Nearly two millennia ago, the Roman emperor and philosopher Marcus
Aurelius wrote: "when unbearable, pain destroys us.. Recollect
this, too, that many of our everyday discomforts are really pain
in disguise, such as drowsiness or want of appetite." Also
for millennia, the mutual interaction between physical pain and
one's world view has been observed by philosophers and religious
figures. Yet with few exceptions (e.g., Burton's The Anatomy of
Melancholy), the systematic analysis of the relationship between
these two experiences from the perspective of medical science is
a relatively recent occurrence.
In the 19th century, medical authors commented explicitly upon pain,
insomnia, weight loss, sweating, dizziness, and cardiac and respiratory
complaints in depressive disorders. Depression was regarded as a
spectrum of disorders with mental and somatic aspects whose relative
proportions reflect individual predisposition, concurrent somatic
disease, and psychosocial influences. Later different authors differentiated
several forms according to heredity, symptoms, course, and prognosis.
In recent decades, in an effort to clarify semantic confusion and
end rancorous academic debate, the American Psychiatric Association
and the World Health Organization introduced formal diagnostic taxonomies
into the field of mental health. These classifications are, the
Diagnostic and Statistical Manual (DSM) and the International Classification
of Diseases (ICD). Both systems abandoned the more explicit term
"endogenous depression" in favor of the etiologically
vague term "major depression". It introduced the category
"psychogenic pain disorder", which was renamed again as
"somatoform pain disorder". Because neither system attempts
to address the root biological cause of the syndrome described,
diagnosis focuses on complains, symptoms, and signs. Rational therapy
that links etiopathogenesis and targeted pharmacotherapy is still
in its infancy. Clinical investigations have disclosed that selective
serotonin reuptake inhibitors, while efficacious for depression,
are much less useful for neuropathic pain than are the older antidepressants
of the tricyclic category. The lack of slelectivity of the latter
agents (e.g, amitriptyline) allows them to modulate noradrenergic
as well as serotonergic pathways and thereby achieve greater analgesic
benefit.
The importance of pain within the symptom complex called depression
was recognized incrementally. Over 70 years ago, it was indicated
that physical complaints are an integral part of the depressive
syndrome. The terms depression larvee (masked depression) and cenestopathie
(cenestopathy) were used for aberrant bodily sensations in mental
illness. Cenesthesias may occur in affective, schizophrenic, and
schizoaffective disorders. They are now considered to be centrally
produced erroneous or bizarre sensory interpretations, in other
words, functional variants of central pain.
Among the vegetative and somatic symptoms of depressive disorders,
pain ranks second only to insomnia. Pain, including headache, facial
pain, neck and back pain, thoracic, abdominal, and pelvic pain,
and extremity pain, occurs in over 50% of depressive disorders.
In some cases, pain-related suffering so dominates the clinical
picture that the underlying depressive disease is not recognized
for months or even years. In older papers, the term "masked
depression" was applied in a broad sense to many physical complaints
and disorders, some of which were later elaborated as separate clinical
entities, for example anorexia nervosa, restless leg syndrome, and
meralgia paresthetica. Modern international classification no longer
use this term.
International recognition of chronic pain as a syndrome - even
a disease in its own right - led to the founding of the International
Association for the Study of Pain in 1973. In the generation since,
the systematic evaluation of patients with acute, recurrent, and
chronic pain states has uncovered comorbidity of pain with depression,
anxiety, anger, cognitive impairment, and abnormal personality traits,
and has revealed various psychosocial and socioeconomic influences.
Depression is more common among patients with chronic pain than
in health controls. A study based on interviews by skilled clinicians
determined that according to standardized criteria, depression afflicted
87% of 300 patients with chronic pain. Depending upon the setting,
population, diagnosis, and diagnostic instruments used, estimates
of major depression and dysthymic disorder can vary greatly. Equally
wide variations in prevalence estimates according to the survey
methods and diagnostic criteria applied are found for chronic pain
itself.
In these diverse surveys, the prevalence of major depression rangs
feom 1.5% to 57%. This figure must be augmented by estimates (when
available) of dysthymic disorder, a milder condition. The high percentage
of depressive symptoms in many clinical investigations of chronic
pain might appear to confirm the essential role of depressive disorders
in such patients. However, the populations sampled are often from
specialized institutions or clinics; as a rule such patients are
more impaired than those seen in primary care. It was found in different
studies in Mayo Clinic, USA, that 30-40% patients were "definitely"
depressed, 20-30% were "probably" depressed.
