Chronic Pains- clinician’s perspective

Dr R Jayamaha MBBS.MD.FIPP

16/24/16 10:06

PM

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Case Scenario A 61 year old man presented to our CPC with Severe low back pain (8/10) going down to Left > Right L/L for 4-5years duration.

He has been treated by many doctors including neurological and neurosurgical specialists. Failing all possible medical treatments, he was asked to get a spinal surgery done. However patient declined that option.

When he presented, 1. he had no red/yellow flags and 2. had no neurological impairment but only pain issues. 3. PACE/FAIR test was negative. SLRT B/L > 70 0

4. He already had two MRI scans of spine done and diagnosed as having two bulging lumbar discs without central or lateral canal stenosis.

Sciatica

Sx Tx Refused

Sx NOT indicated??

•Why do we need to talk about chronic pains (Non-malignant)…?

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Chronic Pain Prevalence in the USA…

• An estimated 50 million to 75 million people live with chronic pains (defined as constant pain lasting at least three months.)

• 22% of all primary care patients have chronic pains.

In Sri Lanka…

 Period of data collection: 24/01/2012 – 03/05/2012 3months No of patients assessed: 536 Ages : 16 – 90yr <20yr – 0.75%

20-50 – 23%50-80 – 74%>80 - 2.25%

Male/ Female: 1/3 Patients with chronic pain complains : 67% Other complains: 33% Systems responsible:

CVS : 17%NS : 46%MSK : 36%Other : 1%

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• Is chronic pain a NCD?• Do all these NCDs have a

common link?

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Inflammation

ImmuneDefense

Resolution

Basal Homeostasis

Classical, Acute,Infectious Response

Im

mun

e Re

actio

n

Chronic Allostasis

Modern, Chronic.Non-infectious Response

Disease‘Dys-MetabOlism’

‘Meta-flammation’

Oxidative stress

InsulinResistance

Lifestyle/Environmental‘Inducer’

‘Agent’ (LDL)

MicrobialPathogen/‘Antigen’

Forms of Inflammation…

Egger G, Dixon J. Obes Rev 2009 )

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Affected Organs

• Endothelium(atherosclerosis)

•Lung(COPD)

• Brain(Alzheimer’s/Dementia)

• Joints(arthritis)

• Bowel (IBD)

• Neuron/Glia(neuropathic/‘gliapathic’? pain)

Range of ‘Metaflammatory’ Effects…

Ref: Libby P. Nature, 2010

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Obesity and chronic pains are linked biologically through ‘metaflammation’ with glia playing a major role.

Metafammation is lifestyle related.

Hence chronic neuropathic (‘gliapathic’?) pain is lifestyle-related – leading to the conclusion that: Lifestyle changes need to be incorporated into any new ‘holistic’ paradigm for chronic pain management.

• What is the definition of PAIN?• When do you call it CHRONIC?

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Definition of Pain

• “An unpleasant sensory and emotional experience associated with actual or potential tissue damage, or described in terms of such damage, or both.”

International Association for the Study of Pain ( IASP:2001

Chronic >3/12

Pathophysiology of Pain

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DINC

What will happen to neural pathways when pain becomes

CHRONIC?

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Pathophysiology of Pain

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DINC

Increase in 1. Area 2. Severity 3. Duration

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1. Increased intensity of pain.2. Increased area of pain.3. Increased duration of pain.4. Allodynia5. Decreased tolerability to pain.6. Development of psychological problems

(e.g.. depression due to decreased serotonin level).

7. SNS mediated: redness, edema, painful joint movements, decreased skin temperature, fall of hairs. ”Complex Regional Pain Syndrome”

8. Neurological deficit in the area of pain

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What Happens When Pain Becomes Chronic?

Sensitization is a phenomenon of inappropriate or disproportionate response

to normal stimulus

Peripheral Sensitization Central Sensitization

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Categorising PainsAcute Pain /Physiological Pain

1. Mostly Nociceptive• Mostly Symptom of a disease

• Treatment of diseases cures pain & it is self-limiting.

