Presented by: Dr Brendan Moore — Pain Medicine Specialist Physician Event: The Team Approach to Low Back Pain - 2014

1. “This
Unbearable
Pain”
The
Post-­‐opera4ve
Dilemma
Dr
Brendan
Moore
Pain
Medicine
Specialist
Physician
Adjunct
Associate
Professor
University
of
Queensland

2. Topics
for
today
• Post
opera0ve
pain
Dilemma
Workshop
• Interven0ons
for
mechanical
back
pain
• Opioid
issues
• Psychology
in
pain
Pa0ents

3. 3
Messages
• Early
Iden0fica0on
and
treatment
of
neuropathic
pain
• Management
of
post
op
opioids
• Example
of
medica0on
regimes

4. • “An
unpleasant
sensory
and
emo0onal
experience
associated
with
actual
or
poten0al
0ssue
damage,
or
described
in
terms
of
such
damage.”
Defining
pain
Interna0onal
Associa0on
for
the
Study
of
Pain
Web
site.
Available
at:
hIp://www.iasp-­‐pain.org/terms-­‐p.html.
Accessed
30
June,
2006.
Interna0onal
Associa0on
for
the
Study
of
Pain
(IASP)

5. The
con(nuum
of
pain1
<1
month
Time
to
resolu4on
≥3-­‐6
months
Acute
Pain
Chronic
Pain
• Usually
obvious
0ssue
damage
• Increased
nervous
system
ac0vity
• Pain
resolves
upon
healing
• Serves
a
protec0ve
func0on
• Pain
for
3-­‐6
months
or
more2
• Pain
beyond
expected
period
of
healing2
• Usually
has
no
protec0ve
func0on3
• Degrades
health
and
func0on3
1.
Cole
BE.
Hosp
Physician
2002;
38:
23-­‐30.
2.
Turk
DC
and
Okifuji
A.
Bonica’s
Management
of
Pain
2001.
3.
Chapman
CR
and
S0llman
M.
Pain
and
Touch
1996.
Insult

6. Classifica(ons
of
pain
Acute
Chronic
Dura4on
Nocicep4ve
Neuropathic
Pathophysiology

7. Biomedical Aspects of Pain1,2
• Nociceptive pain è noxious stimuli, e.g.
ongoing tissue damage
• Neuropathic pain è neurological injury or
dysfunction
• Clinical features suggesting neuropathic pain:
– Absence of obvious tissue damage or inflammation
– Characteristic descriptors:
• Burning, shooting, sharp pain
– Sensory findings both
• Positive e.g. allodynia/hyperalgesia
• Negative e.g. sensory loss
1. Analgesic Expert Group Therapeutic Guidelines: Analgesic. 2007
2. Jensen TS, et al. Eur J Pharmacol 2001;429:1-11.

8. Nocicep4ve
Neuropathic
Nocicep(ve
vs
neuropathic
pain
states
• Arises
from
s0mulus
outside
of
nervous
system
• Propor0onate
to
receptor
s0mula0on
• When
acute,
serves
protec0ve
func0on
• Arises
from
primary
lesion
or
dysfunc0on
in
nervous
system
• No
nocicep0ve
s0mula0on
required
• Dispropor0onate
to
receptor
s0mula0on
• Other
evidence
of
nerve
damage
vs
Serra
J.
Acta
Neurol
Scand
1999;
173(Suppl):
7-­‐11.

9. Nocicep(ve
and
neuropathic
pain
• Arthri0s
• Sports/exercise
injuries
• Postopera0ve
pain
Neuropathic
pain
Nocicep4ve
pain
Mixed
• Painful
DPN
• PHN
• Neuropathic
low
back
pain
• Trigeminal
neuralgia
• Central
poststroke
pain
• Complex
regional
pain
syndrome
• Distal
HIV
polyneuropathy
Caused
by
lesion
or
dysfunc4on
in
the
nervous
system
Caused
by
4ssue
damage
Caused
by
combina4on
of
primary
injury
and
secondary
effects
• Low
back
pain
• Fibromyalgia
• Neck
pain
• Cancer
pain
Interna0onal
Associa0on
for
the
Study
of
Pain.
IASP
Pain
Terminology.
Raja
SN,
et
al.
in
Wall
PD,
Melzack
R
(Eds).
Textbook
of
pain.
4th
Ed.
1999;
11-­‐57.

