update in pain management
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Update in Pain Management
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Defining of PainPain Experience
Pain is a personal, subjective experience that
comprises :Sensory-discriminative, Motivational-affective
So
matiz
atio
???
??
Dep
ressio
n
Expe
c
t
at
Anx
iety
Cat
astr
oph
An unpleasantsensory andemotional experience
associated withactual or potentialtissue damage, ordescribed in terms ofsuch damage.
InternationalAssociation for theStudy of Pain (IASP)1994, Kyoto ProtocolIASP 2008
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Classification of Pain
Physiologic / nociceptive:1 Pain arising from activation of nociceptors Caused by mild and short noxious impulses which usually relieved without any
medication or mild analgesics Example: Pinched, stung by mosquito
Inflammatory:2
Pain caused by injury to body tissues (musculoskeletal, cutaneus or visceral) Example: Pain due to inflammation, limb pain after fracture
Neuropathic:1 Pain arising as a direct consequence of a lesion or disease affecting the
somatosensory system Example: DPN, PHN
Psychogenic (functional):3 Pain due to abnormal responsiveness or function of the nervous system
without neurologic deficit or peripheral abnormality. Example: Fibromyalgia, irritable bowel syndrome
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fracture /Postoper
ative
Ongoing orimpending
injury
sprain
Inflamation /
Infection Infiltrated orcompressed
(tumors)
strangulated(scar
tissue)MuscleStretch
inflamed(infection
)
Type or Category of Pain
3.Psychogenic
clear thatno
somaticdisorder
is present
1. Nociceptive-
Inflamatorik
Caused byactivity
in neuralpathways
in responseto
potentiall
2.
Neuropathic
Initiated orcaused by
primarylesion ordysfunctio
nin the
nervouss s.
4. Mixed type
Caused by acombination of
both
primary injuryorsecondary
effects
The Assessment of the Patient with Pain, Steven Richeimer, M.D. Director USC Pain Management, USC Medical Center, Los Angeles,
Myofascial pain
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The Continuum of Pain1
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Dorsal Horn
Dorsal rootganglion
Peripheral sensoryNerve fibers
A
A
C
Largefibers
Smallfibers
There are Two Sensory AfferentNeurons
1. Large myelinated A fibers Very fast conduction velocity
Respond to innocuous stimuli2. Small myelinated A & C unmyelinated
fibers
Slow conduction velocity Respond to noxious stimuli
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Small-fiber sensory Large-fiber sensory Autonomic
-Burning pain
-Allodinia
-Hyperalgesia
-Hyperesthesia
-Paresthesia/dysesthesia
-Lancinating pain-Loss of pain &temp.
sensation
-Foot ulceration
-Loss of visceral pain
-Loss of vibration
-Loss of
proprioception-Loss of reflexes
-Slowed NCV
-Heart rateabnormalities
-Posturalhypotension
-Abnormal sweating
-Gastroparesis
-Neuropathic
diarrhea-Impotence
-Retrogradeejaculation
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Nociceptive afferentfiber
Normal Nerve Impulses Leadingto Pain
Noxiousstimuli Descendi
ngmodulati
on
Ascendi
nginput
Spinal
cord
Perceivedpain
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Nociception
Spinothalamic
tract
Peripheral
nerve
DorsalHorn
Dorsal rootganglion
Pain
Modulatio
n
Transduction
Ascendinginput
Descending
modulation
Peripheral
nociceptors
Trauma
Adapted from Gottschalk A et al.Am Fam Physician. 2001;63:1981, and Kehlet H et al.Anesth Analg. 1993;77:1049.
Perception
Transmission
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What is Inflammatory Pain?q Often classed along with acute pain as nociceptive,
refers to the spontaneous pain and tenderness feltwhen tissue is inflamed.
q Pain caused by injury to body tissues(musculoskeletal, cutaneous or visceral)
q Painful region is typically localized at the site of injury often described as throbbing, aching or stiffness .
q Usually time-limited and resolves when damagedtissue heals (e.g. bone fractures, burns and bruises)
q Can also be chronic (e.g. osteoarthritis, rheumatoidarthritis)
q Usually responsive to NSAIDs
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NOCICEPTIVE PAIN
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Prostaglandins
produced inresponse totissue injury;increasesensitivity ofnociceptor (pain)
Nociceptor thenreleases substance P,which dilates bloodvessels and increasesrelease ofinflammatorymediators, such as
Bradykinin (redness& heat)Substance P alsopromotesdegranulation of mastcells, which releasehistamine (swelling)
2
3
Pain-sensitive tissue
Painful stimulus
Prostaglandin
Substance P
Histamine
Mast cell
Bloodvessel
Bradykinin
Nociceptor
Substance P
2
3
1
Inflammation Tissue
1
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What is Neuropathic pain?
