The Clinical journal of pain
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Those in professions treating pain must prepare to justify the cost-effectiveness of the treatments they supply. Attempts have been made to define cost-effectiveness. Is it the lowest possible cost? The return of the patient to work and other daily activities? Pain clinics must develop good working relationships with business providers; establish credibility; plan, communicate, evaluate results scientifically; and educate the public.
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It is well established that multiple influences regulate cerebral blood flow; the overwhelming evidence continues to suggest that migraine is a disorder, albeit temporary, of cerebral hemodynamics. Thus, the classical theory of migraine is no longer tenable as viewed strictly and rigidly. Perhaps it would be easier to say that the migraine's aura is characterized by reduction in blood flow, often hemispheric, and that sometime during the headache phase cerebral hyperperfusion occurs. ⋯ The blood flow changes do not necessarily correlate with the patient's symptoms. Thus, even now, migraine and other vascular headaches remain as descriptive diagnoses. The final pathology of migraine remains to be determined.
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A reliable, safe approach to achieving unilateral anesthesia in multiple contiguous thoracic dermatomes would be of great benefit to anesthesiologists in the acute and chronic pain setting. The multidermatomal intercostal technique is one such approach, although the anatomical mechanism of this nerve block is a matter of debate. At our pain clinic, we have used another technique, a modification of the paravertebral block, to achieve multiple segments of unilateral sensory blockade. ⋯ In order to clarify the mechanism of bilateral blockade resulting from a unilateral technique, we injected four fresh cadavers with colored latex solution using the paravertebral-peridural approach. This revealed spread of the latex across the midline prevertebrally to the contralateral paravertebral space. We conclude that the paravertebral-peridural thoracic block is a reliable, safe technique for achieving unilateral anesthesia over multiple dermatomes with a single injection.
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Review Comparative Study
Comparison of clinical characteristics in myogenic, TMJ internal derangement and atypical facial pain patients.
Temporomandibular joint (TMJ) disorders have been collectively grouped as myofascial pain-dysfunction syndrome (MPDS) or temporomandibular joint dysfunction syndrome (TMJDS). In the past, these terms have been used synonomously to describe a set of clinical signs and symptoms that include pain in the TMJ and muscles of mastication, limited or deviant opening of the mandible, and/or joint sounds. The present study segregated two major subgroups subsumed within this diagnostic classification and assigned them to a myogenic facial pain (MFP) group and a TMJ internal derangement (TMJID) group. ⋯ Minnesota Multiphasic Personality Inventory (MMPI) scores from 95 subjects were compared with self-report measures of depression and anxiety. It was concluded that subcategorization of myofascial pain dysfunction patients into a MFP and TMJID group is justified on the basis of psychometric differences, clenching habits, masseter EMG levels, and male:female ratio. Furthermore, psychopathological factors are more significant among MFP and AFP subjects than TMJID patients.
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Reflex sympathetic dystrophy (RSD) usually occurs in an individual who has been experiencing significant personal stress, a state associated with increased discharge of norepinephrine (NE) from perivascular postganglionic sympathetic neurons. RSD is often precipitated by this sequence: traumatic arterial spasm, regional ischemia, neurogenic inflammation, and ischemic/edematous damage to membranes of preterminal perivascular nociceptive neurons. In the natural repair of these membranes, it is suggested that adrenoceptors appear and are ordinarily transitory; but in RSD, they are retained by the increased adjacent NE. This process delays further healing, produces pain, and releases inflammatory substances, resulting in interacting pathophysiologic vicious cycles.