Diagnosing and treating chronic musculoskeletal pain based on the underlying mechanism(s)
Diagnosing and treating chronic musculoskeletal pain based on the underlying mechanism(s)
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DOI：
10.1016/j.berh.2015.04.024
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发表时间：
2015-02-01
影响因子：
5.2
通讯作者：
Clauw, Daniel J.
中科院分区：
文献类型：
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作者：
Clauw, Daniel J.
直到最近，大多数临床医生认为慢性疼痛通常是由于持续的外周伤害性输入（即，损伤或炎症）。临床医生通常知道几种类型的疼痛（例如，头痛和幻肢痛），其中慢性疼痛不是由于这些原因引起的，但大多数人没有意识到，没有一种单一的慢性疼痛状态，其中外周伤害性损伤的任何放射学、手术或病理学描述已被可重复地证明与疼痛的存在或严重程度有关。其主要原因似乎是外周和中枢神经系统在确定外周组织中的感觉神经检测到的伤害性输入将导致人类的疼痛感知方面起着关键作用。这篇文章回顾了一些关于疼痛神经处理的最新发现，特别关注临床医生如何使用从病史和体检中收集的信息来评估哪些机制最有可能导致特定个体的疼痛，并适当地调整治疗。一个关键的结构是，在任何特定的诊断类别（例如，纤维肌痛（FM）、骨关节炎（OA）和慢性下背痛（CLBP）是专门综述的），个体患者可能对他们的疼痛具有显著不同的外周/伤害感受和神经贡献。因此，正如下背痛长期以来被认为具有多种潜在机制一样，所有慢性疼痛状态也是如此，其中一些个体将主要由于外周伤害性输入而具有疼痛，而在其他外周（例如，外周致敏）或中枢神经系统因素（通过脊髓和脑中增强的疼痛处理的疼痛的“中枢致敏”或“集中化”）可能在他们的疼痛和其他症状中起同样或甚至更显著的作用。(C)2015爱思唯尔有限公司版权所有。
Until recently, most clinicians considered chronic pain to be typically due to ongoing peripheral nociceptive input (i.e., damage or inflammation) in the region of the body where the individual is experiencing pain. Clinicians are generally aware of a few types of pain (e.g., headache and phantom limb pain) where chronic pain is not due to such causes, but most do not realize there is not a single chronic pain state where any radiographic, surgical, or pathological description of peripheral nociceptive damage has been reproducibly shown to be related to the presence or severity of pain. The primary reason for this appears to be that both the peripheral and central nervous systems play a critical role in determining which nociceptive input being detected by sensory nerves in the peripheral tissues will lead to the perception of pain in humans. This manuscript reviews some of the latest findings regarding the neural processing of pain, with a special focus on how clinicians can use information gleaned from the history and physical examination to assess which mechanisms are most likely to be responsible for pain in a given individual, and tailors therapy appropriately. A critical construct is that, within any specific diagnostic category (e.g., fibromyalgia (FM), osteoarthritis (OA), and chronic low back pain (CLBP) are specifically reviewed), individual patients may have markedly different peripheral/nociceptive and neural contributions to their pain. Thus, just as low back pain has long been acknowledged to have multiple potential mechanisms, so also is this true of all chronic pain states, wherein some individuals will have pain primarily due to peripheral nociceptive input, whereas in others peripheral (e.g., peripheral sensitization) or central nervous system factors ("central sensitization" or "centralization" of pain via augmented pain processing in spinal and brain) may be playing an equally or even more prominent role in their pain and other symptoms. (C) 2015 Elsevier Ltd. All rights reserved.