DOCSLIB.ORG

Phantom Pain: a Lesson in the Necessity for Careful Clinical Research on Chronic Pain Problems

Total Page：16

File Type：pdf, Size：1020Kb

Download full-text PDF Read full-text
Phantom Pain: a Lesson in the Necessity for Careful Clinical Research on Chronic Pain Problems Journal of Rehabilitation Research and Development Vol . 25 No . 2 A Guest Editorial Phantom pain: A lesson in the necessity for careful clinical research on chronic pain problems by Richard A. Sherman, Jeffrey L . Ernst, Roberto H . Barja, and Glenda M . Bruno Department of Clinical Investigation, D .D. Eisenhower Army Medical Center, Fort Gordon, Georgia and Veterans Administration Medical Center, Augusta, Georgia Summary The Myth Recent findings suggest that major misunder- For years it was thought that phantom pain is standings concerning the prevalence, characteristics, rare among individuals with amputations (1) and, etiology, and treatment effectiveness of phantom when occurring, is most likely of psychological ori- pain have led to the widespread mismanagement of gin (3). amputees throughout the history of modern medi- The Reality cine . For years it has been believed that phantom Recent surveys show that phantom pain is far pain is relatively rare, is of unknown etiology, and more prevalent than previously thought . For exam- probably has a psychological basis. ple, we conducted a series of surveys of over 11,000 Research results over the last few years, however, suggest that phantom pain is widely prevalent amputee veterans (12,15) which showed that experi- encing phantom pain is the norm rather than the among individuals with amputations and most exception. Over 80 percent of respondents reported likely has a physiological basis. Although many significant phantom pain . Other researchers have different treatments have been introduced recently, recently confirmed similar rates of occurrence in few, if any, have yet been documented as effective other populations (2,6,16). due to lack of rigorous follow-up studies. Current evidence demonstrates that chronic phan- Future progress in clinical treatment and tom pain is usually a series of complex types of re- increased scientific understanding of phantom pain ferred pain with very real physiological causes will require an examination of some of the factors (8,10). There is no convincing evidence that a that have led to past confusion regarding scientific greater proportion of amputees reporting chronic research on and clinical treatment of phantom pain. phantom pain are psychologically abnormal or have abnormal personalities than the proportion of psy- chologically abnormal people found in the general population after adjustment is made for the effects The opinions or assertions contained herein are the private views of the authors and are not to be construed as official or as reflecting the views of intractable chronic pain upon patients, their cli- of the United States Department of the Army, the Department of nicians, and test instruments (13). Defense, or the Veterans Administration. Treatment Dynamics that Perpetuate the Myth Correspondence and reprint requests to : Major Richard A . Sherman, Ph.D ., Department of Clinical Investigation, Fitzimmons Army Medical The discrepancy between the long held myth of Center, Aurora, CO 80045-5001 . the rarity of phantom pain and the reality of its vii Journal of Rehabilitation Research and Development Vol . 25 No . 2 Spring 1988 high prevalence has led to treatment anomolies. could not provide a fruitful basis for research or These anomolies help explain why the myth was treatment. able to continue unchallenged until recently. In those cases where patient complaints of In one of our surveys of veterans with amputa- chronic phantom pain persisted, physicians were tions, respondents told us their physicians had, compelled to provide treatment . As is frequently early in treatment, directly stated or clearly implied the case in chronic pain syndromes, if one looks that the pain they felt was "just in their heads." hard enough one can find something in the body The great majority of amputees responding to this which at least appears to be out of the ordinary. survey were afraid to inform their physicians that For phantom pain, the answer was abnormalities in they were continuing to suffer with phantom pain the stump such as formation of neuromas . The for fear that the physician would think them in- logic is that if the patient reports pain, there must sane . They were afraid to jeopardize the critically be something physically wrong with the stump, the important relationship with their physician or risk nerves or blood vessels related to the stump, or the losing credibility in reporting stump problems at a peripheral or central nervous systems. stage when verbal report is likely to be the only evi- dence that problems exist . Stump problems are fre- Medical/Surgical Treatments quently painful and can entirely prevent the use of A wide array of medical and surgical treatments a prosthesis for extended periods of time unless in- have been applied to those few amputees requesting tervention is begun prior to development of obvious treatment for phantom limb pain . We analyzed the skin breakdown and other