כאב. Silviu Brill MD Director, Pain Medicine Center, Tel Aviv-Sourasky Medical Center

כאבכאב

Silviu Brill MDSilviu Brill MD

Director, Pain Medicine Center, Director, Pain Medicine Center, Tel Aviv-Sourasky Medical CenterTel Aviv-Sourasky Medical Center

PAIN - EpidemiologyPAIN - Epidemiology““We don’t have a lot of statistics about pain, but We don’t have a lot of statistics about pain, but

the ones we do have are frightening.” the ones we do have are frightening.”

Chronic pain is the most common cause of Chronic pain is the most common cause of disability, partially or totally disabling disability, partially or totally disabling 50 50 million people in USmillion people in US

‘Chronic Pain in Europe’ Survey (n=46,394)

__________________________________________________________________________

18%

18%

19%

21%

23%

26%

27%30%

0% 100%

11%

13%

13%

15%

16%

16%

17%17%

0% 100%

Norway (n=2,018)

Poland (n=3,812)

Italy (n=3,849)

Belgium (n=2,451)

Finland (n=2,004)

Austria (n=2,004)

Sweden (n=2,563)

Netherlands (n=3,197)

Germany (n=3,832)

Israel (n=2,244)

Denmark (n=2,169)

Switzerland (n=2,083)

France (n=3,846)

UK (n=3,800)

Ireland (n=2,722)

Spain (n=3,801)

Breivik et al. Eur J Pain 2006;10(4):287-333.Breivik et al. Eur J Pain 2006;10(4):287-333.Breivik et al. Eur J Pain 2006;10(4):287-333.Breivik et al. Eur J Pain 2006;10(4):287-333.

Overall Prevalence Overall Prevalence 19%19%Overall Prevalence Overall Prevalence 19%19%

Effects of Chronic PainEffects of Chronic Pain

Physical FunctioningPhysical FunctioningAbility to perform Ability to perform activities of daily livingactivities of daily living

Sleep disturbanceSleep disturbance

KinetophobiaKinetophobia

Psychological Psychological MorbidityMorbidityDepressionDepression

Anger, frustrationAnger, frustration

Loss of self-esteemLoss of self-esteem

AnxietyAnxietySocial ConsequencesSocial Consequences

Relationships with Relationships with family and friendsfamily and friends

Intimacy/sexual activityIntimacy/sexual activity

Social isolationSocial isolation

Loss of workLoss of work

National National ConsequencesConsequencesHealthcare costsHealthcare costs

Lost workdaysLost workdays

DisabilityDisability

OverviewOverview

DefinitionDefinition

Acute vs. Chronic PainAcute vs. Chronic Pain

Nociceptive vs. Neuropathic PainNociceptive vs. Neuropathic Pain

DiagnosticDiagnostic

Pathophysiology Pathophysiology

Treatment Treatment

הגדרת הכאבהגדרת הכאבINTERNATIONAL ASSOCIATION FOR INTERNATIONAL ASSOCIATION FOR

THE STUDY OF PAINTHE STUDY OF PAIN

חוויה חוויה כאב הוא כאב הוא תחושתית ורגשית לא תחושתית ורגשית לא

שקשורה בנזק שקשורה בנזק נעימהנעימהרקמתי אמיתי או רקמתי אמיתי או

פוטנציאלי.פוטנציאלי.

Classifications of PainClassifications of PainAcute

Chronic

Duration

Nociceptive

Neuropathic

Pathophysiology

The Continuum of PainThe Continuum of Pain

<1 month

Time to resolution

3-6 months

AcutePain

ChronicPain

• Usually obvious tissue damage

• Increased nervous system activity

• Pain resolves upon healing

• Serves a protective function

• Pain for 3-6 months or more

• Pain beyond expected period of healing

• Usually has no protective function

• Degrades health and function

Insult

כאב כרוני לעומת כאב אקוטיכאב כרוני לעומת כאב אקוטיכאב כרוני לעומת כאב אקוטיכאב כרוני לעומת כאב אקוטיכאב אקוטיכאב אקוטיסימפטוםסימפטוםקצר טווחקצר טווח

סימן אזהרהסימן אזהרהחרדהחרדה

תגובה טובה לטיפולתגובה טובה לטיפולטיפול יחידטיפול יחיד

כאב כרוניכאב כרונימחלהמחלה

ארוך טווחארוך טווחאזעקת שוואאזעקת שווא

דיכאוןדיכאוןתגובה בעייתית לטיפולתגובה בעייתית לטיפול

גישה רב-תחומיתגישה רב-תחומית

Types of Chronic PainTypes of Chronic Pain

Nociceptive PainNociceptive Pain

OsteoarthritisOsteoarthritis

Deg. Spine Dis.Deg. Spine Dis.

