CONTINUUM Lifelong Learning in Neurology最新文献

Objective: This article explores the multiple etiologies, diagnosis, and management of orofacial pain.

Latest developments: Published in 2019, the International Classification of Orofacial Pain has become the internationally accepted classification system for primary and secondary facial pain. New discoveries in temporomandibular disorders have demonstrated that they are far more complex than the traditional dental mechanistic point of view. A 2020 consensus report released by the National Academies of Sciences, Engineering, and Medicine entitled "Temporomandibular Disorders: Priorities for Research and Care" highlighted this paradigm shift and its importance for patient care, education, and research.

Essential points: Orofacial pain comprises many disorders with different etiologies and pathophysiologies. The subjectivity of the pain experience and the interrelated anatomy and physiology of the craniofacial area add to the complexity of diagnosis when the source and etiology of pain are not clear. As orofacial pain straddles the expertise of multiple disciplines, a multidisciplinary approach combining medication, physical therapy, and procedural and psychological strategies is essential in treating patients with orofacial pain.

Objective: This article introduces the general principles of assessing, diagnosing, and managing pain relevant to neurologic practice.

Latest developments: Scientific understanding of and clinical practices related to pain and pain management are advancing. The field is remarkable for the diversity of health professions engaged in this effort, including physicians, scientists, psychologists, pharmacists, and many others. Pain classification is transforming with pending changes to the International Classification of Diseases diagnostic coding system, and pain assessment has moved toward consistent application of the biopsychosocial model. The diagnosis of pain has continued to become more sophisticated with the development of additional testing modalities, clearer classification systems, and diagnostic criteria. Pain management requires both pharmacologic and nonpharmacologic elements; systematic review evidence for both of these and interventional and surgical management are increasingly available. The context of treatment remains important given the impact of social determinants of health and limitations of access to diagnostic and treatment resources. Due to global and interprofessional collaborations as well as new research funding, the outlook is positive.

Essential points: Pain is a protean experience for humans; functional MRI (fMRI) and other research modalities show that pain perception is highly multifocal, and modulation occurs at many nervous system levels. Neurologists bring special skills to pain evaluation and management, are well equipped to appreciate both the focal and diffuse nature of pain, and can envision how pain attenuates sleep, cognitive function, mobility, motivation, and social connection. By operationalizing expert knowledge of the nervous system, implementing relevant therapies, and collaborating with diverse health professions to manage pain, neurologists can succeed at and find meaning in optimizing patient outcomes.

Objective: This article synthesizes current knowledge on neuropathic pain, with a brief review of mechanisms, diagnostic approaches, and treatment strategies to help neurologists provide effective and individualized care for patients with this complex condition.

Latest developments: The most promising developments in peripheral neuropathic pain are related to the molecular biology of the peripheral nervous system. Systematic molecular and genetic analyses of peripheral nerve terminals and dorsal root ganglia have advanced our understanding of the genetics of function and disease of peripheral nerves, as well as their physiology and clinical manifestations.

Essential points: Peripheral neuropathic pain, similar to central neuropathic pain, is primarily influenced by the biology and pathophysiology of the underlying structures, peripheral sensory nerves, and their central pathways. The clinical course is widely variable in sensory symptoms and intensities, natural history, and response to treatments.

Objective: This article reviews the principles, applications, and emerging trends of neuromodulation as a therapeutic approach for managing painful neuropathic diseases. By parsing evidence for possible mechanisms of action and clinical trial outcomes for various diseases, this article focuses on five common therapy modalities: cutaneous, peripheral nerve, spinal cord, and brain stimulation, and intrathecal drug delivery.

Latest developments: Recent advances in both invasive and noninvasive neuromodulation for pain have introduced personalized and closed-loop techniques, integrating real-time feedback mechanisms and combining therapies to improve physical and psychosocial function. Novel stimulation waveforms may influence distinct neural tissues to rectify pathologic pain signaling.

Essential points: With appropriate patient selection, peripheral nerve stimulation or epidural stimulation of the spinal cord can provide enduring relief for a variety of chronic pain syndromes. Newer technology using high frequencies, unique waveforms, or closed-loop stimulation may have selective advantages, but our current understanding of therapy mechanisms is very poor. For certain diagnoses and patients who meet clinical criteria, neuromodulation can provide profound, long-lasting relief that significantly improves quality of life. While many therapies are supported by data from large clinical trials, there is a risk of bias as most clinical studies were funded by device manufacturers or insurance companies, which increases the importance of real-world data analysis. Emerging methods like invasive or noninvasive brain stimulation may help us dissect basic mechanisms of pain processing and hold promise for personalized therapies for refractory pain syndromes. Finally, intrathecal delivery of drugs directly to segments of the spinal cord can also modify pain signaling to provide therapy for severe pain syndromes.