highly noticeable effects. world literature on treatment of phantom pain (9) Because most patients were afraid to persist in and found that 43 unrelated treatments have been their reports of phantom pain, physicians were only reported to be in recent use . They range from such rarely confronted with patients who would report drastic measures as lobotomies, through spinal sur- chronic phantom pain . In such cases, doctors gery and reamputation, to more innocuous treat- would try to diagnose physiological causes, pre- ments such as injection of the stump with anesthet- scribe a series of treatment regimes until the patient ics and relaxation training. stopped complaining or dropped from the caseload, We sent surveys to virtually all groups and hospi- or refer the patient for psychiatric examination. tals in the United States whom we could identify as The way in which these actions have been carried being likely to treat amputees . This included all VA out has often unwittingly led to perpetuation of the hospitals, all medical schools, all pain centers, and myths surrounding phantom pain. all members of the International Association for the Study of Pain (14) . The respondents identified Diagnosis 50 treatments in wide, current use . When the results In the search for physiological causes, both scien- of the survey and literature analysis were combined, tists and physicians have tried to isolate differences a total of 68 treatments were identified . Almost between patients reporting phantom pain and pa- none of the respondents carried out any follow-ups tients not reporting phantom pain . This is based beyond a month and there were only a few 6-month upon the reasonable hypothesis that if other things follow-ups. Every treatment reported by practitio- are equal, the differences between the two groups ners as being successful was reported by others as might reveal, directly or indirectly, the causes of being identified in their patient's records as unsuc- phantom pain. Causes attributed to identified dif- cessful. ferences could then be treated . Unfortunately, since In an effort to delineate treatment effectiveness, members of the "control group" also experienced we sent surveys to 10,000 randomly selected veteran phantom pain but were afraid to report it, signifi- amputees (15), all 1,200 members of a national am- cant differences were not evident and therefore putee veterans group (12), and over 500 self- Sherman et al .: Phantom pain A Guest Editorial selected amputees whose amputations were of civil- giving up . There is no evidence that patients report- ian origin (11) . Only two percent of the respondents ing phantom pain are psychologically different reported significant benefits from the host of treat- from patients having other chronic pain syndromes ments attempted (1 .7 percent major permanent re- or that phantom pain is frequently caused by psy- duction in pain and 0 .4 percent cure) . The above chological problems (13) . It is exacerbated by psy- surveys of both clinicians and patients indicated chological problems and stress in the same ways that there was no relationship between the treat- other chronic pain syndromes are (13). ment applied and the symptoms of phantom pain reported. There was no way to predict from symp- Conclusions toms or histories why those few patients who re- Over the last decade of research with a variety of ceived at least some benefit from a particular treat- chronic pain conditions, including low back pain, ment reported more success than apparently similar subluxation of the patella, phantom limb pain, patients receiving apparently very similar treat- phantom body pain, and tension headaches, we ments . The lack of any relationship between treat- have gradually come to the realization that careful ment success and any other variables, such as medi- studies are rarely carried out before new treatments cal specialty, symptoms, etc ., leads us to feel that for chronic pain syndromes are introduced into these are randomly applied, useless treatments. clinical practice. All too frequently, little time is Thus, the widespread failure to carry out follow- spent actually attempting to define the physiological up evaluations resulted in the practitioners being characteristics, subclasses, and underlying mecha- unaware that their treatments were usually ineffec- nisms of the problems . The result often is that cli- tive when the criterion of continued significant re- nicians from different specialties use their special- duction of pain at 1 year was used. The realities of ized clinical training and limited experience with current medical practice in the United States make treatments based on exposure to a restricted variety doing appropriate follow-ups exceedingly difficult. of patients to develop treatments based on their If a patient is either unsatisfied or cured he will best, unsubstantiated guess about what the underly- probably not come back, so the practitioner really ing problem might be . If the treatment appears to has no way of knowing the actual results of the at least temporarily ameliorate the problem in a few treatment for a large proportion of cases. patients, the method is often published without waiting for a follow-up period.
