Accompanied by symptoms such as pain. Pain in the hand

Pain is the most common symptom of most diseases. The occurrence of pain in different parts of the body indicates that something is wrong with the body, the problem should be identified and treated as soon as possible.

Often sharp pains become chronic along with the course of the disease that caused discomfort. Therefore, it is important to pay attention to them in time and determine the problem that has arisen, until the disease is in an advanced stage.

Common pain types

Most often, people are annoyed by the following painful sensations:

• headache;
• pain in the joints;
• sore throat and many others.

The nature of such experiences also varies depending on the disease. The pain can be sharp, throbbing, aching, and so on. In some cases, her character can directly tell about the probable disease and the stage of its development.

Important! Do not forget that in some cases, pain can "give" to healthy organs, you should always keep this factor in mind for a correct diagnosis.

Everyone experiences at least once in their life headache. In most cases, this condition is not considered serious, but quite common. However, frequent, unusual, too intense sensations can indicate serious illness.

Headaches are different in intensity and frequency, usually this helps to determine the disease itself. However, the diagnosis is usually confirmed after examination and identification of other symptoms.

Causes

There are many reasons for pain in the head. The most common type of chronic pain, migraine, develops due to stress, constant severe fatigue, abuse of coffee and other invigorating foods.

Other triggers for headaches include:

• high or low blood pressure;
• mental illness;
• excessive physical activity;
• ear diseases;
• spine diseases and others.

Painful sensations in the head can also be accompanied by much more serious conditions, such as a cerebral hemorrhage, a brain tumor, or meningitis.

Symptoms

What features of the symptomatology should be worried and consult a specialist? After all, not all cases of headaches really need to be treated. You should be more careful in the following cases:

1. Painful sensations become literally unbearable, too intense.
2. There is tension, a feeling of pressure in the neck, shoulders, back.
3. Pain is concentrated in one part of the head.
4. Appearance of nausea, photophobia.
5. Increased pain with physical activity or even normal walking.

If seizures appear constantly, they are preceded by “flashes” of light, bright spots, “stars” before the eyes, you should definitely contact a specialist.

Also, the appearance of a headache after a head injury often indicates a concussion.

Important! Normally, the head should not hurt for no apparent reason for more than three days in a row. Otherwise, it is recommended to consult a doctor.

Many people are also worried about pain in the joints. The joints of the legs are especially often affected, pain in the knees is a fairly common reason for visiting a doctor. According to statistics, half of the world's population has experienced them at least once in their lives.

If your knees hurt, first of all, you should establish the cause, the disease that caused the discomfort. After all, improper therapy can greatly harm an already weakened joint.

Causes

Unpleasant sensations in the knees can occur due to ordinary physical overexertion or injury, but most often this is a consequence of developing joint disease. Most often, the following diseases occur:

1. Arthrosis. An inflammatory process in which the tissues of the joint are destroyed, the joint itself is deformed over time.
2. Arthritis. Inflammatory disease is sometimes the result of other problems.
3. Meniscus injury. As a rule, it occurs after an injury, sometimes minor. Can provoke arthrosis with deformation. A distinctive feature of pain experiences in case of damage to the meniscus is its severity and intensity.
4. Inflammation of the tendons - periarthritis. Most often, pain appears on the inside of the knee, occurs when climbing or descending stairs in older people.
5. Various vascular pathologies. They do not affect the joint, but the nature of the pain resembles joint diseases.

Also, knee pain can occur with arthrosis. hip joint. In this case, she will "give" to the knee.

Important! Most knee diseases require careful diagnosis.

Symptoms

There are symptoms, the appearance of which, in the presence of pain in the knee, will accurately show whether there is a problem or discomfort - a consequence of excessive physical activity. You should seriously worry about your health with the following signs:

• swelling, fever;
• crunch in the knee;
• aching nature of pain at night.

These symptoms can indicate serious pathologies, therefore, if they are detected, you should immediately consult a doctor and begin treatment.

Unpleasant sensations in the coccyx area when sitting or walking is a common symptom of certain diseases of the musculoskeletal system. It often appears after an injury, usually a fall. However, pain in the coccyx area may indicate a pinched intervertebral disc or a lack of calcium.

It can also appear during pregnancy. In this case, you should immediately contact your doctor, such pain may indicate the presence of various pathologies of fetal development.

A sore throat

Sore throats are also common. Contrary to popular belief, it can occur not only with a cold. Unpleasant sensations in the throat can indicate various problems. respiratory tract and not only.

Causes

The main reason is colds and various respiratory tract infections. Also, a sore throat can occur with allergies or irritation, for example, from cigarette smoke or carbon monoxide.

