Hand clinics
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Upper extremity neuropathic pain states greatly impact patient functionality and quality of life, despite appropriate surgical intervention. This article focuses on the advanced therapies that may improve pain care, including advanced treatment strategies that are available. The article also surveys therapies on the immediate horizon, such as spinal cord stimulation, peripheral nerve stimulation, and dorsal root ganglion spinal cord stimulation. As these therapies evolve, so too will their placement within the pain care algorithm grounded by a foundation of evidence to improve patient safety and management of patients with difficult neuropathic pain.
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The treatment of pain is a complex process that requires a team approach. This article provides an overview of the pharmaceutical treatments available. ⋯ Pharmaceuticals are an important component in the treatment of chronic pain and opioids are often not a good solution. Knowing what other medications are available can improve the care for these challenging patients.
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If the patient with hand pain remains without significant relief and without recovery of function after appropriate pharmaceutical and physical modality treatments, it is appropriate to consider a surgical approach to the pain. Categories of pain amenable to a surgical approach are pain caused by nerve compression, pain caused by a neuroma, and joint pain of neural origin. ⋯ Painful neuroma must be resected to stop the pain generator. For a painful joint, the biomechanics of that joint must first be stable before denervation.
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Despite the severe pain and disability associated with complex regional pain syndrome (CRPS), the lack of understanding of the pathophysiological mechanisms supporting this enigmatic condition prevents the rational design of new therapies, a situation that is frustrating to both the physician and the patient. The review highlights some of the mechanisms thought to be involved in the pathophysiology of CRPS in preclinical models and CRPS patients, with the ultimate goal that understanding these mechanisms will lead to the design of efficacious, mechanism-based treatments available to the clinic.
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Successful management of problems related to the hands and upper extremities begins with a comprehensive assessment of the pain experience and related factors. Pain intensity is the domain most commonly assessed, and pain relief is often the primary goal of treatment. Because pain is a private and subjective experience, self-report is considered the gold standard of pain measurement. This article describes and discusses the strengths and weaknesses of the most commonly used self-report scales used to measure hand pain intensity, and gives recommendations to help clinicians select from among the various options for measuring the intensity of hand pain.