The document discusses chronic pain and its differences from acute pain. It notes that chronic pain has different pathophysiology, including sensitization and changes in pain threshold. Treatment for chronic pain also differs and involves addressing more than just nociception. The document presents several case studies to illustrate features of chronic pain, including impacts on mood, behavior, function and the multifaceted nature of chronic pain. It also outlines the scope and definition of chronic pain medicine.
The evaluation of back pain can be a pain in the neck or a back-breaking exercise, so to speak. However, the diagnosis hinges always on a focused History and Physical Exam and not really on labs or imaging. Knowing what to ask and where to look can make the evaluation of this all-too-common condition manageable for the internist.
This lecture focuses on the evaluation of low back pain and will guide the reader on the key points in the Hx and PE and prevent unnecessary testing/imaging. It also presents 3 "unusual" cases of low back pain which may be disabling if not recognized immediately.
Chronic pain: Role of tricyclic antidepressants, dolsulepinSudhir Kumar
Chronic pain is common. Depression often co-exist with chronic pain. This article looks at the pathophysiology, prevalence of chronic pain and depression. The role of TCA, especially dosulepin and amitriptyline has been discussed.
No poison can kill a positive thinker and no medicine can cure a negative thinker. Pain is a complex perceptual experience. Pain is a major public health problem. Beat back pain without surgery and conquer pain without painkillers. Delays have dangerous ends. Knee braces invite injury. Chronic pain affects one in three people in the United States. There are more Americans suffering from chronic pain than with diabetes, heart disease, and cancer combined. Chronic pain is caused by degeneration, illnesses, injuries, surgeries, and treatment side effects. Pain is a major public health problem and is the most common reason why Americans use complementary and integrative health practices. Recent imaging evidence suggests a possible hypothalamic origin for a headache attack, but further research is needed. A migraine is associated with a modest increase in the risk of ischemic stroke.
Chronic pain is debilitating to individuals and to our economy, yet most treatments are based on the assumption that it is due to a physical cause. Once it is recognised that chronic pain is caused by our brain and central nervous system as part of a protective stress-processing response, then as this process is reversible, full recovery is possible.
SIRPA Ltd was set up to train health professionals to integrate into their own work the pioneering SIRPA approach, where the emphasis is on recovering from chronic pain, rather than management.
www.sirpauk.com
Title: Sense of Smell
Presenter: Dr. Faiza, Assistant Professor of Physiology
Qualifications:
MBBS (Best Graduate, AIMC Lahore)
FCPS Physiology
ICMT, CHPE, DHPE (STMU)
MPH (GC University, Faisalabad)
MBA (Virtual University of Pakistan)
Learning Objectives:
Describe the primary categories of smells and the concept of odor blindness.
Explain the structure and location of the olfactory membrane and mucosa, including the types and roles of cells involved in olfaction.
Describe the pathway and mechanisms of olfactory signal transmission from the olfactory receptors to the brain.
Illustrate the biochemical cascade triggered by odorant binding to olfactory receptors, including the role of G-proteins and second messengers in generating an action potential.
Identify different types of olfactory disorders such as anosmia, hyposmia, hyperosmia, and dysosmia, including their potential causes.
Key Topics:
Olfactory Genes:
3% of the human genome accounts for olfactory genes.
400 genes for odorant receptors.
Olfactory Membrane:
Located in the superior part of the nasal cavity.
Medially: Folds downward along the superior septum.
Laterally: Folds over the superior turbinate and upper surface of the middle turbinate.
Total surface area: 5-10 square centimeters.
Olfactory Mucosa:
Olfactory Cells: Bipolar nerve cells derived from the CNS (100 million), with 4-25 olfactory cilia per cell.
Sustentacular Cells: Produce mucus and maintain ionic and molecular environment.
Basal Cells: Replace worn-out olfactory cells with an average lifespan of 1-2 months.
Bowman’s Gland: Secretes mucus.
Stimulation of Olfactory Cells:
Odorant dissolves in mucus and attaches to receptors on olfactory cilia.
Involves a cascade effect through G-proteins and second messengers, leading to depolarization and action potential generation in the olfactory nerve.
Quality of a Good Odorant:
Small (3-20 Carbon atoms), volatile, water-soluble, and lipid-soluble.
Facilitated by odorant-binding proteins in mucus.
Membrane Potential and Action Potential:
Resting membrane potential: -55mV.
