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Pain
Chronic pains are highly prevalent conditions that are often linked through metaflammation and lifestyle factors. When pain becomes chronic, it undergoes pathological changes including sensitization of the peripheral and central nervous system. Effective management of chronic pains requires a multimodal approach that addresses both the source of pain and pain control through non-invasive and minimally invasive methods before considering more aggressive options.
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Pain
- 1. Chronic Pains - clinician’s perspective DrR Jayamaha MBBS.MD.FIPP 16/24/16 10:06 PM
- 2. 2 Case Scenario A 61year old man presented to our CPC with Severe low back pain (8/10) going down to Left > Right L/L for 4-5years duration. He has been treated by many doctors including neurological and neurosurgical specialists. Failing all possible medical treatments, he was asked to get a spinal surgery done. However patient declined that option. When he presented, 1. he had no red/yellow flags and 2. had no neurological impairment but only pain issues. 3. PACE/FAIR test was negative. SLRT B/L > 70 0 4. He already had two MRI scans of spine done and diagnosed as having two bulging lumbar discs without central or lateral canal stenosis. Sciatica Sx Tx Refused Sx NOT indicated?
- 3. • Why dowe need to talk about chronic pains (Non-malignant)…? 3
- 4. Chronic Pain Prevalencein the USA… • An estimated 50 million to 75 million people live with chronic pains (defined as constant pain lasting at least three months.) • 22% of all primary care patients have chronic pains. In Sri Lanka… Period of data collection: 24/01/2012 – 03/05/2012 3months No of patients assessed: 536 Ages : 16 – 90yr <20yr – 0.75% 20-50 – 23% 50-80 – 74% >80 - 2.25% Male/ Female: 1/3 Patients with chronic pain complains : 67% Other complains: 33% Systems responsible: CVS : 17% NS : 46% MSK : 36% Other : 1% 4
- 5. • Is chronicpain a NCD? • Do all these NCDs have a common link? 5
- 6. 6 Inflammation Immune Defense Resolution Basal Homeostasis Classical, Acute, InfectiousResponse ImmuneReaction Chronic Allostasis Modern, Chronic. Non-infectious Response Disease‘Dys- Metab Olism’ ‘Meta- flammation’ Oxidative stress Insulin Resistance Lifestyle/ Environmental ‘Inducer’ Microbial Pathogen/ ‘Antigen’ Forms of Inflammation… Egger G, Dixon J. Obes Rev 2009 )
- 7. 7 Affected Organs • Endothelium (atherosclerosis) •Lung (COPD) •Brain (Alzheimer’s/ Dementia) • Joints (arthritis) • Bowel (IBD) • Neuron/Glia (neuropathic/ ‘gliapathic’? pain) Range of ‘Metaflammatory’ Effects… Ref: Libby P. Nature, 2010
- 8. 8 Obesity andchronic pains are linked biologically through ‘metaflammation’ with glia playing a major role. Metafammation is lifestyle related. Hence chronic neuropathic (‘gliapathic’?) pain is lifestyle-related – leading to the conclusion that: Lifestyle changes need to be incorporated into any new ‘holistic’ paradigm for chronic pain management.
- 9. • What isthe definition of PAIN? • When do you call it CHRONIC? 9
- 10. 10 Definition of Pain •“An unpleasant sensory and emotional experience associated with actual or potential tissue damage, or described in terms of such damage, or both.” International Association for the Study of Pain ( IASP:2001 Chronic >3/12
- 11.
