Aches and Pains Online
Kestrel
Swanpool
Falmouth
Cornwall
TR11 5BD
England

t: 01326 312156
f: 01326 211149

Introductory Essay

Gate control theory: on the evolution of pain concepts. Ronald Melzack

Melzacks essay briefly reviews the historical models of pain that led to the development and publication of the gate control theory. This is a fascinating and very personal account of Melzack's own early pain research using Scottish Terriers and how it led to him realising that the brain provides strong controls over incoming sensory inputs. The rest of the chapter is devoted to developments of pain theory subsequent to the 'gate'. Here, using research and many observations of phantom limb pain Melzack develops a fascinating proposal - his 'neuromatrix' theory of neural networks within the brain whose activity results in the perception of our body image. The chapter finishes with a discussion of the implications of his proposals, for example, that the brain can generate sensation on its own with huge implications for chronic pain states.

Part 1: Sympathetic nervous system and pain

Chapter 1. A clinical overview of the autonomic nervous system, the supply to the gut and pathways. Louis Gifford and Mick Thacker.

Reviews and discusses:

• The 'biological' place of the SNS - models for integration.
• Autonomic anatomy with a strong clinical bias and relevance - all systems reviewed - includes the sympathetic nervous system, the nerve supply to the gut and the parasympathetic nervous system.
• Neurotransmitters and receptors - simply explained
• The sensory system of the gut/viscera.
• Effects of deep tissue pathology on somatic tissues - can visceral disease precipitate musculoskeletal disorder?
• The autonomic innervation of the immune system, stress and mind-body links...

Chapter 2. Complex regional pain syndrome: part 1. Louis Gifford and Mick Thacker.

• 'Complex regional pain syndrome' (CRPS) - all new terminology explained.
• Where the 'old' syndromes fit in - reflex sympathetic dystrophy (RSD), causalgia, sympathetically maintained pain...
• Presentation of symptoms of CRPS - onset, sensory symptoms, motor symptoms, autonomic symptoms, trophic changes, stages of disorder.
• Review of many possible mechanisms involved in CRPS and its development - immobilisation and disuse; neurogenic inflammation; oxidative stress and ischaemia; supersensitivity development; oedema; circulatory effects - sympathetically generated oedema.

Chapter 3. Complex regional pain syndrome: part 2. Mick Thacker and LouisGifford

• Reflex sympathetic dystrophy, reasoning models and CRPS.
• Mechanisms explained and reviewed: Nerve damage, nerve irritation and neuropathic changes; electrical coupling; chemical coupling; silent afferents
• Is there a nerve injury in CRPS type 1?
• Central mechanisms explained - wind-up and sensitisation. Mind-body links in central mechanisms Implications for physiotherapists.
• Mechanisms relating to efferent systems - includes the SNS, effects of sympathectomy
• Is CRPS an immune based disease?

Chapter 4. Sympathetically maintained pain: myth or reality? Mick Thacker and LouisGifford

• Sympathetic blocks explained and reviewed.
• Sympathectomies explained.
• Sympathetic stimulation and its effects on pain.
• What animal models of nerve injury have revealed.
• Masses of clinical implications.

Chapter 5. A review of physiotherapy management of complex regional pain syndrome. Mick Thacker and LouisGifford

• Historical review.
• Literature review of the effectiveness of treatments used by physiotherapists - electrotherapy, biofeedback, muscle stimulation, iontophoresis, heat, acupuncture, splinting, desensitisation, movement, passive mobilisations, massage, active exercises.
• Critical review and discussion of manual therapy, sympathetic effects and the sympathetic slump.
• Discussion, plea and proposals for better models of management and care.

Chapter 6. Assessment and case management of complex regional pain syndrome. Suzanne Brook

This chapter provides a fascinating and sometimes moving account of the management of a very pain disabled young man. Brian developed complex regional pain syndrome following a simple soft tissue injury of his knee. Suzanne Brook takes the reader through all stages of management, from the early days where relationships were built-up, barriers and difficulties addressed, and on to the gradual increase in confidence and fitness that led to Brian's recovery and self management. This is not only a brilliant case history; it is also very instructive of the self-management and multidimensional approach process that Brook proposes. Much of her proposal embraces the current evidence for best practice in chronic pain management.

Chapter 7. Improving fitness and function in complex regional pain syndrome. Suzanne Brook

This chapter neatly compliments the previous chapter. It asks why exercises are important and addresses the many issues that make the introduction of exercises so difficult with these patients. The chapter then leads onto practical matters which all physiotherapists will find so useful:

• Identifying the patient's current activity level.
• The overactivity underactivity cycle.
• Pacing.
• Baseline setting.
• Goal setting.
• Desensitising programmes.
• Reducing the use of aids.
• Flare-up management.

Part 2: Pain management

Chapter 8. The distressed and angry low back pain patient. Chris Main and Paul Watson

The editor, Louis Gifford, believes that this chapter provides some of the most useful and important material for physiotherapists working with pain patients - whether acute or chronic in nature. Since high levels of distress and anger predict poor outcome these issues need to be recognized and dealt with effectively and efficiently. The chapter provides the background to the problem as well as helping in practical ways to identifying, managing and dealing with those at-risk patients. What is unique is the way the chapter is geared to the individual therapist working in primary and secondary health care settings. For those who have read and followed the 'yellow flag' guidelines in Topical Issues in Pain 2, this chapter provides further supporting material. Of particular use is the Appendix which provides examples of appropriate questions and interviewing techniques to use when assessing yellow flags.

Part 3: Clinical effectiveness

Chapter 9. An introduction to clinical effectiveness. Ralph Hammond

This is the overview that all of us who are not used to the topic have been waiting for. All the terms used are clearly explained with straight forward examples. The author provides us with a host of sources and resources for further work and study. Topics include:

• Clinical effectiveness - why do we need it? Who is it for? What does it comprise?
• Evidence based practice explained.
• How do you know what you do works?
• Looking at evidence.
• Clinical guidelines.
• Audit.
• Outcome measures.
• Attribution.

Chapter 10. TENS and acupuncture for chronic pain: where's the evidence? Lesley Smith

Lesley Smith's provocative title draws the reader into a beautiful review of a topic that many of us all too easily turn away from. The growing desire for the provision of evidence based practice means that all clinicians need to understand the systematic review process, randomised controlled trials, meta analysis, qualitative reviews and sources of bias in research. This chapter makes it all much easier to understand and follow. Research on TENS and acupuncture effectiveness are used to illustrate the systematic review process and some of the pitfalls that often occur with clinical trials and their interpretation.