Current-Therapy-in-Pain.pdf

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CURRENT THERAPY IN PAIN ISBN: 978-1-4160-4836-7

Copyright ! 2009 by Saunders, an imprint of Elsevier Inc.

All rights reserved. No part of this publication may be reproduced or transmitted in any form or by any means, electronic or mechanical, including photocopying, recording, or any information storage and retrieval system, without permission in writing from the publisher. Permissions may be sought directly from Elsevier’s Rights Department: phone: (+1) 215 239 3804 (US) or (+44) 1865 843830 (UK); fax: (+44) 1865 853333; e-mail: [email protected]. You may also complete your request on-line via the Elsevier website at http:// www.elsevier.com/permissions.

Notice

Knowledge and best practice in this field are constantly changing. As new research and experience broaden our knowledge, changes in practice, treatment, and drug therapy may become necessary or appropriate. Readers are advised to check the most current information provided (i) on procedures featured or (ii) by the manufacturer of each product to be administered to verify the recommended dose or formula, the method and duration of administration, and contraindications. It is the responsibility of the practitioner, relying on his or her own experience and knowledge of the patient, to make diagnoses, to determine dosages and the best treatment for each individual patient, and to take all appropriate safety precautions. To the fullest extent of the law, neither the publisher nor the author assumes any liability for any injury and/or damage to persons or property arising out of or related to any use of the material contained in this book.

The Publisher

Library of Congress Cataloging-in-Publication Data

Current therapy in pain / [edited by] Howard S. Smith. – 1st ed. p. ; cm.

Includes bibliographical references and index. ISBN 978-1-4160-4836-7

1. Pain–Treatment. I. Smith, Howard S., 1956-[DNLM: 1. Pain–therapy. WL 704 C9758 2009] RB127.C92 2009

616’.0472–dc22 2008008166

Executive Publisher: Natasha Andjelkovic Editorial Assistant: Isabel Trudeau Design Direction: Steven Stave

Printed in United States of America

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I would like to dedicate this book to the memory of my mother, Arlene; to my wife Joan, and our children, Alyssa, Joshua, Benjamin, and Eric; and to my father Nathan, and stepmother Priscilla.

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Contributors

Salahadin Abdi, MD, PhD

Professor and Chief, University of Miami Pain Center, Department of

Anesthesiology, Perioperative Medicine and Pain Management, University of Miami Miller School of Medicine, Miami, Florida

PAINFUL DIABETIC PERIPHERAL NEUROPATHY; PAIN IN CHILDREN; BOTULINUM TOXINS FORTHE TREATMENT OF PAIN; EPIDURAL STEROID INJECTIONS; RADIOFREQUENCY TREATMENT; CRYOANALGESIA FOR CHRONIC PAIN Janet Abrahm, MD

Associate Professor of Medicine, Harvard Medical School; Director, Pain and Palliative Care Program, Dana-Farber Cancer Institute and Brigham and Women’s Hospital, and Division Chief, Palliative Care, Dana-Farber Cancer Institute, Boston, Massachusetts

PAIN IN THE PALLIATIVE CARE POPULATION Sanjeev Agarwal, MD

Assistant Professor, and Director,

Interventional Physiatry, SUNY Downstate Medical Center, Brooklyn, New York STEROIDS; SYMPATHETIC BLOCKADE Phillip J. Albrecht, PhD

Assistant Professor, Center for Neuropharmacology and Neuroscience, Albany Medical College; Integrated Tissue Dynamics, LLC, Albany New York COMPLEX REGIONAL PAIN SYNDROME PATHOPHYSIOLOGY

Catalina Apostol, MD Resident in Pain/Anesthesiology,

Department of Anesthesiology, University of Miami, Miami, Florida

BOTULINUM TOXINS FORTHE TREATMENT OF PAIN

Charles E. Argoff, MD

Professor of Neurology, Albany Medical College; Director, Comprehensive Pain Program, Albany Medical Center, Albany, New York

NEUROPATHIC PAIN-DEFINITION, IDENTIFICATION, AND IMPLICATIONS FOR RESEARCH ANDTHERAPY; ANTIDEPRESSANTS; BOTULINUM TOXINS FORTHE TREATMENT OF PAIN

Joseph F. Audette, MA, MD Assistant Professor, Department of Physical Medicine and Rehabilitation, Harvard Medical School, Boston, Massachusetts

COMPLEMENTARYAND ALTERNATIVE MEDICINE FOR NONCANCER PAIN Mark L. Baccei, PhD

Research Assistant Professor, Department of Anesthesiology, University of Cincinnati College of Medicine, Cincinnati, Ohio PATHOPHYSIOLOGY OF PAIN

Misha-Miroslav Backonja, MD Professor, Department of Neurology, Anesthesiology and Rehabilitation Medicine, University of Wisconsin School of Medicine and Public Health; Professor, University of Wisconsin Hospital and Clinics, Madison, Wisconsin

NEUROPATHIC PAIN-DEFINITION, IDENTIFICATION, AND IMPLICATIONS FOR RESEARCH ANDTHERAPY Zahid H. Bajwa, MD

Assistant Professor of Anesthesia and Neurology, Harvard Medical School; Director, Education and Clinical Pain Research, Beth Israel Deaconess Medical Center, Boston, Massachusetts

HEADACHES OTHERTHAN MIGRAINE; TRIGEMINAL NEURALGIA

Jeffrey R. Basford, MD, PhD Professor of Physical Medicine and Rehabilitation, Department of Physical Medicine and Rehabilitation, Mayo Clinic, Rochester, Minnesota

TRANSCUTANEOUS ELECTRICAL NERVE STIMULATION

Allison Baum, DPT

Spinal Cord Injury Peer Mentor Coordinator, St. Charles Hospital and Rehabilitation Center, Port Jefferson, New York

PHYSICAL MEDICINE APPROACHES TO PAIN MANAGEMENT

Joseph M. Bellapianta, MD, MS Department of Orthopaedic Surgery, Albany Medical Center, Albany, New York HAND PAIN; FOOT PAIN

Rafael Benoliel, BDS, LDS, RCS (Eng) Professor and Chairman, Department of Oral Medicine, Faculty of Dental Medicine, Hadassah Hebrew University, Jerusalem, Israel

OROFACIAL PAIN

Karen Bjoro, PhD(c), RN

Doctoral Student, The University of Iowa, Iowa City, Iowa; Nurse Researcher, Department of Orthopedics, Neurology and Neurosurgery, Ulleval University Hospital, Oslo, Norway

ASSESSMENT OF PAIN IN THE NONVERBAL AND/OR COGNITIVELY IMPAIRED

OLDER ADULT

Didier Bouhassira, MD

Universite´ de Versailles Saint Quentin, Versailles; Research Director, INSERM (U 792), Centre d’Evaluation et de Traitement de la Douleur, Hoˆpital Ambroise Pare´, Boulogne, France

BRAIN IMAGING IN PAINFUL STATES: EXPERIMENTAL AND CLINICAL PAIN Daniel Brookoff, MD, PhD Director, Center for Medical Pain Management, Presbyterian/St. Luke’s Medical Center, Denver, Colorado GENITOURINARY PAIN SYNDROMES: INTERSTITIAL CYSTITIS, CHRONIC PROSTATITIS, PELVIC FLOOR DYSFUNCTION, AND RELATED DISORDERS; SICKLE CELL ANEMIA

Patricia Bruckenthal, PhD, RN, ANP-C Clinical Associate Professor, Stony Brook University School of Nursing; Nurse Practitioner, Pain and Headache Treatment Center, Department of Neurology, North Shore/Long Island Jewish Health System, Manhasset, New York

ASSESSMENT OF PAIN IN OLDER ADULTS Sean Burgest, MD

Medical Director, The Burgest Clinic, Austin, Texas

FAILED BACK SURGERY SYNDROME

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Allen L. Carl, MD

Professor of Orthopaedic Surgery and Pediatrics, Albany Medical College, Albany, New York

BACK PAIN Juan Cata, MD

Resident, Institute of Anesthesiology, Critical Care, and Comprehensive Pain Management, Cleveland Clinic, Cleveland, Ohio

