Tackling the debilitating problems of chronic paining ...
Transcript of Tackling the debilitating problems of chronic paining ...
The University of Sydney Page 1
Tackling the Debilitating
Problem of Chronic Pain
following SCI
John Walsh Centre for Rehabilitation Research, Sydney Medical School-Northern, Faculty of Medicine and Health, The Kolling Institute
Professor James Middleton
The University of Sydney Page 2
The problem of pain after SCI
▪ Chronic pain commonly accompanies SCI‒ present in about two-thirds, severe in one-third
▪ Contributes to poorer health and well-being, and reduced participation beyond SCI effects alone
▪ Significant negative impact on mood, sleep, daily activities, social integration & quality of life
… often difficult to manage despite many treatments.
Jensen et al, 2005; Middleton et al, 2007; Rintala et al, 1998; Westgren and Levi, 1998; Widerström-Noga et al, 2001.
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The unwelcome house guest
“The most important thing to me is
to live my life and get out and
experience the things I have
always enjoyed in life… and not
be inhibited by serious pain... and
not let that control my life.“
(person with SCI)
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C
Nerve Root Damage
Spinal Cord Damage
Brain changes
▪ Irritable focus with ectopic firing
▪ Increased excitability & central
sensitization
▪ Deafferentation & disinhibition
▪ Reorganisation with
“neuroplasticity”
Thalamus
S1 Cortex
SCI Pain Mechanisms
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International SCI Pain Classification
SCI Pain
NociceptivePain
Musculo-skeletal
Pain
Visceral Pain
Neuropathic Pain
At-level Neuropathic
Pain
Below-level Neuropathic
Pain
Bryce et al., 2010
Other
Nociceptive
Other
Neuropathic
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Nociceptive Pain Types
Image credit: http://www.aci.health.nsw.gov.au/chronic-pain/spinal-cord-injury-pain
Musculoskeletal Pain
• occurs in normally innervated regions above SCI
• acute pain from damage to bones, joints, discs,
ligaments, muscles) and/or instability
• chronic pain due to ‘overuse’ syndromes
• constant dull, ‘aching’ pain worse with movement
or posture
Visceral Pain
• located in the abdominal region
• often diffuse and dull (depending on lesion level)
• associated with inflammation, distension or
pathology in viscera (e.g., bladder and bowel)
• autonomic dysreflexia
• if investigations do not reveal obvious cause and
treatment unsuccessful neuropathic
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Neuropathic Pain Types
Image credit: http://www.aci.health.nsw.gov.au/chronic-pain/spinal-cord-injury-pain
At-level Neuropathic Pain
• Radicular from nerve root/DRG – unilateral &
paroxysmal
• Central segmental cord damage – bilateral &
continuous
• dermatomal distribution in region of sensory loss
• burning, crushing, shooting, electric, stabbing
• allodynia or hyperaesthesia may be present.
Below-level Neuropathic Pain
• located below level (>3 dermatomes), diffuse, where sensory loss
• hot, burning, freezing, tingling, pins & needles, shooting, electric
• Spontaneous or evoked (e.g., by sudden noise, jarring)
• occasionally allodynia (incomplete injuries)
• bilateral, possibly unilateral.
Above-Level
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0
10
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60
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2 WKS 8 WKS 6 MTHS 5 YEARS
MUSCULOSKELETAL VISCERAL NEUROPATHIC (A) NEUROPATHIC (B) ANY PAIN
Prevalence of Pain after SCI
Siddall PJ, et al. Pain 2003; 103:249-257.
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Aus-InSCI Results – Health Problems
0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100%
Pain
Sexual…
Spasms
Sleep
Bowel
Bladder
Circulation
Pressure Injuries
Auton Dysreflexia
Respiratory
None Mild Moderate Severe Extreme
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Aus-InSCI Results – Health Problems
• The most common health problem was pain (85%).
• Pain intensity was rated as high (mean 5±3/10),
with 39% reporting severe levels (VAS 7-10/10).
• High pain interference with activities (36.4%), mood
(33.8%) and sleep (37.4%).
• Treatments included opioids (18.5%), over-counter
medications (41.3%), anticonvulsants (34.3%),
marijuana (7.5%), alcohol (9.8%), physiotherapy
(20.1%), physical activity (32.7%) and
psychological support (6.5%).
Compared to 1 year ago, general health was rated as:
better in 23%, about same in 55% and worse in 22%.