RARA

Polymyal. rheumPolymyal. rheum

PancreatitisPancreatitis

Neuropathic PainNeuropathic Pain

Diabetic neuropathyDiabetic neuropathy

PHNPHN

Traumatic injuryTraumatic injury

MSMS

Post stroke painPost stroke pain

Dysfunctional PainDysfunctional Pain

FibromyalgiaFibromyalgia

Chronic headachesChronic headaches

IBSIBS

Burning mouth Burning mouth synd.synd.

Chronic PainChronic Pain

… … is not prolonged acute painis not prolonged acute pain

… … must be considered and treated as a must be considered and treated as a diseasedisease

““Pain is a more terrible lord of mankind Pain is a more terrible lord of mankind than even death himself”than even death himself”

Albert SchweitzerAlbert Schweitzer

P a i nP a i nNociceptiveNociceptiveNeuropathicNeuropathicInflamatoryInflamatoryIschemicIschemicIdiopathicIdiopathic

IASP DefinitionsIASP Definitions

Neuropathic painPain initiated or caused by a primary

lesion or dysfunction in the nervous system

Peripheral neuropathic painPain initiated or caused by a primary

lesion or dysfunction in the peripheral nervous system

Central neuropathic painPain initiated or caused by a primary

lesion or dysfunction in the central nervous system

Pain Types: Nociceptive vs Pain Types: Nociceptive vs NeuropathicNeuropathic

Nociceptive PainNociceptive PainArises from activation of Arises from activation of nociceptorsnociceptors (pain receptors) (pain receptors)

ProportionalProportional to degree of activation of afferent pain fibers to degree of activation of afferent pain fibers

Acute, occasionally chronic Acute, occasionally chronic

EXAMPLES: EXAMPLES: - Postoperative pain- Postoperative pain

- Mechanical low back pain- Mechanical low back pain

- Sports/exercise injuries- Sports/exercise injuries

- Sickle cell crisis- Sickle cell crisis

1) 1) Somatic Pain Somatic Pain 2) 2) Visceral PainVisceral Pain- Well localized - Well localized - Poorly localized, few nociceptors - Poorly localized, few nociceptors

- Aching, gnawing, sharp, - Aching, gnawing, sharp, - Crampy, colicky, throbbing, pressure-like, deep - Crampy, colicky, throbbing, pressure-like, deep achingaching

throbbing, pressure-like throbbing, pressure-like - Autonomic: diaphoresis, hypertension, tachycardia- Autonomic: diaphoresis, hypertension, tachycardia

Neuropathic Pain Prevalence Neuropathic Pain Prevalence Ranges From 6.0-7.7%Ranges From 6.0-7.7%

0

1

2

3

4

5

6

7

8

9

10

UK France Germany Spain

% o

f patients

Patients with axial back pain with a neuropathic component included in the surveyNeuropathic Pain Patient Flow Survey

7.5%

6.4%6.0%

7.7%

CRPSCRPS

ExamplesPeripheral• Postherpetic neuralgia• Trigeminal neuralgia• Diabetic peripheral neuropathy• Postsurgical neuropathy• Posttraumatic neuropathyCentral• Poststroke painCommon descriptors2

• Burning• Tingling• Hypersensitivity to touch or cold

Examples • Pain due to inflammation• Limb pain after a fracture• Joint pain in osteoarthritis• Postoperative visceral pain Common descriptors2

• Aching• Sharp• Throbbing

Examples • Low back pain with

radiculopathy• Cervical

radiculopathy• Cancer pain• Carpal tunnel

syndrome

Mixed PainPain with

neuropathic and nociceptive components

Neuropathic PainPain initiated or caused by a

primary lesion or dysfunction in the nervous system (either peripheral or

central nervous system)1

Nociceptive PainPain caused by injury to

body tissues (musculoskeletal,

cutaneous or visceral)2

Signs and Symptoms of Neuropathic Signs and Symptoms of Neuropathic PainPain

Sign/Symptom Description (example)

Spontaneous symptoms

• Spontaneous painPersistent burning, intermittent shock-like or lancinating pain

• DysesthesiasAbnormal unpleasant sensations e.g. shooting, lancinating, burning

• ParasthesiasAbnormal, not unpleasant sensations e.g. tingling

Stimulus-evoked symptoms

• AllodyniaPainful response to a non-painful stimulus e.g. warmth, pressure, stroking

• HyperalgesiaHeightened response to painful stimulus e.g. pinprick, cold, heat

• HypoesthesiaDelayed, explosive response to any painful stimulus

InnocuousInnocuous NoxiousNoxious

Stimulus IntensityStimulus Intensity

Pai

nP

ain

Sen

sati

on

Sen

sati

on

00

1010

NormalNormalPainPain

CurveCurve

AllodyniaAllodynia

HyperalgesiaHyperalgesia

Shift toShift toleft with left with

tissuetissueinjuryinjury

Development of Development of Neuropathic PainNeuropathic Pain

M. Downing

""מדידת כאבמדידת כאב""

