Pain management
MUDr. Marek Hakl, PhD. Centrum pro léčbu bolesti, ARK FN u sv. Anny v Brně a LF MU

Definition
“ An unpleasant sensory and emotional experience arising from actual or potential tissue damage or described in terms of such damage”.

Merskey 1967, WHO, IASP

„ Pain is, what patient feels, when he says, that he feels pain “
Margo Mc. Caffery

„ Pain is.“
Wall

Pain management centre
 Algeziologist  Nurse  attendant  Psychologist  Psychiatrist  Neurologist

2 x 1,0 working load 4 x 1,0 1 x 0,5 1 x 1,0 1 x 0,2 1 x 0,5

Patophysiology of pain
 Nociceptors,

polymodal nocisensors  C fibre nociceptors  A fibre nociceptors  Posterior horns of spinal cord  Tractus spinothalamicus, spino-bulbo thalamicus, spinoreticularis  Brain pain centers (gyrus precentralis….)  Supressive mechanisms (GABA, opioids..)

Pain - division
 Acute

pain

x pain x pain x

chronic pain neuropathic pain

 Nociceptive

 Psychogenic  Malignant

pain

non-malignant pain

Acute pain
        

Useful pain, physiologic pain AP is symptom of disease Fulfill basic role of pain – protect organism against injury, disease … Short duration – hours, days.. max 3 moths Duration of acute pain is adequate to causality of this pain Sharp, itching, localized pain, Localization is the same as causality Stimulation of sympathetic syst. Main risk of AP is its chronification

Chronic pain
 CHP

is syndrome , disease  Long duration – more than 3 months  Usually connected with depression  Parasympathetic stimulation  constipation  Social isolation

Neuropathic pain


cause: dysfunction of nerve systems (peripheral, central, vegetative).



types: periferní (peripheral nerves, nerve roots) Trigeminal neuralgia, post herpetic neuralgia, centrální (braine, spine) cental post stroke pain Character: stabile pain, paroxysmal pain with intensive pain atacks, alodynia) triheminal neuralgie, postherpetic



Nociceptive pain
 

Cause: stimulation of nociceptors Tiypes: somatic (muscles, skin, articulations) visceral (inner organs)

Character: somatic pain id good localized, sharp. Visceral: dull and difficult for localization, sometimes reffered pain.


Pain - division
 Mixed

pain – pain contained nociceptive and neurophatic type of pain (FBSS). pain

 Psychogenic

Pain measurement - VAS

Possibilities of pain treatment
 Pharmacotherapy  Physical

treatment and rehabilitation  Psychotherapy  Invasive pain treatment methods  „Alternative“ treatment approaches (homeopathy, acupuncture ….)

WHO leader of pain treatment
silná středně silná mírná
neopioidní analgetika slabý opioid + neopioidní analgetikum + adjuvans silný opioid + neopioidní analgetikum

Analgetic of the I step of WHO leader
Analgetic - antipyretic:
- paracetamol, ASA, pyrazolony

NSA (non steroid antiphlogistic):
non selective COX inhibitors - ibuprofen, diclofenac, naproxen, indometacin COX II preference inhibitors - nimesulid, meloxicam COX II selective inhibitors - celecoxib, parecoxib (Dynastat), valdecoxib (Arcoxia)

Mechanism of action of NSA
Kyselina arachidonová Cyklooxygenáza

NSA

Prostaglandiny
Podpora ledvinných a destičkových funkcí Ochrana žaludeční sliznice

{

Protizánětlivý účinek Analgetický účinek Nežádoucí účinky v žaludku, ledvinách a při srážení krve

X

Zánětlivá reakce a bolest

Analgetic of the II step of WHO leader
 codein

do 240 mg/d  tramadol do 400 - 600 mg/d  dihydrokodein (DHC) do 240mg/d
Oxfordská liga analgetik http://www.jr2.ox.ac.uk/bandolier/booth/painpag/Acutrev/Analgesics/Leagtab. html

Tramadol
 Number

of application forms  Dual effect – serotonin inhib, opioid agonist.  Very good analgetic effect in nociceptive and neuropathic pain  Low occurence of AE  Long time experience (1956)