INTERPLEURAL ANALGESIA Brian D. Cauley, MD, MPH

Resident, Department of Anesthesiology and Critical Care, Massachusetts

General Hospital, Harvard Medical School, Boston, Massachusetts

POSTHERPETIC NEURALGIA Lucy Chen, MD

Instructor, Harvard Medical School; Attending Physician, Massachusetts General Hospital, Boston, Massachusetts OPIOIDTOLERANCE, DEPENDENCE, AND HYPERALGESIA

Jianguo Cheng, MD, PhD

Staff, Department of Pain Management, Institute of Anesthesiology, Critical Care, and Comprehensive Pain Management, Cleveland Clinic, Cleveland, Ohio INTERPLEURAL ANALGESIA Pradeep Chopra, MD, MHCM Assistant Professor (Clinical), Brown Medical School, Providence, Rhode Island; Assistant Professor (Adjunct), Boston University Medical Center, Boston, Massachusetts

THORACIC PAIN

Paul J. Christo, MD, MBA Assistant Professor, Johns Hopkins University School of Medicine; Director, Multidisciplinary Pain Fellowship, and Director, Pain Treatment Center, The Johns Hopkins Hospital, Baltimore, Maryland

PELVIC PAIN; POSTHERPETIC NEURALGIA; COMPLEX REGIONAL PAIN SYNDROME: TREATMENTAPPROACHES

Daniel Ciampi de Andrade, MD Universite´ de Versailles Saint Quentin, Versailles; Clinical Fellow, INSERM (U 792), Centre d’Evaluation et de Traitement de la Douleur, Hoˆpital Ambroise Pare´, Boulogne, France

BRAIN IMAGING IN PAINFUL STATES: EXPERIMENTAL AND CLINICAL PAIN Eli Cianciolo, MD

Clinical Instructor and Pain Medicine Fellow, Harvard Medical School, and Massachusetts General Hospital, Boston, Massachusetts

NONSTEROIDAL ANTI-INFLAMMATORY DRUGS AND CYCLOOXYGENASE-2 INHIBITORS

Daniel Clayton, MD, PhD

Resident, Division of Neurosurgery, Duke University Medical Center, Durham, North Carolina

NEUROSURGICALTREATMENT OF PAIN Steven P. Cohen, MD

Associate Professor, Department of Anesthesiology, and Director of Medical Education, Johns Hopkins University School of Medicine, Baltimore, Maryland; Director of Pain Research and Colonel, United States Army, Walter Reed Army Medical Center, Washington, DC SPINAL ANALGESIA

Alane B. Costanzo, MD

Anesthesiology Resident, University of Miami Miller School of Medicine, Jackson Memorial Hospital, Miami, Florida EPIDURAL STEROID INJECTIONS Sukdeb Datta, MD, DABIPP, FIPP Associate Professor, and Program Director, Vanderbilt University Pain Medicine Fellowship, Vanderbilt University Medical Center; Director, Vanderbilt University Interventional Pain Center, Nashville, Tennessee

EPIDURAL ADHESIOLYSIS Emily A. Davis, MSN, ACNP

Division of Neurosurgery, Duke University Medical Center, Durham, North Carolina SPINAL CORD STIMULATION FORTHE TREATMENT OF CHRONIC INTRACTABLE PAIN; NEUROSURGICALTREATMENT OF PAIN Timothy R. Deer, MD

President and Chief Executive Officer, The Center for Pain Relief; Clinical Professor, West Virginia University, Charleston, West Virginia

EPIDEMIOLOGY OF COMPLICATIONS IN INTERVENTIONAL PAIN MANAGEMENT Martin L. DeRuyter, MD

Associate Professor of Anesthesiology and Staff Anesthesiologist, University of Kansas Medical Center, University of Kansas School of Medicine, Kansas City, Kansas PERIOPERATIVE EPIDURAL ANALGESIA; CONTINUOUS PERIPHERAL NERVE CATHETERTECHNIQUES

Anthony Dragovich, MD Director, Pain Management Center, Womack Army Medical Center, Fort Bragg, North Carolina; Assistant Professor, Department of Anesthesiology, Uniformed Services University of the Health Sciences, Bethesda, Maryland

SPINAL ANALGESIA

Andrew Dubin, MD, MS

Associate Professor of Physical Medicine and Rehabilitation, Albany Medical College; Attending Physician, Albany Medical Center Hospital; Medical Director, Capital Region Spine, Albany, New York POST AMPUTATION PAIN DISORDERS; POSTSTROKE PAIN

Demetri Economedes, DO Department of Orthopaedic Surgery, Albany Medical Center, Albany, New York HAND PAIN

Eli Eliav, DMD, PhD

Professor and Director, Division of Orofacial Pain, and Susan and Robert Carmel Endowed Chair in Algesiology, University of Medicine and Dentistry of New Jersey-New Jersey Dental School, Newark, New Jersey

OROFACIAL PAIN Jennifer A. Elliott, MD

Assistant Professor, Department of Anesthesiology, University of Missouri-Kansas City School of Medicine; Staff Pain Physician, Saint Luke’s Hospital, Kansas City, Missouri

PATIENT-CONTROLLED ANALGESIA; 2-AGONISTS

Nasr Enany, MD

Assistant Professor and Attending Anesthesiologist, University of Cincinnati, Cincinnati, Ohio

SYMPATHETIC BLOCKADE Jonathan Epstein, MD, MA

Fellow, Obstetric Anesthesia, Mount Sinai Medical Center, New York, New York TRAMADOL

Ike Eriator, MD, MPH

Associate Professor, University of Mississippi School of Medicine; Chief, Pain Management Services, University of Mississippi Medical Center, Jackson, Mississippi

CANCER PAIN MANAGEMENT David Euler, LicAc

Co-Director, Continuing Medical Education Course, Harvard Medical School, Boston, Massachusetts COMPLEMENTARYAND ALTERNATIVE MEDICINE FOR NONCANCER PAIN Vania E. Fernandez, MD

Assistant Professor of Anesthesiology, University of Miami School of Medicine; Pain Management Fellow, Department of Anesthesiology, Perioperative Medicine and Pain Management, Jackson Memorial Hospital, Miami, Florida

PAINFUL DIABETIC PERIPHERAL NEUROPATHY

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Richard Field, MD

Pain Fellow, Massachusetts General Hospital, and Harvard Medical School, Boston, Massachusetts

RADIOFREQUENCY TREATMENT Nanna Brix Finnerup, MD Associate Research Professor, Aarhus University, Aarhus, Denmark SPINAL CORD INJURY

Colleen M. Fitzgerald, MD

Assistant Professor, Feinberg School of Medicine, Northwestern University; Medical Director, Women’s Health Rehabilitation, Rehabilitation Institute of Chicago, Chicago, Illinois

FEMALE PERINEAL/PELVIC PAIN:THE REHABILITATION APPROACH Marc D. Fuchs, MD

Associative Clinical Professor, Department of Orthopaedic Surgery, Albany Medical College, Albany, New York

HIP PAIN

Aimee Furdyna, BS

Department of Orthopaedic Surgery, Albany Medical Center, Albany, New York BACK PAIN

Christine Gallati, BS

Research Assistant, Pharmaceutical Research Institute at Albany College of Pharamacy, Albany, New York PAIN AND SLEEP

Padma Gulur, MD

Pain Specialist, Center for Pain Medicine, Massachusetts General Hospital; Instructor in Anesthesia, Harvard Medical School, Boston, Massachusetts

PAIN IN CHILDREN Payam Hadian, BA College of Arts and Sciences, University of Rochester, Rochester, New York

DIAGNOSIS ANDTREATMENT OF FACET-MEDIATED CHRONIC LOW BACK PAIN

R. Norman Harden, MD

Director, Center for Pain Studies, and Addison Chair, Rehabilitation Institute of Chicago; Associate Professor, Feinberg School of Medicine, Northwestern University, Chicago, Illinois

INTERDISCIPLINARY MANAGEMENT FOR COMPLEX REGIONAL PAIN SYNDROME Keela Herr, PhD, RN, FAAN, AGSF Professor and Chair, Adult and Gerontology, The University of Iowa College of Nursing, Iowa City, Iowa ASSESSMENT OF PAIN IN THE NONVERBAL AND/OR COGNITIVELY IMPAIRED OLDER ADULT

Greg Hobelmann, MD

Postdoctoral Fellow, Division of Pain Medicine, Department of Anesthesiology and Critical Care Medicine, Johns Hopkins University School of Medicine, Baltimore; Pain Medicine Specialists, P.A., Towson, Maryland

PELVIC PAIN

Steven H. Horowitz, MD

Clinical Professor of Neurology, University of Vermont College of Medicine,

Burlington, Vermont; Assistant in Neurology, Massachusetts General Hospital, Boston, Massachusetts NEUROPATHIC PAIN: IS THE EMPEROR WEARING CLOTHES?