Action potential frequency in the olfactory nerve increases with odorant strength.
Adaptation Towards the Sense of Smell:
Rapid adaptation within the first second, with further slow adaptation.
Psychological adaptation greater than receptor adaptation, involving feedback inhibition from the central nervous system.
Primary Sensations of Smell:
Camphoraceous, Musky, Floral, Pepperminty, Ethereal, Pungent, Putrid.
Odor Detection Threshold:
Examples: Hydrogen sulfide (0.0005 ppm), Methyl-mercaptan (0.002 ppm).
Some toxic substances are odorless at lethal concentrations.
Characteristics of Smell:
Odor blindness for single substances due to lack of appropriate receptor protein.
Behavioral and emotional influences of smell.
Transmission of Olfactory Signals:
From olfactory cells to glomeruli in the olfactory bulb, involving lateral inhibition.
Primitive, less old, and new olfactory systems with different path
TEST BANK for Operations Management, 14th Edition by William J. Stevenson, Ve...kevinkariuki227
TEST BANK for Operations Management, 14th Edition by William J. Stevenson, Verified Chapters 1 - 19, Complete Newest Version.pdf
TEST BANK for Operations Management, 14th Edition by William J. Stevenson, Verified Chapters 1 - 19, Complete Newest Version.pdf
The evaluation of back pain can be a pain in the neck or a back-breaking exercise, so to speak. However, the diagnosis hinges always on a focused History and Physical Exam and not really on labs or imaging. Knowing what to ask and where to look can make the evaluation of this all-too-common condition manageable for the internist.
This lecture focuses on the evaluation of low back pain and will guide the reader on the key points in the Hx and PE and prevent unnecessary testing/imaging. It also presents 3 "unusual" cases of low back pain which may be disabling if not recognized immediately.
Chronic pain: Role of tricyclic antidepressants, dolsulepinSudhir Kumar
Chronic pain is common. Depression often co-exist with chronic pain. This article looks at the pathophysiology, prevalence of chronic pain and depression. The role of TCA, especially dosulepin and amitriptyline has been discussed.
No poison can kill a positive thinker and no medicine can cure a negative thinker. Pain is a complex perceptual experience. Pain is a major public health problem. Beat back pain without surgery and conquer pain without painkillers. Delays have dangerous ends. Knee braces invite injury. Chronic pain affects one in three people in the United States. There are more Americans suffering from chronic pain than with diabetes, heart disease, and cancer combined. Chronic pain is caused by degeneration, illnesses, injuries, surgeries, and treatment side effects. Pain is a major public health problem and is the most common reason why Americans use complementary and integrative health practices. Recent imaging evidence suggests a possible hypothalamic origin for a headache attack, but further research is needed. A migraine is associated with a modest increase in the risk of ischemic stroke.
Chronic pain is debilitating to individuals and to our economy, yet most treatments are based on the assumption that it is due to a physical cause. Once it is recognised that chronic pain is caused by our brain and central nervous system as part of a protective stress-processing response, then as this process is reversible, full recovery is possible.
SIRPA Ltd was set up to train health professionals to integrate into their own work the pioneering SIRPA approach, where the emphasis is on recovering from chronic pain, rather than management.
www.sirpauk.com
Title: Sense of Smell
Presenter: Dr. Faiza, Assistant Professor of Physiology
Qualifications:
MBBS (Best Graduate, AIMC Lahore)
FCPS Physiology
ICMT, CHPE, DHPE (STMU)
MPH (GC University, Faisalabad)
MBA (Virtual University of Pakistan)
Learning Objectives:
Describe the primary categories of smells and the concept of odor blindness.
Explain the structure and location of the olfactory membrane and mucosa, including the types and roles of cells involved in olfaction.
Describe the pathway and mechanisms of olfactory signal transmission from the olfactory receptors to the brain.
Illustrate the biochemical cascade triggered by odorant binding to olfactory receptors, including the role of G-proteins and second messengers in generating an action potential.
Identify different types of olfactory disorders such as anosmia, hyposmia, hyperosmia, and dysosmia, including their potential causes.
Key Topics:
Olfactory Genes:
3% of the human genome accounts for olfactory genes.
400 genes for odorant receptors.
Olfactory Membrane:
Located in the superior part of the nasal cavity.
Medially: Folds downward along the superior septum.
Laterally: Folds over the superior turbinate and upper surface of the middle turbinate.