10. “Scia(ca”:
mixed
pain
state
Baron
R,
Binder
A.
Orthopade
2004;
33:
568-­‐75.
Disc
C
fibre
C
fibre
A
fibre
Nocicep4ve
component:
Sprou0ng
from
C-­‐fibres
into
the
disc
Neuropathic
component
I:
Damage
to
a
branch
of
the
C
fibre
due
to
compression
and
inflammatory
mediators
Neuropathic
component
II:
Compression
of
nerve
root
Neuropathic
component
III:
Damage
to
nerve
root
by
inflammatory
mediators
Central
sensi4sa4on

11. Neuropathic Pain
• Bad post operative prognostic
indicator
• Early effective treatment plan
required
1. Analgesic Expert Group Therapeutic Guidelines: Analgesic. 2007
2. Jensen TS, et al. Eur J Pharmacol 2001;429:1-11.

12. Management
of
pain
Belgrade
MJ.
Postgrad
Med
1999;
106:
101-­‐40.
Ashburn
MA,
Staats
PS.
Lancet
1999;
353:
1865-­‐69.
Abuaisha
BB,
et
al.
Diabetes
Res
Clin
Pract
1998;
39:
115-­‐21.
Pharmacotherapy
Physical
rehabilita4on
Interven4onal
regional
anesthesia
Complementary/
alterna4ve
Lifestyle
Neuros4mulatory
Psychological
Treatment
approaches

13. Observa4ons
and
Advice
from
the
clinical
“coal
face”

14. Post
opera0ve
Pain
• Strong
analgesia
ceased
at
2
to
4
weeks
• Important
to
plan
to
cease
strong
analgesia
• Surgeon
doesn’t
intend
long
term
con0nua0on
of
post
op
analgesia
• Propor0on
of
pa0ents
fail
the
plan
!!

15. Need
a
New
Plan
!!
• Change
in
the
Pain
• Mixed
pain
condi0on
– Nocicep0ve
and
Neuropathic
• Comprehensive
Management
plan
– Not
medica0ons
alone
– Aim
at
restora0on
of
physiotherapy
and
func0on

16. Medica0on
Plan
• Paracetamol
/
NSAIDs
• Adjuvant
Analgesics
• Gabapen0n
/
Pregabalin
• Tricyclic
an0depressants
(or
others)
• Strong
Analgesia

17. Strong
Analgesia
A
setback
not
a
sentence!!
• Clear
defini0ve
plan
• Short
term
increase,
then
reduce
and
cease
• Sustained
release
only
• By
the
mouth
and
by
the
Clock
• No
short
term,
no
breakthrough
• Pre-­‐determined
dose
reduc0on

18. Favoured
Cocktails
and
Recipes

19. Favoured
Cocktails
and
Recipes
1. Paracetamol1gm,
qid
2. NSAIDs
– Ibuprofen
400mg
tds
– Celecoxib
200mg
bd
è
100mg
bd
3. Tricyclic
An0depressant
– Amitriptyline
10
è50mg
nocte
– Seda0on
and
sleep
acceptable
(oien
desirable)

20. Favoured
Cocktails
and
Recipes
4.
Gabapen0noids
• Gabapen0n
300mg,
300mg,
600mg
• Pregabalin
150mg,
300mg
Staged
increase
in
dose
Higher
dose
at
night
Opioid
sparing
effect

21. Favoured
Cocktails
and
Recipes
• Strong
Analgesia
Oxycon0n
10
or
20mg
x
20
tabs
2tabs
x
5days
then,
1
tab
x
10
days
Hydromorphone
4mg
x
20
tabs
8mg
daily
x
5
days
then,
4mg
daily
x
10
days

