chronic pain_ho lecture short
TRANSCRIPT
-
8/16/2019 Chronic Pain_HO Lecture Short
1/28
Chronic pain management
-
8/16/2019 Chronic Pain_HO Lecture Short
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?
-
8/16/2019 Chronic Pain_HO Lecture Short
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?
-
8/16/2019 Chronic Pain_HO Lecture Short
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 ?
-
8/16/2019 Chronic Pain_HO Lecture Short
5/28
+o patient (&&
PAI is what the patient sa!s(&
HURTS
-
8/16/2019 Chronic Pain_HO Lecture Short
6/28
Classifcation o Pain
-
8/16/2019 Chronic Pain_HO Lecture Short
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?
Classifcation o Pain
-
8/16/2019 Chronic Pain_HO Lecture Short
8/28
Duration AcuteChronic
Acute on chronicCause Cancer
on-cancer
5echanism
ocicepti,e 6ph!siological7europathic 6pathological7
Classifcation o Pain
-
8/16/2019 Chronic Pain_HO Lecture Short
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
-
8/16/2019 Chronic Pain_HO Lecture Short
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
-
8/16/2019 Chronic Pain_HO Lecture Short
11/28
• Ob,ious tissue in8ur! or illness
• 9Ph!siological pain%
• Description – harp : dull
– Well localised
ocicepti,e Pain
-
8/16/2019 Chronic Pain_HO Lecture Short
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
-
8/16/2019 Chronic Pain_HO Lecture Short
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.
-
8/16/2019 Chronic Pain_HO Lecture Short
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
-
8/16/2019 Chronic Pain_HO Lecture Short
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
-
8/16/2019 Chronic Pain_HO Lecture Short
16/28
A*5*+ O' +2*
C2=OIC PAI PA+I*+
-
8/16/2019 Chronic Pain_HO Lecture Short
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
-
8/16/2019 Chronic Pain_HO Lecture Short
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
-
8/16/2019 Chronic Pain_HO Lecture Short
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
-
8/16/2019 Chronic Pain_HO Lecture Short
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
-
8/16/2019 Chronic Pain_HO Lecture Short
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&
-
8/16/2019 Chronic Pain_HO Lecture Short
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&
-
8/16/2019 Chronic Pain_HO Lecture Short
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
-
8/16/2019 Chronic Pain_HO Lecture Short
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&
-
8/16/2019 Chronic Pain_HO Lecture Short
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
-
8/16/2019 Chronic Pain_HO Lecture Short
26/28
5anagement o patient with chronic
cancer pain
• I a patient has cancer pain$ s
-
8/16/2019 Chronic Pain_HO Lecture Short
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
-
8/16/2019 Chronic Pain_HO Lecture Short
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