Persistent Pain

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Persistent Pain Pain Interventions

• Dr Heide Feberwee
• Pain Specialist
• Specialist Anaesthetist

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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.

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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.

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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.

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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.

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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.

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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.

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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.

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Red flags
Possible fracture Possible tumour or infection Possible significant neurological deficit
From history From history From history
Major trauma Minor trauma in elderly or osteoporotic Age gt50 or lt20 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 physical examination From physical examination From physical examination
Evidence of neurological deficit
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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.

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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.

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CRPS hand
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CRPS foot
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Thermal imaging CRPS
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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.

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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.

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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 201213498-506.
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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 (lt18.5)
  where SIJ pain is more likely (49).
• Males gt 65 facet joint pain is most likely
  (30-54), regardless BMI.
• Females gt 65 FJP most likely (46-57) when BMI
  30-35 SIJ pain more likely when BMI lt25.
• Males gt 80 have other sources of CLBP (47-53)
  when BMI lt30 FJP (49) when BMI gt35.
• Females gt80 had SIJP (45-62) when BMI lt25 FJP
  (47-58) when BMI gt30.

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
201213498-506.
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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.

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Facet joints
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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.

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RF neurotomy facet joint nerves
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Radiofrequency neurotomies FJs
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RF FJ SIJ
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RF FJ SIJ
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Cluneal nerve
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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.

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Spinal Cord Stimulators
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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.

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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.

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Suprascapular nerve block
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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.

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Pharmacological treatment
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Drug treatments
Paracetamol NSAIDs Tramadol Opioids /
Mor-NRI Antidepressants Anticonvulsants
Pregabalin / Gabapentin NMDA antagonists
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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.

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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.

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Universal precautions

• Diagnosis with appropriate DDx.
• Psychological assessment incl. addiction risk.
• Informed consent.
• Treatment agreement.
• Pre post interventional assessment of pain
  level of Fx.

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Universal precautions

1. Appropriate trial of Rx adjuncts.
2. Reassessment pain score Fx.
3. Regularly assess the 4 As.
4. Periodically review Pain Dx comorbidities incl.
   addiction disorders.
5. Documentation.

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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.

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Questions ?