Scabies
Scabies is an easily spread skin disease caused by a very small species of mite.
Causes, incidence, and risk factors
Scabies is found worldwide among people of all groups and ages. It is spread by direct contact with infected people, and less often by sharing clothing or bedding. Sometimes whole families are affected.
Outbreaks of scabies are more common in nursing homes, nursing facilities, and child care centers.
The mites that cause scabies burrow into the skin and deposit their eggs, forming a burrow that looks like a pencil mark. Eggs mature in 21 days. The itchy rash is an allergic response to the mite.
Scabies is spread by skin-to-skin contact with another person who has scabies.
Pets and animals cannot spread human scabies. It is also not very likely for scabies to be spread by:
• A swimming pool
• Contact with the towels, bedding, and clothing of someone who has scabies, unless the person has what is called "crusted scabies"
Symptoms
• Itching, especially at night
• Rashes, especially between the fingers
• Sores (abrasions) on the skin from scratching and digging
• Thin, pencil-mark lines on the skin
Mites may be more widespread on a baby's skin, causing pimples over the trunk, or small blisters over the palms and soles.
• In young children, the head, neck, shoulders, palms, and soles are involved.
• In older children and adults, the hands, wrists, genitals, and abdomen are involved.
Signs and tests
Examination of the skin shows signs of scabies. Tests include an examination under the microscope of skin scrapings taken from a burrow to look for the mites. A skin biopsy can also be done.
Treatment
Prescription medicated creams are commonly used to treat scabies infections. The most commonly used cream is permethrin 5%. Other creams include benzyl benzoate, sulfur in petrolatum, and crotamiton. Lindane is rarely used because of its side effects.
Creams are applied all over the body.
The whole family or sexual partners of infected people should be treated, even if they do not have symptoms. Creams are applied as a one-time treatment or they may be repeated in 1 week.
Wash underwear, towels, and sleepwear in hot water.
Vacuum the carpets and upholstered furniture.
For difficult cases, some health care providers may also prescribe medication taken by mouth to kill the scabies mites. Ivermectin is a pill that may be used.
Itching may continue for 2 weeks or more after treatment begins, but it will disappear if you follow your health care provider's treatment plan. You can reduce itching with cool soaks and calamine lotion. Your doctor may also recommend an oral antihistamine.
Expectations (prognosis)
Most cases of scabies can be cured without any long-term problems. A severe case with a lot of scaling or crusting may be a sign that the person has a disease such as HIV.
Complications
Intense scratching can cause a secondary skin infection, such as impetigo.
Calling your health care provider
Call your health care provider if:
• You have symptoms of scabies
• A person you have been in close contact with has been diagnosed with scabies
Prevention
Avoid contact with infected pers
Saturday, March 12, 2011
ECZEMA
What is eczema?
Introduction
Eczema is a condition that makes patches of your skin become dry, red and itchy. Scratching can make the skin bleed. It can also make the eczema worse. Sometimes the skin becomes thick and scaly.
If you have a child with eczema, there's a good chance they will grow out of it. But some people have eczema all their life. There's no cure for eczema, but there are many treatments that can help with the itchiness and inflammation. There are also things you can do at home to keep eczema under control.
There are several types of eczema. The most common type is atopic eczema. If a condition is described as atopic, it means that it's caused by an allergy. The information here is about atopic eczema, but we just call it 'eczema'.
Key points about eczema
• About 60 in 100 children who have eczema grow out of it or get milder symptoms as they get older.
• Some people have mild symptoms that last a few days at a time, while other people may have more severe symptoms that last longer or never go away completely.
• Eczema can be irritating and painful, but it shouldn't prevent you or your child from taking part in normal activities.
• There are good treatments that can help keep symptoms under control.
• If you or a relative have eczema, and you've had a baby, you may be able to prevent eczema in your baby by breastfeeding and avoiding certain foods.
Your skin
To understand what happens in eczema and how to treat it, it helps to know something about your skin.
• Your skin protects your body from infection and injury. The surface of your skin is made up of a thick layer of dead skin cells. These form a tough barrier that keeps poisons and germs such as bacteria from getting into your body. That barrier also helps to keep in your body's moisture. The dead cells eventually flake off or are washed away. They are always being replaced by new cells that grow from underneath.
• Your skin keeps itself moist and soft so that it can bend and stretch without breaking. The layer of dead cells in your skin holds water, which makes it feel soft. Your skin also makes a kind of thick, oily liquid called sebum that helps it stay moist. Without sebum, the layer of dead cells would dry out and get brittle. When you wash with soap, you take sebum off your skin. This is why your skin and scalp can feel dry after you've washed.
Your skin does many other jobs, too. For example, when it's hot it helps keep your body temperature normal by letting extra blood flow to the surface and by making sweat. Your skin also contains a lot of nerves that give you your sense of touch. When you're in the sun, your skin makes vitamin D.
•
The top layer of your skin starts to get flaky and dry.
• When skin is dry and flaky, bacteria and irritants, such as dust or chemicals, can get into your skin. This can lead to an infection and make the itchiness worse. (See Infections and eczema to find out more.)
• Your skin can become thick and scaly, with small raised bumps or blisters.
• If you scratch the blisters, they may ooze and even bleed.
• Scratching makes the itch worse, and this leads to more scratching. Doctors call this the 'itch-scratch' cycle.
What is an allergy?
The type of eczema we talk about here happens because of an allergy. If you have an allergy, your immune system (your body's system for fighting infection) is supersensitive to certain things that are harmless to other people. Your body overreacts when it comes into contact with those things. It triggers changes called allergic reactions.
