chronic pain_ho lecture short

8/16/2019 Chronic Pain_HO Lecture Short

1/28

Chronic pain management


2/28

Outline

• What is pain? Defnition o pain

• Classifcation o pain

• Dierences between acute and chronic

pain• Principles o management o patient with

chronic non-cancer pain

• Principles o management o patient withcancer pain

• What happens to a patient at a Pain Clinic?


3/28

• International Association or the tud! oPain

Pain is "an unpleasant sensor! and emotionale#perience associated with actual or potentialtissue damage$ or described in terms o suchdamage%&

Merskey,1964

International Association for the Study of Pain (IASP)

What is Pain?


4/28

'rom the defnition o pain$ we

understand that pain is (&• )npleasant

• *motions are important

• +he cause is not alwa!s ,isible

What do !ou understand

about pain ?


5/28

+o patient (&&

PAI is what the patient sa!s(&

HURTS


6/28

Classifcation o Pain


7/28

• ot all pain is the same.

• +hree main /uestions0

1& 2ow long has the patient had pain?

3& What is the cause?

4& What is the pain mechanism?



8/28

Duration AcuteChronic

Acute on chronicCause Cancer

on-cancer

5echanism

ocicepti,e 6ph!siological7europathic 6pathological7



9/28

• Acute – Pain o recent onset and probable limited

duration

• Chronic

– Pain persisting be!ond healing o in8ur! – Oten no identifable cause

– 6Pain lasting or more than 4 months7

Acute ,ersus Chronic


10/28

• Cancer pain – Progressi,e

– 5a! be mi#ture o acute and chronic

• on-cancer pain – 5an! dierent causes

– Acute or chronic

Cancer ,ersus on-Cancer


11/28

• Ob,ious tissue in8ur! or illness

• 9Ph!siological pain%

• Description – harp : dull

– Well localised

ocicepti,e Pain


12/28

• er,ous s!stem damage or abnormalit!

• 9Pathological pain%

• +issue in8ur! ma! not be ob,ious

• Description – ;urning$ shooting : numbness$ pins and needles$allod!nia

– ot well localised

europathic Pain


13/28

Dierences between ocicepti,eand europathic pain

&

&

N o cic e p tiv e &p ain &

“P h ysio lo gic a l&p ain ”&

N e u ro p at h ic&p ai n &

“P a th o lo gica l&p a in ”&

C a u s e . O b , i o u s .t i s su e .i n 8 u r ! . - e r , e .i n 8 u r ! .o r .

C e n t r a l< p e r ip h e r a l.n e r , o u s .

s ! st e m .a b n o r m a li t ! .

' u n c t i o n . P r o t e c t i , e .f u n c t i o n . - o .d i s c e r n a b l e .b i o l o g i c a l .

f u n c t io n .

D e s c r i p t i o n . o f . p a i n . h a r p .

D u ll .

+ h r o b b in g .W e l l.lo c a l i se d .

; u r n i n g .

h o o t in g .

t a b b i n g $.l a n c in a t in g .P o o r l! .lo c a li s e d .

A g g r a , a t in g .< .r e li e , in g .f a c t o r s .

A g g r a , a t e d .b ! .m o , e m e n t .= e li e , e d .b ! .r e s t .

p o n t a n e o u s .p a in .

O t h e r .s! m p t o m s. - o n e .o r .r e la t e d .t o .u n d e r l! in g .

p a t h o lo g ! .

- u m b n e s s .

P in s .a n d .n e e d le s .A ll o d ! n ia .

D ! s a e s t h e si a s.


14/28

pectrum o Pain

ACUTE

PAIN

CHRONIC

PAIN

ACUTE

PAIN

Healing

NO PAIN

CHRONIC

PAIN

Insidious onset

post-surgical, post-trauma syndromes

cancer

5th Vital Sign: Doctors’ training module: Pain Physiology


15/285th Vital Sign: Doctors’ training module: Pain Physiology

Acute ,s Chronic PainAcute Pain Chronic Pain

Onset and

timing

Sudden onset, short duration.

Resolves/disappears whentissues heal.

Onset may e insiduous.

!ain persists despite tissuehealing.

Signal " warning sign o# actual orpotential tissue damage

$ot a warning signal o#damage % a #alse alarm

Severity Severity is correlates with

amount o# damage.

Severity not correlated with

damage.&'ood days( and&)ad days(.

CNSinvolvement

*$S intact – acute pain is asymptom

*$S may e dys#unctional – chronic pain is a disease

Psychological

effects+ess, ut unrelieved pain→

aniety sleeplessness whichimproves when pain is relieved

O#ten associated with

depression, anger, #ear,social withdrawal, etc

Commoncauses e!am"les

Surgery, #racture, urns,myocardial in#arct, laour andchildirth, in#lammatory

conditions e.g. ascess

*hronic headache, ac0pain, chronic pelvic / adpain, cancer pain,

neuropathic pain – !H$,1!$, post stro0e pain, etc


16/28

A*5*+ O' +2*

C2=OIC PAI PA+I*+


17/28

P 0 Place or site o pain“Where does it hurt!

6record on a bod! chart7

! 0 Aggra,ating actors“What "akes the #ain $orse!