Load more

Recommended publications
  • Phantom Pain Syndromes
    chapter 28 Phantom Pain Syndromes Laxmaiah Manchikanti, Vijay Singh, and Mark V. Boswell ■ HISTORICAL CONSIDERATIONS without treatment, except in the cases where phantom pain develops. Phantom sensation or pain is the persistent perception that a The incidence of phantom limb pain has been reported to body part exists or is painful after it has been removed by vary from 0% to 88%.16-32 Prospective evaluations31,37 sug- amputation or trauma. The first medical description of post- gested that in the year after amputation, 60% to 70% of amputation phenomena was reported by Ambrose Paré, a amputees experience phantom limb pain, but it diminishes French military surgeon, in 1551 (Fig. 28–1).1,2 He noticed with time.14,31 The incidence of phantom limb pain increases that amputees complained of severe pain in the missing limb with more proximal amputations. The reports of phantom long after amputation. Civil War surgeon Silas Weir Mitchell3 limb pain after hemipelvectomy ranged from 68% to 88% popularized the concept of phantom limb pain and coined the and following hip disarticulation 40% to 88%.28,30 However, term phantom limb with publication of a long-term study on wide variations exist with reports of phantom limb pain the fate of Civil War amputees in 1871 (Fig. 28–2). Herman after lower extremity amputation as high as 72%21 and as Melville immortalized phantom limb pain in American liter- low as 51% after upper limb amputation.22 Further, 0% preva- ature, with graphic descriptions of Captain Ahab’s phantom lence was reported in below-knee amputations compared to limb in Moby Dick (Fig.
    [Show full text]
  • The Electro Acupuncture: a Mode of Analgesia
    Pak Armed Forces Med J 2005; 55(1): 50-55 Electro Acupuncture THE ELECTRO ACUPUNCTURE: A MODE OF ANALGESIA Sadia Salim, *Ahsin Manzoor, M Mazhar Hussain, Idrees Farooq Butt, Muhammad Aslam Dept of Physiology Army Medical College Rawalpindi, *Dept of Surgery CMH Malir INTRODUCTION perception. In 1960’s, Prof. Melzack and Wall explained the mechanism of analgesia by bringing The role of electroanalgesic modalities in forward the “Gate control theory”, which treatment of chronic pain syndromes has long been suggested that stimulation of large-diameter questioned by medical practitioners because of the afferent nerve fibers may inhibit second-order lack of adequate randomized, double-blind sham- neurons in the dorsal horn of spinal cord to controlled studies to support their use in clinical suppress the conduction of pain impulses through practice [1-3]. Earlier few sham-controlled studies the small-diameter fibers to the higher brain involving the use of electroacupuncture reflected centers [12]. It is the most commonly used some significant benefits in terms of lowering pain hypothesis to explain the relief of pain on using scores, improvement in sense of well-being, high-frequency Transcutaneous Electrical Nerve physical activity, and quality of sleep, and Stimulation (TENS) therapy [13,14]. During reduction in need for oral analgesic medication [4- 1970’s the raphe spinal structures were identified 6]. Recently, Sator-Katzenschlager and co workers as part of brain analgesia system along with the described a prospective, randomized sham- discovery of endogenous opioids [15] which controlled study by using auricular acupuncture. opened the avenues of research on The study involved electrical stimulation of an electroacupuncture mechanisms.
    [Show full text]
  • Management of Post-Amputation Pain
    PAIN MANAGEMENT IN REHABILITATION Management of Post-Amputation Pain JACOB M. MODEST, MD; JEREMY E. RADUCHA, MD; EDWARD J. TESTA, MD; CRAIG P. EBERSON, MD 19 22 EN ABSTRACT infection, the need for revision amputation, economic cost, INTRODUCTION: The prevalence of amputation and and physical disability, one of the most debilitating results post-amputation pain (PAP) is rising. There are two main is chronic PAP. Comorbid conditions such as fibromyalgia, types of PAP: residual limb pain (RLP) and phantom limb migraines, irritable bowel syndrome, irritable bladder, and pain (PLP), with an estimated 95% of people with ampu- Raynaud syndrome have all been associated with chronic tations experiencing one or both. PAP. 4 The management of PAP is primarily medical, but sev- eral surgical options also exist. MEDICAL MANAGEMENT: The majority of chronic PAP is due to phantom limb pain, which is neurogenic in na- ture. Common medications used include tricyclic anti- PATHOPHYSIOLOGY depressants, gabapentin, and opioids. Newer studies are There are several methods to categorize PAP. Acute post-am- evaluating alternative drugs such as ketamine and local putation limb pain lasts less than two months and chronic anesthetics. post-amputation limb pain lasts more than two months.5 REHABILITATION MANAGEMENT: Mirror visual feed- Residual limb pain (RLP), often unfortunately referred to back and cognitive behavioral therapy are often effective as “stump” pain, is pain at the surgical site or proximal adjunct therapies and have minimal adverse effects. remaining extremity. Phantom limb pain (PLP) is described SURGICAL MANAGEMENT: Neuromodulatory treatment as pain localized distal to the amputation level.6 Ephraim and surgery for neuromas have been found to help select et al.