For example, in eczema your immune system's reaction makes your skin itchy. Other conditions that are linked to allergies are hay fever and asthma. In hay fever, an allergy to pollen makes people sneeze and makes their eyes runny. If you have asthma, something irritates your lungs, making you wheeze, cough and feel short of breath.
Allergies often run in families. But not everyone with eczema has it in their family.
There are other types of eczema that aren't caused by an allergy.
Your immune system
Doctors think that people with eczema might have an overactive immune system. If you have this, your immune system will cause an allergic reaction when you come into contact with certain things that don't bother most people. Things that set off an allergic reaction are called allergens. This is how the cycle of symptoms in eczema usually starts.
Eczema happens differently in different people. Not everyone who has eczema reacts to the same things that trigger flare-ups in others. See Things that can trigger eczema for more information.
Some of the things that can trigger allergic reactions in people who have eczema are:
• House dust mites (their droppings trigger allergies)
• Animal fur, feathers or skin
• Stress
• Some foods.
Researchers aren't certain about the part food plays in triggering eczema. It may be important for some people but not for others. The same is true of stress. For some people, things such as moving to a new house or starting a new job or school cause stress that's tied to eczema flare-ups.
Why me?
Some people are more likely to get eczema than others. It's more common in families where a lot of people have allergies such as asthma and hay fever. Doctors think that eczema is inherited in the genes we get from our parents.
If both parents have eczema, a child has an 80 percent chance of getting it too. If just one parent has eczema, a child's chances of getting it is just over 50 percent.
Eczema and the family
Children who have very bad eczema can get upset about their condition. And parents who are trying to help a child with eczema may find it stressful, too.
Introduction
Eczema is a condition that makes patches of your skin become dry, red and itchy. Scratching can make the skin bleed. It can also make the eczema worse. Sometimes the skin becomes thick and scaly.
If you have a child with eczema, there's a good chance they will grow out of it. But some people have eczema all their life. There's no cure for eczema, but there are many treatments that can help with the itchiness and inflammation. There are also things you can do at home to keep eczema under control.
There are several types of eczema. The most common type is atopic eczema. If a condition is described as atopic, it means that it's caused by an allergy. The information here is about atopic eczema, but we just call it 'eczema'.
Key points about eczema
• About 60 in 100 children who have eczema grow out of it or get milder symptoms as they get older.
• Some people have mild symptoms that last a few days at a time, while other people may have more severe symptoms that last longer or never go away completely.
• Eczema can be irritating and painful, but it shouldn't prevent you or your child from taking part in normal activities.
• There are good treatments that can help keep symptoms under control.
• If you or a relative have eczema, and you've had a baby, you may be able to prevent eczema in your baby by breastfeeding and avoiding certain foods.
Your skin
To understand what happens in eczema and how to treat it, it helps to know something about your skin.
• Your skin protects your body from infection and injury. The surface of your skin is made up of a thick layer of dead skin cells. These form a tough barrier that keeps poisons and germs such as bacteria from getting into your body. That barrier also helps to keep in your body's moisture. The dead cells eventually flake off or are washed away. They are always being replaced by new cells that grow from underneath.
• Your skin keeps itself moist and soft so that it can bend and stretch without breaking. The layer of dead cells in your skin holds water, which makes it feel soft. Your skin also makes a kind of thick, oily liquid called sebum that helps it stay moist. Without sebum, the layer of dead cells would dry out and get brittle. When you wash with soap, you take sebum off your skin. This is why your skin and scalp can feel dry after you've washed.
Your skin does many other jobs, too. For example, when it's hot it helps keep your body temperature normal by letting extra blood flow to the surface and by making sweat. Your skin also contains a lot of nerves that give you your sense of touch. When you're in the sun, your skin makes vitamin D.
•
The top layer of your skin starts to get flaky and dry.
• When skin is dry and flaky, bacteria and irritants, such as dust or chemicals, can get into your skin. This can lead to an infection and make the itchiness worse. (See Infections and eczema to find out more.)
• Your skin can become thick and scaly, with small raised bumps or blisters.
• If you scratch the blisters, they may ooze and even bleed.
• Scratching makes the itch worse, and this leads to more scratching. Doctors call this the 'itch-scratch' cycle.
What is an allergy?
The type of eczema we talk about here happens because of an allergy. If you have an allergy, your immune system (your body's system for fighting infection) is supersensitive to certain things that are harmless to other people. Your body overreacts when it comes into contact with those things. It triggers changes called allergic reactions.
For example, in eczema your immune system's reaction makes your skin itchy. Other conditions that are linked to allergies are hay fever and asthma. In hay fever, an allergy to pollen makes people sneeze and makes their eyes runny. If you have asthma, something irritates your lungs, making you wheeze, cough and feel short of breath.
Allergies often run in families. But not everyone with eczema has it in their family.
There are other types of eczema that aren't caused by an allergy.
Your immune system
Doctors think that people with eczema might have an overactive immune system. If you have this, your immune system will cause an allergic reaction when you come into contact with certain things that don't bother most people. Things that set off an allergic reaction are called allergens. This is how the cycle of symptoms in eczema usually starts.
Eczema happens differently in different people. Not everyone who has eczema reacts to the same things that trigger flare-ups in others. See Things that can trigger eczema for more information.
Some of the things that can trigger allergic reactions in people who have eczema are:
• House dust mites (their droppings trigger allergies)
• Animal fur, feathers or skin
• Stress
• Some foods.
