Der Schmerz
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A recently published randomized study failed to show a significant reduction of phantom limb pain after perioperative epidural analgesia EDA [9]. Since these findings were not supported by previous studies,we conducted an analysis of factors contributing to the results of phantom limb pain prophylaxis. We calculated the efficacy of perioperative EDA as "Number Needed to Treat" (NNT). ⋯ Perioperative EDA has been shown to be an effective prophylaxis of phantom limb pain. The most important differences between studies were the definition of phantom limb pain by intensity ratings. Thus, perioperative EDA does not completely abolish phantom limb pain, but increases the number of patients with a mild form of phantom pain.
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Visceral pain is diffusely localized, referred to deep somatic tissues, skin and viscera, frequently not correlated with an actual trauma, commonly correlated with strong negative affective reactions and accompanied by strong protective autonomic and motor reactions. It is correlated with the excitation of spinal (thoraco-lumbar, sacral) visceral afferents and (with a few exceptions) not with the excitation of vagal afferents. Spinal visceral afferents are polymodal and can be excited by physical and chemical stimuli. ⋯ Visceral nociception and pain is presumably (together with other visceral sensations and homeostatic regulations of autonomic body functions) primarily represented in the insula in the context of interoception. The insula obtains its main peripheral afferent input from lamina I neurons via the Nucleus ventromedialis posterior of the thalamus. The transmission of visceral impulses in the spinal cord is modulated by the endogenous control systems in the brain stem which are in turn under the control of cortex and limbic system.
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Results of international epidemiologic studies indicate that orofacial pain occurs in approximately 10 percent of the adult population. Women are constantly more often affected than men by a ratio of 2:1, on the average. Most studies show a decline of prevalence in older age. Several sources of epidemiologic data about pain in the general population are available in Germany. The German National Health Survey ( n=7,124), besides some smaller studies in specific German regions, provides detailed results about gender- and age-specific prevalence (12 months, 7 days) of orofacial pain. ⋯ With generally somewhat higher prevalence figures, results from the National Health Survey are well in the range of findings of international studies. Prevalence of orofacial pain in the total sample was 16 percent (12 months) and 7 percent (7 days), respectively. With 12 months and 7 days prevalence rates of 20 percent and 9 percent, respectively, women were more frequently affected than men (12 percent, 5 percent). Data from the National Health Survey also demonstrate that occurrence of orofacial pain is often associated with pain in other body regions. Of those with orofacial pain during the past 7 days, less than 10 percent reported orofacial pain as the sole pain problem. 43 percent of those with orofacial pain reported pain in 5 or more other localizations. Orofacial pain was less often reported to be the most severe pain problem than pain in other body regions. Yet, comparisons of pain intensity reported by subjects who felt that orofacial pain was the most severe pain problem during the past 7 days with reports of those who indicated that headache, neck pain, or back pain was their most severe pain show a similar distribution of mild, moderate and severe pain in these four localizations. HEALTH-RELATED QUALITY OF LIFE: Health-related quality of life as measured in the National Health Survey by the SF-36 Short Form questionnaire is strongly affected by orofacial pain. Even controlling for gender, age, and number of pains during the past 7 days statistically significant reduction of scores in 5 out of 6 SF-36 subscales was observed in those with prevalent orofacial pain.
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The significance of psychosocial factors (pain concepts, psychological distress eg. depression and anxiety, disability) in patients with temporomandibular pain is increasingly noticed. The major diagnostic domains as well as the appropriate diagnostic procedures are described. ⋯ For the majority of patients, symptomatic treatment in combination with clear behavioral directions is sufficient. However, some studies show that improvement is more stable and faster in patients with combined treatment conditions (e.g.occlusal appliance, stress management, relaxation training) than in patients receiving only singular treatment.
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The German pain questionnaire (DSF) has been developed and validated by the Task force on "Standardization and Economy in Pain Management" of the German Chapter of the International Association for the Study of Pain (DGSS). The concept of the DSF is based on a bio (medical) - psycho - social pain model. The modular approach to pain assessment consists of:demographic data,pain variables (e. g. pain sites, temporal characteristics, duration, intensity),pain associated symptoms,affective and sensory qualities of pain (adjective list by Geissner, SESCopyright ),pain relieving and intensifying factors,previous pain treatment procedures,pain-related disability (Pain Disability Index by Tait et al.),depression test CES-D (Center for Epidemiological Studies Depression Test),comorbid conditions,social factors (educational level, occupation, retirement status, compensation and/or litigation status, disability for work),health related quality of life (SF-36Copyright ). ⋯ The German pain questionnaire is a reliable and valid instrument for recording the multidimensional experience of pain. Data from such questionnaires are indispensable for follow-up studies and internal and external quality assessments. The DSF can be ordered from the German Society for the Study of Pain (www.dgss.org) and is a core instrument of the computer program "quality assurance in pain management" (QUAST) of this society.