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      The development of chronic pain: physiological CHANGE necessitates a multidisciplinary approach to treatment

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          Abstract

          Chronic pain is currently under-diagnosed and under-treated, partly because doctors’ training in pain management is often inadequate. This situation looks certain to become worse with the rapidly increasing elderly population unless there is a wider adoption of best pain management practice. This paper reviews current knowledge of the development of chronic pain and the multidisciplinary team approach to pain therapy. The individual topics covered include nociceptive and neuropathic pain, peripheral sensitization, central sensitization, the definition and diagnosis of chronic pain, the biopsychosocial model of pain and the multidisciplinary approach to pain management. This last section includes an example of the implementation of a multidisciplinary approach in Belgium and describes the various benefits it offers; for example, the early multidimensional diagnosis of chronic pain and rapid initiation of evidence-based therapy based on an individual treatment plan. The patient also receives continuity of care, while pain relief is accompanied by improvements in physical functioning, quality of life and emotional stress. Other benefits include decreases in catastrophizing, self-reported patient disability, and depression. Improved training in pain management is clearly needed, starting with the undergraduate medical curriculum, and this review is intended to encourage further study by those who manage patients with chronic pain.

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          Most cited references65

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          Descending control of pain.

          Upon receipt in the dorsal horn (DH) of the spinal cord, nociceptive (pain-signalling) information from the viscera, skin and other organs is subject to extensive processing by a diversity of mechanisms, certain of which enhance, and certain of which inhibit, its transfer to higher centres. In this regard, a network of descending pathways projecting from cerebral structures to the DH plays a complex and crucial role. Specific centrifugal pathways either suppress (descending inhibition) or potentiate (descending facilitation) passage of nociceptive messages to the brain. Engagement of descending inhibition by the opioid analgesic, morphine, fulfils an important role in its pain-relieving properties, while induction of analgesia by the adrenergic agonist, clonidine, reflects actions at alpha(2)-adrenoceptors (alpha(2)-ARs) in the DH normally recruited by descending pathways. However, opioids and adrenergic agents exploit but a tiny fraction of the vast panoply of mechanisms now known to be involved in the induction and/or expression of descending controls. For example, no drug interfering with descending facilitation is currently available for clinical use. The present review focuses on: (1) the organisation of descending pathways and their pathophysiological significance; (2) the role of individual transmitters and specific receptor types in the modulation and expression of mechanisms of descending inhibition and facilitation and (3) the advantages and limitations of established and innovative analgesic strategies which act by manipulation of descending controls. Knowledge of descending pathways has increased exponentially in recent years, so this is an opportune moment to survey their operation and therapeutic relevance to the improved management of pain.
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            The need for a new medical model: a challenge for biomedicine.

            The dominant model of disease today is biomedical, and it leaves no room within tis framework for the social, psychological, and behavioral dimensions of illness. A biopsychosocial model is proposed that provides a blueprint for research, a framework for teaching, and a design for action in the real world of health care.
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              Models and mechanisms of hyperalgesia and allodynia.

              Hyperalgesia and allodynia are frequent symptoms of disease and may be useful adaptations to protect vulnerable tissues. Both may, however, also emerge as diseases in their own right. Considerable progress has been made in developing clinically relevant animal models for identifying the most significant underlying mechanisms. This review deals with experimental models that are currently used to measure (sect. II) or to induce (sect. III) hyperalgesia and allodynia in animals. Induction and expression of hyperalgesia and allodynia are context sensitive. This is discussed in section IV. Neuronal and nonneuronal cell populations have been identified that are indispensable for the induction and/or the expression of hyperalgesia and allodynia as summarized in section V. This review focuses on highly topical spinal mechanisms of hyperalgesia and allodynia including intrinsic and synaptic plasticity, the modulation of inhibitory control (sect. VI), and neuroimmune interactions (sect. VII). The scientific use of language improves also in the field of pain research. Refined definitions of some technical terms including the new definitions of hyperalgesia and allodynia by the International Association for the Study of Pain are illustrated and annotated in section I.
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                Author and article information

                Journal
                Curr Med Res Opin
                Curr Med Res Opin
                CMO
                Current Medical Research and Opinion
                Informa UK Ltd.
                0300-7995
                1473-4877
                September 2013
                3 July 2013
                : 29
                : 9
                : 1127-1135
                Affiliations
                aDepartment of Medicine, Johns Hopkins University School of Medicine Baltimore, MDUSA
                bNaples Anesthesia and Pain Associates Naples, FLUSA
                cCapio S:t Görans Hospital StockholmSweden
                dChurchill Hospital OxfordUK
                eUniversitätsspital Zurich ZurichSwitzerland
                fDepartment of Anesthesia, Intensive Care and Pain Therapy, Sapienza University of Rome Italy
                gLeiden University Medical Center Netherlands
                hUniversity Hospital RotterdamThe Netherlands
                iPoradnia Leczenia Bólu University Hospital KrakówPoland
                jHospital de Santo André LeiriaPortugal
                kClinique Cecil LausanneSwitzerland
                lUniversity Hospitals Leuven Belgium
                mSchmerz- und Palliativzentrum GöppingenGermany
                nSt. Georges Hospital LondonUK
                oHospital Universitario de la Princesa MadridSpain
                pHôpitaux de Saint-Denis ParisFrance
                qCharité Berlin Germany
                rTeramo ASL TeramoItaly
                Author notes
                Address for correspondence: Joseph Pergolizzi MD, ProfessorNaples Anesthesia and Pain Associates 4840 Sycamore Drive, Naples, FL 34119USA. Tel.: +1 239 597 3564; Fax: +1 239 597 7566; jpjmd@ 123456msn.com
                Article
                10.1185/03007995.2013.810615
                3793283
                23786498
                30720aec-aada-4c96-b851-8521c168a8ed
                © 2013 All rights reserved: reproduction in whole or part not permitted

                This is an open-access article distributed under the terms of the Creative Commons Attribution Noncommercial License which permits any noncommercial use, distribution, and reproduction in any medium, provided the source is credited.

                History
                : 24 May 2013
                Categories
                Pain: Commentary

                central sensitization,chronic pain,evidence-based therapy,improved training,multidisciplinary team,peripheral sensitization

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