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They also 0 20 40 60 80 100 respond to distending stimuli in the noxious range of Distending pressure (mm Hg) 30 mm Hg (see Figure 22–11) cheap atorlip-5 5 mg visa. The response mag- FIGURE 22–11 Mechanosensitive pelvic nerve sensory fibers nitude in the noxious range is greater than that of the that innervate the urinary bladder or distal colon have low ( 5 mm Hg) or high ( 30 mm Hg) thresholds for response to disten- high-threshold fibers purchase 5mg atorlip-5 fast delivery, which do not respond until the sion. Both low- and high-threshold fibers encode the distending stimulus is at or exceeds noxious levels. Visceral afferent neurons should exhibit sensitization (primary hyperalgesia), Experimental inflammation of viscera awakens silent therefore, and the spinal neurons on which they ter- afferent fibers which become sensitive to mechanical minate should change their excitability (secondary stimuli. INFLAMMATORY AND NONINFLAMMATORY MEDIATORS ACC PCC Local tissue injury releases chemical mediators (potassium, hydrogen ions, ATP, bradykinin) and inflammatory mediators (eg, PGE2 [prostaglandin Ins E2]). These substances activate nerve endings and trigger release of algesic mediators (eg, histamine, Hypothal serotonin, nerve growth factor) from other cells and Cb (A) Thal BS M1 S1 PMC IPL 100 IBS 80 (C) Thal PFC 60 (B) S2 Cb Normal subjects FIGURE 22–10 Principal cerebral structures activated in func- 40 tional imaging studies of somatic and visceral stimulation. ACC, anterior cingulated cor- 20 tex; PCC, posterior cingulated cortex; Hypothal, hypothalamus; Thal, thalamus; BS, brainstem; Cb, cerebellum. PFC, prefrontal cortex; PMC, pre- 0 100 200 300 motor cortex; M1, primary motor cortex; S1, primary somatosen- Balloon volume (ml air) sory cortex; S2, secondary somatosensory cortex; IPL, inferior parietal lobule. This sensitizes afferent nerve termi- Vaginal ultrasound provides images of the uterus and nals causing an increased response to painful stimuli. For suspected cholelithiasis and cholecystitis, Activation of immunocytes (ex-mast cells) and local ultrasound is the initial imaging method of choice (the adrenergic nerve fibers results in a state of prolonged liver acts as an acoustic window). Upright x-rays during an attack may show Complete blood count (CBC) and differential dilated loops of bowel caused by intermittent Liver function tests obstructing hernia or intussusception, for example. Serum electrolytes Sigmoidoscopy or barium enema may show ischemic Serum creatinine colitis or endometriosis. Blood urea nitrogen CT scan may reveal various pancreatic or biliary tract Amylase or lipase lesions, masses, or dilated bowel loops. Urine or serum pregnancy test TREATMENT CHRONIC ABDOMINAL PAIN THE TREATMENT OF CHRONIC PAIN In chronic recurrent abdominal pain, tests may iden- SYNDROMES: INTRODUCTION tify a discrete cause. Laboratory studies should be ordered only if their results may alter diagnosis or The goals of pain therapies are to: therapy. CBC, ESR (erythrocyte sedimentation Reduce intensity of pain rate), and liver function tests may lead to a diagno- Improve physical and emotional functioning sis.
Response biases may also occur unwittingly as when the response is influenced by poor memory purchase 5mg atorlip-5 with visa. Highly contentious situations often surround assessment of pain-related impair- ment and disability such as worker compensation generic atorlip-5 5 mg on line, social security disability, veterans’ disability compensation, civil litigation related to accidental inju- ries (e. The validity scales of instruments such as the MMPI and the Eysenck Personality Inventory (Eysenck & Eysenck, 1975) and the variable response scale for the MPI (Bruehl, Lofland, Sherman, & Carlsom, 1998) are at times use in an effort to detect possible biases in patients’ responses. In a preliminary study, Lofland, Semenchuk, and Cassisi (1995) concluded the MPI “appears to be a good screening measure to detect patients who are exhibiting symptom exaggeration. There have been numerous attempts to identify specific psychological profiles of litigation and compensation patients. There is, however, no con- clusive evidence that specific characteristics differentiate those who are lit- igating or who are receiving disability compensation from those who are not (Kolbison, Epstein, & Burgess, 1996). The authors found no difference in the responses to any of the three sections of the in- strument—pain severity, emotional distress, and functional activities. The au- thors concluded that clinicians should not assume that patients who poten- tially have something to gain by poor performance (disability seeking) will inevitably exaggerate the burden of their pain and the resultant disability. Waddell and colleagues (Waddell, McCulloch, Kummel, & Venner, 1980) developed a system of behavioral signs designed to determine the validity of a psychological basis for a given patient’s pain report. Presumably, those patients showing a higher number of nonanatomic (nonorganic) signs with their pain report have a high degree of psychological factors contributing to their pain report. Other investigators have examined facial expressions of pain: the ability of observers to distinguish exaggerated pain expressions from healthy subjects and pain sufferers’ “real” expressions of pain (Craig, Hyde, & Patrick, 1991; Poole & Craig, 1992). Physical tests to evaluate suboptimal performance have also been used to detect malingering (Robinson, O’Connor, Riley, Kvaal, & Shirley, 1994). ASSESSMENT OF CHRONIC PAIN SUFFERERS 237 Some efforts are made to ask patients to repeat standard physical tasks and use discrepancy of performance (“index of congruence”) as an indication of motivated performance. Reviewing efforts to detect deception led Craig, Hill, and McMurtry (1999) to the following conclusion: “Definitive, empiri- cally validated procedures for distinguishing genuine and deceptive report are not available and current approaches to the detection of deception re- main to some degree intuitive” (p. There is a growing body of information concerning the ability of neuro- psychological tests to detect malingering (Inman & Berry, 2002).
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