Please read through this ppt the difference between acute and chronic pain management.

1. Acute and chronic management

6. Classification of pain

7. ACCUTE PAIN CHRONIC PAIN
Transient & self limiting symptoms Persistent & unremitting disease
Positive - attention to injury or illness Negative – no useful purpose
Accompanying features
•Pupillary dilation
•Sweating
•Hypertension
•Tachypnoea
•Tachycardia
vegetative
•Sleep disturbance
•Anorexia
•No pleasure in life
•Personality change
•No sign as in acute pain
•Need to believe patient
Types of pain :-

8. Pain: The Fifth Vital Sign
“Quality care means that pain is measured and treated ”

9. “Freedom From pain is a Human Right ”– WHO 1986

10. Concept of total pain
• Physical Pain
disease location
Other symptoms (e.g nausea)
Physical decline & fatigue
• Spiritual pain
Religious/faith, anger at God
Meaning of life & illness
Why me?
• Psychological Pain
Grief, depression
Anxiety, anger
Change in appearance
• Social
Relationships with
family/friends
Role in the family
Financial problems

11. PAIN terminology

12. ALLODYNIA
• Pain due to a stimulus that does not normally provoke pain
• Allodynia – allo + dynia
• It is important to recognize that allodynia involves a change in the quality of a
sensation, whether tactile, thermal, or of any other sort
• Types
• Mechanical allodynia
• Thermal allodynia
• Movement allodynia
• Eg. Trigeminal neuralgia, Fibromyalgia, CRPS, Migraine etc.
• Treatment – NSAIDs, Lidocaine, Ketamine, Opioids, Lamotrigine

13. ANESTHESIA DOLOROSA
• Pain in an area or region which is anesthetic, numb
• Also called deafferentation pain
• Subdivision of neuropathic pain that may complicate virtually any type of
injury to the somatosensory system
• Peripheral – Phantom limb pain
• Central – Dejerine - roussy syndrome

14. DYSESTHESIA
• An unpleasant abnormal sensation, whether spontaneous or evoked
• A dysesthesia should always be unpleasant
• Include sensations in any bodily tissue , including mouth, scalp, skin, legs
• E.g. – Diabetic neuropathy, GBS, withdrawal from alcohol, MS etc.

15. paresthesia
• An abnormal sensation, whether spontaneous or evoked
• Compare with dysesthesia it is an abnormal sensation that is not
unpleasant while dysesthesia be used preferentially for unpleasant
sensation.
• Paresthesia refers to abnormal sensations in general, it might include
dysesthesia, but the reverse is not true.
• Dysesthesia does not include all abnormal sensations, but only those
that are unpleasant.

16. HYPERALGESIA
• Increased pain from a stimulus that normally provokes pain
• Increased response at a normal threshold, or at an increased threshold, e.g., in patients
with neuropathy
• Hyperalgesia is a consequence of perturbation of the nociceptive system with
peripheral or central sensitization, or both
• Primary - directly in damaged tissue
• Secondary - surrounding undamaged tissue
• E.g. Opioid induced hyperalgesia may develop as a result of long term opioid use in
chronic pain
• Treatment - Antidepressants, anticonvulsants, NSAIDs, TENS etc

17. HYPERESTHESIA
• Increased sensitivity to stimulation, excluding the special senses
• Hyperesthesia may refer to various modes of cutaneous sensibility including touch
and thermal sensation without pain, as well as to pain
• Hyperesthesia includes both allodynia and hyperalgesia, but the more specific terms
should be used wherever they are applicable

18. NEURALGIA
• Pain in the distribution of a nerve or nerves.
NEURITIS
• Inflammation of a nerve or nerves.

19. NEUROPATHIC PAIN
• Pain caused by a lesion or disease of the somatosensory nervous system
• The term lesion is commonly used when diagnostic investigations (e.g. imaging,
neurophysiology, biopsies, lab tests) reveal an abnormality or when there was
obvious traum
• The term disease is commonly used when the underlying cause of the lesion is
known (e.g. stroke, vasculitis, diabetes mellitus, genetic abnormality)

