Pain

1
Pain

• Judit Méray MD, Prof.
• Institute of Anesthesiology and Intensive
  Therapy

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Definition of pain I.

• A complex experience consisting of a
  physiological (bodily) response to
  a noxious stimulus followed by an affective
  (emotional) response.
• A warning mechanism that helps to protect an
  organism by influencing it to withdraw from
  harmful stimuli. It is primarily associated with
  injury or the threat of injury, to bodily
  tissues.
• Physical pain is the unpleasant feeling common to
  a headache and a stubbed toe. It typically
  consists of unpleasantness, motivation to
  withdraw or protect, and an awareness of the
  quality, location, intensity and duration of the
  pain, though it is possible to experience pain in
  the absence of one or more of these elements.
• Pain is often accompanied by negative
  emotions (e.g., fear, anxiety, rage) and
  cognitive impairment (e.g., attention and working
  memory deficits).

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Definition of pain II.

• For scientific and clinical purposes, pain is
  defined by the International Association for the
  Study of Pain (IASP) as "an unpleasant sensory
  and emotional experience associated with actual
  or potential tissue damage, or described in terms
  of such damage
• (Somatic cause/sensation
  
  with negative/unpleasant
  subjective/emotional components)
• McCaffrey (1968) whatever the experiencing
  person says it is, existing whenever he says it
  does."
• An abstract concept which refers to
• A personal, private, sensation of hurt
• A harmful stimulus which signals current or
  impending tissue damage
• A pattern of responses which operate to protect
  the organism from harm

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Pain

• Originally pain is an important signalling/
  warning system it helps to notice and to avoid
  harmful stimuli.
• Pain caused by diagnosed illnesses or by medical
  intervention is of no use, but causes suffering
  and gives start to harmful pathophysiologic
  processes ? it must be prevented or eliminated
  !!!

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Pain sensation

• Physiologic
• activation of sensory nerveous system
• - adequate
• - provisory
• localized ti the injury
• normal pain threshold
• - protective
• unpleasant emotion

• Pathologic
• changed nervous reaction
• -dysfunction of the somatosensory system
• -inadequate
• -long lasting
• -involves non injured regions (secunder zone)
• -reduced pain threshold, exaggerated reaction
• -lack of normal selectivity
• -somatosensory-sympathetic interaction

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Peripheric origin of pain
inflammation

• Nociceptive
• Skin, muscles, viscera,
• tooth, vessels, neural injury
• Neurogenous
• Toxins, neuropathy, fibrosis

Transmitter glutamat (SP, CGRP)
Spinal cord
Periferic nerve
Receptors skin, muscle, bone, periosteum,
joints, dental pulp, pleura, pritoneum,
meninxes, GI system, genitals Stimulation of the
receptors mechanical, chemical, termal
algogen substances K, serotonin, histamin,
bradykinin Sensitizing by PG, LT, SP, CGRP
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The spinal cord wind up

• Continuous/repeated stimuli to the dorsal horn
  sensitization of the sensory neurons
  (stimulus-treshold reduction!)
• Hyper-sensitivity (longer depolarization time)
• Cerebral pain sensation amplificated
• Otherwise not painful stimuli will be considered
  as pain

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Central perception of painful stimuli

• Multidimensional, complex cerebral function
• Sensory-discriminative function (localization)
• Cognitive-evaluative function (realization,
  learning)
• Affective- emotional processing

Pain-related behavior
suffering
pain
nociception
Noxious stimulus
secondary inflammatory reaction
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(n.ventr.posterolat)
Thalamus
Sensory- discriminative function

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Chronic pain

• It starts as an acute pain but it continues
  beyond the normal time expected for resolution of
  the problem or persists or recurs for various
  other reasons. It is not therapeutically
  beneficial to the patient.
• It is not therapeutically beneficial to the
  patient.
• In acute pain, attention is focused to treat the
  cause of pain whereas in chronic pain, the
  emphasis is laid upon reducing the pain to give
  relief, limit disability and improve function.

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• Because of the complex emotional processing
  psychic components play a very important role in
  pain sensation.
• Anxiety, fear can intensify pain
• Patient care, information, reassarance may reduce
  pain sensation!

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Judgement of pain intensity
0 max
For children
Visual Analog Scale



VAS NAS
0 1 2 3 4 5 6 7 8
9 10
Verbal Rating Scale extreme very strong
strong mild no pain at all
Numeric analog scale
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Multidimensional evaluation of pain

• Characteristics, course,
  quality of life.