    [Show full text]
  • Chapter 11 PAIN MANAGEMENT AMONG SOLDIERS with AMPUTATIONS
    Pain Management Among Soldiers With Amputations Chapter 11 PAIN MANAGEMENT AMONG SOLDIERS WITH AMPUTATIONS † ‡ § RANDALL J. MALCHOW, MD*; KEVIN K. KING, DO ; BRENDA L. CHAN ; SHARON R. WEEKS ; AND JACK W. TSAO, MD, DPHIL¥ INTRODUCTION HISTORY NEUROPHYSIOLOGY AND MECHANISMS OF PAIN Neurophysiology Mechanism of Phantom Sensation and Phantom Limb Pain Residual Limb Pain MULTIMODAL PAIN MANAGEMENT IN AMPUTEE CARE Rationale Treatment Modalities LOW BACK PAIN FUTURE RESEARCH SUMMARY * Colonel, Medical Corps, US Army; Chief, Regional Anesthesia and Acute Pain Management, Department of Anesthesia and Operative Services, Brooke Army Medical Center, 3851 Roger Brooke Drive, Fort Sam Houston, Texas 78234; formerly, Chief of Anesthesia, Brooke Army Medical Center, 3851 Roger Brooke Drive, Fort Sam Houston, Texas, and Program Director, Anesthesiology, Brooke Army Medical Center-Wilford Hall Medical Center, Fort Sam Houston, Texas † Major, Medical Corps, US Army; Resident Anesthesiologist, Department of Anesthesiology, Brooke Army Medical Center, 3851 Roger Brooke Drive, Fort Sam Houston, Texas 78234 ‡ Research Analyst, CompTIA, 1815 South Meyers Road, Suite 300, Villa Park, Illinois 60181; Formerly, Research Assistant, Department of Physical Medicine and Rehabilitation, Walter Reed Army Medical Center, 6900 Georgia Avenue, NW, Washington, DC 20307 § Research Assistant, Physical Medicine and Rehabilitation, Walter Reed Army Medical Center, 6900 Georgia Avenue, NW, Washington, DC 20307 ¥ Commander, Medical Corps, US Navy; Associate Professor, Department of Neurology, Uniformed Services University of the Health Sciences, 4301 Jones Bridge Road, Room A1036, Bethesda, Maryland 20814; Traumatic Brain Injury Consultant, US Navy Bureau of Medicine and Surgery, 2300 E Street, NW, Washington, DC 229 Care of the Combat Amputee INTRODUCTION Pain management is increasingly recognized as a reducing hospital stay; decreasing cost; and improving critical aspect of the care of the polytrauma patient.
    [Show full text]
  • Dealing with Pain: Phantom Limb Pain
    AMPUTATIONS Page 2 Dealing with Pain Series : Phantom Limb Pain Page 1 ➢Amputation of the arm is common after motorcycle accident injuries where the impact damages the nerves passing from the arm to the neck. This may leave the arm paralyzed and useless so that amputation is necessary. ➢Amputation of the leg is commonly done to relieve the pain caused by loss of the blood supply to the leg. The blood supply is lost because of www.painrelieffoundation.org.uk hardening of the arteries (called peripheral vascular disease, PVD). This condition is more common in smokers. Gangrene may develop in the leg and then the leg may have to be amputated. ➢Traumatic amputations due to war injuries, such as land mine explosions, PHANTOM LIMB PAIN are common in the armed forces and in war torn countries. WHAT CAUSES PHANTOM LIMB PAIN? WHAT IS PHANTOM LIMB PAIN? ➢The precise cause is unknown. Injury to the nerves during amputation ➢ Phantom limb pain refers to pain felt in an absent limb. The limb may causes changes in the central nervous system. It is likely that there is a have been lost because of an accident, or deliberately removed in an very important change in the way the brain reads messages coming from operation because of disease. This kind of pain is the subject of this the body. Parts of the brain, which controlled the missing limb, stay leaflet. active. This causes the very real illusion of the phantom limb even though the amputee knows it is not real! ➢ Phantom limb sensations, which are not painful, may also be felt in the absent limb.