Christina K. Hynes, MD

Clinical Instructor, Feinberg School of Medicine, Northwestern University; Attending Physician, Rehabilitation Institute of Chicago, Chicago, Illinois FEMALE PERINEAL/PELVIC PAIN:THE REHABILITATION APPROACH Kenneth C. Jackson, II, PharmD Associate Professor, Pacific University School of Pharmacy; Associate Editor, Journal of Pain and Palliative Care Pharmacotherapy, Hillsboro, Oregon OPIOID PHARMACOTHERAPY ChaunceyT. Jones, MD

Resident, Department of Anesthesiology and Critical Care Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland

COMPLEX REGIONAL PAIN SYNDROME: TREATMENTAPPROACHES

Douglas Keene, MD

Director of Pain Management, Department of Anesthesia, Milton Hospital, Milton, Massachusetts; Co-founder, Boston PainCare, Waltham, Massachusetts RADIOFREQUENCY TREATMENT Kenneth L. Kirsh, PhD

Assistant Professor, Pharmacy Practice and Science, University of Kentucky; Attending Clinical Psychologist, The Pain Treatment Center of the Bluegrass, Lexington, Kentucky

POTENTIAL DOCUMENTATION TOOLS FOR OPIOIDTHERAPY; PAIN IN THE SUBSTANCE ABUSE POPULATION

Jan Kraemer, MD

Clinical Fellow, Harvard Medical School, Boston, Massachusetts

HEADACHES OTHERTHAN MIGRAINE Michael A. Krieves, BS

Department of Orthopaedic Surgery, Albany Medical Center, Albany, New York HIP PAIN; KNEE PAIN

Clete A. Kushida, MD, PhD, RPSGT Director, Stanford University Center for Human Sleep Research; Associate Professor, Stanford University Medical Center, Stanford University Center of Excellence for Sleep Disorders, Stanford, California

PAIN AND SLEEP

Elizabeth Demers Lavelle, MD

Assistant Professor, SUNY Upstate Medical University, Syracuse, New York

HAND PAIN; BACK PAIN; HIP PAIN; KNEE PAIN; FOOT PAIN; RHEUMATOID ARTHRITIS; MYOFASCIALTRIGGER POINTS; INTRA-ARTICULAR INJECTIONS

Lori A. Lavelle, DO

Staff Physician, Altoona Arthritis and Osteoporosis Center, Duncansville, Pennsylvania

RHEUMATOID ARTHRITIS; INTRA-ARTICULAR INJECTIONS

William F. Lavelle, MD

Assistant Professor, Department of Orthopaedic Surgery, SUNY Upstate Medical University, Syracuse, New York HAND PAIN; BACK PAIN; HIP PAIN; KNEE PAIN; FOOT PAIN; RHEUMATOID ARTHRITIS; MYOFASCIALTRIGGER POINTS; INTRA-ARTICULAR INJECTIONS

Andrew Linn, MD

Clinical Fellow in Anesthesia, Harvard Medical School, and Beth Israel Deaconess Medical Center, Boston, Massachusetts TRIGEMINAL NEURALGIA

Dave Loomba, MD

Assistant Professor, University of California, Davis, Sacramento;

Anesthesiologist, Enloe Medical Center, Chico, California

SACROILIAC JOINT PAIN Karan Madan, MBBS, MPH

Instructor in Anaesthesia, Harvard Medical School; Staff, Pain Management Center, Department of Anesthesia, Perioperative and Pain Medicine, Brigham and Women’s Hospital, Boston, Massachusetts

PAIN AND PAIN MANAGEMENT RELATEDTO HIV INFECTION

Gagan Mahajan, MD

Associate Professor, and Director,

Fellowship in Pain Medicine, University of California, Davis, Sacramento, California SACROILIAC JOINT PAIN

Jianren Mao, MD, PhD

Associate Professor, Harvard Medical School; Attending Physician, Massachusetts General Hospital, Boston, Massachusetts OPIOIDTOLERANCE, DEPENDENCE, AND HYPERALGESIA

ix CONTRIBUTORS

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John D. Markman, MD Director, Neuromedicine Pain Management Center and Translational Pain Research, Department of Neurosurgery, University of Rochester School of Medicine and Dentistry, Rochester, New York

LUMBAR SPINAL STENOSIS: CURRENT THERAPYAND FUTURE DIRECTIONS; DIAGNOSIS ANDTREATMENT OF FACET-MEDIATED CHRONIC LOW BACK PAIN Eric M. May, MD

Assistant Professor of Anesthesiology, University of Missouri-Kansas City; Staff Anesthesiologist, Saint Luke’s Hospital, Kansas City, Missouri

CONTINUOUS PERIPHERAL NERVE CATHETERTECHNIQUES

Gary McCleane, MD, FFARCSI

Consultant in Pain Management, Rampark Pain Centre, Lurgan, Northern Ireland, United Kingdom

PAIN IN THE ELDERLY; OPIOIDS ISSUES; ANTIEPILEPTIC DRUGS; LOCAL ANESTHETICS; MUSCLE RELAXANTS; TOPICAL ANALGESIC AGENTS James McLean, MDy

Pain Fellow, Rehabilitation Institute of Chicago; Department of

Physical Medicine and Rehabilitation, Feinberg School of Medicine, Northwestern University, Chicago, Illinois

Sangeeta R. Mehendale, MD, PhD Research Associate, Department of Anesthesia and Critical Care, Pritzker School of Medicine, University of Chicago, Chicago, Illinois

GASTROINTESTINAL DYSFUNCTION WITH OPIOID USE

Harold Merskey, DM, FRCPC, FRCPsych

Professor Emeritus of Psychiatry, University of Western Ontario, London, Ontario, Canada

THE TAXONOMY OF PAIN Tobias Moeller-Bertram, MD Assistant Clinical Professor, Department of Anesthesiology, University of California, San Diego, La Jolla, California

Mila Mogilevsky, DO, PT

Resident Physician, Rehabilitation Institute of Chicago, Department of Physical Medicine and Rehabilitation, Northwestern University, Chicago, Illinois

Xavier Moisset, MD

Universite´ de Versailles Saint Quentin, Versailles; Clinical Fellow, INSERM (U 792), Centre d’Evaluation et de Traitement de la Douleur, Hoˆpital Ambroise Pare´, Boulogne, France BRAIN IMAGING IN PAINFUL STATES: EXPERIMENTAL AND CLINICAL PAIN Muhammad A. Munir, MD

Chairman, Southwest Ohio Pain Institute, West Chester, Ohio

STEROIDS; NONSTEROIDAL ANTI-INFLAMMATORY DRUGS AND CYCLOOXYGENASE-2 INHIBITORS; SYMPATHETIC BLOCKADE

Beth B. Murinson, MS, MD, PhD Assistant Professor of Neurology, Johns Hopkins University School of Medicine; Active Staff, Johns Hopkins Medical Institutions, The Johns Hopkins Hospital, Baltimore, Maryland

A MECHANISM-BASED APPROACH TO PAIN PHARMACOTHERAPY:TARGETING PAIN MODALITIES FOR OPTIMALTREATMENT EFFICACY

Lida Nabati, MD

Instructor of Medicine, Harvard Medical School; Attending Physician, Division of Palliative Care, Dana-Farber Cancer Institute, Boston, Massachusetts

PAIN IN THE PALLIATIVE CARE POPULATION Srdjan S. Nedeljkovic¤, MD

Fellowship Director, Pain Medicine Program, and Staff, Pain Management Center, Department of Anesthesia, Perioperative and Pain Medicine, Brigham and Women’s Hospital; Assistant Professor of Anaesthesia, Harvard Medical School, Boston, Massachusetts