v Definition:
Pain arising as a direct consequence of a lesion or diseaseaffecting the somatosensory NERVE system
v Characterized by:
v Pain often described as shooting, electric shock-like or
burning.
v The painful region may not necessarily be the same as thesite of injury.
v Almost always a chronic condition (e.g. post herpetic
neuralgia, post stroke pain)v Responds poorly to conventional analgesics
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IASP Classifications:Peripheral Neuropathic and CentralNeuropathic Pain
Loeser JD, Treede RD. The Kyoto Protocol of IASP Basic Pain Terminology. Pain 2008;137:473-477.
Neuropathic pain
Pain arising as a direct consequenceof
a lesion or disease affecting thesomatosensory system
Peripheralneuropathic painPain arising as a direct
consequence ofa lesion or disease affecting the
peripheralsomatosensorysystem
Central neuropathic painPainarising as a direct consequence ofa lesion or disease affecting thecentralsomatosensory system
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Pathophysiology of Neuropathic Pain
NeP
Centralmechanisms
Peripheralmechanisms
PeripheralNeuron
hyperexcita
bility
Loss ofinhibitory
controlsCentral Neuron
hyperexcitability(central
sensitization)
Abnormal
Discharges
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Development of Neuropathic Pain
Woolf and Mannion. Lancet
Neuropathic pain
Spontaneouspain
Stimulus-evokedpain
Mechanisms
Metabolic Traumatic
ToxicIschemic
Hereditary
Compression
Infectious
Immune-related
Syndr
ome
Symptoms
Pathophys
iology
Etiology
Nerve damage due to:
Si d S t f N thi
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Signs and Symptoms of NeuropathicPain
Delayed, explosive response to any painful
stimulus
Hyperpathia2
Increased pain sensitivity e.g. pinprick, cold,heat
Hyperalgesia3
Painful in response to a non-nociceptivestimuluse.g. warmth, pressure, stroking
Allodynia3
Stimulus-evokedsymptoms
Abnormal, not unpleasant sensations e.g.tingling
Parasthesias2
Abnormal unpleasant sensationse.g. shooting, lancinating, burning
Dysesthesias2
Persistent burning, intermittent shock-like orlancinating pain
Spontaneouspain1
Spontaneoussymptoms
Description (example)Sign/Symptom
1. Baron. Clin J Pain. 2000;16:S12-S20.2. Merskey H et al. (Eds) In: Classification of Chronic Pain: Descriptions of Chronic Pain Syndromes and Definitions of Pain Terms.1994:209-212.
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The Inter-Relationship BetweenPain, Sleep, and Anxiety / Depression
Nicholson and Verma. Pain Med. 2004;5 (suppl.
Pain
Sleepdisturbances
Anxiety &Depression
Functionalimpairment
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Hyperalgesia & Allodynia
Gottschalk A et al.Am Fam Physician.
Injury
Pain
Intensit
y
1
0
8
6
4
Stimulus
Intensity
Normal
PainRespo
nse
Allodynia
Hyperalgesia
Hyperalgesiaheightened sense ofpain to noxious stimuli
Allodyniapain
resulting fromnormally painlessstimuli
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Normal
PeripheralTissue and
Nerves
FUNCTIONAL PAIN
AbnormalCentral
Processin
Spontaneous PainPainHypersensitivity
Brain
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Heat
Cold
Intense
Force
Mechani
cal
Heat
Cold
PainAutonomicResponse
Witdrawal Reflex
Nociceptor sensoryneuron
NOCICEPTIVE PAIN
Noxius PheripheralStimuli
Spinalcord
Brain
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Macrophage
NeutrophilGranulocyte
Tissue
Damage
Spontaneous PainPain Hypersensitivity
ReducedThreshold : Allodynia
IncreasedResponse : Hyperalgesia
Nociceptor sensoryneuron
INFLAMMATORY PAIN
Inflammation
Spinalcord
Mast Cell
Brain
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Spontaneous PainPainHypersensitivity
Peripheral NerveDamage
NEUROPATHIC PAIN
Spinalcord
Injury
Brain
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Three broad categories of free endings orreceptors are recognized:
Mechanoreceptors A- and C fibers
Thermoreceptors C fibers.