20. CENTRAL NEUROPATHIC PAIN
• Pain caused by a lesion or disease of the central somatosensory nervous system
PERIPHERAL NEUROPATHIC PAIN
• Pain caused by a lesion or disease of the peripheral somatosensory nervous system

21. SENSITIZATION
• Increased responsiveness of nociceptive neurons to their normal input, and/or
recruitment of a response to normally subthreshold inputs
• Sensitization can include a drop in threshold and an increase in suprathreshold
response
• Clinically, sensitization may only be inferred indirectly from phenomena such as
hyperalgesia or allodynia

22. CENTRAL SENSITIZATION
• Increased responsiveness of nociceptive neurons in the central nervous system to
their normal or subthreshold afferent input
PERIPHERAL SENSITIZATION
• Increased responsiveness and reduced threshold of nociceptive neurons in the
periphery to the stimulation of their receptive fields.

23. PAIN ASSESSMENT

24. • CHIEF COMPLAINT
• HOPI
• TREATMENT HISTORY
• FAMILY HISTORY
• PERSONAL HISTORY
• OCCUPATIONAL HISTORY
• PSCHYLOGICAL ASSESMENT
1.Quantity or severity and intensity of pain.
a) Unidimensional pain scale
b) Multidimensional pain scale
2. Quality or nature of pain.
3. Mode of onset and location.
4. Duration and chronicity, frequency
5.Provocative and relieving factors.
6. Special character.
7. Timing of pain, diurnal variation
8. In relation to posture.
9. Site of pain and radiation of pain
10. Associated complaints

25. Unidimensional instruments

26. THE NUMERICAL RATING SCALE (NRS)
• Most commonly used
• Two extremes of the pain experience is noted and has a numerical scale between “no
pain” and “worst pain imaginable.”
• “Zero” corresponds to no pain and “10” corresponds to the worst pain imaginable
• Advantage- easy to understand, Disadvantage - digital scale
• A reduction of 30% or 2 points and more from baseline in patient on treatment
indicates positive response for treatment

27. THE FACES RATING SCALE
• Patient is asked to point to various facial expressions ranging from a smiling face (no
pain) to an extremely unhappy one (the worst possible pain)
• It can be used in patients with whom communication may be difficult

28. THE VISUAL ANALOG SCALE (VAS)
• Similar to the numerical rating scale
• There is a 10-cm horizontal line labeled “no pain” at one end and “worst pain
imaginable” on the other end
• Patient is asked to mark on this line where the intensity of the pain lies, distance from
“no pain” to the patient’s mark numerically indicates the severity of the pain
• The VAS is a simple, efficient, valid, and minimally intrusive method
• The disadvantage is it is more time consuming than other instruments

29. Multidimensional Instruments

30. THE MCGILL PAIN QUESTIONNAIRE…
• Words in each class are given rank according to severity of pain
• Translated to multiple languages
• Advantage- Reliable, completed in 5-15 min, it helps in the diagnosis as the choice of
descriptive words that characterize the pain correlates well with pain syndromes
• Disadvantage-High levels of anxiety and psychological disturbance can obscure the
MPQ’s discriminative capacity

31. THE MCGILL PAIN QUESTIONNAIRE (MPQ)
• Developed by Melzack and Torgerson
• Define the pain in three major dimensions by
20 sets of descriptive words divided as
follows:
a. Ten sets describe sensory-discriminative (nociceptive
pathway)
b. Five sets describe motivational-affective (reticular and
limbic structures).
c. One set describes cognitive- evaluative (cerebral cortex).
d. Four sets describe miscellaneous dimensions.

32. Screening tools for neuropathic pain

33. LEEDS ASSESSMENT OF NEUROPATHIC SYMPTOMS AND SIGNS
(LANSS) (2001)
• First screening test to identify pain of neuropathic origin
• Five symptoms, two signs- addressing pain quality and triggers
• Each item is a binary response (yes or no)
• Sensitivity - 82% to 91% , Specificity- 80% to 94%
• Score < 12/24 - Pain is unlikely to be neuropathic in origin Score ≥ 12/24 - Pain is
likely to be neuropathic in origin
• The need for clinical examination and pin prick testing limits its use in clinical
setting.

