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02.09.2014

Chronic pain management, get abs quick diet - Reviews

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With the number of individuals in need of assistance for chronic pain increasing each year, only a small fraction of patients with chronic pain are treated directly by the Pain Clinic.
Numerous studies conducted in countries all over the world have shown chronic pain to be a prevalent and costly problem.
In recognising the scope of the problem, in terms of prevalence, cost and human suffering, the KPNW Pain Management Clinic has created a programme to meet the needs of patients and care providers, all while keeping down costs of the overall organisation. As suggested earlier, the KPNW Pain Clinic firmly believes in the value of a multidisciplinary team. At the core of the KPNW Pain Clinic are the multidisciplinary group visits that help patients learn how to manage their pain on a day-to-day basis. While the PMC serves less than 10 per cent of patients with the most complex care needs, the primary care providers manage the majority of patients with chronic pain. Owing to the success of the PMC's services and the growing recognition of the need for aggressive pain management and the ageing of the population, the Pain Clinic has expanded to meet the growing needs of the KPNW population. The KPNW Pain Management Clinic approach has many components that are transferable to other settings. Lindsay Kindler has been a Clinical Nurse Specialist with the KPNW Pain Management Program since 2004. See related patient information handout on chronic pain, written by the author of this article. Pain epidemiology and health related quality of life in chronic non-malignant pain patients referred to a Danish multidisciplinary pain center.
Phantom limb pain in amputees during the first 12 months following limb amputation after preoperative lumbar epidural blockade.
Influence of physical, psychological and behavioural factors on consultations for back pain. A comparison of amitriptyline and maprotiline in the treatment of painful polyneuropathy in diabetics and nondiabetics. Successful treatment of painful traumatic mononeuropathy with carbamazepine: insights into a possible molecular pain mechanism. Gabapentin for the symptomatic treatment of painful neuropathy in patients with diabetes mellitus: a randomized controlled trial.
Phase III placebo-controlled trial of capsaicin cream in the management of surgical neuropathic pain in cancer patients. Prescription opiate abuse in chronic pain patients: clinical criteria, incidence, and predictors. The American Pain Foundation states that Americans get affected by pain more than diabetes, heart disease and cancer (American Pain Foundation).
Throughout the design and implementation of this pain programme, the KPNW Pain Management Clinic (PMC) has based its services on two facts of chronic pain care.
In order to optimise chronic pain care to all individuals, the PMC is committed to help primary care providers, give more effective, evidence-based pain management care. The electronic medical record now allows us to graph pain severity, functional interference over time (using the Wisconsin Brief Pain Inventory which is embedded in the electronic medical record) (Daut, CLeeland and Flanery, 1983). For instance, in both the states of Oregon and Washington (where KPNW provides care), it is required that all patients taking opioids for chronic pain have a signed consent and opiate therapy plan. Moving more services to regional locations will offer decreased travel distances for patients in pain, offer greater opportunity for collaboration among PMC's staff and regional primary care providers, and offer services specific to local needs. She is co-founder and Regional Coordinator of the Kaiser Permanente Northwest Pain Management Program. Recent animal studies have shown that remodeling within the central nervous system causes the physical pathogenesis of chronic pain.
Another study suggests that the costs of healthcare for patients with chronic pain exceed the combined costs of treating patients with coronary artery disease, cancer and AIDS (Turk, 2002). The two facts are: 1) Research on chronic pain management has consistently demonstrated the need for a multidisciplinary approach for effective long-term results.
These group visits help the primary care provider bring evidence-based pain management to members within their local area.
Each of the first seven weeks presents new ways to manage chronic pain, emphasising the need for a multidisciplinary, multimodal approach. To accomplish this goal, the staff of the PNC offers continuous education on pain management, consults individually via telephone or electronic messaging on questions of care, and provides tools and information to primary care providers. It was hypothesised that this reduced utilisation occurred because patients improved their skills to deal with their pain and felt more confident about their ability to manage the pain and changes in the pain over time (Donovan, Jacobs and Blake, 2002).