The sensation of a lump in the throat is often present with cervical osteochondrosis. It may even be accompanied by a cough. This happens due to pinched nerve endings in the cervical spine.

Symptoms

Unpleasant sensations in the throat are usually accompanied by the following symptoms:

• dry cough, hoarseness;
• inflammation of the cervical lymph nodes;
• temperature increase.

If these symptoms are present, you should consult a doctor. Many respiratory diseases have unpleasant complications that require long-term treatment.

Pain is the most obvious symptom of most diseases and should never be ignored.

Pain is an unpleasant sensation that is accompanied by emotional experiences caused by real, possible or psychogenic damage to the tissue of the body.

What is the pain like?

The meaning of pain lies in its signal and pathogenic functions. This means that when a potential or real threat of damage appears for the body, it communicates this to the brain with the help of unpleasant (painful) echoes.

Pain is divided into two types:

• acute pain, which is characterized by relative short duration and a specific relationship with tissue damage;
• chronic pain that manifests itself during the period of tissue repair.

According to the localization of pain are:

• anal;
• gynecological, menstrual, childbirth, ovulation;
• head, eye and dental;
• chest;
• gastric;
• intestinal;
• intercostal;
• muscular;
• renal;
• lumbar;
• ischial;
• cardiac;
• pelvic;
• other pains.

Headache

Headache is one of the most common types of pain.

It is divided into the following main groups:

• vascular;
• muscle tension;
• liquorodynamic;
• neuralgic;
• psychological;
• mixed.

Some of the groups have their own subtypes. But even despite this, the classification of pain according to the nature of the course and the pathophysiological mechanism is used to make a diagnosis.

In the course of further evolution, the system pain sensitivity acquired a controlling function. When nociceptors are stimulated, a sensation of "physiological" (nociceptive) pain arises, which causes the activation of protective reflexes. The threshold of excitation of nociceptors can be reduced under the influence of inflammatory mediators or peptides released under the influence of neurogenic impulses (neurogenic inflammation). Pain can also develop after damage or dysfunction of the central nervous system that is part of the nociceptive system (neuropathic or neurogenic pain) and in these cases represents a separate syndrome (primary pain disorder; thalamic syndrome). When prescribing analgesic therapy, along with the origin of pain, its intensity and prognosis of the underlying disease should be taken into account.

In chronic pain, there are no signs of hyperactivity of the sympathetic nervous system however, it may also be accompanied by autonomic manifestations (eg, fatigue, decreased libido, loss of appetite) and depressed mood. The ability to tolerate pain varies greatly among people.

Pathophysiology of pain

Visceral pain associated with overstretching of a hollow organ does not have a clear localization and has a deep, aching or cramping character; it can also be projected to distant areas of the skin surface.

Pain thought to be due to psychological factors is often referred to as psychogenic pain. This type of pain can be classified as a group of somatoform disorders (eg, chronic pain disorders, somatization disorders, hypochondria).

Transmission of pain impulses and modulation of pain. pain fibers enter the spinal cord, passing through the spinal ganglia and the posterior roots.

Sensitization of peripheral nerve formations and structures at various levels of the CNS, leading to long-term synaptic rearrangements in cortical sensory fields (remodeling), may eventually lead to the maintenance of increased pain perception.

The pain signal is modulated at several levels, including the segmental level and modulation by efferent fibers, with the help of various neurotransmitters, such as endorphins (including enkephalins) and monoamines (norepinephrine). The interaction (still poorly understood) of these mediators leads to an increase or decrease in the perception and response to pain. They determine the analgesic effect of those affecting the central nervous system medicines in chronic pain (eg, opioids, antidepressants, anticonvulsants, membrane stabilizers) through interaction with certain receptors and changes in neurochemical processes.

Psychological factors not only determine the verbal component of the expression of pain sensation (i.e., whether there is a stoic perception of pain or the patient is sensitive to it), but also lead to the generation of efferent impulses that modulate the transmission of the pain impulse along the entire path.

Pain receptors in the skin, muscles and joints (nocioceptors) detect the sensation of pain and transmit information to the spinal cord and brain via Aβ and C fibers.

Effects on the skin and internal organs strong non-painful stimuli (stretching, temperature) as well as tissue damage cause the opening of specific ion channels (eg TRV1 [vanilloid transit potential receptor], ASIC [acid sensitive ion channel]), which activates pain receptors (nociceptors). During necrosis, K + ions and intracellular proteins are released from cells. K + causes depolarization of pain receptors, and proteins and (in some cases) invading microorganisms contribute to the development of inflammation and the release of pain mediators. Leukotrienes, PGE 2 , bradykinin, cytokines, neutrophils, and histamine sensitize (increase sensitivity) pain receptors. Hypersensitivity to painful stimuli develops, which is called hyperalgesia or allodynia, in which even subthreshold noxious and harmless stimuli cause pain. Tissue damage activates blood clotting, release of bradykinin and serotonin. With blockage of blood vessels, ischemia develops, K + and H + ions accumulate in the extracellular space, which activate already sensitized pain receptors. Histamine, bradykinin and PGE 2 have vasodilating properties and increase vascular permeability. This leads to local swelling, increased pressure in the tissues and stimulation of pain receptors. Substance P and a peptide associated with the calcitonin gene are released, which cause an inflammatory response, as well as vasodilation and an increase in their permeability.

