pain pathways presented in november 2015.pptx
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8/17/2019 Pain Pathways Presented in November 2015.pptx
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Pain Medicine Demystified:British Pain Society Pain Pathways
Dr Sanjeeva GuptaMD; DNB; FR!; F"PP; FFPMR!
onsu#tant in Pain Medicine
Bradford $eachin% &ospita#s N&S
Foundation $rust
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Pain Medicine Demystified: British Pain Society Pain Pathways
• Background• NICE low back pain guidelines in 2009
• Role of Precision diagnosis andmanagement
• Low back pain – eneral management
– !pecialist management
– Radicular pain management
– Recent e"idence
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Precision #iagnosis and$anagement of Pain
• %istor&
• P'&sical E(amination
• In"estigations
• )0 to *0+ of spinal pain cannot bediagnosed
• ,it' Precision diagnostic tec'ni-uesnearl& )0+ of spinal pain can bediagnosed
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.acet /oint $ediated Low Back PainE"aluation $edial Branc' Block
• .acet /ointIn1ections
• $edial Branc'Block
%ig' on t'e e&e3 of t'e !cott& dog3
L4
L5
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'
(
)
*
ap
r"ical .acet /oint Pain
C2
C4
C5
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Britis' Pain !ociet& PainPat'wa&s
• Pain 6Initial assessment 7 earl&management
• Low Back Pain and Radicular Pain• C'ronic widespread pain
• Neuropat'ic pain
• C'ronic Pel"ic pain• .or men and women
Copyright © [2012] Map ofMedicine Limited. All rights
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Low Back Pain and RadicularPain Pat'wa&
• 89 members representing Ps:P'&sio: Ps&c'olog&: !pinal !urger&:Neurosurger&: Pain $edicine:Patient Representati"es
• Pragmatic pat'wa& representing aconsensus opinion based on t'ebest a"ailable e"idence andpractical common sense
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;'e Pain Pat'wa&s were
publis'ed in t'e Britis' /ournal of
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LBP 6 Pat'wa&
• Emp'asis is on t'e principles of – !upported self6management
– Cogniti"e be'a"ioural t'erap& and
– $inimall& in"asi"e approac'es• Includes
– information on 'ow to identif& and manageRE# .L
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Low Back Pain eneral $anagement
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Back Pain eneral $anagement
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Low Back Pain eneral $anagemen
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Back Pain eneral $anagement
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LBP 6 $anagement
•
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LBP !pecialist$anagement
• ;o rule out red Dags and optimieself6care 7 p'armacot'erap&
• ;o perform a biops&c'osocialassessment in t'e conte(t of amultidisciplinar& team @$#;A
• ;o follow indi"idualised stepped
management approac' as part ofan $#;
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Low Back Pain !pecialist $anagement
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Britis' Pain !ociet& Pain Pat'wa&sLow Back Pain !pecialist $anagemen
Copyright © [2012] Map of Medicine Limited. All rights reserved
M hi+ ti , t # ! difi d h t di f id
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Le"el I E"idence obtained from multiple rele"ant 'ig' -ualit&randomied controlled trials FRE"idence obtained from multiple 'ig' -ualit& diagnostic
accurac& studiesLe"el II E"idence obtained from at least one rele"ant 'ig' -ualit&
randomied controlled trial or multiple rele"ant moderateor low -ualit& randomied controlled trials FRE"idence obtained from at least one 'ig' -ualit&diagnostic accurac& stud& or multiple moderate or low-ualit& diagnostic accurac& studies
Le"el III E"idence obtained from at least one rele"ant moderate orlow -ualit& randomied controlled trial stud& FRE"idence obtained from at least one rele"ant 'ig' -ualit&non6randomied trial or obser"ational stud& wit' multiplemoderate or low -ualit& obser"ational studies FRE"idence obtained from at least one moderate -ualit&diagnostic accurac& stud& in addition to low -ualit&studies
Le"el IG E"idence obtained from multiple moderate or low -ualit&rele"ant obser"ational studies FRE"idence obtained from multiple rele"ant low -ualit&diagnostic accurac& studies
Manchi+anti ,- et a#. ! modified approach to %radin% of evidence.