The PMC Multidisciplinary Groups have used this model of delivering Pain Management Clinic services at the site of the local clinic with great benefit over the years. Development of the Wisconsin Brief Pain Inventory to assess pain in cancer and other diseases.
This central neural plasticity results in persistent pain after correction of pathology, hyperalgesia, allodynia, and the spread of pain to areas other than those involved with the initial pathology. In general, pain levels do not significantly improve until the patient has begun reconditioning and has increased his or her level of daily activities.Treatment regimens generally involve a multidisciplinary approach, utilizing education, medication, and physical, occupational and behavioral therapy (Figure 2). The impact of chronic pain in the Northwest Region of Kaiser Permanente (a Health Maintenance Organisation in the Pacific Northwest, United States) has proven to be just as significant. 2) With the number of individuals needing assistance for chronic pain each year, only a small fraction of patients with chronic pain can be directly treated by the Pain Clinic.
For the sub-population of patients with both addictive disease and chronic pain, the clinic works closely with Addiction Medicine.
In the final eighth visit, a Pain Clinic practitioner and the patient work together to devise an individualised treatment plan. The Pain Clinic currently offers some services at a section of the region with a goal of being able to provide most services closer to patients. When there is no benchmark: Designing a primary care based chronic pain management program from the scientific basis up.
Clinical effectiveness and cost-effectiveness of treatments for patients with chronic pain.
Patient evaluation and management focus on pain symptoms, functional disabilities, contributory comorbid illnesses, and medication use or overuse.
Pain described as burning or associated with hypersensitivity over the painful area suggests neuropathic or nerve injury pain. Patients and their family and friends need to understand the pathology of chronic pain, the rationale for rehabilitation and the expected goals of treatment. With these facts in mind, the KPNW Pain Management Clinic devised a programme that has consistently worked to accomplish two goals-to help members with chronic pain get their lives back and to help primary care providers treat members with chronic pain more effectively.
Services offered by the KPNW Pain Management Clinic consist of several interrelated components.
Treatment of chronic pain involves a comprehensive approach using medication and functional rehabilitation. They need to know that pain has a physiologic basis, that improved function is essential to decreased pain, and that chronic pain may not entirely resolve. In 2003, the organisation did a survey of members with various chronic diseases and found that those with chronic pain showed the highest impairment and reported the most significant negative impact on their quality of life. Each of these components works to meet the needs of the individual patient while providing assistance to the primary care provider responsible for ongoing management of the patient's overall care. Functional rehabilitation includes patient education, the identification and management of contributing illnesses, the determination of reachable treatment goals and regular reassessment.
The tightening of the muscles forms a natural cast around the injury, and the negative sensation of pain promotes learning how to avoid similar injury in the future.
Pain quantity identifies pain as constant or intermittent, and whether activity or other factors influence the pain.These variables can be helpful diagnostically. Members with chronic pain are hospitalised more, make more emergency visits and outpatient visits than an average Kaiser Permanente member, even those with other chronic illnesses. As tissues heal, inflammation resolves, and the central nervous system sends out fewer signals, resulting in decreased pain and decreased muscle spasm.Less is known about the etiology of chronic pain. The clinic's anaesthesiologists and physiatrist make recommendations and implement advanced pain management procedures from blocks to radio frequency procedures to implantation. The Pain Management team proposed developing a DVD of the pain management group visits that could be used with telephone coaching as an alternative to group visits when patients cannot afford to attend the group visits in person. In addition, 58 percent of patients with chronic pain experience coexisting symptoms of depression or anxiety that also influence health care. Chronic pain often occurs in the absence of ongoing illness or after healing is completed, and often begins with an injury that causes inflammation and central nervous system changes. The internal medicine physicians and pharmacists consult their patients and their primary care providers to either implement or recommend medication management plan for patients with complex medication needs.
This mixture of physical, emotional and social abnormalities often complicates managing patients with chronic pain. But, for an unknown reason, the nervous system continues to send pain signals to somatic muscles, as though a new injury were occurring.


