Drugs (Pregabalin) Modulates Hyperexcited Neurons s not affect Ca ++ influx in normal neurons
Drugs (Pregabalin) Modulates Hyperexcited Neurons
*Does not affect Ca++ influx in normal neurons
Woolf, 1994.
(4) Central Reorganization(Spinal Cord Injury)
Dorsal root ganglion
SuperficialSuperficial
DeepDeep
CC
AA
Sprouting of injury fiber alter the relationship and modified the pain between stimulant and response
After nerve injuryAfter nerve injury
(5) Loss of Inhibitory Control(Descending disinhibition)
NORMALNORMAL
INJUREDINJURED
Innocuous orInnocuous ornoxious stimulusnoxious stimulus
ExaggerateExaggeratepain responsepain response
To To brainbrain
CentralCentralDescendingDescendingLocalLocal
Dorsal horn neuronDorsal horn neuron
CentralCentralDescendingDescending
locallocal
To To brainbrain
Excitatory synapseExcitatory synapseInhibitory synapseInhibitory synapseMechanoreceptor
Woolf, 1999.
Brain-Gate Theory(閘門理論 )
• Melzack and Wall (1965)
• Melzack-wall-Casey (1982)--- modified theory:cognitive control+ descending brain-stem control
block NE and serotonin reuptake
臨床診斷(3L)
LISTEN
LOCATE LOOKNervous system
lesion / dysfunctionSensory abnormalities,
pattern recognition
Patient verbal descriptors,Q & A
神經評估Neurological Assessment
Holmes GM. Introduction to Clinical Neurology. Baltimore: Williams & Wilkins, 1952.
T10
T4
• History: onset, duration, character…
• Landmark of S level, distribution, location…
• Intensity, quality of pain
• Associated s/s, aggravated factors…
病史 : 問診還是最主要的
Complete information regarding pain
Use scales to aid in defining pain
McGill pain Questionnaire
Visual analog scale (VAS)
Activities of daily living scales (ADS)
Neuropathic pain scale (NPS)
• Quality
• Intensity
• Location
• pattern
也可利用疼痛問卷
Visual Analog Scales (VAS-疼痛評分 )
00 100100
NoNopainpain
ExcruciatingExcruciatingpainpain
00 100100
CompleteCompletepain reliefpain relief
NoNopain reliefpain relief
McQuay, 1998.
Note: Lines must be exactly 100 mm long
1. Tell us how intense your pain is.
The most intensepain sensation imaginable
2. Tell us how sharp your pain feels.
The most sharp
Not sharp sensation imaginable(“like a knife”)
3. Tell us how hot your pain feels.
The most hot
Not hot sensation imaginable
(“on fire”)
Neuropathic Pain Scale (NPS)
00 11 22 33 44 55 66 77 88 99 1010
Galer, 1997.
00 11 22 33 44 55 66 77 88 99 1010
00 11 22 33 44 55 66 77 88 99 1010
No painNo pain
Dull, cold,sensitive, itchy
臉部表情評分表
NCV(神經傳導 )脕隧道症候群 (Carpal tunnel syndrome)
However, small fiber disease can not be detectable( 亦即神經傳導正常 ,不代表神經沒有病變 )
EMG(肌電圖 )(neurogenic or myogenic)
FullInterference
IntermediatePattern
Single UnitPattern
(肌電圖更難以判斷 =正常反應 ,不代表神經肌肉正常 )