22. Favoured
Cocktails
and
Recipes
• Strong
Analgesia
Oxycon0n
10
or
20mg
x
20
tabs
2tabs
x
5days
then,
1
tab
x
10
days
Hydromorphone
4mg
x
20
tabs
8mg
daily
x
5
days
then,
4mg
daily
x
10
days
Tramadol
Tapentadol

23. Pain
the
Fiih
Vital
Sign™
Need
to
regularly
ask
about
the
presence
of
pain.
American
Pain
Society
Mashford
ML
et
al,
Therapeu0c
Guidelines:
Analgesics
Ed
4,
2002

24. 3
Messages
• Management
of
post
op
opioids
• Early
Iden0fica0on
and
treatment
of
neuropathic
pain
• Medica0on
regimes

25. END

26. How persistent pain can
become a problem
Adapted from: Nicholas, 2008.

27. Is
the
Pain
Mechanical
or
Not?
Mechanical Non-Mechanical
(red flags)
Pain
" Poorly localised
" Worse later in the day
" Usually worst when sitting, worsens
with movement
" Usually localised
" No diurnal variations
" Uninfluenced by posture or movement
Spinal movement
" Painful limited movement usually of
several segments
" Normal or hypomobility limited to one
or two segments
Tenderness
" Diffuse " Localised
Other features
" Patient is essentially well " Of underlying disease
Neurological signs
" May be present " May be present
Adapted
from
Mashford.
Therapeu0c
Guidelines
Analgesic;
2002.

28. Acute and Persistent Pain:
Different Clinical Entities1
• Acute pain:
– Recent onset
– Expected to last a short
time
– Expectation is complete
recovery
• Persistent pain:
– Persists for > 3 months
– Expectation is not one
of cure
Recurrent acute pain,
feature elements of both acute and
persistent pain
1. Analgesic Expert Group Therapeutic Guidelines: Analgesic. 2007

29. Red Flags1
• Most clues are in the history
1. Australian Acute Musculoskeletal Pain Guidelines Group. Evidence-based management of acute musculoskeletal pain. A guide for clinicians. 2004.
Feature
or
Risk
Factor
Condi4on
Symptoms
or
signs
of
infec0on
(e.g.
fever)
Risk
of
infec0on
(e.g.
penetra0ng
wound)
Infec0on
History
of
trauma
or
minor
trauma
(if
>
50
years,
osteoporosis
+
cor0costeroid
use)
Fracture
Previous
history
of
cancer
Unexplained
weight
loss
Age
>
50
years
Pain
at
rest
Pain
at
mul0ple
sites
Failure
to
improve
with
treatment
Tumour
Absence
of
aggrava0ng
factors
Aor0c
aneurysm

30. Pain and Impact on Quality of
Life1
Physical well-being Psychological well-being
Stamina/strength
Appetite
Sleep
Functional capacity
Comfort/pain
Coping
Control
Enjoyment/happiness
Sense of usefulness
Anxiety/depression/fear
Social well-being Spiritual well-being
Social support/family
Sexuality/affection
Employment
Finances
Roles and relationships
Isolation/dependence/burden
Religion
Sense of purpose/meaning/
worth
Hopefulness
Uncertainty
Suffering
1. Lynch TJ, Jr. Pain the fifth vital sign. J Intravenous Nursing 2001;24(2):85-94

31. Factors Associated with Persistent Back Pain1
• Structural changes on spinal imaging
• Disc degeneration
• Disc tears / prolapse
• Facet joint degeneration
• Central & lateral canal stenosis
1. Waris E, et al. Spine 2007 15;32(6):681-4. 2. Jarvik JG, et al. Spine 2005;30(13):1541-8.
3. Schenk P, et al. Spine 2006;31(23):2701-6. 4. Videman T, et al. Spine 2003;28(6):582-8.
Common
as we age
but not
associated
with pain

32. GP’s Role1
• Patient education and motivating change
• Biopsychosocial assessment
– Red and yellow flags
– Periodical reassessment and whenever new
symptoms are reported
• Coordination of care and appropriate referral
• Discouraging inappropriate searches for a cure
• Discouraging prolonged treatment that is not
leading to improved function
1. Analgesic Expert Group Therapeutic Guidelines: Analgesic. 2007

