Medicolegal Overview Of Pain Medicine 11.11.10
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Transcript of Medicolegal Overview Of Pain Medicine 11.11.10
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Overview of Pain Medicine.
Dr. Christopher A. Jenner MB BS, FRCA, FFPMRCA
Consultant in Pain Medicine, Imperial Healthcare NHS Trust
Medical Director London Pain Consultants and Spinal Healthcare
11th November 2010
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Agenda
• Definition
• Physiology
• Acute/ Chronic
• Neuropathic
• Differences
• Treatment Options
www.londonpainconsultants.com
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Definitions
• Pain. ‘An unpleasant sensory and emotional experience which we primarily associate with tissue damage or describe in terms of tissue damage, or both.’ (IASP 2001)
www.londonpainconsultants.com
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Definitions (2)
• Time-course:
• acute
• chronic
www.londonpainconsultants.com
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Definitions (3)
• Type:
• nociceptive
• neuropathic
www.londonpainconsultants.com
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Nociceptive Pain
www.londonpainconsultants.com
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Neuropathic Pain
www.londonpainconsultants.com
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Pain Physiology
(boring)
www.londonpainconsultants.com
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Pain Physiology
(funky version)
www.londonpainconsultants.com
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Epidemiology
• 1 in 5 of adults suffers from chronic pain• 1 in 3 in the elderly population
(Blyth et al 2001)
• 70% of people living with chronic pain are under the age of 60 years.
(European Journal of Pain, 2006)
• 49% of people living with chronic pain are forced to take time of work.
(British Pain Society, 2005)
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Physical and Alternative Treatments
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Physical/ Alternative Treatments
• Physical- heat/ cold/ TENS/ hydro/ supports/ US/ IR
• Manipulation- PxTx/ chiropracter/ osteopathy/ deep tissue massage
• Alternative- acupuncture
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Any Vets in the audience?
www.londonpainconsultants.com
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5. (a) Veterinary practitioners?
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Headache!
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Pharmacological Treatment
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Pharmacological Treatment
• WHO analgesic ladder (abridged)
• + tramadol
• + opioids- buprenorphine TDD/ oxycontin/ fentanyl TDD
(New: sufentanyl TDD/ product X)
www.londonpainconsultants.com
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Opioid Therapy
www.londonpainconsultants.com
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Pharmacological treatment of Neuropathic Pain
www.londonpainconsultants.com
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Neuropathic Pain Management
• Antidepressants- Amitryptilline
• Anticonvulsants- Gabapentin/ Pregabalin/ Carbamazepine/ Valproate
• Opioids
• Local Anaesthetics- Lignocaine/ EMLA
www.londonpainconsultants.com
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• NMDA antagonists
• Sympatholytics
• GABA –ergics
• Capsaicinwww.londonpainconsultants.com
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Future Agents for Neuropathic Pain
• Ziconotide (sea snail, conus magnus)
• P2X3- (purine) receptor antagonists (ATP) (knockout mice)
• Epibatidine (Equadorian poison dart frog)
• Morphine and ketamine
• Regular gabapentinwww.londonpainconsultants.com
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Psychologicaly based therapy
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Pain Management• Psychological
CBT
Operant Conditioning
Psychoanalysis
Relaxation
Biofeedback
• Psychiatricwww.londonpainconsultants.com
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Pain Management Programmes
● Medication
• Goals (SMART- specific/ measured/ agreed/ realistic/ timed)
• Coping
• Contingency
• Pacing
• Education
• Pain Behaviours
• Reinforcement www.londonpainconsultants.com
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Functional Restoration Programmes
www.londonpainconsultants.com
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MRI scans
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Other Imaging
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Minimally Invasive Pain Management
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C-arm
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Targets
www.londonpainconsultants.com
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Spine Pain
Cervical/ Thoracic/ Lumbar>65% workload
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Radiofrequency
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• DESTRUCTIVE- Radiofrequency denervation
• Eg: medial branch (facet joint) blocks
• NON-DESTRUCTIVE- Pulsed radiofrequency
• Eg: nerve roots
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Botulinum Toxin A
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Other Minimally Invasive Techniques
www.londonpainconsultants.com
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Musculoskeletal
www.londonpainconsultants.com
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Shoulder
• Suprascapular nerve block
• Suprascapular pulsed radiofrequency
• Intra-articular
• Trigger point
• Botulinum Toxin A
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Limbs
• Tenoperiostial injections
• Intra-articular
• Trigger points
• Intra-articular
• Botulinum Toxin A
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Neuropathic Pain
www.londonpainconsultants.com
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Complex Regional Pain Syndrome (CRPS)
• Upper Limb
• Stellate ganglion block
• Intravenous guanethidine block (IVG)
• Lower Limb
• Lumbar Sympathectomy
• Intravenous guanethidine block (IVG)
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Other Neuropathic Pain
• Coeliac plexus block
• Ganglion of Impar block
• Hypogastric plexus block
• Pulsed radiofrequency to nerves
• EG: intercostal/ obturator
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Advanced Pain Management Techniques
www.londonpainconsultants.com
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Nerve Stimulation
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Nerve Stimulation (2)
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Intrathecal Pumps
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Intrathecal Pumps (2)
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The Future?
www.londonpainconsultants.com
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The Future?
• Demographics
• Healthcare advances
• ↑ Patient expectations and involvement
www.londonpainconsultants.com
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Summary
• Very common (1 in 7 UK)
• Time course- acute n chronic
• Nociceptive and neuropathic
• Multiple treatment modalities
www.londonpainconsultants.com
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Medicolegal Case Histories
Dr. Christopher A. Jenner MB BS, FRCA
Consultant in Pain Medicine, Imperial Healthcare NHS Trust
Medical Director London Pain Consultants andSpinal Healthcare
11th November 2010
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Anatomy of a Medicolegal Report
• Pre Accident/ Incident
• Post Accident/ Incident
• Summary
• Pain History
• Pain Scores
• Previous Treatments
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• Employment and ADL
• Examination
Opinion (including causation)
• Prognosis
• Treatment Plan (costed)
• Glossary and additional info
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49F Severe RTA
Cervical Facet Joint n Secondary Myofacial Pain Syndrome
• Emotionally distressed
• Interim payment
• Clinical pain psychology
• Meds and MIPM
• Discharged
• Case concluded
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52 F School Secretary
• Poor working environment
• Cramped
• High stress
• WRULD
• Ongoing case
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32 F Post Spinal Surgery
• Medical Negligence case
• Unrecognised haematoma formation
• Complicated by infection
• Musculoskeletal pain
• Neuropathic leg pain
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34M Industrial Accident• High pressure oil jet
• Traumatic amputation little/ middle/ ring fingers
• Phantom limb pain
• Neuropathic stump pain
• Phantom sensations
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22M Industrial Accident
• Skip fell on foot
• Crush injury
• Traumatic amputation
• Surgical intervention
• Phantom limb pain
• Neuropthic stump pain
• Phantom sensations
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47 F Post Hysterectomy
• Medical Negligence case
• Genitofemoral neuralgia
•
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42F Cosmetic Filler
• Medical Negligence case
• Facial Neuropathic Pain
• Auriculotemporal nerve
• Improving on medication and local nerve blocks
• ongoing
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New Instructions
• Practice Manager for full details and TnC
• Competitive discounts for volume report writing instructions
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• www.londonpainconsultants.com
• www.spinal-healthcare.com
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Any Questions