Intermittent, short-acting opioids, for example, may be useful for intermittent pain flares. Psychologic treatment addresses symptoms of depression and anxiety, and teaches stress management. Social workers, clinical nurse specialists and the psychiatric nurse practitioner consult Pain Clinic physicians or primary care providers for the management of patients with complex psychosocial needs and help develop treatment plans that optimise the resources and services of Kaiser Permanente. However, if prescribed for constant pain, patients will likely overuse them, taking them every three to four hours throughout the day.An assessment of the patient's functional status should involve a measurement of the ability to perform household chores, work tasks, leisure interests, and sleep.
Patients are also instructed in cognitive and behavioral techniques to improve their view of and reactions to their pain complaints. Although animal models are helpful, they cannot take into account the emotions and other factors that affect human perception of pain.Rodents exposed to injury, such as temporary sciatic nerve ligation, demonstrate pain behavior and central neural plasticity.
Coexisting disease may influence the patient's pain complaints (such as obesity) and the patient's ability to participate in treatment (such as cardiovascular and respiratory disease). Although these medications will not restore nerve function, they will reduce the burning quality of pain in most patients. For example, a temporary peripheral injury results in permanent central changes in the dorsal horn, including increases in neural sensitivity, excitation and receptive field size.4A typical rodent model of chronic pain involves tying a temporary ligature around the sciatic nerve.
Although the pathology has been corrected, the rat continues to demonstrate pain behaviors by biting the injured leg.5 Autopsy reveals structural changes within its central nervous system that alter neural transmission. This rodent model is similar to the human experience of persistent radiculopathy and pain complaints following removal of a herniated disk. The central sensitization that occurs after an acute, painful injury results in hyperalgesia, allodynia and spread of pain.Hyperalgesia is a lowered pain threshold.
Pain medications can be divided into those used for intermittent pain flares and those for chronic, constant pain.
They demonstrate increased numbers of action potentials and spontaneous discharges in response to painful stimuli. Treatment of intermittent flares may include aspirin, acetaminophen, nonsteroidal anti-inflammatory drugs (NSAIDs), tramadol (Ultram) and short-acting opioids.Although NSAIDs and short-acting opioids may be helpful with pain flares, they should not be used chronically on a daily basis in most cases. This increased number of action potentials is experienced as an elevated response to painful stimuli that were previously perceived as less painful.Allodynia is the perception of pain caused by usually nonpainful stimuli, such as touch or vibration. Chronic use of NSAIDs may be associated with significant side effects,23 including end-stage renal disease in two out of every 1,000 patients who use them daily for five or more years. The use of analgesic combination products is associated with the greatest risk of renal disease.24 Chronic use of NSAIDs, aspirin, or acetaminophen is also associated with hepatotoxicity or coagulopathy. After redistribution, mechanoreceptors stimulated by touch or vibration will activate pain pathways in the same way that nociceptive neurons will in response to pain.The spread of pain occurs because of an increase in the size of receptive fields within the dorsal horn.
The relatively short half-life (three to four hours) of these opioids encourages patients to use them every few hours if they are experiencing more constant pain. In a study of postamputation patients, 25 patients with preoperative limb pain were randomized to one of two groups.6 Eleven patients received 72 hours of continuous epidural bupivacaine hydrochloride (Marcaine) and morphine preoperatively, and 14 were in the control group.
This pattern of use encourages the development of tolerance.Use of long-acting opioids should be considered in patients who have a clear pain diagnosis, constant pain, pain with significant disability or regular analgesic overuse.
One week after amputation, 64 percent of the patients in the control group had phantom limb pain, compared with only 27 percent in the group that received the bupivacaine. After six months, 36 percent of patients in the control group and none in the epidural group were still experiencing pain. The epidural anesthetic blocked pain messages and appeared to also prevent remodeling of pain neurons.Nerve injury may result in multiple changes within the central nervous system that perpetuate the pain experience. Chronic use of opioid-only medication is generally not associated with significant organ toxicity or cognitive impairment. Hendler evaluated 106 pain patients with the Wechsler Adult Intelligence Scale, Memory Quotient, Bender Gestalt and electroencephalography.
Interestingly, in one study, patients who would eventually abuse opioids could not be identified by prescreening including a history of drug or alcohol abuse, drug and alcohol abuse screening tests, pain severity or frequency, patient's self-perceived need for opioids, or coexisting depression.29 When used for chronic pain, long-acting opioids should be prescribed in the same manner as other chronic maintenance medications.
These medications can help reduce pain and help increase functioning without significant organ toxicity. They should never be used with the goal of pain elimination or the reduction of psychologic complaints, like life stress, depression, anxiety, suffering and life dissatisfaction.



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