34. Leeds Assessment of neuropathic symptoms and signs

35. PAIN DETECT
• Simple, Patient-based self-report questionnaire
• consisting of nine items: seven sensory descriptors and two related to spatial
(radiating) and temporal characteristics
• Sensory descriptors are scored on a scale of 0 (no) to 5 (very strongly) and
radiating pain as 1 (yes) or 0 (no)
• Score of ≥19 indicate neuropathic pain likely and ≤12 neuropathic pain unlikely
• Sensitivity 85% , Specificity of 80%

40. • A lot of tools are available for mental status assessment, which includes
 PHQ-9
 Beck Depression Inventory
 Hamilton Depression Scale
 Zung Self-Rating Depression Score
 Hospital Anxiety and Depression Scale (HADS)
 Pain Catastrophizing Scale (PCS)
 The Tampa Scale of Kinesophobia

41. (3)Mode of Onset and Location
• Important for the etiology of pain
• Onset may be sudden or gradual
• Sudden onset of severe pain without any provocation e.g. severe intolerable headache
may be due to subarachnoid hemorrhage
• Sudden severe pain on patients with pre-existing pain e.g. severe back pain in elderly
patients with pre-existing back pain may be due to spinal carcinoma metastases

42. (3)Mode of Onset and Location…
• Site of onset gives better idea in finding out primary reason
• Lumbar facet joint arthropathy patient gives history of pain on lower back, buttock,
and thigh but on enquiry they will show onset on paramedial region and later
distributed to other regions
• It is not uncommon for patient to link pain to trauma in the past or present, which may
not be relevant
• Detailed enquiry may reveal pain-free period after trauma

43. (4)Chronicity (Duration and Frequency)
• Plays a vital role in the diagnosis e.g. Migraine, unilateral pain is frequently throbbing
and may last for hours to days
• Patient with long history of pain, physical provocative test may become negative
• In this case, history of pain in leg with neuropathic character, exaggerated on exertion
and relieved by rest may be only clue for its diagnosis
• In chronic pain conditions, sympathetic system (central sensitization) main pain
mediator
• Explain diffuse the nature of pain in patient and failure to respond to conventional
(interventional) treatment

44. (5)Provocative and relieving factor
• Provide valuable clues to the diagnosis
• Leg and back pain due to spinal stenosis worsening with walking or standing and
relieved with sitting or lying down
• Lower lumbar facet and sacroiliac joint may have similar history sitting relieve pain in
facet joint syndrome not in sacroiliac joint arthropathy in which sitting may provoke
pain

45. (6)Special Character
• Special character can clue in diagnosis
• In cluster headache the pain usually deep, boring, wrenching, while vascular headache
it is throbbing, pulsatile, and severe in intensity
• Idiopathic trigeminal neuralgia pain tends to be unilateral, paroxysmal, sharp,
shooting, and lancinating along one or more branches of trigeminal nerve, whereas the
pain of temporomandibular joint dysfunction tends to be unilateral, dull aching, and
around the affected joint
• Postherpetic neuralgia pain may be burning and aching associated with dysesthesias,
and allodynia

46. (7)Timing of Pain and diurnal variation
• Pain and stiff ness felt in the morning hours persisting for more than hours may be
inflammatory arthropathy
• Pain after any inactivity persisting less than half an hour or after prolonged activity
goes more in favor of degenerative arthropathy
• Severe headache occurring regularly at a particular time, particular season may give
clue for cluster headache
• Neuropathic pain can be more severe in the night

47. (8)Relation with Posture
• Pain increase on sitting on floor in sacroiliac(SI) joint arthropathy
• Cross-legged sitting painful in piriformis syndrome, IT band syndrome, AVN hip, Hip
adductors strain
• Pain on change of posture such as turning in bed, standing from sitting position goes
more in favor facet joint syndrome
• Prolonged sitting produces more pain in discogenic pain
• Patients with spinal canal stenosis have more pain on standing and walking