Depression worsens the effect of pain on social and occupational
functioning. Depressed patients with chronic pain have consistently
been found to be less active than their non-depressed counterparts.
The presence of depression in addition to pain codetermines course
and outcome, physical impairment, and disability. Depression reduces
the likelihood of response to pain treatment and increases the utilization
of medical services in patients with pain. When depression is recognized
and treated early in patients who present for treatment of chronic
pain, expensive diagnostic and therapeutic procedures such as multiple
surgeries may be avoided.
An explanation for the hypothesized increased prevalence of chronic
pain in depression may lie in the biochemical features common to
both disorders. These include involvement of serotonergic and noradrenergic
systems, hypercortisolemia, and subnormal suppression of cortisol
production in response to dexamethasone. Patients with chronic severe
pain, such as postherpetic neuralgia or phantom or stump pain, experience
distinct psychopathological sequelae compared with those who have
hereditary, metabolically determined depression (formerly called
"endogenous depression"). Patients with chronic pain typically
show signs and symptoms of irritability, dyphoric mood, narrowing
of interests, and reduced capacity for experience, known as the
algogenic psychosyndrome." In contrast, in patients with severe
depressive states, anhedonia, early morning awakening, indecisiveness,
suicidal tendencies, existential despair, and in some cases psychotic
features are more prominent. Thus, the presence of a long-standing,
clear cut somatic source of pain in combination with the psychopathological
picture of an algogenic psychosyndrome supports a clinical conclusion
that pain is the cause and depression the result.
The casual relationship of
pain and depression has been the subject of long-standing controversy.
In the clinical context, it is critical to establish a correct diagnosis
before speculating about casual relationships. A proper psychiatric
diagnosis is possible through a standardized interview by a trained
clinician or through a systemic evaluation by a qualified psychiatrist
or psychologist. Questionnaires may be helpful to gather demographic
data, complaints and information on the degree of disability, and
even to quantitable psychiatric morbidity.
The cognitive mediation model of Rudy, Kerns, and Turk claims that
the presence of pain is not a sufficient condition for the subsequent
development of depression, these authors hypothesized instrumental
activities along with a decline personal mastery is the link between
pain and depression. In 100 consecutive referrals to an outpatient
pain management program, they found that perceived life interference
and reduced self-control were significant variables. Besides the
relatively typical history of the pain-prone personality, the severity
of pain influences its interference with activity and quality of
life.
The scar hypothesis claims that previous episodes of depression
due to a genetic or acquired susceptibility predispose some individuals
to a depressive episode after the onset of pain. Patients with pain
and depression have been reported to have an increased of rate of
prior depressive episodes. Higher prevalence rates of clinical depression
have also been reported in the families of patients with pain than
in different control groups. Temporal order may provide information
about the cause of pain and depression. In certain patients, the
signs and symptoms of pain and depression develop simultaneously.
According to the antecedent hypothesis, depression precedes chronic
pain. In another theory, known as the consequence hypothesis where
the belief is that depression follows pain. The discussion of whether
pain precedes depression or depression leads to pain reminds me
of asking which came first, the chicken or the egg. The enigma cannot
be solved by linear deterministic thinking, yet it does not seem
to be unsolvable.
From "Clinical Updates" Dec. 2003, IASP.
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| .........M. Mostafa Kamal |
Low back pain is very common and a lot of people usually suffers
form this low back pain specially elderly. Common cause of low back
pain are paravertebral muscle and lumbosacral joint sprain/strain,
intervertebral disc diseases of herniated disc, facet syndrome,
congenital abnormalities, tumours, infection, arthritides etc. Approximately
80-90% of low back pain is due to sprain/strain associated with
lifting having objects, falls, or sudden abnormal movement of the
spine. Another important cause of low back pain is disease of intravertabral
disc which bears one third of the weight of the spinal cord.
Relief of pain is associated with decrease in morbidity and mortality,
shorten hospital stay and increase patients satisfaction. But it
is very difficult to manage the low back pain because the inability
to define pain and measure pain, lack of appropriate equipments,
psychological factors and the great variation in analgesic requirement
in different age group.