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Treatment - Musculoskeletal Pain
▪ Stabilisation procedures (spinal surgery, braces)
▪ Correct underlying contributing factors:
‒ Postural re-education, exercise & stretching
‒ Activity modification (to reduce mechanical loading),
pacing and use of adaptive equipment
‒ Seating & wheelchair biomechanics
Pharmacological treatment for symptom relief
▪ Simple analgesics, NSAIDs
▪ Opioids
▪ Baclofen, Diazepam, Tizanidine (spasm)
▪ Local joint steroid injections (eg. shoulder joint, bicipital
groove)
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▪ Find (and treat) underlying cause – in first instance look
for genitourinary (infection, calculi, obstruction) or bowel-
related (constipation, impaction) pathology.
– Treat infections with antibiotics (eg. UTI, prostatitis)
– Surgical procedures (e.g., lithotripsy/paxy to remove
calculi / ureteric obstruction)
– Disimpaction, adjust bowel regimen/routine
▪ Other (e.g., gall stones, peptic ulcer, etc)
▪ Autonomic dysreflexia, which may be associated,
requires urgent attention.
➔ If no cause identified, treat as ?Neuropathic
Treatment - Visceral Pain
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Pharmacological TreatmentNeuropathic Pain
First-line
– Commence an anticonvulsant (Pregabalin OR Gabapentin)
Add tricyclic antidepressant - Amitriptyline OR Nortriptyline
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Response to Pregabalin in SCI Neuropathic Pain
Siddall et al Neurology 2006; 67: 1792-1800.
0
10
20
30
40
50
Placebo
(n=67)
Pregabalin
(n=69)%
of
pa
tie
nts
0
10
20
30
40
50
Placebo
(n=67)
Pregabalin
(n=69)
% o
f p
ati
en
ts
50% reduction
in pain score
30% reduction
Changes in pain scores
− Double-blind, placebo-controlled
study (n=137)
− Average dose = 460 mg/day
22%
0
1
2
3
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5
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7
8
9
10
0 1 2 3 4 5 6 7 8 9 10 11 12 13
Week
Me
an
pa
in s
co
re
Placebo (n=67)
Pregabalin (n=69)
EP
*** ****** *** *** *** *** *** ** ** ** ** ***
** P<0.01, ***P<0.001 vs. placebo
7.5%
42%
16%
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Pharmacological TreatmentNeuropathic Pain
First-line
– Commence an anticonvulsant (Pregabalin OR Gabapentin)
Add tricyclic antidepressant - Amitriptyline OR Nortriptyline
Second-line
– Weak opioid (Tramadol) - Nb. serotonergic syndrome
– SNRI (e.g., Duloxetine)
Third-line
– Opioids (Buprenorphine, Oxycodone, Morphine, Hydromorphone,
Fentanyl, Methadone)
▪ Spinal drug delivery (Morphine/Clonidine, Alfentanil)
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SCI NP Pain & Medications
Opioids:
▪ Tolerance
▪ Potential abuse
▪ Hypersensitivity / “Hyperalgesia”.
THC:
▪ Mainly negative results from research
▪ Potential misuse, diversion and long-
term mental health risks
▪ Different preparations, with more to
learn about cannabis pharmacology.
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Medications: Effects vs Side-effects
I used to take a lot of pain medication – it
was the only way I could take the edge
off. But it almost didn’t ease the pain – it
just made you care less about it!!
It took a long time to reduce the
medication, but now I’m not on any pain
medication and I’m much happier with
that, I have a clearer head and my
memory is improved! Some things early on
– I just can’t remember as a result of all
the medications.
Joe, incomplete paraplegia
EffectsSide-
Effects
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The Biopsychosocial Model
Tissue damagePain ‘generator’
Pain perception
Emotional distress(suffering)
Coping and painbehaviour (disability)
Social environmentCulture/Sick role
Attitudes &Beliefs
After Loeser, 1982
Social
Psycho
Bio
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Treatment: Physical
▪ Equipment to reduce strain
▪ Environmental set up
▪ Regular gentle exercise
▪ Activity Plan
▪ Pacing Plan
▪ Flare Up Plan
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Time
Activity
Level
Pain, Pacing and Physical Activity
▪ Important to maintain a regular pattern of activity
despite pain.
▪ Use pacing principles to plan, chunk and gradually build
up activity to avoid the “boom and bust” cycle
www.aci.health.nsw.gov.au/chronic-pain/spinal-cord-injury-pain/spinal-crd-injury-
pain-physical-activity-and-exercise
Pain Flare
Pain Flare
Pain Flare
Pain Flare
Over-Doing it
Under-Doing it
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Treatment: Psychological
▪ Includes a combination of:
‒ Relaxation
‒ Mindfulness / Meditation
‒ Distraction
‒ Managing your thoughts
‒ De-sensitisation
‒ Flare up plan
‒ Sleep strategies
▪ Thoughts and feelings can
influence the pain experience
▪ Can re-train the brain to reduce
the impact of pain on your life
“Everyone has a different way to
cope with the pain. I used a lot
of meditation early on and
desensitisation. Now I have
taught myself to play guitar,
and when I play it is like a
meditation for me.”