PAIN AND PAIN MANAGEMENT RELATEDTO HIV INFECTION

Lisa J. Norelli, MD, MPH, MRCPsych Assistant Professor of Psychiatry, Albany Medical College; Director of Psychiatry, Capital District Psychiatric Center, Albany, New York

HYPNOTIC ANALGESIA Akiko Okifuji, PhD

Professor of Anesthesiology, and Attending Psychologist, Pain Management Center, University of Utah, Salt Lake City, Utah PSYCHOLOGICAL ASPECTS OF PAIN

Ike Onyedika, BS

Department of Orthopaedic Surgery, Albany Medical Center, Albany, New York HAND PAIN

Susan Elizabeth Opper, MD

Assistant Professor of Medicine, University of Missouri-Kansas City School of Medicine; Director, Pain Management Services, Saint Luke’s Hospital, Kansas City, Missouri

NECK PAIN

Richard K. Osenbach, MD

Director, Neurosurgical Services, Cape Fear Valley Medical Center, Fayetteville, North Carolina

SPINAL CORD STIMULATION FORTHE TREATMENT OF CHRONIC INTRACTABLE PAIN; NEUROSURGICALTREATMENT OF PAIN Joshua Pal, MD

Clinical Fellow, Harvard Medical School, Boston, Massachusetts

HEADACHES OTHERTHAN MIGRAINE Marco Pappagallo, MD

Professor, Department of Anesthesiology, Mount Sinai School of Medicine; Director, Pain Medicine Research and Development, Mount Sinai Medical Center, New York, New York

NEUROPATHIC PAIN-DEFINITION, IDENTIFICATION, AND IMPLICATIONS FOR RESEARCH ANDTHERAPY;TRAMADOL Amar Parikh

Research Assistant, Albany Medical College, Albany, New York POST AMPUTATION PAIN DISORDERS Winston C.V. Parris, MD, FACPM Professor of Anesthesiology, and Director, Pain Programs, Duke University Medical Center; Division Chief, Duke Pain and Palliative Care Center, Duke University Hospital, Durham, North Carolina CANCER PAIN MANAGEMENT Steven D. Passik, PhD

Associate Professor of Psychiatry, Weill College of Medicine, Cornell University Medical Center; Associate Attending Psychologist, Memorial Sloan Kettering Cancer Center, New York, New York PAIN IN THE SUBSTANCE ABUSE POPULATION

Gira Patel, LicAc

Clinical Associate, Osher Integrative Care Center, Harvard Medical School Osher Institute; Division for Research and Education in Complementary and Integrative Medical Therapies, Arnold Pain Clinic, Beth Israel Deaconess Hospital, Boston, Massachusetts

COMPLEMENTARYAND ALTERNATIVE MEDICINE FOR NONCANCER PAIN

y

Deceased

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Eric M. Pearlman, MD, PhD Director, Pediatric Education, and Assistant Professor of Pediatrics, Mercer University School of Medicine; Savannah Neurology, P.C., Savannah, Georgia

MIGRAINE HEADACHES Richard A. Pertes, DDS

Clinical Professor, Division of Orofacial Pain, University of Medicine and Dentistry of New Jersey-New Jersey Dental School, Newark, New Jersey

OROFACIAL PAIN Annie Philip, MD

Assistant Professor, Department of Anesthesiology, University of Rochester School of Medicine and Dentistry, Rochester, New York

DIAGNOSIS ANDTREATMENT OF FACET-MEDIATED CHRONIC LOW BACK PAIN

Mark Anthony Quintero, MD Pain Management Fellow, Department of Anesthesiology, Perioperative Medicine and Pain Management, University of Miami Miller School of Medicine, Jackson Memorial Hospital, Miami, Florida CRYOANALGESIA FOR CHRONIC PAIN Lynn Rader, MD

Clinical Instructor, Feinberg School of Medicine, Northwestern University; Attending Physician, Rehabilitation Institute of Chicago, Chicago, Illinois PHYSICAL MEDICINE APPROACHES TO PAIN MANAGEMENT

Lakshmi Raghavan, PhD Associate Director, Research and Development, Vyteris Corporation, Inc. Fair Lawn, New Jersey

PAIN IN CHILDREN

Rakesh Ramakrishnan, BS Department of Orthopaedic Surgery, Albany Medical Center, Albany, New York HIP PAIN; KNEE PAIN

Alan M. Rapoport, MD

Clinical Professor of Neurology, David Geffen School of Medicine at UCLA, Los Angeles, California; Founder and Director Emeritus, The New England Center for Headache, P.C., Stamford, Connecticut MIGRAINE HEADACHES

Rahul Rastogi, MD

Assistant Professor, Washington University in St. Louis; Assistant Professor and Attending Anesthesiologist, Barnes-Jewish Hospital, St. Louis, Missouri

SYMPATHETIC BLOCKADE

Scott S. Reuben, MD

Professor of Anesthesiology and Pain Medicine, Tufts University School of Medicine, Boston; Director, Acute Pain Service, Baystate Medical Center, Springfield, Massachusetts

PERIOPERATIVE USE OF COX-2 AGENTS Frank L. Rice, PhD

Professor, Center for Neuropharmacology and Neuroscience, Albany Medical College; Integrated Tissue Dynamics, LLC, Albany, New York

COMPLEX REGIONAL PAIN SYNDROME PATHOPHYSIOLOGY

Melissa A. Rockford, MD

Assistant Professor of Anesthesiology, University of Kansas Medical Center, University of Kansas School of Medicine, Kansas City, Kansas

PERIOPERATIVE EPIDURAL ANALGESIA Carl Rosati, MD

Associate Professor of Surgery, Albany Medical College; Trauma Director, Albany Medical Center, Albany, New York ABDOMINAL PAIN

Mike A. Royal, MD, JD, MBA Vice President, Clinical Development -Analgesics, Cadence Pharmaceuticals, Inc., San Diego, California

ACETAMINOPHEN

Christine N. Sang, MD, MPH Director, Translational Pain Research, Brigham and Women’s Hospital, Harvard Medical School, Boston, Massachusetts GLUTAMATE RECEPTOR ANTAGONISTS Nalini Sehgal, MD, FABPMR Associate Professor, Department of Orthopedics and Rehabilitation, University of Wisconsin School of Medicine and Public Health; Medical Director, Interventional Pain Program, and Pain Fellowship Program Director, University of Wisconsin Hospital and Clinics, Madison, Wisconsin

CRYOANALGESIA FOR CHRONIC PAIN Ashutosh Sharma, PhD

Chief Strategic Officer, Vyteris, Inc., Fair Lawn, New Jersey

PAIN IN CHILDREN Lee S. Simon, MD

Associate Clinical Professor of Medicine, Harvard Medical School, Beth Israel Deaconess Medical Center, Boston, Massachusetts

OSTEOARTHRITIS: ETIOLOGY, PATHOGENESIS, ANDTREATMENT

ThomasT. Simopoulos, MD

Instructor in Anaesthesia, Harvard Medical School; Director of Interventional Pain Management, Beth Israel Deaconess Medical Center, Boston, Massachusetts FAILED BACK SURGERY SYNDROME Jeremy C. Sinkin, BA

Department of Neurosurgery, University of Rochester School of Medicine and Dentistry, Rochester, New York LUMBAR SPINAL STENOSIS: CURRENT THERAPYAND FUTURE DIRECTIONS David J. Skinner, MD

Assistant Professor, Departments of Anesthesiology and Pain Management, Mount Sinai School of Medicine; Assistant Professor, Mount Sinai Medical Center, New York, New York

TRAMADOL

Michelle Skinner, MS

Graduate Student, Department of Psychology, University of Utah, Salt Lake City, Utah