    [Show full text]
  • Diagnosis and Treatment of Atypical Odontalgia: a Review of the Literature and Two Case Reports
    Diagnosis and Treatment of Atypical Odontalgia: A Review of the Literature and Two Case Reports Abstract Aim: This report presents two cases diagnosed with atypical odontalgia (AO) and successfully treated with amitriptyline as well providing a review of the current literature on the subject. Results: The literature indicates the most important issue is an accurate differential diagnosis to distinguish between AO, pulpal pain, myofascial pain, and trigeminal neuralgia. Conclusion: Once the correct diagnosis is made the prognosis of AO is usually fair and the administration of tricyclic antidepressants often resolves symptoms. An effort should be made to avoid any unnecessary dental treatment that would only aggravate the problem. Keywords: Atypical odontalgia, AO, phantom tooth pain, differential diagnosis, treatment, amitriptyline, tricyclic antidepressants Citation: Melis M, Secci S. Diagnosis and Treatment of Atypical Odontalgia: A Review of the Literature and Two Case Reports. J Contemp Dent Pract 2007 March;(8)3:081-089. 1 The Journal of Contemporary Dental Practice, Volume 8, No. 3, March 1, 2007 Introduction Atypical odontalgia (AO) has been defined by signs are present, and anesthetic block of the Merskey1 as “severe throbbing pain in the tooth involved tooth provides equivocal results.2,9,18-20,26 without major pathology.” In fact the primary The pain also stops during sleep.9,18-20 symptom is pain, usually located in a tooth or a tooth site,2-9 that may spread with time involving The pathophysiology of AO is not clear, the entire maxilla or the mandible.2,4,6-10 The yet idiopathic,6,20,27-28 psychogenic,20,29-31 and pain is frequently continuous and persistent , neuropathic3,19-20,32 hypotheses have been but fluctuating in intensity4-5,7,11 with no signs of suggested.
    [Show full text]
  • Assistive Technologies for Pain Management in People With
    Ghoseiri et al. Military Medical Research (2018) 5:1 DOI 10.1186/s40779-018-0151-z REVIEW Open Access Assistive technologies for pain management in people with amputation: a literature review Kamiar Ghoseiri1, Mostafa Allami2*, Mohammad Reza Soroush2 and Mohammad Yusuf Rastkhadiv3 Abstract The prevalence of limb amputation is increasing globally as a devastating experience that can physically and psychologically affect the lifestyle of a person. The residual limb pain and phantom limb pain are common disabling sequelae after amputation surgery. Assistive devices/technologies can be used to relieve pain in people with amputation. The existing assistive devices/technologies for pain management in people with amputation include electrical nerve block devices/technologies, TENS units, elastomeric pumps and catheters, residual limb covers, laser systems, myoelectric prostheses and virtual reality systems, etc. There is a great potential to design, fabricate, and manufacture some portable, wireless, smart, and thin devices/technologies to stimulate the spinal cord or peripheral nerves by electrical, thermal, mechanical, and pharmaceutical stimulus. Although some preliminary efforts have been done, more attention must be paid by researchers, clinicians, designers, engineers, and manufacturers to the post amputation pain and its treatment methods. Keywords: Amputees, Amputation stumps, Self-help devices, Pain, Acute pain, Chronic pain, Pain management Background Category of pain Limb amputation is a devastating experience that can Phantom limb pain physically and psychologically affect the lifestyle of a per- The majority of patients after a partial or complete am- son [1]. Although there is no estimate of the global putation of a limb may feel that the amputated part of prevalence of limb amputation, national reports of some the body is still present and suffer from pain [4, 11–13].