Vasoconstriction (caused by serotonin) followed by vasodilation is thought to cause attacks of migraine (a recurrent severe headache, often occurring in one side of the head and associated with neurological dysfunction due, at least to some extent, to dysregulation of vasomotor regulation in the CNS). The genetic cause of migraine is a mutation in the gene encoding voltage-dependent Ca 2+ -channels of the L-type).

Sensory (afferent) nerve fibers coming from the organs and the surface of the skin are intertwined in segments spinal cord, i.e., the axons of sensitive cells converge on certain neurons of the spinal cord. Irritation of nociceptors of organs causes pain in those areas of the skin, the afferent nerve fibers of which end in the same segment of the spinal cord (reflected pain). So, for example, with myocardial infarction, pain radiates to the left shoulder and left arm (Ged's area).

Projected pain occurs when the nerve that provides the pain signal is irritated and is felt in the region of nerve innervation.

For example, if the ulnar nerve is irritated or damaged, pain occurs in the ulnar groove. A special form of projected pain is phantom pain after limb amputation. With neuralgia, prolonged pathological excitation of the nerve or posterior roots leads to chronic pain in the zone of innervation.

Pain impulses through the synapses of afferent nerve fibers enter the spinal cord and through the anterolateral pathways passing in the anterior and lateral cords of the spinal cord to the thalamus, and from there to the somatosensory cortex, cingulate gyrus and insular cortex. There are several components of pain: sensory (for example, perception of localization and intensity), emotional (malaise), motor (protective reflex, muscle tone, facial expressions) and autonomic (changes in blood pressure, tachycardia, dilated pupils, sweating, nausea). Connections in the thalamus and spinal cord are inhibited by descending pathways that originate from the cortex, the central gray matter of the midbrain, and the raphe nuclei. The descending pathways use the neurotransmitters norepinephrine, serotonin, and especially endorphins. Damage to the thalamus, for example, causes pain by disrupting this inhibition [thalamic syndrome].

Aβ fibers

• Myelinated
• Fast acting
• Concentrated at the point of stimulation
• Surface
• They respond to mechanical and thermal stimuli.

C-fibers

• without myelin sheath
• slow acting
• Located in the deep layers of the skin
• Large well-defined receptor field
• Found in all tissues except the spinal cord and brain
• susceptible to damage
• Respond to mechanical and thermal stimuli
• chronic pain
• Secondary aching pain.

Characteristics of pain

transit (passing)

• short-term
• Localized.

Acute

• sudden attack
• Acute
• Localized.

Chronic

• gradual start
• Long
• Cause may not be known
• No precise localization
• Influences behavior
• Unpredictable.

The pain may also be

• Superficial/deep
• Localized / spilled / irradiating
• Unstoppable
• Psychogenic.

Influencing factors

• Severity, extent and extent of injury
• Cognitive factors:
• Previous experience
• culture
• expectations
• Circumstances and emotions
• Stress
• Environment
• General health
• Social support
• Compensation.

Features in elderly patients

Pain is a complex individual experience that is difficult to objectively assess. Clinical assessment of pain can help our understanding of its origin and be useful in evaluating the effectiveness of treatment.

Basic principles of pain assessment

• Detailed history
• Use of suitable and accessible tools or devices

Pain Rating Scales

Visual analog scale (VAS)

Draw a vertical line 10 cm long with a mark at one end - no pain (0) and the most severe pain imaginable (10 cm) - at the other end. The patient is asked to mark on the line the severity of his pain.

digital scale

The patient is asked to indicate a number on a scale between 0-100 indicating the intensity of their pain.

Pain Questionnaires

McCill Questionnaire

Consists of 20 groups of words. Groups 1-10 define the physical characteristics of the pain; 11-15 characterize subjective characteristics; 16 - describes the intensity and 17-20 - other issues. The patient is asked to look at each group and underline no more than one appropriate word in the group that best matches their pain experience.

Scheme

Body scheme

Used to localize pain. The patient also describes the type of pain, distribution, degree of intensity, whether it is constant or intermittent, and activities that exacerbate or relieve pain.

