update in pain management himaa conference dr tony weaver clinical director of surgical services...
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Update in Pain managementUpdate in Pain managementHIMAA ConferenceHIMAA Conference
Dr Tony WeaverClinical Director of Surgical Services
Director of Pain Management Clinic
Barwon Health
Pain Services Pain Services
What we are--What we are-- Acute Pain Service – In patient - -run
in conjunction with main Anaesthetic Dept. Pain Management Clinic ( Outpatients)
– Chronic (Persistent) Non-Cancer pain– Cancer Pain ( with Oncologists &
Palliative Care Physicians) Referral by GP’s, Hospital Medical Staff,
Private Medical and Surgical Specialists
Pain Pain ---- DefinitionDefinition
Pain is an unpleasant sensory and emotional experience associated with actual or potential tissue damage or described in such terms. IASP
Persistent (Chronic) pain is now recognised as a disease entity.– Symptoms, Signs, Pathology, Psychology.
Pain is a Pain is a Bio-Psycho-SocialBio-Psycho-Social problemproblem
So, we must take a Multi- disciplinary Approach
– Medical, Psychology, Physiotherapy.Review of diagnosis – M/discTreatment plan formulatedThen, Feed-back session with the patient
Pain Patho-physiologyPain Patho-physiologyTypes of PainTypes of Pain
Descartes model ( anatomical model )Physiological painClinical Pain(Injury +individual emotional
& physiological response) Nociceptive PainNeuropathic painSympathetically maintained pain
Pain ConceptsPain Concepts
Nociceptive PainNociceptive Pain Nociceptive Pain - Acute Pain ( also persistent)
– Stimulation of peripheral nociceptors, somatic and visceral, relayed to dorsal horn , modulated, and passed to perception centres.
– Identifiable cause– Acute post injury, post surgery pain– Arthritic pain– Inflammatory pain– Mechanical pain
Pain conceptsPain conceptsNeuropathic pain - CharacteristicsNeuropathic pain - Characteristics
Neuropathic Pain- pain generated from within the nervous system – Spontaneous pain – Burning pain– Stabbing , shooting pain– Dysaesthesiae (ants crawling)– Multi-dermatomal
Allodynia, Hyperalgaesia, Hyperpathia.
Pain ConceptsPain Concepts Sympathetically maintained painSympathetically maintained pain
– Peripheral Sympathetic fibre growth– Dorsal root ganglion ingrowth with adrenergic
fibres– Manifested by Vasomotor, Sudomotor, Trophic
Motor & extra-pyramidal changes– Usually accompanied by Neuropathic pain
features
CRPS / RSDCRPS / RSD
CRPS was called – Reflex Sympathetic Dystrophy– Causalgia ( kausis=burn, algos=pain)– Algodystrophy– Sudek’s atrophy– Peripheral acute trophoneurosis– Traumatic angiospasm– Post infarction sclerodactyly
Pain SyndromesPain Syndromes CRPS Type 1
and Type 2 ( post nerve injury)( Old terminology RSD and Causalgia)
Clinical presentation: – Neuropathic pain i.e. burning ,shooting,
multi dermatomal– Allodynia, Hyperalgaesia, Hyperpathia– Sudomotor, vasomotor, trophic tissue change,
osteopaenia– Motor & extra-pyramidal changes
Target Treatment strategiesTarget Treatment strategies
Medical– Pharmacological– Interventional
Psychology– Cognitive Behavioural Therapies
Individual & GroupsPhysiotherapy
– Always active exercises, restoration of function
Cognitive Behavioural TherapyCognitive Behavioural TherapyPsychology, Physiotherapy, MedicalPsychology, Physiotherapy, Medical
Individual and GroupsIMPACT and MG group work
– Certainly Interventional – Re- engineering of Beliefs– Re-establishment of Self -Efficacy– Restoration of Function
both Physically and Socially– Sustainable gains– 3 weeks full time + follow-up
Chronic , Persistent Pain.Chronic , Persistent Pain. Cancer PainCancer Pain
Cancer Pain– ~ 95 % managed with chemo/ radio therapy and
‘conventional’ analgaesics including Opioids, nsaid’s, Steroids, Adjuvant agents, Tramadol , Lignocaine, Ketamine.
Advanced management – includes specific nerve blocks e.g. splanchnic,
(coeliac) paraverterbral.– Intraspinal: Epidural and Intrathecal drug Rx
Interventional Therapies Interventional Therapies
Specific nerve and plexus targetsSpecific nerve and plexus targets
Peripheral & Cranial nerve blocksRadiofrequency lesioning
– Continuous and Pulsed current– Somatic afferents from facet joints
( Medial Branch of Post.Primary Rami.)– Dorsal root ganglia, sympathetic ganglia.
Cryotherapy
Interventional TherapiesInterventional Therapies Chronic non-cancer PainChronic non-cancer Pain
Epidurals: cervical, thoracic, lumbar, caudal Nerve root sleeve injectionsSacro-iliac joints
L.A. & Steroids
Epidurolysis : lysis of fibrotic tissue in epidural space
Interventional Therapies Interventional Therapies Specific nerve and plexus targets Specific nerve and plexus targets
Sympathetic Nerve blocksSympathetic Nerve blocks– Stellate– Thoracic– Lumbar L.A– Coeliac Neurolytic– Splanchnic R.F.– Hypogastric – Ganglion impar
Chronic - non-Cancer PainChronic - non-Cancer Pain
Intraspinal TherapiesIntraspinal TherapiesDiscovery of receptors in Spinal cord for
– Opioids– Adrenergic alpha agonists– Alpha 2 agonists ( Clonidine)– Serotonergic– GABA
Chronic - non-Cancer PainChronic - non-Cancer Pain
Intraspinal TherapiesIntraspinal TherapiesPortals
– Epidural and Intrathecal catheters.Implanted Pumps & Intrathecal
catheterAllows 10- 100 times decrease in dose c.f.
systemic delivery with increased efficacy and marked decrease in side effects.
Spinal column Stimulation/ Spinal column Stimulation/ Intrathecal pumpsIntrathecal pumps
SCS potentially good in CAREFULLY SELECTED patients for Neuropathic pain problems.
( Failed Back , CRPS Type 1 & 2,) Intrathecal pumps potentially useful for
- nociceptive pain states
lower body spasticity
cancer pain with reasonable prognosis
Chronic - non-Cancer PainChronic - non-Cancer Pain
Intraspinal therapiesIntraspinal therapiesSpinal Cord Stimulation
– Relies on the “Gate theory” principle – continuous non-noxious stimuli via A beta fibres inhibit nociceptive traffic in dorsal horn & cord.