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Complex Regional Pain Syndromes

SUMMARY Complex regional pain syndrome (CRPS) is clinically characterized by pain, abnormal regulation of blood flow and sweating, edema of the skin and subcutaneous tissue, active and passive movement disorders, and trophic changes in the skin, appendages of the skin, and subcutaneous tissue. It is classified into type 1 (previously known as reflex sympathetic dystrophy) and type 2 (previously known as causalgia). CRPS patients exhibit changes…

Trigeminal and Glossopharyngeal Neuralgia

SUMMARY Trigeminal neuralgia (TN) and glossopharyngeal neuralgia are uncommon facial pain syndromes associated with multiple sclerosis, increasing age, and possibly hypertension. The diagnosis of TN is based on a comprehensive clinical history and physical examination, assisted by radiological investigations. A precise diagnosis is essential because there are important therapeutic and prognostic implications. From a clinical viewpoint, classic or typical TN is characterized by recurrent episodes of…

Painful Peripheral Neuropathies

SUMMARY It is common clinical experience that most diseases affecting the peripheral nervous system produce negative neurological symptoms or signs. Conditions in which damage to the nervous system does cause pain are a paradox since impairment of nerve fibers carrying nociceptive information should result in a decrease in pain sensibility. Painful neuropathies are a heterogeneous group of conditions usually manifested as stimulus-independent, ongoing pain and stimulus-induced…

Phantom Limb

SUMMARY Phantom phenomena are experienced by almost all amputees following amputation. Most patients feel that the missing limb is still there, and some may have vivid sensations of shape, length, posture, and movement. These non-painful phantom sensations rarely pose any clinical problem. Between 60 and 80% of all amputees also have painful sensations referred to the missing limb. Phantom limb pain is often intermittent, and in…

Central Consequences of Peripheral Nerve Damage

SUMMARY Peripheral nerve injury of various types, for example, complete nerve transection or loose nerve constrictions (Bennett model), results in changes in the expression of a large number of molecules in the parent neuronal cell bodies in the sensory dorsal root ganglia, as elegantly illustrated in recent global expression analyses. These molecules include neuropeptides, seven-transmembrane G protein–coupled receptors, ion channels, enzymes, and other types of molecules.…

Animal Models of Experimental Neuropathic Pain

SUMMARY Neuropathic pain has an adverse impact on quality of life and remains an important unmet medical need. Consequently, many attempts have been made to “model” neuropathic pain in animals, each with its strengths and shortcomings. The observation that animals would attack a denervated limb (“autotomy”) following axotomy of a nerve led to the suggestion that such behavior reflected the presence of pain (i.e., a possible…

Neuropathic Pain : Pathophysiological Response of Nerves to Injury

SUMMARY When a telephone cable is cut across, the phone falls silent. Damaged nerves behave differently. Nerve injury causes “negative” symptoms such as hypoesthesia and numbness, the equivalent of the silent telephone. However, in addition there are often “positive” symptoms such as spontaneous pain and pain in response to weak stimuli that are normally painless. This is neuropathic pain. The pain in neuropathy results from pathophysiological…

Pain in and around the Eye

SUMMARY The sensory innervation of the eye is provided by the peripheral axons of primary sensory neurons located in the trigeminal ganglion that enter the eyeball mainly through the ciliary nerves and reach all ocular tissues with the exception of the lens and the retina. Ocular innervation is particularly rich in the cornea, but all tissues of the anterior segment of the eye receive an abundant…

Tension-Type Headache

SUMMARY Tension-type headache (TTH) is an ill-defined and heterogeneous syndrome, with its diagnosis based mainly on the absence of features found in other types of headaches, such as migraine. It is thus above all a “featureless” headache characterized by nothing but pain in the head. The headaches formerly described as “muscular contraction,” “psychogenic,” “psychomyogenic,” “tension,” “stress,” and “essential or non-migrainous” are classified in this group. However,…

Migraine and the Trigeminal Autonomic Cephalalgias

SUMMARY Headache is a common human experience and provides a considerable clinical challenge when it occurs. This chapter covers the major disabling primary headaches: migraine and the trigeminal autonomic cephalalgias, including cluster headache and hemicrania continua. These disorders share the pathobiology of activation—or the perception of activation—of the pain-producing innervation of the cranial vessels: the trigeminovascular system. Their individual phenotypes seem to have a substantial inherited…