Linden scheme

The patient is shown a diagram with a series of faces, with a variety of expressions from joy to suffering. The patient points to the face that most closely matches his feelings. This method is more suitable for examining children.

Acute and chronic pain

• The choice of treatment method is carried out according to a stepwise scheme in accordance with the intensity of pain and the effectiveness of previous treatment. The combination of drugs that act at the peripheral and central (CNS) levels enhances the analgesic effect.
• Complementary therapies include medication (eg, psychotropic drugs, pain relief, local anesthetics) and non-pharmacological (eg, physiotherapy, exercise therapy, surgical treatment, radiation therapy, psychotherapy) methods.
• In the treatment of chronic pain, it is necessary to take into account the role of the mental factor in the origin pain syndrome(psychogenic pain), the state of psychological protection and the form of expression of complaints (psychosocial aspects, psychodynamics). The use of opiates for the treatment of severe pain almost never leads to psychological dependence, but is addictive (in the pharmacological sense of the term). After the withdrawal of opiates, somatic signs of withdrawal syndrome (physical dependence) may appear.

Pain management often becomes an interdisciplinary medical problem and requires the use of many drugs. In this regard, scientific advisory centers for the treatment of pain are being created, to which patients with persistent pain syndrome resistant to treatment should be referred.

Pain in diseases of the musculoskeletal system

Pain in diseases of the musculoskeletal system includes conditions such as myofascial syndromes, lumbago, cervicobrachialgia, facet syndrome, Costen's syndrome, fibromyalgia, pseudoradicular syndrome. Any functional element of the musculoskeletal system can become a source of nociceptive pain caused by the above diseases or excessive functional loads.

Myofascial Syndrome

Myofascial syndromes are associated with excessive functional loading of muscles, tendons, joints and other elements of the musculoskeletal system and/or with pseudo-inflammatory changes (eg, fibromyalgia, polymyalgia rheumatica). Pain appears or increases during movements, in addition, they can be caused using special techniques used in the examination.

Treatment

• The main method of treatment is consistent targeted therapeutic exercises designed to correct excessive and non-adaptive functional loads on muscles and tendons. Special treatment programs have been developed.
• Many studies have shown that in lumbago or other myofascial syndromes that do not have morphological correlates, bed rest for more than 2 days is contraindicated. Early mobilization and therapeutic exercises are aimed at preventing chronic pain.
• Additionally, physiotherapy, thermal or cold procedures should be used.
• Massage usually gives only a short-term effect and is indicated in rare cases.
• Blockades with subcutaneous or intramuscular administration of local anesthetics have an immediate effect, interrupt the vicious circle between pain and reflex muscle tension, facilitate therapeutic exercises, but, unfortunately, have only a short-term effect.
• One of the methods of local action that does not give side effects is transcutaneous electrical nerve stimulation (TENS), which has a therapeutic effect in 30-40% of cases. It is used as a preparation or addition to therapeutic exercises and physiotherapy.
• Analgesics with a peripheral mechanism of action are not indicated in all cases and have a very limited range of indications in the long-term treatment of pain. They are needed only in the acute period, as emergency therapy. These include diclofenac, ibuprofen, meloxicam, lornoxicam (xefocam), naproxen. Sometimes it is possible to use corticosteroids (prednisolone).

Pain due to damage to the peripheral nervous system

Damage peripheral nerves cause pain, referred to as neuropathic (neurogenic) pain. Neuropathic pain is associated with the process of pathological regeneration. Neuropathic pain often has a dull, painful, burning character, may be accompanied by paresthesias and a violation of superficial sensitivity.

Treatment

Basic principles for the treatment of neuropathic pain:

• Medical treatment depends on the nature of the pain. Paroxysmal, stabbing pains are treatable with carbamazepine, gabapentin, and other anticonvulsants.
• With constant monotonous excruciating pain, tricyclic and other antidepressants can have an effect. The effectiveness of amitriptyline has been most fully investigated. Doxepin (Sinekvan), imipramine (Melipramine) and other tricyclic antidepressants are also used.
• It is possible to combine the above drugs with a low-potential neuroleptic, for example, levomepromazine (tisercin). (Warning: possible fall blood pressure) or benzodiazepines, which are given as a short course to reduce pain.

Stump pain and phantom pain

Both of these types of pain are referred to as deafferent pain. Painful sensations (phantom pain) or painless sensations (phantom feeling) in the amputated limb are observed in 30-90% of cases. The main role in the pathogenesis of these sensations is played by the processes of functional restructuring in the central nervous system and the processes of regeneration in the peripheral nerve. Phantom sensations are most pronounced in distal parts amputated limb. Over the years, their "area" tends to gradually decrease, similar to how the telescope tube is folded (telescope phenomenon). Phantom pain can be paroxysmal or chronic persistent. Degenerative processes in the stump, neuroma nerve ending and the use of a prosthesis can lead to the progression of pain. Phantom pain is often combined with pain in the stump, which develops due to mechanical irritation of the nerve endings by the neuroma and is accompanied by painful paresthesias. Pain can persist throughout life and worsen with age.

