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Managing patients with chronic pain . Dr Lorraine de Gray Lead Consultant in Pain Medicine, QEH Chair, UK Regional Advisors in Pain Medicine, Faculty of Pain medicine, Royal College of Anaesthetists. Back pain - a slippery slope. Case scenario 1. - PowerPoint PPT Presentation
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MANAGING PATIENTS WITH CHRONIC PAIN
Dr Lorraine de GrayLead Consultant in Pain Medicine, QEHChair, UK Regional Advisors in Pain Medicine, Faculty of Pain medicine, Royal College of Anaesthetists
BACK PAIN - A SLIPPERY SLOPE
CASE SCENARIO 1 IE is a 55 year old male who presents with a
four month history of intractable low lumbar back pain.
He is struggling to work (accounts clerk) He has tried over the counter analgesics His wife has made him come and see you
What questions would you ask?
USEFUL TO KNOW: Type of pain Radiation? Referral? Weight loss? What makes it better? Sitting, standing, walking? Any bladder symptoms Any other relevant clinical symptoms? Any relevant past medical history Any relevant past medical history Smoker?
INFLUENCES ON THE PAIN EXPERIENCE
Pain
Age
Gender
Culture
Previous pain experience (self/family)
Education and understanding
Fears
EXAMINATION Paraspinal spasm low lumbar bilaterally Pain worse on extending the spine Lower limbs normal power, sensation, reflexes Positive straight leg raise at 60 degrees
bilaterally Looks well otherwise
Outcome measures Oswestry Roland Morris PHQ 9 HADS
WHAT DO YOU DO?
WHAT DO YOU DO? Reassure Simple analgesics, NSAIDS +/- muscle
relaxant Heat Physiotherapy/Manual therapy via back pain
pathway
Review in four weeks
FOUR WEEKS LATER No better Off work “Physiotherapy made me worse” His wife comes with him and says you have
to sort him out.
What do you do?
RED FLAGS Gross neurology Sphincter disturbance Saddle anaesthesia Up going planters Weight loss History of malignancy Recent significant trauma Severe thoracic back pain Severe bilateral leg pain Spinal deformity Severe constant night pain Gait disturbance Fever or night sweats
YELLOW FLAGSPersonal
Fear avoidance Pessimism depression, expressed stress, anger and
sometimes sleeplessness Illness behaviour and adoption of the sick role Passivity (external locus of control) Helplessness Tendency to see pain in a catastrophic light Family: beliefs, expectations, reinforcement Work: job satisfaction, difficulty working with pain,
flexibility of employer, work options Non-health problems (financial, marriage?) Mobility and function Hobbies and pleasures. Restrictions
PAIN CLINIC Undiagnosed back pain Likely mechanical Need to exclude sinister underlying cause Need to help patient understand why he has
pain Take history Examine
What do I do?
BEST TOOL
Why Does The
PatientHurt?
BLOOD TESTS Full blood count Bone profile PSA Serum protein electrophoresis – Bence Jones
proteins CRP ESR
IMAGING??
MRI scan or REASSUROgram
Any point in doing a lumbar spine X-ray?
Uncertainty & fear Catastrophising
Anger &blame Failed treatment
HelplessnessDepression Avoidance
Sick leaveInvalidism
Acute
Chronic
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OBJECTIVES OF CHRONIC PAIN MANAGEMENT Alleviate pain Alleviate psychological and behavioural
dysfunction Reduce disability and restore function Rationalize usage of medicines Reduction of utilization of health care
services Attention to social, family and
occupational issues
MANAGEMENT PLAN Explain, explain and explain again Look at medication – is it nociceptive,
neuropathic or mixed pain Practical pain management advice ?Intervention – role of facet joint injections Back programme Support Back to work, ergonomics,
employment support
LUMBAR FACET JOINT INJECTIONS
TO INTERVENE OR NOT TO INTERVENE? Spinal injections are simply a way of giving
patients a window of pain relief. They are not a long term fix. Even a successful denervation will not last more than eighteen months as a procedure in its own right.
