The International Association for the Study of Pain (IASP) defines pain as: Pain is a painful experience caused by actual or potential tissue damage with sensory, emotional, cognitive, and social dimensions. Not only is pain one of the most common clinical symptoms, but chronic pain has been recognized as a type of disease. The nature of pain is often difficult to describe, there are no specific indicators, mainly rely on the patient's complaint, there is no clear and objective classification diagnosis criteria, pain treatment is diverse and lack of norms.

IASP allows the same pain to be classified into multiple categories. However, the classification of ICD-10 and ICD-11 lacks an explanation of the pain mechanism, and its clinical practicality is not good. Based on years of clinical practice and basic research on pain, the author discussed with colleagues in the industry and proposed that pain classification based on pathophysiology is a tool that can link many pain disorders and even pain diseases in series.

Pain classification based on pathophysiology

Pain is divided into 6 categories based on pathophysiology:

Inflammatory pain

Etiologies include infections and injuries, which have a common histopathology: inflammation. Inflammation can be divided into tissue-derived, immunogenic and neurogenic inflammation. Most of the head, neck, shoulder, waist and leg joint pain and myofascial pain belong to the category of inflammatory pain.

Neuropathic pain

Etiology includes nerve entrapment, nerve ischemia and hypoxia, amputation, and bacterial and viral invasion. Common histopathological and neurophysiological changes: neurodegeneration, absence of myelinated fibers and demyelination of myelinated fibers, plasticity changes in the central nervous system, and abnormal conduction. Causes of demyelination include neurological microcirculation disorders and connective tissue proliferation, such as trigeminal neuralgia, postherpetic neuralgia, diabetic peripheral neuropathy, central pain after stroke, and sympathetic neuropathy.

Cancer pain

Cancerous pain is a series of syndromes caused by different pathophysiological changes, including early inflammatory pain. As the disease progresses, neuropathic pain caused by sensory and sympathetic nerve damage, visceral pain, bone damage, cell death, bone pain Etc., and at the same time lead to changes in pain and emotions causing anxiety, fear, cognitive impairment and so on.

Spasmodic pain

Also known as ischemic pain, histopathological and physiological changes include structural or functional changes in blood vessels, skeletal muscles, or visceral smooth muscles, leading to vascular stenosis, tissue ischemia, and dysfunction, such as most visceral pain, Raynaud's disease, and surgery. After smooth muscle spasm and so on.

Psychogenic pain

The central nervous system of the human body not only integrates the production of pain sensations in the process of receiving peripheral nociceptive afferents, but also is accompanied by changes and experiences of pain emotions. With the development of functional MRI on brain function, when the body is suffering from pain, the body produces a clear analysis and integration of moderate and above pain, which leads to the enhancement of the function of the brain core group that controls emotional regulation, which affects emotional cognition and pain regulation. Physiological response. The occurrence of pain is consistent in time and degree with the psychosocial factors, accompanied by emotional states of depression and anxiety.

other

Including idiopathic (primary) pain, reflex pain (involved pain), and non-painful diseases (such as hyperhidrosis, sleep disorders, etc.), the etiology of these diseases is not clear, the pathophysiology changes are complex and diverse, the pathogenesis has not been identified.

Clinical pain treatment principles

The treatment principle is adopted based on the pathophysiology of pain combined with the nature of the pain, the main complaint, physical examination, imaging data, laboratory tests and the actual situation of the patient.

General Treatment Principles

(1) Targeting the cause: Determine the medication and treatment plan for pathophysiological changes. For example, anti-infective drugs, steroidal or non-steroidal anti-inflammatory drugs, or other immunomodulatory drugs are used as first-line drugs for inflammatory pain, and combined with nerve block and ozone therapy; neuropathic pain is blocked by ion channels. As a first-line drug to reduce and control central sensitization, or to suppress abnormal signal transmission of pain through exogenous neuromodulation techniques (ozone therapy, spinal cord stimulation, etc.); and cancerous pain according to its different causes and stages of pathophysiological characteristics, Use anti-inflammatory analgesics, standardized opioid analgesics, ion channel blockers, and adjust bone metabolism. The biggest feature of this type of pain is the unrestricted use of opioids; spastic pain is the first-line application of anticonvulsants, non-steroidal anti-inflammatory drugs, vasodilators, and the implementation of sympathetic nerve blocks; etc. And behavior correction, antidepressant and anxiety drugs. Other types of pain should be treated according to the characteristics of each disease.