Mild

Moderate

Severe

Pain Intensity

Non-Opioids+Adjuvants

Weak-Opioids+ Non-Opioids+Adjuvants

Strong-Opioids+ Non-Opioids+Adjuvants

Pain TreatmentPain Treatment

The WHO Analgesic LadderThe WHO Analgesic Ladder

1. Mackin G.A. J Hand Ther. 1997;10:96-109. 2. Gobal H. et al,Clin Drug Invest 1995;10:208-214. 3. Harati Y. et al, Neurology 1998;50:1842-1846

TransductionTransduction

TransmissionTransmission

ModulationModulation

PerceptionPerception

Emotion

A multifaceted model for the A multifaceted model for the components of paincomponents of pain

suffering

pain

nociception

Pain behavior

””Prevalence of chronic pain Prevalence of chronic pain after surgery”after surgery”

Prevalence of chronic pain following Prevalence of chronic pain following surgerysurgery

Type of surgeryType of surgery Perkins &KehletPerkins &Kehlet

AnesthesiologyAnesthesiologyMacraeMacraeBrit JAnaesBrit JAnaes

BreastBreast 11-49%11-49% 23-49%23-49%

ThoracotomyThoracotomy 22-67%22-67% 5-67%5-67%

CholecystectomyCholecystectomy 3-56%3-56% 3-27%3-27%

Inguinal hernia Inguinal hernia 0-37%0-37% 15-63%15-63%

VasectomyVasectomy 0-37%0-37%

Risk factors for Risk factors for chronchroniicc pain after pain after surgery or traumasurgery or trauma

Severe acute pain after surgery or trauma Severe acute pain after surgery or trauma Pain before surgery Pain before surgery Immobilization Immobilization after trauma or surgeryafter trauma or surgeryRe-operationRe-operationRadiation and cytotoxic drugsRadiation and cytotoxic drugsGenetics!Genetics!

How do we build an algorithmHow do we build an algorithm

NNT (Number needed to treat)NNT (Number needed to treat)

EBMEBM

Safety Profile NNH (Number needed to Safety Profile NNH (Number needed to harm)harm)

Side effectSide effect

PricePrice

RegistrationRegistration

Treatment of Chronic Neurophatic Treatment of Chronic Neurophatic PainPain

1) Pharmacologic1) Pharmacologic

2) Physical and occupational therapy2) Physical and occupational therapy

3) Alternative approaches3) Alternative approaches

5) Cognitive behavioral strategies, relaxation 5) Cognitive behavioral strategies, relaxation techniquestechniques

6) Interventional procedures6) Interventional procedures

Multi Disciplinary Integrative Multi Disciplinary Integrative approachapproach

Barriers to Optimal Pain Management Barriers to Optimal Pain Management

Factors related to health care professionalsFactors related to health care professionals – inadequate knowledge of analgesic pharmacology and pain therapy inadequate knowledge of analgesic pharmacology and pain therapy – poor pain assessment poor pain assessment – concern about regulatory oversight concern about regulatory oversight – fear of patient addiction fear of patient addiction – concern about the side effects of analgesics concern about the side effects of analgesics – concern about development of tolerance to analgesics concern about development of tolerance to analgesics

Factors related to patientsFactors related to patients – reluctance to report pain reluctance to report pain – reluctance to take pain medications reluctance to take pain medications

Factors related to the health care systemFactors related to the health care system – low priority given to pain management low priority given to pain management – inadequate or inappropriate provisions for reimbursement inadequate or inappropriate provisions for reimbursement

– restrictive regulation of therapeutic agents that are controlled substancesrestrictive regulation of therapeutic agents that are controlled substances

הולכת הכאבהולכת הכאב

Dysregulation of 5-HT and NE Dysregulation of 5-HT and NE in the brain are strongly in the brain are strongly associated with depression.associated with depression.

The brain may perceive an The brain may perceive an amplified pain signal due to the amplified pain signal due to the imbalance of 5-HT and NE in imbalance of 5-HT and NE in the spinal cord.the spinal cord.

This may explain why physical This may explain why physical symptoms are often the chief symptoms are often the chief complaint in depressed complaint in depressed patients presented in primary patients presented in primary care settings.care settings.

Pain Signal

NE5-HT

5-HTNE

Pain Signal

Ep

idu

rals for P

ost –O

p A

nalg

esia .

הזרקה אפידורלית

Brachial Nerve Block –Axillary Brachial Nerve Block –Axillary approachapproach

SCS TechniqueSCS Technique

Patient controlled analgesiaPatient controlled analgesia

PCAPCA

0

20

40

60

80

100

120

0 1 2 3 4 5 6 7 8

intramuscular

PCA

Special issuesSpecial issues

Postoperative Pain Management in:Postoperative Pain Management in:

Chronic Pain PatientsChronic Pain Patients

Patients on Chronic Opioid TreatmentPatients on Chronic Opioid Treatment