Researchers aren't certain about the part food plays in triggering eczema. It may be important for some people but not for others. The same is true of stress. For some people, things such as moving to a new house or starting a new job or school cause stress that's tied to eczema flare-ups.
Why me?
Some people are more likely to get eczema than others. It's more common in families where a lot of people have allergies such as asthma and hay fever. Doctors think that eczema is inherited in the genes we get from our parents.
If both parents have eczema, a child has an 80 percent chance of getting it too. If just one parent has eczema, a child's chances of getting it is just over 50 percent.
Eczema and the family
Children who have very bad eczema can get upset about their condition. And parents who are trying to help a child with eczema may find it stressful, too.
Thursday, March 10, 2011
Preventing Asthma
Asthma Prevention
Acute attacks can be triggered by many things, including irritants (smoke or strong odors), allergens (dust mites, molds, etc.), exercise (especially in kids with exercise induced symptoms), upper respiratory infections, and changes in the weather. The best treatments are to avoid the things that trigger your child's attacks (keep a diary), follow the environmental controls described below, use any preventative treatments that have been prescribed for your child everyday, and get a flu shot each year.
Uncontrolled medical problems, including allergic rhinitis and gastroesophageal reflux can also make asthma worse, and should be treated if also present.
You may also be able to prevent asthma attacks if you can predict when your child is going to have an asthma attack and begin his medications early. You can learn to predict attacks by watching for warning signs, including a drop in peak flows, worsening allergies, runny nose, cough, exposure to a known trigger, etc.
Environmental Controls
These steps are aimed at controlling the most common allergens that can trigger an acute attack.
• Get rid of dust collectors, including heavy drapes, carpeting, & stuffed animals.
• Control cockroaches with insect sprays and roach traps, as cockroach allergens are a very common asthma and allergy trigger.
• Use an airtight, allergy-proof plastic cover on all mattresses and pillows.
• Wash all bedding and stuffed animals in hot water every 7-14 days.
• If you must keep pets in the house, at least keep them out of your child's bedroom and choose pets without fur or feathers (such as fish).
• Avoid exposing your child to molds by keeping them away from damp basements, water-damaged areas of the house, wet leaves or garden debris.
• Keep indoor humidity low (less than 50%), since dust mites and mold increase in high humidity.
• Provide a smoke-free environment for your child (it is not enough to smoke outside).
• Vacuum frequently, but only when your child is not at home.
• Avoid the use of ceiling fans.
• Cover air vents with filters.
• Avoid allowing strong odors and sprays in the home. Do not allow your child to stay at home if it is being painted, avoid using strong perfumes, or room deodorizers and household cleaning products that have a strong odor.
• For seasonal problems, keep windows closed in the car and home to avoid exposure to pollens and use air conditioning instead. Stay indoors during the midday and afternoon when pollen counts are at their highest.
• Avoid being outside on days when pollution or ozone counts are high.
• Consider using a HEPA filter to control airborne allergens.
• Take any allergy medication that have been prescribed on a daily basis, since uncontrolled allergies can make your symptoms worse.
Acute attacks can be triggered by many things, including irritants (smoke or strong odors), allergens (dust mites, molds, etc.), exercise (especially in kids with exercise induced symptoms), upper respiratory infections, and changes in the weather. The best treatments are to avoid the things that trigger your child's attacks (keep a diary), follow the environmental controls described below, use any preventative treatments that have been prescribed for your child everyday, and get a flu shot each year.
Uncontrolled medical problems, including allergic rhinitis and gastroesophageal reflux can also make asthma worse, and should be treated if also present.
You may also be able to prevent asthma attacks if you can predict when your child is going to have an asthma attack and begin his medications early. You can learn to predict attacks by watching for warning signs, including a drop in peak flows, worsening allergies, runny nose, cough, exposure to a known trigger, etc.
Environmental Controls
These steps are aimed at controlling the most common allergens that can trigger an acute attack.
• Get rid of dust collectors, including heavy drapes, carpeting, & stuffed animals.
• Control cockroaches with insect sprays and roach traps, as cockroach allergens are a very common asthma and allergy trigger.
• Use an airtight, allergy-proof plastic cover on all mattresses and pillows.
• Wash all bedding and stuffed animals in hot water every 7-14 days.
• If you must keep pets in the house, at least keep them out of your child's bedroom and choose pets without fur or feathers (such as fish).
• Avoid exposing your child to molds by keeping them away from damp basements, water-damaged areas of the house, wet leaves or garden debris.
• Keep indoor humidity low (less than 50%), since dust mites and mold increase in high humidity.
• Provide a smoke-free environment for your child (it is not enough to smoke outside).
• Vacuum frequently, but only when your child is not at home.
• Avoid the use of ceiling fans.
• Cover air vents with filters.
• Avoid allowing strong odors and sprays in the home. Do not allow your child to stay at home if it is being painted, avoid using strong perfumes, or room deodorizers and household cleaning products that have a strong odor.
• For seasonal problems, keep windows closed in the car and home to avoid exposure to pollens and use air conditioning instead. Stay indoors during the midday and afternoon when pollen counts are at their highest.
• Avoid being outside on days when pollution or ozone counts are high.
• Consider using a HEPA filter to control airborne allergens.
• Take any allergy medication that have been prescribed on a daily basis, since uncontrolled allergies can make your symptoms worse.
Tuesday, March 8, 2011
Dealing with pain Continued
Procedures
Pulsed radiofrequency, neuromodulation, direct introduction of medication and nerve ablation may be used to target either the tissue structures and organ/systems responsible for persistent nociception or the nociceptors from the structures implicated as the source of chronic pain.
