Pain Management

Front 1

• Associated w/ tissue damage
• ↑Autonomic nervous activity
• Resolves w/ healing of injury
• Serves an adaptive function

A vital, protectinve mechanism that permist us to live in an environment fraught w/ potential dangers. Rare cases of congenitally absent nocicpetors show continuous environmental injuries and self mutilation usually resulting in death a very young age

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Acute Pain

Front 2

• Extends beyond the expected time of healing of injury
• No adaptive fuction, rather it degrades health and function, causes further morbidity

Pain which lasts beyond the ordinary duration for time that an insult or injury to the body neds to heal (between 4-6 wk and 3 months)

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Chronic Pain

Front 3

Arthritis, Low back pain & disc disease are all examples of this type of pain.

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Chronic Pain

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• No longer a symptom but a disease state.
• A condition of chronic pain often disproportionate to physical findings, associated w/ interference in function or coping in daily life (professional, social)
• Dysfunctional pain! Altered perception of modality, location, intensity, duration.
• May be due to ongoing injury, but usually other factors perpetuate the pain perception.

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Chronic Pain syndrome

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What facotrs may perpetuae the pain perception in Chronic pain syndrome?

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• Sensitization phenomenon in the PNS
• Sensitization phenomenon in the CNS
• Psychosocial context

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Perception of nociceptive input in terms of tissue damage, either somatic or visceral, mediated by an intact nervous system.

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Nociceptive pain

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• Sensation of phsycial pain that is rooted in psychological conflict
• Common symptoms are headache, back pain, abdominal pain

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Psychogenic pain

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This type of pain may be a protective coping mechanism, distrctor from, or more culturally sanctioned expression of dangerous repressed emotions such as anger or rage.

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Psychogenic pain

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Arise from damage to body tissues. Well localized but variable in description and experience.

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Somatic Pain

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Arises from the viscera and is mediated by stretch receptors. Poorly localized, deep, full, & cramping.

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Visceral Pain

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Examples of this type of pain are appendicitis, cholecystitis, pleurisy, labor

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Visceral Pain

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Arises from abnormal neural activity secondary to disese or injury of the nervous system. It persists in the absence of ongoing disease.

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Neuropathic Pain

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Examples of this type of pain are: diabetic neuropathy, trigeminal neuralgia, post-herpetic neuralgia

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Peripheral Neuropathic Pain

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Abdominal cutaneous nerve entrapment syndrome and meralgia paresthetica are examples of this kind of pain

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Peripheral Neuropathic Pain

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Examples od this type of pain are stroke w/ thalamic pain syndrome, phantom pain phenomenon

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Central Neuropathic Pain

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What are the mechanisms of neuropathic pain?

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• Spontaneous discharges or disregulated dischares
• Abnormal expression of ion channels
• Localized demyelination
• Disregulated cell bodies in dorsal root ganglia

Front 17

What disorders classically have mixed nocicpetive & neuropathic pains?

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• Fibromyalgia
• Cervicalagia (neck pain)
• Lumbalgia (LBP)
• Cancer pain

Front 18

How can the nerve itself perpeutate an inflammatory response?

Back 18

Neurogenic inflammation:
• Activated microglia release several pro-inflammatory cytokines, chemokines and other agents that modulate pain processing by affecting either presynaptic release of neurotransimitters and/or post-synaptic excitability

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A disturbance of fuction or pathologic changes in one or more nerve roots.

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Radiculopathy

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Example of this is damage at the level of the 6th cervical nerve root presents as weakness and paresthesia of the thumb.

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Radiculopathy

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Abnormal CNS activity (phantom limb pain, pain from spinal cord injury, post-stroke pain)

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Central pain syndrome

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Pain perceived at a site other than the site of tissue damage (Sclero/Myo/Dermatomal)

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Referred pain

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What are the types of referred pain?

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• Viscero-somatic
• Somato-somatic
• Viscero-visceral.

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Pain that is mediated of maintained by norepinephrine secreted by the SNS, often due to nerve injury and associated with autonomic changes (CRPS).

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Sympathetically mediated pain

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A stellate ganglion block terminates this kind of pain

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Sympathetically mediated pain

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Peripheral nerve damage without autonomic change.

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Nonsympathetically mediated

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• Presence of physical symptoms suggesting a medical conidtion despite the lack of any organic or physical findings.
• The symptoms cause clinically significant distress or impariment in social, occupational, or other areas of functioning.
• They do not appear to be under voluntary control.

