Michael J. Carl, MD 1
Pain Medicine
Table of Contents
I.
II.
III.
IV.
V.
General………………………………………………………………………………………...2
Assessment and Psychology of Pain………………………………………………………......2
Treatment of Pain
A. Pharmacokinetics, pharmacodynamics, adverse effects, drug interactions, and
indications/ contraindications……………………………….………………………….....3
B. Other Methods…………………………………………………………………………….4
Clinical States
A. Taxonomy…………………………………………………………………………………5
B. Cervical Pain…………………………………………….………………………………...5
C. Lumbar Pain…………………………………………..…………………………………...6
D. Musculoskeletal Pain……………………………………………………………………...6
E. Neuropathic Pain…………………………………….……………………………………7
F. Special Cases…………………………...…………………………………………………7
Summary
A. Key Points…………………………………………………………………………………7
B. Best Practice Guidelines…………………………………………………………………..7
Reference for Presentation: American Board of Anesthesiology: Pain Medicine Content Outline,
January 2010
Michael J. Carl, MD
Credentials:
Diplomate, American Board of Physical Medicine & Rehabilitation
Diplomate, ABPM&R Subspecialty in Pain Medicine
Diplomate, American Board of Electrodiagnostic Medicine
Diplomate, Harvard School of Acupuncture for Physicians
Contact Information:
Oklahoma Algiatry Group
105 S. Bryant Ave, Ste. 301
Edmond, OK 73034
PH: 401.509.6241
FX: 401.509.6242
Email: carl@oagok.com
Michael J. Carl, MD 2
Pain Medicine
I.
II.
General
A. Anatomy and Physiology: Mechanisms of Nociceptive Transmission
a. Peripheral mechanisms
b. Central mechanisms: spinal and medullary dorsal horns, segmental and brain
stem, thalamocortical
B. Pharmacology of Pain Transmission and Modulation
a. Experimental models: limitations
b. Peripheral mechanisms of pain transmission and modulation
c. Synaptic transmission of pain in the dorsal horn
d. Central sensitization: mechanisms and implications for treatment of pain
e. Neurotransmitters involved in pain modulation
C. Development of Pain Systems
a. Development of pain behavior in the fetus and newborn
b. Physiologic and behavioral pain assessment measures in infants: use and
limitations
c. Development of peripheral and dorsal horn mechanisms of nociception and
nociceptive connections in higher centers
d. Long-term consequences of neonatal pain
D. Designing, Reporting, and Interpreting Clinical Research Studies about Treatments for
Pain: Evidence-Based Medicine
a. Critical analysis of literature and evidence-based medicine: basic concepts
b. Principles and effects of valid clinical research
E. Animal Models of Pain and Ethics of Animal Experimentation
a. Common animal models in the study of pain
b. Ethics of animal experimentation
Assessment and Psychology of Pain
A. Assessment and Psychology of Pain
a. Pain as a subjective, multidimensional experience
b. Introspection and measurement of subjective experience: basic concepts
c. Measurement of pain in special populations: challenges and limitations
d. Direct pain measurement: self-report
e. Indirect pain measurement: observations
f. Outcome measures in clinical studies: basic issues
g. Outcomes measures in studies of the impact of pain: requirements
B. Placebo and Pain
a. Placebo: definition and incidence
b. Historic aspects of placebo
c. Placebo response: mechanisms and interpretation
d. Role of placebo in clinical trials and clinical practice: response bias, ethics
e. Open-hidden paradigm
f. Placebo as treatment modality
g. Nocebo effect
C. Clinical Nerve Function Studies and Imaging
a. Electrical nerve stimulation (EMG/NCV/evoked potentials): uses and limitations
b. Laser-evoked potentials: uses and limitations
c. Quantitative sensory testing: uses and limitations
d. Skin punch biopsy: assessment of innervation density
e. MRI, fMRI, and MR spectroscopy: uses
f. PET scans: uses
g. EEG, MEG: uses
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III.