PSYCHOLOGICAL ASPECTS OF PAIN Howard S. Smith, MD, FACP, FACNP Associate Professor of Anesthesiology, Internal Medicine, Physical Medicine and Rehabilitation, Albany Medical College, Academic Director of Pain Management, Department of Anesthesiology, Albany Medical Center, Assistant Director of Clinical Research at The Pharmaceutical Research Institute, Albany College of Pharmacy, Albany, New York NEUROPATHIC PAINçDEFINITION, IDENTIFICATION, AND IMPLICATIONS FOR RESEARCH ANDTHERAPY; POTENTIAL DOCUMENTATION TOOLS FOR OPIOID THERAPY; POST AMPUTATION PAIN DISORDERS; COMPLEX REGIONAL PAIN SYNDROME PATHOPHYSIOLOGY; PAIN AND SLEEP; OPIOIDS ISSUES; ACETAMINOPHEN; ANTIDEPRESSANTS; GLUTAMATE RECEPTOR ANTAGONISTS; BOTULINUM TOXINS FOR THE TREATMENT OF PAIN; CRYOANALGESIA FOR CHRONIC PAIN

Paul E. Spurgas, MD

Associate Professor of Neurosurgery, Division of Neurosurgery, Albany Medical Center, Albany, New York; Temple University, Philadelphia, Pennsylvania VERTEBROPLASTYAND KYPHOPLASTY Steven C. Stain, MD

Neil Lempert Professor, and Chair, Department of Surgery, Albany Medical College; Chief of Surgery, Albany Medical Center Hospital, Albany, New York ABDOMINAL PAIN

xi CONTRIBUTORS

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Steven Stanos, DO

Assistant Professor, Feinberg School of Medicine, Northwestern University; Medical Director, Rehabilitation Institute of Chicago, Chicago, Illinois

Roland Staud, MD

Professor of Medicine, University of Florida, Gainesville, Florida FIBROMYALGIA SYNDROME Richard L.Uhl, MD

Professor of Surgery, Albany Medical College, Albany; Adjunct Professor of Biomedical Engineering, Rensselaer Polytechnic Institute, Troy; Chief, Orthopaedic Surgery, Albany Medical Center Hospital, Albany, New York SHOULDER PAIN; ELBOW PAIN Mark Wallace, MD

Professor of Clinical Anesthesiology, and Program Director, Center for Pain Medicine, Department of Anesthesiology, University of California, San Diego, La Jolla, California

Deirdre M.Walsh, DPhil, BPhysio Professor of Rehabilitation Research, Health and Rehabilitation Sciences Research Institute, University of Ulster, Newtownabbey, County Antrim, Northern Ireland, United Kingdom

TRANSCUTANEOUS ELECTRICAL NERVE STIMULATION

Chris Warfield, BA

Research Assistant, Arnold Pain

Management Center, Beth Israel Deaconess Medical Center, Boston, Massachusetts COGNITIVE THERAPY FOR CHRONIC PAIN Ajay D.Wasan, MD, MSc

Assistant Professor, Harvard Medical School; Departments of Anesthesiology and Psychiatry, Brigham and Women’s Hospital, Boston, Massachusetts ANTIDEPRESSANTS

Lynn R.Webster, MD, FACPM, FASAM Medical Director, Lifetree Clinical Research and Pain Clinic, Salt Lake City, Utah

PAIN AND SLEEP Richard Whipple, MD

Assistant Clinical Professor, Department of Orthopaedic Surgery, Albany Medical College, Albany, New York

HAND PAIN

Joshua Wootton, MDiv, PhD Assistant Professor, Department of Anaesthesia, Harvard Medical School; Director of Pain Psychology, Arnold Pain Management Center, Beth Israel Deaconess Medical Center, Boston, Massachusetts COGNITIVE THERAPY FOR CHRONIC PAIN

James P.Wymer, MD, PhD

Assistant Professor of Neurology, Albany Medical College; Upstate Clinical Research, Albany, New York

GLUTAMATE RECEPTOR ANTAGONISTS Chun-SuYuan, MD, PhD

Cyrus Tang Professor, Department of Anesthesia and Critical Care, Pritzker School of Medicine, University of Chicago, Chicago, Illinois

GASTROINTESTINAL DYSFUNCTION WITH OPIOID USE

Jun-Ming Zhang, MD, MSc Associate Professor and Director of Research, Department of Anesthesiology, University of Cincinnati College of Medicine, Cincinnati, Ohio

PATHOPHYSIOLOGY OF PAIN; STEROIDS; NONSTEROIDAL ANTI-INFLAMMATORY DRUGS AND CYCLOOXYGENASE-2 INHIBITORS

YiLi Zhou, MD, PhD

Courtesy Clinical Assistant Professor, University of Florida; Medical Director, Comprehensive Pain Management of North Florida, Gainesville, Florida DIAGNOSIS AND MINIMALLY INVASIVE TREATMENT OF LUMBAR DISCOGENIC PAIN xii CONTRIBUTORS

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Preface

The International Association for the Study of Pain (IASP) has defined pain as ‘‘an unpleasant sensory and emotional experience associated with actual or potential tissue damage, or defined in terms of such damage’’. Donald Price in his 1999 book Psychological Mechanisms of Pain and Analgesia by IASP Press pro-posed an alternative definition, arguing that the IASP definition does not emphasize the experiential nature of pain. He holds that pain is a ‘somatic perception containing (1) a bodily sensation with qualities like those reported during tissue-damaging stimulation, (2) an experienced threat associated with this sensation, (3) a feeling of unpleasantness or other negative emotion based on this experi-enced threat’.

In 1931, the French medical missionary, Dr. Albert Schweitzer wrote ‘‘Pain is a more terrible lord of mankind than even death itself’’. These words emphasize the scope of total human suffering due to pain which may dramatically affect a person’s life/quality of life. Pain remains among one of the most debilitating symptoms as well as one of the most common symptoms which patients report. Blair Smith and Nicole Torrance have addressed the Epidemiology of Chronic Pain as a chapter in the book, Systematic Reviews in Pain Research: Methodology Refined edited by Henry J. McQuay, Eija Kalso, and R. Andrew Moore and pub-lished by IASP Press in 2008. They write that it seems that up to half of the adult population suffers from chronic pain as defined by the broad IASP definition and that 10-20% experience chronic pain when measures of clinical significance are added to the definition. They further state that the incidence of chronic pain (though diffi-cult to estimate) may be between 5% and 10% per year and is associated with poor health-related quality of life in all studies that measured this variable.

Numerous potential therapeutic targets exist which may modulate nociceptive processing including: ion channels, TRP channels, ASIC channels, stretch-activated channels, signaling molecules/casades (pERK, p38MAPK protein kinases), neurotrophins (BDNF, GDNF, NGF) inflammatory mediators, cytokines, adhesion molecules, immune cells/glia, neurotransmitters (SP, NK1, CCK), adrenergic receptors, purinergic receptors, toll-like receptors, and glutamate receptors. Furthermore, it is not uncommon that opposing anti-inflammatory processes may exist for certain pro-anti-inflammatory/ pro-nociceptive processes (e.g., acetylation of MKP-1 promotes the interaction of MKP-1 with its substrate p38 MAPK, which results in dephosphorylation of p38 MAPK). However, some of these targets do not have clinically available agents to specifically enhance or inhibit their function and even if these agents existed, clinicians would not know which agents to utilize for a specific individual patient’s pain complaints.

Furthermore, analgesics, modalities, neuromodulation, and interventional techniques, etc. should not be used ‘‘in a vacuum’’, but rather optimally in conjunction with physical medicine, beha-vioral medicine, and other techniques as part of an interdisciplinary team approach. Additionally, it is conceivable that some pain

complaints in some patients may need therapies targeting periph-eral, spinal, as well as supraspinal mechanisms in efforts to fully address their issues.

Despite an explosion of basic science pain research, the transla-tion of these advances into tangible and clinically useful diagnostic and therapeutic measures to identify and ameliorate various human painful conditions has lagged. Unfortunately, despite valiant efforts, too many people continue to exist with horrific pain and suffering, some who have been helped a little, and some who have not been helped at all. The field of Pain Medicine is still relatively in its infancy, but continues to gradually mature. Thus, it was heartening to learn that as we approach the tail end of the ‘‘decade of pain’’; Elsevier is adding the book ‘‘Current Therapy in Pain’’ to its criti-cally acclaimed ‘‘Current Therapy’’ series. Perhaps one of the best known books in this series is Conn’s Current Therapy, which was initially published in 1943 and has been revised yearly since. After 65 years, Current Therapy in Pain has surfaced in efforts to deliver a source of current information on the field of pain medicine which will be updated reasonably frequently. In keeping with the style of the series ‘‘Current Therapy in Pain’’ is clinically oriented. However, in contrast to other Current Therapy texts, ‘‘Current Therapy in Pain’’ does not present all chapters without references. Although I initially set out with the intention to keep this format, which is seen in some chapters, it became apparent that it would be challenging to have all the chapters without references, largely due to the immaturity and dynamic nature of the field of pain medicine.

