Cancer Treatment Centers of America® Midwestern Regional Medical Center

Pain Management Service

Presented by: Dr. Rahman

Date: 5/10/2012 – Thursdaywww.cancercenter.com

© 2011 Rising Tide

2

Pain

© 2011 Rising Tide

3

Objectives

To describe the history of pain.

To describe what pain is.

To explain the types of pain.

To give examples of the types of pain.

• Open Discussion – Okay to ask questions during the lecture.

© 2011 Rising Tide

4

History of Pain

• Ancient Greeks times:– Aristotle (384 B.C. – 322 B.C.)

Pain due to evil spirits who entered the

body during injury.

– Hippocrates (460 B.C. – 370 B.C.)

Pain due to an imbalance in the

vitals fluids of the body.

Pain was not well understood and was believed to originate outside

the body. As a punishment from God.

© 2011 Rising Tide

5

What is Pain?

• In the past, pain defined as “whatever the experiencing person says it is, existing whenever s/he says it does.”

• Stresses that pain is a subjective experience

• The patient not the clinician is the authority

• Patient’s self report is the most reliable indicator of pain

• Emphasizes that pain is a complex experience with multiple dimensions

© 2011 Rising Tide

6

Pain defined as:

“An unpleasant sensory and emotional experience associated with actual or potential tissue damage, or described in terms of such damage.”

Emphasizes that pain is a complex experience with multiple dimensions

International Association for the Study of

Pain 1979

© 2011 Rising Tide

7

Types of Pain : Time vs Location

• Acute vs Chronic

• Nociceptive (S&M) vs Neuropathic

© 2011 Rising Tide

8

Acute Pain

• Trauma• Surgery• Infection• Burns• Appendicitis• Inflammatory

© 2011 Rising Tide

9

Chronic

• Pancreatitis• Diabetic Peripheral Neuropathy• Osteoarthritis• Headache• Fibromyalgia• Phantom Pain

© 2011 Rising Tide

10

Nociceptive

• Osteoarthritis• Rheumatoid Arthritis• Muscle Injury• Inflammation• Neoplasm• Degenerative Disc Disease

© 2011 Rising Tide

11

Neuropathic

• Diabetic Peripheral Neuropathy• Stroke Pain• Post Herpetic Neuralgia• Complex Regional Pain Syndrome• Multiple Sclerosis• Neoplasm

© 2011 Rising Tide

12

© 2011 Rising Tide

13

The 5th Vital Sign

• Vitals Signs:– Temperature– Pulse– Respiratory Rate– Blood Pressure

– Pain Score

Types of Pain

Low Back Pain Headaches & Migraines Myofascial Pain Cancer Pain (Head, Neck, Chest, Abdomen, Pelvis, Extremities, etc.) Complex Regional Pain Syndrome (RSD) Musculoskeletal Disorders Sciatica Post Surgical Pain Neuropathic Pain Syndromes e.g. Diabetic Neuropathy Abdominal and Pelvic Pain Spine Pain Post-Herpetic Neuralgia

• Here are the kinds of pain

blocks the pain service can offer

Caudal, Lumbar, Thoracic, and Cervical Epidural Steroid blocks

Patient-Controlled Analgesia (PCA) pumps

Patient-Controlled Epidural (PCEA) pumps

Trigger point injections

Blocks of Somatic and Visceral Cancer Pain Syndromes

Facet Joint Injections

Minor and Major Joint and Bursa injections

Peripheral and Central Somatic Nerve and Plexus Blocks

Tunneled catheter placements for various nerve sheaths

Radiofrequency ablative procedures

Intraspinal catheters for intrathecal opioid trials and implanted infusion devices

Spinal cord/Dorsal Column Stimulators

Discography

Ultrasound-Guided Procedures

Anatomical Landmark Guided Procedures

Pain Assessment

• Pain History• Pain Physical Exam• Labs/Imaging Studies• Pain Diagnosis• Pain Plan

• Then Follow-up Evaluation

16

© 2011 Rising Tide

17

Pain Assessment

Spinal Pain Generators

Multi-Disciplinary Care

MRI

© 2011 Rising Tide

22

© 2011 Rising Tide

23

Potential Pain Therapies

• A. Nonpharmacologic

• B. Pharmacologic

• C. Interventional

© 2011 Rising Tide

24

Nonpharmacologic

• Acupuncture• Biofeedback• Chiropractic Care• Massage• Physical Therapy• TENS unit• Cognitive Behavioral Therapy

© 2011 Rising Tide

25

Pharmacologic

• Topical Agents• NSAIDS• Oral/IV steriod• Opioids• Antidepressants • Anticonvulsants• Infusions

© 2011 Rising Tide

26

Interventional

• Trigger Point Injections• Medial Branch Block• Epidural Steroid• Intradiscal Therapy• Laminectomy/Fusion• Vertobroplasty• Discectomy

Interlaminar approach

Transforaminal approach

OA

Anterior Approach

Greater Trochanter Injection

Shoulder/Bursa Injections

Elbow Bursa Injections

FJI

Retrobulbar Block

Stellate Ganglion Block

Sacrum Injections

SCS

ITP

TPI

Lower Cranial Nerve Blocks

Conclusion

• A good history is crucial in helping you develop a Differential Diagnosis

• The physical exam maneuvers we use can help us to rule out some cause and in some cases rule in others

• Although radiology has become standard, it is no substitute for the clinical exam

© 2011 Rising Tide

47