- 12. What will happento neural pathways when pain becomes CHRONIC? 12
- 13. Pathophysiology of Pain 13 DINC Increase in1. Area 2. Severity 3. Duration
- 14. 14 1. Increased intensityof pain. 2. Increased area of pain. 3. Increased duration of pain. 4. Allodynia 5. Decreased tolerability to pain. 6. Development of psychological problems (e.g.. depression due to decreased serotonin level). 7. SNS mediated: redness, edema, painful joint movements, decreased skin temperature, fall of hairs. ”Complex Regional Pain Syndrome” 8. Neurological deficit in the area of pain
- 15. 15 What Happens WhenPain Becomes Chronic? Sensitization is a phenomenon of inappropriate or disproportionate response to normal stimulus Peripheral Sensitization Central Sensitization
- 16. 16 Categorising Pains Acute Pain/Physiological Pain 1. Mostly Nociceptive • Mostly Symptom of a disease • Treatment of diseases cures pain & it is self-limiting. • Simple relationship between pain and tissue damage • Proportionate to the clinical finding Chronic Pain /Pathological Pain 1. Mostly Neuropathic • Mostly a disease by itself (a disease of nervous system). • Difficult to treat & sustaining. Our aim is to control but cure • Dissociated relationship between pain and tissue damage • Disproportionate to the clinical finding True for Acute Pain which is an ALARM. However Chronic Pain can be a false alarm and it may be a disease.
- 17. 17 In Treating Pains… Source+ Pain Control •Non Pharmacological methods •NSAIDs/Paracetamol •Tramadol/Opioids •Regional analgesia Correcting neuropathy/sensitization Treatment for peripheral sensitization Na-Channel blocker, Ca-Channel blocker Treatment for central sensitization NMDA antagonist, Ca-Channel blocker, Opioids, drugs inhibiting Sub P, drugs enhances inhibitory synapses. Restoration of descending neuronal inhibitory Control (DINC) Tramadol OR Tricyclics /SNRI Cure Control
- 18. What are theimportant aspects of managing Chronic Pains (Non Malignant)? 18
- 19. 19 1. Diagnosis ofPain AETIOLOGY 2. ASSESSMENT of Pain 1.Severity ,Type, Location/origin (Somatic/Visceral/Referred) 2.Pain is DYNAMIC - reassess 3. Control Pain and Treat Aetiology in a TIMELY MANNER. 4. Treatment of COMORBIDITIES eg. Psychological issues/ Other NCDs
- 20. 20 • Non-Self ReportMeasurement (Respiratory and cardiovascular changes as well as changes in expression and movements) • Self-Report Measurement (Numerical or adjective ratings and visual analogue scales) Pain Severity Assessment…
- 21. 21 In Controlling ChronicPain…. MUTIMODAL/ INTER-DISCIPLINARY APPROACH Cure sometimes, Treat often, Comfort always. -Hippocrates – Dysfunction in family, vocational, and social life – Mental and physical suffering – Increased suicide rates – Extensive, costly, unhelpful work- ups and treatment – Increased disability costs
- 22. What are thetreatment modalities to control chronic pains? 22
- 23. 23 Modalities of Treatment •Non Invasive –Non pharmacological –Pharmacological • Invasive –Interventional Pain Procedure –Surgeries
- 24. 24 How do youcombine these treatment modalities to control chronic pains?
- 25. 25 •Evidence & Experienceon disease entity •Non Invasive –Non pharmacological –Pharmacological •Invasive –Interventional Pain Procedure –Surgeries
- 26.
- 27. 27 Non-pharmacological methods Non- opioids Weak opioids +/- non-opioids Strong opioids Recovery? Neurosurgical Procedures/Surgical Destructionof Neuro-pathways WHO Model… +/- adjuvant Cancer Pains Chronic Non-Cancer Pains Missing link Between Med & Sx Mx Strong Opioid can not be given to non cancer chronic pains as they cannot be rehabilitated and can get addicted. So that the gap is broader
- 28. 28 Recovery? Lest Your PatientSuffer When your Pharmacological Armamentarium is empty…???... World of Misery Non- opioids Weak opioids +/- non- opioids Strong opioids Operation Non-pharmacological methods
- 29. 29 Weak opioids +/- non- opioids Recovery? InterventionalPain Management Procedures Non-opioids Strong opioids Surgical Tx Non-pharmacological methods
