The document discusses pain classification and mechanisms. It defines pain and different types including nociceptive, neuropathic, and chronic pain. It describes peripheral and central sensitization mechanisms. It discusses evaluation and management of neuropathic pain including first-line options like gabapentin, pregabalin, amitriptyline and second-line options like duloxetine, tramadol, opioids. Adverse effects and considerations with long term use are also summarized.
this presentation discusses pain pathways, definition and glossary of pain symptoms, classification of pain, pathogenesis, causes, diagnosis , types and treatment of neuropathic pain
illustrated with figures
this presentation discusses pain pathways, definition and glossary of pain symptoms, classification of pain, pathogenesis, causes, diagnosis , types and treatment of neuropathic pain
illustrated with figures
An update on the epidemiology and treatment of neuropathic pain. The slides were developed for a presentation in a departmental seminar at the Curtin University, Australia.
The presence of symptoms and/or signs of peripheral nerve dysfunction in people with diabetes after exclusion of other causes is called diabetic peripheral neuropathy.
The diagnosis is principally a clinical one. Patients with type 1 diabetes for 5 or more years and all patients with type 2 diabetes should be assessed annually.Treatment goals include
good glycemic control,symptomatic treatment and halt progressive nerve damage.
Medical management of neuropathic painSudhir Kumar
This presentation looks at medical therapies for the treatment of neuropathic pain. Neuropathic pain is commonly caused by diabetes, herpes zoster, trigeminal neuralgia, cancer, vitamin B12 deficiency, vasculitis, etc.
An update on the epidemiology and treatment of neuropathic pain. The slides were developed for a presentation in a departmental seminar at the Curtin University, Australia.
The presence of symptoms and/or signs of peripheral nerve dysfunction in people with diabetes after exclusion of other causes is called diabetic peripheral neuropathy.
The diagnosis is principally a clinical one. Patients with type 1 diabetes for 5 or more years and all patients with type 2 diabetes should be assessed annually.Treatment goals include
good glycemic control,symptomatic treatment and halt progressive nerve damage.
Medical management of neuropathic painSudhir Kumar
This presentation looks at medical therapies for the treatment of neuropathic pain. Neuropathic pain is commonly caused by diabetes, herpes zoster, trigeminal neuralgia, cancer, vitamin B12 deficiency, vasculitis, etc.
Neuropathic pain poses a challenge to effective rehabilitation. Best practice, considerations & the use of Action Potential Simulation therapy to effectively treat neuropathic pain, sharing our results from a 2 year research project in people with MS.
Overview of the anatomical pathways of acute and chronic pain, detailed explaination of the synapse, and summary of various types of pharmacological agents for chronic pain
Pharmacology of drugs for pain management important
Route of drugs administration change pharmacodynamic and pharmacokinetic of the drug must be explore to enrich our modality in pain management
Postoperative pain management not resolved completely still a problem for most of the physician involved in this area and the patients
a detailed description of pain and therpaeutic options available and clinical assessment of pain, approach to the patient with pain, assessment of intensity of pain, nsaids and opioids, tca. WHO pain ladder, chronic opioid therapy
yes this is my first presentation just prepared for my wkly presentation of oncology department RAJSHAHI MEDICAL COLLEGE. Though it was not that much good.
Neuropathic pain poses a challenge to effective rehabilitation. Best practice, considerations & the use of Action Potential Simulation therapy to effectively treat neuropathic pain, sharing our results from a 2 year research project in people with MS.
CONCEPT OF NODOPATHIES AND PARANODOPATHIES.pptxNeurologyKota
emergence of autoimmune neuropathies and role of nodal and paranodal regions in their pathophysiology.
Peripheral neuropathies are traditionally categorized into demyelinating or axonal.
dysfunction at nodal/paranodal region key for better understanding of patients with immune mediated neuropathies.
antibodies targeting node and paranode of myelinated nerves have been increasingly detected in patients with immune mediated neuropathies.
have clinical phenotype similar common inflammatory neuropathies like Guillain Barre syndrome and chronic inflammatory demyelinating polyradiculoneuropathy
they respond poorly to conventional first line immunotherapies like IVIG
This presentation briefs out the approach of dementia assessment in line with consideration of recent advances. Now the pattern of assessment has evolved towards examining each individual domain rather than lobar assessment.