An intrathecal pump used to deliver very small quantities of medications directly to the spinal fluid. This is similar to epidural infusions used in labour and postoperatively.
The major differences are that it is much more common for the drug to be delivered into the spinal fluid (intrathecal) rather than epidurally, and the pump can be fully implanted under the skin. This approach allows a higher dose of the drug to be delivered directly to the site of action, with fewer systemic side effects.
A spinal cord stimulator is an implantable medical device that creates electric impulses and applies them near the dorsal surface of the spinal cord provides a paresthesia ("tingling") sensation that alters the perception of pain by the patient.
Physical approach
Physiatry
Physical medicine and rehabilitation (physiatry) employs diverse physical techniques such as thermal agents and electrotherapy, as well as therapeutic exercise and behavioral therapy, alone or in tandem with interventional techniques and conventional pharmacotherapy to treat pain, usually as part of an interdisciplinary or multidisciplinary program.
TENS
Transcutaneous electrical nerve stimulation has been found to be ineffective for lower back pain, however, it might help with diabetic neuropathy.
Acupuncture
Acupuncture involves the insertion and manipulation of needles into specific points on the body to relieve pain or for therapeutic purposes. In 2003, the World Health Organization published an article synthesizing the scientific research (controlled trials) of the time, and concluded acupuncture is helpful for the treatment of pain in some cases of acute pain in the epigastric area, facial pain, headache, knee pain, low back pain, neck pain, pain in dentistry, postoperative pain, renal colic, and sciatica. The authors also concluded acupuncture has demonstrated effectiveness in other conditions for which further proof is needed.
This review has been criticized for giving too much weight to low-quality clinical trials, and including a large number of trials originating in China. The latter issue is considered problematic because trials originating in the West include a mixture of positive, negative and neutral results while all trials in China are positive (attributed to publication bias rather than fraud).
An analysis of the 13 highest quality studies of pain treatment with acupuncture, published in January 2009 in the British Medical Journal, concluded there was little difference in the effect of real, sham and no acupuncture. There is general agreement that acupuncture is safe when administered by well-trained practitioners using sterile needles, and that further research is appropriate.
LLLT
A 2007 review concluded low level laser therapy may be effective in reducing inflammation and pain, while a 2008 Cochrane collaboration review concluded that there was insufficient evidence to support the use of LLLT in the management of low back pain.
Psychological approach
Cognitive and behavioral therapy
Mindfulness-based cognitive therapy, the use of stress reduction and relaxation, has been found to reduce chronic pain in some patients. Applied behavior analysis views chronic pain as a consequence of both respondent and operant conditioning, where a patient learns to display pain behavior in the presence of specific environmental antecedents and consequences. The model was first proposed by Fordyce in 1976. The behavioral model has shown effectiveness in reducing pain responses though operant based interventions. Though cognitive-behavioral intervention can be an effective and economical means of treating chronic pain, the effects are rather modest and a substantial portion of patients gain no benefit.
Biofeedback
Biofeedback based on behavioral principles has shown some success for chronic pain,demonstrating greater improvement in one study than peers undergoing cognitive-behavioral therapy and conservative medical treatment, though a different study showed improvements over wait-list controls but no difference between biofeedback and cognitive-behavioral therapy.
Hypnosis
A 2007 review of 13 studies found evidence for the efficacy of hypnosis in the reduction of pain in some conditions, though the number of patients enrolled in the studies was small, bringing up issues of power to detect group differences, and most lacked credible controls for placebo and/or expectation. The authors concluded that "although the findings provide support for the general applicability of hypnosis in the treatment of chronic pain, considerably more research will be needed to fully determine the effects of hypnosis for different chronic-pain conditions." (p. 283)
Under-treatment
Inadequate treatment of pain is widespread throughout surgical wards, intensive care units, accident and emergency departments, in general practice, in the management of all forms of chronic pain including cancer pain, and in end of life care. This neglect is extended to all ages, from neonates to the frail elderly. In September 2008, the World Health Organization (WHO) estimated that approximately 80 percent of the world population has either no or insufficient access to treatment for moderate to severe pain. Every year tens of millions of people around the world, including around four million cancer patients and 0.8 million HIV/AIDS patients at the end of their lives suffer from such pain without treatment. Yet the medications to treat pain are cheap, safe, effective, generally straightforward to administer, and international law obliges countries to make adequate pain medications available.
Reasons for deficiencies in pain management include cultural, societal, religious, and political attitudes, including acceptance of torture. Moreover, the biomedical model of disease, focused on pathophysiology rather than quality of life, reinforces entrenched attitudes that marginalize pain management as a priority. Other reasons may have to do with inadequate training, personal biases or fear of prescription drug abuse.
In the United States, Hispanic and African Americans are more likely to suffer needlessly in the hands of a physician than whites; and women's pain is more likely to be undertreated than men's.
It is often recognized that a great number of patients suffering from chronic pain are being under-treated because physicians fail to provide comprehensive pain treatment. This failure may be due to physicians' fear of being accused of over-prescribing (see for instance the case of Dr William Hurwitz), despite the relative rarity of prosecutions (147 cases across USA in 2006), or physicians' poor understanding of the health risks attached to opioid prescription.
As a result of two recent cases in California though, where physicians who failed to provide adequate pain relief were successfully sued for elder abuse, the North American medical and health care communities appear to be undergoing a shift in perspective.