D. Epidemiology
a. Use of data from epidemiologic studies of pain
b. Measurement of burden in a population, including epidemiologic measures of
occurrence (prevalence, incidence)
c. Observational studies: uses and limitations (e.g., measurement of strength of
association between risk factors and pain); known major risk factors for
development of chronic pain
d. Cohort studies: use to determine natural history and predictors of outcome
e. Use of risk factors to guide treatment
E. Psychosocial and Cultural Aspects of Pain
a. Pain as a biopsychological experience: definition and measurement
b. Individual differences in affective, cognitive, and behavioral responses to pain
c. Coping styles: definition and effect on pain experience and response to treatment
d. Expectations, coping, cultural and environmental factors: affect on disability,
treatment outcome, maintenance of treatment effects
e. Cultural, environmental, and racial variations in experience and expression of
pain
f. Role of family in promoting illness and well behavior
g. Common emotional problems and psychiatric disorders associated with pain
F. Sex and Gender Issues in Pain
a. Definition of sex and gender
b. Sex differences: role in epidemiology of pain in relation to age and reproductive
history
c. Sex differences in nociceptive responses and pain perception in animal (acute
and chronic) and human (acute) experimental models
d. Analgesic response: differences between sexes and within the same sex (e.g.,
child bearing)
e. Sex differences: biologic and psychosocial contributions to pain response
f. Sex differences: role in treatment seeking, delivery and effectiveness of
treatment
g. Sex differences: factors influencing the outcome of pain experiments or therapy
Treatment of Pain
A. Opiods
a. Classification of opiod compounds
b. Pharmacology of pain transmission and modulation
c. Pharmacokinetics, pharmacodynamics, adverse effects, drug interactions, and
indications/contraindications
B. Antipyretic Analgesics: Nonsteroidals, Acetaminophen, and Phenazone Derivatives
a. Pharmacokinetics, pharmacodynamics, adverse effects, drug interactions, and
indications/contraindications
C. Antidepressants and Anticonvulsants
a. Antidepressants: pharmacokinetics, pharmacodynamics, adverse effects, drug
interactions, and indications/contraindications
b. Anticonvulsants: pharmacokinetics, pharmacodynamics, adverse effects, drug
interactions, and indications/contraindications
D. Miscellaneous Agents: Pharmacokinetics, pharmacodynamics, adverse effects, drug
interactions, and indications/contraindications
a. Neuroleptic drugs
b. Antihistamines
c. Analeptic drugs
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E.
F.
G.
H.
I.
d. Corticosteroids
e. Muscle relaxants and antispasticity drugs
f. NMDA antagonists
g. Local anesthetics and membrane-stabilizing drugs
h. Sympatholytic drugs
i. Miscellaneous adjuvant analgesics
Psychological Treatments (Cognitive-Behavioral and Behavioral Interventions)
a. Cognitive and behavioral strategies: application to specific pain syndromes (e.g.,
TMJ pain, neck and back pain, fibromyalgia, arthritis pain, burn pain,
postoperative pain)
b. Integration of approaches: cognitive behavioral treatments, combined behavioral
and drug treatments, economic benefits of integrating treatment
c. Stages of behavioral change and their effect on readiness to adopt selfmanagement strategies for chronic pain
d. Cognitive behavioral and self-management interventions: common process
factors (e.g., rapport, engendering hope and positive expectations, developing a
therapeutic alliance, communication strategies, support, suggestion)
Psychiatric Treatment
a. Psychiatric and psychologic morbidities of chronic pain (e.g., depression,
anxiety, drug dependence, somatoform disorders, bipolar disorder)
b. Pharmacotherapy for treatment of comorbid conditions: antidepressants, moodstabilizing agents, anxiolytics, neuroleptics
c. Psychotherapy for depression: cognitive behavioral, marital, family, interpretive,
group therapy
d. Differential diagnosis of anxiety conditions that may augment pain and suffering
e. Anger in chronic pain patients and relation to perceived pain
f. Opiods in chronic noncancer pain: use in substance abusers, addiction vs
tolerance vs dependence, withdrawal symptoms
g. Somatic complaints in chronic pain: conversion disorder and hypochondriasis
h. Role of family: importance of interviewing and training patient and relatives,
evaluating information from relatives
i. Role of patient beliefs and expectations in pain and disability; coping strategies
j. Sleep disorders in chronic pain, diagnosis and evaluation
k. Work history and education in evaluation of chronic pain; frequency of
personality disorders
Stimulation-Produced Analgesia
a. Peripheral stimulation techniques (TENS, acupressure, acupuncture,
electroacupuncture, vibration, Calmare MC5-A)
b. Postulated mechanisms
c. Clinical applications and efficacy
Interventional Pain Management Including Nerve Blocks and Lesioning
a. Anatomy
b. Pharmacology and use of drugs
c. Nerve blocks and neurolytic techniques: diagnostic and treatment purposes,
clinical indications, risks, associated complications
d. Side effects: recognition and treatment
Surgical Pain Management
a. Importance of general health status in preoperative evaluation
b. Surgical lesioning of brain, brain stem, spinal cord, peripheral nerves:
indications, risks, associated complications
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IV.