- 30. 30 Interventional Pain Management Procedures •Minimallyinvasive procedures done under local anesthesia and image guidance (X Ray/ US) which are capable of detecting pain generators and treating them giving permanent/long term pain relief by stopping nociceptive inputs and/or correcting neuropathy. •They fill the gap between pharmacologic management of pain & more invasive operative procedure. (The missing link) • Injections – Local/Spinal/ ITDD » Dry needling » LA/ Steroids /Ozone/ Prolotherapy/Botox » ITDD systems » Vertibroplasty/ kyphoplasty • Ablation – Cryo/Radiofrequency • Electro-stimulation – Peripheral / spinal cord StimulationDiagnosis and management of… • Non Spinal – MFPS – Joints/Enthesis – Peripheral Nn – Sympathetically mediated/ Maintained pains by Ganglion BLK • Spinal – Facet Joint – Disc – Vertibrae – Intraspinal
- 31. 31 A -Physiotherapy andphysical therapy | B -Mind–body integration (e.g. yoga, meditation and religious support) | C -Hypnosis and relaxation therapy | D -Acupuncture | E -Chiropractic | F -External rub/lotions | G -Other CAM options (Tai chi, Tui Na) | H -Muscle relaxants (e.g. cyclobenzaprine, baclofen and dantrolene) | I -Injectable agents (steroids, local anaesthetics) | J -Interpersonal reinforcement (e.g. support group) | K -Anticonvulsants (e.g. gabapentin, pregabalin and lamotrigine) | L -Antidepressants (e.g. tricyclics, SSRI, SNRI) | M -Compounds that act synergistically with opioids like cannabinoids (nabilone) | N -Cognitive behaviour therapy and psychological counselling O -Surgical and neurosurgical procedures (e.g. spinal cord stimulation, deep brain stimulation, spinal delivery of opioids, ganglion ablation by phenol or electrofrequency, sympathectomy) Lawrence Leung MBBChir(Cantab), MFM(Clin), CCFP, FRACGP, FRCGP VOLUME 4 • NUMBER 3 • SEPTEMBER 2012 JOURNAL OF PRIMARY HEALTH CARE
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- 33. 33 •What are the commonly encounteredchronic pain issues?
- 34. 34 • Spinal Pains •Headaches • Shoulder pains • Lower Limb Degenerative arthritis • Painful neuropathies • Enthesopathies like G/E , T/E & Plantar Fasciitis • Carpal Tunnel XD In Our Clinic
- 35. 35 Low Back Pain A61 year old man presented with Severe low back pain (8/10) going down to Left > Right L/L for 4-5years duration. He has seen many doctors including neurological specialists. In the end, he was asked to get a spinal surgery done but he was not consenting for that. He was prescribed with all possible pain killers over the past with almost no relief. When he presented, he had no red/yellow flags and had no neurological impairment but only pain issues. PACE/FAIR test was negative. He already had two MRI scans of spine done and diagnosed as having two bulging lumbar discs without central or lateral canal stenosis. Sciatica Sx Tx Refused Sx NOT indicated?
- 36. 36 Facts …… 1. Redand Yellow flags (Waddell sings) of Spinal pains. 2. Spinal Pains originate from multiple sites (multiple pain generators) 3. Clinical findings and Investigations (Imaging) should be correctly correlated 4. Surgical interventions may not be the 1st line treatment for spinal pains without neurological deficit 5. Evidence/ Experience on various interventions?... Therefore derangement of one structure will create multiple pain generators in the back!
- 37. 37 When assessing thispatient… we found multiple pain generators…. 1.Myofascial low back pains with trigger points 2.B/L Sacro-illiac dysfunction 3.Facet Joint Arthritis 4.Discogenic Low back Pain with L/Sciatica
- 38. 38 Management 1. Analgesics (Nociceptive+ Neuropathic) 2. Physical Therapy & Counseling 3. Trigger point injection 4. Sacro-illiac Joint injection 5. Facet Denervation 6. Selective Nerve Root Block B/L - L4, L5 7. Dekompressor discectomy
- 39. Take Home Message! 39 • SpinalPains (Back Pain)…Neck Pains • Headaches • Shoulder pains • Lower Limb Degenerative arthritis • Painful neuropathies • Enthesopathies like G/E , T/E & Plantar Fasciitis • Carpal Tunnel XD There is still a lot of hopes….. …for those whose pain issues are not addressed by Thank You www.painclinic.lk http://www.painclinic.lk/wp-content/uploads/2012/11/Chronic-Pains.pdf