Pain Intervention in Modern Practice

Kees Besse, anesthesiologist, FIPP

Campus Dekkerswald Nijmegen

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IASP definition of pain

An unpleasant sensory and emotional experienceassociated with actual or potential tissue damage, ordescribed in terms of such damage.

Nociception

Activation of sensory transduction in nerves by thermal, mechanical or chemical energy impinging on specializednerve endings. The nerve(s) involved conveysinformation about tissue damage to the central nervoussystem.

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Pain transmission

Neuropathic pain

Pain arising as a direct consequence of a lesion ordisease affecting the somatosensory system.

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Multidimensional Pain neuromatrix:

Melzack R MD Consult 2003

Input in body neuromatrix of:

Cognitive brain sites

Sensorial conduction system

Emotional systems

Output towards brain site responsible for:

Pain perception

Action programming

Stress-related programms

C

S

E

time timeModified Loeser

Pain assessment at intake

• Pain assessment is the responsibility of doctors, nurses and patients

• Careful history and physical examination

• Use of Numeric Rating Scale (NRS) on every visit at the outpatient department

• Use of the Brief Pain Inventory (BPI)

Diagnosis

•Established: treatment proposition

•Preliminary: multidisciplinary assessment

Multidisciplinary assessment

•Pain nurse: social assessment, medication

•Pain psychologist: psychological assessment

•Pain physiotherapist: pain related physical examination

•Pain specialist: coordination

Treatment targets

•Pain reduction

•Rehabilitation

•Resocialisation

Painreduction

•Medication

•Nerve blocks

•Neurostimulation

Nerve blocks

•Diagnostic

•Therapeutic

•Pulsed radiofrequency

•Thermal radiofrequency

Nerve block performance

•Meticulous explanation to the patient of nerve block goal

•Explanation of expected effects and side effects

•Written informed consent

•Block supported by fluoroscopy or echo guided

Neurostimulation

•Transcutaneous Electrical Nerve Stimulation (TENS)

•Dorsal column stimulation

•Motor cortex stimultion

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Spinal cord stimulation

Non anesthesiologic pain treatment

•Cognitive behavioural therapy (psychologist)

•Rehabilitation center

Conclusion

•Assessment and treatment of chronic pain is a

multidisciplinary task

•Anesthesiologists/pain specialist are the preferred

coordinators