Chronic Pains www.painclinic.lk

1. Chronic
Pains
- clinician’s perspective
Dr R Jayamaha
MBBS.MD.FIPP
16/24/16 10:06 PM

2. 2
Case Scenario
A 61 year 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 do we need to talk
about chronic pains
(Non-malignant)…?
3

4. Chronic Pain Prevalence in 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 chronic pain a NCD?
• Do all these NCDs have a
common link?
5

6. 6
Inflammation
Immune
Defense
Resolution
Basal Homeostasis
Classical, Acute,
Infectious Response
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 and chronic 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 is the 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. Pathophysiology of
Pain
11
DINC

12. What will happen to neural
pathways when pain becomes
CHRONIC?
12

13. Pathophysiology of
Pain
13
DINC
Increase in 1. Area 2. Severity 3. Duration

14. 14
1. Increased intensity of 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 When Pain
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 the important aspects of
managing Chronic Pains (Non
Malignant)?
18

19. 19
1. Diagnosis of Pain 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 Report Measurement
(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 Chronic Pain….
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 the treatment
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 you combine
these treatment
modalities to control
chronic pains?

25. 25
•Evidence & Experience on
disease entity
•Non Invasive
–Non pharmacological
–Pharmacological
•Invasive
–Interventional Pain Procedure
–Surgeries

26. Algorithm???
•Analgesic Ladder
•Analgesic Platform
26

27. 27
Non-pharmacological
methods
Non-
opioids
Weak opioids +/-
non-opioids
Strong
opioids
Recovery?
Neurosurgical
Procedures/Surgical
Destruction of
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 Patient Suffer 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?
Interventional Pain
Management Procedures
Non-opioids
Strong
opioids
Surgical Tx
Non-pharmacological methods

30. 30
Interventional Pain Management
Procedures
•Minimally invasive 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 and physical 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

32. 32

33. 33
•What are the
commonly
encountered chronic
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
A 61 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. Red and 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 this patient…
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
• Spinal Pains (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