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Clinical Aspects of Pain Management

Dr. Richard Walker


FRCA, 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 more information

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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 Opioid therapy, among other therapies.

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Definitions (3)
Chronic Pain
A 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 medical condition or disease.

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Pain Classification Nociceptive Somatic Visceral Non Nociceptive Neuropathic Sympathetic

Nociceptive Pain arises from the stimulation of specific pain receptors. These receptors can respond to heat, cold, vibration, stretch and chemical stimuli released from damaged cells.

Non Nociceptive Pain arises from within the peripheral and central nervous system. Specific receptors do not exist here, with pain being generated by nerve cell injury.

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Somatic Pain Characteristics


Source
Skin, muscle, joints, bones, and ligaments - often known as musculo-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 and lungs), 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, oxygen starvation 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 Antidepressants, Anti-convulsants, Anti-arrhythmics, and NMDA Antagonists. Topical Lignocaine 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 arms and legs may lead to Complex Regional Pain Syndrome (CRPS) was known 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 combining occupational and physiotherapy.
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Pain Mechanisms Normal Sensations


Sensory Cortex

Normal HR, BP, RR, Skin temp

CVS / RS Centres

Brain Stem

Limbic System

Feeling Happy

Descending Inhibition Closing The Gate

Dorsal Horn

Skin Stimulation

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What Happens In Acute Pain


Sensory Pain Perception Cortex

Normal Raised HR, BP, RR, HR, BP, RR Skin temp Cold Skin

CVS / RS Centres

Brain Stem

Limbic System

Feeling Pain Behaviour Happy

Descendingstate Mental Inhibition determines gate Closing The Gate closure

Sensitised Dorsal Horn (Wind Up)


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Tissue Skin Stimulation Injury

Recovery After Acute Pain


Sensory Pain Perception Subsides Cortex

Normal Raised HR, BP, RR, HR, BP, RR Warmtemp Skin Skin Cold Skin

CVS / RS Centres

Brain Stem

Limbic System
Descending Inhibition Helps Close The gate Helps close the Gate

Feeling Pain Behaviour Happy

Sensitised Dorsal Horn Dorsal Horn Winds Back Down (Wind Up)
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Tissue Healing Injury

Why Does Chronic Pain Develop ?


Sensory Chronic Pain Perception Cortex Pain

Normal Raised ? Risk HR, BP, RR, HR, BP, RR of HT / IHD Skin temp Cold Skin
Setting The Scene

CVS / RS Centres

Brain Stem

Limbic System
Poor Descending Descending Inhibition Inhibition Helps Close The Gate Closing The Gate - Gate Wide Open

Chronic Feeling Pain Behaviour Pain Pt Happy

Activated

Badly Managed Acute Pain


Emotionally Sensitive Patient Low IQ Poor Coping Skllls

Silent Channels

Previous Bad Pain Experiences


Pain Goes on For Longer Surgical Complications

Permanently Sensitised Dorsal Horn Sensitised Dorsal Horn (Wind Up)


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Continuing Tissue Pain Input Injury

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 inflammatory mediators Phagocytosis followed by resolution in 1 2 weeks

Clinical findings
Local muscle tenderness and swelling Generalised protective muscle spasm in the neck and shoulders Increased risk of developing chronic neck and shoulder pain

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Painful Muscle Spasm


Acute Muscle Spasm

Chronic Muscle Spasm

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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 not more 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 spinal stiffness (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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Lumbar Root Pain Patterns

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Cervical Root Pain Patterns

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Treatment
Important
Anyone with sciatica and recent onset incontinence should have 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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Epidural LA / Steroid Injections

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Epidural Injection Technique


Alternative

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Nerve Root Blocks

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Epiduroscopy

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Surgical Decompression

Micro-discectomy

Full Laminectomy

Fusion

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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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Sympathetic Pain
Upper Limb Complex Regional 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 Block


Reduced allodynia in the arm / hand Horners Syndrome Meiosis Ptosis Enophthalmos Warmth and vasodilation face and arm

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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 with the 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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