Total surface area: 5-10 square centimeters.
Olfactory Mucosa:
Olfactory Cells: Bipolar nerve cells derived from the CNS (100 million), with 4-25 olfactory cilia per cell.
Sustentacular Cells: Produce mucus and maintain ionic and molecular environment.
Basal Cells: Replace worn-out olfactory cells with an average lifespan of 1-2 months.
Bowman’s Gland: Secretes mucus.
Stimulation of Olfactory Cells:
Odorant dissolves in mucus and attaches to receptors on olfactory cilia.
Involves a cascade effect through G-proteins and second messengers, leading to depolarization and action potential generation in the olfactory nerve.
Quality of a Good Odorant:
Small (3-20 Carbon atoms), volatile, water-soluble, and lipid-soluble.
Facilitated by odorant-binding proteins in mucus.
Membrane Potential and Action Potential:
Resting membrane potential: -55mV.
Action potential frequency in the olfactory nerve increases with odorant strength.
Adaptation Towards the Sense of Smell:
Rapid adaptation within the first second, with further slow adaptation.
Psychological adaptation greater than receptor adaptation, involving feedback inhibition from the central nervous system.
Primary Sensations of Smell:
Camphoraceous, Musky, Floral, Pepperminty, Ethereal, Pungent, Putrid.
Odor Detection Threshold:
Examples: Hydrogen sulfide (0.0005 ppm), Methyl-mercaptan (0.002 ppm).
Some toxic substances are odorless at lethal concentrations.
Characteristics of Smell:
Odor blindness for single substances due to lack of appropriate receptor protein.
Behavioral and emotional influences of smell.
Transmission of Olfactory Signals:
From olfactory cells to glomeruli in the olfactory bulb, involving lateral inhibition.
Primitive, less old, and new olfactory systems with different path
TEST BANK for Operations Management, 14th Edition by William J. Stevenson, Ve...kevinkariuki227
TEST BANK for Operations Management, 14th Edition by William J. Stevenson, Verified Chapters 1 - 19, Complete Newest Version.pdf
TEST BANK for Operations Management, 14th Edition by William J. Stevenson, Verified Chapters 1 - 19, Complete Newest Version.pdf
Lung Cancer: Artificial Intelligence, Synergetics, Complex System Analysis, S...Oleg Kshivets
RESULTS: Overall life span (LS) was 2252.1±1742.5 days and cumulative 5-year survival (5YS) reached 73.2%, 10 years – 64.8%, 20 years – 42.5%. 513 LCP lived more than 5 years (LS=3124.6±1525.6 days), 148 LCP – more than 10 years (LS=5054.4±1504.1 days).199 LCP died because of LC (LS=562.7±374.5 days). 5YS of LCP after bi/lobectomies was significantly superior in comparison with LCP after pneumonectomies (78.1% vs.63.7%, P=0.00001 by log-rank test). AT significantly improved 5YS (66.3% vs. 34.8%) (P=0.00000 by log-rank test) only for LCP with N1-2. Cox modeling displayed that 5YS of LCP significantly depended on: phase transition (PT) early-invasive LC in terms of synergetics, PT N0—N12, cell ratio factors (ratio between cancer cells- CC and blood cells subpopulations), G1-3, histology, glucose, AT, blood cell circuit, prothrombin index, heparin tolerance, recalcification time (P=0.000-0.038). Neural networks, genetic algorithm selection and bootstrap simulation revealed relationships between 5YS and PT early-invasive LC (rank=1), PT N0—N12 (rank=2), thrombocytes/CC (3), erythrocytes/CC (4), eosinophils/CC (5), healthy cells/CC (6), lymphocytes/CC (7), segmented neutrophils/CC (8), stick neutrophils/CC (9), monocytes/CC (10); leucocytes/CC (11). Correct prediction of 5YS was 100% by neural networks computing (area under ROC curve=1.0; error=0.0).
CONCLUSIONS: 5YS of LCP after radical procedures significantly depended on: 1) PT early-invasive cancer; 2) PT N0--N12; 3) cell ratio factors; 4) blood cell circuit; 5) biochemical factors; 6) hemostasis system; 7) AT; 8) LC characteristics; 9) LC cell dynamics; 10) surgery type: lobectomy/pneumonectomy; 11) anthropometric data. Optimal diagnosis and treatment strategies for LC are: 1) screening and early detection of LC; 2) availability of experienced thoracic surgeons because of complexity of radical procedures; 3) aggressive en block surgery and adequate lymph node dissection for completeness; 4) precise prediction; 5) adjuvant chemoimmunoradiotherapy for LCP with unfavorable prognosis.