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The most important questions

• Where? - the localization of pain -segmental?
• When? How long do you experience the
  pain? What does provoke the start of the pain?
  How often?
• Changes in the character of the pain?
  Fluctuation? Sesonal appearance?
• How? - quality, characteristics of the pain
• Lancinating, stiching, lightning, continuous,
  spastic, etc.
• How strong? - scales, scores
• Accompanying symptoms
• What gives help/attenuation of pain?

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Important points of medical help

• Let the patient speak!!! TIME!!
• Physical evaluation
• General state, habitus, antropometric measures,
• Psychosomatic character, neurologic
  disorders/deficits?
• Painful spots, areas - continuous pain, or?
  Raction to touching (allodynia?)
• Temperature differences? Others? (edema, muscle
  strength, sensory function, colour ? etc.)
• Instreumental diagnostic evaluation
• Laboratory, X ray, CT, MRI - recognition of
  pathology requireing surgery or other medical
  intervention
• Therapeutic plan - long term care necessary!
• Causal therapy if possible
• Systemic analgetics adjuvant therapy (!)
• Regional anesthesia techniques
• Mechanic/physical therapeutic methods physicoth,
  AKU, TENS..
• Invasive methods?

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Typical exmaples of chronic pain

• Migrain
• Tension headache
• Cluster
• Cervicogenic
• Vascular

• Headaches
• Primarily neurogenic pain
• Trigeminus neuralgia
• Herpes zooster
• Phantom pain
• Sympathetic reflex distrophia -
  causalgia-forms
• Central pain -e.g. thalamic pain
• Ischaemic pain -extremities, mesenteric
• Tumor pain infltration, compression, ulceration,
  edema, perfusion disturbences
• Locomotor disorders
• Back ache - radicular / non radicular
• Shoulder-arm syndrome
• Rheumatism polyarthritis, fibromyalgia,
  myofascial pain
• Abdominal pain - e.g. pancreatitis

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Headache
Do not concentrate solely on medical therapy!
(multimodal approach!)

• Migrain unilateral, frontotemporal pain aura,
  characteristic accompanying syndromes
• Th ASA, metoclopramide naproxene or
  paracetamol
• Prophylaxis metoprolol
• Tension headache dull, pressing, helmet-like
• Cluster - unilateral, sudden onset, short,
  devastating sesonal appearance
• Th indomethacinum, dihydroergotamintartarate
• Cerviocogenic headache unilateral,
  frontotemporal dull pain, influenced by
  movement, position
• Headaches caused by drogs - pl.. nitrates,
  Ca-antagonists.
  cameleon type
• Adjuvant therapy physicoth, TENS,
  relaxation-training

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Pain caused by locomotor diesases

• Rheumatism
• Polyarthritis symmetric appearance (small
  joints)
• Arthrosis knee, tigh-joint
• Fibromyalgia -tender points
• Myofascial pain local trigger points
• Backache
• Radicular -segmental reflexion!
• Non radicular
• Shoulder-arm syndrome
• Radikular C6-8 (trigger head movement,
• rotation, coughing)
• Intervertebral
• Scalenus syndrome
• Periarthritis humerosclapularis

• Th NSAIDs, physicoth., TENS, (steroid,)
  antidepressants

• Th bed rest, NSAIDs, physicoth., TENS, AKU,
  (steroids,) antidepressants
• Psychotherapy, relaxation training,
• Learning, active rehabilitation!

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Disorders of connecting tissues, vasculitis

• SLE, Sjögren, rh. arthritis, scleroderma,
  polymyositis
• Polyarteritis nodosa, Wegener granulomatosis,
  arteritis temporalis, CNS vasculitis
• Laboratory tests STD?
• Rheumatoid factor
• Antinuclear antibody (ANA)
• Anti SM
• .

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Neurogenic pain (compression neuropathy,
neuritis, ischemic, deafferentation)
The pain reflects to the innervation field of the
nerve

• Trigeminus neuralgia
• Unilateral, lightning-like attacks, triggered
  by.
• Medical therapy carbamazepine (2x100 mg)
• Ganglion blockade local anesthetics/ Janetta
  operation
• Atypical facial pain
• Myoarthropathia, masseter spasms, trismus, TMJ
  dental rehabilitation
• Antidepresssants (amitryptilin)
• Sympathetic reflex dystrophy
• Burning pain, generalized edema of the distal
  extremity, temperature (autonome) motoric and
  sensoric difference, trophic disturbances
• Other pain-syndromes of sympathetic origin
• Phantom pain -continuous burning pain sharp,
  shooting pain - Prevention!
• Cause? prosthesis? Neuroma?, perfusion of the
  stump?
• TENS, sympatheticj blockade/neurolysis