Objective: Spine pain is one of the most common presenting concerns in health care settings. This article reviews clinical strategies for evaluating and managing patients with spine pain.

Latest developments: Minimally invasive interventional procedures, virtual reality, predictive analytics, neuromodulation, and other evolving technologies are significantly impacting the management of spine pain. Advances in modern pain science have also led to effective skills and treatment strategies, including patient interviews and queries for insight regarding pain, education, and cognitive restructuring, and adjusting the timing of examination (after reeducation) and examination techniques to encourage the experience of movement in the absence of assumed tissue damage. An evolving understanding of the influence of patient-centric thoughts, framing, emotional status, and cognitive restructuring's influence on the brain's response to perceived threat are important aspects of spine pain management.

Essential points: The correlation of clinical presentations with structural abnormalities is necessary but insufficient to evaluate and manage spine pain. Modern pain science acknowledges pain as a subjective experience but recognizes a critical distinction between tissue damage, nociception, and the experience of pain. What and how we communicate with patients, as well as evolving neuromodulation technologies, augment conventional approaches.

Objective: This article provides an approach to the assessment, diagnosis, and treatment of central neuropathic pain.

Latest developments: Recent studies of the pathophysiology of central neuropathic pain, including evidence of changes in the expression of voltage-gated sodium channels and N-methyl-d-aspartate (NMDA) receptors, may provide the basis for new therapies. Other areas of current research include the role of cannabinoid-receptor activity and microglial cell activation in various animal models of central neuropathic pain. New observations regarding changes in primary afferent neuronal activity in central neuropathic pain and the preliminary observation that peripheral nerve blocks may relieve pain due to central neuropathic etiologies provide new insights into both the mechanism and treatment of central neuropathic pain.

Essential points: In the patient populations treated by neurologists, central neuropathic pain develops most frequently following spinal cord injury, multiple sclerosis, or stroke. A multimodal, individualized approach to the management of central neuropathic pain is necessary to optimize pain relief and may require multiple treatment trials to achieve the best outcome.

Objective: This article reviews the potential etiologies of chronic widespread pain syndromes and outlines a practical approach to the management of patients with these disorders.

Latest developments: Recent updates to diagnostic criteria for primary chronic widespread pain syndromes have allowed for more effective diagnosis. Fibromyalgia is the most common presentation of chronic widespread pain, and the concept of nociplastic pain has been used to describe pain that is related to altered processing of pain sensory pathways. Research studies have provided a better understanding of the pathophysiology of the central augmentation that occurs in patients with nociplastic pain and fibromyalgia.

Essential points: Primary chronic widespread pain and fibromyalgia have established diagnostic criteria in which chronic pain involves multiple defined regions and occurs for longer than 3 months. Evaluation of chronic widespread pain should be directed by the clinical presentation. Neurologic disease can present with chronic widespread pain but is accompanied by associated signs and symptoms. Patients with chronic widespread pain benefit from effective communication that validates concerns, provides an understandable explanation of the presenting symptoms, and sets realistic expectations in outcomes using a comprehensive multimodal care plan.

Objective: This article reviews pain disorders encountered in pediatric neurology practice and provides current information regarding the assessment and treatment of pediatric chronic pain.

Latest developments: Data about pediatric pain management remain sparse, owing to a dearth of controlled trials and longitudinal studies in these patients. However, the field of pain management and understanding of central and peripheral pain processing has expanded to allow more effective treatment of a broad group of children and adolescents with pain associated with neurologic disease. Neuroimaging visualizes sensory and nonsensory systems, and genetic markers of sensitivity and disease may guide specific therapy. The concept of central sensitization in chronic pain disorders has supported the development of multidisciplinary paradigms for the comprehensive care of these patients.

Essential points: Pain involves sensory activation and central nervous system modulation in pediatric patients. Pediatric neurologists should be prepared to define, investigate, and treat pain disorders in this complex patient population. Appropriate interventions during childhood may attenuate or prevent chronic pain later in life. Current interventions include behavioral, physical, and pharmacologic approaches, as well as potential noninvasive tools for neuromodulation. Research is progressing in sensory measurement, neuroimaging, genetics, and neuroinflammation to guide future targeted therapies.