The Essentials of Pain Management

8/3/2019 The Essentials of Pain Management

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LannyLanny

dr. Laniyati Hamijoyo SpPD-KR. M.Kes

Pendidikan:

1994 : FK Universitas Atma Jaya, Jakarta

1996 : Internship di CWZ Nijmegen-Netherland

2005 : Spesialis Penyakit Dalam FK.UNPAD, Bandung2005 : Magister kesehatan FK. UNPAD, Bandung

2007 : Subspesialisasi Reumatologi di Univ.Santo Tomas Manila

2008 : Adaptasi Konsultan Reumatologi FKUI,Jakarta

Organisasi: Anggota:

IRA, PAPDI, PRA, IDI, APLAR

Penghargaan:

JCR, APLAR, EULAR, TIR, PRA

Curriculum Vitae:

Staf pengajar Departemen Ilmu Penyakit Dalam FK UNPAD/RS Hasan Sadikin Bandung


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The Essentials ofThe Essentials ofPain ManagementPain Management

Laniyati HamijoyoLaniyati Hamijoyo

Divisi Reumatologi Departemen Ilmu Penyakit DalamDivisi Reumatologi Departemen Ilmu Penyakit Dalam

FK Universitas Padjadjaran/ RS Hasan Sadikin BandungFK Universitas Padjadjaran/ RS Hasan Sadikin Bandung


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Case # 1

Mr B 23/M Acute pain 2 hours ago

On his right ankle

History of falling during play

basketball 2 hour ago

What is the diagnosis?

What will you suggest?


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Case # 1

Ms. D 35/F

Pain on both hands

Since 2 months

Swollen


What medicine will you start

on her?


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Case # 2

Mrs. L 55/F

Sharp and burned like pain

on her fingers especially

right hand

Since 3 months

Worse in the morning

History of type 2 DM

What is her diagnosis?

Therapy?


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Pain


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PainPain

How to diagnose?

Therapy?

Whichmedicine?


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Problems related to

healthcare professionals

Inadequate knowledge

Poor assessment

Concern about regulation of controlled substances

Fear of patient addiction

Concerns of side effects of analgesics

Concerns about patients tolerant to analgesics

Barriers to effective pain managementBarriers to effective pain management


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Problems related to

patients

Reluctance to report Fear that pain means disease is worse

Reluctance about taking pain medicines

Concerns of being tolerant to medicines

Poor adherence

Worries about unmanageable side effects



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Problems related to

healthcare system

Cost

Reimbursement

Restrictive regulation

Availability



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Definition of pain1

Assessment and diagnosisof pain2

3 Management and monitoring of pain

Outline the essentials of painOutline the essentials of pain

managementmanagement

1

2


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Definition of painDefinition of pain

An unpleasant sensory and emotional

experience associated with actual or

potential tissue damage, or described

in terms of such damage IASP

In reality,

its what the patient says it is.

Merskey H, Bogduk N. 2nded Seattle, WA: IASP Press; 1994.


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Physiology of Pain PerceptionPhysiology of Pain Perception

InjuryInjury

DescendingDescendingPathwayPathway

PeripheralPeripheralNerveNerve

DorsalDorsalRootRootGanglionGanglion

C-FiberC-Fiber

A-beta FiberA-beta Fiber

A-delta FiberA-delta Fiber

AscendingAscendingPathwaysPathways

DorsalDorsalHornHorn

BrainBrain

Spinal CordSpinal Cord

Adapted with permission from WebMD Scientific AmericanAdapted with permission from WebMD Scientific American MedicineMedicine..


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Injury-induced Pain:Injury-induced Pain:

Patient FactorsPatient Factors

McQuay H. BMJ 1997;314:1531.

Individual

variation in

response to injury:

physiological,behavioral,

and cultural

Individual

variation in

response totreatment

Injury

Complaint of pain


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Definition of pain1

Assessment and diagnosis of pain2

3 Management and monitoring of pain

OutlineOutline

1

2


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Assessment of painssessment of painGoals:

Achieve diagnosis of pain and underlyingAchieve diagnosis of pain and underlying

disorderdisorder

Characterizing and quantifying the painCharacterizing and quantifying the pain


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Achieve diagnosis andAchieve diagnosis and

underlying disorderunderlying disorder

History takingHistory taking

Pattern : onset, duration, frequency

Area : location, topography

Intensity: level

Nature : description, history of

similar episodes,intervention & what helped


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Question to evaluate painQuestion to evaluate pain

P-Q-R-S-T formatProvocation How the injury occurred & what activities

the pain, exacerbating and alleviating factors

Quality characteristics of pain (tingling, burning, dull)

Referral/Radiation

Referred site distant to damaged tissue thatdoes not follow the course of a peripheralnerve.