The California Medical Board publicly reprimanded the physician in the second case; the federal Center for Medicare and Medicaid Services has declared a willingness to charge with fraud health care providers who accept payment for providing adequate pain relief while failing to do so; and clinical practice guidelines and standards are evolving into clear, unambiguous statements on acceptable pain management, so health care providers, in California at least, can no longer avoid culpability by claiming that poor or no pain relief meets community standards.
Strategies currently applied for improvement in pain management include framing it as an ethical issue; promoting pain management as a legal right, providing constitutional guarantees and statutory regulations that span negligence law, criminal law, and elder abuse; defining pain management as a fundamental human right, categorizing failure to provide pain management as professional misconduct, and issuing guidelines and standards of practice by professional bodies.
Pulsed radiofrequency, neuromodulation, direct introduction of medication and nerve ablation may be used to target either the tissue structures and organ/systems responsible for persistent nociception or the nociceptors from the structures implicated as the source of chronic pain.
An intrathecal pump used to deliver very small quantities of medications directly to the spinal fluid. This is similar to epidural infusions used in labour and postoperatively.
The major differences are that it is much more common for the drug to be delivered into the spinal fluid (intrathecal) rather than epidurally, and the pump can be fully implanted under the skin. This approach allows a higher dose of the drug to be delivered directly to the site of action, with fewer systemic side effects.
A spinal cord stimulator is an implantable medical device that creates electric impulses and applies them near the dorsal surface of the spinal cord provides a paresthesia ("tingling") sensation that alters the perception of pain by the patient.
Physical approach
Physiatry
Physical medicine and rehabilitation (physiatry) employs diverse physical techniques such as thermal agents and electrotherapy, as well as therapeutic exercise and behavioral therapy, alone or in tandem with interventional techniques and conventional pharmacotherapy to treat pain, usually as part of an interdisciplinary or multidisciplinary program.
TENS
Transcutaneous electrical nerve stimulation has been found to be ineffective for lower back pain, however, it might help with diabetic neuropathy.
Acupuncture
Acupuncture involves the insertion and manipulation of needles into specific points on the body to relieve pain or for therapeutic purposes. In 2003, the World Health Organization published an article synthesizing the scientific research (controlled trials) of the time, and concluded acupuncture is helpful for the treatment of pain in some cases of acute pain in the epigastric area, facial pain, headache, knee pain, low back pain, neck pain, pain in dentistry, postoperative pain, renal colic, and sciatica. The authors also concluded acupuncture has demonstrated effectiveness in other conditions for which further proof is needed.
This review has been criticized for giving too much weight to low-quality clinical trials, and including a large number of trials originating in China. The latter issue is considered problematic because trials originating in the West include a mixture of positive, negative and neutral results while all trials in China are positive (attributed to publication bias rather than fraud).
An analysis of the 13 highest quality studies of pain treatment with acupuncture, published in January 2009 in the British Medical Journal, concluded there was little difference in the effect of real, sham and no acupuncture. There is general agreement that acupuncture is safe when administered by well-trained practitioners using sterile needles, and that further research is appropriate.
LLLT
A 2007 review concluded low level laser therapy may be effective in reducing inflammation and pain, while a 2008 Cochrane collaboration review concluded that there was insufficient evidence to support the use of LLLT in the management of low back pain.
Psychological approach
Cognitive and behavioral therapy
Mindfulness-based cognitive therapy, the use of stress reduction and relaxation, has been found to reduce chronic pain in some patients. Applied behavior analysis views chronic pain as a consequence of both respondent and operant conditioning, where a patient learns to display pain behavior in the presence of specific environmental antecedents and consequences. The model was first proposed by Fordyce in 1976. The behavioral model has shown effectiveness in reducing pain responses though operant based interventions. Though cognitive-behavioral intervention can be an effective and economical means of treating chronic pain, the effects are rather modest and a substantial portion of patients gain no benefit.
Biofeedback
Biofeedback based on behavioral principles has shown some success for chronic pain,demonstrating greater improvement in one study than peers undergoing cognitive-behavioral therapy and conservative medical treatment, though a different study showed improvements over wait-list controls but no difference between biofeedback and cognitive-behavioral therapy.
Hypnosis
A 2007 review of 13 studies found evidence for the efficacy of hypnosis in the reduction of pain in some conditions, though the number of patients enrolled in the studies was small, bringing up issues of power to detect group differences, and most lacked credible controls for placebo and/or expectation. The authors concluded that "although the findings provide support for the general applicability of hypnosis in the treatment of chronic pain, considerably more research will be needed to fully determine the effects of hypnosis for different chronic-pain conditions." (p. 283)
Under-treatment
Inadequate treatment of pain is widespread throughout surgical wards, intensive care units, accident and emergency departments, in general practice, in the management of all forms of chronic pain including cancer pain, and in end of life care. This neglect is extended to all ages, from neonates to the frail elderly. In September 2008, the World Health Organization (WHO) estimated that approximately 80 percent of the world population has either no or insufficient access to treatment for moderate to severe pain. Every year tens of millions of people around the world, including around four million cancer patients and 0.8 million HIV/AIDS patients at the end of their lives suffer from such pain without treatment. Yet the medications to treat pain are cheap, safe, effective, generally straightforward to administer, and international law obliges countries to make adequate pain medications available.
Reasons for deficiencies in pain management include cultural, societal, religious, and political attitudes, including acceptance of torture. Moreover, the biomedical model of disease, focused on pathophysiology rather than quality of life, reinforces entrenched attitudes that marginalize pain management as a priority. Other reasons may have to do with inadequate training, personal biases or fear of prescription drug abuse.