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• Ischemic pain
• Arterial occlusion of the extremities
• Thrombangiitis obliterans
• Mesenteric ischemia
• Neuropathies (diabetic, toxic, alcoholic, etc.)
• burning feet, restless leg
• Amyotrophia (myelopathia) tighs, legs
• Pancreatitis epigastrial pain history,
  labor., US, clinical picture
• Th EDA, PCA (antibiotics, steroids)

Th symp. blockade, EDA antidepressants
(amitryptilin)
Th ASA, carbamazepine, antidepressants
(amitryptilin) Vitamine B, TENS
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Tumor painCurative possibilities? Surgery?
Chemotherapy? Irradiation?

• Origin infiltration, compression,
  ulceration,edema, perfusion disturbances
• (pseudorheumatism, radiculopathy,
  peripheric neuropathies, plexus syndrome,
  osteonecrosis)
• History, physical examination, consultation with
  the oncologist/surgeon/radiologist compleme
  tary investigations (e.g. Se Ca), US,
  scintigraphy, MRI, etc.
• Therapeutic plan
• Analgesia medical therapy (WHO
  recommendation!) regional technics
• Adjuvant therapy anticonvulsive, antidepressant,
  sedative, anti-obstipation, anti-osteolytic,
  etc.
• Nutrition, psychotherapy, sport, improvement of
  the general state

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WHO recommandation for the treatment of tumor pain
invasive
Spinal, epidural, regional blocks
p.os, sublinqual, transdermal
Strongopioids NSAID
Week opioids NSAID
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Choice of the analgetic plan

• Prepared protocols for typicalal situations
• Starts automatically, without delay
• Easier for the medical personal
• Simple management even for beginners
• BUT
• Individual reactions and situations should be
  regarded!
• Individual reaction, different pharmacologic
  effect
• individual pharmacokinetics, pharmacodynamics!
• Treat the patient, who is in pain and not the
  symptoms!

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Therapeutic modalities

• Medical therapy - never alone, as sole therpay!
• local
• systemic
• Psychotherapy
• Therapeutical equipment (eg. Arch
  support,othopedic shoes, corset, etc.)
• Physical therapy methods (physicoth.) (pl.
  medical gymnastics, massage, hydroth.,
  acupressure, acupuncture, TENS, electric
  stimulation
• Neural blockades
• Interventional pain therapy
• Surgical intervention - operation or minimal
  invasive techniques (eg. Janetta op.,
  percutaneous laser technique)

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Steps before the medical intervention

• History - most important!!! let the patient
  speek!
• Physical examination
• general state, antropometric measures, physical
  abilities
• psychosomatic state, neurologic
  disorders/deficits?
• painful parts, points - continuous pain?
  Reaction to palpation, tactile stimuli?
• temperature, edema, other disorders at the
  painful site?
• Physical tolerance of the patient?
• Instrumental diagnostic measures evaluation
• X-ray, CT, MRI - diagnosis exclusion of
  disorders where surgical or other intervention
  is necessary
• Therapeutic plan - long term care of the
  patient!
• Causal therapy
• medication painkillers adjuvant therapy
• regional anesthesia
• invasive methods
• mechanical therpeutic measures physioth, AKU,
  TENS..

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Medicinal therapyWays of application

• Oral
• Subcutaneous
• Intramuscular
• Intravenous (single, continuous, PCA)
• Intradural
• Epidural (continuous, PCA)
• Intra(cerebro)vetricular

• Rectal
• Intrarticular
• Intrapleural
• Transdermal
• Endotracheal
• Sublinqual, intranasal
• Superficial

Aim Basic therapy therapy of the break
through pain
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Analgetic medication

• Administration
• repeated bolus
• continuous
• Applying person
• medical personal
• patient (parents)

• Routes
• tablet
• suppositorium
• sc., im. injection
• iv. injection
• transdermal
• special

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Anelgetics

• morfine gold standard
• new systhetic opioids (fentanyl,
  alfentanil, sufentanil, remifentanil)
• agonist-antagonist ceiling-effect
  (nalbuphin)
• codeine family
• oral administration
• combinations
• NSAID
• oral administration
• opioid dose reduction
• If given alone only for mild - medium pain

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Non-steroidal antiinflammatory drugs

• Antiphlogistic action
• ? causal therapy, if the pain is caused by
  inflammatory mediators
• Cave contraindications and possible dangers
  (gastric ulceration, GI bleeding, MI,
  thromboembolic complications) !