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Somatiform disorders

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Diagnoses of these conditions must be made with caution, especially given the incomplete knowledge about the physical bases of pain condition. For example, individual nociceptive cells in the dorsal horn respond to stimulation from receptor fields that are much wider than a single dermatome, and there is a certain plasticity in the nervous system that can result in alteration in the presence of persistent pain.

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Somatiform disorders

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The following disorders are all examples of what umbrella term:
• Somatization
• Conversion
• Hypochondriasis
• Factitious disorders
• Malingering

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Somatiform disorders

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• A type of somatiform disorder
• Polysymptoms disorder involving multiple organ systems and often accompanied by a belief that one is sickly.
• High utilization of medical resources.
• Presentation is often overly dramatic, but vague, imprecise or inconsistent history.

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Somatization

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• A type of somatiform disorder
• Pain, numbness and weakness is the triad.
• Often there is an unconcious conflict or motivation and a temporal relation between a psychosocial stressor and onset of symptoms.
•  In up to 30% of cases, patients do eventually develop a diagnosable physical disorder.

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Conversion disorder

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• A type of somatiform disorder
• Preoccupation w/ a disease state - either fear that you have it or misinterpretation of bodily sensations/function leading to the belief that a serious condition exists.
• The preoccupation results in significant distress or impairment in social, occupational or other important areas of function.

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Hypochondriasis

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• A type of somatiform disorder
• Are intentionally created on the part of the patient (either producing or faking symptoms) in order to assume the sick role.

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Factitious disorders

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• A type of somatiform disorder
• Intentionally created disorder but motivation is often extrenal incentives - financial compensation, avoiding work, evading prosecution, obtaining drugs.

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Malingering

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• Pain associated w/ a potentially life-limiting, progressive disease (Cancer, AIDS, end-stage organ failure)
• May be related to the disease or treatments for the disease
• Often distinct in the associated psychosocial issues.

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Malignant pain

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A process by which pain becomes sustainted by modualation of factors within the PNS and/or CNS

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Sensitization

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Drugs derived from the opium poppy

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Opiates

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Natural and synthetic derivatives, including opium.

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Opioids

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Substances that produce narcosis, legal definition includes opiods and cocaine

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Narcotics

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Drugs used in pain mamangement that may or may not have intrinsic analgesic properties. However, they provide pain releif in certain pain syndromes or potentiate the common analgesics such as opiods. Important to be really clear with paitents why these drugs are being used.

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Co-analgesics

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Increasing doses are required to elicit the same initial effect.

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Tolerance

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Withdrawal symptoms develop with abrupt withdrawal of the substance (or administration of an antagonist)

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Physical dependence

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Primary chronic neurobiological disease with genetic, psychosocial, and environmental factors influencing its manifestation. Characterized by cravings, compulsive, uncontrolled use of a substance, resulting in physical, psychological or social harm to the user, and continued drug use despite negative consequences (even if acute use is associated with pleasant or euphoric effects)

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Addiction

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Pattern of drug-seeking behavior of patients with pain receiving inadequate pain management that can be mmistaken for addition (concerns, about availability, "clock-watching," unsanctioned dose escalation.

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Pseudoaddiction

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Pain due to a stimulus that does not normally provoke pain. Ex: A wisp of cotton brushed over an area is perceived as painful by the patient.

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Allodynia

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Increased sensitivity to stimulation (painful or otherwise), excluding the special senses.

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Hyperesthsia.

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Perception of more pain in response to a noxious stimulus than would normally be evoked by that stimulus.

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Hyperalgesia

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Explosive response to normally painful stimulus.

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Hyperpathia

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Abnormal sensation in the distribution of a nerve. May be spontaneous or evoked.

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Paresthesia

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An example of this type of pain is light tapping over the wrist of a patient with carpal tunnel syndrome evokes electrical shocks in the median nerve distribution (Tinel sign). Pins & needles.

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Paresthesia

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Abnormal and unpleasant sensation in the distribution of a nerve.

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Dysesthesia

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Absence of pain in response to stimulation that wold normally be painful. Or, a decrease in pain/increase in pain threshold, which results when analgesics such as opiods are used.

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Analgesia

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An agent that produces analgesia. This may be a pharmacoloic agent such as an opiod, or a nonpharmacologic method such as a TENS unit.

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Analgesic

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A law signed on October 4, 2001 that requires CA-licensed physicians to take, as a one-time requirement, 12 units or CME on "pain-management"

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AB 487

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Pre-conscious neural activity. The transduction of an external stimulus into a neural impulse

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Nociception

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An unpleasant sensory and emotional experience. The sensation + the perception.

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Pain

Front 57

Aspect of pain that is being treated. Influence by behavioral reinforcement contingencies, family systems issues, psychodynamic formulations, etc.

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Suffering