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Update in Pain management HIMAA Conference

Update in Pain management HIMAA Conference. Dr Tony Weaver Clinical Director of Surgical Services Director of Pain Management Clinic Barwon Health. Pain Services What we are--. Acute Pain Service – In patient - -run in conjunction with main Anaesthetic Dept.

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Update in Pain management HIMAA Conference

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  1. Update in Pain managementHIMAA Conference Dr Tony Weaver Clinical Director of Surgical Services Director of Pain Management Clinic Barwon Health

  2. Pain Services What we are-- • Acute Pain Service – In patient - -run in conjunction with main Anaesthetic Dept. • Pain Management Clinic ( Outpatients) • Chronic (Persistent) Non-Cancer pain • Cancer Pain ( with Oncologists & Palliative Care Physicians) • Referral by GP’s, Hospital Medical Staff, Private Medical and Surgical Specialists

  3. Pain is a Bio-Psycho-Social problem So, we must take a • Multi- disciplinary Approach • Medical, Psychology, Physiotherapy. • Review of diagnosis – M/disc • Treatment plan formulated • Then, Feed-back session with the patient

  4. Pain Patho-physiology Types of Pain • Descartes model ( anatomical model ) • Physiological pain • Clinical Pain(Injury +individualemotional & physiological response) • Nociceptive Pain • Neuropathic pain • Sympathetically maintained pain

  5. Pain ConceptsNociceptive Pain • Nociceptive Pain - Acute Pain ( also persistent) • Stimulation of peripheral nociceptors, somatic and visceral, relayed to dorsal horn , modulated, and passed to perception centres. • Identifiable cause • Acute post injury, post surgery pain • Arthritic pain • Inflammatory pain • Mechanical pain

  6. Pain conceptsNeuropathic pain - Characteristics • Neuropathic Pain- pain generated from within the nervous system • Spontaneous pain • Burning pain • Stabbing , shooting pain • Dysaesthesiae (ants crawling) • Multi-dermatomal Allodynia, Hyperalgaesia, Hyperpathia.

  7. Pain ConceptsSympathetically maintained pain • Peripheral Sympathetic fibre growth • Dorsal root ganglion ingrowth with adrenergic fibres • Manifested by Vasomotor, Sudomotor, Trophic Motor & extra-pyramidal changes • Usually accompanied by Neuropathic pain features

  8. CRPS / RSD • CRPS was called • Reflex Sympathetic Dystrophy • Causalgia ( kausis=burn, algos=pain) • Algodystrophy • Sudek’s atrophy • Peripheral acute trophoneurosis • Traumatic angiospasm • Post infarction sclerodactyly

  9. Pain Syndromes • CRPS Type 1 and Type 2 ( post nerve injury) ( Old terminology RSD and Causalgia) Clinical presentation: • Neuropathic pain i.e. burning ,shooting, multi dermatomal • Allodynia, Hyperalgaesia, Hyperpathia • Sudomotor, vasomotor, trophic tissue change, osteopaenia • Motor & extra-pyramidal changes

  10. Target Treatment strategies • Medical • Pharmacological • Interventional • Psychology • Cognitive Behavioural Therapies Individual & Groups • Physiotherapy • Always active exercises, restoration of function

  11. Cognitive Behavioural TherapyPsychology, Physiotherapy, Medical • Individual and Groups IMPACT and MG group work • Certainly Interventional • Re- engineering of Beliefs • Re-establishment of Self -Efficacy • Restoration of Function both Physically and Socially • Sustainable gains • 3 weeks full time + follow-up

  12. Chronic , Persistent Pain.Cancer Pain • Cancer Pain • ~ 95 % managed with chemo/ radio therapy and ‘conventional’ analgaesics including Opioids, nsaid’s, Steroids, Adjuvant agents, Tramadol , Lignocaine, Ketamine. • Advanced management • includes specific nerve blocks e.g. splanchnic,(coeliac) paraverterbral. • Intraspinal: Epidural and Intrathecal drug Rx

  13. Interventional Therapies Specific nerve and plexus targets • Peripheral & Cranial nerve blocks • Radiofrequency lesioning • Continuous and Pulsed current • Somatic afferents from facet joints ( Medial Branch of Post.Primary Rami.) • Dorsal root ganglia, sympathetic ganglia. • Cryotherapy

  14. Interventional TherapiesChronic non-cancer Pain • Epidurals: cervical, thoracic, lumbar, caudal • Nerve root sleeve injections • Sacro-iliac joints L.A. & Steroids • Epidurolysis : lysis of fibrotic tissue in epidural space

  15. Interventional Therapies Specific nerve and plexus targets Sympathetic Nerve blocks • Stellate • Thoracic • Lumbar L.A • Coeliac Neurolytic • Splanchnic R.F. • Hypogastric • Ganglion impar

  16. Chronic - non-Cancer PainIntraspinal Therapies • Discovery of receptors in Spinal cord for • Opioids • Adrenergic alpha agonists • Alpha 2 agonists ( Clonidine) • Serotonergic • GABA

  17. Chronic - non-Cancer PainIntraspinal Therapies • Portals • Epidural and Intrathecal catheters. • Implanted Pumps & Intrathecal catheter Allows 10- 100 times decrease in dose c.f. systemic delivery with increased efficacy and marked decrease in side effects.

  18. Spinal column Stimulation/ Intrathecal pumps • SCS potentially good in CAREFULLY SELECTED patients for Neuropathic pain problems. ( Failed Back , CRPS Type 1 & 2,) • Intrathecal pumps potentially useful for - nociceptive pain states lower body spasticity cancer pain with reasonable prognosis

  19. Chronic - non-Cancer PainIntraspinal therapies • Spinal Cord Stimulation • Relies on the “Gate theory” principle – continuous non-noxious stimuli via A beta fibres inhibit nociceptive traffic in dorsal horn & cord.

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