Treatment

• Transcutaneous electrical nerve stimulation (TENS): on initial stage has an effect in 80% of patients, 4 years after the onset of pain, the effectiveness is 47%. TENS in the stump area is usually well tolerated by patients, side effects (unpleasant sensations under the influence of electrodes) are observed very rarely.
• With insufficient TENS efficiency, implantation of an epidural stimulation electrode is possible. However, persistent paresthesias can develop, covering the entire limb; after overcoming the technical problems, a good therapeutic effect is possible.
• At severe pain an opioid analgesic is often required.
• There are reports of successful parenteral use of calcitonin at a dose of 200 IU in the form of a short course. Controlled studies have not been conducted, the mechanism of action is unknown.
• In some cases, spinal opioid analgesia has a long-term effect. To date, there has not been much experience in the use of this method of treatment outside the field of malignant neoplasms, therefore, the appointment of this treatment for pain in the stump and phantom pain is experimental.
• Since phantom pain and pain in the stump can exist for many years and remain extremely intense and painful, methods of surgical destruction are used. Chemical neurolysis with the use of ethanol or phenol of the spinal roots or peripheral nerves causes pronounced sensory disturbances and is not currently used. Coagulation of the zone of occurrence of the posterior roots at various levels of the spinal cord is successfully used.
• Excision of the neuroma of the nerve ending, repeated amputation or surgical debridement of the stump does not always lead to the expected reduction in pain. Treatment outcomes can be improved with microsurgical techniques, as recurrence of the neuroma can be prevented. Studies show that the propensity to form neuromas has significant individual variation.

Pain with peripheral nerve damage and reflex sympathetic dystrophy

Synonyms of these concepts are the terms "Zude's disease", "algodystrophy", "causalgia", "sympathetically maintained pain" ("sympathetically maintained pain").

Symptoms and signs

• Damage to the peripheral nerves initially leads to impaired sensation. Then, in the process of pathological regeneration, ephaptic contacts are formed. Pain is usually accompanied by paresthesias, dysesthesias, allodynia or hyperalgesia, in the origin of which leading role play regenerative processes at the peripheral and central levels. Dysesthesias caused during examination (for example, Tinel's symptom) regress in the process of further regeneration, their persistence is a sign of poor recovery. The prognosis for pain is more favorable in the case of early suturing or replacement of the defect with a graft (eg, sural nerve).
• With the pathological growth of efferent sympathetic fibers, autonomic innervation disorders develop in the form of trophic disorders, sweating, pilomotor reactions, and peripheral circulation. Over time, due to plastic reorganization and regeneration, a syndrome of autonomic disorders can form, occurring in several stages, in which signs of hyper- and hypoexcitability of sympathetic nerves replace each other (sympathetic reflex dystrophy, algodystrophy, causalgia). This disease can not always be completely cured, sometimes individual symptoms persist for a long time. Therefore, in the treatment of pain associated with damage to peripheral nerves, agents that act on the sympathetic nervous system should be used.

Treatment

• If there are signs of dysfunction of the sympathetic nervous system (reflex sympathetic dystrophy), blockade with the use of a local anesthetic in the projection of the sympathetic trunk, stellate ganglion or regional blockade with guanethidine and a local anesthetic is recommended. If the treatment is effective, it is continued, conducting a course of blockades at intervals of several days. The effect of this treatment method can be long lasting. In case of recurrence (only with a positive effect of blockades), consideration of the issue of sympathectomy is possible.
• A new variant of sympathetic trunk blockade is ganglionic local opioid analgesia, in which an opioid drug is used instead of a local anesthetic. The efficiency does not appear to be significantly different from that of the previous method.
• There are reports of a dramatic effect with parenteral administration of calcitonin at a dose of 100-200 IU in short courses. After a few minutes after intravenous administration the pain decreased, the effect persisted for several months. No controlled trials have been conducted. Before treatment, it is recommended to determine the level of calcium in the plasma.
• Operative neurolysis is indicated only in the presence of visible neuromas, its effectiveness has not been proven.