The text is organized to initially present background informa-tion on pain —taxonomy, pathophysiology and assessment. Various treatment strategies for acute pain are then presented. The next sections deal with a number of conditions/syndromes/ issues which are painful or may interface with pain. Section IV is devoted to Pain in Special Populations. Finally, Sections VII through XIII deal with treatment approaches to pain (pharmaco-logic, behavioral medicine, physical medicine and rehabilitation, neuromodulation, complementary and alternative medicine, neuro-surgical, and interventional). The text, although not comprehensive of all pain-relieving strategies, is felt to present a reasonable repre-sentation of available therapeutic options which may help alleviate pain. Furthermore, because of the dynamic nature of pain and the attempt to present current information, it is not intended that all treatment strategies presented in the text are ‘‘tried and true’’ thera-pies which have stood the test of time, but only that they are or may be available options for certain circumstances, now or in the future. It is hoped that the experts who contributed to this text have presented information which may be helpful/educational to clini-cians and/or patients and that future editions continue to present current and useful information related to the ever-changing field of pain medicine.

HOWARDS. SMITH, MD

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Acknowledgments

The editor would like to thank and acknowledge the enormous efforts of Pya Seidner who helped to bring this project to fruition. The editor would like to acknowledge and thank the Reflex Sympathetic Dystrophy Association (RSDA) for the use of Dr. R. Norman Harden’s chapter which was initially written for RSDA.

The editor would also like to acknowledge and thank Dr. Kevin W. Roberts, Chairman of the Department of Anesthesiology for Albany Medical College, for his continued support throughout this project.

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Foreword

I distinctly remember the moment, more than 25 years ago. It is frozen in my memory as if it occurred yesterday. With eyes closed, my senses recall the dim lighting, the squeaking of aged and rarely waxed tongue-and-groove flooring underfoot, the musty smell of weathered paper, dried binding glue and dust. This was the library in the teaching hospital that served as my ‘‘home away from home’’ as a neophyte physician. And that was where I went to seek help when I began to steadily encounter patients with pain problems. And there were, it seemed, so many . . . yet, on whose behalf my attending physicians shrugged their collective shoulders and skill-fully redirected the stream of discussion to more discernible pathol-ogy. There was no malice, just discomfort, and I discovered why. No one knew anything. The library shelves were devoid of journals and texts on the subject.

Fast forward to 2008, and there is such an outpouring of pain-related literature, I have to purposefully block out my schedule every Friday afternoon to peruse what comes across my desk just to keep up before the week ends. Sure, I have learned that it’s okay to say ‘‘I don’t know’’, but there will be no shoulder-shrugging or

avoidance of the subject when medical trainees ask me those diffi-cult questions about the most common problem experienced by people seeking medical care: pain! But how can most clinicians— who have so many areas of medicine to keep up on—also keep up on all the advances in pain assessment and management?

The answer lies between the covers of this well-written, compre-hensive yet pointedly practical text. In this new addition to the highly valued ‘‘Current Therapy’’ series, Dr. Howard Smith has assembled many of the leading authorities in this rapidly-evolving field to do that all-important and selfless work: write a book that really can, and will, help to improve peoples’ lives. Would that I could have discovered such a gem when I went searching, way back in ‘‘the dark ages’’ of the late 20th century!

PERRYG. FINE, MD

Professor of Anesthesiology Pain Research Center University of Utah School of Medicine Salt Lake City, Utah

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I

P

AIN

B

ACKGROUND

Chapter 1 T

HE

T

AXONOMY OF

P

AIN

Harold Merskey

INTRODUCTION

Taxonomy is the theory and practice of classification. For an ideal classification, each item to be considered should be independent of all other items so that it stands in its own place in the classification. For example, if we wish to classify peoples’ names for a telephone directory, each name must represent a separate and distinguishable item. The classification must also be comprehensive (Box 11). If two or more people have names such as John A. Smith, then an additional criterion must be used to distinguish each John A. Smith and this can be done by adding a street address. If there are two John A. Smiths, each with his own telephone number at exactly the same address—most likely father and son, or if there are three, grandfather, father, and son—they may use a numeric superscript or a numeric postscript as John A. Smith1, John A. Smith2, John A. Smith.3That provides a perfect classification useful for the pur-pose for which it is intended and of little or no interest besides.

Natural classifications such as animal, vegetable, or mineral are more exciting and even sometimes intellectually beautiful, for example, the periodic table in chemistry. Nearly always (apart per-haps from some isotopes made by people) this meets the highest standards of classification also. Each element has a place of its own into which it fits and no other element with which it can be con-fused. Evolutionary classifications of flora and fauna similarly achieve great success, although disputes may arise in marginal cases (Box 12).

Medical classification lacks the rigor of either the telephone directory or the periodic table. It is exceptionally untidy, but it is taken to reflect in some way ‘‘the absolute truth’’ or at least the wonderful truth, as known to the best practitioners. Accordingly, physicians endeavor to create true descriptions of individual ‘‘true’’ disorders, each helping to some extent to improve upon the worth of the previous ones. Classification may then be bedeviled by an argument about the criteria that apply to a particular diagnosis, for example, what is Cervicogenic Headache? What is the difference after an injury between that and Migraine if Migraine occurs with photophobia or phonophobia and nausea? Are there two or more disorders, each with its essential characteristics?

These disputes form an interesting adjunct to classification and may or may not be illuminating, but resolving them is not part of the primary function of a classificatory system. Classification is not a means of reaching an absolute truth but rather a means of estab-lishing ways to code data that can be shared and compared between different practitioners or investigators.

The main task of the classifier is simply to make sure that indi-viduals can identify and locate types of objects or events. The clas-sifier is not required to establish a true ‘‘meaning.’’1 Thus, if physicians in different parts of the world wish to exchange infor-mation about headache, it is not necessarily important to resolve, first, whether Migraine should or should not include phonophobia in its classification. Rather, it is important to identify headaches that are unilateral or bilateral, and then whether photophobia, phono-phobia, nausea, and vomiting occur together with varying durations of the event. Thus, data can be collected for comparison between different groups with respect to the items used to identify particular events, and any consequences that we wish to suppose follow from them, such as loss of response to different treatments and so forth. Of course, this does mean that one has to have some sort of idea about which criteria one wishes to put together in one classificatory slot and which criteria go into another classificatory slot. We are not really interested in comparing cases of headache with cases of elephantiasis. That separation is easily made. Separations between types of headache become a topic for study within the framework of an overall definition.

It is just as well that classification can be used in the way just mentioned. Were that not the case, we would be left with irrecon-cilable arguments and spend all our time trying to determine whether all physical illnesses were hereditary and secondary to psy-chological status, or whether some physical illnesses certainly were due to environmental causes and others resulted from ill treatment in childhood.

A workable system of classification needs to proceed on the basis of information that is largely agreed and to define areas of disagreement so that these can be further explored. This is a reasonable way to avoid controversy about medical diagnoses and to pursue knowledge.

EXISTING MEDICAL CLASSIFICATIONS

Existing medical classifications vary enormously but are all, or nearly all, illogical. In the International Classification of Diseases and Related Health Problems, 10th edition (ICD-10),2for example, we find that conditions are classified by causal agent (e.g., infectious diseases or neoplasms); by systems of the body (e.g., gastrointestinal or genitourinary); or by symptom pattern and type of psychiatric illnesses (including affective psychosis, schizophrenic psychosis, organic psychoses, depressive and anxiety disorders, and personality disorders) (Box 13).