33. The Evolution of
a Persistent Pain
Dr
James
O’Calla
ghan
Anaesthetist
andPain
Medicine
Specialist
MaterPrivate
Clinic,
Brisbane

34. Recovery
Chronic Pain Disability Cycle1
1. Analgesic Expert Group Therapeutic Guidelines: Analgesic. 2007
Surgery
Rehabilitation
despite pain
Pain-dependent
behaviour
Behaviour NOT
dependent on pain
ACUTE PAIN
CHRONIC PAIN
DISABILITY CYCLE Desperation
Hopelessness
Anger
Loss of controlInappropriate management
Social stresses
Anxiety
Activity avoidance
Unhelpful beliefs
Passive treatments
Demands for treatment
Deconditioning
Drug tolerances

35. Transition To Persistent Pain1
Emotionally
charged
Loss of:
• Hope
• Confidence
• Trust
Stressed
relationships
• Family
• Doctor
Poor
communication
Desperation
1. Analgesic Expert Group Therapeutic Guidelines: Analgesic. 2007

36. Psychosocial Yellow Flags1
Work Behaviours
Believe pain is harmful è
fear avoidance behaviour
Believe pain must be
abolished before returning to
work
Compensation issues
Passive attitude to rehab.
Use of extended rest
ê activity
Avoidance normal activities
é alcohol consumption
Beliefs Affective
Catastrophising, thinking of
the worst
Misinterpreting bodily
symptoms
Believe pain is uncontrollable
Depression
Feeling useless, not needed
Irritability
Anxiety
Lack of support
Overprotective partner
1. Jensen S. Aust Fam Physician 2004;33(6):393-401

37. Factors Associated with Persistent Back Pain1
• Premorbid factors
– Older age
– High levels of psychological distress
– Below average self rated health
– Low levels of physical activity
– A history of low back pain
– Not being employed, dissatisfaction with current employment
• Episodic factors
– The presence of widespread pain
– Long duration of symptoms prior to consultation
– Radiating leg pain
– Restriction of spinal movement
1. Thomas E, et al. BMJ 1999;318(7199):1662-7.

38. Influences on Progress and Outcome1
• Negative influences
– Maladaptive ‘treatment’
style
– Maladaptive family
‘support’
– Maladaptive work
environment
– Conflict
– Unrealistic expectations
– Maladaptive response to
life stressors
• Positive influences
(on early response)
– Adequate assessment,
treatment and support
– Early pain relief
– Appropriate style
• Patient, family, GP
– Understanding their
situation
– Realistic expectations
– Adaptive response to life
stressors
1. As adapted from Analgesic Expert Group Therapeutic Guidelines: Analgesic. 2007

39. Persistent Postoperative Pain1
• Preoperative factors
– Moderate – severe pain lasting more than 1 month
– Repeat surgery
– Psychological vulnerability
– Worker’s compensation
• Intraoperative factors
– Nerve damage during surgery
• Postoperative factors
– Pain (acute, moderate – severe)
– Depression
– Psychological vulnerability
– Anxiety
– Neuroticism
1. Perkins FM, Kehlet H. Anesthesiology 2000;93(4):1123-33.

40. Persistent Pain Requires a Different Approach1,2
Acute pain Persistent pain
Cure the illness causing the pain Restore physical, psychological, social
function, minimise distress
Symptom relief Control pain to tolerable level, ê distress
Focus on the painful part “Whole person” rehabilitation
Expectation: return to previous health
status
Adjustment is necessary,
new skills/lifestyle
Passive dependent patient Active coping, participating patient
Active “hands on” practitioner Practitioner who acts as a “coach”
Analgesics given according to current
level of pain, dose reviewed frequently
Regular, predictable schedule of
analgesics
Medication and physical modalities Multidisciplinary approach
Short-term focus Long-term focus
Rest is often appropriate Activity is generally appropriate
1. Analgesic Expert Group Therapeutic Guidelines: Analgesic. 2007. 2. NSW TAG. Prescribing guidelines for
primary care clinicians. General principles. 2002.