In the United States, Hispanic and African Americans are more likely to suffer needlessly in the hands of a physician than whites; and women's pain is more likely to be undertreated than men's.
It is often recognized that a great number of patients suffering from chronic pain are being under-treated because physicians fail to provide comprehensive pain treatment. This failure may be due to physicians' fear of being accused of over-prescribing (see for instance the case of Dr William Hurwitz), despite the relative rarity of prosecutions (147 cases across USA in 2006), or physicians' poor understanding of the health risks attached to opioid prescription.
As a result of two recent cases in California though, where physicians who failed to provide adequate pain relief were successfully sued for elder abuse, the North American medical and health care communities appear to be undergoing a shift in perspective.
The California Medical Board publicly reprimanded the physician in the second case; the federal Center for Medicare and Medicaid Services has declared a willingness to charge with fraud health care providers who accept payment for providing adequate pain relief while failing to do so; and clinical practice guidelines and standards are evolving into clear, unambiguous statements on acceptable pain management, so health care providers, in California at least, can no longer avoid culpability by claiming that poor or no pain relief meets community standards.
Strategies currently applied for improvement in pain management include framing it as an ethical issue; promoting pain management as a legal right, providing constitutional guarantees and statutory regulations that span negligence law, criminal law, and elder abuse; defining pain management as a fundamental human right, categorizing failure to provide pain management as professional misconduct, and issuing guidelines and standards of practice by professional bodies.
Monday, March 7, 2011
Taking care of pain
Medical specialties
Pain management practitioners come from all fields of medicine. Most often, pain fellowship trained physicians are anesthesiologists, neurologists, physiatrists or psychiatrists. Palliative care doctors are also specialists in pain management. Some practitioners have not been fellowship trained and have opted for certification by the American Board of Pain Medicine which is not recognized by the American Board of Medical Specialties and does not indicate fellowship training. However, the American Board of Anesthesiology and the American Board of Physical Medicine and Rehabilitation have a subspecialty in pain management which is recognized by the American Board of Medical Specialties and does indicate fellowship training.
Some practitioners focus more on the pharmacologic management of the patient, while others are very proficient at the interventional management of pain. Interventional procedures - typically used for chronic back pain - include: epidural steroid injections, facet joint injections, neurolytic blocks, spinal cord stimulators and intrathecal drug delivery system implants. Over the last several years the number of interventional procedures done for pain has grown.
As well as medical practitioners, the area of pain management may often benefit from the input of physiotherapists, chiropractors, clinical psychologists and occupational therapists, amongst others. Together the multidisciplinary team can help create a package of care suitable to the patient.
Because of the fast growth in the field of pain medicine many practitioners have entered the field, with many of these practitioners being not board certified or being certified by unrecognized boards.
Medications
The World Health Organization (WHO) recommends a pain ladder for managing analgesia. It was first described for use in cancer pain, but it can be used by medical professionals as a general principle when dealing with analgesia for any type of pain.
In the treatment of chronic pain, whether due to malignant or benign processes, the three-step WHO Analgesic Ladder provides guidelines for selecting the kind and stepping up the amount of analgesia.
The exact medications recommended will vary with the country and the individual treatment center, but the following gives an example of the WHO approach to treating chronic pain with medications. If, at any point, treatment fails to provide adequate pain relief, then the doctor and patient move onto the next step.
Mild pain
Paracetamol (acetaminophen), or a non steroidal anti-inflammatory drug such as ibuprofen.
Mild to moderate pain Paracetamol, an NSAID and/or paracetamol in a combination product with a weak opioid such as hydrocodone used in combination, may provide greater relief than their separate use.
Moderate to severe pain
When treating moderate to severe pain, the type of the pain, acute or chronic, needs to be considered. The type of pain can result in different medications being prescribed. Certain medications may work better for acute pain, others for chronic pain, and some may work equally well on both. Acute pain medication is for rapid onset of pain such as from an inflicted trauma or to treat post-operative pain. Chronic pain medication is for alleviating long-lasting, ongoing pain.
Morphine is the gold standard to which all narcotics are compared. Fentanyl has the benefit of less histamine release and thus fewer side effects. It can also be administered via transdermal patch which is convenient for chronic pain management.
Oxycodone is used across the Americas and Europe for relief of serious chronic pain; its main slow-release formula is known as OxyContin, and short-acting tablets, capsules, syrups and ampoules are available making it suitable for acute intractable pain or breakthrough pain. Diamorphine, methadone and buprenorphine are used less frequently.
Pethidine, known in North America as meperidine, is not recommended for pain management due to its low potency, short duration of action, and toxicity associated with repeated use.
Pentazocine, dextromoramide and dipipanone are also not recommended in new patients except for acute pain where other analgesics are not tolerated or are inappropriate, for pharmacological and misuse-related reasons.
Amitriptyline is prescribed for chronic muscular pain in the arms, legs, neck and lower back. While opiates are often used in the management of chronic pain, high doses are associated with an increased risk of opioid overdose.
Opioids
Opioid medications can provide a short, intermediate or long acting analgesia depending upon the specific properties of the medication and whether it is formulated as an extended release drug. Opioid medications may be administered orally, by injection, via nasal mucosa or oral mucosa, rectally, transdermally, intravenously, epidurally and intrathecally.
In chronic pain conditions that are opioid responsive a combination of a long-acting or extended release medication is often prescribed in conjunction with a shorter-acting medication for breakthrough pain, or exacerbations.