c. Radiofrequency treatment: indications, risks, associated complications
d. Spinal cord and peripheral nerve stimulation: indications, risks, associated
complications
e. Intrathecal drug delivery: indications, risks, associated complications
J. Physical Medicine and Rehabilitation
a. Temperature modalities (e.g., heat, cold, ultrasound)
b. Manipulation, mobilization, massage, traction
c. Casting and splinting
d. Exercise therapy
K. Work Rehabilitation
a. Importance of early intervention and early return to work in reducing absence
b. Psychosocial factors as the main determinants of disability and as predictors of
prolonged work absence
c. Identification of obstacles to recovery (e.g., fear of reinjury, low expectations of
recovery, low mood, anxiety, withdrawal from social interaction); reliance on
passive treatments, negative attitude to physical activity and self-management,
poor relationship with coworkers and supervisors
d. Components of successful comprehensive rehabilitation program (general
exercise, cognitive therapy, vocational elements)
e. Multidisciplinary approaches for those who do not return to work within a few
weeks (active exercise, addressing distorted beliefs about pain, enhancing coping
strategies, promoting self-management)
f. Functional Capacity Evaluation: definition, usefulness, and limitations
L. Complementary Therapies (CAM)
a. Range of available CAM: alternative medical systems (e.g., traditional Chinese
medicine, homeopathy, mind-body interventions); biologically based therapies
(e.g., herbs, foods, vitamins); manipulative methods (e.g., osteopathy); energy
therapy (e.g., therapeutic touch, magnetic fields)
b. Prevalence and patient reasons for use
c. Evidence base
d. Implications, costs, and side effects (including drug interactions)
Clinical States
A. Taxonomy
a. IASP classification of chronic pain syndromes: basis and application
b. Applications and definition of pain terms
B. Cervical Radicular Pain
a. Anatomy
b. Causes and differentiation from neck pain and somatic nerve pain
c. History taking and neurologic examination: role and limitations
d. Medical imaging: reliability and validity
e. Electrodiagnostic studies: reliability and validity
f. Natural history and relevance to management
g. Commonly used interventions: evidence base
h. Injection therapy: indications and use
i. Surgical treatment: indications and use
C. Neck pain
a. Anatomy
b. Differentiation of neck pain and somatic referred pain from radicular pain and
radiculopathy: differences in evaluation and treatment
c. Mechanisms of referred pain perceived as headache
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d.
e.
f.
g.
h.
i.
D.
E.
F.
G.
