The document discusses pain management, including definitions of pain, classifications of pain types (nociceptive, neuropathic, and inflammatory), assessing pain intensity on a scale of mild, moderate and severe, pain duration categories of acute and chronic, and the structure of the pain analyzer in the body. It then outlines various treatment principles and methods for pain management, including nonpharmacological interventions like cognitive-behavioral techniques and physical modalities, as well as pharmacological approaches using analgesics, and interventional pain management procedures.

1. PAIN
MANAGEMENT

2. CONTENTS
• PAIN DEFINITION
• CLASSIFICATION OF PAIN
• PAIN INTENSITY
• TIME OF PAIN
• PAIN ANALYZER STRUCTURE
• TREATMENT PRINCIPLES AND METHODS

3. DEFINITION
• Pain is an unpleasant sensory and
emotional experience associated with
actual or potential tissue damage, or
described in terms of such damage
(according to IASP)

4. CLASSIFICATION OF PAIN (TYPES)
1. Nociceptive pain: It represents normal
response to noxious insult or injury of tissues. It
can be of 2 main groups:
a) Somatic: musculoskeletal, cutaneous
b) Visceral: hollow organs and smooth
muscles

5. 2. NEUROPATHIC PAIN:
pain initiated or caused by a primary lesion or
disease in the somatosensory nervous system.
o Sensory abnormalities range from deficits
perceived as numbness to hypersensitivity
(hyperalgesia or allodynia), and to paresthesias
such as tingling.
o Examples include, but are not limited to,
diabetic neuropathy, postherpetic neuralgia,
spinal cord injury pain, phantom limb (post-
amputation) pain, and post-stroke central pain.

6. 3. INFLAMMATORY PAIN:
a result of activation and sensitization of the
nociceptive pain pathway by a variety of mediators
released at a site of tissue inflammation.
o The mediators that have been implicated as key players
are proinflammatory cytokines such IL-1-alpha, IL-1-
beta, IL-6 and TNF-alpha, chemokines, reactive oxygen
species, vasoactive amines, lipids, ATP, acid, and other
factors released by infiltrating leukocytes, vascular
endothelial cells, or tissue resident mast cells
o Examples include appendicitis, rheumatoid arthritis,
inflammatory bowel disease, and herpes zoster.

7. PAIN INTENSITY
• Pain Intensity can be broadly categorized as:
mild, moderate and severe. It is common to
use a numeric scale to rate pain intensity
where 0 = no pain and 10 is the worst pain
imaginable:
• Mild: <4/10
• Moderate: 5/10 to 6/10
• Severe: >7/10

8. PAIN DURATION
• Acute pain: pain of less than 3 to 6 months
duration
• Chronic pain: pain lasting for more than 3-6
months, or persisting beyond the course of an
acute disease, or after tissue healing is
complete.
• Acute-on-chronic pain: acute pain flare
superimposed on underlying chronic pain.

9. STRUCTURE OF THE PAIN ANALYZER

11. Treatment principles and methods
1. NONPHARMACOLOGIC INTERVENTION.
This involves two main principles: cognitive-behavioral
and physical modalities(techniques)
a) Cognitive-behavioral:
approaches include such techniques as passive relaxation
with mental imagery, distraction, progressive relaxation,
biofeedback, hypnosis, and music therapy.
HOW IT WORKS
Cognitive-behavioral strategies can help patients understand
more about their pain, alter their pain behavior and coping skills,
and change their perception of pain or even forget about their
pain.

13. b).Physical techniques
include applications of heat and cold,
massage, exercise, and transcutaneous nerve
stimulation.
1. Heat application(thermotherapy):
Heat stimulates heat-sensing nerves in the skin
to send messages to the brain, which sends signals
back to the heated area to relax muscles and
increase blood flow. The theory is that the thermo-
receptor signals block the pain signals so that you
aren't as aware of the pain. Also, increased blood
flow due to the heat brings nutrients, oxygen and
white blood cells to the area to clean up the
damage and stimulate healing.

16. 2. COLD APPLICATION (CRYOROTHERAPY)
Physiological Effects of Cold Therapy
Systemic
Vasoconstriction
Piloerection
Shivering
Local
Temperature sensitive nerve endings send signals to
hypothalamus
Local vasoconstriction
Decreased capillary refill
Decreased cellular metabolism
Cold decreases pain by numbing the area and can also be very
effective against Inflammatory pain sensations due to it’s systemic
and local vasoconstriction effect and decrease metabolism.

18. 3.MASSAGE AND EXERCISE
Massage and exercise have the same effect of alleviating
muscle tension thereby reducing the neural activity (tone) of the
muscle. This reduces transmission of pain sensations to the brain
higher centers.

19. 3.Transcutaneous Electrical Nerve
Stimulation (TENS)
Transcutaneous electrical nerve stimulation (TENS) is
a therapy that uses low-voltage electrical current for pain relief.
HOW IT WORKS
When the current is delivered, some people experience
less pain. This may be because the electricity from the
electrodes stimulates the nerves in an affected area and sends
signals to the brain that block or "scramble" normal pain signals.

22. OTHER METHODS OF PAIN
MANAGEMENT
1. The use of Analgesics: they can be of 3 types:
- non-opioids (acetaminophen and the non-
steroidal anti-inflammatory drugs).
- opioid (hydromorphone, hydrocodone,
oxycodone, fentanyl etc)
- adjuvant analgesics(Dexamethasone,
Predsinone etc)

23. 2. INTERVENTIONAL PAIN MANAGEMENT
• What and When (indications):
Injection procedures and minimally invasive surgical
procedures are often used in combination with
medications, rehabilitation and psychological treatments to
treat or evaluate patients with acute and chronic, non-
cancer and cancer pain.

24. o Diagnostic injections to selectively target potential sources of pain
and differentiate the nociceptive pain generating structure when
the cause or source of pain is not obvious, e.g., non-radiating neck
or back pain.
o Treatments such as epidural steroid injections (for radiating limb
pain from herniated disc or spinal stenosis), and vertebroplasty
(for trunk pain in patients with vertebral compression fractures).
o Intrathecal drug delivery via implanted pump in certain situations
when systemic analgesia is not tolerated
o Spinal cord stimulation to relieve pain and/or spasticity in patients
who are refractory to systemic medication and have exhausted
other treatments.
o Neurolysis by radiofrequency or surgery to destroy nerve
structures; reserved for patients with a limited life expectancy.

25. THANKS FOR
YOUR
ATTENTION