Pain Management In The 21st Century Presented At Vista Diagnostics 17.6.09

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Pain Management In The 21st Century

Presented At Vista Diagnostics (MRI scanning centre) to Medical personnel

17th June 2009

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Pain Management In The 21st Century Presented At Vista Diagnostics 17.6.09

  1. 1. Pain Management in the 21 st Centuary. Dr. Christopher A. Jenner MB BS, FRCA Consultant in Pain Medicine, Imperial Healthcare NHS Trust Medical Director London Pain Consultants and Spinal Healthcare 17 th June 2009
  2. 2. Agenda <ul><li>Definition </li></ul><ul><li>Physiology </li></ul><ul><li>Acute/ Chronic </li></ul><ul><li>Neuropathic </li></ul><ul><li>Differences </li></ul><ul><li>Treatment Options </li></ul><ul><ul><li>www.londonpainconsultants.com </li></ul></ul>
  3. 3. Definitions <ul><li>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) </li></ul><ul><ul><li>www.londonpainconsultants.com </li></ul></ul>
  4. 4. Definitions (2) <ul><li>Time-course: </li></ul><ul><li>• acute </li></ul><ul><li>• chronic </li></ul><ul><li>www.londonpainconsultants.com </li></ul>
  5. 5. Definitions (3) <ul><li>Type: </li></ul><ul><li>• nociceptive </li></ul><ul><li>• neuropathic </li></ul><ul><li>www.londonpainconsultants.com </li></ul>
  6. 6. Nociceptive Pain www.londonpainconsultants.com
  7. 12. Neuropathic Pain www.londonpainconsultants.com
  8. 15. Pain Physiology <ul><li>(boring) </li></ul><ul><ul><li>www.londonpainconsultants.com </li></ul></ul>
  9. 17. Pain Physiology (funky version) www.londonpainconsultants.com
  10. 19. Noxious Stimulus
  11. 20. Impulse Transmission
  12. 21. Afferent sensory fibres
  13. 22. Spinal cord
  14. 23. Dorsal Horn
  15. 24. Synapse
  16. 25. Ca and Glutamate
  17. 26. Synaptic Cleft
  18. 27. Post Synaptic
  19. 28. Nociceptive Neuron
  20. 29. Pain perception
  21. 30. Brain
  22. 31. Prevalence <ul><li>Acute pain </li></ul><ul><li>• SMH 13,213 operations p.a. (Nov 03-04, DSU 41%) </li></ul><ul><li>• SMH 484 operations p.m. (Sep 04, Main, 15% PCA/ epi) </li></ul>
  23. 32. Epidemiology <ul><li>1 in 5 of adults suffers from chronic pain </li></ul><ul><li>1 in 3 in the elderly population </li></ul><ul><li>(Blyth et al 2001) </li></ul><ul><li>70% of people living with chronic pain are under the age of 60 years. </li></ul><ul><li>(European Journal of Pain, 2006) </li></ul><ul><li>49% of people living with chronic pain are forced to take time of work. </li></ul><ul><li>(British Pain Society, 2005) </li></ul>
  24. 33. The Challenges of Acute Pain <ul><li>• Primary Care </li></ul><ul><li>• ↑ healthcare utilisation </li></ul><ul><li>• Secondary Care </li></ul><ul><li>• ↑ length stay/ complications </li></ul><ul><li>• 10-15% post-op chronic pain (Macrae) </li></ul>
  25. 34. Acute Pain Management <ul><li>Non-pharmacological </li></ul><ul><li>• RICE </li></ul><ul><li>Pharmacological </li></ul><ul><li>• WHO ladder (amended from cancer) </li></ul><ul><li>Step 1 paracetamol/ NSAID/ COX 2 </li></ul><ul><li>Step 2 + weak opioids </li></ul><ul><li>Step 3 + strong opioids </li></ul>
  26. 36. Massive Financial Burden <ul><li>NHS/ DWP/ tax-payers </li></ul><ul><li>• Lower back pain (CSAG 1994) </li></ul><ul><li>• NHS £481 million </li></ul><ul><li>• The Exchequer £1.4 billion </li></ul><ul><li>www.londonpainconsultants.com </li></ul>
