Pain and Musculo Skeletal Disorders
Transcript of Pain and Musculo Skeletal Disorders
-
8/13/2019 Pain and Musculo Skeletal Disorders
1/47
Musculoskeletal Disorders
and pain
-
8/13/2019 Pain and Musculo Skeletal Disorders
2/47
Inflammation
What is inflammation ?
Response of a living tissue to a harmful stimuli
May be Mechanical, Chemical, Physical, Thermal, Microbialor any other.
Primary objectives of inflammation.
Remove unwanted
stimulus.
Minimize damage.
Hasten recovery.
Provide defence.
-
8/13/2019 Pain and Musculo Skeletal Disorders
3/47
Inflammation
Cardinal Symptoms
Heat (Calor)
Redness(Rubor)
Pain(Dolor)
Swelling(Tumor)
Loss of function(Functio Laesa)
-
8/13/2019 Pain and Musculo Skeletal Disorders
4/47
Physiology of Inflammation
Occurs in 3 phases Acute transient phase (vasodilation & capillary
permeability).
Delayed sub-acute phase (infiltration of WBCs &phagocytic cells).
Chronic proliferative phase (tissue degeneration &
fibrosis).Inflammation is essential but at times gets
exaggerated & sustained with no apparent
benefit.
-
8/13/2019 Pain and Musculo Skeletal Disorders
5/47
Physiology of Inflammation
Chemical mediators released
Prostaglandins
Thromboxanes (TXA2)
Histamine
Kinins
Leukotrienes Complements
Platelet activating factor (PAF)
Cytokines
-
8/13/2019 Pain and Musculo Skeletal Disorders
6/47
Prostaglandins intensify effect of Bradykinin & Histamine Stimulate migration of phagocytes through capillary walls
Free nerve
ending
(senses pain)
Capillary
Mast cell
Mechanical,Chemicalinjury,Microbes,Antigens.triggersinflammatory
response
Monocyte
Macrophage
Neutrophil Inflammatory mediators
Prostaglandins
Histamine
Bradykinin
Inflammatory
Response
-
8/13/2019 Pain and Musculo Skeletal Disorders
7/47
Physiology of Inflammation
ArachidonicAcid Metabolism
Harmful Stimulus
Cell Perturbation (agitation or disturbance)
Liberates
Membrane PhospholipidsChemical & Mechanical stimuli
activates Phospholipase A
Lipoxygenase
Endoperoxides
PGG2 PGH2
PROSTAGLANDINS PROSTACYCLINS THROMBOXANE
PGE2 PGD2 PGF2 PGI2 TXA2
ARACHIDONIC ACID (AA)
STOMACH, KIDNEYS BLOOD VESSEL WALL PLATELETS
Release
Hydroperoxides
LEUKOTRIENES
Cyclo-oxygenase
-
8/13/2019 Pain and Musculo Skeletal Disorders
8/47
Pain
"An unpleasant sensory and emotional experience
associated with actual or potential tissue damage, or
described in terms of such damage.
Pain that accompanies tissue injury and inflammation
results from local stimulation and enhances sensitivity of
pain fibres which in turn leads to excitation of neurons in
spinal cord.
Prostaglandins, bradykinin, sub P causes pain.
-
8/13/2019 Pain and Musculo Skeletal Disorders
9/47
Characteristics of Pain
Acute Chronic
1. Limited to days or weeks Duration unpredictable
2. Well defined Poorly defined
3. Involves anxiety Involves depression &
frustration
4. Useful physiological signal Has no useful function
5. Expect cure of pain Only can hope to controlpain
-
8/13/2019 Pain and Musculo Skeletal Disorders
10/47
Central &
Peripheral
ReceptorsBrain
Spinal cord
Peripheral
receptors
-
8/13/2019 Pain and Musculo Skeletal Disorders
11/47
PERCEPTION OF PAIN
Injury
Signals
Spinal cord
Hypothalamus
Initiation of pain signals
Pain
Nociceptors
Sensory neuron
Nerve Pathways
-
8/13/2019 Pain and Musculo Skeletal Disorders
12/47
Musculoskeletal Disorders
Illness resulting from cumulative trauma to themuscles, nerves, tendons, ligaments, joints, bones,
cartilage, or spine discs
Musculoskeletal disorders have high impact on* The patient Society The primary care physician
* Glazier, et al. J Rheum. 1996;23:351356
-
8/13/2019 Pain and Musculo Skeletal Disorders
13/47
OA
In India 7.35 % of the total population suffering fromOsteoarthritis
Degenerative arthritis rises steeply with age. Less than 1% haveit between the ages of 25 and 34, >30% after the age of 70
As with many other forms of arthritis, women aredisproportionately affected, especially with hand and knee (OA)
-
8/13/2019 Pain and Musculo Skeletal Disorders
14/47
What is
Osteoarthritis ?
Affects the joint, commonlyoccurs in the hands, hips,
knees, neck & lower back.
-
8/13/2019 Pain and Musculo Skeletal Disorders
15/47
Tendon
Ligament
Synovium
Muscle
Knee Joint(Side view)
Cartilage
What is
Osteoarthritis ?