• Simple relationship between pain and tissue damage

• Proportionate to the clinical finding

Chronic Pain /Pathological Pain

1. Mostly Neuropathic • Mostly a disease by itself (a disease of

nervous system).• Difficult to treat & sustaining.

Our aim is to control but cure• Dissociated relationship between pain

and tissue damage• Disproportionate to the clinical finding

True for Acute Pain which is an ALARM.

However Chronic Pain can be a false alarm and it may be a

disease.

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In Treating Pains…

Source + Pain Control •Non Pharmacological methods•NSAIDs/Paracetamol •Tramadol/Opioids•Regional analgesia

Correcting neuropathy/sensitizationTreatment for peripheral sensitization Na-Channel blocker, Ca-Channel blockerTreatment for central sensitization

NMDA antagonist, Ca-Channel blocker, Opioids, drugs inhibiting Sub P, drugs enhances inhibitory synapses.

Restoration of descending neuronal inhibitory Control (DINC)

Tramadol OR Tricyclics /SNRI

Cure

Control

What are the important aspects of managing Chronic Pains (Non Malignant)?

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1. Diagnosis of Pain AETIOLOGY

2. ASSESSMENT of Pain 1.Severity ,Type, Location/origin

(Somatic/Visceral/Referred)

2.Pain is DYNAMIC - reassess

3. Control Pain and Treat Aetiology in a

TIMELY MANNER.

4. Treatment of COMORBIDITIESeg. Psychological issues/ Other NCDs

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• Non-Self Report Measurement (Respiratory and cardiovascular changes as well as changes in expression and movements)

• Self-Report Measurement (Numerical or adjective ratings and visual analogue scales)

Pain Severity Assessment…

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In Controlling Chronic Pain….MUTIMODAL/ INTER-DISCIPLINARY APPROACH

Cure sometimes, Treat often,

Comfort always.

-Hippocrates

– Dysfunction in family, vocational, and social life

– Mental and physical suffering

– Increased suicide rates

– Extensive, costly, unhelpful work-ups and treatment

– Increased disability costs

What are the treatment modalities to control chronic pains?

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Modalities of Treatment

• Non Invasive–Non pharmacological–Pharmacological

• Invasive –Interventional Pain Procedure–Surgeries

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How do you combine these treatment modalities to control chronic pains?

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•Evidence & Experience on disease entity

•Non Invasive–Non pharmacological–Pharmacological

• Invasive –Interventional Pain Procedure–Surgeries

Algorithm???•Analgesic Ladder•Analgesic Platform

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Non-pharmacological methods

Non-opioids

Weak opioids +/- non-opioids

Strong opioids

Recovery?

Neurosurgical Procedures/Surgical Destruction of Neuro-pathways

WHO Model…

+/- adjuvant

Cancer Pains

Chronic Non-Cancer Pains

Missing linkBetween Med & Sx Mx

Strong Opioid can not be given to non cancer chronic pains as they cannot be rehabilitated and can get addicted. So that the gap is broader

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Recovery?

Lest Your Patient Suffer When your Pharmacological Armamentarium is empty…???...

World of Misery

Non-opioids

Weak opioids +/- non-opioids

Strong opioids

Operation

Non-pharmacological methods

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Weak opioids +/- non-opioids

Recovery?

Interventional Pain Management Procedures

IPM

Non-opioids

Strong opioids

Surgical Tx

Non-pharmacological methods

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Interventional Pain Management Procedures

•Minimally invasive procedures done under local anesthesia and image guidance (X Ray/ US) which are capable of detecting pain generators and treating them giving permanent/long term pain relief by stopping nociceptive inputs and/or correcting neuropathy.

