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irritable bladder
temporomandibular joint (TMJ) disorder
restless leg syndrome
dry eyes and dry mouth
morning stiffness
anxiety and depression
Cause is unknown
Abnormally high levels of Substance P in
spinal fluid in some patients
Substance P important in transmission
and amplification of pain signals to and
from brain
Volume control is turned up too high in
brains pain centers
Symptoms in Fibromyalgia
Syndrome
SYMPTOMS
(%)
MEAN
Musculoskeletal
Pain at multiple sites
100
Stiffness
76
62
52
SYMPTOMS
MEAN (%)
Depression
37
Cognitive dysfunctione (27)
61
Mental stress
61
Nonmusculoskeletal
General fatigue
87
Morning fatigue
75
Sleep difficulties
Paresthesia
72
54
59
Tinnitus (24)
17
Anxietyd
60
%
65
70
61
49
22
Relieving Factors
Local heat
Rest
Moderate activities
Massage
Stretching exercise
58
54
46
40
43
Differential Diagnosis
Comorbid Conditions
Associated with Fibromyalgia
Migraine headache
Chronic fatigue
Irritable bowel syndrome
Depression
Restless legs syndrome
Temporomandibular joint syndrome
Myofascial pain syndrome
Peripheral
(nociceptive)
Primarily due to
inflammation or damage in
periphery
NSAID, opioid responsive
Behavioral factors minor
Examples
Central (nonnociceptive)
OA
pain models
(e.g. third molar, postMixed
surgery)
Neuropathic
RA
Cancer pain
Acute
Fibromyalgia
Irritable bowel
syndrome
Tension and migraine
headache
Interstitial cystitis /
vulvodynia, non-cardiac
chest pain / etc.
EXPOSURE
SYNDROMES e.g.
Gulf War Illnesses, silicone
breast implants, sick building
syndrome
Pharmacologic Treatments
Neuropathic pain
Acute Pain
Generally known
Chronic Pain
Often unknown
Duration of pain
Short,
well-characterized
Treatment
approach
Resolution of
underlying cause,
usually self-limited
Psychological Morbidity
Depression
Anxiety, anger
Sleep disturbances
Loss of self-esteem
Social Consequences
Socioeconomic
Marital/family
relations
Intimacy/sexual activity
Social isolation
Consequences
Healthcare costs
Disability
Lost workdays
Nociceptive vs Neuropathic
Pain
Nociceptive
Pain
MixedType
Caused by activity in
neural pathways in
response to potentially
tissue-damaging stimuli
Caused by a
combination of both
primary injury and
secondary effects
Neuropathic
Pain
Initiated or caused by
primary lesion or
dysfunction in the
nervous system
CRPS*
Postoperative
pain
Arthritis
Mechanical
low back pain
Sickle cell
crisis
Sports/exercise
injuries
*Complex regional pain syndrome
Postherpetic
neuralgia
Trigeminal
neuralgia
Neuropathic
low back pain
Distal
polyneuropathy
(eg, diabetic, HIV)
Possible Descriptions
of Neuropathic Pain
Sensations
numbness
tingling
burning
paresthetic
paroxysmal
lancinating
electriclike
raw skin
shooting
deep, dull, bonelike ache
Signs/Symptoms
Transduction
Transmission
Modulation
Perception
Interpretation
Behavior
Injury
Brain
Descending
Pathway
Peripheral
Nerve
Dorsal
Root
Ganglion
Ascending
Pathways
C-Fiber
A-beta Fiber
A-delta Fiber
42
Dorsal
Horn
Spinal Cord
Clinical presentation
Pathophysiology
Peripheral mechanisms
Peripheral mechanisms
(1)
Peripheral mechanisms
(2)
Central mechanisms
Sympathetically
maintained pain
Painful Diabetic
Neuropathy
Mechanisms of Pain
Painful Diabetic
Neuropathy
Mechanisms of Pain
Pathophysiology of common
neuropathic pain syndromes
Hyperglycemia,hyperlipidemia,hypoinsuli
nemia, growth factor deficiency
oxidative stress and autoimmunity
progressive demyelination and axonal
loss sensory loss, paresthesia,
dysesthesias, pain and allodynia
Type 1
DIABETES
Hyperglycemia
Hypoinsulinemia
Polyol
pathway
AGE
production
Oxidative
stress
Neurotrophin
deficiency
Mitochondria
l
dysfunction
ATP ?
Impairment in
calcium
homeostasis
Pathological changes
in nerve, microvessel, and ganglia
Decreased
axonal
transport
Decreased
protein
synthesis
Distal axonal
degeneration
Sensory distribution of
Diabetic Peripheral Neuropathy
Summary
TENSION-TYPE HEADACHE
C.
REFERENCE