Describe the characteristics of acute pain.
Predictable
Associated with tissue damage
Circuitry well defined
Self limiting
unimodal treatment
responds predictably
useful warning function.
Describe the characteristics of chronic pain.
Unpredictable
Relationship with tissue damage unclear
Circuitry unknown
Continues
Multimodal treatment
Difficult to treat
No useful warning function.
What is chronic pain by definition?
Chronic pain is an unpredictable response of an often abnormal nervous system,
where the relationship to injury or tissue damage is unclear. Neuroplasticity gone
wrong. Chronic Pain considered more a brain problem than a tissue problem.
Lasts at least 3 months- although some literature will use 6 months.
What is acute pain by definition?
Acute pain is a predictable response of a normal sensory system to a defined injurious
process. When we touch a hot surface, without thinking, acute pain protects us from
more tissue damage, and we remove our hand from the source by reflex. As the small
burn heals, the pain diminishes and stops.
What is allodynia?
Pain due to a stimulus that does not normally provoke pain.
What is hyperaalgesia?
Increased pain from a stimulus that normally provokes pain.
What is nociceptive pain?
Pain that arises from actual or threatened damage to non-neural tissue and is
due to the activation of nociceptors.
What is neuropathic pain?
Pain caused by a lesion or disease of the somatosensory nervous system.
What is central sensitization?
Increased responsiveness of nociceptive neurons in the central nervous system to their normal or subthreshold afferent input.
What are examples of some chronic pain related conditions?
Musculoskeletal: Spinal pain syndromes (eg, degenerative disc
disease with or without spinal stenosis, post-laminectomy, and
post-fusion surgeries); osteoarthritis; regional muscle pain
disorders
* Neurologic: Migraine and other recurring headache disorders,
including tension-type headaches; peripheral and traumatic
neuropathies; trigeminal neuropathies and neuralgia; multiple
sclerosis
* Gastrointestinal: Irritable bowel syndrome; Crohn disease;
ulcerative colitis; pancreatitis
* Urogynecological: Interstitial cystitis (bladder pain syndrome);
vulvodynia; chronic endometriosis; chronic (male and female)
pelvic pain
* Metabolic: Diabetes (peripheral neuropathy); pernicious anemia
* Infectious: Post-herpetic neuralgia; HIV-associated neuropathy;
Lyme disease
* Autoimmune disorders: Rheumatoid arthritis; systemic lupus
erythematosus; spondyloarthropathies; Sjögren’s syndrome;
chronic inflammatory demyelinating polyneuropathy
* Neoplastic: Cancer survivor pain syndromes.
What are “yellow flags”?
Identify those who are more likely to go on to have an illness.
Yellow flags are psychosocial factors
associated with unfavourable clinical outcomes and the transition to
persistent pain and disability.
They also flag other factors relating to perceptions about the relationship
between work and health which are associated with reduced ability to work and prolonged absence.
What are examples of yellow flags?
Attitudes and beliefs- eg pain is harmful and severely disabling.
Emotions and behaviours- Fear avoidance behaviours.
Other psychosocial factors- poor relationships and financial concerns.
As well as-
- Biologic: severity and extent of surgery, trauma[8] or disease
condition (eg, poly-trauma, including burns), persistent
cancer-related pain[9], genetic factors[10] including sickle cell
disease[11], recurrent bouts of autoimmune inflammatory
disease[12], metabolic disorders (eg diabetes), advanced
age[13] and frailty. - Psychological: pre-existing mental health issues[14] (eg,
poorly controlled depression, anxiety, catastrophizing, PTSD.) - Substance use or abuse (includes: tobacco, alcohol,
sedatives, opioids[15]) - Social: disabled, disconnection[16], loneliness[16], unstable
housing, poverty, low health literacy, poor access to medical
and behavioral care - Repeated surgeries[17] or ineffective procedures intended to
relieve the same pain condition eg Failed back surgery
syndrome FBSS, - Unintended and/or prolonged exposure to opioid
analgesics[18] - Pre-existing wide-spread pain (eg, fibromyalgia[19].
What are long term conditions?
- Any condition that has a protracted (usually at least 6 months) clinical course can be
considered a long-term or chronic condition. - Chronic diseases require long-term therapy, response is often suboptimal, and
a return to a state of complete or pre-morbid normalcy is the exception, not the rule. - Risk factors for chronic disease include cigarette smoking, sedentary lifestyle
and obesity. - Obesity is also considered a long term condition in its own right.
What is the inverse care law?
- 50 years ago Julian T Hart identified this
- Still apparent today
- Those that need Healthcare most will access it least
- Those who need it least will access it most
- We consider Health provision in deprived inner cities v affluent commuter belt
- Homeless , Addicts , Sex workers , Refugees , Immigrants , Disabled , Lonely.
What does the probability of returning to work decrease with?
Increased time off work.
How do you manage chronic pain?
- There is no medical intervention, pharmacological or non-pharmacological, that is
helpful for more than a minority of people with chronic pain, and benefits of
treatments are modest in terms of effect size and duration. - Additional morbidity resulting from treatment for chronic pain is not unusual, so it is
important to evaluate the treatments we offer for chronic pain, to focus resources
appropriately and to minimise harm. (NICE Guidelines draft 2021).
Why is neuropathic pain challenging to manage?
- The International Association for the Study of
Pain (IASP 2011) defines neuropathic pain as
‘pain caused by a lesion or disease of the somatosensory nervous system’ - Neuropathic pain is very challenging to
manage because of the heterogeneity of its
aetiologies, symptoms and underlying mechanisms - peripheral neuropathic pain as a symptom are painful diabetic neuropathy, post-herpetic
neuralgia, trigeminal neuralgia, radicular pain, post-surgical chronic neuropathic pain,
and neuropathic cancer pain - cause central neuropathic pain include stroke, spinal cord injury and multiple
sclerosis.
Is obesity preventable?
Yes.
What does high BMI increase the risk of?
Cardiovascular diseases (mainly heart disease and
stroke), which are a leading cause of death
Diabetes
Musculoskeletal disorders (especially osteoarthritis –
a highly disabling degenerative disease of the joints)
Some cancers (including endometrial, breast, ovarian,
prostate, liver, gallbladder, kidney, and colon).
What lifestyle changes should be made to combat obesity?
Limit energy intake
from total fats and sugars
Increase consumption of fruit
and vegetables, as well as
legumes, whole grains and
nuts
Engage in more regular
physical activity (60 minutes
a day for children and 150
minutes spread through the
week for adults). This will be
difficult for Sean.
Reduce his alcohol intake.
Give examples of some good medical practices.
|Involvement Primary care team- Long term conditions
Asking Red Flag questions
Safety netting and checking understanding
Keeping good medical records
Re-asking of Cauda Symptoms at subsequent consultation
Identifying potential crisis situation-high index of suspicion
Chaperone policy adherence
Effective communication between primary and secondary care to patients benefit.
Who can you refer to NI self management services?
Adults living with chronic/persistent
pain & long-term health conditions – not ‘just’ arthritis/MSK conditions.
Focus on the common impacts of
long-term conditions.
What should always be considered with lower back pain/ pins and needles in that area.
CES- Cauda Equina Syndrome.
However is not common.