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Non-steroidal antiinflammatory drugs

• Ceiling effect
• ? If given alone, only for moderate pain
• superficial surgery (e.g.
  dentoalveolar surgery), ortopedic
  interventions, etc.
• Preferred application po. or supp.
• In combination basic analgesia, -nearly
  always necessary!
• Synergistic action - opioid saving action
• better analgesia
• less side effects

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Most common NSDAIDs

• pharmacon duration single daily
  maximum application dose dose
  form
• Acetyl salicylic acid 4-6 hours 0.5-1 g 4-5
  g p.o.
• Paracetamol 4-6 hours 0.5-1 g 4 g p.o.
• Metamizole 4-6 hours 0.5-1(-2) g 4 g p.o., iv.,
  im.
• Ibuprofen 4-6 hours 200-400 mg 3600 mg p.o.
• Naproxen 12 hours 250 mg 1375 mg p.o.
• Diclofenac 8-12 hours 25-50 mg 100-150mg p.o.,
  iv.
• Ketorolac 6 hours 30 mg 120 mg p.o., iv., im.
• Piroxicam 12-24 hours 20-40 mg 40 mg p.o., im.
  
• Tenoxicam 24 hours 20 mg 20 mg p.o., iv.,
  im.
• Nalbuphin 3-6 hours 10-30 mg 160 mg iv., im.
• Tramadol 4-6 hours 50-100 mg 600 mg iv., im.

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NSAIDS

• Indometacine
• Diclofenac CATAFLAM 50 mg drg.
• DICLAC, DICLOFENAC, DICLOMEL, FLECTOR,
  VOLTAREN 50, 75 mg, VOLTAREN DOLO 12,5 mg
• Piroxicam FELDENE, HOTEMIN
• Tenoxicam TILCOTIL
• Meloxicam MOVALIS
• Ibuprofen ADVIL 200 mg
• Naproxen APRANAX 275, 550 mg tbl.,
  NAPROSYN, NAPROXEN
• Nifluminic acid DONALGIN 250 mg

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Others

• ASA
• ALKA SELTZER effervescent tbl
• ASPIRIN tbl.100, 500 mg, ASPIRIN FORTE,
  ASPIRIN PLUS C, ASSC
• KALMOPYRIN
• Metamizole ALGOPYRIN 1, 2,5, g (500 mg/ml)
• Algopyrin complex, Quarelin
  (metamizolecoffeinedrotaverine)
• Aminophenazon DERMICID, DEMALGON, DEMALGONIL
• Paracetamol BENURON, EFFERALGAN, MEXALEN,
  PANADOL, PARACETAMOL, RUBOPHEN
• Solpadeine, Saridon, Miralgin, Neo
  Citran
• Phenacetin combinations Antineuralgica,
  (coffeineamidazophenphenacetin) DOLOR
  (aethylmorphineamidazophenphenacetin)

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Narcotic analgesics

• Morphine Morphinum hydrochloricum 1, 2,
  3
• M-ESLON (10), 30, 60, 100, (200) mg
• MST CONTINUS 10, 30, 60, 100 mg retard tbl.,
  PALLADONE-SR 4, 8, 16, 24 MG
• CR 20, 30, 60, 100, 200 mg granulátum (susp.)
• MST UNO 30, 60, 90, 120, 150, 200 mg retard
  kapsz.
• Oxycodone Oxycontin 10, 20, 40, 80 mg retard
  filmtabl.
• Dihydrocodeine DHC Continus 60, 90, 120 mg retard
  tbl.
• Pethidine DOLARGAN inj., tabl.
• Fentanyl DUROGESIC 25, 50, 75, 100 mg/h
  TTS tapasz 50 mg/ml inj., DOLFORIN
• Nalbuphine NUBAIN 20 inj.

Accurate documentation, storage necessary!!!
CAVE abuse!
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Injection in prn system
Serum conc.

Side effects
analgesia
Pain!
t
Im.
Im.
Im.
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Adjuvant methods

• Infiltration of the area (subcutaneous,
  intramuscular) with local anesthestics
• Intraarticular injection
• Peripheric blocks - local anesthetics
  continuous or repeated injection through
  cannula (axillary, femoral, caudal)
• Spinal anesthesia with opioids fentanyl,
  sufentanyl
• EDA - continuous infusion with syringe pumps,
  PCA
• e.g. Marcain 0,1 Fentanyl 10 mg/ml indul
  2-7 ml/hour, PRN ?

