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Clinical Aspects of PainManagement

Dr. Richard WalkerFRCA, Dip MS Med, MLCOM, FFPMRCA

Consultant in Pain Medicine

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Outline

Pain classification and characteristics

Common pain syndromes with treatment

examples

Please look at www.PainClinic.org for moreinformation

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Definitions (1)

Pain "An unpleasant sensory and emotional experience

associated with actual or potential tissue damage, or

described in terms of such damage

International Association for the Study of Pain

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Definitions (2)

Acute Pain The normal, predicted physiological response to an

adverse chemical, thermal, or mechanical stimulus

associated with surgery, trauma, and acute illness. It

is generally time-limited and is responsive to Opioidtherapy, among other therapies.

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Definitions (3)

Chronic PainA pain state which is persistent and in which the

cause of the pain cannot always be removed or is

difficult to treat. Chronic Pain may be associated

with a long term incurable or intractable medicalcondition or disease.

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Pain Classification

Nociceptive Non Nociceptive

Somatic Visceral Neuropathic Sympathetic

Nociceptive Pain arises from thestimulation of specific painreceptors. These receptors canrespond to heat, cold, vibration,stretch and chemical stimulireleased from damaged cells.

Non Nociceptive Pain arises fromwithin the peripheral and centralnervous system. Specific receptors donot exist here, with pain beinggenerated by nerve cell injury.

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Somatic Pain Characteristics Source

Skin, muscle, joints, bones, and ligaments - often known asmusculo-skeletal pain.

Receptors activated Heat, cold, vibration, stretch (muscles), inflammation (e.g.

cuts and sprains which cause tissue disruption), and oxygen

starvation (ischaemic muscle cramps). Characteristics Often sharp and well localised, and can often be reproduced

by touching or moving the area or tissue involved.

Often causes referred pain see diagrams

Useful Medications May respond to combinations of Paracetamol, Weak Opioid's

OR Strong Opioid's, and NSAID's.

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Dermatomes

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Myotomes

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Sclerotomes

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Visceral Pain Characteristics

Source Internal organs of the main body cavities - thorax (heart andlungs), abdomen (liver, kidneys, spleen and bowels), pelvis(bladder, womb, and ovaries).

Receptors activated Specific receptors (nociceptors) for stretch, inflammation, and

oxygen starvation (ischaemia).

Characteristics Often poorly localised, and may feel like a vague deep ache,

can be continuous (liver, kidney), or colicky (hollow organ).

Often causes referred pain

Useful medications Usually very responsive to Weak Opioid's and Strong

Opioid's.

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Neurogenic Pain Characteristics Source

From within the nervous system itself - peripheral and central nervous system.

Nerve Degeneration - multiple sclerosis, stroke, brain haemorrhage, oxygenstarvation

Nerve Pressure carpal tunnel syndrome

Nerve Inflammation - torn or slipped disc

Nerve Infection - shingles and other viral infections

Receptors activated No specific receptors electrically unstable nerve firing off in a completely

inappropriate, random, and disordered fashion.

Characteristics Often described as lancinating, shooting, burning, and hypersensitive.

Associated with signs of nerve malfunction such as hypersensitivity (touch,vibration, hot and cold), tingling, numbness, and weakness.

Useful Medications Only partially sensitive to paracetamol, NSAID's, opioids. More sensitive to Anti-

depressants, Anti-convulsants, Anti-arrhythmics, and NMDA Antagonists. TopicalLignocaine or Capsaicin, may be helpful.

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Sympathetic Pain Characteristics Source

Over-activity sympathetic nervous system associated with nerve pain Occurs more commonly after fractures and soft tissue injuries of the armsand legs may lead to Complex Regional Pain Syndrome (CRPS) wasknown as Reflex Sympathetic Dystrophy.

Receptors activated No specific pain receptors (non nociceptive).

Characteristics Allodynia = extreme hypersensitivity to light touch and temperature.

Signs of sympathetic overactivity.

Useful medications As for Nerve Pain also nifedipine improves circulation

Treatment should include appropriate multi-modal medications,sympathetic nerve blocks, and intensive rehabilitation combiningoccupational and physiotherapy.

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Pain MechanismsNormal Sensations

SensoryCortex

SkinStimulation

Dorsal Horn

BrainStem

LimbicSystem

FeelingHappy

NormalHR, BP, RR,Skin temp

Descending Inhibition

Closing The Gate

CVS / RSCentres

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What Happens InAcute Pain

SensoryCortex

Dorsal Horn

BrainStem

LimbicSystem

FeelingHappy

NormalHR, BP, RR,Skin temp

Descending Inhibition

Closing The Gate

CVS / RSCentres

Sensitised

Dorsal Horn(Wind Up)

BrainStem

PainPerception

CVS / RSCentres

RaisedHR, BP, RRCold Skin

LimbicSystem

PainBehaviour

Mental state

determines gate

closure

SkinStimulation

TissueInjury

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Recovery After Acute Pain

SensoryCortex

Dorsal Horn

BrainStem

LimbicSystem

FeelingHappy

NormalHR, BP, RR,Skin temp

CVS / RSCentres

Sensitised

Dorsal Horn(Wind Up)

BrainStem

PainPerception

CVS / RSCentres

RaisedHR, BP, RRCold Skin

LimbicSystem

PainBehaviour

TissueInjuryTissueHealing

Dorsal HornWinds Back Down

BrainStem

PainSubsides

CVS / RSCentres

NormalHR, BP, RRWarm Skin

LimbicSystem

FeelingHappy

Descending Inhibition

Helps Close The Gate

Descending Inhibition

Helps close the gate

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Why Does Chronic Pain Develop ?

