Pain Management In The 21st Century Presented At Vista Diagnostics 17.6.09

Pain Management in the 21st Centuary.

Dr. Christopher A. Jenner MB BS, FRCA

Consultant in Pain Medicine, Imperial Healthcare NHS Trust

Medical Director London Pain Consultants and Spinal Healthcare

17th June 2009

Agenda

• Definition

• Physiology

• Acute/ Chronic

• Neuropathic

• Differences

• Treatment Options

www.londonpainconsultants.com

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)


Definitions (2)

• Time-course:

• acute

• chronic


Definitions (3)

• Type:

• nociceptive

• neuropathic


Nociceptive Pain


Neuropathic Pain


Pain Physiology

(boring)


Pain Physiology

(funky version)


Noxious Stimulus

Impulse Transmission

Afferent sensory fibres

Spinal cord

Dorsal Horn

Synapse

Ca and Glutamate

Synaptic Cleft

Post Synaptic

Nociceptive Neuron

Pain perception

Prevalence

• Acute pain

• SMH 13,213 operations p.a. (Nov 03-04, DSU 41%)

• SMH 484 operations p.m. (Sep 04, Main, 15% PCA/ epi)

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)

The Challenges of Acute Pain

• Primary Care

• ↑ healthcare utilisation

• Secondary Care

• ↑ length stay/ complications

• 10-15% post-op chronic pain (Macrae)

Acute Pain Management

• Non-pharmacological

• RICE

• Pharmacological

• WHO ladder (amended from cancer) Step 1 paracetamol/ NSAID/ COX 2 Step 2 + weak opioids Step 3 + strong opioids

Massive Financial Burden

• NHS/ DWP/ tax-payers

• Lower back pain (CSAG 1994)

• NHS £481 million

• The Exchequer £1.4 billion


Physical and Alternative Treatments

Pain Management – A Physiotherapist’s Perspective

Helen Dawson MSc, BSc, MCSPExtended Scope Physiotherapy Practitioner

in Pain Management

[email protected]

Physical/ Alternative Treatments

• Physical- heat/ cold/ TENS/ hydro/ supports/ US/ IR

• Manipulation- PxTx/ chiropracter/ osteopathy/ deep tissue massage

• Alternative- acupuncture

Any Vets in the audience?


5. (a) Veterinary practitioners?

Headache!

Pharmacological Treatment

Pharmacological Treatment

• WHO analgesic ladder (abridged)

• + tramadol

• + opioids- buprenorphine TDD/ oxycontin/ fentanyl TDD

(New: sufentanyl TDD/ product X)


Opioid Therapy


Pharmacological treatment of Neuropathic Pain


Neuropathic Pain Management

• Antidepressants- Amitryptilline

• Anticonvulsants- Gabapentin/ Pregabalin/ Carbamazepine/ Valproate

• Opioids

• Local Anaesthetics- Lignocaine/ EMLA


• NMDA antagonists

• Sympatholytics

• GABA –ergics

• Capsaicinwww.londonpainconsultants.com

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

Psychologicaly based therapy

Pain Management• Psychological

CBT

Operant Conditioning

Psychoanalysis

Relaxation

Biofeedback

• Psychiatricwww.londonpainconsultants.com

Pain Management Programmes

● Medication

• Goals (SMART- specific/ measured/ agreed/ realistic/ timed)

• Coping

• Contingency

• Pacing

• Education

• Pain Behaviours

• Reinforcement www.londonpainconsultants.com

Functional Restoration Programmes


MRI scans

Other Imaging

Minimally Invasive Pain Management

Targets


Spine Pain

Cervical/ Thoracic/ Lumbar>65% workload

Epidural Steroid Injections

Facet Joint Injections

Nerve Root Injections

Sacroiliac Joint Injection

Radiofrequency

• Radiofrequency denervation (destructive)

• Eg: medial branch (facet joint) blocks

• Pulsed radiofrequency (non-destructive)

• Eg: nerve roots


Botulinum Toxin A

Other Minimally Invasive Techniques


Epiduroscopy

Disc Dekompressor

Vertebroplasty/ Kyphoplasty

Musculoskeletal


Shoulder

• Suprascapular nerve block

• Suprascapular pulsed radiofrequency

• Intra-articular

• Trigger point

• Botulinum Toxin A

Limbs

• Tenoperiostial injections

• Intra-articular

• Trigger points

• Intra-articular

• Botulinum Toxin A

Neuropathic Pain


Complex Regional Pain Syndrome (CRPS)

• Upper Limb

• Stellate ganglion block

• Intravenous guanethidine block (IVG)

• Lower Limb

• Lumbar Sympathectomy

• Intravenous guanethidine block (IVG)

Other Neuropathic Pain

• Coeliac plexus block

• Ganglion of Impar block

• Hypogastric plexus block

• Pulsed radiofrequency to nerves

• EG: intercostal/ obturator

Advanced Pain Management Techniques


Nerve Stimulation

Nerve Stimulation (2)

Intrathecal Pumps

Intrathecal Pumps (2)

The Future?


The Future?

• Demographics

• Healthcare advances

• ↑ Patient expectations and involvement



http://www.londonpainconsultants.com/

London Pain Consultants Clinics

• London • 15 Harley Street, W1G

• Wellington, NW8

• HSJSE, NW8

• Lindo Wing (St Marys), W2

• Surrey •Mount Alvernia, Guildford

The Team

• Consultant Pain Medicine (Dr.C.A.Jenner)

• Consultant Orthopaedic Spine Surgeon (Mr. Mo Akmal)

• Consultant Interventional Radiologist (Dr. D. Connel)

• Consultant Rheumatologist (Dr. Rees)

The Team (2)

• Consultant Gynaecologist (Miss D. Lyons)

• Consultant Neurologist (Dr. J. Ball)

• Consultant Psychologist (Dr J. Neilson)

• Specialist Physiotherapists (West London Physiotherapy- Sarah Morton, Cameron Tudor)

www.spinal-healthcare.com

Summary


Summary

• Very common (1 in 7 UK)

• Time course- acute n chronic

• Nociceptive and neuropathic

• Multiple treatment modalities


Case reports/ Blogs/ Links/ Appointments

[email protected]

0845 045 0250

Any Questions

Pain Management In The 21st Century Presented At Vista Diagnostics 17.6.09

Health & Medicine

Transcript of Pain Management In The 21st Century Presented At Vista Diagnostics 17.6.09