Patients need multidisciplinary input aimed at improving their pain management skills
Pain Management Advice seminars Back Programme Individual physiotherapy (including hydrotherapy) Individual psychotherapy
SUGGESTED READING Back Pain Revolution: Gordon Waddell
2004 2nd edition
British Medical Journal – EDITORIAL Red flags for back pain BMJ 2013; 347 doi: http://dx.doi.org/10.1136/bmj.f7432 (Published 12 December 2013)
NICE guidelines – CG 88 (2009)
WIDESPREAD BODY PAIN CHRONIC FATIGUE SYNDROME
CASE PRESENTATION 33 year old woman Five year history of widespread body pain Chronic headaches, irritable bowel, irritable
bladder Low mood Constant fatigue, can’t do anything, can’t
concentrate, can’t sleep Joints feel swollen, non dermatomal upper and
lower limb pain Tried a variety of analgesics and anti-depressants
– none help Unable to cope at home, two small children,
partner unsympathetic
DIFFERENTIAL DIAGNOSIS Inflammatory arthropathy Polymyalgia rheumatica Somatiform disorder/primary mental health
problem Hypothyroidism Lyme’s disease
MAJOR CHALLENGES Lack of trust in the medical system Multitude of symptoms Yellow flags Keep an open mind Manage in a holistic way Engage multidisciplinary pain management Neuropathic medication Physiotherapy to improve level of function Psychology: group, individual Occupational therapy Complementary therapy – TENS, acupuncture Where appropriate involve mental health services Fibromyalgia Support groups
SUGGESTED READING Arnold LM, Sarzi-Puttini P, Arsenault P, et al. Efficacy and safety of Pregabalin in patients
with fibromyalgia and co-morbid depression receiving concurrent antidepressant therapy: a randomized, 2-way crossover, double-blind, placebo-controlled study [abstract L6]. Presented at: American College of Rheumatology (ACR) 2013 Annual Meeting; October 29, 2013; San Diego, California. Available at https://ww2.rheumatology.org/apps/MyAnnualMeeting/Abstract/39039. Accessed November 11, 2013
Yunus MB. Fibromyalgia and overlapping disorders: the unifying concept of central sensitivity syndromes. Semin Arthritis Rheum. Jun 2007;36(6):339-56. [Medline].
Gracely RH, Petzke F, Wolf JM, Clauw DJ. Functional magnetic resonance imaging evidence of augmented pain processing in fibromyalgia. Arthritis Rheum. May 2002;46(5):1333-43. [Medline].
Wolfe F, Clauw DJ, Fitzcharles MA, et al. The American College of Rheumatology preliminary diagnostic criteria for fibromyalgia and measurement of symptom severity. Arthritis Care Res (Hoboken). May 2010;62(5):600-10. [Medline].
Crombez G, Eccleston C, Van den Broeck A, et al. Hypervigilance to pain in fibromyalgia: the mediating role of pain intensity and catastrophic thinking about pain. Clin J Pain. Mar-Apr 2004;20(2):98-102. [Medline].
NEUROPATHIC PAIN ?CAUSESPEED IS OF THE ESSENCE
CLINICAL PRESENTATION 35 year old female otherwise healthy Trapped her left index finger in a door a two
weeks ago. At the time, finger bruised, treated with cold compress, and simple analgesics
She comes to see you, complaining of severe pain in her left finger and hand. The pain is burning in nature and keeping her awake
What do you ask?
CLINICAL SCENARIO
COMPLEX REGIONAL PAIN SYNDROME CRPS type I requirements feature causation
by an initiating noxious event, such as a crush or soft tissue injury; or by immobilization, such as a tight cast or frozen shoulder.
CRPS type II is characterized by the presence of a defined nerve injury.
Both types demonstrate continuing pain, allodynia, or hyperalgesia that is usually disproportionate to the inciting event.
