SPONSORED

BY

Ehlers-Danlos Society Learning Conference,

December 2018

SPONSORED

BY

Ehlers-Danlos Society Learning Conference,

December 2018

Understanding and managing acute and chronic pain

2018 PERTH PATIENT DAY: 10-11 December

Dr Helen Cohen

Consultant – Rheumatology & Chronic Pain

Royal National Orthopaedic Hospital, UK

An evil triad

Pain & Stress

Hypermobility Physical

Deconditioning

What is pain? • *!@£$$^!!!

• “an unpleasant sensory and emotional experience

associated with actual or potential tissue damage, or

described in terms of such damage” (IASP)

• Acute pain

• Chronic pain

• Multiple complex mechanisms involved

Acute Pain

• Damage to tissue

• Activates pain receptors on pain nerve fibres (c-fibres)

• Transmit pain signal to the spinal cord

• Spinal cord transmits to the brain

• Brain processes pain signal and reacts – Ow!

• Behavioural and emotional protective responses

• Fight/flight stress response

• Followed by rest and repair phase

http://cdn.attackofthecute.com/October-05-2011-18-01-19-get52011almlfcomaoplh8yg.jpeg. Accessed Nov 2018.

Medication

Acute dislocations, injuries • Treat as any other acute musculoskeletal injury • ‘RICE’ Rest, ice, compression, elevation • Analgesic medication eg NSAIDs,

paracetamol, cocodamol • AVOID prolonged immobilisation • Judicious use of splints

Why is pain so pervasive?

• Pain is an evolutionary protective signal

• Danger/damage – stop using – repair – pain stops – start using again

• So HAS to link with brain stress centres

• Includes emotion areas - anxiety, panic

• Chronic pain: Constant ‘on’ signal

• Now pain is no longer about damage

https://image.shutterstock.com/image-vector/silhouette-theory-evolution-man-human-260nw-1024476247.jpg. Accessed Nov 2018.

Pain mechanisms in hypermobility

Biomechanical – Dislocations, subluxations – Ligamentous rupture / instability – Tendon injuries – Secondary osteoarthritis -? – ‘Clumsiness’, so more injuries

• Musculoskeletal pain

– Muscle irritability/tone – ‘spasms’ – Deconditioning – Chronic overuse injury

• Nerve impingement / compression • Some get chronic generalised pain, many do

not

http://cfvod.kaltura.com/p/1745101/sp/174510100/thumbnail/entry_id/1_camthpoa/version/100011/width/569/height/407. Accessed Nov 2018.

https://www.wfmt.com/wp-content/uploads/2016/10/flat_hands.jpg Accessed Nov 2018.

• Peripheral sensitisation

Pain mechanisms in hypermobility

• A reduction in threshold and an increase in responsiveness of the peripheral ends of nociceptors though peripheral nerves to the central nervous system.

• Previously ‘silent’ c-fibres become active

• Central sensitization

• Central sensitization is an increase in the excitability of neurons within the central nervous system, so that normal inputs begin to produce abnormal responses.

Pain nerves fire more easily and more often

Pain nerve relays in the spine fire more easily and more often

https://cdn1.medicalnewstoday.com/content/images/articles/319/319732/nerve-firing.jpg. Accessed Nov 2018.

Pain mechanisms in hypermobility

Descending control • Brain stem centres

(medulla, pons)

• These systems can be inhibitory or facilitatory

• Many different neurotransmitters

https://tse3.mm.bing.net/th?id=OIP.PGEeuR2w8akds9i86gbLowHaFz&pid=Api&P=0&w=300&h=300. Accessed Nov 2018.

https://brainchemist.files.wordpress.com/2010/11/painpathways.gif. Accessed Nov 2018.

Why is pain so pervasive?

• Pain is an evolutionary protective signal

• Danger!! • Fight it, or run away! • Anger, rage, fear, panic, terror etc • Basic powerful inborn emotions linked with

stressful situations • So pain HAS to link with brain stress centres

https://i.ytimg.com/vi/YWTJ8iZr7ro/hqdefault.jpg. Accessed Nov 2018.

• Neuroendocrine

– Role of hypothalamus

– Coordinated responses to pain eg. stress

hormones

– Autonomic responses

• Sympathetic nervous system

• ‘fight or flight’

Pain mechanisms in hypermobility

https://onceuponascreen.files.wordpress.com/2017/05/daffy.jpg. Accessed Nov 2018.

If that isn’t enough…

Drugs don’t seem to work

Individuals vary…

So do their pain mechanisms – so different patterns of pain & problems

• Yet chronic pain syndromes often overlap in the same person

eg. irritable bowel, chronic fatigue/ME, fibromyalgia, chronic pelvic pain

• Certain pain mechanisms may be common across chronic pain

https://www.virginmegastore.ae/medias/sys_master/root/hac/h4d/9011581747230/Spot-the-Difference-Animals-Can-You-Find-the-Odd-One-Out-167852-Detail.jpg. Accessed Nov 2018.