Most opioid treatment is oral (tablet, capsule or liquid), but suppositories and skin patches can be prescribed. An opioid injection is rarely needed for patients with chronic pain. Although opioids are strong analgesics, they do not provide complete analgesia regardless of whether the pain is acute or chronic in origin. Opioids are efficacious analgesics in chronic malignant pain and modestly effective in nonmalignant pain management. However, there are associated adverse effects, especially during the commencement or change in dose. When opioids are used for prolonged periods drug tolerance, chemical dependency, diversion and addiction may occur.
Clinical guidelines for prescribing opioids for chronic pain have been issued by the American Pain Society and the American Academy of Pain Medicine. Included in these guidelines is the importance of assessing the patient for the risk of substance abuse, misuse, or addiction; a personal or family history of substance abuse is the strongest predictor of aberrant drug-taking behavior. Physicians who prescribe opioids should integrate this treatment with any psychotherapeutic intervention the patient may be receiving.
The guidelines also recommend monitoring not only the pain but also the level of functioning and the achievement of therapeutic goals. The prescribing physician should be suspicious of abuse when a patient reports a reduction in pain but has no accompanying improvement in function or progress in achieving identified goals.
Non-steroidal anti-inflammatory drugs
The other major group of analgesics are non-steroidal anti-inflammatory drugs (NSAID). Acetaminophen is not always included in this class of medications. However, acetaminophen may be administered as a single medication or in combination with other analgesics (both NSAIDs and opioids). The alternatively prescribed NSAIDs such as ketoprofen and piroxicam, have limited benefit in chronic pain disorders and with long-term use is associated with significant adverse effects. The use of selective NSAIDs designated as selective COX-2 inhibitors have significant cardiovascular and cerebrovascular risks which have limited their utilization.
Antidepressants and antiepileptic drugs
Some antidepressant and antiepileptic drugs are used in chronic pain management and act primarily within the pain pathways of the central nervous system, though peripheral mechanisms have been attributed as well. These mechanisms vary and in general are more effective in neuropathic pain disorders as well as complex regional pain syndrome. Drugs such as gabapentin have been widely prescribed for the off-label use of pain control. The list of side effects for these classes of drugs are typically much longer than opiate or NSAID treatments for chronic pain, and many antiepileptics cannot be suddenly stopped without the risk of seizure.
Other analgesics
Other drugs are often used to help analgesics combat various types of pain and parts of the overall pain experience. In addition to gabapentin, the vast majority of which is used off-label for this purpose, orphenadrine, cyclobenzaprine, trazodone and other drugs with anticholinergic properties are useful in conjunction with opioids for neuropathic pain. Orphenadrine and cyclobenzaprine are also muscle relaxants and are therefore particularly useful in painful musculoskeletal conditions. Clonidine has found use as an analgesic for this same purpose and all of the mentioned drugs potentiate the effects of opioids overall.
Sunday, March 6, 2011
Pain Management
Pain management (also called pain medicine; algiatry) is a branch of medicine employing an interdisciplinary approach for easing the suffering and improving the quality of life of those living with pain. The typical pain management team includes medical practitioners, clinical psychologists, physiotherapists, occupational therapists, and nurse practitioners. Pain sometimes resolves promptly once the underlying trauma or pathology has healed, and is treated by one practitioner, with drugs such as analgesics and (occasionally) anxiolytics. Effective management of long term pain, however, frequently requires the coordinated efforts of the management team.
Medicine treats injury and pathology to support and speed healing; and treats distressing symptoms such as pain to relieve suffering during treatment and healing. When a painful injury or pathology is resistant to treatment and persists, when pain persists after the injury or pathology has healed, and when medical science cannot identify the cause of pain, the task of medicine is to relieve suffering. Treatment approaches to long term pain include pharmacologic measures, such as analgesics, tricyclic antidepressants and anticonvulsants, interventional procedures, physical therapy, physical exercise, application of ice and/or heat, and psychological measures, such as biofeedback and cognitive behavioral therapy.
There are many causes of acute or chronic back pain such as back strain, spinal stenosis, and osteoarthritis. But how is back pain treated? What happens if pain doesn't go away? To help answer those questions and others, this article provides information about many aspects of pain management including:
• Different types of pain
• The role of the pain management specialist
• Diagnosis; determining the cause of pain
• Pain relieving treatments
• Pain control improves lives
Different Types of Pain
Most often, pain is classified as being either acute or chronic. Broader definitions and examples follow.
Acute pain may begin suddenly and is often described as feeling sharp. It is likened to the body's warning system signaling something is wrong. Most times, acute pain is quickly resolved, although by definition it may last 3 to 6 months. Patterns of recovery from acute pain are usually predictable and aid in developing a treatment plan.
Pain specialists realize it is important to control acute pain to prevent it from becoming chronic. Causes of acute pain include:
• Broken bones (spinal vertebral fracture)
• Burns or cuts
• Certain diseases
• Dental work
• Labor and childbirth
• Soft tissue injury, such as whiplash
• Surgical pain (post-operative pain)
Chronic pain is defined as lasting longer than 6 months, is persistent and may be severe. Chronic pain is more difficult to treat. A multi-disciplinary approach, involving several specialists who offer treatment separately or simultaneously, has become a standard of care. Such specialists include physiatrists and anesthesiologists.
Chronic pain affects people physically and emotionally. Physical symptoms include muscle tension, loss of mobility, lack of energy and appetite. The emotional affects can be similarly devastating and include depression, anger, and anxiety. Causes of chronic pain can include:
• Arthritis (osteoarthritis)
• Cancer
• Degenerative disc disease and other spinal disorders
• Nerve dysfunction (with or without nerve damage)
• Soft tissue injury, such as trauma from a fall or motor vehicle accident
• Unresolved disease or injury (psychogenic pain)
There are many kinds of pain that can be described as acute or chronic. Some include:
Myofascial pain is caused by painful trigger points that develop in a muscle or a group of muscles. A trigger point is a locally sensitive and tender area in a muscle or where a muscle and fascia (band-like tissue encasing muscle) meet.