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All of the psychiatric conditions just mentioned, except for Personality Disorders, are segregated into a category known in the American Psychiatric Association’s Diagnostic and Statistical Manual of Mental Disorders in several editions (DSM-IV TR, at present3) as ‘‘Axis I Type Disorders,’’ and Personality Disorders are classified in an additional axis (Axis II). Patients may have any number of disorders from Axis I (e.g., Major Depressive Disorder plus Post-Traumatic Stress Disorder), and another diag-nosis as well on Axis II (e.g., 301.4 Obsessive Compulsive Personality Disorder) (Box 14).

Medical diagnoses can also be classified by time of occurrence in relation to stages of life, for instance, congenital anomalies, condi-tions originating in the perinatal period, or presenile and senile disorders. At the lowest level of classification, that is, the simplest and least complex description of phenomena, conditions used to be classified simply as ‘‘Symptoms, Signs and Ill-Defined Conditions’’ and are now classified as Symptoms and Signs, which actually con-stitute a group on their own in the ICD-10.2Not only illness is classified in medical lists. There was also a code in ICD-94: ICD650 for delivery in a completely normal case of pregnancy. The nearest to this now appears in ICD-10 as Single Spontaneous Delivery.

Within the major medical groups of ICD-9 and -10 and partic-ularly the neurologic section, there are subdivisions by symptom pattern (e.g., epilepsy or migraine), by the presence of hereditary or degenerative disease (e.g., cerebral degenerations that may be manifest in childhood or adult life), and by symptom pattern (e.g., Parkinson’s disease, chorea, and types of cellular change).

Accordingly, there are also diagnoses by location (e.g., spinocer-ebellar disease) and by infectious causes within the neurologic group (which is defined first by location, e.g., meningitis).

If we look at pain disorders, there are codes in the ICD-10 for ‘‘Migraine’’ (G43) and 9 subtypes, and separately for ‘‘Other Headache Syndromes’’ (G44) with 10 subcategories. There are codes for ‘‘Juvenile Ankylosing Spondylitis’’ (M081) and for ‘‘Ankylosing Spondylitis in adults’’ (M45), as for ‘‘Seropositive Rheumatoid Arthritis’’ (M05) with 6 subordinate categories and for ‘‘Other Rheumatoid Arthritis’’ with 9 subordinate categories (M06). Among Symptoms and Signs, we find ‘‘Headache’’ (R51). In the Cardiologic section, R07 includes precordial pain in the anterior chest wall (NOS); this may be pain in the musculoskeletal system or refer to a neuralgic type of pain and precordial pain, which may well not be cardiac. If we look at Endocrinology, we may simply diagnose ‘‘Diabetes,’’ which was once one disorder but is now defined in terms of 5 subtypes on a biochemical and therapeutic basis. Among Musculoskeletal conditions, we have ‘‘Fibromyalgia’’ defined by a distribution of pain and tender points and not by what might be its supposed innermost essence, and ‘‘Repetitive Strain Syndrome’’ is diagnosed, whether rightly wrongly, on the basis of pain in parts that are overused.

To resolve some of the problems of comparing these illnesses, the American Psychiatric Association’s DSM-III5provided at least

five different Axes on which conditions might be classified includ-ing Axis I: Clinical Disorders; Axis II: Personality Disorders, Mental Retardation, or Specific Development Disorders; Axis III: General Medical Conditions; Axis IV: Psychosocial and Environmental Problems; and Axis V: Global Assessment of Functioning. This system allows us to classify both symptom patterns and people, an interesting conclusion, although the classification of people is notoriously unreliable whether by psychiatrists or by anyone else in the medical context.

To add to these hazards, we can also note that we may diagnose psychiatric conditions from serology (e.g., genetics [e.g., Huntington’s chorea]), symptom pattern (e.g., schizophrenia, depression, bipolar illness), reported mechanism (e.g., tension headache), and even the presence or the absence of irrational behavior (e.g., psychosis vs. neurosis, although the latter term is not much used nowadays and was dropped from DSM-III onward).

One of the obvious responses in a situation in which classifica-tion cannot be provided on a theoretical basis is to provide agreed operational definitions. This brings us back to the starting point of this discussion at which it was pointed out that only two things really matter in a classification system, one is a distinction between A, B, and C and the other is that everything from A to Z will be included that is part of the material to be classified.

Thus, it follows that even within medicine, the range of classi-ficatory systems can be enormous. There are highly specialized and valuable classifications that will code the varieties and degrees of a single diagnostic category such as stroke,6and there are also classi-fications that cover not just the type of illness or condition exam-ined but simply the reason for consultation. Thus, the ICCPC, the International Classification of Conditions in Primary Care7 _does not classify diseases but rather the reason for contact between the family practitioner and her or his patient. Such a classification will include the reason for a patient being in the doctor’s office (e.g., advice on a symptom, review of treatment, completion of a referral form, and completion of an insurance company form). Box 11 IDEALCLASSIFICATION

Comprehensive

Specific place for each item

Box 14 AMERICANPSYCHIATRICASSOCIATION DIAGNOSTIC ANDSTATISTICALMANUAL OF MENTALDISORDERS

From American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders, 4th ed. (DSM-IV). Washington, DC: APA Press, 2000.

Box 13 MEDICALCLASSIFICATION By Cause Bacteria By Organ Pneumonia By System Pneumonia Parkinson’s Disease By Site

Low back pain By Symptom Headache

Box 12 TYPES OFCLASSIFICATION Natural

Mineral Vegetable Artificial Telephone directory

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All these items are classifiable and can be examined for whatever statistical purpose desired. The one thing classification does not do is provide a statement of absolute truth about the ultimate meaning of all medical disorders—or even one.

CLASSIFICATIONOF PAIN

In 1983, citing others, it was said that, ‘‘There has long been a need for classification in the field of pain.’’1A classification of pain was prepared originally for the International Association for the Study of Pain, and first published in 1986,8with a second edition in 1994. The aim of the classification is described in the introduction to the 1994 volume9_{as being to classify the major causes of chronic pain} and to organize descriptions of the syndromes. It turned out slightly differently.

At first, it was not felt possible nor desirable to classify all painful conditions. A good classification of pain was principally required for practitioners who were specializing in the treatment of painful disorders and who needed to distinguish them from other disorders and disabilities. Thus, it was inappropriate to include the pain of appendicitis or tonsillectomy in a classification of chronic pain, but it was desirable to have a systematic arrangement of conditions that commonly caused chronic pain. Any attempt to do otherwise would, of course, have amounted to writing an extensive textbook of medicine. The purpose of such a classification would be to pro-vide a means of communication between specialists in the field of pain, enable them to know that when one published a report on, for example, sprain injuries, the same disorders would be at least broadly similar to that which a different person would call by the same name, even internationally. A few types of acute pain were admitted to the classification for comparative purposes and because they frequently gave rise to chronic pain (e.g., postherpetic neur-algia). The Taxonomy of Chronic Pain, which was produced by the Task Force on Taxonomy of the International Association for the Study of Pain (IASP), known as the Sub-Committee, thus attempted to cover the major causes of chronic pain and some illustrative examples of acute pain.

That being easily decided, the most difficult problem was to determine the best approach to organizing pain syndromes. It is obviously theoretically possible to arrange pain syndromes by region of the body or by organ system (e.g., cardiac pains, muscu-loskeletal pains, and pain due to neurologic illness, and so forth). Alternatively, one might arrange pain syndromes by their purported causes (e.g., postherpetic neuralgia, which it is immediately obvious also could come under the Neurologic rubric.

THE IASP CLASSIFICATION

The Task Force on Taxonomy of the IASP decided, after some vig-orous discussion, that it would be unwise to classify on the basis of etiology. Etiology is the topic that most concerns practitioners because we think that it leads us to make the most useful diagnoses. Diagnosis is seen as the avenue to correct treatment. To give up the idea that we can classify by etiology first means recognizing that the empirical methods of medicine are not yet good enough to provide etiologic classification, at least in the field of pain.

