Overview of Pain Medicine.Dr. Christopher A. Jenner MB BS, FRCA, FFPMRCAConsultant in Pain Medicine, Imperial Healthcare N...
Agenda•   Definition•   Physiology•   Acute/ Chronic•   Neuropathic•   Differences•   Treatment Options                   ...
Definitions• Pain. ‘An unpleasant sensory and  emotional experience which we primarily  associate with tissue damage or de...
Definitions (2)• Time-course:         • acute         • chronic www.londonpainconsultants.com
Definitions (3)• Type:         • nociceptive         • neuropathic www.londonpainconsultants.com
Nociceptive Pain   www.londonpainconsultants.com
Neuropathic Pain   www.londonpainconsultants.com
Pain Physiology     (boring)            www.londonpainconsultants.com
Pain Physiology   (funky version)              www.londonpainconsultants.com
Epidemiology• 1 in 5 of adults suffers from chronic pain• 1 in 3 in the elderly population                                ...
Physical and Alternative      Treatments
Physical/ Alternative Treatments  • Physical- heat/ cold/ TENS/ hydro/ supports/ US/ IR  • Manipulation- PxTx/ chiropracte...
Any Vets in the audience?              www.londonpainconsultants.com
5. (a) Veterinary practitioners?
Headache!
Pharmacological Treatment
Pharmacological Treatment• WHO analgesic ladder (abridged)• + tramadol• + opioids- buprenorphine TDD/ oxycontin/ fentanyl ...
Opioid Therapy        www.londonpainconsultants.com
Pharmacological treatment of     Neuropathic Pain                www.londonpainconsultants.com
Neuropathic Pain Management• Antidepressants- Amitryptilline• Anticonvulsants- Gabapentin/ Pregabalin/ Carbamazepine/ Valp...
• NMDA antagonists• Sympatholytics• GABA –ergics• Capsaicin                     www.londonpainconsultants.com
Future Agents for Neuropathic Pain• Ziconotide (sea snail, conus magnus)• P2X3- (purine) receptor antagonists (ATP) (knock...
Psychologicaly based therapy
Pain Management•   Psychological      CBT      Operant Conditioning      Psychoanalysis      Relaxation      Biofeedback• ...
Pain Management Programmes● Medication• Goals (SMART- specific/ measured/ agreed/ realistic/ timed)• Coping• Contingency• ...
Functional Restoration    Programmes             www.londonpainconsultants.com
MRI scans
Other Imaging
Minimally Invasive Pain     Management
C-arm
Targetswww.londonpainconsultants.com
Spine PainCervical/ Thoracic/ Lumbar       >65% workload
Radiofrequency
• DESTRUCTIVE- Radiofrequency  denervation• Eg: medial branch (facet joint) blocks• NON-DESTRUCTIVE- Pulsed  radiofrequenc...
Botulinum Toxin A
Other Minimally Invasive      Techniques              www.londonpainconsultants.com
Musculoskeletal  www.londonpainconsultants.com
Shoulder• Suprascapular nerve block• Suprascapular pulsed radiofrequency• Intra-articular• Trigger point• Botulinum Toxin A
Limbs• Tenoperiostial injections• Intra-articular• Trigger points• Intra-articular• Botulinum Toxin A
Neuropathic Pain         www.londonpainconsultants.com
Complex Regional Pain        Syndrome (CRPS)• Upper Limb     • Stellate ganglion block     • Intravenous guanethidine bloc...
Other Neuropathic Pain• Coeliac plexus block• Ganglion of Impar block• Hypogastric plexus block• Pulsed radiofrequency to ...
Advanced Pain Management       Techniques       www.londonpainconsultants.com
Nerve Stimulation
Nerve Stimulation (2)
Intrathecal Pumps
Intrathecal Pumps (2)
The Future?      www.londonpainconsultants.com
The Future?• Demographics• Healthcare advances• ↑ Patient expectations and involvement                         www.londonp...
Summary• Very common (1 in 7 UK)• Time course- acute n chronic• Nociceptive and neuropathic• Multiple treatment modalities...
Medicolegal Case HistoriesDr. Christopher A. Jenner MB BS, FRCAConsultant in Pain Medicine, Imperial Healthcare NHS Trust ...
Anatomy of a Medicolegal              Report•   Pre Accident/ Incident•   Post Accident/ Incident•   Summary•   Pain Histo...
• Employment and ADL• Examination  Opinion (including causation)• Prognosis• Treatment Plan (costed)• Glossary and additio...
49F Severe RTA    Cervical Facet Joint n Secondary    Myofacial Pain Syndrome•   Emotionally distressed•   Interim payment...
52 F School Secretary•   Poor working environment•   Cramped•   High stress•   WRULD•   Ongoing case
32 F Post Spinal Surgery•   Medical Negligence case•   Unrecognised haematoma formation•   Complicated by infection•   Mus...
34M Industrial Accident• High pressure oil jet• Traumatic amputation little/ middle/ ring  fingers• Phantom limb pain• Neu...
22M Industrial Accident•   Skip fell on foot•   Crush injury•   Traumatic amputation•   Surgical intervention•   Phantom l...
47 F Post Hysterectomy• Medical Negligence case• Genitofemoral neuralgia•
42F Cosmetic Filler• Medical Negligence case• Facial Neuropathic Pain• Auriculotemporal nerve• Improving on medication and...
New Instructions• Practice Manager for full details and TnC• Competitive discounts for volume report  writing instructions
• www.londonpainconsultants.com• www.spinal-healthcare.com
AnyQuestions
Medicolegal Overview Of Pain Medicine 11.11.10
Medicolegal Overview Of Pain Medicine 11.11.10
Medicolegal Overview Of Pain Medicine 11.11.10
Medicolegal Overview Of Pain Medicine 11.11.10
Medicolegal Overview Of Pain Medicine 11.11.10
Medicolegal Overview Of Pain Medicine 11.11.10
Medicolegal Overview Of Pain Medicine 11.11.10
Medicolegal Overview Of Pain Medicine 11.11.10
Medicolegal Overview Of Pain Medicine 11.11.10
Medicolegal Overview Of Pain Medicine 11.11.10
Medicolegal Overview Of Pain Medicine 11.11.10
Medicolegal Overview Of Pain Medicine 11.11.10
Medicolegal Overview Of Pain Medicine 11.11.10
Medicolegal Overview Of Pain Medicine 11.11.10
Medicolegal Overview Of Pain Medicine 11.11.10
Medicolegal Overview Of Pain Medicine 11.11.10
Medicolegal Overview Of Pain Medicine 11.11.10
Medicolegal Overview Of Pain Medicine 11.11.10
Medicolegal Overview Of Pain Medicine 11.11.10
Medicolegal Overview Of Pain Medicine 11.11.10
Medicolegal Overview Of Pain Medicine 11.11.10
Upcoming SlideShare
Loading in …5
×