This presentation contains information about Dementia in Young onset. Also it describes the etiologies, clinical feature of common YOD & their management.
Entrapment Syndromes of Lower Limb.pptxNeurologyKota
This presentation contains information about the various Entrapment syndromes of Lower limb in descending order of topography. It also contains information about etiology, clinical features and management of each of these entrapment syndromes with special emphasis on electrodiagnostic confirmation.
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
micro teaching on communication m.sc nursing.pdfAnurag Sharma
Microteaching is a unique model of practice teaching. It is a viable instrument for the. desired change in the teaching behavior or the behavior potential which, in specified types of real. classroom situations, tends to facilitate the achievement of specified types of objectives.
Flu Vaccine Alert in Bangalore Karnatakaaddon Scans
As flu season approaches, health officials in Bangalore, Karnataka, are urging residents to get their flu vaccinations. The seasonal flu, while common, can lead to severe health complications, particularly for vulnerable populations such as young children, the elderly, and those with underlying health conditions.
Dr. Vidisha Kumari, a leading epidemiologist in Bangalore, emphasizes the importance of getting vaccinated. "The flu vaccine is our best defense against the influenza virus. It not only protects individuals but also helps prevent the spread of the virus in our communities," he says.
This year, the flu season is expected to coincide with a potential increase in other respiratory illnesses. The Karnataka Health Department has launched an awareness campaign highlighting the significance of flu vaccinations. They have set up multiple vaccination centers across Bangalore, making it convenient for residents to receive their shots.
To encourage widespread vaccination, the government is also collaborating with local schools, workplaces, and community centers to facilitate vaccination drives. Special attention is being given to ensuring that the vaccine is accessible to all, including marginalized communities who may have limited access to healthcare.
Residents are reminded that the flu vaccine is safe and effective. Common side effects are mild and may include soreness at the injection site, mild fever, or muscle aches. These side effects are generally short-lived and far less severe than the flu itself.
Healthcare providers are also stressing the importance of continuing COVID-19 precautions. Wearing masks, practicing good hand hygiene, and maintaining social distancing are still crucial, especially in crowded places.
Protect yourself and your loved ones by getting vaccinated. Together, we can help keep Bangalore healthy and safe this flu season. For more information on vaccination centers and schedules, residents can visit the Karnataka Health Department’s official website or follow their social media pages.
Stay informed, stay safe, and get your flu shot today!
These simplified slides by Dr. Sidra Arshad present an overview of the non-respiratory functions of the respiratory tract.
Learning objectives:
1. Enlist the non-respiratory functions of the respiratory tract
2. Briefly explain how these functions are carried out
3. Discuss the significance of dead space
4. Differentiate between minute ventilation and alveolar ventilation
5. Describe the cough and sneeze reflexes
Study Resources:
1. Chapter 39, Guyton and Hall Textbook of Medical Physiology, 14th edition
2. Chapter 34, Ganong’s Review of Medical Physiology, 26th edition
3. Chapter 17, Human Physiology by Lauralee Sherwood, 9th edition
4. Non-respiratory functions of the lungs https://academic.oup.com/bjaed/article/13/3/98/278874
Prix Galien International 2024 Forum ProgramLevi Shapiro
June 20, 2024, Prix Galien International and Jerusalem Ethics Forum in ROME. Detailed agenda including panels:
- ADVANCES IN CARDIOLOGY: A NEW PARADIGM IS COMING
- WOMEN’S HEALTH: FERTILITY PRESERVATION
- WHAT’S NEW IN THE TREATMENT OF INFECTIOUS,
ONCOLOGICAL AND INFLAMMATORY SKIN DISEASES?
