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Neuromodulary Approaches to Treatment of Chronic Pain

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Maureen Furlong

on 11 February 2011

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Transcript of Neuromodulary Approaches to Treatment of Chronic Pain

Neuromodulary Approaches to Treatment of Chronic Pain

By: Maureen Furlong, SRNA Chronic pain
1. Is any etiology of pain not directly related to
chronic medical condition
2. Extends beyond the expected period of healing
3. Adversly affects the function or well being of the individual Allodynia: Pain from a stimulus that does not normally cause pain
Light touch Hyperalgesia: Increased response to a normally painful stimulus Central Sensitization & Chronic Pain

Central sensitization can result from continuous firing of peripheral afferent fibers that release excitatory transmitters in the dorsal horn. This increase in transmitter release causes postsynaptic changes of the second order nociceptive neurons

These changes lead to hyperexcitibility of afferent fibers to activate the second order nociceptive neurons

Allodynia & Hyperalgesia Neuromodulary approaches in pain managment that change brain and nerve cell activity Ablative techniques
Chemical denervation- Not to be routinely used (2-24 weeks).
Cryoablation- Used for select patients with post-thoracotomy, low back, and peripheral nerve pain (1-12 months).
Thermal intradiscal procedure- Considered for young active patients with single level DDD (6-12 months).
Radiofrequency- Performed for low back pain when other therapys have failed (2-6 months). Acupuncture (1 week-6months)
Adjuvent to conventional therapy for noninflammatory low back pain. Blocks
Joint blocks- For facet mediated and sacroiliac pain.
Nerve & nerve root- Celiac plexis for chronic pancreatitis. Lumbar sympathetic or stellate ganglion blocks for CRPS (complex regional pain syndrome). Medial branch blocks for facet mediated pine pain. Botulinum toxin
May be used as adjunct for treatment of piriformis syndrome (Caused by compression of sciatic nerve by the piriformis muscle) Electrical nerve stimulation
Subcutaneous peripheral nerve stimulation- Used at multimodal therapy for pheripheral nerve pain (4 months-2 years).
Spinal cord stimulation- Multimodal treatment of radicular pain, also used for CRPS, neuropathic pain, PVD, and post herpatic neuralgia. (6 months- 2 years when combined with PT).
TENS (transcutaneous electrical nerve stimulation)- Multimodal treatment for chronic back, neck, and phamtom limb pain (3-6 months). Epidural steriods- Multimodal therapy that can be combined with local anesthetics to treat radiculopathy
Image guidance by fluroscopy for transforaminal and interlaminar approaches. Intrathecal drugs
Neurolytic blocks- Not to be used on patients with non cancer pain
Intrathecal nonopioid injections- Relief of postherpatic neuralgia not responsive to other therapies.
Intrathecal opioid injections- Neuropathic pain Minimally invasive spinal procedures
Vertebroplasty & kyphoplasty
Treat pain related to vertebral compression fractures, lasting 6-12 months Pharmacologic management
Anticonvulsants- Multimodal tx for neuropathic pain
Antidepressants- multimodal tx for chronic pain, SSRI's for diabetic neuropathy
Benzodiazepines- Questionable if should be used for chronic pain
NMDA receptor antagonists- Neuropathic pain tx
NSAIDS- Back pain
Opioids (oral, transdermal, transmucosal, internasal, sublingual)- Low back and neuropathic pain
Skeletal muscle relaxants- Insufficient evidence for chronic pain relief (use as multimodal tx)
Topical agents (lidocaine, capsicin, ketamine)- Relieve peripheral pain from neuropathy

Goal is to manage side effects, adverse effects, and establish compliance Physical therapy
Especially for low back pain, and be used in all chronic pain conditions as multimodal therapy Psychological Treatment
Cognitive behavioral therapy, biofeedback, and relaxation therapy
Supportive psychotherapy, group therapy, or counseling Trigger point injections
Used for myofasical pain lasting 1-4months Sensitization enhanced by tissue factors and inflammatory mediators released in the course of tissue injury. Interventions can modulate activity at each point. First line treatment in patients with neuropathic pain Up and coming research

Neurofeedback (EEG operant conditioning)
EEG bandwidths (Alpha, Beta) have been shown to be associated with more or less pain
Analgesia determined by decreased power of Beta activity & increased power of Alpha activity
Real time EEG monitoring, where subjects are trained to increase or decrease bandwidth

Improves functions, and symptoms associated with memory, mood, seizure severity, and attention
EEG is non-invasive and relatively inexpensive

Example- Case report of self induced analgesia during meditation, where EEG measured increased Alpha frequency Chronic Post Surgical Pain (CPSP)

One of the most common and serious complications after surgery
Associated with increased analgesic use
Restriction of ADL's
Effects of quality of life
Increased health care utilization Definition of CPSP

Pain developing after a surgical procedure
Pain of at least 2 months duration
Other causes of pain excluded (Malignancy, infection)
Pain continuing from a pre-existing pain problem excluded Cortical Stimulation
(No brain, no pain)
Deep brain electrical stimulation of periventricular/periaqueductal gray matter, internal capsule, and sensory thalamus, has shown promising results for chronic pain management
28-47% reduction in pain intensity when electrodes are placed on motor cortex to inhibit relay of pain to thalamus
Invasive and costly Risk factors for CPSP

Existance and intensity of pre op pain
Increasing age
Genetic susceptability
Psychological factors
Fear of surgery
Longer, more complicated surgeries
Adjuvant interventions ( i.e. radiotherapy)
Severity of post op pain Preventative Anesthetic Techniques

Pre-emptive regional analgesia that is continued well into the post operative does reduce CPSP in patients having thoracotomy and laparotomy
Paravertebral block before insicion and continued into the post opertaive period reduces CPSP in thoracic and breast cancer surgery

The theory is: Establishing sufficient afferent block before surgical incision and continuing it post operatively reduces central sensitization

Used alone for 30 days after surgery does NOT prevent CPSP
When used with local anesthetics it DID reduce the incidence of CPSP in mastectomy, thoracotomy, and rectal cancer surgey

Combined with local anesthetics reduces CPSP Hypnosis

Short term reduction in chronic pain that occurs during the treatment session and lasts for several hours in about 70% of people
Long term reduction in baseline pain in about 25% of people
Show EEG changes discussed earlier (increased power of Alpha activity) Refrences

Baron, R., Binder, A., Wasner, G. (2010). Neuropathic pain: diagnosis, pathophysiological mechanisms, and treatment. The Lancet, 9, 807-819.
Frederick, C., (2011). Pain. Advanced Principles IV, 1-14.
Jensen, M., Hakimian, S., Sherlin, L., Fregni, F. (2008). New Insights Into Neuromodulatory Approaches for the Treatment of Pain. The Journal of Pain, 9, 193-199.
Rosenquist, R., Benzon, H., Connis, R., et al (2010). Practice Guidelines for Chronic Pain Management. Anesthesiology, 112, 810-833.
Searle, R., Simpson, K. (03/17/2010). Chronic Post-Surgical Pain. Medscape.com. Retrieved from http://www.medscape.com/viewarticle/717825
Whitten, C., Donovan, M., Cristobal, K. Treating Chronic Pain: New Knowledge, More Choices. Clinical Contributions.

Thorough patient history, physical exam, and diagnostic eval should be combined to provide an individualized treatment plan, weighing risks and benefits. Treatment should progress from lesser to greater degree of invasivness.
Ongoing contact with the patient and the patients other physcians will ensure optimal care.
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