Medicolegal Overview Of Pain Medicine 11.11.10

604 views
478 views

Published on

Overview of the Medicolegal aspects of Pain Medicine.

0 Comments
2 Likes
Statistics
Notes
  • Be the first to comment

No Downloads
Views
Total views
604
On SlideShare
0
From Embeds
0
Number of Embeds
3
Actions
Shares
0
Downloads
11
Comments
0
Likes
2
Embeds 0
No embeds

No notes for slide

Medicolegal Overview Of Pain Medicine 11.11.10

  1. 1. Overview of Pain Medicine.Dr. Christopher A. Jenner MB BS, FRCA, FFPMRCAConsultant in Pain Medicine, Imperial Healthcare NHS Trust Medical Director London Pain Consultants and Spinal Healthcare 11th November 2010
  2. 2. Agenda• Definition• Physiology• Acute/ Chronic• Neuropathic• Differences• Treatment Options www.londonpainconsultants.com
  3. 3. Definitions• Pain. ‘An unpleasant sensory and emotional experience which we primarily associate with tissue damage or describe in terms of tissue damage, or both.’ (IASP 2001) www.londonpainconsultants.com
  4. 4. Definitions (2)• Time-course: • acute • chronic www.londonpainconsultants.com
  5. 5. Definitions (3)• Type: • nociceptive • neuropathic www.londonpainconsultants.com
  6. 6. Nociceptive Pain www.londonpainconsultants.com
  7. 7. Neuropathic Pain www.londonpainconsultants.com
  8. 8. Pain Physiology (boring) www.londonpainconsultants.com
  9. 9. Pain Physiology (funky version) www.londonpainconsultants.com
  10. 10. Epidemiology• 1 in 5 of adults suffers from chronic pain• 1 in 3 in the elderly population (Blyth et al 2001)• 70% of people living with chronic pain are under the age of 60 years. (European Journal of Pain, 2006)• 49% of people living with chronic pain are forced to take time of work. (British Pain Society, 2005)
  11. 11. Physical and Alternative Treatments
  12. 12. Physical/ Alternative Treatments • Physical- heat/ cold/ TENS/ hydro/ supports/ US/ IR • Manipulation- PxTx/ chiropracter/ osteopathy/ deeptissue massage • Alternative- acupuncture
  13. 13. Any Vets in the audience? www.londonpainconsultants.com
  14. 14. 5. (a) Veterinary practitioners?
  15. 15. Headache!
  16. 16. Pharmacological Treatment
  17. 17. Pharmacological Treatment• WHO analgesic ladder (abridged)• + tramadol• + opioids- buprenorphine TDD/ oxycontin/ fentanyl TDD(New: sufentanyl TDD/ product X) www.londonpainconsultants.com
  18. 18. Opioid Therapy www.londonpainconsultants.com
  19. 19. Pharmacological treatment of Neuropathic Pain www.londonpainconsultants.com
  20. 20. Neuropathic Pain Management• Antidepressants- Amitryptilline• Anticonvulsants- Gabapentin/ Pregabalin/ Carbamazepine/ Valproate• Opioids• Local Anaesthetics- Lignocaine/ EMLA
  21. 21. • NMDA antagonists• Sympatholytics• GABA –ergics• Capsaicin www.londonpainconsultants.com
  22. 22. Future Agents for Neuropathic Pain• Ziconotide (sea snail, conus magnus)• P2X3- (purine) receptor antagonists (ATP) (knockout mice)• Epibatidine (Equadorian poison dart frog)• Morphine and ketamine• Regular gabapentin www.londonpainconsultants.com
  23. 23. Psychologicaly based therapy
  24. 24. Pain Management• Psychological CBT Operant Conditioning Psychoanalysis Relaxation Biofeedback• Psychiatric www.londonpainconsultants.com
  25. 25. Pain Management Programmes● Medication• Goals (SMART- specific/ measured/ agreed/ realistic/ timed)• Coping• Contingency• Pacing• Education• Pain Behaviours• Reinforcement www.londonpainconsultants.com
  26. 26. Functional Restoration Programmes www.londonpainconsultants.com
  27. 27. MRI scans