- ARTIFICIAL INTELLIGENCE AND ETHICS
- GENE THERAPY
- BEYOND BORDERS: GLOBAL INITIATIVES FOR DEMOCRATIZING LIFE SCIENCE TECHNOLOGIES AND PROMOTING ACCESS TO HEALTHCARE
- ETHICAL CHALLENGES IN LIFE SCIENCES
- Prix Galien International Awards Ceremony
Ethanol (CH3CH2OH), or beverage alcohol, is a two-carbon alcohol
that is rapidly distributed in the body and brain. Ethanol alters many
neurochemical systems and has rewarding and addictive properties. It
is the oldest recreational drug and likely contributes to more morbidity,
mortality, and public health costs than all illicit drugs combined. The
5th edition of the Diagnostic and Statistical Manual of Mental Disorders
(DSM-5) integrates alcohol abuse and alcohol dependence into a single
disorder called alcohol use disorder (AUD), with mild, moderate,
and severe subclassifications (American Psychiatric Association, 2013).
In the DSM-5, all types of substance abuse and dependence have been
combined into a single substance use disorder (SUD) on a continuum
from mild to severe. A diagnosis of AUD requires that at least two of
the 11 DSM-5 behaviors be present within a 12-month period (mild
AUD: 2–3 criteria; moderate AUD: 4–5 criteria; severe AUD: 6–11 criteria).
The four main behavioral effects of AUD are impaired control over
drinking, negative social consequences, risky use, and altered physiological
effects (tolerance, withdrawal). This chapter presents an overview
of the prevalence and harmful consequences of AUD in the U.S.,
the systemic nature of the disease, neurocircuitry and stages of AUD,
comorbidities, fetal alcohol spectrum disorders, genetic risk factors, and
pharmacotherapies for AUD.
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
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.
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
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
2. “Pain is an unpleasant sensory
and emotional experience
associated with actual or potential
tissue damage or described in
terms of such damage.”
3. Allodynia: Painless stimuli that are experienced
as pain eg. clothing, light touch.
Dysesthesias: Unpleasant perception of sensory
stimuli to skin
Hyperalgesia: An amplified response to a
noxious stimulus
Hyperesthesia: Delayed and explosive response
to noxious stimulus applied to affected area.
Paraesthesia: Spontaneous pins and needle
sensation.
4. The International Association for the Study of
Pain (IASP), defines chronic pain as pain
without apparent biologic value that has
persisted beyond the normal tissue healing
time (usually taken to be three months)
The American College of Rheumatology (ACR)
defines chronic pain as widespread or
regional pain Or at least three months
(DSM-IV) defines chronic pain as persistent
pain for six months
5.
6. Nociceptive pain — A nociceptor is a nerve fiber
preferentially sensitive to a noxious stimulus or
to a stimulus that would become noxious if
prolonged
Somatic and Visceral pain
Neuropathic Pain - arises from abnormal neural
activity secondary to disease, injury, or
dysfunction of the nervous system
1. Sympathetically mediated pain
2. Peripheral neuropathic pain
3. Central Pain
7. Mixed Type
Caused by a
combination of both
primary injury and
secondary effects
Nociceptive
Pain
Caused by activity in
neural pathways in
response to potentially
tissue-damaging
stimuli
Neuropathic
Pain
Initiated or caused by
primary lesion or
dysfunction in the
nervous system
Postoperative
pain
Mechanical
low back pain
Sickle cell
crisis
Arthritis
Postherpetic
neuralgia
Neuropathic
low back pain
Sports/exercise
injuries
*Complex regional pain syndrome
Central post-
stroke pain
Trigeminal
neuralgia
DPNP
8. Four physiologic processes are associated with pain:.
Transduction - the conversion of a noxious stimulus
(thermal, mechanical, or chemical) into electrical
activity in the peripheral terminals of nociceptor
sensory fibers.
Transmission - passage of action potentials from the
peripheral terminal along axons to the central
terminal of nociceptors in the central nervous
system..
Modulation - alteration (eg, augmentation or
suppression) of sensory input.
Perception refers to interpretation of afferent input in
the brain that gives rise to the individual's specific
sensory experience.
9.
