Persistent Pain &
Pain Interventions
Dr Heide Feberwee
Pain Specialist
Specialist Anaesthetist
Persistent Pain
Pain present for more than 3 months.
Persistent Pain is a chronic disease.
Associated with anatomical changes in the body.
Affects 20% of the population (3.5 M).
High utilization of healthcare resources.
Labour intensive.
Persistent Pain
Managing pain is a long term process like all chronic
diseases.
Patients often have flare ups & multiple sites of pain.
Often associated with complex medical and
psychosocial history.
Patient and healthcare practitioner distress is
common.
Managing long term pain and having strategies to deal
with flare ups are important.
Approach
Multidisciplinary team approach important in dealing
with all aspects of patient care.
Pain specialists, Psychiatrists, Neurosurgeons,
Rehabilitation Specialists, Practice Nurse,
Psychologists, Physiotherapists, Occupational
therapists worth considering.
Palliative Care for terminal patients.
Group sessions including Pain Management Program,
hydrotherapy, mindfulness stress based reduction.
Role of Pain Specialist
Specialist with the Faculty of Pain Medicine ANZCA
(FFPMANZCA).
Already a specialist in another field e.g. Anaesthesia,
Psychiatry, Addiction Specialists, Rehabilitation
Medicine, General Practitioners etc. who are further
trained in Pain Medicine (extra 1-2 years plus exam at
an accredited multidisciplinary Pain Management unit).
Biopsychosocial approach to pain management.
Consultation looks at full pain history, treatment
history, psychological and social issues.
Role of Pain Specialist
Physical exam directed specifically at areas of pain and
aspects thereof that may be targeted with treatment.
Screening for ‘red flag’ conditions – serious conditions that
has significant morbidity.
Comprehensive report and possible management strategies
outlined.
Further investigations ordered / suggested as needed.
Pain condition discussed with patient & questions answered.
Role of Pain Specialist
Advice on drug management including complex opioid
related issues (some may be DDU directed).
Depending on skill set & interest some acquire Pain
Interventional management skills.
Diagnostic & therapeutic Interventional procedures can
be offered.
Referrals with adequate information including previous
specialist reviews and results (laboratory, radiology
etc.) useful.
Role of Pain Specialist
• Patients with pure addiction problems should see also
be referred to ATODS / Addiction Specialist.
• Active suicidal patients & psychosis should be treated
as per normal guidelines first.
• Workcover can occasionally complicate treatment if
ongoing claims / litigation.
• Look at non-pharmacological, pharmacological and
interventional aspects of pain management.
Red flags
Possible
fracture
Possible tumour or
infection
Possible significant
neurological deficit
• Age >50 or <20 years
• History of cancer
• Constitutional symptoms
• IV drug use
• Immunosuppression
• Pain worsening at
night/when supine
• Severe or progressive
sensory alteration or
weakness
• Bladder or bowel dysfunction
From history
• Major
trauma
• Minor
trauma in
elderly or
osteoporotic
From physical examination
• Evidence of neurological
deficit
High acuity cases
Complex Regional Pain Syndrome (CRPS).
CA pain, especially with limited life expectancy.
Adolescents & parents looking after young children.
Threatened loss of employment.
Consideration for severe psychological impact of pain.
CRPS
• Complex Regional Pain Syndrome.
• Debilitating syndrome with sudden onset, can be after
major (type 2) or minor trauma (type 1).
• Swelling / sweating, colour changes, sensory (pain),
motor dysfunction / atrophy.
• Need signs and symptoms in all categories.
• Timely (early) treatment has best outcome.
CRPS hand
CRPS foot
Thermal imaging CRPS
Interventions for CRPS
• Depending limb affected, different types of
sympathetic blocks can be offered – stellate ganglion
blocks, brachial plexus blocks, lumbar
sympathectomies, ankle blocks.
• Normally done as a series of 5 procedures.
• Physiotherapy critical in keeping limb moving.
• Procedure provides window of opportunity for patient
to engage in active therapy.
Chronic Back Pain
• Very common.
• Often multiple causes contributing to pain.
• May be recent onset or long standing.
• Surgery may not be indicated or pain may be
ongoing after surgery.
• May be associated with radicular pain.
Chronic Back Pain
• Significant relationship between gender, age,
BMI & structural causes of CLBP.
• Lumbar internal disc disruption is more common
in young males while facet joint pain is more
common in females with increased BMI.
• Female gender and low BMI is associated with
sacroiliac joint pain.
