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Basics of Chronic Pain - Dr Venugopal Kochiyil

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Basics of Chronic Pain - Dr Venugopal Kochiyil

  1. 1. Basics of chronic pain Venugopal Kochiyil Rehabilitation and Pain Medicine Physician
  2. 2. Pain • An unpleasant sensory and emotional experience associated with actual or potential tissue damage or described in terms of such damage (IASP) • Acute and chronic pain • Somatic and visceral pain • Nociceptive and neuropathic pain
  3. 3. Chronic pain • Pain that persists beyond the expected time frame for a given disease or injury • May not have any temporal relationship with the inciting cause • Maladaptive • Time frame? • Pain without apparent biological value that has persisted beyond the normal tissue healing time (3 months) - IASP
  4. 4. Neuropathic pain IASP clinical update September 2010
  5. 5. Neuropathic pain IASP Pain Update September 2010
  6. 6. http://www.medscape.org/viewarticle/498353
  7. 7. Process by which we feel pain • Transduction – noxious stimulus converted to electrical impulse by nociceptors • Transmission – Transmission of these impulses from periphery to spinal cord and brain • Perception – Appreciation of these signals arriving in the higher structures • Modulation – What influences nociceptive transmission
  8. 8. Ascending tracts
  9. 9. Cortical and subcortical connections
  10. 10. Peripheral sensitization
  11. 11. Wind up – Temporal summation • Repeated peripheral stimulation causes increased firing at the level of DH • NMDA receptors play a key role
  12. 12. Central Sensitization • Nervous system gets upregulated in a persistent state of high reactivity – a state of hyperexcitability • Tissue injury and nerve injury can cause this • Continue even after stimuli has stopped • Associated with reduction in central inhibition, spontaneous dorsal horn activity, alteration of neuronal connections • Allodynia and hyperalgesia, persistent pain, referred pain
  13. 13. Woolf CJ. Pain 2011;152(3): S2-15
  14. 14. Central sensitization Woolf CJ. Pain 2011; 152(3):S2-15
  15. 15. Cortical plasticity
  16. 16. Psycholoy – Affective - Depression • More prevalent in chronic pain than other chronic illness • Prevalence varied in studies (10 – 75%) • Somatic symptoms of depression in common in patients with chronic pain • What is the first symptom • Predictors • High levels of pain, less activity, greater disability, pain behaviours
  17. 17. Psychology – Affective - Anxiety • High levels of anxiety is another disabling effect of chronic pain • Activity avoidance • Implicated in imbalance between excitatory and inhibitory descending system
  18. 18. Psychology – Affective - Anger • Up to 70% had anger feelings – towards themselves or others • Anger was related to pain intensity and decreased function • Perceived injustice Burns JW, Gerhart JI. Health Psychol 2015;34(5):547-55 Scott W, Trost Z. Pain 2013;154:1691-8
  19. 19. Cognitive factors • Passive life style / passive coping • Somatic focus • Pain related fear • Pain Catastrophizing • Kinesiophobia • Maladaptive behaviours
  20. 20. Sleep • Relationship is well documented • More than 50% of patients are affected • Decreased quality of sleep, longer sleep latency and fragmented sleep • Associated with depression, Diabetes, obesity • Sleep disturbances may be a stronger predictor of pain • Sleep deprivation increases pain sensitivity • Affect pain processing in multiple levels of neuaxis Finan PH, Goodin BR. J Pain 2013; 14 (12): 1539-1552

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