies, results may be unreliable.Conclusion: Although the number of studies and individual sample sizes are small, these initial findings are promising. Given the limited options available for the effective treatment of neuropathic SCI pain and early evidence of efficacy, they provide valuable incentive for further research.     

Enigma of urethral pain syndrome: Why are there so many ascribed etiologies and therapeutic approaches?

Urethral pain syndrome has had several sobriquets, which have led to much confusion over the existence of this pathological condition and the useful options in the care of the afflicted patient. Our aim was to explore the proposed etiologies of this syndrome, and to provide a critical analysis of each proposed etiology and present a balanced argument on the plausibility of the proposed etiology and therapeutic approaches. We carried out an English language electronic search in the following databases: Medline, Embase, Amed, Cinahl, Pubmed, Cochrane Library, Trip Database and SUMSearch using the following search terms: urethral syndrome, urethral diseases, urethra, urologic diseases etiology/etiology, presentation, treatment, outcome, therapeutics and treatment from 1951 to 2011. In excess of 200 articles were recovered. With the clearly defined objectives of analyzing the proposed etiologies and therapeutic regimes, two author(s) (HP and IO) perused the abstracts of all the recovered articles, selecting those that addressed the etiologies and therapeutic approaches to treating the urethral pain syndrome. The number of articles was reduced to 25. The full text of all 25 articles were retrieved and reviewed. Through the present article, we hope to elucidate the most probable etiology of this condition whilst simultaneously, advance a logical explanation for the apparent success in the treatment of this condition using a range of different therapeutic modalities. We have carried out a narrative review, which we hope will reduce some of the confusion around this clinical entity by combining the known facts about the disease.     

Prostate cancer pain management: EAU guidelines on pain management

Context

The first publication of the European Association of Urology (EAU) guidelines on Pain Management in Urology dates back to 2003. Since then, these guidelines have been revised several times with the most recent update achieved in 2010.

Objective

Given the scope of the full text guidelines, condensing the entire document was no option in this context. This paper presents a summary of the section of pain management in prostate cancer, a topic considered of direct relevance for the practicing urologist.

Evidence acquisition

A multidisciplinary expert panel (urologists, anaesthesiologists, radio-oncologists) compiled this document based on a comprehensive consultation of the literature. Data were identified through a structured search, covering the time frame 2000 through 2010, using Medline and Embase as well as the Cochrane Library of systematic reviews. The scientific papers were weighed by the expert panel and a level of evidence (LE) assigned. Recommendations have been graded as a means to provide transparency between the underlying evidence and the guidance provided.

Evidence summary

Pain can occur in each stage of prostate cancer. It could be caused by the cancer itself (77%), be related to the cancer treatment (19%) or be unrelated to either (3%). The incidence of pain rises to 90% as patients enter the terminal phase of their illness. The physician’s task is to discover and treat the cause of pain and the pain itself, to determine whether or not the underlying cause is treatable, to provide pain relief and palliative care. These tasks more often than not require a multidisciplinary team. Pain management involves mainly pharmacotherapy, including direct anticancer therapy such as androgen deprivation and chemotherapy, as well as analgetics, for instance non-steroidal anti-inflammatory drugs (NSAIDs) or opioids. In case of local impairment due to the cancer or its metastases, primary treatments like surgery, radiotherapy or radionuclides can provide adequate pain relief. In addition, in palliative care, functional, psychosocial and spiritual support are essential components. The EAU guidelines on Pain Management in Urology are available in a number of different formats through the EAU Central Office and the EAU website (http://www.uroweb.org/guidelines/online-guidelines/).

Conclusion

The mainstay of pain management in prostate cancer is involvement of and collaboration between experts from a number of disciplines to be able to achieve a complete pain evaluation and to offer the full range of treatment options. Prostate cancer–related pain can, in most cases, be managed effectively, but it requires careful monitoring where a balance should be found between pain relief and potential side effects of treatment and quality of life (QoL).