‘Centralised’ pain

Central Sensitization in Chronic Pain Pain itself can change how pain works, resulting in more pain with less provocation

https://anjumsultanablog.files.wordpress.com/2015/11/new-doc-22_1.jpg?w=930. Accessed Nov 2018

https://www.painscience.com/imgs/knob-pain-l.jpg. Accessed Nov 2018.

Chronic pain associations

• Poor memory, poor concentration,

• Poor sleep

• Fatigue

• Sensory sensitivity

– Skin sensitivity

– Loud noise

– Bright lights

– Strong smells

What about the brain?

https://d3jjg4nf4bbybe.cloudfront.net/u/276207/aa9cfb9f96691a5ba630ba9c6a8f97dc35d54637/large/bc-002-no-brain-no-pain-cover-3000x3000.png. Accessed Nov 2018.

Pain is a

sensation

And a

Perception

www.worldofweirdthings.com

www.farangtalk.com

www.coolpics.zxq.net

When sense information conflicts

https://sharkandsafari.co.za/wp-content/uploads/Seasickness.jpg. Accessed Nov 2018.

Bridget Riley

Akiyoshi Kitaoka

Smoke and mirrors

Sensory Conflict (and other ‘odd

sensations’)

• Can produce pain

• Heaviness

• Feeling of swelling

• Pins & needles

• Clumsiness

https://is3-ssl.mzstatic.com/image/thumb/Music/v4/f8/c1/ed/f8c1ed58-1630-7b73-bf1d-bd078b959c23/00_Cover_Art.jpg/268x0w.jpg. Accessed Nov 2018.

Medication • Multiple drugs (polypharmacy) Vs none

(‘sensitivity/intolerance’)

• Limited effect

• Poor side effect profile of opiates in

HSD/hEDS

• Habituation/addiction

• Illegal substances

• Internet weird stuff & machines

• Supplements

https://i.dailymail.co.uk/i/pix/2017/08/01/12/42DE1B1F00000578-4749580-image-a-13_1501585207188.jpg. Accessed Nov 2018.

Medications Chronic widespread pain

• Keep it simple

• AVOID HIGH STRENGTH OPIATES or use with caution and close

monitoring

• Neuromodulatory medications may help

– Amitriptyline

– Gabapentin/pregabalin

– Duloxetine

• If marked anxiety/depression, treat

• ‘Muscle spasms’ – avoid diazepam, or use short doses with close

monitoring

https://cdn.microfilenetwork.com/gallery/274/BIG-15-whatever-this-guy-is-doing.jpg . Accessed Nov 2018.

Medications

• Above all, balance benefits against short & long term side-effects

• If drugs don’t help, or side effects outweigh benefits, STOP them

• Drugs have only a very limited role in this condition

• DON’T BECOME A DRUG ZOMBIE

– you will still have pain but won’t care;

– and you won’t be you

Mind and body

• Cannot separate one from the other

• People in chronic pain get depression & anxiety

• Depression, anxiety & stress feed back into pain

• Higher rates of anxiety disorders in hypermobility

• Higher rates of previous abuse, adverse childhood

experiences in chronic pain

Jones GT, Power C, MacFarlane GJ. Adverse events in childhood and chronic widespread pain in adult life: Results from the 1958 British Birth Cohort Study. Pain 2009 May;143(1-2):92-6.

Pain Management

• Depression & anxiety

• Are very common

• It is not ‘madness’ or ‘weakness’

• Part of the brain stress response to pain

• If not tackled, will continually feed into the pain cycle

• Sometimes does need counselling &/or drug treatment to allow a regain of control

http://www.oxfordschoolblogs.co.uk/psychcompanion/blog/how-to-tell-if-your-mouse-is-depressed-2244/

Summary In hypermobility:

• Acute pain – better at dealing with this

• Chronic pain – much more complex

• Look at the individual & the mechanisms operating in them

• Pain killers may help but will not take all the pain away

• Importance of physical rehabilitation

• Remember the pain/stress/emotion interaction

• For some, psychology approaches may help

• Don’t be afraid of psychology/psychiatry – it’s another tool in the

box!

To name but a few…

• RNOH team

• UCL team

• Prof. Aziz - neurogastoenterology

• Prof. Mathias – autonomic dysfunction

• Prof Pope – clinical genetics

• And many others…

Thanks

https://mymorningmeditations.files.wordpress.com/2013/10/that-s-all-folks.jpg. Accessed Nov 2018.