Postherpetic neuralgia

Reactivation of the herpes zoster virus in the spinal ganglia leads to acute inflammation and necrosis of pseudounipolar ganglion cells, followed by degeneration of the proximal and distal processes (shingles). Pathological growth and defective regeneration of both peripheral and central fibers leads to disturbances in the generation and conduction of pain impulses. In elderly patients with concomitant diseases, regeneration disorders and, accordingly, postherpetic neuralgia develop more often (in persons over 80 years old, in 80% of cases of herpes zoster). The main manifestations of postherpetic neuralgia are chronic burning, shooting neuropathic pains, as well as disturbances in superficial sensitivity (allodynia, hyperalgesia).

Treatment

• For local action, the use of 0.025-0.075% capsaicin ointment (found in capsicum) is recommended. Capsaicin with regular use contributes to the depletion of tissue reserves of substance P. It is absorbed into the skin and, moving by retrograde transport, acts both at the distal and proximal levels. In 30-40% of patients, there is a decrease in pain. Patient compliance is rarely good enough due to the burning sensation that occurs during the first procedures, as well as due to the need for frequent and long-term use. To reduce burning sensation, an ointment containing local anesthetics (for example, xylocaine) is used.
• TENS (transcutaneous electrical nerve stimulation) is particularly effective.
• In the absence of effect, long-acting opioid analgesics, such as tilidine, tramadol, or morphine sulfate, are used.
• The method of spinal opioid analgesia is also effective.
• Neurosurgical methods of treatment, such as coagulation of the zone of occurrence of the posterior roots, are used only as a last resort (ultima ratio).

Chronic compression of the spinal roots

Treatment

• The principles of treatment are generally the same as for musculoskeletal pain syndromes. Basic therapy consists of therapeutic exercises and physiotherapy. It is aimed at preventing and eliminating secondary changes in posture, antalgic postures that support and worsen the course of the pain syndrome.
• Often falls on a short time prescribe a course of treatment with painkillers and anti-inflammatory drugs. These include diclofenac, ibuprofen, naproxen, meloxicam, lornoxicam, in exceptional cases weak opioid analgesics are used.
• Injections of local anesthetics, blockades of the facet joints also have a good, but short-term effect.
• Along with TENS, stimulation of the posterior columns of the spinal cord using an implanted electrode is indicated for this type of pain syndrome.
• A stable effect was obtained with the implantation of an infusion pump for spinal opioid analgesia. Morphine is administered epidurally. Due to the fact that in case of a long and severe illness, the patient may fall out of active professional life for a long time, it is recommended to carefully consider the choice of treatment, especially when prescribing expensive therapies.
• The psychological state of a patient with chronic intense pain often requires the intervention of a psychotherapist. Methods of behavioral and supportive psychotherapy are effective.

Central pain syndromes

The central pain syndromes include thalamic syndrome, loop (lemniscus) pain syndrome, root detachment.

Violation of the functioning of the system that controls the conduction of pain impulses can lead to the occurrence of pain syndromes. Vascular, traumatic or iatrogenic lesions of the thalamus (thalamic syndrome), loop (loop pain syndrome), posterior horns of the spinal cord or the zone of entry of the roots (rupture of the root), spinal ganglia or gasser node (pain anesthesia) can cause severe persistent chronic pain. Along with dull excruciating pains, there are also violations of sensitivity of central origin, such as allodynia, hyperalgesia, dysesthesia. Pain syndromes in almost all cases are accompanied by significant affective disturbances; patients become grumpy, agitated, depressed, or agitated, making it difficult to differentiate from primary mental disorder.

Treatment

• With central pain syndromes, the use of psychotropic drugs is necessary. As with other types of chronic pain, tricyclic antidepressants are recommended, alone or in combination with antipsychotics (see above).
• In most cases, it is necessary to prescribe narcotic analgesics for a long time, usually morphine sulfate is used.
• With the separation of roots and other lesions for more than high level possible intraventricular administration of opioids. Due to the fact that the drugs are administered in close proximity to opioid-sensitive areas of the brain stem, effective low doses(1-3 mg of morphine per day). Like spinal opioid analgesia, this method is experimental.
• Used to help the patient cope with pain various methods psychotherapy, for example, behavioral psychotherapy, autosuggestion methods, psychodynamic methods.
• Surgical destructive methods, such as thalamotomy, chordotomy, or coagulation of the dorsal root entry zone, are indicated only as a last resort. After them, relapses and complications are possible.

Pain treatment

Analgesics

• Simple analgesics
• Paracetamol
• Opiates
• Codeine, dihydrocodeine (weak)
• Tramadol (drug of choice)
• Morphine (strong)
• Non-steroidal anti-inflammatory drugs
• Diclofenac
• Ibuprofen, etc.

Pain from a nerve injury

• Antidepressants
• Amitriptyline
• Anticonvulsants
• Gabapentin and its predecessor pregabalin.