•They fill the gap between pharmacologic management of pain & more invasive operative procedure. (The missing link)

• Injections – Local/Spinal/ ITDD» Dry needling» LA/ Steroids /Ozone/

Prolotherapy/Botox» ITDD systems» Vertibroplasty/ kyphoplasty

• Ablation – Cryo/Radiofrequency• Electro-stimulation – Peripheral /

spinal cord StimulationDiagnosis and management of…• Non Spinal

– MFPS– Joints/Enthesis– Peripheral Nn– Sympathetically mediated/ Maintained pains by

Ganglion BLK• Spinal

– Facet Joint– Disc– Vertibrae– Intraspinal

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A -Physiotherapy and physical therapy | B -Mind–body integration (e.g. yoga, meditation and religious support) | C -Hypnosis and relaxation therapy | D -Acupuncture | E -Chiropractic | F -External rub/lotions | G -Other CAM options (Tai chi, Tui Na) |

H -Muscle relaxants (e.g. cyclobenzaprine, baclofen and dantrolene) | I -Injectable agents (steroids, local anaesthetics) | J -Interpersonal reinforcement (e.g. support group) |

K -Anticonvulsants (e.g. gabapentin, pregabalin and lamotrigine) | L -Antidepressants (e.g. tricyclics, SSRI, SNRI) | M -Compounds that act synergistically with opioids like cannabinoids (nabilone) | N -Cognitive behaviour therapy and psychological counselling

O -Surgical and neurosurgical procedures (e.g. spinal cord stimulation, deep brain stimulation, spinal delivery of opioids, ganglion ablation by phenol or electrofrequency, sympathectomy)

Lawrence Leung MBBChir(Cantab), MFM(Clin), CCFP, FRACGP, FRCGPVOLUME 4 • NUMBER 3 • SEPTEMBER 2012 JOURNAL OF PRIMARY HEALTH CARE

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•What are the commonly encountered chronic pain issues?

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• Spinal Pains• Headaches• Shoulder pains• Lower Limb Degenerative

arthritis• Painful neuropathies• Enthesopathies like G/E ,

T/E & Plantar Fasciitis • Carpal Tunnel XD

In Our Clinic

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Low Back Pain

A 61 year old man presented with Severe low back pain

(8/10) going down to Left > Right L/L for 4-5years duration.

He has seen many doctors including neurological specialists.

In the end, he was asked to get a spinal surgery done but he

was not consenting for that. He was prescribed with all

possible pain killers over the past with almost no relief.

When he presented, he had no red/yellow flags and had no

neurological impairment but only pain issues. PACE/FAIR test

was negative. He already had two MRI scans of spine done

and diagnosed as having two bulging lumbar discs without

central or lateral canal stenosis.

Sciatica

Sx Tx Refused

Sx NOT indicated??

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Facts ……1. Red and Yellow flags (Waddell

sings) of Spinal pains.2. Spinal Pains originate from

multiple sites (multiple pain generators)

3. Clinical findings and Investigations (Imaging) should be correctly correlated

4. Surgical interventions may not be the 1st line treatment for spinal pains without neurological deficit

5. Evidence/ Experience on various interventions?...

Therefore derangement of one structure will create multiple pain generators in the back!

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When assessing this patient…we found multiple pain generators….

1.Myofascial low back pains with trigger points

2.B/L Sacro-illiac dysfunction3.Facet Joint Arthritis 4.Discogenic Low back Pain with L/Sciatica

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Management1. Analgesics (Nociceptive + Neuropathic)2. Physical Therapy & Counseling3. Trigger point injection4. Sacro-illiac Joint injection5. Facet Denervation 6. Selective Nerve Root Block B/L - L4, L57. Dekompressor discectomy

Take Home Message!

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• Spinal Pains (Back Pain)…Neck Pains• Headaches• Shoulder pains• Lower Limb Degenerative arthritis• Painful neuropathies• Enthesopathies like G/E , T/E & Plantar

Fasciitis • Carpal Tunnel XD

There is still a lot of hopes…..

…for those whose pain issues are not addressed by drug treatment alone…

Thank Youwww.painclinic.lk

http://www.painclinic.lk/wp-content/uploads/2012/11/Chronic-Pains.pdf