Pain Physician /01(; 12:3'1453'/) 612(7
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6t'e diagnostic accurac& and utilit& of facet
1oint ner"e in1ections in c'ronic spinalpain Pain P'&sician 2085? 8* E49)6E5>>
• Le"el I e"idence for diagnosticaccurac& of lumbar facet 1oint ner"eblocks wit' at least )5+ pain relief
as criterion standard
• Le"el II e"idence for – Cer"ical facet 1oint ner"e blocks wit' at
least *0+ pain relief as t'e criterionstandard
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e"idence s&nt'esis of t'erapeutic facet 1oint inter"entions in managing c'ronic
spinal pain Pain P'&sician 2085? 8* E5>56
E5*2
• Le"el II e"idence for long termimpro"ement of ./ pain for
– Lumbar and cer"ical radiofre-uenc&neurotom&
– ;'erapeutic facet 1oint ner"e blocks incer"ical: t'oracic and lumbar spine
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Pre"alence and #iagnosis of !I/Pain
Pre"alence of !I/pain was 80620+!c'warer: !pine: 20>8:8995: $aigne: !pine28:8**9: 899
!I/ was found to be a
source of post6fusionpain in >2+ ofpatients b& single I<block Kat / !pinal #isorders 8?9699 200> $ai ne Euro ! ine
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E"idence for !I/ Inter"entions;; !imopoulos: L $anc'ikanti: ! upta: et al
!&stematic re"iew of #iagnostic 6)5
• 88 diagnostic accurac& studies 7 84t'erapeutic studies
• Le"el II E"idence for diagnostic accurac&
• Le"el II to III E"idence for cooledradiofre-uenc& neurotom& in managing !I/pain
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#ancinatin%- shootin%- or
8e#ectric9 pain; trave#in%
down the #im in a
narrow and
R!D",!R P!"N
Presentation can
a#ter if treated
Bo%du+ N- Govind
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spinal nerve
dorsal root
ganglion
R!D",!R P!"N
N=
P,!/ P,3/
$NF
inter#eu+ins >- 1/
meta##oproteinases
"% M- "% G
"NF,!MM!$"=N
#eu+otriene B(
throma?ane
interferon
macropha%es
#ymphocytes
firo#asts
S$3R="DS
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;ransforamenal Epidural!teroid In1ection
L5
!8
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Radicular Pain
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RadicularPain
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Radicular Pain
• Imaging and In"estigations inPain $edicine
di l i
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Radicular Pain
#r ;im $aus: $a&o Cli
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,'at Can Mou !ee ,ould Mou In1ect!teroid
!8 !8
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,'at Can Mou !ee ,ould MouIn1ect !teroid
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#e( ;riam #e( ;riam #e( ;riam
+!urger&
0 2)+ 84+ 82+ 84+ 8*9+
50 +PainRelief
>8)+ 4>2+ )>2+ )>+ )>2+ )5)+
50 +F#Idecrease
2*+ >58+ *2+ )+ )0)+ 49+
2 Weeks 3 Months 6 Months
#/ Kenned&: et al Pain $edicine 2084? 85 @4A 54*655
Randomied: #B comparati"e eecti"eness trial0 mg ;riamcinalone FR 85 mg #e(amet'asone
r !im Ma"s# Mayo Clini
Number of In1ections
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Number of In1ections#/ Kenned&: et al Pain Medicine 2084? 85
@4A 54*655
No ofIn1ections
#e(amet'asone
N O 48
;riamcinalone
N O >)
P
8 In1ection N O 22 N O 2> 0>>
2 In1ections N O 82 N O 82 04)
> In1ections N O ) N O 8 00052
!pinal cord stimulation for c'ronic pain of
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!pinal cord stimulation for c'ronic pain ofneuropat'ic
NICE tec'nolog& appraisal guidance ;
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!ummar&• Pain Pat'wa&s
• Pain 6 Initial assessment and earl& management• Low Back Pain and Radicular Pain
• C'ronic widespread pain
• Neuropat'ic pain
• C'ronic Pel"ic pain @for men and womenA
• Low back Pain and Radicular Pain• Pragmatic: e"idence based w'ere possible
• Earl& diagnosis 7 management of Neuropat'ic 7 RadicularPain
• Patients sub1ected to !;ar; back tool to stratif& risk 7 guidemanagement
• ;ime based pat'wa&
• $ultidisciplinar& assessment
• !tepped management approac' empowers patients
d P ti id li
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ood Practice uidelinesof t'e .P$ and BP!
https$%%&&&.'ritishpainsociety.org%static%"ploads%reso"rces%(les%spinal)intervention)A*)+inal)April)201*)1.pdf
https$%%&&&.'ritishpainsociety.org%static%"ploads%reso"rces%(les%m'')201,)-) +/AL.pdf http$%%&&&.rcoa.ac."%node%220
https://www.britishpainsociety.org/static/uploads/resources/files/spinal_intervention_A5_Final_April_2015_1.pdfhttps://www.britishpainsociety.org/static/uploads/resources/files/mbb_2013_-_FINAL.pdfhttp://www.rcoa.ac.uk/node/2206http://www.rcoa.ac.uk/node/2206https://www.britishpainsociety.org/static/uploads/resources/files/mbb_2013_-_FINAL.pdfhttps://www.britishpainsociety.org/static/uploads/resources/files/mbb_2013_-_FINAL.pdfhttps://www.britishpainsociety.org/static/uploads/resources/files/spinal_intervention_A5_Final_April_2015_1.pdfhttps://www.britishpainsociety.org/static/uploads/resources/files/spinal_intervention_A5_Final_April_2015_1.pdf
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;'ank Mou
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