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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

Update in Pain managementHIMAA Conference

Dr Tony Weaver

Clinical Director of Surgical Services

Director of Pain Management Clinic

Barwon Health

pain services what we are
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
pain is a bio psycho social problem
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
pain patho physiology types of pain
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
pain concepts nociceptive pain
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
pain concepts neuropathic pain characteristics
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.

pain concepts sympathetically maintained pain
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
crps rsd
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
pain syndromes
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
target treatment strategies
Target Treatment strategies
  • Medical
    • Pharmacological
    • Interventional
  • Psychology
    • Cognitive Behavioural Therapies Individual & Groups
  • Physiotherapy
    • Always active exercises, restoration of function
cognitive behavioural therapy psychology physiotherapy medical
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
chronic persistent pain cancer pain
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
interventional therapies specific nerve and plexus targets
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
interventional therapies chronic non cancer pain
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
interventional therapies specific nerve and plexus targets sympathetic nerve blocks
Interventional Therapies Specific nerve and plexus targets Sympathetic Nerve blocks
  • Stellate
  • Thoracic
  • Lumbar L.A
  • Coeliac Neurolytic
  • Splanchnic R.F.
  • Hypogastric
  • Ganglion impar
chronic non cancer pain intraspinal therapies
Chronic - non-Cancer PainIntraspinal Therapies
  • Discovery of receptors in Spinal cord for
    • Opioids
    • Adrenergic alpha agonists
    • Alpha 2 agonists ( Clonidine)
    • Serotonergic
    • GABA
chronic non cancer pain intraspinal therapies27
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.

spinal column stimulation intrathecal pumps
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

chronic non cancer pain intraspinal therapies34
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.