Myofascial pain may cause "referred pain" because when a trigger point is pressed the pain may be felt elsewhere. This pain may be chronic and described as nagging, burning, aching, or stabbing.
Psychogenic pain presents as real physical pain caused by a psychological problem. This means the pain is caused by the patient's mental or emotional issues.
Radicular pain, or radiculitis, is caused by inflammation of a spinal nerve root. Other associated terms are "cervical radiculitis" or "lumbar radiculitis" meaning the pain originates from a cervical (neck) or lumbar (low back) spinal nerve.
Sciatica is a commonly used term to describe pain that descends into the leg. Different disorders can cause spinal nerve compression, inflammation, and pain. A spinal tumor or cyst, disc herniation, spinal stenosis, and osteoarthritis can cause radiculitis.
Somatic pain is caused by bodily injury or other event affecting the pain receptors in the skin, ligaments, muscles, bones, or joints. This pain may be chronic and is sometimes associated with cancer.
Visceral pain is caused by internal organs that are damaged or injured.
Pain management (also called pain medicine; algiatry) is a branch of medicine employing an interdisciplinary approach for easing the suffering and improving the quality of life of those living with pain. The typical pain management team includes medical practitioners, clinical psychologists, physiotherapists, occupational therapists, and nurse practitioners. Pain sometimes resolves promptly once the underlying trauma or pathology has healed, and is treated by one practitioner, with drugs such as analgesics and (occasionally) anxiolytics. Effective management of long term pain, however, frequently requires the coordinated efforts of the management team.
Medicine treats injury and pathology to support and speed healing; and treats distressing symptoms such as pain to relieve suffering during treatment and healing. When a painful injury or pathology is resistant to treatment and persists, when pain persists after the injury or pathology has healed, and when medical science cannot identify the cause of pain, the task of medicine is to relieve suffering. Treatment approaches to long term pain include pharmacologic measures, such as analgesics, tricyclic antidepressants and anticonvulsants, interventional procedures, physical therapy, physical exercise, application of ice and/or heat, and psychological measures, such as biofeedback and cognitive behavioral therapy.
There are many causes of acute or chronic back pain such as back strain, spinal stenosis, and osteoarthritis. But how is back pain treated? What happens if pain doesn't go away? To help answer those questions and others, this article provides information about many aspects of pain management including:
• Different types of pain
• The role of the pain management specialist
• Diagnosis; determining the cause of pain
• Pain relieving treatments
• Pain control improves lives
Different Types of Pain
Most often, pain is classified as being either acute or chronic. Broader definitions and examples follow.
Acute pain may begin suddenly and is often described as feeling sharp. It is likened to the body's warning system signaling something is wrong. Most times, acute pain is quickly resolved, although by definition it may last 3 to 6 months. Patterns of recovery from acute pain are usually predictable and aid in developing a treatment plan.
Pain specialists realize it is important to control acute pain to prevent it from becoming chronic. Causes of acute pain include:
• Broken bones (spinal vertebral fracture)
• Burns or cuts
• Certain diseases
• Dental work
• Labor and childbirth
• Soft tissue injury, such as whiplash
• Surgical pain (post-operative pain)
Chronic pain is defined as lasting longer than 6 months, is persistent and may be severe. Chronic pain is more difficult to treat. A multi-disciplinary approach, involving several specialists who offer treatment separately or simultaneously, has become a standard of care. Such specialists include physiatrists and anesthesiologists.
Chronic pain affects people physically and emotionally. Physical symptoms include muscle tension, loss of mobility, lack of energy and appetite. The emotional affects can be similarly devastating and include depression, anger, and anxiety. Causes of chronic pain can include:
• Arthritis (osteoarthritis)
• Cancer
• Degenerative disc disease and other spinal disorders
• Nerve dysfunction (with or without nerve damage)
• Soft tissue injury, such as trauma from a fall or motor vehicle accident
• Unresolved disease or injury (psychogenic pain)
There are many kinds of pain that can be described as acute or chronic. Some include:
Myofascial pain is caused by painful trigger points that develop in a muscle or a group of muscles. A trigger point is a locally sensitive and tender area in a muscle or where a muscle and fascia (band-like tissue encasing muscle) meet.
Myofascial pain may cause "referred pain" because when a trigger point is pressed the pain may be felt elsewhere. This pain may be chronic and described as nagging, burning, aching, or stabbing.
Psychogenic pain presents as real physical pain caused by a psychological problem. This means the pain is caused by the patient's mental or emotional issues.
Radicular pain, or radiculitis, is caused by inflammation of a spinal nerve root. Other associated terms are "cervical radiculitis" or "lumbar radiculitis" meaning the pain originates from a cervical (neck) or lumbar (low back) spinal nerve.
Sciatica is a commonly used term to describe pain that descends into the leg. Different disorders can cause spinal nerve compression, inflammation, and pain. A spinal tumor or cyst, disc herniation, spinal stenosis, and osteoarthritis can cause radiculitis.
Somatic pain is caused by bodily injury or other event affecting the pain receptors in the skin, ligaments, muscles, bones, or joints. This pain may be chronic and is sometimes associated with cancer.
Visceral pain is caused by internal organs that are damaged or injured.
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