Joint is surrounded by
a fibrous envelope or
capsule called -
synovium whichproduce fluid to
reduce friction & wear
in a joint. Muscles &
tendons power the
joint.
-
8/13/2019 Pain and Musculo Skeletal Disorders
16/47
How does OA
develop ?
Breakdown ofcartilage results in
joint pain.
It becomes pitted &
weak.
Loses elasticity
leading to damage by
excess use or injury.
Cartilage destruction
Knee(Front View)
-
8/13/2019 Pain and Musculo Skeletal Disorders
17/47
-
8/13/2019 Pain and Musculo Skeletal Disorders
18/47
Loose bone pieces
Fluid-filled cystsLoosecartilageparticles
How does OA
develop ?
Fluid-filled cysts
may form in the
bone near the joint.
Bits of bone or
cartilage may float
loosely in the jointspace.
-
8/13/2019 Pain and Musculo Skeletal Disorders
19/47
How does OA
develop ?
In OA joints become
swollen & damage.
Can be painful & difficult to
move due to inflammation.
-
8/13/2019 Pain and Musculo Skeletal Disorders
20/47
OSTEO RTHRITIS
Progressive Disease
Exposed Bone
Eroding Meniscus
Eroding cartilage
Bone Spurs
-
8/13/2019 Pain and Musculo Skeletal Disorders
21/47
O ManagementNon pharmacological methods
Social support
Weight loss, if the patient is overweight
Physiotherapy and exercise Occupational therapy
Bracing
-
8/13/2019 Pain and Musculo Skeletal Disorders
22/47
O ManagementPharmacological management
Symptom modifying drugs
Analgesics
Nonsteroidal anti-inflammatory drugs
Visco-supplementation (Sodium Hyaluronate inj. (HyaluronicAcid) - an important component of synovial fluid, provides
lubricating properties)
Corticosteroids
Other Nutraceuticals
Glucosamine sulfate
Chondroitin sulfate
-
8/13/2019 Pain and Musculo Skeletal Disorders
23/47
RA & AS
Approximately 1% of Caucasian adults is affected by
rheumatoid arthritis (RA). It is two to three times more
frequent among women and its prevalence also
increases with age
Ankylosing spondylitis affects between 0.5-1% of the
population and has a male predominance
-
8/13/2019 Pain and Musculo Skeletal Disorders
24/47
What is
Rheumatoid Arthritis ?
Is a chronic, inflammatory
disorder wherein bodys
immune system attacks its
own tissues (autoimmunedisorder) leading to
inflammatory disease of joints.
Affects both sides of the bodyeg. hand, knuckles, knee etc.
-
8/13/2019 Pain and Musculo Skeletal Disorders
25/47
Rheumatoid Arthritis
of the hand
Affects finger joints
closest to the body.
H d RA
-
8/13/2019 Pain and Musculo Skeletal Disorders
26/47
How does RA
develop ?
Healthy joint cartilagecovers & cushions
bones for smooth
movement.
In RA cells of
synovium grow &
divide abnormallyleading to thickening
& swelling.
-
8/13/2019 Pain and Musculo Skeletal Disorders
27/47
How does RA
develop ?
Inflammation causes
warmth, redness,
swelling & pain.
Abnormal synovial
cells begin to invade
& destroy cartilage &
bone within the joint.
Bone loss/erosion
Cartilage loss
-
8/13/2019 Pain and Musculo Skeletal Disorders
28/47
RA of the
finger
Surrounding
muscles, ligaments &
tendons that support
& stabilize jointbecome weak &
unable to work
normally leading to
pain & deformities.
-
8/13/2019 Pain and Musculo Skeletal Disorders
29/47
Bone
Inflamed joint capsule
Inflamed
synovium
Synovial
fluid
Destruction ofcartilage
Joint pain
occurring in
various jointsEnlarge view of a joint
RA of the Knee
-
8/13/2019 Pain and Musculo Skeletal Disorders
30/47
Rheumatoid Arthritis
-
8/13/2019 Pain and Musculo Skeletal Disorders
31/47
Comparison of OA & RA
Osteoarthritis Rheumatoid Arthritis
Begins after age 40 or as a Begins between the ages of
result of direct joint injury. 25 & 50.
Is caused due to breakdown of Is an auto-immune disorder.cartilage because of wear &
tear.
Common in both men & women. 3 times more common in women.
Develops gradually over several Unpredictable course with
years. occasional spontaneous remission.
-
8/13/2019 Pain and Musculo Skeletal Disorders
32/47
Comparison of OA & RA
Osteoarthritis Rheumatoid Arthritis
Usually begins in joints on Strikes joints on both sides of
one side of the body. the body at the same time.
Primarily affects joints of knees,
Affects most joints symmetrically -hands, hips, feet & spine. knuckles, wrist, elbows, or shoulders.
Rarely affects knuckles, wrist,
elbows, or shoulders
Morning stiffness lasts usually Morning stiffness lasts longerless than 30 mins. than 2 hrs.