  28. 28. Other Imaging
  29. 29. Minimally Invasive Pain Management
  30. 30. C-arm
  31. 31. Targetswww.londonpainconsultants.com
  32. 32. Spine PainCervical/ Thoracic/ Lumbar >65% workload
  33. 33. Radiofrequency
  34. 34. • DESTRUCTIVE- Radiofrequency denervation• Eg: medial branch (facet joint) blocks• NON-DESTRUCTIVE- Pulsed radiofrequency• Eg: nerve roots
  35. 35. Botulinum Toxin A
  36. 36. Other Minimally Invasive Techniques www.londonpainconsultants.com
  37. 37. Musculoskeletal www.londonpainconsultants.com
  38. 38. Shoulder• Suprascapular nerve block• Suprascapular pulsed radiofrequency• Intra-articular• Trigger point• Botulinum Toxin A
  39. 39. Limbs• Tenoperiostial injections• Intra-articular• Trigger points• Intra-articular• Botulinum Toxin A
  40. 40. Neuropathic Pain www.londonpainconsultants.com
  41. 41. Complex Regional Pain Syndrome (CRPS)• Upper Limb • Stellate ganglion block • Intravenous guanethidine block (IVG)• Lower Limb • Lumbar Sympathectomy • Intravenous guanethidine block (IVG)
  42. 42. Other Neuropathic Pain• Coeliac plexus block• Ganglion of Impar block• Hypogastric plexus block• Pulsed radiofrequency to nerves• EG: intercostal/ obturator
  43. 43. Advanced Pain Management Techniques www.londonpainconsultants.com
  44. 44. Nerve Stimulation
  45. 45. Nerve Stimulation (2)
  46. 46. Intrathecal Pumps
  47. 47. Intrathecal Pumps (2)
  48. 48. The Future? www.londonpainconsultants.com
  49. 49. The Future?• Demographics• Healthcare advances• ↑ Patient expectations and involvement www.londonpainconsultants.com
  50. 50. Summary• Very common (1 in 7 UK)• Time course- acute n chronic• Nociceptive and neuropathic• Multiple treatment modalities www.londonpainconsultants.com
  51. 51. Medicolegal Case HistoriesDr. Christopher A. Jenner MB BS, FRCAConsultant in Pain Medicine, Imperial Healthcare NHS Trust Medical Director London Pain Consultants andSpinal Healthcare 11th November 2010
  52. 52. Anatomy of a Medicolegal Report• Pre Accident/ Incident• Post Accident/ Incident• Summary• Pain History• Pain Scores• Previous Treatments
  53. 53. • Employment and ADL• Examination Opinion (including causation)• Prognosis• Treatment Plan (costed)• Glossary and additional info
  54. 54. 49F Severe RTA Cervical Facet Joint n Secondary Myofacial Pain Syndrome• Emotionally distressed• Interim payment• Clinical pain psychology• Meds and MIPM• Discharged• Case concluded
  55. 55. 52 F School Secretary• Poor working environment• Cramped• High stress• WRULD• Ongoing case
  56. 56. 32 F Post Spinal Surgery• Medical Negligence case• Unrecognised haematoma formation• Complicated by infection• Musculoskeletal pain• Neuropathic leg pain
  57. 57. 34M Industrial Accident• High pressure oil jet• Traumatic amputation little/ middle/ ring fingers• Phantom limb pain• Neuropathic stump pain• Phantom sensations
  58. 58. 22M Industrial Accident• Skip fell on foot• Crush injury• Traumatic amputation• Surgical intervention• Phantom limb pain• Neuropthic stump pain• Phantom sensations
  59. 59. 47 F Post Hysterectomy• Medical Negligence case• Genitofemoral neuralgia•
  60. 60. 42F Cosmetic Filler• Medical Negligence case• Facial Neuropathic Pain• Auriculotemporal nerve• Improving on medication and local nerve blocks• ongoing
  61. 61. New Instructions• Practice Manager for full details and TnC• Competitive discounts for volume report writing instructions
  62. 62. • www.londonpainconsultants.com• www.spinal-healthcare.com
  63. 63. AnyQuestions

×