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PAINLocated in a region of
normal sensation
Dull, aching pain
Related to posture,
activity, movement
Somatic tenderness
Vague, poorly localised,
cramping, intermittent
pain in thorax, abdomen
Related to visceral function
Antibiotics
Cystoscopy
Lithotripsy
Disempaction
Adjust bowel
aperients &
routine
Oral baclofen
Tizanidine
Diazepam
NOCICEPTIVE
VISCERALMUSCULO
SKELETAL
Acetaminophen
NSAIDs Botulinum
toxin (if focal
spasm)
Intrathecal
baclofen
Colonoscopy
Bowel transit
studies
Transanal
irrigation
Colostomy
Treat muscle imbalance, exercise
Postural reeducation, seating
Retrain transfer techniques
Address wheelchair
biomechanics
Activity pacing & modification
Environmental modifications
NEUROPATHIC
(see Figure 4)
-Nociceptive pain
indirectly related or
unrelated to SCI, such as
dysreflexic headache,
pressure areas, migraine
Electric shock, shooting,
squeezing, burning pain
Segmental pattern,
located at NLI and/or
within 3 dermatomes, or
involves cauda equina
Electric shock, shooting,
squeezing, burning pain
Located more than 3
dermatomes below NLI
(but may include them)
BELOW-LEVEL
NEUROPATHICAT-LEVEL
NEUROPATHIC
OTHER
NOCICEPTIVE
- - -
Related to repetitive
movement
Local tenderness,
pain on stretching,
resisted movement
Neck or back pain
Kyphus / scoliosis
Worsens during day
Relieved by lying
Possible trigger pts
POOR POSTURE
& MECHANICS“OVERUSE
SYNDROME”
Increased
muscle tone
MUSCLE SPASM
--Fever, frequency,
urine leakage, debris,
blood, spasms, AD
WCC, urinalysis,
MCS, ultrasound, CT
Constipation,
diarrhoea, bloating
Worse after meal,
Improved by evacuation
Impacted on AXR
Pounding headache,
sweating, flushing,
blurred vision, etc
Elevated blood
pressure (>20mmHg)
-
PSEUDOBOWEL
OBSTRUCTIONINFECTION,
CALCULUS
AUTONOMIC
DYSREFLEXIA
--
-
Tramadol
“Strong” opioids
Located in a region of
impaired sensation
Spinal
fusion
Signs of instability
on examination
Structural changes
evident on imaging
FRACTURE
DISLOCATION
-Exclude pathology,
such as peptic ulcer,
gall stones, etc
on ultrasound, CT
scan, endoscopy
-
-
Identify and
treat cause
Identify and
treat cause
BP lowering
drugs
Further
investigatio
n
-
+++++
++ +++ + +
ALL - ASSESS AND TREAT PSYCHOSOCIAL & ENVIRONMENTAL CONTRIBUTORS - POOR PACING, UNHELPFUL COGNITIONS, MOOD DYSFUNCTION (e.g. CBT, Anxiolytics, Antidepressants)
- --
+ -
Siddall & Middleton. ISCoS Textbook on Comprehensive Management , Chapter 55, 2015.
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Surgicaldecompression
Nerve conduction
studies
Electromyography
CT scan, MRI scan
Monitor
Shunting/
Detethering
Strong opioids (controversial)
Refer to Multidisciplinary Pain Service
Non-pharmacological approaches
(ie. stimulation, surgical, procedural
and psychological interventions
described in text)
Treat appropriate to
condition, eg. carpal
tunnel release,
neuropathic pain
medications
BELOW-LEVEL
NEUROPATHIC
AT-LEVEL
NEUROPATHIC
Unilateral distribution
correlates with nerve
root compression on
CT or MRI scan
NERVE ROOT
COMPRESSION
Ascending sensory
level, loss of muscle
strength, reflexes
Cystic cavity on MRI
SYRINX
-
Pregabalin / Gabapentin
+/-Tricyclic antidepressant
Tramadol (with
anticonvulsant)
Replace TCA with SNRI
a
-
-
-
-
Located in a region of
normal sensation
NOCICEPTIVE
(see Figure 3)
MUSCULO
SKELETAL
NEUROPATHIC
-Nociceptive pain
indirectly related or
unrelated to SCI, such as
dysreflexic headache,
pressure areas, migraine
Electric shock, shooting,
squeezing, burning pain
Segmental pattern,
located at NLI and/or
within 3 dermatomes, or
involves cauda equina
Electric shock, shooting,
squeezing, burning pain
Located more than 3
dermatomes below NLI
(but may include them)
-
Located in a region of
impaired sensationPAIN-
OTHER
NOCICEPTIVE
Dull, aching pain
Related to posture,
activity, movement
Somatic tenderness
Vague, poorly localised,
cramping, intermittent
pain in thorax, abdomen
Related to visceral function
VISCERAL
-
ALL - ASSESS AND TREAT PSYCHOSOCIAL & ENVIRONMENTAL CONTRIBUTORS - POOR PACING, UNHELPFUL COGNITIONS, MOOD DYSFUNCTION (e.g. CBT, Anxiolytics, Antidepressants)
OTHER
NEUROPATHIC
Neuropathic pain indirectly
related or unrelated to SCI,
such as carpal tunnel
syndrome, postherpetic
neuralgia
+
++
+ ++++
+
Siddall & Middleton. ISCoS Textbook on Comprehensive Management , Chapter 55, 2015.