SensoryCortex

Dorsal Horn

BrainStem

LimbicSystem

FeelingHappy

NormalHR, BP, RR,Skin temp

Descending Inhibition

Closing The Gate

CVS / RSCentres

Sensitised

Dorsal Horn(Wind Up)

BrainStem

PainPerception

CVS / RSCentres

RaisedHR, BP, RRCold Skin

LimbicSystem

PainBehaviour

TissueInjury

Descending Inhibition

Helps Close The Gate

Setting The Scene

Badly Managed Acute Pain

Emotionally Sensitive Patient

Low IQ

Poor Coping Skllls

Previous Bad Pain Experiences

Pain Goes on For Longer

Surgical Complications

Poor Descending

Inhibition

- Gate Wide Open

ContinuingPain Input

Permanently

SensitisedDorsal Horn

Activated

Silent

Channels

BrainStem

ChronicPain

CVS / RSCentres

? Riskof HT / IHD

LimbicSystem

ChronicPain Pt

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Pain

Inter-relationships

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Common Pain Syndromes

with Treatment Examples

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Somatic Pain Muscle Sprain

Mechanism of whiplash injury

Flexion / extension movement

Muscle fibre tearing trapezius, posterior neck muscles

Muscle cell disruption with liberation of inflammatorymediators

Phagocytosis followed by resolution in 1 2 weeks

Clinical findings Local muscle tenderness and swelling

Generalised protective muscle spasm in the neck andshoulders

Increased risk of developing chronic neck and shoulder pain

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Painful Muscle SpasmAcute Muscle

Spasm

Chronic MuscleSpasm

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Early Treatment Rule out slipped disc / nerve root entrapment / spinal

disruption x-rays / CT scan / MRI scan Reassure the patient - the body has tremendous

powers of healing

Soft collar short term

Drugs Paracetamol + NSAIDs + weak opioid

Muscle relaxants short term (diazepam, methocarbamol notmore then 1 week)

Physical therapy Heat, ultrasound, gentle stretches

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Late Treatment

Trigger Point Injections Local anaesthetic / steroid

Botulinum Toxin A

Spinal Manipulation for secondary spinalstiffness (in the absence of disc herniation / spinal disruption)

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Trapezius Trigger Points

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Trigger Point Injections

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Cervical

Spine

Manipulation

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Thoracic

Spine

Manipulation

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Lumbar

Spine

Manipulation

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Neurogenic Pain - Sciatica Spinal nerve pain caused by:-

Disc prolapse Annular tear

Foraminal stenosis

Post-operative epidural scar tissue

Mechanism

Inflammation (PLA2) or compression or both Clinical findings

Radiating leg pain, tingling, numbness, weakness, dural tension signs

Investigations Spinal MRI scan

Electro-myogram to investigate nerve function

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Prolapsed disc

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Annular

Tear

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Foraminal Stenosis

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L b R P i P

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Lumbar Root Pain Patterns

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C i l R t P i P tt

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Cervical Root Pain Patterns

Treatment

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Treatment Important

Anyone with sciatica and recent onset incontinence shouldhave an urgent referral to a spinal surgeon

Drugs Traditional analgesics ineffective

Anti-depressants / anti-convulsants more useful

Injections Epidural local anaesthetic / steroid injections Nerve Root Blocks

Epiduroscopy Breaking down scar tissue under direct vision

Surgical decompression Laminectomy, hemi-laminectomy, microdiscectomy

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E id l LA / St id I j ti

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Epidural LA / Steroid Injections

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Epidural Injection Technique

Alternative

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N R t Bl k

http://uk.youtube.com/watch?v=1zRhApo0lkohttp://uk.youtube.com/user/liambroadhttp://uk.youtube.com/user/liambroadhttp://uk.youtube.com/watch?v=1zRhApo0lko

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Nerve Root Blocks

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Epid roscop

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Epiduroscopy

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Surgical Decompression

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Surgical Decompression

Micro-discectomy Full Laminectomy Fusion

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Visceral Pain Pancreas Carcinoma

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Visceral Pain Pancreas Carcinoma

Mechanism

Extra-peritoneal, pressure on adjacent structures

Symptoms

Central abdominal pain (T7)

Referred pain to the interscapular area (T7)

Investigations

MRI scan

Treatment

Surgical resection Whipples procedure

Palliation - Analgesic titration + Coeliac Plexus Block

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Coeliac

Plexus Block

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S th ti P i

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Sympathetic Pain

Upper Limb ComplexRegional Pain Syndrome

Type I (CRPS I)

Diagnostic Stellate Ganglion

Block

Sympathetic supply to the

ipsilateral arm / hemi-face

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Stellate Ganglion Block

(Anterior Paratracheal Approach)

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Signs of a Successful

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Block

Reduced allodynia in the arm/ hand

Horners Syndrome

Meiosis

Ptosis

Enophthalmos Warmth and vasodilation

face and arm

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Summary

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Summary Principles of pain management

History, examination, relevant investigations

Arrive at a diagnosis to establish:- Type of pain

Pathological process causing the pain

Perform triage surgical referral for treatable causes(sciatica, cancer)

Choose the correct oral multi-modal drugs for the type of pain

Consider appropriate conservative treatments starting withthe least invasive

Talk to your patient and explain in simple language

Set patient expectations (drugs achieve only 50% relief)

Dont use frightening adjectives like arthritis, crumbling,

degenerative etc

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Thank you for your attention any questions ?

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