Multivariable Analyses of the relationship between age, gender and body mass index and
the source of chronic low back pain. De Palma et al. Pain Medicine 2012;13:498-506.
Chronic Back Pain
•
Young adult (20-35) internal disc disruption (IDD) most likely source of
pain (70-98%), regardless age or gender.
•
Over age 50, IDD is the most likely source (40-65%) except for
females with low BMI (<18.5) where SIJ pain is more likely (49%).
•
Males > 65 facet joint pain is most likely (30-54%), regardless BMI.
•
Females > 65 FJP most likely (46-57%) when BMI 30-35 & SIJ pain
more likely when BMI <25.
•
Males > 80 have other sources of CLBP (47-53%) when BMI <30 &
FJP (49%) when BMI >35.
•
Females >80 had SIJP (45-62%) when BMI <25 & FJP (47-58%)
when BMI >30.
Multivariable Analyses of the relationship between age, gender and body mass index and the source of
chronic low back pain.
De Palma et al. Pain Medicine 2012;13:498-506.
Chronic Back Pain
• Need to exclude ‘red flags’.
• Radiological appearance may not coincide with
area of pain.
• Need clinical examination to ascertain pain
contributors.
• Facet joint & Sacroiliac joint common causes for
pain.
Facet joints
Chronic Back Pain
• Other causes include cluneal nerve neuropathy,
piriformis syndrome, greater trochanter bursitis.
• Diagnostic followed by therapeutic procedures
possible for these.
• Often trial injections followed by radiofrequency
neurotomies done.
• Caudal epidural / lumbar epidural with local
anaesthetic and steroid may be useful.
RF neurotomy facet
joint nerves
Radiofrequency
neurotomies FJs
RF FJ & SIJ
RF FJ & SIJ
Cluneal nerve
Spinal Cord Stimulators
• Has a place for especially chronic back pain
post surgery.
• Specific guidelines for usage.
• Conservative management strategies
exhausted.
• Normally trial done followed by permanent
implant.
Spinal Cord Stimulators
Head & Neck Pain
• Many causes for headaches.
• Drug management needs optimization.
• Interventions can be done for Greater Occipital
Nerve neuralgia, Cervical facet joint disease.
• Trial injections followed by RF.
• Advice on drug management.
Shoulder Pain
• Very common.
• Possible to treat most causes of shoulder pain,
before & after surgery & where not indicated.
• Frozen shoulder syndrome common & overuse
e.g. wheelchair bound spinal injury patients.
• Trial suprascapular nerve block followed by RF.
Suprascapular nerve
block
Other Pains
• Can do scar injections post procedures, especially
with neuropathic pain post caesarean sections /
hysterectomy, mastectomy scar pain etc.
• Neuroma injection for amputees.
• Intercostal nerve Phenol injections for infiltrating chest
wall tumours (palliative care).
• Many others directed at specific conditions including
knee joint injections.
Pharmacological
treatment
Drug treatments
Paracetamol
NSAIDs
Tramadol
Opioids / Mor-NRI
Antidepressants
Anticonvulsants –
Pregabalin / Gabapentin
NMDA antagonists
Opioids
• Schedule 8 drugs.
• Regulatory requirements as drugs of abuse / addiction.
• DDU oversees prescribing in QLD.
• Need to have a single opioid prescriber (GP).
• Consider opioid contract even for trial.
• Universal precautions & opioid risk screening tool.
Opioid potency - OMED
•
OMED = Oral Morphine Equivalent Dose
•
10mg Oxycodone = 20mg Morphine
•
10mg Methadone = 70-140mg Morphine
•
8mg Hydromorphone = 40mg Morphine
•
12mcg/hr Fentanyl patch = 40mg Morphine
•
5-20mcg/hr Buprenorphine patch = 10-50mg Morphine (up to 90mg)
•
100mg Tapentadol = 40mg Morphine
•
Dose above OMED 90 - 120mg per day considered high dose.
Universal precautions
1. Diagnosis with appropriate DDx.
2. Psychological assessment incl. addiction risk.
3. Informed consent.
4. Treatment agreement.
5. Pre & post interventional assessment of pain &
level of Fx.
Universal precautions
6. Appropriate trial of Rx & adjuncts.
7. Reassessment pain score & Fx.
8. Regularly assess the 4 A’s.
9. Periodically review Pain Dx & comorbidities
incl. addiction disorders.
10. Documentation.
Conclusion
• Multiple sites of pain can be targeted.
• Need to address other aspects of patient care,
including drug management, psychological
stressors and social issues.
• Team of healthcare practitioners useful to
reduce burden of care.
Questions ?