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ACI Pain Website – Spinal Page
Consumer Resources
8 Key Topic Areas:
Introduction to SCI and Chronic Pain
Understanding Pain after SCI
Getting help from your health care team
SCI Pain, Physical Activity and Exercise
Pain: Lifestyle and Nutrition
Medications for SCI Pain
SCI Pain: Thoughts and Feelings
Pain and Sleep
http://www.aci.health.nsw.gov.au/chronic-pain
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▪ Screening – activates tool
▪ Pain Assessment:
‒ Pain severity & interference
‒ Pain location (in relation to SCI level)
‒ Pain features & type
‒ Aggravating / easing factors
‒ Treatment & medication details
▪ Red Flags
▪ Yellow Flags
▪ Treatment – Pain Management Plan
▪ Referrals
▪ Resources
Clinical Decision-Support Tool
http://www.aci.health.nsw.gov.au/chronic-pain
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Clinical Decision-Support Tool
https://www.aci.health.nsw.gov.au/chronic-pain/spinal-cord-injury-pain
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Quicksteps
https://www.aci.health.nsw.gov.au/chronic-pain/health-professionals/spinal-cord-injury-pain-quick-steps
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Quicksteps
https://www.aci.health.nsw.gov.au/chronic-pain/health-professionals/spinal-cord-injury-pain-quick-steps
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Quicksteps
https://www.aci.health.nsw.gov.au/chronic-pain/health-professionals/spinal-cord-injury-pain-quick-steps
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Quicksteps
https://www.aci.health.nsw.gov.au/chronic-pain/health-professionals/spinal-cord-injury-pain-quick-steps
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Quicksteps
https://www.aci.health.nsw.gov.au/chronic-pain/health-professionals/spinal-cord-injury-pain-quick-steps
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Quicksteps
https://www.aci.health.nsw.gov.au/chronic-pain/health-professionals/spinal-cord-injury-pain-quick-steps
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Quicksteps
https://www.aci.health.nsw.gov.au/chronic-pain/health-professionals/spinal-cord-injury-pain-quick-steps
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Quicksteps
https://www.aci.health.nsw.gov.au/chronic-pain/health-professionals/spinal-cord-injury-pain-quick-steps
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Quicksteps
https://www.aci.health.nsw.gov.au/chronic-pain/health-professionals/spinal-cord-injury-pain-quick-steps
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https://www.aci.health.nsw.gov.au/chronic-pain/health-professionals/spinal-cord-injury-pain-quick-steps
Quicksteps
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Quicksteps
https://www.aci.health.nsw.gov.au/chronic-pain/health-professionals/spinal-cord-injury-pain-quick-steps
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Quicksteps
https://www.aci.health.nsw.gov.au/chronic-pain/health-professionals/spinal-cord-injury-pain-quick-steps
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Quicksteps
https://www.aci.health.nsw.gov.au/chronic-pain/health-professionals/spinal-cord-injury-pain-quick-steps
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Quicksteps
https://www.aci.health.nsw.gov.au/chronic-pain/health-professionals/spinal-cord-injury-pain-quick-steps
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Quicksteps
https://www.aci.health.nsw.gov.au/chronic-pain/health-professionals/spinal-cord-injury-pain-quick-steps
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Quicksteps
https://www.aci.health.nsw.gov.au/chronic-pain/health-professionals/spinal-cord-injury-pain-quick-steps
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Quicksteps
https://www.aci.health.nsw.gov.au/chronic-pain/health-professionals/spinal-cord-injury-pain-quick-steps
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Quicksteps
https://www.aci.health.nsw.gov.au/chronic-pain/health-professionals/spinal-cord-injury-pain-quick-steps