+ 0 Intensit!“%o$ &ad is the #ain!

N 0 ature and neutraliBingactors

“What does it feel like! “What "akesthe #ain &etter!

2ow to assess pain0


18/28

(ther /uestions to as0 about pain in patientswith chronic pain

Pattern of pain0

• Is the pain alwa!s there 6constant7? Or does the paincome and go 6intermittent or episodic pain7?

!ssociated sy1pto1s0

• Do !ou ha,e the ollowing s!mptoms in the painul area orelsewhere?

• umbness$ tingling$ allod!nia 6pain rom a non painulstimulus7$ h!peralgesia 6pain out o proportion to a painul

stimulus7


19/28

(ther /uestions to as0 about pain in patientswith chronic pain

+1pact of pain on 1ood and function0

• 2ow does the pain aect !our sleep? our appetite? ourmood? our dail! acti,ities? our relationships? our wor?

Past 2istory0

• Past medical


20/28

Principles in the management ochronic non-cancer pain

• )se a multimodal approach

–on-drug techni/ues 6e&g& e#ercise$ rela#ation$ counselling$acupuncture

–Analgesic medications• on opioids e&g& Paracetamol

• Opioids e&g& +ramadol

• Antineuropathic agents e&g& Amitriptline$ abapentin

–er,e blocs and other inter,entions

• In,ol,e the patient as an acti,e participant

–el-management techni/ues are ,er! important

• 5anagement is targetted at achie,ing long-term beneft aschronic pain is a disease which needs long term solutionsincluding lie-st!le changes 6similar to diabetes$ heartdisease7


21/28

Practical tips on management o patientswith chronic non-cancer pain in the ward

• 'irst$ !ou must recognise that the patient haschronic pain F i&e& pain or more than 4 months

• o need or urther in,estigations i patient isadmitted 6or comes to *mergenc! dept7 ore#acerbation 69Gare up%7 o the chronic pain& – Onl! in,estigate i patient has dierent t!pe o pain

or has new s!mptoms e&g& loss o weight$ ,omiting$

etc

• All patients with chronic pain should bereerred to the chronic pain clinic or ullassessment and long term management&


22/28

Practical tips on management o patientswith chronic non-cancer pain in the ward

In the ward or *mergenc! department

1& A,oid analgesic in8ections i&e& do not gi,e I5 or I@Pethidine or Dicloenac&

3& i,e regular oral analgesic eg oral tramadol 1>>mg +D or HID Paracetamol 1 g HID

4& =eer to a chronic pain clinic

J& =eer to ph!siotherap! or assessment and an

e#ercise program that the patient can do at homeK& Discharge the patient as soon as the pain is under

control F do not eep the patient in the ward orlong periods o time&


23/28

I a pain clinic is nota,ailable0

• i,e the patient a ollow up appointment at !ourclinic 6e&g& surgical$ medical7

• *mphasiBe to the patient that s


24/28

What happens to a patient withchronic pain at the Pain Clinic?

+he patient has a thorough multidisciplinar! assessment$ whichincludes

• 5edical assessment b! a pain specialist – +o mae a diagnosis and decide whether an! urther in,estigations are

indicated$

– =e,iew o current treatment

• Ph!sical assessment b! a ph!siotherapist – +o assess or primar! and secondar! musculoseletal eects o chronic

pain&

• Ps!chological assessment b! a clinical ps!chologist orps!chiatrist&

– +o assess the ps!chological impact o the pain$ le,el o an#iet! anddepression$ how the patient copes with the pain$ eect onrelationships$ sleep$ wor$ etc&


25/28

What happens to a patient withchronic pain at the Pain Clinic?

• Ater assessment$ a management plan is made&5anagement is multidisciplinar! and multimodal$ andincludes an! or all o the ollowing modalities0 – Pharmacotherap!$ using appropriate drugs

– ner,e blocs and other inter,entions$

– acti,e ph!siotherap!$ including e#ercises and acti,ities thatpatients can do at home

– ps!chological therap!$ including rela#ation training and otherpain management strategies

• In the management o chronic pain$ emphasis is on self3

1anage1ent 6what the patient can do or him


26/28

5anagement o patient with chronic

cancer pain

• I a patient has cancer pain$ s


27/28

WHO Analgesic Ladder

23

rom0 5ala!sian CP on 5anagement o Cancer Pain$ 3>1>E

dapted rom World 2ealth OrganiBation& Cancer pain relie 6econd *dition7 with a guide to opioid a,ailabilit!& ene,a0 W2OE 1LLM


28/28

ummar!

• Pain can be classifed as acute or chronic$ cancer or non-cancer and nocicepti,e or neuropathic

• Acute and chronic pain are dierent – Acute pain is a s!mptom o tissue damage

– Chronic pain is a disease o the ner,ous s!stem• Acute and chronic pain need to be treated dierentl!$

using non-drug as well as drug techni/ues&

• 'or patients with chronic cancer or non-cancer pain$man! other actors 6e&g& ps!chosocial7 ma! be

important and need to be taen into consideration in themanagement& – el-management or long term beneft is essential in patients

with chronic pain

chronic pain_ho lecture short

Documents