Pain Management


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Pain Management

  1. 1. Pain management <ul><li>Dr. Vaibhav Kamath </li></ul><ul><li>Interventional pain therapist </li></ul>
  2. 2. Pain management <ul><li>Pain medicine & interventional pain therapy is a super-specialty of anesthesia. </li></ul><ul><li>This branch deals with all kinds of pain along with other specialist. </li></ul><ul><li>Apart from pharmacotherapy this branch treats patients with other modalities of pain treatment. </li></ul>
  3. 3. Is it better to tolerate pain? <ul><li>There is a common idea that it is better to tolerate pain than the treatment of pain. That’s why even extreme pain is often not considered important enough by us, even by health professionals to require immediate action. After all, pain is not going to kill you. Or is it? </li></ul><ul><li>Unrelieved pain has consequences </li></ul>
  4. 4. Effects of pain <ul><li>Decreases length of survival </li></ul><ul><li>Sympathetic stimulation & consequences </li></ul><ul><li>Healing is actually delayed </li></ul><ul><li>Adverse effect on our immune system </li></ul><ul><li>Lower our body's ability to respond to stressful situations such as surgery, chemotherapy, and psychological stress. </li></ul><ul><li>Acute pain becomes chronic pain </li></ul><ul><li>Psychological disturbances & even suicides </li></ul>
  5. 5. Effects of postoperative & posttraumatic pain <ul><li>Endocrine : Metabolic stress response- stimulation of HPA axis, activation of sympathetic system, increase in glucagon secretion. --hypertensive crisis, diabetic ketoacidosis, flaring of psychological disease etc. </li></ul><ul><li>Pulmonary dysfunction </li></ul><ul><li>G.I. Effects: ileus, nausea, vomiting </li></ul><ul><li>Impaired immunological function </li></ul><ul><li>Coagulation function- thrombotic phenomena </li></ul><ul><li>Cognitive dysfunction </li></ul>
  6. 6. Effects of labor pain <ul><li>Hyperventilation associated with painful contraction </li></ul><ul><li>Labor pain may precipitate hypertensive crisis in hypertensive mother </li></ul><ul><li>It increases intracranial pressure </li></ul><ul><li>It may precipitate diabetic ketoacidosis in uncontrolled diabetic mother </li></ul><ul><li>May cause incoordinate uterine contraction. </li></ul>
  7. 7. What is Pain? <ul><li>“ Pain, like pleasure, is a passion of the soul, that is, an emotion and not one of the senses.” </li></ul><ul><li>Pain is &quot;an unpleasant sensory and emotional experience associated with actual or potential tissue damage, or described in terms of such damage&quot; </li></ul><ul><li>Pain is to Somatic Stimulus what Beauty is to Visual Stimulus.It is highly Subjective. </li></ul>
  8. 8. Pain classification <ul><li>Peripheral pain vs.Central pain </li></ul><ul><li>Nociceptive vs. Neuropathic </li></ul><ul><li>Somatic vs. Sympathetically mediated </li></ul><ul><li>Acute vs. Chronic or persistent </li></ul>
  9. 9. Acute vs. Chronic or persistent <ul><li>There is no clear cut definition of chronic pain. American chronic pain association defines it as Pain that continues a month or more beyond the usual recovery period. It may be continuous or it may come and go. Chronic pain is difficult to treat because of central modulation and sensitization </li></ul>
  10. 10. Peripheral pain vs.Central pain <ul><li>Peripheral pain originates in muscles, tendons, etc., or in the peripheral nerves themselves. </li></ul><ul><li>Central pain arises from central nervous system pathology ... a &quot;primary&quot; CNS dysfunction. Some of this may arise due to maladaptive thought processes, true &quot;psychogenic&quot; pain. But most of it is due to structural changes in the CNS, e.g., spinal cord injury, multiple sclerosis, stroke and epilepsy. </li></ul>
