Update in Pain Management

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Defining of Pain Pain Experience

An unpleasant sensory and emotional experience associated with actual or potential tissue damage, or described in terms of such damage. S E International o x m Association for the p at Study is a personal, subjective experience that of Pain (IASP) Pain e iz 1994, Kyoto Protocola comprises ct : t 4/9/12 t io IASP 2008 Sensory-discriminative, Motivational-affectivea
A nx ie ty
e D pr es si on

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Classification of Pain

Physiologic / nociceptive:1

Pain arising from activation of nociceptors Caused by mild and short noxious impulses which usually relieved without any medication or mild analgesics Example: Pinched, stung by mosquito

Inflammatory:2 Pain caused by injury to body tissues (musculoskeletal, cutaneus or visceral) Example: Pain due to inflammation, limb pain after fracture Neuropathic:1 Pain arising as a direct consequence of a lesion or disease affecting the somatosensory system Example: DPN, PHN Psychogenic (functional):3 Pain due to abnormal responsiveness or function of the nervous system without neurologic deficit or peripheral abnormality. Example: Fibromyalgia, irritable bowel syndrome

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Type or Category of Pain

3. Psychog enic clear that 1. Nocicep 2. no 4. Mixed type tiveNeuropat somatic Inflamato hic disorder Caused by a rik Initiated or is present combination of Caused by caused by both activity primary spra primary injury in neural fracture / in or Postoper strang lesion or pathway Inflamati inflamed dysfunctio ative secondary ulated s on / (infection Ongoing or n Myofasc (scar Infection effects in response Infiltrated or ) impending ial pain tissue) in the injury to Muscle compressed 4/9/12 nervous potentiallStretch Steven Richeimer, M.D. Director USC Pain Management, USC Medical Center, Los Angeles, (tumors) The Assessment of the Patient with Pain, sys.

The Continuum of Pain1

Ins ult
Acut e Pain

Time to resolution

Chroni c Pain

<1 mont Usually obvious tissue h damage Increased nervous system activity Pain resolves upon healing Serves a protective 1. Cole BE. Hosp Physician. 2002;38:23-30. 2. Turk and Okifuji. Bonicas Management of Pain. 2001. function

3-6 months Pain for 3-6 months or more2 Pain beyond expected period of healing2 Usually has no protective 4/9/12 function3

There are Two Sensory Afferent Neurons Large myelinated A fibers Very fast conduction velocity Respond to innocuous stimuli Small myelinated A & C unmyelinated fibers Slow conduction velocity Respond to noxious stimuli
A A Dorsal root ganglion Dorsal Horn C Peripheral sensory Nerve fibers

1.

Large 2. fibers

Small fibers

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Small-fiber sensory

Large-fiber sensory

Autonomic -Heart rate abnormalities -Postural hypotension -Abnormal sweating -Gastroparesis -Neuropathic diarrhea -Impotence -Retrograde ejaculation

-Burning pain -Loss of vibration -Allodinia -Loss of proprioception -Hyperalgesia -Loss of reflexes -Hyperesthesia -Slowed NCV Paresthesia/dysesth esia -Lancinating pain -Loss of pain & temp. sensation -Foot ulceration -Loss of visceral pain

Normal Nerve Impulses Leading to Pain

Perceived pain

Noxiou s stimuli

Descendi ng modulati on Nociceptive afferent fiber Spinal cord 4/9/12

Ascendi ng input

Perception

Nociception

Pai n

Descending modulation Ascending input

Dorsal Horn

Modulatio n
Dorsal root ganglion

Transmissi on Transducti on
Trau ma

Spinothalami c tract

Peripher al nerve Periphera l nocicepto rs

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Adapted from Gottschalk A et al. Am Fam Physician. 2001;63:1981, and Kehlet H et al. Anesth Analg. 1993;77:1049.

Ange r

PERCEPTION OF PAIN

Anxie ty

Fear

PSYCHOLOGIC AL

Depr essio A n
B

Noxious

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NOCICEPTIVE MELIALA 2004

What is Inflammatory Pain?

q

Often classed along with acute pain as nociceptive, refers to the spontaneous pain and tenderness felt when tissue is inflamed. Pain caused by injury to body tissues (musculoskeletal, cutaneous or visceral) Painful region is typically localized at the site of injury often described as throbbing, aching or stiffness . Usually time-limited and resolves when damaged tissue heals (e.g. bone fractures, burns and bruises) Can also be chronic (e.g. osteoarthritis, rheumatoid arthritis) Usually responsive to NSAIDs
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NOCICEPTIVE PAIN

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Inflammation Tissue
1 Prostaglandins produced in response to tissue injury; increase sensitivity of nociceptor (pain) 2 Nociceptor then releases substance P, which dilates blood vessels and increases release of inflammatory mediators, such as Bradykinin (redness & heat) 3 Substance P also promotes degranulation of mast cells, which release histamine (swelling)