IASP REVISED CRITERIA FOR CRPS Continuing pain that is
disproportionate to any inciting event At least 1 symptom reported in at least
3 of the following categories: Sensory: Hyperesthesia or allodynia Vasomotor: Temperature asymmetry, skin colour
changes, skin colour asymmetry Sudomotor/oedema: Oedema, sweating changes,
or sweating asymmetry Motor/trophic: Decreased range of motion, motor
dysfunction (eg, weakness, tremor, dystonia), or trophic changes (eg, hair, nail, skin)
IASP REVISED CRITERIA FOR CRPS At least 1 sign at time of evaluation in at least 2 of the
following categories:
Sensory: Evidence of hyperalgesia (to pinprick), allodynia (to light touch, temperature sensation, deep somatic pressure, or joint movement)
Vasomotor: Evidence of temperature asymmetry (>1°C), skin colour changes or asymmetry
Sudomotor/oedema: Evidence of oedema, sweating changes, or sweating asymmetry
Motor/trophic: Evidence of decreased range of motion, motor dysfunction (eg, weakness, tremor, dystonia), or trophic changes (eg, hair, nail, skin)
No other diagnosis better explaining the signs and symptoms
COURSE OF CRPS
The severity rather than the aetiology seems to determine the disease course.
Age, sex and affected side are not associated with the outcome .
Fractures may be associated with a higher resolution rate (91%) than sprain (78%) or other inciting event (55%) .
A low skin temperature at the onset of the disease may predict an unfavourable course and outcome
A retrospective analysis of 1006 CRPS cases, mostly female, and younger patients with CRPS of the lower limb showed an incidence of severe complications in about 7%, such as infection, ulceration, chronic oedema, dystonia and/or myoclonus
RECURRENCE OF CRPS In 1183 patients (Veldman et al) the
incidence of recurrence was 1.8% per year. The patients with a recurrent CRPS were
significantly younger but did not differ in gender or primary localization. The recurrence of CRPS presents more often with few symptoms and signs and spontaneous onset.
SPEED IS OF THE ESSENCE WITH CRPS Urgent referral to pain clinic Physiotherapy: Desensitization, graded motor imagery
Medication Sympathetic nerve block: Stellate ganglion
block Occupational therapy Neuromodulation Ongoing trials with immunoglobulin
GRADED MOTOR IMAGERY
Step 1 - Laterality Reconstruction
Quite often, people with painful limb problems lose the ability to recognise left or right images which can obstruct a successful recovery. The good news is the brain is plastic, and changeable, if given the right stimuli for long enough. So with a little bit of work, patience and persistence it is possible to reconstruct the brain’s feature of laterality, which would have existed prior to the limb problem.
Step 2 - Motor ImageryAround 25 percent of the neurons in your brain are called ‘Mirror Neurons’ and are activated when you watch someone else moving or think of performing an action. Motor Imagery is the process where you observe others’ actions or positions and copy them in your head without actually moving. The brain is being exercised and re-trained with no motion required.
Part 3: Mirror therapy
This is the use of a mirror to present the reverse image of a body part limb to the brain. It is also the final stage of Graded Motor Imagery because there is evidence that mirror therapy will be more effective if your sense of laterality is intact
By using a mirror, you can trick the brain into believing that an injured part is actually okay, providing a powerful synaptic exercise. For example, if the left hand was a problem, it could be hidden behind the mirror. And by using the mirror image of the right hand and concentrating on the mirror image, the brain would construct that the left hand was now somehow okay. It is a way of signalling to the brain that ‘the hand is fine, it’s now time to represent it properly and look after it.’
http://www.rcplondon.ac.uk/sites/default/files/documents/complex-regional-pain-full-guideline.pdf
FUNCTIONAL ABDOMINAL PAIN HEART SINK PAR EXCELLENCE
CLINICAL SCENARIO 23 year old university graduate presents with
unexplained abdominal and pelvic pain.She has had extensive gastrointestinal, gynaecological and urological investigations.
Pain is unremitting associated with nausea, pallor, and intermittent diarrhoea or constipation.
She is jobless, unable to seek work because she is in too much pain. She is low in mood and accompanied by her mother who is very concerned about her.
How do you manage her?