  11. 11. Nociceptive , Neuropathic & neurogenic <ul><li>Nociceptive pain is the pain in which normal nerves transmit information to the central nervous system about trauma to tissues (nocere = to injure, Latin). </li></ul><ul><li>Neuropathic pain is pain in which damaged nerves transmit information. Damaged means there are structural and/or functional nervous system adaptations/alterations, may be secondary to injury. It may take place either centrally or peripherally (Jensen, 1996). Much of what has previously been considered psychogenic pain is now better understood as neuropathic pain of central origin. </li></ul>
  12. 12. Modalities of pain management <ul><li>Pharmacotherapy : Opioid & non-opioid analgesics, anti-convulsant, anti-depressant etc . </li></ul><ul><li>Physical therapy </li></ul><ul><li>Nerve block : Central neuro-axial block like epidural, peripheral nerve block, nerve root & plexus block, ganglion block, permanent neurolysis for cancer pain and treatment of spastic C.P. </li></ul><ul><li>Advanced interventional therapy </li></ul><ul><li>Laser therapy </li></ul><ul><li>Prolotherapy </li></ul><ul><li>Acupuncture; Yoga and meditation </li></ul>
  13. 13. Organization of pain clinic <ul><li>An ideal pain clinic should have all modalities of pain treatment. </li></ul><ul><li>Apart from the pain therapist there should have other specialists for proper diagnosis of the pain syndrome. </li></ul><ul><li>A pain clinic deals with all kinds of pain. </li></ul>
  14. 14. Commonly treated diseases <ul><li>Headache & Facial Pain syndrome </li></ul><ul><li>Glossopharyngeal neuralgia </li></ul><ul><li>Neck & shoulder pain </li></ul><ul><li>Low back pain </li></ul><ul><li>Phantom limb pain & other limb pain </li></ul><ul><li>Primary and secondary cancer pain </li></ul><ul><li>Herpetic and post-herpetic neuralgia </li></ul><ul><li>Raynaud’s and Burger’s disease </li></ul><ul><li>Muscular and soft tissue pain </li></ul><ul><li>Spastic cerebral palsy & other myo-spastic diseases </li></ul><ul><li>Obstetrics analgesia and painless labor </li></ul><ul><li>Chronic regional pain syndrome </li></ul>
  15. 15. Interventions done commonly at pain clinic. <ul><li>Nerve blocks: occipital, trigeminal, vagus, brachial plexus & its branches, glossopharyngeal, intercostal, lumber plexus, nerves of lower extremity, nerve root </li></ul><ul><li>Ganglion block: gasserian, stellate, coeliac </li></ul><ul><li>Autonomic nerve block: lumber sympathetic etc. </li></ul><ul><li>Epidural block </li></ul><ul><li>Sub-arachnoid block </li></ul><ul><li>Advanced interventions: spinal cord stimulation, continuous spinal/epidural </li></ul><ul><li>Trigger point injections, </li></ul><ul><li>Ligament, joints, soft tissue injections. </li></ul>
  16. 16. Epidural interventions: indications <ul><li>Headache </li></ul><ul><li>Neck pain </li></ul><ul><li>Reflex sympathetic dystrophy </li></ul><ul><li>Permanent block for cancer pain </li></ul><ul><li>Myofascial pain </li></ul><ul><li>Disc prolapse </li></ul><ul><li>Radiculopathy </li></ul>
  17. 17. Myofascial pain syndrome <ul><li>Pharmacotherapy including analgesics, anti-depressants, muscle relaxants etc. </li></ul><ul><li>Trigger points injections </li></ul><ul><li>Injections of Botulinum Toxins </li></ul><ul><li>Epidural deposteroids </li></ul><ul><li>Physiotherapy </li></ul><ul><li>Acupuncture </li></ul><ul><li>Yoga and meditation </li></ul>
  18. 18. Low back pain syndrome <ul><li>Epidurogram, Epiduroscopy, Volumetric Epidurolysis & Epidural steroids </li></ul><ul><li>Pharmacotherapy including analgesics, anti-depressants, muscle relaxants etc. </li></ul><ul><li>Spinal cord stimulation </li></ul><ul><li>Permanent spinal/epidural catheter with implantable drug delivery system </li></ul><ul><li>Prolotherapy Physitherapy Acupuncture </li></ul><ul><li>Yoga and meditation </li></ul>
