Pain Forum最新文献

A reduction of maladaptive responses to pain is crucial in adjustment to chronic painful states. However, previous research has also demonstrated that adjustment to pain is predicted by interactions between coping attempts and characteristics of individuals. Therefore, we contend that examination of what patients should do, as well as what they should not do is necessary. We propose an alternate model of pain adjustment, within which the constructs of beliefs and coping are separated. Also, catastrophizing is conceptualized as a secondary appraisal, rather than a failed coping attempt. We discuss our assertions within the context of the appropriate distinction between mediator and moderator variables.

The “modern” criterion of 50% pain relief has long-standing precedents in the “ancient” literature. We agree that other measures of outcome, which reflect pain relief indirectly, are important, and accordingly for over two decades have routinely reported activities of daily living, return to work, patient satisfaction, need for additional treatment, and medication requirements. Physician and patient may deceive themselves (L. fallax, deceit) by undue reliance on any single outcome criterion. Relief of pain per se, however, is most relevant to the patient's presenting complaint, and however we choose to quantitate it, it is a sine qua non.

Kream and Carr have described the suffering caused by medicine's denial and dismissal of interstitial cystitis (IC), and the improved diagnosis and treatment of IC resulting from patient advocacy by the Interstitial Cystitis Association (ICA). The ICA's efforts helped initiate National Institutes of Health (NIH) funding to study this disorder. Recent research suggests that IC is 50% more common than previously thought, affecting nearly 700,000 people. Most IC patients are women, but both men and children have been diagnosed with increasing frequency. No universally effective treatment exists, and many patients do not respond to available therapies. Until the etiology of IC is clearly understood and new, more effective treatments are found, it is imperative that IC pain be adequately addressed and treated.

Case reports of patients with painful idiopathic bladder ulceration and symptoms of dysuria and frequency first appeared in the late 19th century. The term interstitial cystitis (IC) was coined soon after, yet for nearly a century this disorder has been underrecognized or dismissed as a psychosomatic symptom complex seen mostly in women. Since the mid-1980s, patient self-advocacy has won federal and other support to develop consensus approaches to the clinical diagnosis and evaluation of IC, and to investigate its pathophysiology. Diverse etiologies, many supported by credible preclinical models, have been advanced for this disorder or group of disorders. Treatments remain heterogeneous and empirical. Recent insights into visceral pain and hyperalgesia, together with clinical and basic research on IC, suggest that self-sustaining peripheral and central nociceptive sensitization after any of several inciting events is the final common pathway that leads to IC. IC shares many features in common with other debilitating, self-sustaining neurogenic pain syndromes recognized in other visceral organs or somatic sites. One may advance the term complex visceral pain syndrome to encourage a holistic and mechanistic rather than organ-specific, empiric approach to the diagnosis, treatment, and taxonomy of chronic neurogenic pain evoked by a spectrum of insults to distinct visceral organs.

Interstitial cystitis (IC) does indeed appear linked to neurogenic inflammation. A direct link to substance P/neurokinin 1 receptor is unproven but highly suggested by the literature. Patients with IC may have a propensity to develop chronic inflammatory bladder disease from usually benign events. The inability of the urothelium to repair itself leaves it open to neurogenic inflammation. Neurogenic inflammation may also have its origin in the brain and not only in the dorsal root ganglion or spinal cord. IC may be promulgated by neurogenic inflammation. If this is the case, then early detection is crucial to prevent central pain.

The study of pain could benefit from approaches that study mechanisms whereby sensory input is shaped by principles of self-organization. Multisensory integration represents a set of self-organizing principles wherein various dimensions of pain experience, such as perceived degree of threat presented by an object, may be partly related to spatiotemporal convergence of multisensory information. Similar self-organizing principles might explain the integration of sensory aspects of pain with other functions, such as memory and learning.

Interstitial cystitis is a visceral pain syndrome whose incidence and severity have long been underestimated. Classifying it as a “complex visceral pain syndrome” rather than as a “disease of the bladder” is justified based on evidence that the driving process behind this illness is neurogenic inflammation, which is often not restricted to the bladder. This reclassification should help us understand that many of the current urologic therapies for interstitial cystitis can cause a worsening of the syndrome and should lead practitioners to offer rational pain-relieving treatments to their patients early on in the course of their illness.

Functional brain imaging studies reveal the complexity of brain activity during pain. The marked explanatory gaps that separate such research from classical neurophysiology and perceptual psychology raise the challenge of integrating knowledge gleaned at multiple levels of investigation into a coherent multidisciplinary account of pain. A conceptual framework from consciousness research, grounded in the concept of self-organization, can address this challenge through nonlinear dynamical systems and related models. We propose a constructivist model that construes pain, not as the passive registration of sensory information that traditional research would presume, but rather an active process of generating and shaping awareness. If pain is a dynamic product of a self-organizing brain, then pain research needs a theoretical framework to address the observations that functional brain imaging yields.