PAIN MANAGEMENT

CONTENTS

• PAIN DEFINITION• CLASSIFICATION OF PAIN• PAIN INTENSITY• TIME OF PAIN• PAIN ANALYZER STRUCTURE• TREATMENT PRINCIPLES AND METHODS

DEFINITION

• Pain is an unpleasant sensory and emotional experience associated with actual or potential tissue damage, or described in terms of such damage (according to IASP)

CLASSIFICATION OF PAIN (TYPES) 1. Nociceptive pain: It represents normal response to noxious insult or injury of tissues. It can be of 2 main groups: a) Somatic: musculoskeletal, cutaneous b) Visceral: hollow organs and smooth muscles

2. NEUROPATHIC PAIN: pain initiated or caused by a primary lesion or disease in the somatosensory nervous system.

oSensory abnormalities range from deficits perceived as numbness to hypersensitivity (hyperalgesia or allodynia), and to paresthesias such as tingling.

oExamples include, but are not limited to, diabetic neuropathy, postherpetic neuralgia, spinal cord injury pain, phantom limb (post-amputation) pain, and post-stroke central pain.

3. INFLAMMATORY PAIN: a result of activation and sensitization of the nociceptive pain pathway by a variety of mediators released at a site of tissue inflammation.

o The mediators that have been implicated as key players are proinflammatory cytokines such IL-1-alpha, IL-1-beta, IL-6 and TNF-alpha, chemokines, reactive oxygen species, vasoactive amines, lipids, ATP, acid, and other factors released by infiltrating leukocytes, vascular endothelial cells, or tissue resident mast cells

o Examples include appendicitis, rheumatoid arthritis, inflammatory bowel disease, and herpes zoster.

PAIN INTENSITY

• Pain Intensity can be broadly categorized as: mild, moderate and severe. It is common to use a numeric scale to rate pain intensity where 0 = no pain and 10 is the worst pain imaginable:

• Mild: <4/10• Moderate: 5/10 to 6/10• Severe: >7/10

PAIN DURATION

• Acute pain: pain of less than 3 to 6 months duration• Chronic pain: pain lasting for more than 3-6 months, or persisting beyond the course of an acute disease, or after tissue healing is complete.• Acute-on-chronic pain: acute pain flare superimposed on underlying chronic pain.

STRUCTURE OF THE PAIN ANALYZER

Treatment principles and methods1. NONPHARMACOLOGIC INTERVENTION. This involves two main principles: cognitive-behavioral and physical modalities(techniques) a) Cognitive-behavioral: approaches include such techniques as passive relaxation with mental imagery, distraction, progressive relaxation, biofeedback, hypnosis, and music therapy. HOW IT WORKS Cognitive-behavioral strategies can help patients understand more about their pain, alter their pain behavior and coping skills, and change their perception of pain or even forget about their pain.

b).Physical techniques include applications of heat and cold, massage, exercise, and transcutaneous nerve stimulation.1. Heat application(thermotherapy): Heat stimulates heat-sensing nerves in the skin to send messages to the brain, which sends signals back to the heated area to relax muscles and increase blood flow. The theory is that the thermo-receptor signals block the pain signals so that you aren't as aware of the pain. Also, increased blood flow due to the heat brings nutrients, oxygen and white blood cells to the area to clean up the damage and stimulate healing.

2. COLD APPLICATION (CRYOROTHERAPY)

Physiological Effects of Cold Therapy Systemic Vasoconstriction Piloerection Shivering Local Temperature sensitive nerve endings send signals to hypothalamus Local vasoconstriction Decreased capillary refill Decreased cellular metabolism

Cold decreases pain by numbing the area and can also be very effective against Inflammatory pain sensations due to it’s systemic and local vasoconstriction effect and decrease metabolism.

3.MASSAGE AND EXERCISE

Massage and exercise have the same effect of alleviating muscle tension thereby reducing the neural activity (tone) of the muscle. This reduces transmission of pain sensations to the brain higher centers.

3.Transcutaneous Electrical Nerve Stimulation (TENS)

Transcutaneous electrical nerve stimulation (TENS) is a therapy that uses low-voltage electrical current for pain relief.

HOW IT WORKS

When the current is delivered, some people experience less pain. This may be because the electricity from the electrodes stimulates the nerves in an affected area and sends signals to the brain that block or "scramble" normal pain signals.

OTHER METHODS OF PAIN MANAGEMENT

1. The use of Analgesics: they can be of 3 types: - non-opioids (acetaminophen and the non-steroidal anti-inflammatory drugs). - opioid (hydromorphone, hydrocodone, oxycodone, fentanyl etc) - adjuvant analgesics(Dexamethasone, Predsinone etc)

2. INTERVENTIONAL PAIN MANAGEMENT

• What and When (indications): Injection procedures and minimally invasive surgical procedures are often used in combination with medications, rehabilitation and psychological treatments to treat or evaluate patients with acute and chronic, non-cancer and cancer pain.

o Diagnostic injections to selectively target potential sources of pain and differentiate the nociceptive pain generating structure when the cause or source of pain is not obvious, e.g., non-radiating neck or back pain.

o Treatments such as epidural steroid injections (for radiating limb pain from herniated disc or spinal stenosis), and vertebroplasty (for trunk pain in patients with vertebral compression fractures).

o Intrathecal drug delivery via implanted pump in certain situations when systemic analgesia is not tolerated

o Spinal cord stimulation to relieve pain and/or spasticity in patients who are refractory to systemic medication and have exhausted other treatments.

o Neurolysis by radiofrequency or surgery to destroy nerve structures; reserved for patients with a limited life expectancy.

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