Control of chronic painBMJ 1998; 317 doi: https://doi.org/10.1136/bmj.317.7170.1438 (Published 21 November 1998) Cite this as: BMJ 1998;317:1438
- T J Nurmikko, consultant in pain relief,
- T P Nash, consultant in pain relief,
- J R Wiles, consultant in pain relief.
- Walton Centre for Neurology and Neurosurgery NHS Trust, Liverpool L9 1AE
- Correspondence to: Dr Nurmikko
The most important clinical development in chronic pain during the past decade has not been new treatments but a thoroughly revised interpretation of the mechanisms that act to maintain pain. Pain is no more seen as a predetermined result of simple activation of certain neural structures. It is now understood to be a dynamic phenomenon due to myriad pathophysiological changes in the peripheral and central nervous system in response to disease, injury, or loss of function1 (box 1). These changes reflect the surprising but indisputable fact that the human nervous system is adaptable and capable of substantial plasticity. Initially reversible, the changes tend to become fixed depending on the nature and duration of the original cause, as well as the age and perhaps the genetic susceptibility of the patient
In chronic pain the abnormal activity in the altered pain mediating afferent system continues irrespective of its original causation. Simple blocking or severing of neural pathways is not helpful: the locus of abnormal barrages is simply shifted more centrally. Recent advances in the pharmacology of pain have unravelled some of the mediators of chronic pain, and they offer potential targets for treatments that are currently being developed (box 2). New investigative techniques are also being developed for improved detection of factors maintaining chronic pain. Alongside pharmacological advances, stimulation treatments and psychological approaches have seen innovative developments.
Chronic pain is now known to be maintained by several pathophysiological mechanisms which currently can be dealt with only partially
New generation non-steroidal anti-inflammatory drugs have been developed for the treatment of rheumatic pain, but their true potential awaits the test of time
Choices for the treatment of neuropathic pain have increased with the advent of new anticonvulsants and topical agents
Indications for spinal cord stimulation have widened and include chronic angina and peripheral …