  27. 37. Physical and Alternative Treatments
  28. 38. Pain Management – A Physiotherapist’s Perspective Helen Dawson MSc, BSc, MCSP Extended Scope Physiotherapy Practitioner in Pain Management [email_address]
  29. 39. Physical/ Alternative Treatments <ul><li>• Physical- heat/ cold/ TENS/ hydro/ supports/ US/ IR </li></ul><ul><li>• Manipulation- PxTx/ chiropracter/ osteopathy/ deep tissue massage </li></ul><ul><li>• Alternative- acupuncture </li></ul>
  30. 40. Any Vets in the audience? <ul><ul><li>www.londonpainconsultants.com </li></ul></ul>
  31. 41. 5. (a) Veterinary practitioners?
  32. 42. Headache!
  33. 43. Pharmacological Treatment
  34. 44. Pharmacological Treatment <ul><li>• WHO analgesic ladder (abridged) </li></ul><ul><li>• + tramadol </li></ul><ul><li>• + opioids- buprenorphine TDD/ oxycontin/ fentanyl TDD </li></ul><ul><li>(New: sufentanyl TDD/ product X ) </li></ul><ul><ul><li>www.londonpainconsultants.com </li></ul></ul>
  35. 45. Opioid Therapy <ul><ul><li>www.londonpainconsultants.com </li></ul></ul>
  36. 48. Pharmacological treatment of Neuropathic Pain <ul><ul><li>www.londonpainconsultants.com </li></ul></ul>
  37. 49. Neuropathic Pain Management <ul><li>Antidepressants- Amitryptilline </li></ul><ul><li>Anticonvulsants- Gabapentin/ Pregabalin/ Carbamazepine/ Valproate </li></ul><ul><li>Opioids </li></ul><ul><li>Local Anaesthetics- Lignocaine/ EMLA </li></ul><ul><ul><li>www.londonpainconsultants.com </li></ul></ul>
  38. 50. <ul><li>NMDA antagonists </li></ul><ul><li>Sympatholytics </li></ul><ul><li>GABA –ergics </li></ul><ul><li>Capsaicin </li></ul><ul><ul><li>www.londonpainconsultants.com </li></ul></ul>
  39. 51. Future Agents for Neuropathic Pain <ul><li>Ziconotide (sea snail, conus magnus) </li></ul><ul><li>P2X3- (purine) receptor antagonists (ATP) (knockout mice) </li></ul><ul><li>Epibatidine (Equadorian poison dart frog) </li></ul><ul><li>Morphine and ketamine </li></ul><ul><li>Regular gabapentin </li></ul><ul><li>www.londonpainconsultants.com </li></ul>
  40. 52. Psychologicaly based therapy
  41. 53. Pain Management <ul><li>Psychological </li></ul><ul><li>CBT </li></ul><ul><li>Operant Conditioning </li></ul><ul><li>Psychoanalysis </li></ul><ul><li>Relaxation </li></ul><ul><li>Biofeedback </li></ul><ul><li>• Psychiatric </li></ul><ul><ul><li>www.londonpainconsultants.com </li></ul></ul>
  42. 54. Pain Management Programmes <ul><li>● Medication </li></ul><ul><li>• Goals (SMART- specific/ measured/ agreed/ realistic/ timed) </li></ul><ul><li>• Coping </li></ul><ul><li>• Contingency </li></ul><ul><li>• Pacing </li></ul><ul><li>• Education </li></ul><ul><li>• Pain Behaviours </li></ul><ul><li>• Reinforcement www.londonpainconsultants.com </li></ul>
  43. 55. Functional Restoration Programmes www.londonpainconsultants.com
  44. 56. MRI scans
  45. 60. Other Imaging
  46. 62. Minimally Invasive Pain Management
  47. 64. C-arm
  48. 65. Targets www.londonpainconsultants.com
  49. 67. Spine Pain Cervical/ Thoracic/ Lumbar >65% workload
  50. 68. Epidural Steroid Injections
  51. 69. Facet Joint Injections
  52. 70. Nerve Root Injections
  53. 71. Sacroiliac Joint Injection
  54. 72. Radiofrequency