Painful stimulus

Pain-sensitive tissue

Prostaglandin Mast cell Histamine Bradykinin Substance P

Substance P

Blood vessel

3
Nociceptor

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What is Neuropathic pain?

v

Definition:
Pain arising as a direct consequence of a lesion or disease affecting the somatosensory NERVE system

Characterized by:
v

Pain often described as shooting, electric shock-like or burning. The painful region may not necessarily be the same as the site of injury. Almost always a chronic condition (e.g. post herpetic neuralgia, post stroke pain) Responds poorly to conventional analgesics

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IASP Classifications: Peripheral Neuropathic and Central Neuropathic Pain

Neuropathic pain Pain arising as a direct consequence of a lesion or disease affecting the somatosensory system

Pain arising as a direct consequence of a lesion or disease affecting the peripheral somatosensory system

Peripheral neuropathic pain

Pain arising as a direct consequence of a lesion or disease affecting the central somatosensory system

Central neuropathic pain

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Loeser JD, Treede RD. The Kyoto Protocol of IASP Basic Pain Terminology. Pain 2008;137:473-477.

Pathophysiology of Neuropathic Pain

Peripheral mechanisms Peripheral Neuron hyperexcita bility Central Loss of mechanisms inhibitory controls
Central Neuron hyperexcitability (central sensitization)

Abnorma l Discharg es

NeP

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Development of Neuropathic Pain

Etiol ogy Nerve damage due to:
Metabolic Ischemic Hereditary Compression Traumatic Toxic Infectious Immune-related

Pathophys iology Sympt oms Syndr ome

Woolf and Mannion. Lancet

Mechanisms
Spontaneous pain Stimulus-evoked pain

Neuropathic pain
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Signs and Symptoms of Neuropathic Pain

Sign/Symptom Spontaneous symptoms Spontaneous pain1 Dysesthesias2 Parasthesias2 Stimulus-evoked symptoms Allodynia3

Description (example) Persistent burning, intermittent shock-like or lancinating pain Abnormal unpleasant sensations e.g. shooting, lancinating, burning Abnormal, not unpleasant sensations e.g. tingling Painful in response to a non-nociceptive stimulus Increased pain sensitivity e.g. pinprick, cold, e.g. warmth, pressure, stroking heat Delayed, explosive response to any painful 4/9/12 stimulus

Hyperalgesia3 Hyperpathia2

1. Baron. Clin J Pain. 2000;16:S12-S20. 2. Merskey H et al. (Eds) In: Classification of Chronic Pain: Descriptions of Chronic Pain Syndromes and Definitions of Pain Terms.

The Inter-Relationship Between Pain, Sleep, and Anxiety / Depression

Pain

Functional impairment Anxiety & Depression

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Nicholson and Verma. Pain Med. 2004;5 (suppl.

Sleep disturbances

Hyperalgesia & Allodynia

1 0 Hyperalge sia Allodyn ia Injury Norm al Pain Respo Hyperalgesia heightened sense of nse
Allodyniapain resulting from normally painless stimuli

Pain Intensit y 8

pain to noxious stimuli

6 Stimulus Intensity

Gottschalk A et al. Am Fam Physician.

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FUNCTIONAL PAIN
Spontaneous Pain Pain Hypersensitivity Brai n

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Normal Peripheral Tissue and Nerves

Abnormal 4/9/12 Central Processin

NOCICEPTIVE PAIN
Noxius Pheripheral Stimuli Heat Cold Pain Autonomic Response Witdrawal Reflex Brai n

Inte nse Mec Nociceptor Click to edit Master subtitle style sensory hani neuron Forc cal e Heat Cold
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Spinal cord

INFLAMMATORY PAIN
Inflammati on Macro
phage Mast Cell

Neutrophil Granulocyte

Spontaneous Pain Pain Hypersensitivity Reduced Threshold : Allodynia Increased Brai Response : Hyperalgesia n

Nociceptor Click to edit Master subtitle style sensory

Tiss ue Dam age

neuron

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Spinal cord

NEUROPATHIC PAIN
Spontaneous Pain Pain Hypersensitivity Brai n

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Peripheral Nerve Damage

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Spinal cord Injury

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 Three broad categories of free endings or

receptors are recognized:

Mechanoreceptors A- and C fibers Thermoreceptors fibers. C polymodal nociceptors majority of C fibers

noxious or tissue-damaging stimuli

mechanical Thermal chemical mediators (inflammation)

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The 3L Approach to Diagnosis LISTEN

Patient verbal descriptors, Q&A

LOCATE
Nervous system lesion / dysfunction

LOOK
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Sensory abnormalities, pattern recognition

