- Email: [email protected]
The pain clinic (Advances in pain research and therapy, volume 13)
BodRReviews
Updating Your Knowledge of Pain John
C. Rowlingson,
MD
The Pain Climi (Advancesin Pain Researchand Thmfi, Volume 13) F.&red by S. Lipton, E. Tunks, and M. Zoppi Published by Raven Press, New York 1999,402 pages, x92.99 This book is the 13th in a I4-uolutne series published annually by Raven Press. This parvolume presents some of the pa&n from the 3rd International Svmwsium “The Pain Clinic” that took place in ~lo&tce, Italy. in September. 1988. One of the editors (SL) states that many docton and surgeons take a referral to a pain specialist as an affront. They still believe that they have to be all-knowing and alldoing to remain legitimate. However, with this self-indulgent attitude, the editor notes that cancer pain and postoperative pain are still poorly managed. &do dinics can&t handle all dte work demanded due to a lack of personnel, equipment, and occasionally skill. ihus, diswmioation of contemporary infomtation to more practitioners is vital to effective pain management. This text provides 48 presentations on a wide range of subjects. These are not comprehensive discussions, but rather summaries of recent basic science and/or clinical information (with empbasis on the latter) that will appeal to anyone interested in the field of pain evaluation and relief. Though soome of the presentations are short, the information is current and practical. The lack of detail in some of the chapters may leave some wanting for more oo a particular
kku
John C. Rowlingson. MD, is Professor of Anesthcri. ology and Director of the bin Management Center at *e Heal* Sciences Center, University al Vitginia,
Chadottnville, Virginia.
topic, but by-and-large the brevity is not problematic. One chapter had no bibliography and two chapters did not include titles in the citations which makes specific folloar.up less direct. In general, adequate references arr provided to lead those interested in a given topic to more depth. There are very few typographical errors that distract the reader from the significance of the text, and the tables and figures are ample and comributory. Some of the research work is presented without having met the usual publication standard of peer review. so the reader most discriminate for his/her owe valid results from that which might be subsequently criticized. The baok is organized into nine major sections, three dealing with basic science/research issues such as pain mechanisms, nettrocbemis try, and pharmacology. and the remaining six with general therapy or specific types of pan, such as headaches, cervical, low backand muscle pain. cancer pain, and neuropathic pain. There are some excellent chapters that stand out for the clarity of the presentation and/or the novelty of the ideas presented. Tbe short chapter on neurooharmacoloeic aooroaches to nociceotors by Pdnerai and colleagues is very precixly’witten and is hiehlv informative. It fosters aoorec&ion for the incredible degree of interaction between tteurocltemicals ad mechattistic ap proaches to pain. For iartance, of the drugs that increase CNS serownin content. only CID mipramine sod amitriptyline hale analgesic effects through an augmenwtiort of morphine analgesia. But, baclofen, a GABA agonist with analgesic properties, also can potentiate morphine analgesia as may rhc ralc;um channel Wockw. nifedipine. Tbc zntbas conclude that Y
Y
I
.
.
*.
the persistent challenge is to identify receptorspecific agonist drugs that will have the desired effect, that is analgesia, for long periods of time. In P subsequent discussion by Pith and colleagues on evidence that neuropcpdde Y has a role in the control of pain and the arousal mechanism, the intriguing statement that a central transmitter system can change its functional role in pathologic conditions is presented. This concept gives new meaning to that of adaptive plasticity in the nervous system. The implication is that long chain neuropeptides may be split into different active fragments under different conditions, giving rise to changes in modulation of I’... and peripheral neural and endocrine transmission lines. The article by Chrobasik on opiates and peptides notes that there are more than 200 neuropeptides and that nonopiate related substances such as cholerystokinin, somatostatin, cakitonin, neurotensin. ACTH. vasopressin. and bambesin have known analgesic effects. The classic confrontation of the specificity versus the intensity theory of pain discrimination is characterized in the chapter by Malliani on the peripheral mechanisms of visceral pain. Clearly, the author endorses the latter. The generic but erudite point that “pain is a conscious experience that can only be indirectly explored with experimentation models” is made. Furthermore, “. different opinions of peripheral nociceptive mechanisms are often the result of different (experimental) preparations”. By these statements, the complexity of “pain” is eodorsed and we must appreciate the innumerable neurochernical processes tbat influence the physiologic responses as well as the Possibility that different conclusions may be reached even when similar data are evperimeotally demonstrated, Finally. in the chapter by Siegfried, the comment that “there is r,. wincing evidence that paiphenl nerve Injury wes induce alterations in the CNS” reinforces the idea that chanra in the nervous system in one area can have farreachinK physioloeic impact. Thus. an evolving knowledge bf ne;roph&nacology and nrur~ circuitry is necessary to assure a contemporary understanding of pain. A constructive description of animal models for chronicpain research is presented in a comparison of techniques by Albe-Fersard. Hyperstimulation models basically involve those in
various central
.”