Low back pain management may involve the following after full pain
evaluation-
1) Simple measure i.e. rest, exercise, heat and cold treatment,
vibration etc.
2) Medication -NSAID, Muscle relaxants, Anti-depressents.
3) Surgery-PLID.
4) Radio ablation of the disc.
5) Stimulation technique - TENS.
6) Nerve block-Epidural steroid.
7) Rehabilitation/Exercise.
To reduce low back pain & its radiation by a safe, easy &
acceptable Method many study has been done on different procedures.
Nerve block by epidural steroid is an acceptable method to reduce
low back pain. There are so many corticosteroid but here we use
Methyl Prednisolone and Triamcinolone. They are effective for the
Treatment of low back pain because of their anti-inflammatory effect.
There are other reasons they might effect pain perception in the
presence of nerve route pathology (1) Corticosteroid inhibit ectopic
discharge origination from experimentally neuron. And this stabilizing
effect may be responsible for symptomatic improvement of patients
with nerve route pathology. (2) Persistent noxious stimulation lead
to enhanced responsiveness of dorsal horn neuron. This central sensitization
is in part mediated by increased production of prostaglandin and
steroid block prostaglandin production.
August 2008
Glasgow, United Kingdom
12th WORLD CONGRESS
ON PAIN
International Association
For the Study of Pain
909 NE 43rd St, Suit 306
Seattle, WA 98105, USA
Tel: 206-547-6409, Fax: 206-547-1703
E-mail:
Web:
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Considering the effectiveness of steroid and
lack of any comparative study between methyl presnisolone and
triamcinolone, the present study was performed to compare these
two steroids & to see their effectiveness in controlling
low back pain.This study was a randomized, prospective study.
Sixty patients with low back pain. With radiation, age group
40-70 years, and with positive CT/MRI support has been randomly
selected by blind envelop method. Patient with known allergy
to study drugs, with haemorrhagic diathesis, with diabetes has
been excluded. The patient were divided into two groups of thirty
patients each. |
Group-I: These patients received inj. Methyle Prednisolone
80 mg epidurally
Group-II: These patients received inj. Triamcinolone 80 mg
epidurally
Single shot epidural steroid injection technique has been followed.
The results of the study showed that, methyl prednisolone and triamcinolone
both produced effective analgesia in low back pain as assessed by
visual analogue scale (VAS) and verbal rating scale (VRS) for the
period up to 30 days after administration. Comparison of their degree
of analgesia using VAS/VRS showed that triamcinolone reduced pain
more than methyl prednisolone at baseline. Moreover, comparison
by VRS showed tramcinolone reduced pain more than methl prednisolone
at baseline, 10 min and 30 min after administration. Both the corticosteroids
produced sustained rise of systolic and diastolic blood pressure
for the period up to 7 days after administration, but they did not
have any demonstrable effect on heart rate. Comparing haemodynamic
changes (heart rate, systolic blood pressure and diastolic blood
pressure) of prednisolone and triamcinolone administration showed
no significant difference between the two drugs. Methyl prednisolone
and triamcinolone both produced significant rise of fasting plasma
glucose for the period up to 30 days after administration. Changes
in glycaemic status following prednisolone and triamcinolone administration
were also comparable.
c) Methyl prednisolone and triamcinolone both have comparable predictable
side effects on haemodynamic state and glycaemic status. Both the
drugs cause initial rise in blood pressure (systolic and diastolic)
and fasting plasma glucose level & also Leukocyte count.
Aim of Investigation: The effective treatment of post-operative
pain should be for humanitarian reasons. Pre-emptive analgesia and
epidural are the two most effective methods that are recently used.
Ketamine is a drug which has a very strong analgesic action without
opioid side effects. This study was performed to compare the effects
of pre-emptive epidural ketamine and fentanyl in reducing post-operative
wound hyperalgesia.
Methods: After obtaining informed consents and approval of the
ethical committee, 60 patients were randomly divided into fentanyl,
ketamine and control groups of 20 patients each. They received epidural
fentanyl (50 mg), ketamine (50 mg) and 1 ml of normal saline with
9 ml of 0.25% bupivacaine respectively 30 minutes before incision.
All patients received general anaesthesia Using the same technique
and without any opioid. Post-operatively, all patients received
epidural bupivacaine (0.25%) as required to keep the VAS score below
2.
