כאב. silviu brill md director, pain medicine center, tel aviv-sourasky medical center
TRANSCRIPT
כאבכאב
Silviu Brill MDSilviu Brill MD
Director, Pain Medicine Center, Director, Pain Medicine Center, Tel Aviv-Sourasky Medical CenterTel Aviv-Sourasky Medical Center
PAIN - EpidemiologyPAIN - Epidemiology““We don’t have a lot of statistics about pain, but We don’t have a lot of statistics about pain, but
the ones we do have are frightening.” the ones we do have are frightening.”
Chronic pain is the most common cause of Chronic pain is the most common cause of disability, partially or totally disabling disability, partially or totally disabling 50 50 million people in USmillion people in US
‘Chronic Pain in Europe’ Survey (n=46,394)
__________________________________________________________________________
18%
18%
19%
21%
23%
26%
27%30%
0% 100%
11%
13%
13%
15%
16%
16%
17%17%
0% 100%
Norway (n=2,018)
Poland (n=3,812)
Italy (n=3,849)
Belgium (n=2,451)
Finland (n=2,004)
Austria (n=2,004)
Sweden (n=2,563)
Netherlands (n=3,197)
Germany (n=3,832)
Israel (n=2,244)
Denmark (n=2,169)
Switzerland (n=2,083)
France (n=3,846)
UK (n=3,800)
Ireland (n=2,722)
Spain (n=3,801)
Breivik et al. Eur J Pain 2006;10(4):287-333.Breivik et al. Eur J Pain 2006;10(4):287-333.Breivik et al. Eur J Pain 2006;10(4):287-333.Breivik et al. Eur J Pain 2006;10(4):287-333.
Overall Prevalence Overall Prevalence 19%19%Overall Prevalence Overall Prevalence 19%19%
Effects of Chronic PainEffects of Chronic Pain
Physical FunctioningPhysical FunctioningAbility to perform Ability to perform activities of daily livingactivities of daily living
Sleep disturbanceSleep disturbance
KinetophobiaKinetophobia
Psychological Psychological MorbidityMorbidityDepressionDepression
Anger, frustrationAnger, frustration
Loss of self-esteemLoss of self-esteem
AnxietyAnxietySocial ConsequencesSocial Consequences
Relationships with Relationships with family and friendsfamily and friends
Intimacy/sexual activityIntimacy/sexual activity
Social isolationSocial isolation
Loss of workLoss of work
National National ConsequencesConsequencesHealthcare costsHealthcare costs
Lost workdaysLost workdays
DisabilityDisability
OverviewOverview
DefinitionDefinition
Acute vs. Chronic PainAcute vs. Chronic Pain
Nociceptive vs. Neuropathic PainNociceptive vs. Neuropathic Pain
DiagnosticDiagnostic
Pathophysiology Pathophysiology
Treatment Treatment
הגדרת הכאבהגדרת הכאבINTERNATIONAL ASSOCIATION FOR INTERNATIONAL ASSOCIATION FOR
THE STUDY OF PAINTHE STUDY OF PAIN
חוויה חוויה כאב הוא כאב הוא תחושתית ורגשית לא תחושתית ורגשית לא
שקשורה בנזק שקשורה בנזק נעימהנעימהרקמתי אמיתי או רקמתי אמיתי או
פוטנציאלי.פוטנציאלי.
Classifications of PainClassifications of PainAcute
Chronic
Duration
Nociceptive
Neuropathic
Pathophysiology
The Continuum of PainThe Continuum of Pain
<1 month
Time to resolution
3-6 months
AcutePain
ChronicPain
• Usually obvious tissue damage
• Increased nervous system activity
• Pain resolves upon healing
• Serves a protective function
• Pain for 3-6 months or more
• Pain beyond expected period of healing
• Usually has no protective function
• Degrades health and function
Insult
כאב כרוני לעומת כאב אקוטיכאב כרוני לעומת כאב אקוטיכאב כרוני לעומת כאב אקוטיכאב כרוני לעומת כאב אקוטיכאב אקוטיכאב אקוטיסימפטוםסימפטוםקצר טווחקצר טווח
סימן אזהרהסימן אזהרהחרדהחרדה
תגובה טובה לטיפולתגובה טובה לטיפולטיפול יחידטיפול יחיד
כאב כרוניכאב כרונימחלהמחלה
ארוך טווחארוך טווחאזעקת שוואאזעקת שווא
דיכאוןדיכאוןתגובה בעייתית לטיפולתגובה בעייתית לטיפול
גישה רב-תחומיתגישה רב-תחומית
Types of Chronic PainTypes of Chronic Pain
Nociceptive PainNociceptive Pain
OsteoarthritisOsteoarthritis
Deg. Spine Dis.Deg. Spine Dis.