Title: Sense of Taste
Presenter: Dr. Faiza, Assistant Professor of Physiology
Qualifications:
MBBS (Best Graduate, AIMC Lahore)
FCPS Physiology
ICMT, CHPE, DHPE (STMU)
MPH (GC University, Faisalabad)
MBA (Virtual University of Pakistan)
Learning Objectives:
Describe the structure and function of taste buds.
Describe the relationship between the taste threshold and taste index of common substances.
Explain the chemical basis and signal transduction of taste perception for each type of primary taste sensation.
Recognize different abnormalities of taste perception and their causes.
Key Topics:
Significance of Taste Sensation:
Differentiation between pleasant and harmful food
Influence on behavior
Selection of food based on metabolic needs
Receptors of Taste:
Taste buds on the tongue
Influence of sense of smell, texture of food, and pain stimulation (e.g., by pepper)
Primary and Secondary Taste Sensations:
Primary taste sensations: Sweet, Sour, Salty, Bitter, Umami
Chemical basis and signal transduction mechanisms for each taste
Taste Threshold and Index:
Taste threshold values for Sweet (sucrose), Salty (NaCl), Sour (HCl), and Bitter (Quinine)
Taste index relationship: Inversely proportional to taste threshold
Taste Blindness:
Inability to taste certain substances, particularly thiourea compounds
Example: Phenylthiocarbamide
Structure and Function of Taste Buds:
Composition: Epithelial cells, Sustentacular/Supporting cells, Taste cells, Basal cells
Features: Taste pores, Taste hairs/microvilli, and Taste nerve fibers
Location of Taste Buds:
Found in papillae of the tongue (Fungiform, Circumvallate, Foliate)
Also present on the palate, tonsillar pillars, epiglottis, and proximal esophagus
Mechanism of Taste Stimulation:
Interaction of taste substances with receptors on microvilli
Signal transduction pathways for Umami, Sweet, Bitter, Sour, and Salty tastes
Taste Sensitivity and Adaptation:
Decrease in sensitivity with age
Rapid adaptation of taste sensation
Role of Saliva in Taste:
Dissolution of tastants to reach receptors
Washing away the stimulus
Taste Preferences and Aversions:
Mechanisms behind taste preference and aversion
Influence of receptors and neural pathways
Impact of Sensory Nerve Damage:
Degeneration of taste buds if the sensory nerve fiber is cut
Abnormalities of Taste Detection:
Conditions: Ageusia, Hypogeusia, Dysgeusia (parageusia)
Causes: Nerve damage, neurological disorders, infections, poor oral hygiene, adverse drug effects, deficiencies, aging, tobacco use, altered neurotransmitter levels
Neurotransmitters and Taste Threshold:
Effects of serotonin (5-HT) and norepinephrine (NE) on taste sensitivity
Supertasters:
25% of the population with heightened sensitivity to taste, especially bitterness
Increased number of fungiform papillae
These lecture slides, by Dr Sidra Arshad, offer a quick overview of physiological basis of a normal electrocardiogram.
Learning objectives:
1. Define an electrocardiogram (ECG) and electrocardiography
2. Describe how dipoles generated by the heart produce the waveforms of the ECG
3. Describe the components of a normal electrocardiogram of a typical bipolar leads (limb II)
4. Differentiate between intervals and segments
5. Enlist some common indications for obtaining an ECG
Study Resources:
1. Chapter 11, Guyton and Hall Textbook of Medical Physiology, 14th edition
2. Chapter 9, Human Physiology - From Cells to Systems, Lauralee Sherwood, 9th edition
3. Chapter 29, Ganong’s Review of Medical Physiology, 26th edition
4. Electrocardiogram, StatPearls - https://www.ncbi.nlm.nih.gov/books/NBK549803/
5. ECG in Medical Practice by ABM Abdullah, 4th edition
6. ECG Basics, http://www.nataliescasebook.com/tag/e-c-g-basics
- Video recording of this lecture in English language: https://youtu.be/lK81BzxMqdo
- Video recording of this lecture in Arabic language: https://youtu.be/Ve4P0COk9OI
- Link to download the book free: https://nephrotube.blogspot.com/p/nephrotube-nephrology-books.html
- Link to NephroTube website: www.NephroTube.com
- Link to NephroTube social media accounts: https://nephrotube.blogspot.com/p/join-nephrotube-on-social-media.html
Couples presenting to the infertility clinic- Do they really have infertility...Sujoy Dasgupta
Dr Sujoy Dasgupta presented the study on "Couples presenting to the infertility clinic- Do they really have infertility? – The unexplored stories of non-consummation" in the 13th Congress of the Asia Pacific Initiative on Reproduction (ASPIRE 2024) at Manila on 24 May, 2024.