10. CNS processing /Modulation –
- descending inhibitory and facilitatory signals
arising from the brain ie
somatosensory cortex, the hypothalamus, the
periaqueductal gray matter, and areas in the pons.
-synapse with nociceptive neurons in the dorsal horn
of the spinal cord interact with the opioid system,
noradrenergic system, and serotonergic system
11. Nociceptors –
high-threshold mechanoreceptors (HTMs) –
myelinated A delta
C-polymodal nociceptors (C-PMN) –
unmyelinated C fibres
Can respond to multiple stimuli –
heat,cold,chemical
12.
13. Peripheral sensitization -
Tissue damage releases chemicals –
Protons,K+,Serotnin ,Histamine ,Prostaglandins
,substance P activate nociceptors
Repeated/prolonged noxious stimuli causes
changes along the neuron and DRG+
Responds to lower threshold
Formation of neuromas ,collaterel spruting
Increased sodium channel expression
Demyelination
14. Ectopic Discharge- Increase in level of
spontaneous firing in injured neurons as well
as uninjured neighbouring neurons
Occurs due to alteration in expression of
sodium channels
Collateral Sprouting- Primary afferent neuron
injury leads to sprouting become sensitive to
low threshold mechanoreceptors
- These mechanisms may be Important in
Hyperalgesia and Allondynia
15. Central or spinal cord level
Increased sensitivity of spinal neurons
Expansion of the affected area- Normally
A delta & C innervate Lamina I and II of Dorsal horn
Large myelinated neurons also project to Lamina II
The glutamate-activated N-methyl-D-aspartic
acid (NMDA) receptor
NMDA receptor is phosphorylated, which
increases its distribution in the synaptic
membrane and its responsiveness to glutamate
20. 1. Initial management - treatment targeted to the
specific diagnosis. Eg.- Control of Diabetes,
Removing offending drug ,Releiving
compression
2. Simple Analgesics Acetaminophen /Nsaids
rarely helpful
3. Despite treatment – 3o -50 % reduction
4. Start at lowest dose increase every 3 to 7 days
to max tolerated dose
5. Physical, psychological, environmental and
behavioural factors
21. I. Most studies have been performed in postherpetic
neuralgia (PHN) and painful diabetic neuropathy (PDN)
II. Specific drug recommendations for the pharmacologic
treatment of neuropathic pain vary between these
multiple guidelines- IASP,EFNS,AAN ,NICE
III. First line agents include either calcium channel alpha
2-delta ligands (gabapentin or pregabalin ) or tricyclic
IV. Opioids should be considered a second or third-line
option.
V. Cause specific – Carbamzepine for trigeminal
neuralgia
23. Gabapentin and pregabalin bind to the voltage-gated
calcium channels at the alpha 2-delta subunit
PREGABALIN
Started at 50-75 mg/day increased till 150-600mg /day
Pregabalin may provide analgesia more quickly
than gabapentin
pregabalin has the limitation having a short half-life (5–
6.5 hours), which necessitates frequent administration
FDA approved in - Neuropathic pain – diabetic,post
herpetic neurlagia,Fibromyalgia
European Union appoved for Central Neuropathic pain –
Spinal Cord injuries ,Multiple sclerosis
24. American Academy of Physical Medicine and
Rehabilitation, in their joint evidence-based
guideline (2010), reported that pregabalin was
established to be effective and recommended that
it be offered for relief of painful diabetic
neuropathy (Level A recommendation)
AAN guidelines for painful diabetic
neuropathy(Level A) Pregabalin should be offered
"if clinically appropriate.“
25. Cardiovascular: Peripheral edema (≤16%)
Central nervous system: Dizziness (8% to 45%),
somnolence (4% to 36%), ataxia (1% to 20%),
headache (5% to 14%), fatigue (5% to 11%)
Gastrointestinal: Weight gain (≤16%), xerostomia
(1% to 15%)
Neuromuscular & skeletal: Tremor (≤11%)
Ocular: Blurred vision (1% to 12%), diplopia
(≤12%)
Miscellaneous: Infection (3% to 14%), accidental
injury (2% to 11%)
26. FDA approved for postherpetic neuralgia
Anticonvulsant: uncertain mechanism
Limited intestinal absorption
Usually well tolerated; serious adverse effects
rare
◦ dizziness and sedation can occur
No significant drug interactions
Peak time: 2 to 3 h; elimination half-life: 5 to
7 h
Usual dosage range for neuropathic pain up
to 3,600 mg/d (tid–qid)*
*
27. Mechanism of action – unknown
serotonin and norepinephrine reuptake inhibitors
- Amitriptyline most widely used
- doxepin , imipramine , nortriptyline ,
and desipramine also have been used with
success.