which the peripheral nerve input is increased and subsequent animal behavior (i.e., vccaliration, rcmtching, or biting) is measured. When using deafferentadon pain models, the peripheral input is suppressed, resulting in self-rnutilarion and autotomy. If irritative central focus techniques are employed, the afferent nervous system is not modified but an excitatoryldisruplive lesion is created centrally. Other points generally relating to the assessment of resarch resole and/or evaluation of patients follow in succeeding articles. Ltromm and Scharein write about the effects of analgesics on the EEC in humans. Their discussion about pain as a result of nociceptor activity is a concise review of the events of neural conducdon that allow measurement. This research is representative of that with the goal of finding objective, measurable variables within the nociceptive system which correlate highly with subjective pain ratings. That we need techniques that identify variables that can be used to qoantitate analgesic efficacy and differentiate between specific analgesic ar..l nonspecific vigilance-reducing effects is highlighted in subsequent articles by Kohal and CO11C33UeS on the usr of evoked potentials to reflect the painfulness of an applied noxious stimulus, and Oyama and colleagues on the endoaine respoose to pain. Chapman and colleagues highlight the dinical problems of evaluating the effects 01 opioids in humans. They point out that the “. of opiate aoalgesia is task of measuring human perception; thr effect variables are the response of the brain to controlled adminisuadon of the drug”. When we move from research to the strictly clinical arena, an excellent article by Aronoff and McAlary presents the necessity of multidisciplinary treatment of patients with intractable pain syndromes. This is even more understandable given the effective discourse by Cleeland concerning patient assessment and the well-balanced discussion by Tanks concerning the reality of the chronic pain syndrome. Benederti reminds readers that acute pain is significant because it “. morbidity, mortality, soffering, and increased cost;” therefore. “everv ohvsician must treat it with the same concern, enthusiasm and effort as any other pathologic affliction of humankind”. The managemenr of chronic pain as a specific dis-
mem
a
causes
,. ,
&sew
ease entity is so important that meer’ngs such as the international one these papers are from are necessary. There are go4 presentations dealing with the two most common chronic pain problems, headaches and low pack pain. Clearly, the field of headache control is benefitting f;om our enhanced understanding of new mchemical effects as enusaiw of the clinical m~rtifestations of migraine and idiopathic headaches. Migraine headache is now defined as a three-feature syndrome characterized by the simultaneous onset of pain and \rgetative and affective disardets lasting hours or days. Idiopathic headache is a rewlt of a defect in the two main suppression systems, serotonergicand opioidergic, that permits spontaneous impulses to trigger central pain. Because there is a causal relationship between postural stress and musmloskeleta~low back pain, Pedotti stwzeests that the risk factors for iow back pain mitt be evaluated by a multidisciplinary approach if we are to begin to prevent back pain. The facet syndrome is characterized concisely by Rossi and Pemak. That treatment of low back pain nnost involve active exercise is distinctly emphasized in each article. An excellent discussion of cervical pain based upon an anatomic progression from the midline to peripheral sttuctttres 1s provided by Addison. Muscle pain is cleverly conceptualized by Mense in a format parallel to that of cutaneoos pain. Muscles have both touch and moderate p-ore units that are equivalent to low threshold mechano-receptors. Noxious pressure units in the muscles behave like peripheral nwicepton. Research work is cited that demonstrates that a short-lasting noxious stimulus to skeletal muscles can change the property of nociceptive dorsal horn neurons for prolonged periods of time. Thus, pain can persist in spite of treatment to lesions of deep tissue. Subseqttent chapters reveal experimental and clinical data about musclepain and visceral pathway interactions, lwking at a muscle painlureteral colic model, and convergence projection in osteoarthritis of the hoer. The topic of cancer pain is addressed in a number of chapters. The point is repeatedly