48. (9)Site of pain and radiation of pain

49. (10) Associated Complaints
• Weakness, numbness may indicate neurologic deficits.
• Weakness may also be present muscular injury
• Fever may indicate infections
• Nausea/vomiting have diagnostic value in migraine, space occupying lesion of brain
etc

50. Past History
• Any pain events mimicking present, ask for progress, diagnosis, and any treatment
taken and procedure/operation done
• History of rash, vesicles in the same dermatome as of present neuropathic pain can
confirm post-herpetic neuralgia
• Some diseases have periodic occurrence and they can have multiple same type of
previous episodes before presenting to us at present e.g. cluster headache

51. Past History…
• Patient with multiple episodes of pain can have associated significant cognitive
disturbance
• Patient can have some disease, which can influence the manifestation of pain (e.g,
dementia) or it can interfere with treatment (organ damage)
• History targeted on finding etiology of pain can help in finding other pain
manifestations of a disease (eg, multiple sclerosis).
• Diabetes, hypertension, thyroid disorder, dementia, parkinsonism, liver and kidney
compromise, inflammatory disorders should be given more importance on its
presence

52. Personal History Including Sleep, Bladder/Bowel Habit
• Patient with pain can have some psychological disorders, such as anxiety and
depression, which occurs primarily because of pain, leads to patient’s less tolerance to
pain and decreased coping capacity
• e.g. Dementia, bipolar disorder, Post Traumatic Stress Disorder (PTSD) and Attention
Deficit Hyperactivity Disorder (ADHD)

53. • Sleep disorder and pain is highly inter linked together, sleep disorder in over 70% of
patient
• Pain may be interrupted e.g. posttraumatic stress disorder
• Patient can feel inadequate sleep on waking up e.g. fibromyalgia
• Effective treatment of sleep disturbance will involve assessing and treating all of the
contributing factors
• Chance of pregnancy should be ruled out in women of child-bearing age
• Bladder and bowel disturbance may be an associated component or etiology for
present pain complaint e.g. history of inflammatory bowel disease may be a reason for
seronegative inflammatory arthropathy, and irritable bowel disease may be an
associated disease of fibromyalgia
Personal History…

54. Treatment History
• Initial questionnaire should allow the patient to list all the therapeutic modalities
they are currently using or have used in the past
• Chances of drug addiction should be ruled out before prescribing any drugs
• Any drug allergy, any side effect/complication to past treatment or comorbid
condition (renal, hepatic compromise) should be taken into consideration before
prescribing medicine

55. Family History
• History of pain and diseases in family members can support in getting diagnosis as
some diseases run among families e.g. Rheumatoid arthritis, Fibromyalgia etc.
• History of family dispute should be ruled out in patients having disproportionate,
irrelevant, and unusual manifestations

56. Understanding or Warning Signals
• We must be very cautious in dealing certain painful conditions, which can be potentially
dangerous
• We must be having multidisciplinary approach to deal with these patients
I. Pain with major trauma
II. Suspecting tumor
III. Suspecting infection with fever, rigor, vomiting, and so on
IV. Unconsciousness
V. Motor weakness
VI. Progressive sensory deficit
VII. Loss of vision
VIII. Loss of bladder control with retention and incontinence
IX. Loss of bowel control with inability to force to pass stool
X. Sudden onset pain, which is progressing rapidly
XI. Not relieved by analgesic within few days

57. Pain pharmacotherapy

59. Drugs in WHO ladder
Non- opioids Weak opioids Strong opioids Adjuvants or coanalgecics
•Paracetamol
•Ibuprofen
•Diclofenac
•Meloxicam
•Naproxen
•Aspirin
•Indomethacin
•Etoricoxib
•Nimesulide
•Ketorlac
•Tramadol
•Codeine
•Dihydrocodeine
•Morphine
•Fentanyl
•Buprenorphine
•Methadone
•Oxycodone
•Anti-emetics
•Ant- depressant
•Anticonvulsants
•Muscle relaxants
•Antispasmodics
•Antibiotics
•Anxiolytics
•Antacids

60. Which step to start ?
• Depending on the severity of the pain
• Mild pain (1–3/10)- start at step 1
• Moderate pain (4–6/10) - start at step 2
• Severe pain (7–10/10) - start at step 3
• It is not necessary to climb the ladder step by step
• A patient with severe pain may need to have Step 3 with
opioids right away.