- Amitriptyline /nortriptyline may be started at
10 mg/d bedtime and slowly titrated up to an effective
analgesic dose (eg, 75 mg/d).
It can take up to six to eight weeks, including two
weeks at the highest dosage tolerated
- AAN guidelines in diabetic neuropathy – insufficient
evidence .
- IASP recommendation +
29. venlafaxine , desvenlafaxine , duloxetine ,
and milnacipran
1. Venlafaxine – Fewer side effects than TCAs
Less efficacious max- 150-225mg/day
2. Duloxetine – 60 -120 mg /day . Started at
30 mg/day ADR - nausea, somnolence, dry
mouth, constipation, reduced appetite,
diarrhea, hyperhidrosis, and dizziness,
30. topiramate , lamotrigine , levetiracetam ,phen
ytoin , valproate , zonisamide ,tiagabine ,
have been utilized anecdotally and in
randomized trials for various pain conditions
in general these agents should be reserved
for second line treatment
Except Carbamzepine for trigeminal neuralgia
31. The effi cacy of tramadol, including the combination
with acetaminophen, has been established mainly in
PDN
Tramadol should be initiated at low
dosages,particularly in elderly patients (50 mg once
daily), and then titrated as tolerated. The effective
dosage range is 200–400 mg/day.
Induces dizziness, dry mouth, nausea, constipation,
and somnolence and can cause or aggravate cognitive
impairment, particularly in the elderly.
There is an increased risk of seizures in patients with
previous epilepsy
32. now established that strong opioids
(oxycodone, methadone, and morphine) have
effi cacy in peripheral neuropathic pain.
doses necessary to reach efficacy may be
higher in neuropathic pain than in nociceptive
pain
Longterm morphine administration may be
associated with immunological changes and
hypogonadism
Long term use –addiction -2.6 %
33. Lidocaine 5% in pliable patch
Up to 3 patches applied once daily directly over
painful site
◦ 12 h on, 12 h off (FDA-approved label)
Efficacy demonstrated in 3 randomized controlled
trials on postherpetic neuralgia
Most appropriate for patients with well localized
neuropathic pain and Allodynia
Drug interactions and systemic side effects unlikely
◦ most common side effect: application-site sensitivity
Clinically insignificant serum lidocaine levels
34. Systemic activity
Applied away from painful site
Serum levels necessary
Systemic side effects
Peripheral tissue activity
Applied directly over painful site
Insignificant serum levels
Systemic side effects unlikely
Topical
(lidocaine patch 5%)
Transdermal
(fentanyl patch)
35.
36.
37.
38.
39. Capsaicin Patches
agonist of the transient receptor potential
vanilloid receptor (TRPV1) and activates
TRPV1 ligand-gated channels on nociceptive
fibers
Several days of capsaicin application, TRPV1-
containing sensory axons are desensitized,
which inhibits the transmission of pain
Can act as counterirritant
optimal duration of the patches - PHN (60
minutes) and HIV neuropathy (30 minutes).