Physical therapy & exercise Gentle exercise & rest is the
improves out come. best course of action.
-
8/13/2019 Pain and Musculo Skeletal Disorders
33/47
Systemic manifestationdecreased chest expansion, iritis,
fever, fatigue, anaemia, anorexia, weight loss, aortic
insufficiency. Synovitis followed by pannus formation (new bone)
Erosion of cartilage.
Ossification of the cartilage and obliteration of the entire
joint.
Bony extensions formed in the intervertebral discs
connecting the vertebral bodies.
Ankylosing Spondylitis
-
8/13/2019 Pain and Musculo Skeletal Disorders
34/47
Pathology
-
8/13/2019 Pain and Musculo Skeletal Disorders
35/47
Course of disease is highly variable ranging from mild
stiffness with radiographic feature of sacroilitis to patient
with fused spine and bilateral hip arthritis.
Diagnosis- Modified New York criteria
History of back pain
Limitation of lumbar spine mobility
Limited chest expansion for age and sex
Radiographic sacroilitis
Presence of any of criteria with X ray positive finding
Ankylosing Spondylitis
-
8/13/2019 Pain and Musculo Skeletal Disorders
36/47
Ankylosing Spondylitis Management
No definite treatment for AS
Exercise is one of the most important activities to maintain
restore spinal mobility, maintain posture, chest expansion.
NSAIDsIndomethacin is particularly effective.
Intraarticular injection of steroids only in severe
unresponsive to NSAIDs.
-
8/13/2019 Pain and Musculo Skeletal Disorders
37/47
Acute painful conditions & Infections like Pharyngitis,
Sinusitis & Tonsilitisare always accompanied by
inflammation of the surrounding tissues and pain in that
region (Localized). In addition, the patient also experiences
generalized fever, bodyache and malaise.
Viral fevercharacterized by high grade fever and severebodyache, malaise.
Pain and Fever in URTI & Viral Fever
-
8/13/2019 Pain and Musculo Skeletal Disorders
38/47
Radiofrequency : frequency of electrical signals
Radiofrequency : a development of heat based radiofrequency denervation, procedures
used in medicine to treat especially chronic pain.
Heat may be applied to the body's surface or to deep tissues. Hot packs, infrared heat, paraffin (heated wax) baths, and
hydrotherapy (agitated warm water) provide surface heat. Heat may be generated in deep tissues by electric currents
(diathermy) or high-frequency sound waves (ultrasound).
-
8/13/2019 Pain and Musculo Skeletal Disorders
39/47
Current Treatment Options
Patient Education
Physiotherapy
Medications
Analgesics & anti-inflammatory form the important
component of medications which includes
paracetamol, NSAIDs, Coxibs
-
8/13/2019 Pain and Musculo Skeletal Disorders
40/47
Postoperative Pain
An unpleasant sensory & emotional experience associated
with actual or potential tissue damage.
Complex process influenced by both physiological &
psychological factors
77% patients experience pain after surgery
Among them 80% experience moderate to severe pain
-
8/13/2019 Pain and Musculo Skeletal Disorders
41/47
Postoperative Pain
Postoperative pain can be divided into acute pain and
chronic pain:
Acute pain is experienced immediately after
surgery (up to 7 days)
Chronic pain which lasts more than 3 months after
the injury
Recent suggested criteria pain more than 2
month post-surgeryJoshi GP. Anesth Clin North Am 2005; 23; 21-36
-
8/13/2019 Pain and Musculo Skeletal Disorders
42/47
Goals of Post Operative Pain
Management
Improve quality of life for patient
Facilitate rapid recovery & return to full function
Reduce mortality Allow early discharge from hospital
-
8/13/2019 Pain and Musculo Skeletal Disorders
43/47
-
8/13/2019 Pain and Musculo Skeletal Disorders
44/47
MOA of Conventional NSAIDs
Harmful Stimulus
Cell Perturbation
Liberates
Membrane PhospholipidsChemical & Mechanical stimuli
activates Phospholipase A
Lipoxygenase
ARACHIDONIC ACID (AA)
Release
Hydroperoxides
LEUKOTRIENES
Non-Selective NSAIDs
Cyclo-oxygenase
Cyclo-oxygenase-1
(COX-1)
Cyclo-oxygenase-2
(COX-2)
Protective Prostaglandins &
Thromboxane
Inflammatory
Prostaglandins
-
8/13/2019 Pain and Musculo Skeletal Disorders
45/47
MOA of Conventional NSAIDs
Arachidonic acid
COX-1 COX-2
Conventional NSAIDs
Constitutive
Good Prostaglandins
Thromboxane A2
Inducible
Bad Prostaglandins
Gastrointestinal
toxicity
Impaired
platelet function
Inflammation
Pain, & Fever
7
-
8/13/2019 Pain and Musculo Skeletal Disorders
46/47
Limitations of Conventional
NSAIDs GI distress, ulceration/bleeding
Renal impairment or failure
Increase in incidence and severity of cardiovascular
side effects
Platelet inhibition may cause bleeding
-
8/13/2019 Pain and Musculo Skeletal Disorders
47/47