HOW DO YOU MANAGE HER? Take a history Ensure patient feels she is believed Think outside the box Take a good psychosocial history
Useful outcome measures
Brief pain inventory Pain catastrophizing scale
THINK MULTIDISCIPLINARY Hyper vigilant gut Think neuropathic Think desensitisation Think complementary Think psychology Think Hypnotherapy Think occupational therapy
VISCERAL PAIN Visceral pain is the most frequent form of
pain, felt by most people at one time or another
the number one reason for patients to seek medical attention.
it is insufficiently treated as it is considered just a symptom of an underlying disease
many forms of visceral pain are diseases in their own right and require focused and specific therapies
IASP CLASSIFICATION OF VISCERAL PAIN Visceral and other chest pain Chest pain of psychological origin Chest pain referred from the abdomen or gut Abdominal wall pain Abdominal pain of visceral origin Abdominal pain of generalised diseases Chronic pelvic pain syndromes Diseases of the pelvic organs Pain in the rectum, perineum and external
genitalia
SIMPLER CLASSIFICATION OF VISCERAL PAIN Organic abdominal pain
Functional gastrointestinal disorders
Defined as a ‘variable combination of chronic or recurrent gastrointestinal symptoms which are not explained by structural or biochemical abnormalities’
HYPNOTHERAPY IN IRRITABLE BOWEL SYNDROME J Psychosom Res. 2008 Jun;64(6):621-3. doi:
10.1016/j.jpsychores.2008.02.022. Epub 2008 Apr 28. Hypnotherapy for irritable bowel syndrome: the response of colonic and noncolonic symptoms. Whorwell PJ.
CG61 Irritable bowel syndrome: NICE guideline 08 October 2012 1.2.3.1
Referral for psychological interventions (cognitive behavioural therapy [CBT], hypnotherapy and/or psychological therapy) should be considered for people with IBS who do not respond to pharmacological treatments after 12 months and who develop a continuing symptom profile (described as refractory IBS).
SUGGESTED READING LIST IASP clinical updates – Visceral Pain, Vol
XIII, No 6, December 2005 Visceral Pain, Cervero et al, THE LANCET •
Vol 353 • June 19, 1999 Gut pain & visceral hypersensitivity
published online 21 March 2013 British Journal of Pain Adam D Farmer and Qasim Aziz http://bjp.sagepub.com/content/early/2013/03/19/2049463713479229
Central sensitisation in visceral pain disorders, Moshiree et al, GUT, 2006 July; 55(7): 905–908
CLINICAL SCENARIO Mr XX is a 65 year old gentleman scheduled to
undergo a left below knee amputation. Two years ago, he was involved in a work related incident when his left foot was mangled in machinery.
Despite five attempts at surgical reconstruction of the foot, the patient remains in severe pain with a foot that is structurally unsound. In the interim he has also undergone a right total knee replacement which remains rather painful to date.
Clinically he has signs and symptoms of uncontrolled neuropathic pain and he has pleaded with the surgeon to amputate his foot.
CLINICAL SCENARIO: PAST MEDICAL HISTORY
He has an aortic abdominal aneurysm (40mm) under annual surveillance
He has a history of chronic lumbar back pain for which he had attended the pain clinic in the past (prior to the accident)
He had one episode of dvt many years previously after undergoing a knee arthroscopy
He has an ongoing personal injury claim He is also awaiting trial at the high court for
unrelated offences
CLINICAL SCENARIOMedication/other treatment:Fentanyl 87 micrograms per hour patchOramorph up to 120mg per dayDuloxetine 60mg am, 30mg pmPregabalin 300mg bdParacetamolClexane 40mg daily (ever since the accident)Ramipril, Bendrofluazide, Simvastatin
Graded motor imageryBeckham bootDesensitisation therapy
FENTANYL MORPHINE EQUIVALENT
Fentanyl 12 = Morphine 45mg per day
Fentanyl 25 = Morphine 90mg per day
Fentanyl 50 = Morphine 180mg per day
Fentanyl 75 = Morphine 270mg per day
Fentanyl 100 = Morphine 360mg per day
HOW WOULD YOU MANAGE THIS PATIENT
POINTS TO CONSIDER Preventive analgesia Regional anaesthesia Polypharmacy – significant amount of opiates Management of pain post-operatively Stump pain Phantom pain Likely recurrence of back pain Ongoing psychological stresses Need for Clexane
ANY QUESTIONS?
THANK YOU FOR LISTENING