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An Overview of Chronic Pain

A presentation for non-specialists in healthcare settings
by

Ajit Panickar

on 2 November 2017

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Transcript of An Overview of Chronic Pain

Chronic Pain: An Overview
Dr. Ajit Panickar, MBBS MRCP(UK) FRCA
Consultant, Anaesthesia & Pain Management
South Glasgow University Hospitals
ACUTE PAIN
Mechanisms
PATHWAYS
Key messages
Acute pain is
normal
Acute pain is
protective
Acute pain
resolves

Chronic Pain is...
Mechanisms
MULTIDISCIPLINARY
Physicians
Specialist Nurses
Physiotherapists
Psychologists
Drugs
Exclude treatable illness
Injections
Nerves are wires
But nerves are more than wires....
They connect
CHRONIC PAIN
> 3 months
OR
extends beyond expected
period of healing
ABNORMAL
USELESS
INDIVIDUAL
EMOTIONAL
FUNCTIONAL
SOCIAL
a condition
"something we can manage but not cure"
diabetes
arthritis
copd
cancer
They modulate
Pain goes away as
injury heals
Extracts from
‘Gunshot Wounds and Other Injuries':


The last of the immediate symptoms of grave lesions of nerves is pain,
elsewhere than in the wound
..(in some) the pain was of that
strange burning nature
...it was rare to observe this peculiar and agonizing form of suffering among the immediate consequences of a nerve wound.

The seat of burning pain is very various. Its favourite site is the foot and hand. Its
intensity varies
from the most trivial burning to a state of torture. The part itself becomes
exquisitely hyperaesthetic
so that
a touch or a tap of the finger increases the pain
. Exposure to the air is avoided by the patient with a care which seems absurd and most bad cases keep the hand constantly wet, finding relief in the moisture.

As the pain increases, the
general sympathy becomes more marked
. The
temper changes
and
grows irritable
, the face becomes
anxious
and has a look of
weariness
and
suffering
. The
sleep is restless
. At last the patient grows
hysterical
. He
walks carefully
, carries the limb tenderly with the sound hand, is
tremulous
,
nervous
and has
all kinds of expedients
for lessening his pain.

elasticity
plasticity
Removal of stress (injury)
does not lead to
relief of pain
Pain persists once injury healed
An example
The pain service
Anticonvulsants
Antidepressants
Local anaesthetics
Opioids
Exotics
Make a diagnosis
54 year old male
Longstanding low back pain
Off work for 6 months
Long periods bed rest
Cannot go out/socialize
scared to bend/exert himself
Now walks with a stick - embarassed
Depressed, cannot sleep
MRI: "wear and tear"
Worried about serious illness
convinced doctors have "missed problem"
looking for cure
wife insists on "looking after him"
Biopsychosocial model
Infusions
Pharmacist
mobility, range of movement, strength
one-to-one
education is key
accupuncture, TENS
education
review of patients & medication
TENS
occupational therapist
activity planning
goal setting
domestic aids
education
fear & worry
thoughts, beliefs, emotions
relationships

A chronic pain diagnosis
mechanical back pain + neuropathic leg pain
fear avoidance
anxiety, depression
unhelpful beliefs about cause & meaning of pain
unhelpful coping strategies
oversolicitous partner
BIO
PSYCHO
SOCIAL
Definition
Classification
time
type
acute
chronic
nociceptive
neuropathic
"An unpleasant sensory &
emotional
experience
associated with actual or
potential
tissue damage
or described in terms of such damage"
some chronic pain conditions
Degenerative disease
infections
trauma & surgery
soft tissue conditions
nerve diseases
Modern Medicine
+
Chronic Pain
=

TOO MUCH
Diagnosis
Medication
Intervention
NOT ENOUGH
Personal responsibility
Understanding
Acceptance
Good communication
Conversation, not lecture
Shared understanding
Decide goals

I avoid emotive or technical terms
I don't assume understanding
I take time (more if needed)
YELLOW JACKET
RED HARVESTER ANT
BULLET ANT
SCHMIDT STING PAIN INDEX
1.0: "light, fruity; a tiny spark has singed a single hair on your arm"
SWEAT BEE
2.0: "hot, smoky, a cigar extinguished on your tongue"
3.0: "bold, unrelenting, using a drill to excavate your own toenail"
4.0: "pure, intense, like walking over charcoal with a nail in your heel"
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