61. Four Rules & principal of Pain control
• BY THE CLOCK
• BY THE PATIENT
• BY THE PATIENT’S EASIEST ROUTE
• BY THE LADDER

62. DRUGS IN PAIN MANAGEMENT
ANLGESICS CO-ANALGESICS
NSAIDS PARACETMOL OPIOIDS
• ANTI-CONVULSANTS
• ANTI-DEPRESSANTS
• LOCAL ANESTHETICS
• STEROID
• MUSCLE RELAXANTS
• BOTULINUM TOXIN
• NMDA RECEPTOR
ANTAGONIST
• CALCIUM CHANNEL BLOCKER

63. PARACETAMOL

66. Indication and dose

67. Side effects and adverse effects

68. NSAIDs - NON STEROIDAL
ANTI-INFLAMMAYORY DRUGS

70. The Two isoforms of cox

71. NSAIDs
• Acetylsalicylic acid (aspirin)- Tablet, Suppository
• Ibuprofen - Tablet, Suspension for children
• Indomethacin – Tablet
• Diclofenac – Tablet, Suppository, parenteral form available
• Mefenamic acid – Oral tablets

72. Cox-2 selective inhibitors
• Celecoxib - Oral capsule
• Etoricoxib – Oral tablets
• Parecoxib – Parenteral

73. Absorption and elimination
• When administered orally, aspirin, ns-NSAIDs and Coxibs are well absorbed and
reach therapeutic level within 30-60 minutes
• They are eliminated by the renal mechanism

74. • Both ns-NSAIDs and coxibs have the same efficacy in postoperative analgesia
• Sole analgesia for day surgery
• Along opioids for major surgery
• Musculoskeletal pain- back pain, joint pain, muscle
• Osteoarthritis
• Rheumatoid arthritis
Indication

75. ns- NSAIDs vs Coxibs

77. opioids

80. Opioids can be classified as

81. Opioids can be administered via several routes

82. Morphine

83. Oral morphine

84. Parenteral morphine (10 mg/ ml ampule)

85. metabolism

86. Codeine phosphate- weak opioid

87. tramadol

88. tramadol

89. metabolism

91. ketamine

92. ketamine

93. indication

94. Anti convulsants

96. Anti-depressants

97. Tricyclic anti-depressants

98. Selective serotonin reuptake inhibitors

99. Muscle relaxants

101. Drugs used for interventions

103. corticosteroids

105. Local anaesthetics

107. Contrast agents

108. Botulinum toxin

109. Non-Pharmacologic Therapies
• Physiotherapy
• Exercise
• Heat or cold
• Mediation
• Music
• Distraction
• Prayers
• Massage
• Homeopathy
• Aruveyda
• Home remedies

110. Special points
of
Acute Pain Management

111. Objectives
• Appropriate assessment of acute pain
• Concept of multi-modal analgesia
• Indications and side effects of analgesics
• How to rationally prescribe opioids
• side effects and complications of opioids
• Special populations ie elderly, opioid tolerant
• Neuraxial/regional analgesia
• side effects and complications of neuraxial analgesia
• interaction of various anticoagulant medications and neuraxial analgesia

112. Multimodal analgesia
• Using more then one analgesia
• Several analgesics with different mechanisms of action, each working
at different sites in the nervous system

113. OPIOIDS
Efficacy is limited by Side-Effects
• The harder we “push” with single mode analgesia, the greater the degree of
side-effects
Analgesia
Side-effects

114. Multimodal Analgesia
• Lower doses of each drug can be used therefore minimizing side effects
• With the multimodal analgesic approach there is additive or even synergistic
analgesia, while the side-effects profiles are different and of small degree (Pasero
& Stannard, 2012).
Analgesia
Side-effects

115. Neuraxial Techniques
Who Gets Them?
Patient factors:
• Low pain tolerance, opioid tolerance
• Sleep apnea
• Narcolepsy
• Obesity
• COPD
• Cardiac disease
• Elderly – those at risk for post-operative cognitive dysfunction

