Simultaneous Bilateral Knee Replacement The Barwon Health Experience
Update in Pain management HIMAA Conference Dr Tony Weaver Clinical Director of Surgical Services...
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Update in Pain managementUpdate in Pain managementHIMAA ConferenceHIMAA Conference
Dr Tony WeaverClinical Director of Surgical Services
Director of Pain Management Clinic
Barwon Health
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Pain Services Pain Services
What we are--What we are-- Acute Pain Service – In patient - -run
in conjunction with main Anaesthetic Dept. Pain Management Clinic ( Outpatients)
– Chronic (Persistent) Non-Cancer pain– Cancer Pain ( with Oncologists &
Palliative Care Physicians) Referral by GP’s, Hospital Medical Staff,
Private Medical and Surgical Specialists
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Pain Pain ---- DefinitionDefinition
Pain is an unpleasant sensory and emotional experience associated with actual or potential tissue damage or described in such terms. IASP
Persistent (Chronic) pain is now recognised as a disease entity.– Symptoms, Signs, Pathology, Psychology.
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Pain is a Pain is a Bio-Psycho-SocialBio-Psycho-Social problemproblem
So, we must take a Multi- disciplinary Approach
– Medical, Psychology, Physiotherapy.Review of diagnosis – M/discTreatment plan formulatedThen, Feed-back session with the patient
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Pain Patho-physiologyPain Patho-physiologyTypes of PainTypes of Pain
Descartes model ( anatomical model )Physiological painClinical Pain(Injury +individual emotional
& physiological response) Nociceptive PainNeuropathic painSympathetically maintained pain
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Pain ConceptsPain Concepts
Nociceptive PainNociceptive Pain Nociceptive Pain - Acute Pain ( also persistent)
– Stimulation of peripheral nociceptors, somatic and visceral, relayed to dorsal horn , modulated, and passed to perception centres.
– Identifiable cause– Acute post injury, post surgery pain– Arthritic pain– Inflammatory pain– Mechanical pain
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Pain conceptsPain conceptsNeuropathic pain - CharacteristicsNeuropathic pain - Characteristics
Neuropathic Pain- pain generated from within the nervous system – Spontaneous pain – Burning pain– Stabbing , shooting pain– Dysaesthesiae (ants crawling)– Multi-dermatomal
Allodynia, Hyperalgaesia, Hyperpathia.
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Pain ConceptsPain Concepts Sympathetically maintained painSympathetically maintained pain
– Peripheral Sympathetic fibre growth– Dorsal root ganglion ingrowth with adrenergic
fibres– Manifested by Vasomotor, Sudomotor, Trophic
Motor & extra-pyramidal changes– Usually accompanied by Neuropathic pain
features
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CRPS / RSDCRPS / RSD
CRPS was called – Reflex Sympathetic Dystrophy– Causalgia ( kausis=burn, algos=pain)– Algodystrophy– Sudek’s atrophy– Peripheral acute trophoneurosis– Traumatic angiospasm– Post infarction sclerodactyly
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Pain SyndromesPain Syndromes CRPS Type 1
and Type 2 ( post nerve injury)( Old terminology RSD and Causalgia)
Clinical presentation: – Neuropathic pain i.e. burning ,shooting,
multi dermatomal– Allodynia, Hyperalgaesia, Hyperpathia– Sudomotor, vasomotor, trophic tissue change,
osteopaenia– Motor & extra-pyramidal changes
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Target Treatment strategiesTarget Treatment strategies
Medical– Pharmacological– Interventional
Psychology– Cognitive Behavioural Therapies
Individual & GroupsPhysiotherapy
– Always active exercises, restoration of function
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Cognitive Behavioural TherapyCognitive Behavioural TherapyPsychology, Physiotherapy, MedicalPsychology, Physiotherapy, Medical
Individual and GroupsIMPACT and MG group work
– Certainly Interventional – Re- engineering of Beliefs– Re-establishment of Self -Efficacy– Restoration of Function
both Physically and Socially– Sustainable gains– 3 weeks full time + follow-up
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Chronic , Persistent Pain.Chronic , Persistent Pain. Cancer PainCancer Pain
Cancer Pain– ~ 95 % managed with chemo/ radio therapy and
‘conventional’ analgaesics including Opioids, nsaid’s, Steroids, Adjuvant agents, Tramadol , Lignocaine, Ketamine.
Advanced management – includes specific nerve blocks e.g. splanchnic,
(coeliac) paraverterbral.– Intraspinal: Epidural and Intrathecal drug Rx
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Interventional Therapies Interventional Therapies
Specific nerve and plexus targetsSpecific nerve and plexus targets
Peripheral & Cranial nerve blocksRadiofrequency lesioning
– Continuous and Pulsed current– Somatic afferents from facet joints
( Medial Branch of Post.Primary Rami.)– Dorsal root ganglia, sympathetic ganglia.
Cryotherapy
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Interventional TherapiesInterventional Therapies Chronic non-cancer PainChronic non-cancer Pain
Epidurals: cervical, thoracic, lumbar, caudal Nerve root sleeve injectionsSacro-iliac joints
L.A. & Steroids
Epidurolysis : lysis of fibrotic tissue in epidural space
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Interventional Therapies Interventional Therapies Specific nerve and plexus targets Specific nerve and plexus targets
Sympathetic Nerve blocksSympathetic Nerve blocks– Stellate– Thoracic– Lumbar L.A– Coeliac Neurolytic– Splanchnic R.F.– Hypogastric – Ganglion impar
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Chronic - non-Cancer PainChronic - non-Cancer Pain
Intraspinal TherapiesIntraspinal TherapiesDiscovery of receptors in Spinal cord for
– Opioids– Adrenergic alpha agonists– Alpha 2 agonists ( Clonidine)– Serotonergic– GABA
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Chronic - non-Cancer PainChronic - non-Cancer Pain
Intraspinal TherapiesIntraspinal TherapiesPortals
– Epidural and Intrathecal catheters.Implanted Pumps & Intrathecal
catheterAllows 10- 100 times decrease in dose c.f.
systemic delivery with increased efficacy and marked decrease in side effects.
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Spinal column Stimulation/ Spinal column Stimulation/ Intrathecal pumpsIntrathecal pumps
SCS potentially good in CAREFULLY SELECTED patients for Neuropathic pain problems.
( Failed Back , CRPS Type 1 & 2,) Intrathecal pumps potentially useful for
- nociceptive pain states
lower body spasticity
cancer pain with reasonable prognosis
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Chronic - non-Cancer PainChronic - non-Cancer Pain
Intraspinal therapiesIntraspinal therapiesSpinal Cord Stimulation
– Relies on the “Gate theory” principle – continuous non-noxious stimuli via A beta fibres inhibit nociceptive traffic in dorsal horn & cord.
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