40. Adverse effects w-local capsaicin-related
reactions at the application site
(pain, erythema, and sometimes edema and
itching)
potential risk of high blood pressure during
treatment
41. long-term efficacy of a series of
subcutaneous injections of BTX-A (from 100
to 200 units) injected into the painful area in
patients with mononeuropathies
(mainly of traumatic origin) , in patients with
diabetic painful polyneuropathies
discrepant data indicate the need for further
large-scale trials
42. 2007 review of studies found that injected)
administration of alpha lipoic acid (ALA) was
found to reduce the various symptoms of
peripheral diabetic neuropathy
at a dosage of 600 mg once daily over a
period of three weeks, alpha lipoic acid leads
to a significant and clinically relevant
reduction in neuropathic pain
Isosorbide dinitrite Spray For diabetic
neuropathy – NO generation ,local
vasodilating effect
43. α2- Agonists like clonidine reduce NT release
and decrease postsynaptic transmission.
Benzodiazepines
Baclofen – a GABAB receptor agonist
Botulinum toxin – inhibits Ach release at NMJ.
Ziconotide- blocks N-type voltage sensitive
Ca2+ channel.
Other Analgesics and Adjuvants
44. Neural blockade
◦ sympathetic blocks for CRPS-I and II
(reflex sympathetic dystrophy and causalgia)
Neurolytic techniques
◦ alcohol or phenol neurolysis
◦ pulse radio frequency
Stimulatory techniques
◦ spinal cord stimulation
◦ peripheral nerve stimulation
Medication pumps
45. TENS — Transcutaneous Electrical
Stimulation (TENS) involves the application of
electrical currents to the skin primarily for the
purposes of pain relief.
46. delivery of a low voltage electrical current from a
small battery-operated device to the skin via
surface electrodes
conventional TENS (high frequency >50hz, short pulse
duration, low intensity);
acupuncture-like TENS (low frequency <10 hz , long pulse
duration, high intensity);
burst TENS (high frequency trains of pulses delivered at a low
frequency);
and brief-intense TENS (high frequency and long pulse
duration pulses delivered at a high intensity)
systematic reviews have found variable and inconclusive
results of efficacy of TENS in chronic pain management
COCHRANE review 2008 – inconclusive
47. TENS electrodes are contraindicated:
1. Over the eyes due to the risk of increasing intraocular pressure
2. Transcerebrally
3. On the front of the neck due to the risk of an
acute hypotension (through a vasovagal reflex) or even
a laryngospasm
4. Through the chest using an anterior and posterior electrode
positions
5. Avoided if Cardiac Pacemaker present
6. Internally, except for specific applications of dental, vaginal,
and anal stimulation that employ specialized TENS units
7. On broken skin areas or wounds,
8. Over a tumour/malignancy
9. Directly over the spinal column
48. Exert pulsed electrical signals to the spinal
cord to control chronic pain
consists of a pulse generator with its remote
controls, implanted stimulating electrodes
and conducting wires
temporary screening trial with an external
pulse generator
49.
50. The most common use of SCS is failed back
surgery syndrome (FBSS)
treatment of inoperable ischemic limb pain
Complications include
lead migration,
lead breakage,
infection.
Other complications
include haematomas (subcutaneous or
epidural),cerebrospinal fluid (CSF) leak, post
dural puncture headache, discomfort at pulse
generator site, seroma and transient paraplegia.
51.
52. Cognitive behavioral therapy
Biofeedback
Relaxation therapy
Psychotherapy and individual or group
counseling
Aerobic exercise
Acupuncture
Physical and occupational therapy
53.
54. 1.International Association for the Study of Pain.
Classification of chronic pain. Pain; 24:S1.Guidelines for
Management .NOV 2010
2 .Attal N, Cruccu G, Baron R, et al. EFNS guidelines on the
pharmacological treatment of neuropathic pain: 2010
revision. Eur J Neurol 2010; 17:1113.
.3. . AAN Guidelines on Painful Diabetic Neuropathy
Susan Jeffrey – April 2011
4. NICE clinical guidelines – April 2013
55. - 5.. Bradley s Neurology – 6th Edition
- 6. www.uptodate .com
- 7.The neurologic Basis of Pain – Marco Pappagalo
2005
- 8. Nature Clinical Practice Neurology (2006) 2, 95-
106
doi:10.1038/ncpneuro0113 .Mechanisms of
neuropathic pain