116. REGIONAL ANESTHESIA
❏ Local anesthetic applied around a peripheral nerve at any point along
the length of the nerve
(from spinal cord up to, but not including, the nerve endings) for the
purposes of reducing or preventing impulse transmission
❏ No CNS depression (unless overdose (OD) of local anesthetic); patient
conscious
❏ Regional anesthetic techniques categorized as follows
• Epidural and spinal anesthesia
• Peripheral nerve blockades
• IV regional anesthesia

117. EPIDURAL AND SPINAL ANESTHESIA

118. anatomy
• The vertebrae are 33 number, divided by
structural into five region: cervical 7, thoracic
12, lumber 5, sacral 5, coccygeal 4

119. EPIDURAL AND SPINAL ANESTHESIA
Anatomy of Spinal/Epidural Area
The spinal cord lies within the spinal canal.
Surround by meanings, dura mater sub archnoid space, then piamatter, end by
hoarse tail (Couda equina)
The spinal cord receives blood supply from ant spinal artery, and posterior spinal
artery.
Spinal cord extends to L2, dural sac to S2
Nerve roots (cauda equina) from L2 to S2
Needle inserted below L2 should not encounter cord, thus L3-L4, L4-L5 interspace
commonly used

120. Structures penetrated
• Skin, subcutaneous fat
• Supraspinous ligament
• Interspinous ligament
• ligamentum flavum (last layer before epidural space)
• dura + arachnoid for spinal anesthesia

121. anatomy

122. anatomy
• The spine double “C” curve with cervical and lumbar. Structural of the
vertebra:

123. anatomy
• The vertebrae are joined together by
intervertebral disc by strong ant and
post longitudinal ligaments.

124. Epidural Anesthesia
❏ LA deposited in epidural space (potential space between ligamentous
flavum and dura)
❏ Solutions injected here spread in all directions of the potential space;
SG of solution does not affect spread
❏ Initial blockade is at the spinal roots followed by some degree of spinal
cord anesthesia as LA diffuses into the subarachnoid space through the
dura
❏ Larger dose of LA used

125. Spinal Anesthesia
❏ Relatively small LA dose injected into subarachnoid space in the dural sac
surrounding the spinal cord + nerve roots
❏ LA solution may be made hyperbaric (of greater specific gravity (SG) than the
cerebrospinal fluid (CSF) by mixing with 10% dextrose, thus increasing spread
of LA to the dependent (low) areas of the subarachnoid space

126. Peripheral nerve blockades

129. Common chronic pain conditions
• Musculoskeletal Pain- Cervical radiculuopathy, cervical facet pain,
spondylosis,rotator cuff tendinopathy, tennis elbow, carpal tunnel
syndrome, thoracic pain, lower back pain, lumbar facet pain, si joint pain,
oa hip , meralgia paresthetica, oa knee, tarsal tunnel syndrome etc.
• Facial pain
• Headache
• Chronic cancer pain
• Chronic post traumatic pain
• Neuropathic pain syndromes- CRPS, diabetic neuropathy, post HIV pain
• Phantom limb pain.

130. Common modalities used in pain interventions
usg

131. C-arm

132. Radiofrequency ablation

133. PAIN AND PALLIATIVE CARE IN
AIIMS JODHPUR

135. OPD START IN AIIMS
AUG 2018

136. ADDRESS IN AIIMS

137. VISIT OUR CLINIC BY OUTER TEAM

139. AIIMS Jodhpur.pdf
AIIMS Jodhpur.p

140. OUR SERVICES
• PAIN MANAGEMENT
• DISPENSE T-MORPHINE( FREE)
• COUNSELING & SUPPORTIVE CARE
• WOUND AND OSTOMY CARE
• HOME CARE BY NAVCHETNA
• EDUCATE & TRAINING

141. DISPENSE TAB-MORPHINE( FREE)

142. MORPHINE DRUG BOOK AND INSTRUCTIONS

143. STORAGE OF DRUGS

145. PATIENTS FEEDBACK

146. Thank you