The prostate is an exocrine gland of the male mammalian reproductive system
It is a walnut-sized gland that forms part of the male reproductive system and is located in front of the rectum and just below the urinary bladder
Function is to store and secrete a clear, slightly alkaline fluid that constitutes 10-30% of the volume of the seminal fluid that along with the spermatozoa, constitutes semen
A healthy human prostate measures (4cm-vertical, by 3cm-horizontal, 2cm ant-post ).
It surrounds the urethra just below the urinary bladder. It has anterior, median, posterior and two lateral lobes
It’s work is regulated by androgens which are responsible for male sex characteristics
Generalised disease of the prostate due to hormonal derangement which leads to non malignant enlargement of the gland (increase in the number of epithelial cells and stromal tissue)to cause compression of the urethra leading to symptoms (LUTS
Ozempic: Preoperative Management of Patients on GLP-1 Receptor Agonists Saeid Safari
Preoperative Management of Patients on GLP-1 Receptor Agonists like Ozempic and Semiglutide
ASA GUIDELINE
NYSORA Guideline
2 Case Reports of Gastric Ultrasound
Report Back from SGO 2024: What’s the Latest in Cervical Cancer?bkling
Are you curious about what’s new in cervical cancer research or unsure what the findings mean? Join Dr. Emily Ko, a gynecologic oncologist at Penn Medicine, to learn about the latest updates from the Society of Gynecologic Oncology (SGO) 2024 Annual Meeting on Women’s Cancer. Dr. Ko will discuss what the research presented at the conference means for you and answer your questions about the new developments.
HOT NEW PRODUCT! BIG SALES FAST SHIPPING NOW FROM CHINA!! EU KU DB BK substit...GL Anaacs
Contact us if you are interested:
Email / Skype : kefaya1771@gmail.com
Threema: PXHY5PDH
New BATCH Ku !!! MUCH IN DEMAND FAST SALE EVERY BATCH HAPPY GOOD EFFECT BIG BATCH !
Contact me on Threema or skype to start big business!!
Hot-sale products:
NEW HOT EUTYLONE WHITE CRYSTAL!!
5cl-adba precursor (semi finished )
5cl-adba raw materials
ADBB precursor (semi finished )
ADBB raw materials
APVP powder
5fadb/4f-adb
Jwh018 / Jwh210
Eutylone crystal
Protonitazene (hydrochloride) CAS: 119276-01-6
Flubrotizolam CAS: 57801-95-3
Metonitazene CAS: 14680-51-4
Payment terms: Western Union,MoneyGram,Bitcoin or USDT.
Deliver Time: Usually 7-15days
Shipping method: FedEx, TNT, DHL,UPS etc.Our deliveries are 100% safe, fast, reliable and discreet.
Samples will be sent for your evaluation!If you are interested in, please contact me, let's talk details.
We specializes in exporting high quality Research chemical, medical intermediate, Pharmaceutical chemicals and so on. Products are exported to USA, Canada, France, Korea, Japan,Russia, Southeast Asia and other countries.
9. Remarks from Case 1
Pathophysiology is different from acute pain
Sensitization
Reduced pain threshold (hyperalgesia)
Non-painful stimulus (allodynia)
10. Remarks from Case 1
Pathophysiology is different from acute pain
Neuropathic pain
Site
Character
Timing
More than that…
11. Case 2
A man with fracture forearm, compartment syndrome
Fracture fixed, fasciotomy healed
Neurovascular integrity OK
But he has pain and other things
12. Case 2
A man with fracture forearm, compartment syndrome
What else do you noticed?
13. Case 2
A man with fracture forearm, compartment syndrome
What are the differentials?
14. Case 2
A man with fracture forearm, compartment syndrome
He want to chop his forearm off. Useful?