Acute and Chronic Orofacial and Dental Pain

SUMMARY The constellation of orofacial pain disorders is a major health care issue with high prevalence, intensity, and immeasurable impact on quality of life. Although there are many common aspects of pain transduction and processing between the trigeminal and spinal systems, there are also numerous examples of unique features in the peripheral and central components of the trigeminal pain system. Accordingly, ongoing basic and clinical research…

Trigeminal Mechanisms of Nociception

SUMMARY The trigeminal system is involved in processing nociceptive information from the oral, facial, and cranial territories. Trigeminal mechanisms of nociception have some specific features, and these are outlined in this chapter. The more relevant features of the central processing mechanisms of trigeminal nociception are described on the basis of animal studies, which provide valuable models for our understanding of human oro- and craniofacial pain disorders.…

Obstetric Pain

SUMMARY This chapter provides an overview of the nature of childbirth pain, its analgesic management, and the resulting impact on the safety of the mother, the fetus, and the newborn. This chapter examines the lessons learned from the history of obstetric anesthesia, reviews the current understanding of the mechanism of labor pain, and discusses the basis for current therapy, as well as the impact of current…

Genitourinary Pain

SUMMARY Chronic pain localized to the lower abdominal, groin, or perineal region is a common clinical entity with multiple causes. Yet specific mechanisms for many common urogenital pain syndromes are still unknown. The different sources of urogenital pain and their unique aspects are discussed in this chapter. There are profound similarities in the evaluation and treatment of these different sources of pain. Because the sensory elements…

A Clinical Perspective on Abdominal Pain

SUMMARY The diagnosis of abdominal pain, a challenging task that physicians often face, ranges from life-threatening conditions to chronic functional disorders with little mortality but significant impact on health-related quality of life. Although acute abdominal pain of organic etiology is generally caused by an easily identifiable noxious stimulus, chronic pain occurs most commonly in the absence of detectable nociceptive causes and is referred to as functional…

Thoracic Pain

SUMMARY Thoracic pain can signal acute life-threatening disease, and this drives the need for accurate and timely diagnosis in patients with such pain. Obtaining a diagnosis is not always straightforward since many conditions that are more benign can convincingly be manifested as life-threatening ones and, conversely, a life-threatening disease can sometimes appear benign. Moreover, conditions such as myocardial ischemia and pulmonary embolism, which should not be…

Visceral Pain: Basic Mechanisms

SUMMARY Afferent (sensory) innervation of the viscera typically involves the bilateral spinal and, for all thoracic and most abdominal organs, vagal afferents as well. Mechanosensitive spinal afferents readily sensitize and encode into the noxious range, whereas vagal afferents contribute principally to chemonociception and autonomic and emotional responses to visceral stimuli. Both voltage- and ligand-gated ion channels contribute to increased neuron excitability in the face of organ…

Non-specific Arm Pain

SUMMARY Non-specific arm pain (NSAP) is a common chronic upper limb pain disorder that has previously been referred to as repetitive strain injury. NSAP is frequently associated with tasks that involve repetitive upper limb activities, such as intense computer use and light production work. What differentiates NSAP from other specific work-related upper limb conditions is the lack of obvious tissue injury on clinical testing. It is…

Low Back Pain

SUMMARY Low back pain (LBP) is a tremendous medical and socio-economic problem. Many individual, psychosocial, and occupational risk factors for the onset of LBP have been identified, but their independent prognostic value is usually low. A number of factors have been identified that may increase the risk for chronic disability, but not one single factor appears to have a strong impact. Exercises seem to be the…

Fibromyalgia Syndrome and Myofascial Pain Syndrome

SUMMARY Fibromyalgia syndrome (FMS) is a common, chronically painful soft tissue pain condition. The typical finding is chronic widespread pain and tenderness to palpation as a result of a generalized low pain threshold. Associated or co-morbid manifestations may include chronically dysfunctional sleep, fatigue, morning stiffness, cognitive dysfunction, depression, anxiety, recurrent headaches, dizziness, irritable bowel syndrome, and urogenital pain. Criteria-based diagnoses of FMS can be made with…