pain management in the 21st century presented at vista diagnostics 17.6.09
DESCRIPTION
Pain Management In The 21st Century Presented At Vista Diagnostics (MRI scanning centre) to Medical personnel17th June 2009TRANSCRIPT
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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
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Agenda
• Definition
• Physiology
• Acute/ Chronic
• Neuropathic
• Differences
• Treatment Options
www.londonpainconsultants.com
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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)
www.londonpainconsultants.com
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Definitions (2)
• Time-course:
• acute
• chronic
www.londonpainconsultants.com
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Definitions (3)
• Type:
• nociceptive
• neuropathic
www.londonpainconsultants.com
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Nociceptive Pain
www.londonpainconsultants.com
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Neuropathic Pain
www.londonpainconsultants.com
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Pain Physiology
(boring)
www.londonpainconsultants.com
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Pain Physiology
(funky version)
www.londonpainconsultants.com
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Noxious Stimulus
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Impulse Transmission
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Afferent sensory fibres
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Spinal cord
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Dorsal Horn
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Synapse
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Ca and Glutamate
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Synaptic Cleft
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Post Synaptic
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Nociceptive Neuron
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Pain perception
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Brain
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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)
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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)
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The Challenges of Acute Pain
• Primary Care
• ↑ healthcare utilisation
• Secondary Care
• ↑ length stay/ complications
• 10-15% post-op chronic pain (Macrae)
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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
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Massive Financial Burden
• NHS/ DWP/ tax-payers
• Lower back pain (CSAG 1994)
• NHS £481 million
• The Exchequer £1.4 billion
www.londonpainconsultants.com
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Physical and Alternative Treatments
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Pain Management – A Physiotherapist’s Perspective
Helen Dawson MSc, BSc, MCSPExtended Scope Physiotherapy Practitioner
in Pain Management
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Physical/ Alternative Treatments
• Physical- heat/ cold/ TENS/ hydro/ supports/ US/ IR
• Manipulation- PxTx/ chiropracter/ osteopathy/ deep tissue massage
• Alternative- acupuncture
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Any Vets in the audience?
www.londonpainconsultants.com
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5. (a) Veterinary practitioners?
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Headache!
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Pharmacological Treatment
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Pharmacological Treatment
• WHO analgesic ladder (abridged)
• + tramadol
• + opioids- buprenorphine TDD/ oxycontin/ fentanyl TDD
(New: sufentanyl TDD/ product X)
www.londonpainconsultants.com
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Opioid Therapy
www.londonpainconsultants.com
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Pharmacological treatment of Neuropathic Pain
www.londonpainconsultants.com
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Neuropathic Pain Management
• Antidepressants- Amitryptilline
• Anticonvulsants- Gabapentin/ Pregabalin/ Carbamazepine/ Valproate
• Opioids
• Local Anaesthetics- Lignocaine/ EMLA
www.londonpainconsultants.com
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• NMDA antagonists
• Sympatholytics
• GABA –ergics
• Capsaicinwww.londonpainconsultants.com
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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
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Psychologicaly based therapy
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Pain Management• Psychological
CBT
Operant Conditioning
Psychoanalysis
Relaxation
Biofeedback
• Psychiatricwww.londonpainconsultants.com
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Pain Management Programmes
● Medication
• Goals (SMART- specific/ measured/ agreed/ realistic/ timed)
• Coping
• Contingency
• Pacing
• Education
• Pain Behaviours
• Reinforcement www.londonpainconsultants.com
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Functional Restoration Programmes
www.londonpainconsultants.com
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MRI scans
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Other Imaging
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Minimally Invasive Pain Management
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C-arm
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Targets
www.londonpainconsultants.com
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Spine Pain
Cervical/ Thoracic/ Lumbar>65% workload
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Epidural Steroid Injections
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Facet Joint Injections
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Nerve Root Injections
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Sacroiliac Joint Injection
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Radiofrequency
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• Radiofrequency denervation (destructive)
• Eg: medial branch (facet joint) blocks
• Pulsed radiofrequency (non-destructive)
• Eg: nerve roots
www.londonpainconsultants.com
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Botulinum Toxin A
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Other Minimally Invasive Techniques
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Epiduroscopy
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IDET
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Disc Dekompressor
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Vertebroplasty/ Kyphoplasty
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Musculoskeletal
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Shoulder
• Suprascapular nerve block
• Suprascapular pulsed radiofrequency
• Intra-articular
• Trigger point
• Botulinum Toxin A
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Limbs
• Tenoperiostial injections
• Intra-articular
• Trigger points
• Intra-articular
• Botulinum Toxin A
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Neuropathic Pain
www.londonpainconsultants.com
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Complex Regional Pain Syndrome (CRPS)
• Upper Limb
• Stellate ganglion block
• Intravenous guanethidine block (IVG)
• Lower Limb
• Lumbar Sympathectomy
• Intravenous guanethidine block (IVG)
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Other Neuropathic Pain
• Coeliac plexus block
• Ganglion of Impar block
• Hypogastric plexus block
• Pulsed radiofrequency to nerves
• EG: intercostal/ obturator
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Advanced Pain Management Techniques
www.londonpainconsultants.com
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Nerve Stimulation
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Nerve Stimulation (2)
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Intrathecal Pumps
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Intrathecal Pumps (2)
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The Future?
www.londonpainconsultants.com
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The Future?
• Demographics
• Healthcare advances
• ↑ Patient expectations and involvement
www.londonpainconsultants.com
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London Pain Consultants Clinics
• London • 15 Harley Street, W1G
• Wellington, NW8
• HSJSE, NW8
• Lindo Wing (St Marys), W2
• Surrey •Mount Alvernia, Guildford
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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)
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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)
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www.spinal-healthcare.com
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Summary
www.londonpainconsultants.com
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Summary
• Very common (1 in 7 UK)
• Time course- acute n chronic
• Nociceptive and neuropathic
• Multiple treatment modalities
www.londonpainconsultants.com
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Any Questions