made that up to 90% of patients with pain related to cancer could be comfortable if only available medications were used in the recotttmended sequential fashion. That they are not. and bemuse not every p&en& has hisiber pain well-controlled, demand that there be alternate techniques available. Cotdieb and colleagues provide as fine a commentary as thete is on the reaiistic and practical neumsurgical approaches to pain contml. Spinal narmtics are discussed by Magom as appropriate for patients in whom high serum concentrations from oral/parenteral narcotics produce bother wane side effects. or in those who have become insensitive to svstsmic opioids. suffered an acute increase in piin and who then need intense analgesia for a short period of time, or in patients where neurolysis has failed or is impractical. Venmfridda reminds us that _. only with continuous monitoring can we effectively Ithesel patients’ needs”. When there is no more be&fit to be gained fmm medicallsurgical intervention, palliative care is the compassionate answer to cancer pain. Twycmss states that palliative care ioeludes relief from pain and other distressing rymp:oms, psychological and spiritual care, provision of a support system to help the patient live as actively as possible while facing death, and be creation of g support system tha~sustains the family throuab the illness and bereavement. This b&k p&ides updated information on many basic science and clinical topics in pain research. patient assessment. and analgesic therapy. By comparing the information presented on a particular topic in past volumes, one can appreciate the progress being made in a @en area. This volume focuses on mauers relevant to pain clinic practice but will be of interest to many health care workers and scientists who deal with pain. It is impressive how crucial an understanding of tteurophamtamlogy and the adaptability of the nervous system is in our clinical~maoagement of patients. This book pmrides the reader insight into the sinnificann of these interactions aid urges practitioners to provide contemporary care that is responsive to the patient’s needs and based upon upto-date knowledge.
treat
I
Updating Your Knowledge of Pain John
C. Rowlingson,
MD
The Pain Climi (Advancesin Pain Researchand Thmfi, Volume 13) F.&red by S. Lipton, E. Tunks, and M. Zoppi Published by Raven Press, New York 1999,402 pages, x92.99 This book is the 13th in a I4-uolutne series published annually by Raven Press. This parvolume presents some of the pa&n from the 3rd International Svmwsium “The Pain Clinic” that took place in ~lo&tce, Italy. in September. 1988. One of the editors (SL) states that many docton and surgeons take a referral to a pain specialist as an affront. They still believe that they have to be all-knowing and alldoing to remain legitimate. However, with this self-indulgent attitude, the editor notes that cancer pain and postoperative pain are still poorly managed. &do dinics can&t handle all dte work demanded due to a lack of personnel, equipment, and occasionally skill. ihus, diswmioation of contemporary infomtation to more practitioners is vital to effective pain management. This text provides 48 presentations on a wide range of subjects. These are not comprehensive discussions, but rather summaries of recent basic science and/or clinical information (with empbasis on the latter) that will appeal to anyone interested in the field of pain evaluation and relief. Though soome of the presentations are short, the information is current and practical. The lack of detail in some of the chapters may leave some wanting for more oo a particular
kku
John C. Rowlingson. MD, is Professor of Anesthcri. ology and Director of the bin Management Center at *e Heal* Sciences Center, University al Vitginia,
Chadottnville, Virginia.
