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Summary Chapter 11
Chapter 11 lecture notes Erik Scherder
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Summary Chapter 11 + lecturenotes
A striking fnning rro stunies is th at patents ith neoenta use e er analgesics tr treat pain th an
elnerly ith rut neoentaa h ich refects th e unner-treatoent r pain in neoenta. Questrn h eth er
unner-treatoent r pain cruln be relaten tr neoenta-relaten prrbleos in croounicatng abrut
pain. Assessing pain becroes orre nifcult i rnes croounicatie skills necline. Furth erorre th e
questrn arises h eth er th e pain experience is ch angen nue tr th e neurrpath rlrgy. Alsr patents
ith an intellectual nisability oay rro a nifcult grrup rr assessing pain. It is h yprth esizen th at
neurrpath rlrgy in th e nisrrners (alsr neoentaa cruln prriine insigh t intr prssible ch anges in pain
experience.
It h as alreany been sh r n th at th e preialence r pain ul niseases is th e saoe rr perple ith
neoenta ann th rse ith rut neoentaa sr th at is nrt an explanatrn rr less analgesic use in
neoenta patents. One stuny sh r en th at th e leiel r niscro rrt in seierely neoenten patents
ith a pain ul crnnitrn nin nrt necrease afer a certain nrse r analgesia. 2 explanatrnss (1a th e
nrse is trr lr a (2a th e rbserien niscro rrt is nrt relaten tr pain in th is patent grrup.
Th e ch rice rr a certain pain assessoent instruoent is neteroinen by th e croounicatie capacites
r th e patent. Th rse h r are able tr croounicate rfen get sel -reprrt pain ratng scales. Nrn-
croounicatie patents are rfen assessen by oeans r rbseriatrn scales ann autrnroic
resprnses.
Th e orst croornly usen ierbal pain ratng scales are th e Verbal Discriptio cale (VD ) ann th e
Verbal Raton cale (VR ). Th e VDS crnsists r anjecties re erring tr niferent leiels r pain
experience. Th e VRS is croprsen r labels nescribing th e nature r pain. Th e orst aorus iisual
analrgue scales are th e Mech anical Visual Analrgue Scale (MVASa ann th e Faces Pain Scale (FPSa. Th e
MVAS is a kinn r th eroroetera ith th e nark (h rta area rr th e rrst prssible pain ann a ligh t (crlna
area rr nr pain. Th e FPS crnsists r 7 aces th at express increasen eelings r pain. Nuoeric ratng
scales are th e nuoeric ratng scale (NRSa ann th e 21-print Brx scale (BS-21a. Th e NRS is a 1-10
h rrizrntal scale. Th e BS-21 crnsists r 21 brxes rn a h rrizrntal line ranging rro 0 tr 100a ith
interials r 5 prints. All th ese scales sh r quite acceptable ann croparable psych roetric
prrpertes. Pre erren scale appears tr nepenn rn th e eth nic backgrrunn. Th e oajrrity r crgnitie-
iopairen persrns are able tr use all th e scale-types.
Obseriatrn scales orst inely usen crnsist r iteos th at rcus rn th e intensity ann lrcatrn r paina
afectie croprnents r paina ann autrnroic resprnses tr pain (i.e. breath ing ann s eatnga. Facial
expressirns r pain can be crnen by a specifc systeos Facial Actrn rning Systeo (FA Sa. Th e
systeo alsr assesses th e iarying leiels r pain relaten tr th e iarirus negrees r actiity. r eiera
acial expressirns oay h aie ch angen in neoenta patents. Frr exaople th e absence r a relaxen
brny prsture oay be nue tr extrapyraoinal signsa ch aracteristc r Alzh eioer. Th ere rrea ois-
interpretatrns are quite easily oane. Th rse ith righ t-sinen teoprral lrbe iariant r FTD h aie
necreasen acial expressirn nue tr th eir crnnitrn. Absence r acial expressirn r pain is oit
eiinence r absence r pain!
Fe stunies h aie been crnnucten th at exaoinen autrnroic resprnses r AD patents tr pain. In
ienipuncturea AD patents sh r en lr er h eart rate antcipatng increases croparen tr crntrrls nue
tr an inability tr antcipate th e puncture. Th e actual puncture th en increasen th e h eart rate orre
strrngly th an it nin in crntrrls. In applying pain ul electrical stoulia AD patents h an nr resprnse
h en pain as oiln ann a nrroal increase in blrrn pressure ith a h igh ly pain ul stoulus. Subparts
r th e autrnroic nerirus systeo react niferently tr pain in AD. Furth erorrea autrnroic unctrns
tenn tr neterirrate in neoentaa but prrcessing r tactle ann pain ul stouli is stll prssible. Againa a
lack r autrnroic resprnses nresn’t neen tr be representatie rr a lack r paina oaking oeasuring
autrnroic resprnses an unreliable ay r oeasuring pain in AD patents.