(2) Relieving symptoms: The first priority is to relieve symptoms on the basis of the etiology treatment, and then restore cell and tissue functions without forcefully restoring anatomical structure or histopathology. The minimally invasive treatment of neuropathic pain has changed from the original nerve damage to the current nerve repair and neuromodulation. These are the results of in-depth research based on a large number of clinical practice and pathophysiology.

(3) Recovery function: Restore physiological functions as much as possible on the basis of relieving symptoms.

(4) Dynamic evaluation: Through dynamic evaluation, real-time adjustment of medication and treatment plan.

(5) Delaying development: The purpose of delaying tissue damage or degeneration is achieved through real-time treatment plan adjustment and prevention education.

(6) Focus on prevention: Through health education and online management, popularize pain knowledge to allow more patients and medical workers to understand and understand pain, thereby reducing recurrence.

Supplementary principle

(1) The principles of conservative, minimally invasive and comprehensive treatment. Based on the comprehensive consideration of the actual situation of the patient, whether the reference has been seen in different levels of hospitals? Severe symptoms? Whether the first-line drugs have been used for standardized, precise, individualized and rationalized diagnosis and treatment procedures.

(2) Diagnostic treatment needs to adhere to the principle of first peripheral, then central; or first outside the spinal canal and then inside the spinal canal. Avoid targeted patients who have unclear etiology or who need diagnostic treatment during dynamic assessment.

Summary

Pain is a common clinical symptom and disease, and its wide audience and influence have drawn more and more attention from medical staff and the general public. However, in terms of pain classification and treatment status, there are diversified and differentiated diagnosis and treatment modes in hospitals at various levels at home and abroad, and the scope of diagnosis and treatment overlaps, which leads to repeated repeated diagnosis and treatment of patients. The pain classification and treatment principles proposed by the author can not provide a perfect solution for all pain diseases, but we believe that the pain classification is determined according to the different course development and pathophysiological characteristics of the same disease. Based on this, the medication and treatment plan are selected. The consistent and general principles of treatment and supplementary principles can help clinical thinking of pain and guide diagnosis and treatment.

Article excerpted from Chinese Journal of Pain Medicine 2017, 23 (5)

Further reading

Anti-inflammatory and anti-infective

Ozone comes into contact with body fluids to produce a single oxygen atom and hydrogen peroxide. These are two strong oxidants. Once they enter the body or come into contact with infections on the surface of the body, bacteria, viruses and parasites can be directly deleted and eliminated.

Analgesic

Medical ozone can inhibit myeloinjured sensory fibers and achieve analgesic effects by stimulating inhibitory intermediate neurons and releasing substances such as enkephalin

Dilate blood vessels, improve tissue microcirculation and oxygen supply

Medical ozone can stimulate the release of NO by vascular endothelial cells, and endogenous NO can directly lead to vasodilation. It can also inhibit the adhesion of platelets on the surface of endothelial cells and platelet aggregation. The content of 2,3-DPS in red blood cells increases, making hemoglobin oxygen Move right off the curve to increase oxygen release.

Activates antioxidant enzymes and removes excess free radicals

Medical ozone can activate the over-expression of antioxidant enzymes and neutralize excess reactive oxidation products (superoxide dismutase, catalase, etc.) to remove excess free radicals and peroxides during physiological and pathological processes.

Ozone Treatment Direction

1. Acute stroke and stroke rehabilitation

2. Brain edema treatment after brain surgery and traumatic brain injury

3. Cardiovascular disease treatment

4. Treatment of viral hepatitis and drug-induced hepatitis

5. Minimally invasive treatment of cervical and lumbar disc herniation

6. Pain treatment

7. Diabetes and complications treatment

8. Burns and scald treatment

9. Cancer Support Therapy

10. Other directions: sub-healthy people, ulcerative colitis, cervical erosion, urticaria immune system disease, chronic fatigue syndrome, etc.

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