Therapy

• Reduce swelling.
• Reducing tissue tension reduces chemical irritation of nociceptors.
• Peace:
• Reducing inflammation
• Reducing muscle spasm.
• Mobilization:
• Swelling reduction
• Change in sensory impulses from joints and muscles
• Prevention of scar tissue formation.
• Function.
• Electrotherapy
• Changes in sensory impulses in the nervous system.
• Thermal effect:
• Elimination of local ischemia
• Change of sensitive impulses.
• Acupuncture
• Change in energy flows.
• Electroneurostimulation:
• Stimulation of large nerve fibers; closes painful
• Stimulation of the production of endorphins.
• Massage.
• Relaxation.
• Education.

Pain reduction is achieved by suppressing the activity of pain receptors (for example, by cooling the injured area) and inhibiting prostaglandin synthesis. With cooling of body parts and the use of local anesthetics that inhibit Na + channels, the transmission of pain signals also decreases. Anesthesia and alcohol inhibit the transmission of pain impulses to the thalamus. The transmission of pain stops when the nerve is surgically cut. Electroacupuncture and transcutaneous nerve stimulation activate descending pathways that inhibit pain. Endorphin receptors are activated by morphine and other drugs. Endogenous mechanisms that inhibit pain are activated during psychological treatment.

When treated with some medicines or in rare cases of congenital analgesia (eg, SCN9A Na + channel mutations), the person may not feel pain. If the cause of the pain is not addressed, the consequences can be life threatening. Variants of certain genes related to pain sensation and pain transmission mechanisms lead to genetic hypalgesia. These include, for example, mutations in opioid receptors (OPRM1), catechol-O-methyltransferase (COMT), melatonin receptor 1 (MCIR), and transient receptor potential (TRPV1).

One of the most urgent problems in the framework of general somatic medicine, psychiatry and psychology is the problem of pain. If you strongly generalize, it turns out that the whole life of a person is aimed at avoiding pain - physical or mental, strong or not so much. When a person does experience pain, he perceives it differently within the range of "trouble": from feeling slight discomfort to a state of unbearable torment. We are accustomed to associate pain with a continuous negative, and sometimes we forget about the important role of pain in our lives...

In fact, pain sensations perform a signaling function: they report the existence of a disorder in the body, an injury, an illness, in a word, a pathology that should be paid attention to. Pain manifests itself as a symptom of the disease, as if it highlights a problem area with a flashlight, so that a person can quickly start “sounding the alarm” and direct his efforts to treat and eliminate the problem that has arisen.

The intensity and nature of the pain itself should correspond to the damage existing in the body: the more pronounced the pathological process, the stronger, usually, we feel pain, and after the end of the healing or recovery process, the pain goes away. But sometimes the intensity and nature of the pain may not correspond to the nature of the existing damage, or the pain may not go away even after a complete somatic recovery.

If the pain continues for more than 3-6 months, they talk about chronic pain syndrome. In this case, the pain does not always have an organic basis.

Of the three main groups of pain syndromes (nociceptive, neuropathic and psychogenic) in this article, the subject of consideration was psychogenic pain syndrome or psychogenic pain. In this case, pain sensations owe their appearance to the existence of traumatic situations or psychological conflicts.

Psychogenic pain: features of psychogenic pain syndrome

The group of pain sensations of a psychogenic nature includes the following types of pain:

• Pain arising from the influence of emotional factors, psychological conflicts and psycho-traumatic events (the appearance of these pain sensations is caused by muscle tension);
• Pain during delusions and hallucinations (the patient gets rid of these pain sensations when cured of the disease, the symptom of which was pain);
• Pain in hypochondria, hysteria (devoid of a somatic basis);
• Pain that appears during depression (the amount of the neurotransmitter serotonin decreases - the threshold of pain sensitivity decreases, subthreshold pains appear, which a person normally does not feel).

Thus, psychogenic pain cannot be explained by the existence of a somatic basis that could lead to the manifestation of pain. The patient in many cases determines the area of ​​localization of pain, the damage in which (even if they were) could not cause pain of such intensity. In some cases, some damage to the somatosensory system is indeed detected as a result of the examination - however, they are unable to explain the significant severity and intensity of pain. That is, the leading factor is not a pathological process, not a trauma, but emotional and psycho-traumatic factors, a psychological conflict.

The biological basis of pain sensations of a psychogenic nature is nociceptive system: the occurrence of chronic pain of a psychogenic nature is preceded by the activation of nocireceptors, most often due to muscle tension.

Psychological conflict can also activate the work of the sympathetic nervous system and the hypothalamus-pituitary-adrenal axis: retrograde excitation of the receptors of the nociceptive system occurs, after which these receptors are sensitized. An example of such nociceptor sensitization may be the occurrence of zones of high sensitivity to pain stimulation (for example, in cases of fibromyalgia and tension headache).