RARA
Polymyal. rheumPolymyal. rheum
PancreatitisPancreatitis
Neuropathic PainNeuropathic Pain
Diabetic neuropathyDiabetic neuropathy
PHNPHN
Traumatic injuryTraumatic injury
MSMS
Post stroke painPost stroke pain
Dysfunctional PainDysfunctional Pain
FibromyalgiaFibromyalgia
Chronic headachesChronic headaches
IBSIBS
Burning mouth Burning mouth synd.synd.
Chronic PainChronic Pain
… … is not prolonged acute painis not prolonged acute pain
… … must be considered and treated as a must be considered and treated as a diseasedisease
““Pain is a more terrible lord of mankind Pain is a more terrible lord of mankind than even death himself”than even death himself”
Albert SchweitzerAlbert Schweitzer
P a i nP a i nNociceptiveNociceptiveNeuropathicNeuropathicInflamatoryInflamatoryIschemicIschemicIdiopathicIdiopathic
IASP DefinitionsIASP Definitions
Neuropathic painPain initiated or caused by a primary
lesion or dysfunction in the nervous system
Peripheral neuropathic painPain initiated or caused by a primary
lesion or dysfunction in the peripheral nervous system
Central neuropathic painPain initiated or caused by a primary
lesion or dysfunction in the central nervous system
Pain Types: Nociceptive vs Pain Types: Nociceptive vs NeuropathicNeuropathic
Nociceptive PainNociceptive PainArises from activation of Arises from activation of nociceptorsnociceptors (pain receptors) (pain receptors)
ProportionalProportional to degree of activation of afferent pain fibers to degree of activation of afferent pain fibers
Acute, occasionally chronic Acute, occasionally chronic
EXAMPLES: EXAMPLES: - Postoperative pain- Postoperative pain
- Mechanical low back pain- Mechanical low back pain
- Sports/exercise injuries- Sports/exercise injuries
- Sickle cell crisis- Sickle cell crisis
1) 1) Somatic Pain Somatic Pain 2) 2) Visceral PainVisceral Pain- Well localized - Well localized - Poorly localized, few nociceptors - Poorly localized, few nociceptors
- Aching, gnawing, sharp, - Aching, gnawing, sharp, - Crampy, colicky, throbbing, pressure-like, deep - Crampy, colicky, throbbing, pressure-like, deep achingaching
throbbing, pressure-like throbbing, pressure-like - Autonomic: diaphoresis, hypertension, tachycardia- Autonomic: diaphoresis, hypertension, tachycardia
Neuropathic Pain Prevalence Neuropathic Pain Prevalence Ranges From 6.0-7.7%Ranges From 6.0-7.7%
0
1
2
3
4
5
6
7
8
9
10
UK France Germany Spain
% o
f patients
Patients with axial back pain with a neuropathic component included in the surveyNeuropathic Pain Patient Flow Survey
7.5%
6.4%6.0%
7.7%
CRPSCRPS
ExamplesPeripheral• Postherpetic neuralgia• Trigeminal neuralgia• Diabetic peripheral neuropathy• Postsurgical neuropathy• Posttraumatic neuropathyCentral• Poststroke painCommon descriptors2
• Burning• Tingling• Hypersensitivity to touch or cold
Examples • Pain due to inflammation• Limb pain after a fracture• Joint pain in osteoarthritis• Postoperative visceral pain Common descriptors2
• Aching• Sharp• Throbbing
Examples • Low back pain with
radiculopathy• Cervical
radiculopathy• Cancer pain• Carpal tunnel
syndrome
Mixed PainPain with
neuropathic and nociceptive components
Neuropathic PainPain initiated or caused by a
primary lesion or dysfunction in the nervous system (either peripheral or
central nervous system)1
Nociceptive PainPain caused by injury to
body tissues (musculoskeletal,
cutaneous or visceral)2
Signs and Symptoms of Neuropathic Signs and Symptoms of Neuropathic PainPain
Sign/Symptom Description (example)
Spontaneous symptoms
• Spontaneous painPersistent burning, intermittent shock-like or lancinating pain
• DysesthesiasAbnormal unpleasant sensations e.g. shooting, lancinating, burning
• ParasthesiasAbnormal, not unpleasant sensations e.g. tingling
Stimulus-evoked symptoms
• AllodyniaPainful response to a non-painful stimulus e.g. warmth, pressure, stroking
• HyperalgesiaHeightened response to painful stimulus e.g. pinprick, cold, heat
• HypoesthesiaDelayed, explosive response to any painful stimulus
InnocuousInnocuous NoxiousNoxious
Stimulus IntensityStimulus Intensity
Pai
nP
ain
Sen
sati
on
Sen
sati
on
00
1010
NormalNormalPainPain
CurveCurve
AllodyniaAllodynia
HyperalgesiaHyperalgesia
Shift toShift toleft with left with
tissuetissueinjuryinjury
Development of Development of Neuropathic PainNeuropathic Pain
M. Downing
""מדידת כאבמדידת כאב""
Mild
Moderate
Severe
Pain Intensity
Non-Opioids+Adjuvants
Weak-Opioids+ Non-Opioids+Adjuvants
Strong-Opioids+ Non-Opioids+Adjuvants
Pain TreatmentPain Treatment