Analgetic of the III step of WHO leader
 morphin  fentanyl  oxykodon  morphin

SR

IR  buprenorphin  hydromorfon

The most frequent mistakes in chronic pain treatment
Doctors don´t use advantgeous combinations of different analgetics groups (opioids+ NSA, NSA+paracetamol)  In case of increasing analgetic combinations (step up on the WHO leader) change non opioid remedy to weak opoioid – instead to add weak opioid  Dosage of drug inappropriate to pharma cocinetics of drug (tramadol 50 mg twice daily – but effect of 1 cps is only 8 hours  Insufficient dosage of opioid, they are untimely changed  Combinations of different NSA (indometacin supp + ibuprofen)  Untimely canceling treatment due to AE, opioids related AE disappear during 2 weeks (exclude constipation) Occurence of AE is reason for its treatment – no canceling


Invasive Pain treatment indications
 In

case of leak of effect of pharmacotherapy  Pharmacotherapy with severe adverese event  Supplement of Pharmacotherapy

Types of blockades
 Reversible

x irreversible  Vegetative x somatic  single x repeated x continual  Diagnostic x prognostic x therapeutic

Division of blockades due to localisation
 Local

application of LA (reflexive blockades, trigger points, tender points, painful scars, intraraticular applications (SI? …)  Peripherial nerve blockades (axil ar, and intercostal nerv block)  Paravertebral blocks  Central (spinal) block (epidural, subarachnoidal)

Epidural application of steroids

Indication
 Acute

(days) and subacute (weeks up to 3-6 monts) radicular pain (pain irradiating do leg) and caused by intervertebral disc herniation.  CT exam.  Patient is not indicated to back surgery
Breivik, Pain Digest 1999

Recommendation after a application
2

weeks of resting regime  First improvement of pain during 2-3 weeks  4 weeks next visit in pain amb.  From 6 th moth after appl. Started rehabilitation  Recommended daily exercising (15-20 min) - improve body muscle unbalance

Subarachnoidal analgesia
 Single

shot – before surgery – 24 hours post surgery analgesia – LA + morphin spinal 0,2-0,3 mg  Subarachnoidal catheters – Spinocath  Subarachnoidal ports

Subarachnoidal ports
 Treatment

of chronic pain – moths, years (FBSS. Cancer)  Patient or his family training of applications  Be prepare to solve complications of this treatment method (CNS infections, local infections, technical complications, withdrawal syndrome)

Neuromodulation

Neuromodulations centres in CR
 FN

Homolka  FN Motol  ÚVN Praha  FN Olomouc  FN Brno  FN u sv. Anny v Brně

obraZEK PUMPA A stimulátor

Necessary pre-implantation examinations
 Neurologic  Psychologic  Psychiatric  Imunologic  Ortopedic

!!!!

or neurosurgery  Summary of health condition from GP  Algeziologic exam  Positive result of test period

Indikacation
SCS – spinal cord stimulation  Predominant neuropathic lower limb pain Subarachnoidal pumps  Predominant low back pain

Subarachnoidal programmable pump – test period
 Insertion

of subarachnoidal catheter  Connecting of external programmable pump  Setting of adequate mode for application  1 week in patient, 1 week out patient (better simulation of normal daily life of pat.)

Sympathetic blocks
 Reversible

Lokální anaesthetic  Ireversible Etanol 50–80% Fenol 6-8%

Ganglion stellatum – cervical sympathetic syst.
 Upper

cervical ganglion (C2-C3)  Middle cervical ganglion (C4-C6)  Lower cervical ganglion, ggl. Stellatum (C7 -Th1)

Indication
 CRPS

I. a II. Type (after surgery or injury, prolonged healling and edema, followed with muscle atrophy and articulation freezing  Postherpetic neuralgia  Phantom pain  Morbus Paget  Postiradiation neuritis  Raynauld´s didease

Therapy
 Series

ml  Possibility of blockades of other nerves in this region (n. glossopharyngeus, n. recucurent – gulping disorder, huskiness)  Presence of Horner ´s trias

of 10 blocks, Marcain O,25% 10- 15

Neurolysis of ggl. coeliacum
 Epigastrial

pain (painfull attacks in case of chronic pancreatitis, cancer of pancreas – very painful type of cancer
 Blockade

under CT controle

Thank you for your attention
www.pain.cz www.poradna-bolesti.cz marek.hakl@fnusa.cz

Děkuji za pozornost

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