topic, but by-and-large the brevity is not problematic. One chapter had no bibliography and two chapters did not include titles in the citations which makes specific folloar.up less direct. In general, adequate references arr provided to lead those interested in a given topic to more depth. There are very few typographical errors that distract the reader from the significance of the text, and the tables and figures are ample and comributory. Some of the research work is presented without having met the usual publication standard of peer review. so the reader most discriminate for his/her owe valid results from that which might be subsequently criticized. The baok is organized into nine major sections, three dealing with basic science/research issues such as pain mechanisms, nettrocbemis try, and pharmacology. and the remaining six with general therapy or specific types of pan, such as headaches, cervical, low backand muscle pain. cancer pain, and neuropathic pain. There are some excellent chapters that stand out for the clarity of the presentation and/or the novelty of the ideas presented. Tbe short chapter on neurooharmacoloeic aooroaches to nociceotors by Pdnerai and colleagues is very precixly’witten and is hiehlv informative. It fosters aoorec&ion for the incredible degree of interaction between tteurocltemicals ad mechattistic ap proaches to pain. For iartance, of the drugs that increase CNS serownin content. only CID mipramine sod amitriptyline hale analgesic effects through an augmenwtiort of morphine analgesia. But, baclofen, a GABA agonist with analgesic properties, also can potentiate morphine analgesia as may rhc ralc;um channel Wockw. nifedipine. Tbc zntbas conclude that Y
Y
I
.
.
*.
the persistent challenge is to identify receptorspecific agonist drugs that will have the desired effect, that is analgesia, for long periods of time. In P subsequent discussion by Pith and colleagues on evidence that neuropcpdde Y has a role in the control of pain and the arousal mechanism, the intriguing statement that a central transmitter system can change its functional role in pathologic conditions is presented. This concept gives new meaning to that of adaptive plasticity in the nervous system. The implication is that long chain neuropeptides may be split into different active fragments under different conditions, giving rise to changes in modulation of I’... and peripheral neural and endocrine transmission lines. The article by Chrobasik on opiates and peptides notes that there are more than 200 neuropeptides and that nonopiate related substances such as cholerystokinin, somatostatin, cakitonin, neurotensin. ACTH. vasopressin. and bambesin have known analgesic effects. The classic confrontation of the specificity versus the intensity theory of pain discrimination is characterized in the chapter by Malliani on the peripheral mechanisms of visceral pain. Clearly, the author endorses the latter. The generic but erudite point that “pain is a conscious experience that can only be indirectly explored with experimentation models” is made. Furthermore, “. different opinions of peripheral nociceptive mechanisms are often the result of different (experimental) preparations”. By these statements, the complexity of “pain” is eodorsed and we must appreciate the innumerable neurochernical processes tbat influence the physiologic responses as well as the Possibility that different conclusions may be reached even when similar data are evperimeotally demonstrated, Finally. in the chapter by Siegfried, the comment that “there is r,. wincing evidence that paiphenl nerve Injury wes induce alterations in the CNS” reinforces the idea that chanra in the nervous system in one area can have farreachinK physioloeic impact. Thus. an evolving knowledge bf ne;roph&nacology and nrur~ circuitry is necessary to assure a contemporary understanding of pain. A constructive description of animal models for chronicpain research is presented in a comparison of techniques by Albe-Fersard. Hyperstimulation models basically involve those in
various central
.”
which the peripheral nerve input is increased and subsequent animal behavior (i.e., vccaliration, rcmtching, or biting) is measured. When using deafferentadon pain models, the peripheral input is suppressed, resulting in self-rnutilarion and autotomy. If irritative central focus techniques are employed, the afferent nervous system is not modified but an excitatoryldisruplive lesion is created centrally. Other points generally relating to the assessment of resarch resole and/or evaluation of patients follow in succeeding articles. Ltromm and Scharein write about the effects of analgesics on the EEC in humans. Their discussion about pain as a result of nociceptor activity is a concise review of the events of neural conducdon that allow measurement. This research is representative of that with the goal of finding objective, measurable variables within the nociceptive system which correlate highly with subjective pain ratings. That we need techniques that identify variables that can be used to qoantitate analgesic efficacy and differentiate between specific analgesic ar..l nonspecific vigilance-reducing effects is highlighted in subsequent articles by Kohal and CO11C33UeS on the usr of evoked potentials to reflect the painfulness of an applied noxious stimulus, and Oyama and