Pain Assessment Scales

Uni-Dimensional Scale

Only measures pain intensity Appropriate for acute pain The most common scale used in outcome assessment (Analgesic efficacy)

MultiDimensional Scale Both intensity (severity) and unpleasantness (affective) Appropriate for chronic pain Research /pathophysiology McGill Pain Questionnaire Should be used in (MPQ) clinical outcome The Brief Pain Inventory (BPI)assessment 4/9/12
The Memorial Pain

Verbal Rating Scale (VRS) None, mild, moderate, severe Numeric Rating Scale (NRS) Visual Analog Scale (VAS)

Uni-Dimensional Pain Assessment Scales

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Photographic/Numeric Pain Scale

Multi-Dimensional Pain Assessment Scales

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Modified McGill Pain Questionna ire

15 Minutes Sensorik Afektif Evaluatif Macam2 IRN INS

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71,4% Baik 28,6% Lumayan dan sedang

Treat ment Reli ef

Quicker and easier Well established reliability in cancer, arthritis, and AIDs. Sensory, affective and functional status Useful for treatment response Takes up to 15 min Good choice for patients with progressive disease

General Activity Mo od Walking ability Wor st Lea st Aver age Right Now Normal work Relation with other people Sle ep Enjoyment of life

 Rapid: Sensory and affective Reliable in Cancer

ID PAIN : Screening tool to help differentiate nociceptive from neuropathic pain

Neuropathic pain screening questionnaire A multicenter study Patients (N = 586) with non-headache chronic pain

A second multicenter study (N = 384) evaluated reliability and validity.

89-item questionnaire 6 items ID Pain appeared to accurately indicate the

presence of a neuropathic component of pain (c 74,2%)

Portenoy R et al. Curr Med Res Opin. 2006 Aug;22(8):1555-65. 4/9/12

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Mark Yes to the following items that describe your pain over the past week and No to the ones that do not.

If patients have more than one painful area, they are to consider the one area that is most 4/9/12 relevant to them when answering the ID Pain

Location:

Patient or nurse marks drawing

Intensity:

Patient rates the pain. Scale Used:

Quality:

Use patints words, e.g. prick, ache, burn, sharp, hot etc.

Onset, duration, variations, rhythms (spontaneus or Manner of (Pain evoked): 4/9/12 expressing Behaviou What

What causes or increases the Effect of pain: (Note decreased pain? function, decreased quality of life)
Accompanying symptoms (eg nausea) Sle ep Appet ite Physical activity Relation with others (eg irritability) Emotion (eg anger, suicidal, crying) Consentr ation Oth er

Other commen Pl ts: an :

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Past Medical History

1. Medical related problems 2. Problems potentially affect the choice of

pain treatments? history?

3. Prior or current substance abuse

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Current Medications
1.Dosage and pattern of use 2.Effectiveness 3.Drug tolerance

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Physical Examination

The history will often generate a differential diagnosis The physical exam will often lead to the selection of the primary diagnosis, and occasionally a test will help to confirm this diagnosis

Mental status exam (facial expression) 2. Vital signs 3. Inspection (body position, gait, redness, swelling) 4. Palpation & Musculoskeletal exam (atrophy, location tenderness to 4/9/12 pressure, mass, )
1.

Acute Pain
Remove the cause Of pain
Surgery Splinting

(McQuay & Moore, 1999) TREATMENT METHODS Regiona Physical l methods analges ia Low Tech
Nerve blocks Local anaesthetic opioid

Medica tion

Psycholog ical approach es

Opioid Morphine others

Non-opioid Aspirin & others NSAIDS Paracetamol combination

High Tech Epidural infusion Local anaesthetic

relaxati physiother on psycho apy manipulati proon phylaxis TENS hypnosi 4/9/12 Acupunct s

ACUTE AND SEVERE PAIN

Recommended Initial Dosing Significant Toxicity Significant Sedation

Pain/Analgesia Threshold Some Analgesia

Traditional Initial Dosing

No Analgesia

Analgesic

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ANALGESIC MEDICATIONS
PRIMARY ANALGESICS
Acetminophen Prostaglandin synthesis inhibitors Salicylates Traditonal NSAIDs COX-2-selective NSAIDs (coxibs) Tramadol Opioids Traditional Mixed

ADJUVANT MEDICATIONS
Antidepressants

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Chronic Pain

(McQuay & Moore, 1999)

TREATMENT METHODS Analgesics Block nerve transmission Irreversible surgery Nerve destruction Reversible Local anaesthetic steroid Alternatives

Conventio nal NSAID Unconventiona Parasetam l ol antidepressant to opioid anticonvulsant others

Stimulators Acupunctur e Hypnosis Psychology

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