• Lidocaine
• Bupivacaine
• Ropivacaine

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Medicinal adjuvant therapy

• Tricyclic antidepressants
• Anticonvulsive, spasmolytic medication
• Anticholinergics
• Gastric ulcer prevention (H2 receptor blocking,
  PPI)
• Antinauseal therapy
• Laxativa
• Anxiolytics
• Coritcosteroids
• Antihistamine, sympatholytics, etc.

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Ways of interrupting the pain afferentation

1. Superficial (surface) anaesthesia (spray,
   application of anesthetic solutions, gels)
2. Inflitration anesthesia (injection)
3. Conduction type anesthesia (perineural injection,
   plexus blockade)
4. Ganglion anesthesia
5. Peridural /epidural anesthesia
6. Spinal /intradural anesthesia
7. General anesthesia

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Ggl. Coeliacum blokád
Ggl. . Stellatum blokád
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Non systematic/non medicinal therapy Non
invasive methods

• TENS
• Akupuncture tradicional, elektric, laser
  stimulation of the points
• Magnetotherapy
• Psychotherapy, relaxation training, physicotherapy

Invasive techniques

• Surgery
• Infiltration, conduction analgesia
• Ganglion blockade with local anaesthetics
  neurolysis
• Intradural, epidurals analgesia (local
  anesthetic, opioids,)

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Inthratecal opioid application

• Obstetric use
• Additive (synergistic) application with
  local anesthetics
• Postoperative analgesia
• Improve the effect of EDA
• Unsuccesful EDA COPD
• Attenuation of chronic pain in special
  situations

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Important consideration before the use of
interventional techniques in chronic pain therapy

• Indication possible effectiveness possible
  failure?
• (motivation, patient compliance, danger of
  dependency, educational level, accompanying
  diseases .? Existence period of pain, previous
  interventions, sympatic components of pain?)
• Risk of the intervention? (legal responsibility?)
• Cost-benefit relation?
• Patients insurance?
• Necessary documentation?
• Existence of objective (instrumental) and
  subjective (personal) conditions?

(eg. sterile OR surroundings, equipment,
competency, practice, )
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Examples of methods at the interventional pain
clinic

• Pulsating radiofrequency treatment of nerve
  routes
• 3-500 kHz AC application through isolated
  needle-electrodes in an intermittent pulsating
  mode no thermal effect, analgesia achieved by
  the electric field
• Percutaneous spinal electro (thermo) radicotomy
• 3-500 kHz AC through isolated needle-electrodes
  causes thermal laesion of the nerve roots,
  causing irreversible, long lasting effect.
• Epidural neuroplastic method
• Through a specially formed epidural cannula,
  after contrast-identification of the nerve root
  responsible for the pain, injection of
  triamcinolon, hyase local anesthetic.
  (liberation of the adhered nerve root)
• Epiduroscopy (diagnostic and therapeutic.)
• Introduction of a disposable fiberoptic device
  into the epidural space (epiduroscope),
  diagnostic and therapeutic interventions
  (medicine, lavage, liberation of adhesions,
  drainage, etc.)
• Facet anesthesia
• facet joint zygophyseal articulation local
  anesthesia of the joint and nerve in the chosen
  segments. Disappearance of pain is of diagnostic
  value!

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Important

• Everybody has the right to be releaved, from
  suffering and pain within the bounds of
  possibility in every period of life.
• Sometimes there can not be found any organic
  disorder in the background of pain even in
  these situations the pain has to be treated!!!
• Chronic pain nearly always is associated with
  psychosocial elements (Need of complex therapy!)
• ? The relation of the patient
• to himself(herself (internal)
• to his/her environments (external)
• Transzcendentally (upwards)
• Strong pain is inacceptable!!! (cause is
  irrelevant)!
• After exclusion of the possibility of causal
  therapy an effective symptomatic therapy is
  necessary!
• Opioid tolerance addiction - elevate
  the dose according to requirement! but
  recognize the tricks of the addicts
• Rule effective basic therapy
  complementary therapy for the break through
  pain!
• Do not be loath to ask for help, or to send the
  patient to a pain centre, if necessary!

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Hyppocrates

• European Chart of human rights 2002
• Everybody has the right to be releaved, from
  suffering and pain within the bounds of
  possibility in every period of life

Most important task today to organize pain
clinics under the leadership of well trained
pain specialists