The WHO Analgesic LadderThe WHO Analgesic Ladder
1. Mackin G.A. J Hand Ther. 1997;10:96-109. 2. Gobal H. et al,Clin Drug Invest 1995;10:208-214. 3. Harati Y. et al, Neurology 1998;50:1842-1846
TransductionTransduction
TransmissionTransmission
ModulationModulation
PerceptionPerception
Emotion
A multifaceted model for the A multifaceted model for the components of paincomponents of pain
suffering
pain
nociception
Pain behavior
””Prevalence of chronic pain Prevalence of chronic pain after surgery”after surgery”
Prevalence of chronic pain following Prevalence of chronic pain following surgerysurgery
Type of surgeryType of surgery Perkins &KehletPerkins &Kehlet
AnesthesiologyAnesthesiologyMacraeMacraeBrit JAnaesBrit JAnaes
BreastBreast 11-49%11-49% 23-49%23-49%
ThoracotomyThoracotomy 22-67%22-67% 5-67%5-67%
CholecystectomyCholecystectomy 3-56%3-56% 3-27%3-27%
Inguinal hernia Inguinal hernia 0-37%0-37% 15-63%15-63%
VasectomyVasectomy 0-37%0-37%
Risk factors for Risk factors for chronchroniicc pain after pain after surgery or traumasurgery or trauma
Severe acute pain after surgery or trauma Severe acute pain after surgery or trauma Pain before surgery Pain before surgery Immobilization Immobilization after trauma or surgeryafter trauma or surgeryRe-operationRe-operationRadiation and cytotoxic drugsRadiation and cytotoxic drugsGenetics!Genetics!
How do we build an algorithmHow do we build an algorithm
NNT (Number needed to treat)NNT (Number needed to treat)
EBMEBM
Safety Profile NNH (Number needed to Safety Profile NNH (Number needed to harm)harm)
Side effectSide effect
PricePrice
RegistrationRegistration
Treatment of Chronic Neurophatic Treatment of Chronic Neurophatic PainPain
1) Pharmacologic1) Pharmacologic
2) Physical and occupational therapy2) Physical and occupational therapy
3) Alternative approaches3) Alternative approaches
5) Cognitive behavioral strategies, relaxation 5) Cognitive behavioral strategies, relaxation techniquestechniques
6) Interventional procedures6) Interventional procedures
Multi Disciplinary Integrative Multi Disciplinary Integrative approachapproach
Barriers to Optimal Pain Management Barriers to Optimal Pain Management
Factors related to health care professionalsFactors related to health care professionals – inadequate knowledge of analgesic pharmacology and pain therapy inadequate knowledge of analgesic pharmacology and pain therapy – poor pain assessment poor pain assessment – concern about regulatory oversight concern about regulatory oversight – fear of patient addiction fear of patient addiction – concern about the side effects of analgesics concern about the side effects of analgesics – concern about development of tolerance to analgesics concern about development of tolerance to analgesics
Factors related to patientsFactors related to patients – reluctance to report pain reluctance to report pain – reluctance to take pain medications reluctance to take pain medications
Factors related to the health care systemFactors related to the health care system – low priority given to pain management low priority given to pain management – inadequate or inappropriate provisions for reimbursement inadequate or inappropriate provisions for reimbursement
– restrictive regulation of therapeutic agents that are controlled substancesrestrictive regulation of therapeutic agents that are controlled substances
הולכת הכאבהולכת הכאב
Dysregulation of 5-HT and NE Dysregulation of 5-HT and NE in the brain are strongly in the brain are strongly associated with depression.associated with depression.
The brain may perceive an The brain may perceive an amplified pain signal due to the amplified pain signal due to the imbalance of 5-HT and NE in imbalance of 5-HT and NE in the spinal cord.the spinal cord.
This may explain why physical This may explain why physical symptoms are often the chief symptoms are often the chief complaint in depressed complaint in depressed patients presented in primary patients presented in primary care settings.care settings.
Pain Signal
NE5-HT
5-HTNE
Pain Signal
Ep
idu
rals for P
ost –O
p A
nalg
esia .
הזרקה אפידורלית
Brachial Nerve Block –Axillary Brachial Nerve Block –Axillary approachapproach
SCS TechniqueSCS Technique
Patient controlled analgesiaPatient controlled analgesia
PCAPCA
0
20
40
60
80
100
120
0 1 2 3 4 5 6 7 8
intramuscular
PCA
Special issuesSpecial issues
Postoperative Pain Management in:Postoperative Pain Management in:
Chronic Pain PatientsChronic Pain Patients
Patients on Chronic Opioid TreatmentPatients on Chronic Opioid Treatment