An attempt was made by a group at the National Institutes for Dental Research in the late 1970s to classify orofacial pain by etiology. The IASP subcommittee concluded that, although the clas-sification was detailed and well worked out, there was insufficient agreement on etiology to make that approach satisfactory for pain as a whole. An impressive classification had actually been developed by the late Dr. John Bonica in his classic work, The Management of Pain.10_{Bonica had started with regions of the body and turned to} diagnosis only after he had arranged the subject by region. The committee was unanimous that the best way to start was by

region of the body because this was the least controversial and should be the first basis for classification.

The next step was to look at whether systems, patterns of pain, or etiology should come next. Etiology again lost out. The system involved seemed to be the next obvious agreed basis for arranging observations on pain. Not only was etiology displaced from the first position and the second position, but there was also agreement that it should be left to the end to work out what we could best do about it. Accordingly, the next part of the classification system focused upon the temporal characteristics of pain and the pattern of occur-rence for which coding was provided. Everyone was comfortable after that in grading the pain according to its intensity, and so, the first four Axes of a pain classification had emerged as regions, systems, temporal characteristics, and intensity combined with duration since onset. Finally, room was left for etiology, and that was classified as genetic or congenital: trauma; surgery; infective or parasitic; inflammatory but with no known infective agent and immune reactions; neoplasm; toxic; metabolic; degenerative; dys-functional (including psychophysiologic); unknown or other; and lastly, psychological origins. Each of these codings acquired a number from 0 to 9 (Box 15).

As an example of how the coding system works, consider common migraine. Migraine was coded 4 in the third Axis on the basis the pattern of occurrence being one of recurring irregularly. A period is inserted for convenience of citing extra numbers. Axis IV reflects the patient’s statement of intensity and time since the onset of pain, so that a mild pain present for 1 month or less was coded at.1, and a severe pain present for more than 6 months was coded at.9. Because this criterion can vary from case to case within the same diagnostic category, the letter X was placed to reflect the fourth Axis and to signify that each case would have its features determined on the occasion of coding and not arbitrarily beforehand.

Code 7 concerning Migraine was a statement indicating modesty about knowledge of the exact origins of the condition. Thus, the initially constructed code for Common Migraine ran 004.X7. However, Classical Migraine also satisfies these criteria, and there-fore, Classical Migraine was coded as 004.X7a and Common Migraine was coded as 004.X7b.

A code of 0 is given for the head, face, and mouth; 0 for the nervous system, whether central, peripheral autonomi,c or special senses.

As indicated, the X code symbol was used to permit the clinician to determine the features of that particular case in accordance with whether the intensity was mild, medium, or severe, and the dura-tion was less than 1 month, between 1 month and 6 months, or more than 6 months. Thus, mild intensity of more than 6 months was rated as 3, medium intensity of more than 6 months was rated as 6, severe intensity equal to or more than 1 month but less than 6 months was rated at 8, and so on.

Lastly as indicated, codes were given for etiology. Despite using five places organized at a default sequence of XXX.XX which in the case of common migraine, as just discussed, was shown as 004.X7b, a number of classifications could theoretically use these additional codes. In order to discriminate between conditions occupying the same five Axis locations, additional letters were required, namely a, b, c, and d, so that Classical and Common Migraine were coded as 0004.X7a and 004.X7b, respectively.

Box 15 IASP CLASSIFICATION I. Site

II. System III. Pattern of Pain

IV. Intensity and Duration of Pain V. Etiology

IASP, International Association for the Study of Pain.8

3 I PAIN BACKGROUND

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This system of coding by special characteristics is intended to allow comparisons between groups of cases. To the best of my knowledge, it has not been used a lot in clinical practice or in research investigations. However, a number of the diagnostic cate-gories have been popular, clinicians frequently referring to the descriptions and characteristics provided for them. This particularly applies to fibromyalgia and complex regional pain syndrome, con-ditions in which there was more doubt about the traditional appre-ciation of the disorder. The section on Back Pain is also used by some. As well, occasional rare syndromes that appeared in the clas-sification were conveniently identified through it by members of the IASP who were able to refer to relevant sections of the classification in order to assist a diagnosis. This was noted, for example, with the fairly rare syndrome of painful legs and moving toes, which some-times also involves the arms and which is due to dorsal ganglion or spinal cord damage. This is a condition that was on occasion previously treated as ‘‘hysteria.’’

THE USES OF CLASSIFICATION

The uses of classification are thus essentially pragmatic (Box 16). It is important to understand that issues as to what a ‘‘real illness’’ is or what constitutes ‘‘a genuine syndrome’’ are not easily solved and should not get in the way of the diagnosis and treatment of patients.

Rather, it is necessary to have a structured method of characterizing syndromes, whether or not this describes their supposed true essence or is in accordance with particular claims about etiology or signifi-cance. Given the structured method, we can proceed to identify the subordinate phenomena that may lead to a more refined diagnosis. Even when there is a refined diagnosis, it still may not be something that can be called an absolute truth but rather a step on the way to improved management, which is what clinical medicine is actually about. Such a modest aim nevertheless does not inhibit clinical description from proceeding to more fundamental analyses by inter-ested scientists who may or may not be the clinicians.

R

E F E R E N C E S

1. Merskey H. Development of a universal language of pain syndromes. In Bonica JJ (ed): Advances in Pain Research and Therapy, Vol 5. New York: Raven, 1983; pp 3752.

2. World Health Organization. International Classification of Diseases and Related Health Problems, 10th rev. (ICD-10). Geneva: WHO, 1992. 3. American Psychiatric Association. Diagnostic and Statistical Manual of

Mental Disorders, 4th ed. (DSM-IV). Washington, DC: APA Press, 2000. 4. World Health Organization: International Classification of Diseases

and Related Health Problems, 9th rev. (ICD-9). Geneva: WHO, 1978. 5. American Psychiatric Association. Diagnostic and Statistical Manual of

Mental Disorders, 3rd ed. (DSM-III). Washington, DC: APA Press, 1980. 6. Capildeo R, Haberman S, Rose FC. New classification of stroke.

Preliminary communication. Br Med J 1977;2:15781580. 7. Lamberts H, Wood M. International Classification of Primary Care.

Oxford: Oxford University Press, 1989. (Reprinted with corrections, 1989.)

8. Merskey H (ed): Classification of chronic pain: descriptions of chronic pain syndromes and definitions of pain terms. Monograph for the Sub-Committee on Taxonomy, International Association for the Study of Pain. Pain (suppl 3). Amsterdam: Elsevier Science, 1986. 9. Merskey H, Bogduk N (eds): Classification of Chronic Pain:

Descriptions of Chronic Pain Syndromes and Definitions of Pain Terms, 2nd ed. Seattle: IASP Press, 1994.

10. Bonica JJ. The Management of Pain. Philadelphia: Lippincott, 1953.

Chapter 2 P

ATHOPHYSIOLOGY OF

P

AIN

Jun-Ming Zhang and Mark L. Baccei

INTRODUCTION

Pain is defined as ‘‘an unpleasant sensory and emotional experi-ence associated with actual or potential tissue damage, or described in terms of such damage.’’ Under normal physiologic conditions, pain is elicited by the activation of specific nociceptors (nociceptive pain). However, it may also result from a lesion or dysfunction of peripheral afferent fibers or the central nervous system (CNS) itself (neuropathic pain). Although acute nociceptive pain serves as a warning signal regarding possible

severe tissue damage, chronic and/or neuropathic pain is persistent and maladaptive.

CLASSIFICATIONOF PAIN

Pain involves sensory, emotional, and cognitive components. Although it may be classified in many ways, pain can often be categorized as nociceptive, neuropathic, mixed, or idiopathic pain.

Nociceptive Pain

Pain is termed nociceptive when the clinical evaluation suggests that it is sustained primarily by the nociceptive system. Nociceptive pain is pain that is proportionate to the degree of actual tissue damage. A more severe injury results in a pain that is perceived to be greater than that caused by a less severe injury. Such pain serves a protective function. Sensing a noxious stimulus, a person behaves in certain ways to reduce the injury and promote healing (e.g., pulling his or her finger away from a hot object). This ‘‘good’’ pain serves a positive function. Examples of nocicep-tive pain include acute burns, bone fracture, and other somatic and visceral pains.

Box 16 USES OFCLASSIFICATIONSYSTEMS Communication

Uniform standards of diagnosis Statistical

Service delivery Financial Billing and planning

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