    [Show full text]
  • Transcutaneous Electrical Nerve Stimulation (TENS): REVIEW Adults
    CLINICAL Transcutaneous Electrical Nerve Stimulation (TENS): REVIEW Adults Indexing Metadata/Description › Device/equipment: Transcutaneous Electrical Nerve Stimulation (TENS): Adults › Synonyms: N/A › Area(s) of specialty: Acute care, cardiovascular rehabilitation, pulmonary rehabilitation, hand therapy, oncology, neurological rehabilitation, orthopedic rehabilitation, sports rehabilitation, women’s health, wound management › Description/use • Transcutaneous electrical nerve stimulation (TENS)(1) –Electrical stimulation is delivered through electrodes placed on the skin –Units can be powered by batteries to allow for ease of use during functional tasks –Most often used in an effort to reduce/eliminate pain • “Standard” TENS devices(1) –Administer biphasic pulsed currents –Pulse durations range from 50 to 1,000 µs –Pulse frequencies range from 1 to 250 pps –Pulse patterns are typically continuous or burst • Common terminology –Pulse amplitude – milliamps (mA)(3) –Pulse duration – microseconds (µs)(4) –Pulse frequency - Pulses per second (pps)(1) - Hertz (Hz)(1) - Note: Hz and pps are equivalent units of measure (1 Hz = 1 pps) Authors –Waveform – “A visual representation of the flow of electric current through a Amy Lombara, PT, DPT conductor on an amplitude-time plot”(1) Cinahl Information Systems, Glendale, CA (1) Michael Granado, PT, MPT, ATC, CSCS –Biphasic pulsatile current Cinahl Information Systems, Glendale, CA - A type of waveform - There is a positive and a negative phase Reviewers – (4) Diane Matlick, PT Low-frequency TENS is
    [Show full text]
  • Phantom Limb Pain
    European Journal of Molecular & Clinical Medicine ISSN 2515-8260 Volume 07, Issue 10, 2020 Phantom Limb Pain Fakhrurrazy1, Husnul Khatimah2, Fauziah3, Huldani4 1Department of Neurology, Faculty of Medicine, University of Lambung Mangkurat, Banjarmasin, South Kalimantan 2Department of Biomedical Sciences, Faculty of Medicine, University of Lambung Mangkurat, Banjarmasin, South Kalimantan 3Clinical Clerkship, Faculty of Medicine, Lambung Mangkurat University, Banjarmasin, South Kalimantan 4Department of Physiology, Faculty of Medicine, University of Lambung Mangkurat, Banjarmasin, South Kalimantan 1E-mail: [email protected] ABSTRACT Amputation is often causing chronic postoperative pain with an incidence of 85%. Phantom limb pain or PLP is one of the post-amputation phenomena characterized by pain in the limb that has been removed, including the amputation. Neuropathic pain occurs due to hyperexcitability of damaged nerves and other functional nerves around them, causing changes in neuroma sensitivity, decreased potassium channel expression, and increased voltage-gate of sodium channel (VGSC) activity. VGSC buildup triggers cell membrane hyperexcitability, becomes an ectopic initiator of pain, and causes central and peripheral sensitization. Neuromas in the stump respond more to stimuli because they are sensitive to cytokines and amines, causes the massive process of nociceptive impulses and resulting in pain. Neural plasticity allows the nervous system to compensate for the damage after amputation, the brain undergoes a somatotopic map adjustment due to missing limbs. Plasticity is the brain's response to pain that causes the increase of pain signal transmission in the spinal cord. This is known as central sensitization and causes hyperalgesia and allodynia. The plasticity of nerve damage leads to ectopic discharge, it leads to spontaneous pain in the area innervated by the damaged nerve or the nerves surrounding the damaged nerve.
    [Show full text]
  • Effects of Lowdose IV Ketamine on Peripheral and Central Pain from Major Limb Injuries Sustained in Combat
    bs_bs_banner Pain Medicine 2013; *: **–** Wiley Periodicals, Inc. Effects of Low-Dose IV Ketamine on Peripheral and Central Pain from Major Limb Injuries Sustained in Combat Rosemary C. Polomano, PhD, RN, FAAN,*‡ Sciences, 418 Curie Blvd. RM 324, Philadelphia, PA Chester C. Buckenmaier III, MD,††‡‡ 1904, USA. Tel: 215-898-0934; Fax: 215-573-7507; Kyung H. Kwon, MSN, CRNP,†† E-mail: [email protected]. Alexandra L. Hanlon, PhD,† ¶¶ Christine Rupprecht, MSN, RN, Conflict of Interest/Disclosure: There are no perceived Cynthia Goldberg, MSN, RN-BC,§§ and conflicts of interests by any authors related to the Rollin M. Gallagher, MD, MPH§¶** conduct of this research. *Department of Biobehavioral Health Sciences Funding: This work was supported by institutional funding and the Defense and Veterans Center for †University of Pennsylvania School of Nursing, Integrative Pain Management. Philadelphia, Pennsylvania; Copyright Protection: Our team is comprised Departments of ‡Anesthesiology and Critical Care partly of military service members and employees of the US Government. This work was prepared (Secondary) and as part of our official duties. Title 17 United States Code (USC) 105 provides that “Copyright protection § Psychiatry and Anesthesiology and Critical Care, under this title is not available for any work of the University of Pennsylvania Perelman School of United States Government.” Title 17 USC 101 Medicine, Philadelphia, Pennsylvania; defines a US Government work as a work prepared by a military service member or employee ¶Pain Management, Veterans Health System, of the US Government as part of that person’s offi- Philadelphia, Pennsylvania; cial duties. Disclaimer: The views expressed in this presentation **Pain Policy Research and Primary Care, Penn Pain are those of the authors and do not necessarily reflect Medicine, Philadelphia, Pennsylvania; the official policy of the Department of the Army, the Department of Defense, or the United States ††Defense and Veterans Center for Integrative Pain Government.