History taking: use and limitations
Conventional medical imaging: use and limitations
Risk factors: etiologic and prognostic
Natural history after whiplash injury
Invasive tests (e.g., diagnostic joint blocks, discography)
Nonsurgical intervention: evidence for efficacy of reassurance, maintaining
activity, and exercises
j. Surgical treatment
k. Medial branch neurotomy
Lumbar Radicular Pain
a. Anatomy
b. Causes and differentiation from low back pain and somatic referred pain
c. History and neurologic examination: reliability, validity, and limitations
d. Medical imaging and electrodiagnostic testing: indications and validity
e. Natural history and relevance to management
f. Commonly used interventions: evidence base
g. Surgical treatment: indications and efficacy
Low Back Pain
a. Anatomy
b. Differentiation of low back pain and referred somatic pain from radicular pain,
radiculopathy, and sciatica: relevance to investigation and treatment
c. History taking: significance and use
d. Physical examination and conventional medical imaging: limitations
e. Invasive tests (e.g., diagnostic joint blocks, discography): use
f. Natural history
g. Etiologic and prognostic risk factors: differences, clinical significance, and use
h. Psychosocial and occupational uses for acute and chronic low back pain:
evidence for efficacy
i. Surgical treatment
j. Medial branch neurotomy and intradiscal therapy
k. Multidisciplinary therapy: use and limitations
Musculoskeletal Pain
a. Epidemiology
b. Anatomy and physiology
c. Mediators of inflammation, tissue destruction, and repair
d. Molecular and cellular basis of immunity and autoimmunity
e. Anatomy and biomechanics of joints and muscles
f. Neurophysiology
g. Psychosocial aspects
h. Classification and clinical characteristics of musculoskeletal diseases
i. Assessment of activity and severity of rheumatic disease
j. Treatment and rehabilitation of musculoskeletal pain/disability
Muscle and Myofascial Pain
a. Diagnostic labels for muscle pain: myalgia, nonskeletal musculoskeletal pain,
chronic regional pain, regional soft-tissue pain, myofascial pain
b. Anatomy (muscle nociceptors and ergoreceptors)
c. Multifactorial pathophysiology
d. Common clinical characteristics
e. Assessment (including fibromyalgia, spasticity, and myopathies)
f. Treatment: evidence base
Michael J. Carl, MD 7
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V.
H. Neuropathic Pain
a. Definition
b. Epidemiology
c. Neuropathic pain syndromes: epidemiology
d. Clinical characteristics
e. Pathologic mechanisms in nervous system
f. Pathophysiologic mechanisms in peripheral nerve fibers
g. Diagnostic studies: use and limitations
h. Common neuropathic pain syndromes: clinical, laboratory, and radiographic
findings, differential diagnosis, natural course, proposed pathology
i. Therapeutic interventions
I. Complex Regional Pain Syndromes
a. Definition
b. Common clinical characteristics
c. Pathophysiologic mechanisms
d. Diagnostic procedures
e. Therapeutic interventions
J. Pain Relief in Substance Abusers
a. Biopharmacologic and neurophysiologic basis of addiction
b. Interactions between addiction and pain
c. Screening for drug abuse or addiction in patients with pain
d. Principles of comprehensive approach to pain management in patients with
addictive disease, active or in recovery
e. Pharmacologic treatment of patients with addiction
f. Acute pain management of patients with active addiction or in recovery
g. Analgesic response to opioids in patients with addiction
h. Risks and benefits of opioid use in treatment of chronic/cancer pain in patients
with abuse or addiction
i. Needs of special populations or treatment groups of patients with addiction
j. Legal, regulatory, reimbursement issues limiting access to care for patients with
pain and addiction
Summary
A. Key Points
a. Anatomy and physiology of common pain conditions
b. Pain transmission and modulation
c. Medical research in pain: ethics, uses, limitations
d. Assessment of pain: measurements, tests, imaging
e. Psychology of pain: evaluation and treatment
f. Medications for pain: opiods and adjuvant analgesics, uses and limitations,
risks for addiction or toxicity
g. Physical medicine: modalities, therapeutic exercise
h. Interventional pain management: indications, limitations
i. Surgical intervention: indications, limitations
j. Complementary alternative medicine (CAM): uses, limitations
k. Work related injury concerns
B. Best Practice Guidelines
a. Oklahoma Senate Bill 878 adoption of Work Loss Data Institute’s Official
Disability Guidelines (ODG) as the standard for evidence-based medicine in
determining scope and duration of treatment in workers’ compensation