colleagues on the endoaine respoose to pain. Chapman and colleagues highlight the dinical problems of evaluating the effects 01 opioids in humans. They point out that the “. of opiate aoalgesia is task of measuring human perception; thr effect variables are the response of the brain to controlled adminisuadon of the drug”. When we move from research to the strictly clinical arena, an excellent article by Aronoff and McAlary presents the necessity of multidisciplinary treatment of patients with intractable pain syndromes. This is even more understandable given the effective discourse by Cleeland concerning patient assessment and the well-balanced discussion by Tanks concerning the reality of the chronic pain syndrome. Benederti reminds readers that acute pain is significant because it “. morbidity, mortality, soffering, and increased cost;” therefore. “everv ohvsician must treat it with the same concern, enthusiasm and effort as any other pathologic affliction of humankind”. The managemenr of chronic pain as a specific dis-
mem
a
causes
,. ,
&sew
ease entity is so important that meer’ngs such as the international one these papers are from are necessary. There are go4 presentations dealing with the two most common chronic pain problems, headaches and low pack pain. Clearly, the field of headache control is benefitting f;om our enhanced understanding of new mchemical effects as enusaiw of the clinical m~rtifestations of migraine and idiopathic headaches. Migraine headache is now defined as a three-feature syndrome characterized by the simultaneous onset of pain and \rgetative and affective disardets lasting hours or days. Idiopathic headache is a rewlt of a defect in the two main suppression systems, serotonergicand opioidergic, that permits spontaneous impulses to trigger central pain. Because there is a causal relationship between postural stress and musmloskeleta~low back pain, Pedotti stwzeests that the risk factors for iow back pain mitt be evaluated by a multidisciplinary approach if we are to begin to prevent back pain. The facet syndrome is characterized concisely by Rossi and Pemak. That treatment of low back pain nnost involve active exercise is distinctly emphasized in each article. An excellent discussion of cervical pain based upon an anatomic progression from the midline to peripheral sttuctttres 1s provided by Addison. Muscle pain is cleverly conceptualized by Mense in a format parallel to that of cutaneoos pain. Muscles have both touch and moderate p-ore units that are equivalent to low threshold mechano-receptors. Noxious pressure units in the muscles behave like peripheral nwicepton. Research work is cited that demonstrates that a short-lasting noxious stimulus to skeletal muscles can change the property of nociceptive dorsal horn neurons for prolonged periods of time. Thus, pain can persist in spite of treatment to lesions of deep tissue. Subseqttent chapters reveal experimental and clinical data about musclepain and visceral pathway interactions, lwking at a muscle painlureteral colic model, and convergence projection in osteoarthritis of the hoer. The topic of cancer pain is addressed in a number of chapters. The point is repeatedly
made that up to 90% of patients with pain related to cancer could be comfortable if only available medications were used in the recotttmended sequential fashion. That they are not. and bemuse not every p&en& has hisiber pain well-controlled, demand that there be alternate techniques available. Cotdieb and colleagues provide as fine a commentary as thete is on the reaiistic and practical neumsurgical approaches to pain contml. Spinal narmtics are discussed by Magom as appropriate for patients in whom high serum concentrations from oral/parenteral narcotics produce bother wane side effects. or in those who have become insensitive to svstsmic opioids. suffered an acute increase in piin and who then need intense analgesia for a short period of time, or in patients where neurolysis has failed or is impractical. Venmfridda reminds us that _. only with continuous monitoring can we effectively Ithesel patients’ needs”. When there is no more be&fit to be gained fmm medicallsurgical intervention, palliative care is the compassionate answer to cancer pain. Twycmss states that palliative care ioeludes relief from pain and other distressing rymp:oms, psychological and spiritual care, provision of a support system to help the patient live as actively as possible while facing death, and be creation of g support system tha~sustains the family throuab the illness and bereavement. This b&k p&ides updated information on many basic science and clinical topics in pain research. patient assessment. and analgesic therapy. By comparing the information presented on a particular topic in past volumes, one can appreciate the progress being made in a @en area. This volume focuses on mauers relevant to pain clinic practice but will be of interest to many health care workers and scientists who deal with pain. It is impressive how crucial an understanding of tteurophamtamlogy and the adaptability of the nervous system is in our clinical~maoagement of patients. This book pmrides the reader insight into the sinnificann of these interactions aid urges practitioners to provide contemporary care that is responsive to the patient’s needs and based upon upto-date knowledge.
treat
I