    [Show full text]
  • Non-Odontogenic Toothache Revisited
    Open Journal of Stomatology, 2011, 1, 92-102 OJST doi:10.4236/ojst.2011.13015 Published Online September 2011 (http://www.SciRP.org/journal/OJST/). Non-odontogenic toothache revisited Ramesh Balasubramaniam1*, Lena N. Turner2, Dena Fischer3, Gary D. Klasser4, Jeffrey P. Okeson5 1School of Dentistry, University of Western Australia, Perth, Australia; 2Department of Oral Medicine, School of Dental Medicine, University of Pennsylvania, Philadelphia, America; 3Department of Oral Medicine and Diagnostic Sciences, University of Illinois at Chicago, Chicago, America; 4Division of Diagnostic Sciences, Louisiana State University Health Sciences Centre, School of Dentistry, New Orleans, America; 5Department of Oral Health Science, University of Kentucky, Lexington, America. Email: *[email protected] Received 17 May 2011; revised 23 June 2011; accepted 5 July 2011. ABSTRACT ache. Ultimately, this article will aid the dental practi- tioner with preventing misdiagnosis and delivery of in- Although pain of dental origin is the most common correct and sometimes irreversible procedures for non- orofacial pain, other non-odontogenic pains can af- odontogenic pains. fect the orofacial region and occasionally mimic den- tal pain. These non-odontogenic pains may pose a 2. CLINICAL CHARACTERISTICS OF diagnostic dilemma for the dental practitioner who ODONTOGENIC PAIN routinely diagnoses and treats dental pain. Knowl- Odontogenic pain is generally derived from either one of edge of the various non-odontogenic pains will ulti- two structures associated with the tooth: pulpal or pe- mately prevent misdiagnosis and the delivery of in- riodontal tissue. Although the mechanisms for both are correct and sometimes irreversible and invasive pro- of inflammatory origin, their distinct functionality and cedures to patients.
    [Show full text]
  • Diagnostic Challenges of Neuropathic Tooth Pain
    C LINICAL P RACTICE Diagnostic Challenges of Neuropathic Tooth Pain • Michael J. Matwychuk, DMD • Abstract This article presents the clinical characteristics, epidemiology, pathophysiology and treatment of 2 neuropathic conditions: trigeminal neuralgia and atypical odontalgia. A case report highlights the complexities involved in diagnosing neuropathic pain. Neuropathic pain is chronic, diverse in quality, difficult to localize and it occurs in the absence of obvious pathology. To avoid multiple, ineffective dental treatments, general practitioners must be familiar with the signs of nonodontogenic sources of tooth pain. MeSH Key Words: diagnosis, differential; facial pain/diagnosis; facial pain/physiopathology; toothache/diagnosis © J Can Dent Assoc 2004; 70(8):542–6 This article has been peer reviewed. ne of the most challenging and rewarding aspects tions in teeth 34 and 36 (Fig. 1). The patient was subse- of general practice is the diagnosis and treatment quently referred to me when the pain did not abate. O of pain. An estimated 22% of the general popula- Clinical examination revealed that teeth 34 and 36 were tion experiences orofacial pain in any given 6-month heavily restored. The fillings were well sealed and the period.1 Furthermore, persistent and chronic pain is more occlusal and interproximal contacts were adequate. No prevalent in the head and neck region than in any other signs of gingival inflammation or pathology were present. part of the body.2 The patient reported that tooth 35 was treated by root canal Misdiagnosis of orofacial pain is common. The conver- therapy 20 years earlier and the tooth had been crowned gence of sensory neurons to higher centres makes localiza- only 3 years ago.
    [Show full text]