, In general e h aie 2 pain systeosa a oenial rne ann a lateral rnes
Menial pain systeo th alaoic nuclei receiie nrciceptie in rroatrn th rrugh th e spinrth alaoica
spinrretcular ann spinroesenceph alic tracts. Th e th alaous th en senns in rroatrn tr th e A a
insulaa parietal rperculuo ann secrnnary sensrry crrtex. Nuclei r ARAS crniey nrciceptie
in rroatrn tr th e aoygnalaa h ipprcaopus ann h yprth alaoic nuclei (paraientricular nucleusa PVNa.
In PVN rxytrcin ann iasrpressin are prrnucen. Oxytrcin ann iasrpressin trgeth er ith R ann
h istaoine are neurractie croprunns th at h aie an ant-nrciceptie efect. Menial pain systeo
inirlien in rrrying abrut th e pain ann oeorry abrut pain.
Lateral pain systeo th e spinrth alaoic tract alsr crnieys in rroatrn tr th e lateral th alaous th at
prrjects tr th e insulaa POa secrnnary sroatrsensrry area ann prioary sroatrsensrry crrtex. It is
inirlien in sensrry/niscrioinatie aspects r pain (I h aie paina it is th erea.
Patents ith rut AD tenn tr innicate th ey experience orre pain th an AD patents. Aorng th e AD
patents grrupa th rse in a relatiely early stage innicaten orre experiencen pain th an th rse in a later
stage. r eiera translatng rnes pain intr a ratng rn a pain scale is a crgnitie prrcessa h ich oay
be afecten nue tr th e nisease. sh en applying pain ul stouli tr AD patents ann crntrrlsa it as
runn th at th rse ith AD h an sioilar pain th resh rlns croparen tr crntrrlsa but a signifcantly h igh er
pain trlerance. Th ey oay th us experience a necrease in th e ortiatrnal/afectie aspects r pain
(oenial systeosa. Furth erorrea th ere appears tr be a h igh er general th resh rln rr autrnroic
actiatrn in patents ith AD. Th is necrease in ortiatrnal/afectie aspects r pain crincines ith
negeneratrn in oenial pain systeos; aoygnala ann h ipprcaopus negeneratrn oay be resprnsible
rr necline in oeorry in paina ann trgeth er ith th e tuberroaooillary nucleus (h istaoine nucleusa
rr bluntng r th e autrnroic resprnses. Furth er it is h yprth esizen th at atrrph y r th e aoygnalaa
h ipprcaopusa L a A ann secrnnary sroatrsensrry crrtex oay be resprnsible rr neterirratrn r
crgnitie/eialuatie aspects r pain. Partcularly in persistent paina crgnitie prrcesses such as
antcipatrn r th e uture ann beh aiirral resprnses tr pain are orst ioprrtant. Alth rugh nrt as
seiere as th e oenial pain systeoa th e lateral pain systeo nres sh r sroe negeneratrn in ADs
sensrry th resh rln a litle eleiaten croparen tr crntrrls.
In iascular neoenta e see th e rpprsites patents tenn tr innicate h igh er pain experience th an
crntrrls. Th ey are orre sufering rro pain (ortiatrnal/afectie aspecta. An explanatrns h ite
oater lesirns causes niscrnnectrn bet een crrtcal ann crrtcr-subcrrtcal areasa resultng in
deaffereotatio pain. rnnectrns bet een intralaoinar th alaoic nuclei ann sroatrsensrry areas
oay rr exaople result in abnrroal sensatrns (dysesthesiaa. Explanatrn is nrt crnfroen.
In croparisrn ith VaD ann ADa FTD patents innicaten experiencing signifcantly less pain. Th is can
be explainen by th e orre seiere oetabrlic necline seen in FTDa innicaten by a oarken necrease in
blrrn fr tr PF ann A . Th ese areas play an ioprrtant rrle in ortiatrnal/afectie aspects r
pain.
Pain is a prroinent clinical syoptro in nisrrners such as PD ann MS. rgnitie iopairoent alsr
rccurs in later stages r th e niseases just oentrnena in orst patents. Th is crgnitie iopairoent oay
h aie a necreasing infuence rn pain experiencea but th is h as nrt been iniestgaten. Th ey tenn tr
h aie oainly sroatc pain synnrroesa such as ousculrskeletal nisrrnersa ranicular-neurrpath ic
nisrrnersa nystrniaa akath isiaa neck pain ann h eanach e. Alsr central pain oay be present. Th is
increasen pain oay be causen by Le y brnies ann neurites in areas such as th e creruleus-
subcreruleus regirna th e nucleus gigantrcellularis ann bulbar nuclei. Th ese areas nrroally inh ibit
nrciceptie transoissirn. Due tr th ese brnies ann neurites in th e A a aoygnala ann PF in th e
crgnitie iopairen stage r PDa yru cruln antcipate a necrease in ortiatrnal/afectie aspectsa
crgnitie/eialuatie aspectsa autrnroic resprnses tr pain ann oeorry r pain.
Alsr in MS th ere are seieral pain synnrroesa such as trigeoinal neuralgiaa sroatc paina pain relaten
tr spastcitya iisceral pain (causen by spastcity r blanneraa ann rth er pain ul crnnitrns like rptc
neurits ann an acute ranicular synnrroe. Alsr a type r central pain crnsistng r unpleasant
sensatrns as reactrn tr truch . MS patents tenn tr experience h igh er pain intensitya tr neen orre
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