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The Science of Chronic Pain Management. Dr Alexander Crighton Consultant in Oral Medicine Glasgow Dental Hospital & School. What is Pain?. “Arrows shot by the Gods” Homer “Passion of the Soul” Aristotle “Pain & Pleasure arise from within the body” Plato. What is Pain?.

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the science of chronic pain management

The Science of Chronic Pain Management

Dr Alexander CrightonConsultant in Oral MedicineGlasgow Dental Hospital & School

what is pain
What is Pain?

“Arrows shot by the Gods” Homer

“Passion of the Soul”Aristotle

“Pain & Pleasure arise from within the body” Plato

what is pain3
What is Pain?

“an unpleasant sensory and emotional experience associated with actual or potential tissue damage or described in terms of such damage”

International Association for the Study of Pain

what is pain4
What is Pain?

“an unpleasant sensory and emotional experience associated with actual or potential tissue damage or described in terms of such damage”

International Association for the Study of Pain

what is pain5
What is Pain?

“an unpleasant sensory and emotional experience associated with actual or potential tissue damage or described in terms of such damage”

International Association for the Study of Pain

what is pain6
What is Pain?

“an unpleasant sensory and emotional experience associated with actual or potential tissue damage or described in terms of such damage”

International Association for the Study of Pain

why get pain when there is no obvious tissue damage
Why get pain when there is no obvious tissue damage?
  • Damaged nociception
  • Damaged transmission of signal
  • Central processing of signal defective
neuropathic pain
Neuropathic Pain
  • Somatic nerve damage
  • Somatic nerve dysfunction
  • Autonomic nerve damage/dysfunction
    • Chronic Regional Pain Syndrome
how do we feel pain10
How do we feel pain?
  • Nociception
  • Peripheral Nerve Transmission
  • Spinal Modulation
  • Central Appreciation
peripheral nociception
Peripheral Nociception

Tissue Damage

5-HT Bradykinin

Nociceptor

Spinal Cord

Substance PProstaglandins

peripheral sensitisation
Peripheral Sensitisation

Tissue Damage

5-HT Bradykinin

Nociceptor

Spinal Cord

Substance PProstaglandins

peripheral sensitisation13
Peripheral Sensitisation
  • Prostaglandins act directly on peripheral terminals of Aδ & C fibres to lower their thresholds
    • Allodynia
    • Hyperalgesia
  • Preventative & therapeutic role for NSAID!
descartes
Descartes

Stimulus response model

Ascending pain

+

N

N

Spinal cord

gate control of chronic pain

Pain fibre

Descending facilitation

N

+

Pain

Ascending pain ‘C’

N

-

-

Descendinginhibition

N

Sensory fibre

Sensation

N

Gate control of Chronic Pain

Melzak & Wall

Touch ‘A’

neuronal plasticity
Neuronal Plasticity

Sprouting of Spinal Segment nerves

Pain fibre

Descending facilitation

N

+

Pain

Ascending pain ‘C’

N

+

-

Descendinginhibition

N

Sensory fibre

Sensation

Touch ‘Ab’

N

the spinal cord
The Spinal Cord
  • 5 ascending tracts which are concerned in pain processing.
  • These may show some specificity for:
    • Types of pain e.g. visceral or somatic
    • Components of pain: e.g.sensory, emotional
    • Integration, orientation and reaction
receptors
Receptors
  • Nerve transmission CHEMICAL
    • Drugs and other nerves can modify activity
receptors20
Receptors
  • Nerve transmission CHEMICAL
    • Drugs and other nerves can modify activity
  • pre AND post synaptic
    • excitatory & inhibitory
    • Chemical or Voltage Operated
    • GABA, Adrenergic, NaN & SNS SodiumProton, Opiate, Potassium, Calcium, ATP, Capsaicin, NMDA
receptors21
Receptors
  • Nerve transmission CHEMICAL
    • Drugs and other nerves can modify activity
  • pre AND post synaptic
    • excitatory
    • inhibitory
    • GABA, Adrenergic, NaN & SNS SodiumProton, Opiate, Potassium, Calcium, ATP, Capsaican, NMDA
  • Transmitters modulate activity
    • Glutamate, Glycine, Norepinepherine, Adenosine, Opioids, Bradykinin, Eicosanoids, 5HT, H+
receptors22
Receptors

NMDA

Opiate

Adrenergic

chronic stimulation
Chronic Stimulation?
  • NORMALRepeated stimulus REDUCES receptor sensitivity
  • NMDARepeated Stimulus INCREASES receptor sensitivity
chronic pain summary
Chronic Pain Summary
  • Peripheral Sensitisation
    • Tissue damage
  • Neuronal Sprouting
    • Tissue Damage
  • Chronic Stimulation
    • Tissue damage

Tissue Healing

chronic pain summary25
Chronic Pain Summary
  • Peripheral Sensitisation
  • Neuronal Sprouting
  • Chronic Stimulation
slide26
PAIN
  • Pain is a complex feeling created in our brains, with affective & cognitive components.
    • Nociception
    • Transmission
    • Understanding
central control of chronic pain
Central Control of Chronic Pain

PAIN

Central Processes

N

Descending facilitation

N

Motor

Pain

+

M-A

-

S-D

N

Descendinginhibition

Sensory fibre

Effect

Sensation

the cortex
The Cortex
  • Somatosensory cortex
    • spatial, temporal & intensity discrimination
  • Anterior Cingulate
    • affective, motor and autonomic reactions.
  • Insular
    • visceral pain, homeostasis
    • integrating pain & memory
  • BUT they all communicate & discrete lesions don’t produce discrete deficits
the cortex30
The Cortex

PAIN

Central Processes

N

Descending facilitation

N

+

Motor

Pain

M-A

-

S-D

N

Descendinginhibition

Sensory fibre

Sensation

Effect

treatments do they fit the science
TreatmentsDo they fit the Science?
  • Drug therapy
  • Clinical Psychology
  • TENS
  • Acupuncture
drug therapy
Drug therapy
  • NSAID
  • Local Anaesthetics
  • Opioid drugs
  • Tricyclic based drugs
  • NMDA Blocking drugs
  • ‘Anti-epileptic’ drugs
  • Membrane stabilising drugs
drug treatments
Drug treatments
  • Opioids
    • tramadol
    • MST
  • Tricyclic based drugs
    • amitriptyline
    • dothiepin
    • nortriptyline
  • NMDA Blockers (+GABA antagonists)
    • ketamine
    • amantadine
    • dextropopoxyphene
drug treatments35
Drug treatments
  • ‘Anti-epileptic’ Drugs (+ calcium channel blockers)
    • gabapentin
    • valproate
    • topiramate
    • vigabatrin
    • carbamazepine
  • Membrane stabilising drugs
    • mexilitene
    • tocainamide
clinical psychology37
Clinical Psychology
  • Cognitive Behavioural therapy
  • Pain perception influences Mood
  • Mood changes influence Pain perception
  • Modulation of ONE will alter BOTH
  • ATTENTION control is important
slide39
TENS
  • High Frequency TENS
  • Low Frequency TENS
  • Burst TENS
the future
The future?
  • Pregabalin 2004
  • Membrane Stabilising drugs
  • ‘Gene therapy’
  • NMDA therapies
  • AMPA therapies (NGX 424)