GA was given in all groups with thiopental sodium 5 mg/kg and vecuronium
0.1 mg/kg to facilitate endotracheal intubation. Anaesthesia was
maintained as necessary to maintain heart rate and blood pressure
within 20% of preinduction values. Opioid was not administered during
the induction of general anaesthesia or during the operation.
The intensity of spontaneous incisional pain and movement associated
pain was measured with a visual analog self-rating method. The surgical
wound hyperalgesia was assessed by measuring area of wound hyperalgesia
with a blunt end of a pin 24 hours (1st POD) and after 48 hrs (3rd
POD). In the group I area of wound hyperalgesia was 38.80±3.80
at 1st POD and 31.75±2.33 at the 3rd POD. In the group II
was 31.80 ±2.92 at 1st POD (P<000 from group I) and 25.05±3.17
at 3rd POD (P<000 from group I). In the ketamine group was 30.10±3.32
at 1st POD (P>000 from group I) and 22.05±3.80 at 3rd
POD (P<000 from group -I). Over all satisfaction after 24 hrs
was high in fentanyl and ketamine group. No well known psychomimetic
effects were noted in the ketamine group.
So the result suggest that preemptively used epidural fentanyl and
ketamine decreases post operative pain and surgical wound hyperalgesia.
Pain, particularly chronic pain is a major threat to the quality
of life worldwide, and will become more so as the average age increases.
In developing parts of the world the major epidemics "killer
deiseses" produce a lot of severe pain for which there is little
or no relief available. This is especially true for patients with
HIV/AIDS and cancer, but also for the millions of people suffering
injuries from road accidents, child birth, acts or war and even
after surgery.
April 14-15, 2005
Rajendrapur, BRAC Centre
6th ANNUAL CONGRESS OF
BANGLADESH SOCIETY
FOR
STUDY OF PAIN (BSSP)
Secretariat
Dept. of Anaesthesia, Analgesia and
Intensive Care Medicine
Bangabandhu Sheikh Mujib Medical University Shahbag,
Dhaka
E-mail:
Web:
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The control of pain has been a relatively neglected
area of governmental concern in the past, despite the facts
that cost-effective methods of pain control are available. The
time is right to raise the profile of pain, to promote the recognition
that chronic pain is a disease in its own right and an important
health concern, but above all, to raise global awareness to
a fundamental truth-the relief of pain should be a human right.
The Ultimate aims are twofold, to inform and sensitive policy
makers about the issue of pain and to the needs of both those
sufferings from pain and those providing care for people with
pain, together with its economic costs.
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Second, to Improve knowledge on pain and pain management among
physicians and allied health care professionals, in order to promote
higher standards of care throughout the world.
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| President |
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Prof Q Deen Mohammad |
| President Elect |
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Dr. Jonaid Shafiq |
| Vice President |
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Dr. Lutful Aziz |
| Immediate Past President |
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Prof KM Iqbal |
| Secretary General |
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Dr. AKM Akhtaruzzaman |
| Treasurer |
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Dr. Manzoorul Hoq Laskar |
| Joint Secretary |
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Dr. ANM Badruddozza |
| Scientific Secretary |
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Dr. Zerzina Rahman |
| Members |
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Dr. Mohammad Saiful Islam
Dr. Taslimuddin Ahmed
Dr. Mizanur Rahman
Dr. Mahmudur Rahman Khandker |
| Editor-in-Chief |
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Prof KM Iqbal |
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Bangladesh
Society for Study of Pain (BSSP) was formed in 1997.
By this time it has become an affiliated Chapter of
International Association for Study of Pain (IASP).
It has taken active interest in the formation of (SARPS)
South Asian Regional Pain Society. The need for a News
Letter of BSSP was felt for a long time. I am happy
to see that this is coming as a informative media of
BSSP.
It
is my great pleasure to write this message for the first
News Letter of BSSP. As we all know, BSSP was established
in 1997 with a motto of expanding the subject of pain
throughout Bangladesh. During the past years we tried
to do that in various ways like meetings, congresses,
workshop in Dhaka & other part of the country. We
also did some media awareness through round table conference.
This is the latest achievement of BSSP. Through this
News Letter we would like to give our message to the
concerned people of the country. I hope our sincerity
pay off through this venture. I invite all to read this
News Letter and advice us, So that it can serve its
purpose successfully.