  19. 19. Painless labor <ul><li>Continuous epidural analgesia (gold standard) </li></ul><ul><li>Continuous spinal analgesia </li></ul><ul><li>Combined spinal epidural analgesia </li></ul><ul><li>PCA (patient controlled analgesia) </li></ul><ul><li>Parenteral Opioid , Entonox, Low dose ketamine, TENS </li></ul>
  20. 20. Post-operative analgesia <ul><li>Opiod & non-opiod analgesics & sedatives </li></ul><ul><li>Infiltration of LA around operative fields </li></ul><ul><li>Continuous LA infiltration via fine catheter in the sub-fascial plane </li></ul><ul><li>Continuous or on demand epidural analgesia via epidural catheter . </li></ul><ul><li>Continuous spinal analgesia by spinal catheter </li></ul><ul><li>Continuous or intermittent nerve block, root block, or nerve plexus block </li></ul>
  21. 21. Exercise Non-opioids Weak opioids +/- non-opioids +/- adjuvant Strong opioids Recovery Operation Treatment of Pain
  22. 22. Exercise Non-opioids Weak opioids +/- non-opioids Strong opioids Recovery Operation Treatment of Pain World of Misery
  23. 23. Exercise Non-opioids Weak opioids +/- non-opioids Strong opioids Recovery Operation Treatment of Pain IPM
  24. 24. IPM
  25. 25. IPM Basic Advanced <ul><li>Trigger point inj. </li></ul><ul><li>Diff. peripheral nv. block </li></ul><ul><li>Stellate ganglion block </li></ul><ul><li>Epidurals & neuro-axial block </li></ul><ul><li>Neurolytic blocks </li></ul><ul><li>Disc related procedures </li></ul><ul><li>Radiofrequency ablation </li></ul><ul><li>Epiduroscopy </li></ul><ul><li>Spinal cord stimulator </li></ul><ul><li>Implantable drug delivery system </li></ul>
  26. 26. IPM IPM are group of procedures with different mechanism of actions <ul><li>Targeted delivery of drugs. </li></ul><ul><li>Aims to correct the pathology </li></ul><ul><li>Blocking of nerve signals corrects neuropathy. </li></ul>
  27. 27. Interventional Pain Management <ul><li>Coeliac Plexus Block, </li></ul><ul><li>Lumber sympathectomy, </li></ul><ul><li>Epidurogram & Epidurolysis, </li></ul><ul><li>Cervical epidural block </li></ul><ul><li>Nerve root sleeve inj. </li></ul><ul><li>Facet joint Block </li></ul><ul><li>Trigeminal nv. Block </li></ul><ul><li>Inf hypogastric plexus block </li></ul><ul><li>Thoracic epidural block </li></ul><ul><li>Thoracic sympathetic block </li></ul>
  28. 28. Interventional Pain Management <ul><li>Suprascapuler nv. Block </li></ul><ul><li>Glossopharyngeal nv. Block </li></ul><ul><li>Paravertebral plexus block </li></ul><ul><li>Stellate ganglion block </li></ul><ul><li>Intercostal Nv. Block </li></ul><ul><li>Occipital Nv. Block </li></ul><ul><li>Lat. Fem. Cut. Nv. Block </li></ul><ul><li>Intraarticular inj. </li></ul><ul><li>Soft tissue inj. </li></ul><ul><li>Trigger point inj. </li></ul>
  29. 29. Interventional Pain Management: advantages <ul><li>Effectively brakes pain cycles. </li></ul><ul><li>Treats peripheral sensitization. </li></ul><ul><li>Addition of Ketamine & Tramadol treats central sensitization. </li></ul><ul><li>Diagnostic blocks identifies some of the pain syndromes </li></ul>
  30. 30. 104 patients low back pain without any identifiable cause <ul><li>Facet joint(s) disease in 24% </li></ul><ul><li>Lumbar nerve root and facet disease in 24% </li></ul><ul><li>Facet(s) and sacroiliac joint(s) in 4% </li></ul><ul><li>Lumbar nerve root irritation in 20% </li></ul><ul><li>Disc disorder in 7% </li></ul><ul><li>Sacroiliac joint in 6% </li></ul><ul><li>Sympathetic dystrophy in 2% </li></ul><ul><li>No cause was identified in 13% </li></ul>Ref: Pang WW et al . Application of spinal pain mapping in the diagnosis of low back pain—analysis of 104 cases. Acta Anaesthesiol Sin 1998; 36:71-74.
  31. 31. Diagnostic IPM procedures <ul><li>Diagnostic nerve block </li></ul><ul><li>Facet joint block </li></ul><ul><li>Provocative discography </li></ul><ul><li>Epidurogram, epiduroscopy </li></ul><ul><li>Selective nerve root block </li></ul><ul><li>SI joint block </li></ul><ul><li>Sympathetic Nerve Block </li></ul>
  32. 32. <ul><li>Thank You </li></ul>