15. Remarks from Case 2
Impairment is different from acute pain
Pain can come without obvious pathology
Pain, motor, sudomotor or sensory changes
Trophic changes
Exclude differentials
One more example…
16. Case 3
A lady with difficulty in her dress
Diagnosis?
17. Case 3
A lady with difficulty in her dress
Does physiotherapy help?
18. Case 3
A lady with difficulty in her dress
Does topical therapy help?
19. Case 3
A lady with difficulty in her dress
Does NSAID help?
20. Case 3
A lady with difficulty in her dress
Does opioids help?
21. Remarks from Case 3
Treatment are different from acute pain
Partial response to “common” analgesics
Long term side effects
Tolerances, organ damages
Not all chronic pains are neuropathies…
23. Case 4
Lung cancer with pain in his chest, arm and abdomen
Why does he has a chest pain?
24. Case 4
Lung cancer with pain in his chest, arm and abdomen
Why does he has an arm pain?
25. Case 4
Lung cancer with pain in his chest, arm and abdomen
Why does he has an abdominal pain?
26. Case 4
Lung cancer with pain in his chest, arm and abdomen
What bother him most?
27. Remarks from Case 4
Pain is common source of distress
Multiple etiologies
Iatrogenic
Other somatic symptoms
Other psychosocial factors
Role of palliative medicine
Now, the classical onion…
32. Ms. Unhappy
She insisted to use a neck collar, visited 4 doctors for the
“right diagnosis”, alcohol to “knock me off the pain”
Behavior
33. Remarks from Case 5
Multi-facet problems of chronic pain
Nociception is different
Mood is altered
Behavior and thoughts are changed
Function is impaired
They are a different person altogether
Chronic pain is a disease of its own
Pain Management is a specialty of its own
35. Chronic pain as a disease
Definitions
“Pain extending for a long period of time, represents low
levels of underlying pathology that does not explain the
presence and extent of pain, or both”
Turk in: Bonica’s Management of Pain 3rd Ed.
“Pain without apparent biological value that persists beyond
normal tissue healing (usually taken to be 3 months)”
IASP 1986
36. Chronic pain as a disease
Impact of chronic pain
Elliott et al Lancet 1999
37. Chronic pain as a disease
Impact of chronic pain
10.8% of local adult Chinese
38% work affected
34% daily activities affected
30% on long term analgesics
Ng et al Clin. J. Pain 2002
38. Chronic pain as a disease
Impact of chronic pain
38 Billion Euro per year in Germany
62 Billion US$ per year in US
Zimmermann Orthopade 2004
Steward et al JAMA 2003
How much is this?
39. Chronic pain as a disease
How much is this?
Cost: 7 billion US$
40. Chronic pain as a disease
How much is this?
Cost: 4 million US$ per year
41. Chronic pain as a disease
Impact of chronic pain
White et al J. Occu. & Environ. Med. 2005
43. Scope of pain medicine
Etiology
Trauma (including iatrogenic)
Cancer (and its treatment)
Infections / inflammations
Mechanical / functional
Idiopathic
44. Scope of pain medicine
Etiology
Trauma (including iatrogenic)
Cancer (and its treatment)
Infections / inflammations
Mechanical / functional
Idiopathic
45. Scope of pain medicine
Complex Regional Pain Syndrome (CRPS)
Type I and II (with obvious nerve injury)
Which type is this one?
46. Scope of pain medicine
Complex Regional Pain Syndrome (CRPS)
Pathophysiology is unknown
Diagnosis is clinical
Investigations are not diagnostic
Treatment is empirical
Prognosis: 30% loss of work at 1 year
“early intervention to prevent disability”
Atkins J. Bone & Joint Surg 2003
47. Scope of pain medicine
Persistent post-operative pain
Bay-Nielson Annals of Surgery 2001
48. Scope of pain medicine
Persistent post-operative pain
Predictive factor: intensity of early post-op. pain
Most will resolve slowly
Is it preventable?
Role of pre-emptive analgesia still uncertain
Should be part of the surgical consent
49. Scope of pain medicine
Etiology
Trauma (including iatrogenic)
Cancer (and its treatment)
Infections / inflammations
Mechanical / functional
Idiopathic
50. Scope of pain medicine
Cancer pain
Over 50% cancer patients have severe pain at their end
What contribute to this un-desirable outcome?
