anoverviewofpaintreatments

8/7/2019 AnOverviewofPainTreatments

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www.PainClinic.orgwww.PainClinic.org

Pain TreatmentsPain Treatments

Dr. Richard S. WalkerDr. Richard S. WalkerMB.BS, FRCA, DipMSMed, MLCOM, FFPMRCAMB.BS, FRCA, DipMSMed, MLCOM, FFPMRCA

Consultant in Pain MedicineConsultant in Pain Medicine


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What Do Pain Clinics Do? (1)What Do Pain Clinics Do? (1)

Improve education about the source of the pain 85%is muscular.

Undo all the bad things that health professionals havesaid about it Spinal arthritis, crumbling discs, degenerative spinal disease,

osteoporosis.

Change the way the patient feels about the pain Reduce fear avoidance, catastrophising

Take the pain away for a short time drugs / blocks /manipulation

Start / encourage rehabilitation muscle stretching /strengthening


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What Do Pain Clinics Do? (2)What Do Pain Clinics Do? (2)

Treatment (Contd)

When all else fails encourage acceptance of pain,

disability, social effects Help the patient / partner/ carer grieve for their loss

Palliation multi-modal drug regimes



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The Hard FactsThe Hard Facts

Chronic pain is harder to treat than cancer pain

It lasts for longer and has psychological / physical

effects lasting a number of decades The drugs dont work

50% relief is a success

Pre-morbid psychological state / belief system /

socioeconomic factors determine the outcome We dont have access to a psychologist



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Pain ClassificationPain Classification

Pain

Specific Pain Receptors No Pain Receptors

Musculoskeletal Visceral Nerve Pain Sympathetic Pain


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Pain




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Somatic PainSomatic Pain Pain arising from nociceptors in skin, muscle, bone,

joints, fascia, and ligaments.

Receptors respond to heat, cold, vibration, pressure,and inflammatory mediators.

Referred pain is common in known dermatomal,myotomal and sclerotomal patterns.

Sharp, well localised, worse on movement, reproducedby tissue palpation

Responds moderately well to combination of

paracetamol + NSAID + Opioid. Consider physical / manual therapy and injections.


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MyotomesMyotomes


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SclerotomesSclerotomes


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Spinal Ligament SclerosantsSpinal Ligament Sclerosants


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Pain




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Visceral PainVisceral Pain

Pain arising from nociceptors in viscera.

Receptors respond to stretch, ischaemia,inflammatory mediators.

Poorly localised, dull, aching, colicky for holloworgans, constant for solid organs.

Referred pain mainly follows the sympathetic

supply of the viscera concerned e.g. uterus,heart.

Very opioid sensitive.


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Pain




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Neurogenic PainNeurogenic Pain Source is from within the nervous system itself central, spinal,

peripheral

Causes ischaemia, demyelination, trauma, compression,inflammation, infection.

Shooting, electrical, associated with nerve dysfunction tingling,numbness, weakness, cutaneous hypersensitivity

Referred pain follows spinal nerve distribution.

Partial opioid response.

Better response to anti-depressants (amitriptyline), anti-

convulsants (gabapentin), anti-arrhythmics (mexiletine). Consider surgical decompression, epidurals, nerve blocks.


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Pain




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Sympathetic PainSympathetic Pain Least well understood type of pain excessive

sympathetic activity peripherally

Major sign = allodynia.

No specific receptors May be a form of neurogenic pain with exaggerated

sympathetic activity.

Responds to early physiotherapy, sympathetic nerve

blocks, anti-depressants, and anti-convulsants. Poor prognosis if left untreated.


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Medication Tips (1)Medication Tips (1)1. Try to understand the pathological basis for the

pain. If necessary investigate further. Eliminatetreatable causes.

2. Match the type of medication to the type ofpain.

3. Match the release system of the medication tothe pattern of the pain intermittent, constant,both.

4. Consider combinations of medications insteadof single drugs.


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Medication Tips (2)Medication Tips (2)

5. Match the strength of the medication withseverity of the pain.

6. Review and adjust the dose and intervalbetween doses according to how the painresponds to treatment.

7. Consider other routes of administration ifnecessary when the oral route is not available- IV, SC, PR, SL.

8. Early Pain Team referral for problem patients.


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Spinal ManipulationSpinal Manipulation


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CervicalCervicalSpineSpine

ManipulationManipulation


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ThoracicThoracicSpineSpine

ManipulationManipulation


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LumbarLumbar

SpineSpineManipulationManipulation


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Trigger Point Palpation and InjectionsTrigger Point Palpation and Injections


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Trapezius Trigger PointsTrapezius Trigger Points


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AcupunctureAcupuncture


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Facet Joint TreatmentsFacet Joint Treatments


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Spinal Ligament SclerosantsSpinal Ligament Sclerosants


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Intrathecal Morphine PumpIntrathecal Morphine Pump


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Visceral PainVisceral Pain Treatment ExamplesTreatment Examples

Pancreatitis LA Coeliac Plexus Block

CA Pancreas Phenol Coeliac Plexus Block

CA rectum Ganglion of Impar Block

Is it really visceral pain ?

Dysmenorrhoea / IBS / Kidney spinal T10 -T12

Gall Bladder Right spinal T7

Angina spinal T2 T4


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CoeliacCoeliac

Plexus BlockPlexus Block


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Referred from theReferred from theThoracic SpineThoracic Spine


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Neurogenic PainNeurogenic Pain -- Treatment ExamplesTreatment Examples

Deafferentation Pain

IV lignocaine infusion

Spinal Nerve Root Dysfunction

Epidural LA / Steroid injections, Spinal Nerve Root Blocks,

Epiduroscopy, Spinal Cord Stimulation

Peripheral Nerve Dysfunction

Peripheral Nerve Blocks

Scar Infiltration PHN, surgical scars Surgical Decompression - when there is clinical weakness


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SciaticaSciatica


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Epidural LA / Steroid InjectionsEpidural LA / Steroid Injections


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Spinal Nerve Root BlocksSpinal Nerve Root Blocks


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Nerve Blocks in the Groin RegionNerve Blocks in the Groin Region


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Scar Infiltrations (PHN)Scar Infiltrations (PHN)


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EpiduroscopyEpiduroscopy


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Spinal Cord StimulationSpinal Cord Stimulation


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Sympathetic PainSympathetic Pain

Sympathetic Nerve Blocks

Stellate Ganglion, Lumbar Sympathetic Chain

Guanethidine Biers Block LA + Guanethidine

In-patient epidural infusion + rehabilitation


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Sympathetic BlockadeSympathetic Blockade Stellate GanglionStellate Ganglion


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Sympathetic BlockadeSympathetic Blockade Lumbar Sympathetic ChainLumbar Sympathetic Chain


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Sympathetic BlockadeSympathetic Blockade Guanethidine Biers BlockGuanethidine Biers Block


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