Radiating follows peripheral nerve; diffuse

Severity How bad is it? Pain scale

Timing When does it occur? p.m., a.m., before, during,after activity, all the time


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Pain assessment toolsPain assessment tools


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Pain assessment toolsPain assessment tools

Brief pain inventory

Patients rate pain intensity and its effect ongeneral activity, mood, ability to walk, work,relationships, sleep, and enjoyment of life

McGill Pain questionnaire

Patients rank pain in words sets that are groupedin 4 main categories: sensory, affect, evaluative,

and miscellaneous


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Physical examinationPhysical examination

General PE: Vital sign

Regional examination


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Musculoskeletal examinationMusculoskeletal examination

Inspection: look for redness,

swelling, deformity

Palpation : Test for warmness

Test for deep/ superficial

muscle tenderness

Range of motion


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Neurological examinationNeurological examination

Mental status

Cranial nerves

Motor function: weakness, ataxia Sensory function

Reflexes


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Classify PainClassify Pain

AcuteAcute

Recent onsetRecent onset

Limited durationLimited duration

The cause is generally knownThe cause is generally known

resolution of underlyingresolution of underlying

cause, self limitedcause, self limited

ChronicChronic

Persist for > 3- 6 monthsPersist for > 3- 6 months

Persist at least 1 month beyondPersist at least 1 month beyond

the usual course of acute painthe usual course of acute pain

Associated with chronicAssociated with chronic

pathologic processpathologic process

Recurs at relatively short intervalRecurs at relatively short interval

duration:

htt ://www. medsca e.org 2011
http://www/http://www/http://www/


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NociceptiveNociceptive Irritation/Irritation/

TissueTissueinjuryinjury

Classify the PainClassify the Pain

Malfunction

on peripheral /

central nerves

PsychologicPsychologic

factorfactor

NeuropathicNeuropathic

PsychogenicPsychogenic Nociceptive &Nociceptive &

neuropathicneuropathicMixedMixed

mechanism:


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Type of painType of pain

Pain

Nociceptive

Visceral Somatic

Pleurisy

Appendicitis

cholecystitis

Poorly localized

Cramping, dull

well localized

Variably

Skin, muscle

Soft tissue,

bone

Neuropathic

Abn neural activity

due to injury or

disease of the

nervous system

Thalamic pain

Trigeminal neuralgia

Diabetic neuropathy


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Nociceptive VS neuropathic painNociceptive VS neuropathic pain

Neuropathic painInitiated or caused by primary

lesion or dysfunction in the

nervous system

Nociceptive painCaused by activity in neural

pathway in response to

potentially tissue- damaging

stimuli

Postoperative

pain

Mechanical LBP

Sport / exercise

injuries

Sickle cell crisis

ARTHRITIS PHN

Neuropathic LBP

Distal

polyneuropathy

(e.g. diabetic)

Central post

stroke pain

Trigeminal

neuralgia

CRPS

International Association for the Study of Pain. IASP Pain Terminology.Raja et al. in Wall PD, Melzack R (Eds). Textbook of pain. 4th Ed. 1999.;11-57

Mixed painCaused by a combination of

both primary injury or

secondary effects


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Pain characteristicPain characteristic

NociceptiveNociceptive

Focal/ diffuse painFocal/ diffuse pain

Sharp, dull, acheSharp, dull, ache

with sign of inflammationwith sign of inflammation

usually acuteusually acute

Often decrease over timeOften decrease over time


Regional/ dermatomalRegional/ dermatomal

Burning, tingling, numbness,Burning, tingling, numbness,

needle prick painneedle prick pain

Often persists / worsen overOften persists / worsen over

timetime


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Pain characteristicPain characteristic

NociceptiveNociceptive

Alodinia/ hyperalgesiaAlodinia/ hyperalgesia

MS regional pain (arthritis,MS regional pain (arthritis,

bursitis, tenosynovitis, etc)bursitis, tenosynovitis, etc)

Post traumatic pain , fracturePost traumatic pain , fracture

Inflammation painInflammation pain

Bone metastasesBone metastases

NSAIDs often workNSAIDs often work, opiods, opiods

effective, adjuvant and topicaleffective, adjuvant and topical

analgesics somewhat effectiveanalgesics somewhat effective


Peripheral neuropathic pain:Peripheral neuropathic pain:

- post herpetic neuralgia- post herpetic neuralgia

- diabetic neuropathic- diabetic neuropathic

- radiculapathic pain etc- radiculapathic pain etc

- metastases on plexus- metastases on plexus

Central neuropathic painCentral neuropathic pain

NSAIDs not effective, opioidNSAIDs not effective, opioid

less effective, adjuvant andless effective, adjuvant and

topical analgesics somewhattopical analgesics somewhat

effectiveeffective


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Evaluate the functional statusEvaluate the functional status

How does it affect physical function

and work (ADLs)?