51. Scope of pain medicine
Cancer pain
Difficulties with treatment
Side effects may be intolerable
Oral intolerance
Fatigue or impaired consciousness
52. Scope of pain medicine
Cancer pain
Difficulties with treatment
Patients and doctors refuse treatment
Denial of disease progression
Hope of curing the incurable
Myths of analgesics, including addiction
“Opio-phobia”
53. Scope of pain medicine
Etiology
Trauma (including iatrogenic)
Cancer (and its treatment)
Infections / inflammations
Mechanical / functional
Idiopathic
54. Scope of pain medicine
Acute low back pain
Leading cause for GP consultations
Most (>90%) gets better in 2 weeks
Blind investigation yield is very low (< 5%)
How many of you have this?
55. Scope of pain medicine
Acute low back pain
Most important: to exclude organic pathology
“Red flags”
Fever
History of trauma
Constitutional (weight / appetide loss)
Neurological (cauda equina /radiculopathy)
Non-spine pathology eg: pulsatile abdominal mass
56. Scope of pain medicine
Acute low back pain
Most important: to exclude organic pathology
“Red flags”
57. Scope of pain medicine
Acute low back pain
NSAID, paracetamol
Avoid opioids / muscle relaxants
Avoid aggressive physio
Avoid bed rest
Live a normal life
58. Scope of pain medicine
Acute low back pain
Predictive of chronicity and disability
“Yellow flag”
Fear avoidance behavior
Negative belief that pain is harmful or disabling
Excessive focusing on pain
Expectation on passive pain management
Linton Spine 2000
59. Scope of pain medicine
Acute low back pain
Predictive of chronicity and disability
“Yellow flag”
Depressed mood, social withdrawal
Co-existing financial and social problems
Poor job satisfaction
Linton Spine 2000
60. Scope of pain medicine
Chronic low back pain
We all pay if pain allowed to progress
61. Scope of pain medicine
Chronic low back pain
Structures potentially involved
Bone, disc, facet joints, ligaments, muscle, nerves
How can we tell?
62. Scope of pain medicine
Chronic low back pain
Musculoskeletal Examination k value
Tenderness 0.24
Muscle spasm < 0.2
Deyo JAMA 1992
63. Scope of pain medicine
Chronic low back pain
Neurological Examination k value
Weak ankle dorsiflexion 1.0
Normal ankle reflexes 0.39
Straight leg raising 0.6
Deyo JAMA 1992
64. Scope of pain medicine
Chronic low back pain
Non-organic signs
“find ways of predicting surgical failure to treat back pain”
8 physical signs associated with higher personality score
abnormalities, multiple surgeries and surgeon’s
suspicion.
Waddell 1980
65. Scope of pain medicine
Chronic low back pain
Non-organic signs
Non-anatomical motor / sensory loss
Superficial / non-anatomical tenderness
Simulation (pelvic rotate, axial load, distraction SLR)
Over-reaction
3 out of 8
66. Scope of pain medicine
Chronic low back pain
Mis-interpretation of non-organic signs
Malingering
Secondary gain
Exclude pathology
False positives
67. Scope of pain medicine
Chronic low back pain
Investigations
Poor correlation with imaging findings
This is obvious
68. Scope of pain medicine
Chronic low back pain
Investigations
Poor correlation with imaging findings
This is less obvious
69. Scope of pain medicine
Chronic low back pain
Investigations
Diagnostic nerve / joint blocks
Under-utilized
70. Scope of pain medicine
Chronic low back pain
Surgery is indicated if
Failed conservative treatment
Demonstrable pathology
Correlation with clinical findings
Minimal psychosocial complications
Why are we so cautious?
71. Scope of pain medicine
Chronic low back pain
Failed back surgery syndrome (FBSS)
More MRI, more surgery
Therefore…
72. Scope of pain medicine
Chronic low back pain
Failed back surgery syndrome (FBSS)
Fritsch Spine 1996
73. Try this one
37 year old kindergarten teacher
Sprained her back while lifting a child 2 years ago
Seen GP and several Orthopediac surgeons
Had a few spine X-rays and an MRI
“Bone spurs everywhere”
Scheduled for spinal fusion
Patient next bed: “I have that 3 times, and I’m still here”
You are consulted: “for better analgesics”
74. Try this one
37 year old kindergarten teacher
How would you assess her?
Any “better analgesic” to offer?