During the course of treatment, the detection psychological reason the onset of pain is of paramount importance - only after identifying the root cause, medical and psychological assistance will ensure the patient's recovery. Also, in the process of diagnosing a pain disorder, it is very important to consult a psychiatrist in order to check whether psychogenic pain is associated with a mental disorder (depression, schizophrenia, etc.).

Pain (or pain syndrome) in the structure of somatoform and somatized disorders

Quite often, pain sensations of a psychogenic nature can occur in the form of a chronic somatoform pain disorder (in the modern classification of ICD 10 it is interpreted under the code F 45.4.), which is characterized by complaints of persistent and painful pain. The pain that manifests itself in this disorder cannot be explained by the presence of a pathological process in the body or a somatic disorder, and emotional conflicts and various psychosocial problems are considered the main cause of psychogenic pain.

The main symptom of a somatic disorder is multiple somatic symptoms: they appear for at least two years, may disappear from time to time and resume again, and change. Also, with somatoform pain disorder, there may be unpleasant symptoms associated with the disorder digestive system: nausea, pain in the abdomen, a feeling of fullness or fullness of gases, etc. Sometimes there may be pain in the chest, in the genital area and pain in the joints and limbs.

A person experiencing pain begins to receive care and support in a significantly increased volume, because his close circle (and often medical staff) show increased attention to the patient. In any case, this is conditional and certainly beneficial to the sick person, as he receives additional and desired attention, care and love.

Therefore, if the patient experiences pain for the first time, it is necessary, of course, to exclude the somatic cause - the disease, but the psychogenic cause cannot be discounted, since the tactics of helping in these cases have a completely different approach. Of course, at first they exclude a somatic disease, but if, with numerous examinations and clinical examinations of doctors of various profiles, there is no bodily disease, go to psychiatrists, psychotherapists and psychologists for help. By taking a thorough history, they will find psychological, emotional or psychosocial problems that have transformed into pain. But how to cope with such pain, what to do and how to help the patient, they know something, believe me! Because if this vicious circle is not interrupted at the very beginning, the pain will return, changing in its color, intensity, character and location at the slightest psychotraumatic situations. Over time, such patients lose their usual social functions, since the basis of their life position is an excessive hypochondriacal fixation on the state of their health, and the “center of their universe” is numerous and endless examinations, studies and visits to doctors of various specialties and directions!

As if on purpose, when this article was being written, a married young woman of 25 years old, who several years ago had two lymph node on the neck . The reason for their increase was not found, and numerous morphological and histological studies, fortunately, confirmed their benign process. Maybe it was not necessary to remove them at all ... but that's not the point at all. There was then such a “good” doctor who scared me that the nodes could “degenerate into oncology” and gave a lot of “well, sooo necessary advice and recommendations." Among other things, he forbade the patient to consume ... sugar, "because cancer cells feed on sweets." You haven’t forgotten yet that this woman’s oncological problem wasn’t even close? In principle, excessive consumption of carbohydrates has never led to particularly good consequences. But if this idea becomes a "fixed idea" of life? Banal food poisoning and intravenous drip of rheosorbilact resulted in severe abdominal pain, nausea and vomiting with the smallest amount of food and liquid. And why? After reading the instructions for rheosorbilact, “she found sorbitol in the composition, and it should not be used by patients with diabetes, ... and, therefore, I could not use it ... ”The patient began to think about the possible occurrence of“ now for sure ”oncological pathology and a whirlpool of psychosomatic and somatoform complaints - symptoms swirled ... .. There was severe anxiety, insomnia, internal tension, mood decreased ….. All is well that ends well. As in that fairy tale, but already from life, “they had a familiar psychiatrist and, having turned to him and received proper treatment, no longer sick, a young woman went to her parents to celebrate Christmas ...

Pain (or pain syndrome) and depression

Often, manifestations of depression can be masked by pain, that is, pain can be considered as a kind of "screen" or "mask" of depression. Why is this happening? A decrease in the synaptic cleft of such a “good mood” neurotransmitter as serotonin leads to a decrease in the threshold of pain sensitivity, and patients with depression feel subthreshold pains that they do not normally feel. When pain occurs against the background of depression, they form a specific “vicious circle”: a depressive disorder provokes an experience of helplessness and hopelessness, disbelief in the improvement of the state, then, as a result, the pain intensifies, and this, in turn, exacerbates depressive symptoms.

Thus, to overcome the problem of psychogenic pain, the help of psychiatrists, psychotherapists or psychologists is needed. Individual and comprehensive approach, as well as a combination drug treatment and psychotherapy allows you to influence both the somatic mechanism of pain formation and the psychological problem that caused psychogenic pain.