How does it affect social andmental functioning?


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Evaluate the painEvaluate the pain

Identify comorbid conditionsIdentify comorbid conditions

Identify past medical historyIdentify past medical history

Family historyFamily history


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Additional examinationAdditional examination

Imaging

Laboratory

Psychosocial


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Identify Pain Treatment OptionsIdentify Pain Treatment Options

Non-Drug Therapies

Drug Therapies

More Invasive Therapies


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Pain Treatment Continuum

Least

invasive

Most

invasive

Psychological/physical approaches

Topical medications

*Consider referral if previous treatments were unsuccessful.

Systemic medications*

Interventional techniques*

Continuumnot related to efficacy


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Non-Drug TherapiesNon-Drug Therapies

Ice/Heat

Exercise/Rest

Physical Therapy

Chiropractic Care

Acupuncture

TENS Units

Behavioral Therapy

And Many More.


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Drugs for PainDrugs for Pain

Non-Opioid Analgesics Acetaminophen

Salicylates and Non-Selective NSAIDS

Selective COX-2 Inhibitors

Adjuvant Analgesics Antidepressants

Anticonvulsants

Topicals, Muscle Relaxants, and Others Opioids

Short- and long-acting formulations


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WHO (World Health Organization) Three-WHO (World Health Organization) Three-

Step Analgesic LadderStep Analgesic Ladder

Non-opioid

+ Adjuvant

Pain

Pain persisting or increasing

Opioid for mild to moderate pain

+ Non-opioid

+ Adjuvant

Pain persisting or increasing

Opioid for moderate to severe pain

+ Non-opioid

+ Adjuvant

Satisfactory Symptom Management


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WHO3-STEP

LADDER SEVERE3

MorphineHydromorphone

MethadoneOxycodone

Fentanyl

+/- Adjuvants

MODERATE3

A/CodeineA/Hydrocodone

A/Oxycodone

Tramadol+/- Adjuvants

MILD3

ASA/NSAIDS

AcetaminophenCox-3

+/- Adjuvants


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Bio-psycho-social in pain managementBio-psycho-social in pain management

Pain Behaviors

Suffering

Pain

Perception

Nociception

Local block

NSAIDs

Surgery

Physical modalities

Opioid

Adjuvants

NSAIDs?

Acetaminophene

Neural augmentation

Ablative surgery

Anti-depressants /psychotropics

Relaxation

Spiritual

Cognitive therapies

Functional restoration


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Some More Invasive TherapiesSome More Invasive Therapies

Trigger Point Injections

Intra-arthricular Injections

Regional Nerve Blocks

Epidural Injection

Various Surgeries


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Evaluation of pain managementEvaluation of pain management

Follow upFollow up::

- reassessed pain- reassessed pain

- functional improvement- functional improvement

- side effect therapy- side effect therapy- adherence to therapy- adherence to therapy

Educate patientsEducate patients::

- about the cause of pain- about the cause of pain

- set appropriate expectations of- set appropriate expectations oftreatmenttreatment


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Case # 1

Mr B 23/M Acute pain 2 hours ago

On his right ankle

History of falling during play

basketball 2 hour ago


PE: Warmth, swelling, painlimited range of motion

What will you suggest?



Intensity: level


similar episodes,

intervention & what helped


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Case # 1

Ms. D 35/F

Pain on both hands

Since 2 months

Swollen, tender. Warm,morning stiffness

Lab: RF (+), ESR


What medicine will you starton her?



Intensity: level


similar episodes,intervention & what helped


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Case # 2

Mrs. L 55/F

Sharp and burned like pain

on her fingers especially

right hand

Since 3 months

Worse in the morning

History of type 2 DM

Test: Tinel (+), Phallen (+)

What is her diagnosis?

Therapy?



Intensity: level


similar episodes,

intervention & what helped

S f P ti l A h tS f P ti l A h t


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Summary of a Practical Approach toSummary of a Practical Approach to

Pain ManagementPain Management

1. Evaluate and treat the underlying

cause.

2. Evaluate and treat the pain itself.

3. Listen to and trust your patients.4. Use all the resources at your disposal.

5. Re-evaluate the treatment

6. Refer if you get stuck


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The Essentials of Pain Management

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