Overview of Pain Medicine.

Dr. Christopher A. Jenner MB BS, FRCA, FFPMRCA

Consultant in Pain Medicine, Imperial Healthcare NHS Trust

Medical Director London Pain Consultants and Spinal Healthcare

11th November 2010

Agenda

• Definition

• Physiology

• Acute/ Chronic

• Neuropathic

• Differences

• Treatment Options

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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)

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Definitions (2)

• Time-course:

• acute

• chronic

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Definitions (3)

• Type:

• nociceptive

• neuropathic

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Nociceptive Pain

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Neuropathic Pain

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Pain Physiology

(boring)

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Pain Physiology

(funky version)

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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)

Physical and Alternative Treatments

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?

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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)

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Opioid Therapy

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Pharmacological treatment of Neuropathic Pain

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Neuropathic Pain Management

• Antidepressants- Amitryptilline

• Anticonvulsants- Gabapentin/ Pregabalin/ Carbamazepine/ Valproate

• Opioids

• Local Anaesthetics- Lignocaine/ EMLA

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• 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

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MRI scans

Other Imaging

Minimally Invasive Pain Management

C-arm

Targets

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Spine Pain

Cervical/ Thoracic/ Lumbar>65% workload

Radiofrequency

• DESTRUCTIVE- Radiofrequency denervation

• Eg: medial branch (facet joint) blocks

• NON-DESTRUCTIVE- Pulsed radiofrequency

• Eg: nerve roots

Botulinum Toxin A

Other Minimally Invasive Techniques

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Musculoskeletal

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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

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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)

Other Neuropathic Pain

• Coeliac plexus block

• Ganglion of Impar block

• Hypogastric plexus block

• Pulsed radiofrequency to nerves

• EG: intercostal/ obturator

Advanced Pain Management Techniques

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Nerve Stimulation

Nerve Stimulation (2)

Intrathecal Pumps

Intrathecal Pumps (2)

The Future?

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The Future?

• Demographics

• Healthcare advances

• ↑ Patient expectations and involvement

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Summary

• Very common (1 in 7 UK)

• Time course- acute n chronic

• Nociceptive and neuropathic

• Multiple treatment modalities

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Medicolegal Case Histories

Dr. Christopher A. Jenner MB BS, FRCA

Consultant in Pain Medicine, Imperial Healthcare NHS Trust

Medical Director London Pain Consultants andSpinal Healthcare

11th November 2010

Anatomy of a Medicolegal Report

• Pre Accident/ Incident

• Post Accident/ Incident

• Summary

• Pain History

• Pain Scores

• Previous Treatments

• Employment and ADL

• Examination

Opinion (including causation)

• Prognosis

• Treatment Plan (costed)

• Glossary and additional info

49F Severe RTA

Cervical Facet Joint n Secondary Myofacial Pain Syndrome

• Emotionally distressed

• Interim payment

• Clinical pain psychology

• Meds and MIPM

• Discharged

• Case concluded

52 F School Secretary

• Poor working environment

• Cramped

• High stress

• WRULD

• Ongoing case

32 F Post Spinal Surgery

• Medical Negligence case

• Unrecognised haematoma formation

• Complicated by infection

• Musculoskeletal pain

• Neuropathic leg pain

34M Industrial Accident• High pressure oil jet

• Traumatic amputation little/ middle/ ring fingers

• Phantom limb pain

• Neuropathic stump pain

• Phantom sensations

22M Industrial Accident

• Skip fell on foot

• Crush injury

• Traumatic amputation

• Surgical intervention

• Phantom limb pain

• Neuropthic stump pain

• Phantom sensations

47 F Post Hysterectomy

• Medical Negligence case

• Genitofemoral neuralgia

•

42F Cosmetic Filler

• Medical Negligence case

• Facial Neuropathic Pain

• Auriculotemporal nerve

• Improving on medication and local nerve blocks

• ongoing

New Instructions

• Practice Manager for full details and TnC

• Competitive discounts for volume report writing instructions

• www.londonpainconsultants.com

• www.spinal-healthcare.com

Any Questions