polymodal nociceptors majority of C fibersnoxious or tissue-damaging stimuli
mechanical
Thermal
chemical mediators (inflammation)
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The 3L Approach to Diagnosis
LISTEN
LOCATE LOOKNervous system
lesion / dysfunctionSensory
abnormalities,pattern recognition
Patient verbal descriptors,Q & A
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Pain Assessment Scales
Uni-DimensionalScale
Multi-DimensionalScale Only measures pain
intensity
Appropriate for acutepain
The most commonscale used inoutcome assessment(Analgesic efficacy)
Both intensity(severity) andunpleasantness(affective)
Appropriate forchronic pain
Research/pathophysiology Should be used in
clinical outcomeassessment
Verbal Rating Scale (VRS)None, mild, moderate,
severeNumeric Rating Scale
(NRS)Visual Analo Scale VAS
McGill Pain Questionnaire(MPQ)The Brief Pain Inventory
(BPI)The Memorial Pain
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Uni-Dimensional Pain AssessmentScales
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Ph t hi /N i P i S l
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Photographic/Numeric Pain Scale
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Multi-Dimensional Pain
Assessment Scales
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Quicker and easier
Well establishedreliability in cancer,arthritis, and AIDs.
Sensory, affectiveand functionalstatus
Useful fortreatment response
Takes up to 15 min
Good choice forpatients withprogressive disease
Worst
Lea
st
Average
RightNow
Treatment
Relief
GeneralActivity
Mood
Walkingability
Normalwork
Relation withother people
Sleep
Enjoymentof life
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Rapid: Sensory and affective Reliable in Cancer
ID PAIN S i l h l
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ID PAIN : Screening tool to helpdifferentiate nociceptive fromneuropathic pain
Neuropathic pain screening questionnaire
A multicenter study
Patients (N = 586) with non-headache chronic painA second multicenter study (N = 384) evaluated
reliability and validity.
89-item questionnaire 6 items
ID Pain appeared to accurately indicate thepresence of a neuropathic component of pain (c74,2%)
Portenoy R et al. Curr Med Res Opin. 2006 Aug;22(8):1555-65.
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Mark Yes to the following items that describe your
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Mark Yes to the following items that describe yourpain over the past week andNo to the ones that do not.
If patients have more than one painful area,they are to consider the one area that is most
relevant to them when answering the ID Pain
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Location: Patient ornurse marks drawing
Intensity: Patient ratesthe pain. Scale Used:
Quality: Use patints words, e.g. prick,ache, burn, sharp, hot etc.
Onset, duration, variations,rhythms (spontaneus orevoked):Manner of
expressingWhat
(Pain
Behaviou
Wh t
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What causes orincreases thepain?Effect of pain: (Note decreasedfunction, decreased quality of life)
Othercommen
ts:Plan:
Accompanying symptoms(eg nausea)SleepAppetitePhysicalactivityRelation with others (egirritability)Emotion (eg anger,suicidal, crying)ConsentrationOther
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Past Medical History
1.Medical related problems
2.Problems potentially affect the choice ofpain treatments?
3.Prior or current substance abusehistory?
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Current Medications
1.Dosage and pattern of use
2.Effectiveness
3.Drug tolerance
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Acute Pain (McQuay & Moore, 1999)TREATMENT
METHODSRemove the
causeOf pain
Medication
Regional
analges
ia
Physicalmethods
Psychological
approach
esSurgerySplinting
Low TechNerve blocksLocalanaesthetic
opioid
HighTechEpiduralinfusion
Localanaesthetic
physiotherapymanipulation
TENSAcu unct
relaxati
onpsychopro-phylaxis
hypnosis
Non-opioidAspirin &othersNSAIDS
Paracetamolcombination
OpioidMorphineothers
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ACUTE AND SEVERE
PAINRecommendedInitial Dosing
TraditionalInitial Dosing No Analgesia
Some Analgesia
Pain/AnalgesiaThreshold
SignificantSedation
SignificantToxicity
Analgesic
ANALGESIC MEDICATIONS
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ANALGESIC MEDICATIONS
PRIMARY ANALGESICS
Acetminophen
Prostaglandin synthesis inhibitors
Salicylates
Traditonal NSAIDs
COX-2-selective NSAIDs (coxibs)
Tramadol
Opioids
Traditional
Mixed
ADJUVANT MEDICATIONS
Antidepressants
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Chronic Pain (McQuay & Moore, 1999)
TREATMENT METHODS
Analgesics Block nervetransmission
Alternatives
Conventional
NSAIDParasetamolto opioid
Unconventionalantidepressant
anticonvulsantothers
ReversibleLocalanaesthetic
steroid
IrreversiblesurgeryNerve
destruction
Stimulators
AcupunctureHypnosisPsychology
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