  55. 73. <ul><li>Radiofrequency denervation (destructive) </li></ul><ul><li>Eg: medial branch (facet joint) blocks </li></ul><ul><li>Pulsed radiofrequency (non-destructive) </li></ul><ul><li>Eg: nerve roots </li></ul><ul><li>www.londonpainconsultants.com </li></ul>
  56. 74. Botulinum Toxin A
  57. 75. Other Minimally Invasive Techniques www.londonpainconsultants.com
  58. 76. Epiduroscopy
  59. 77. IDET
  60. 78. Disc Dekompressor
  61. 79. Vertebroplasty/ Kyphoplasty
  62. 80. Musculoskeletal www.londonpainconsultants.com
  63. 81. Shoulder <ul><li>Suprascapular nerve block </li></ul><ul><li>Suprascapular pulsed radiofrequency </li></ul><ul><li>Intra-articular </li></ul><ul><li>Trigger point </li></ul><ul><li>Botulinum Toxin A </li></ul>
  64. 82. Limbs <ul><li>Tenoperiostial injections </li></ul><ul><li>Intra-articular </li></ul><ul><li>Trigger points </li></ul><ul><li>Intra-articular </li></ul><ul><li>Botulinum Toxin A </li></ul>
  65. 84. Neuropathic Pain www.londonpainconsultants.com
  66. 85. Complex Regional Pain Syndrome (CRPS) <ul><li>• Upper Limb </li></ul><ul><li>• Stellate ganglion block </li></ul><ul><li>• Intravenous guanethidine block (IVG) </li></ul><ul><li>• Lower Limb </li></ul><ul><li>• Lumbar Sympathectomy </li></ul><ul><li>• Intravenous guanethidine block (IVG) </li></ul>
  67. 86. Other Neuropathic Pain <ul><li>Coeliac plexus block </li></ul><ul><li>Ganglion of Impar block </li></ul><ul><li>Hypogastric plexus block </li></ul><ul><li>Pulsed radiofrequency to nerves </li></ul><ul><li>EG: intercostal/ obturator </li></ul>
  68. 87. Advanced Pain Management Techniques www.londonpainconsultants.com
  69. 88. Nerve Stimulation
  70. 89. Nerve Stimulation (2)
  71. 90. Intrathecal Pumps
  72. 91. Intrathecal Pumps (2)
  73. 92. The Future? www.londonpainconsultants.com
  74. 93. The Future? <ul><li>Demographics </li></ul><ul><li>• Healthcare advances </li></ul><ul><li>• ↑ Patient expectations and involvement </li></ul><ul><li>www.londonpainconsultants.com </li></ul>
  75. 94. www.londonpainconsultants.com
  76. 95. London Pain Consultants Clinics <ul><li>London </li></ul><ul><li>• 15 Harley Street, W1G </li></ul><ul><li>• Wellington, NW8 </li></ul><ul><li>• HSJSE, NW8 </li></ul><ul><li>• Lindo Wing (St Marys), W2 </li></ul><ul><li>• Surrey </li></ul><ul><li>• Mount Alvernia, Guildford </li></ul>
  77. 96. The Team <ul><li>Consultant Pain Medicine (Dr.C.A.Jenner) </li></ul><ul><li>Consultant Orthopaedic Spine Surgeon (Mr. Mo Akmal) </li></ul><ul><li>Consultant Interventional Radiologist (Dr. D. Connel) </li></ul><ul><li>Consultant Rheumatologist (Dr. Rees) </li></ul>
  78. 97. The Team (2) <ul><li>Consultant Gynaecologist (Miss D. Lyons) </li></ul><ul><li>Consultant Neurologist (Dr. J. Ball) </li></ul><ul><li>Consultant Psychologist (Dr J. Neilson) </li></ul><ul><li>Specialist Physiotherapists (West London Physiotherapy- Sarah Morton, Cameron Tudor) </li></ul>
  79. 98. www.spinal-healthcare.com
  80. 99. Summary www.londonpainconsultants.com
  81. 100. Summary <ul><li>Very common (1 in 7 UK) </li></ul><ul><li>Time course- acute n chronic </li></ul><ul><li>Nociceptive and neuropathic </li></ul><ul><li>Multiple treatment modalities </li></ul><ul><li>www.londonpainconsultants.com </li></ul>
  82. 101. Case reports/ Blogs/ Links/ Appointments [email_address] 0845 045 0250
  83. 102. <ul><li>Any Questions </li></ul>

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