This document provides an overview of pain medicine, including definitions, physiology, types of pain (acute vs chronic, nociceptive vs neuropathic), epidemiology, treatment options (physical therapies, pharmacological, psychological, minimally invasive procedures), and examples of medicolegal case histories. The key topics covered are the definition of pain, differences between acute and chronic pain and nociceptive and neuropathic pain, the wide range of treatment modalities available including medications, therapies, and procedures, and how pain impacts many people as indicated by the epidemiology statistics presented.

1. Overview of Pain Medicine.
Dr. Christopher A. Jenner MB BS, FRCA, FFPMRCA
Consultant in Pain Medicine, Imperial Healthcare NHS Trust
Medical Director London Pain Consultants and Spinal Healthcare
11th November 2010

2. Agenda
• Definition
• Physiology
• Acute/ Chronic
• Neuropathic
• Differences
• Treatment Options
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3. Definitions
• Pain. ‘An unpleasant sensory and
emotional experience which we primarily
associate with tissue damage or describe
in terms of tissue damage, or both.’ (IASP 2001)
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4. Definitions (2)
• Time-course:
• acute
• chronic
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5. Definitions (3)
• Type:
• nociceptive
• neuropathic
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6. Nociceptive Pain
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12. Neuropathic Pain
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15. Pain Physiology
(boring)
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17. Pain Physiology
(funky version)
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19. Epidemiology
• 1 in 5 of adults suffers from chronic pain
• 1 in 3 in the elderly population
(Blyth et al 2001)
• 70% of people living with chronic pain are under the age
of 60 years.
(European Journal of Pain, 2006)
• 49% of people living with chronic pain are forced to take
time of work.
(British Pain Society, 2005)

20. Physical and Alternative
Treatments

21. Physical/ Alternative Treatments
• Physical- heat/ cold/ TENS/ hydro/ supports/ US/ IR
• Manipulation- PxTx/ chiropracter/ osteopathy/ deep
tissue massage
• Alternative- acupuncture

22. Any Vets in the audience?
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23. 5. (a) Veterinary practitioners?

25. Headache!

26. Pharmacological Treatment

27. Pharmacological Treatment
• WHO analgesic ladder (abridged)
• + tramadol
• + opioids- buprenorphine TDD/ oxycontin/ fentanyl TDD
(New: sufentanyl TDD/ product X)
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29. Opioid Therapy
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31. Pharmacological treatment of
Neuropathic Pain
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32. Neuropathic Pain Management
• Antidepressants- Amitryptilline
• Anticonvulsants- Gabapentin/ Pregabalin/
Carbamazepine/ Valproate
• Opioids
• Local Anaesthetics- Lignocaine/ EMLA

33. • NMDA antagonists
• Sympatholytics
• GABA –ergics
• Capsaicin
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34. Future Agents for Neuropathic Pain
• Ziconotide (sea snail, conus magnus)
• P2X3- (purine) receptor antagonists (ATP) (knockout
mice)
• Epibatidine (Equadorian poison dart frog)
• Morphine and ketamine
• Regular gabapentin
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35. Psychologicaly based therapy

36. Pain Management
• Psychological
CBT
Operant Conditioning
Psychoanalysis
Relaxation
Biofeedback
• Psychiatric
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37. Pain Management Programmes
● Medication
• Goals (SMART- specific/ measured/ agreed/ realistic/ timed)
• Coping
• Contingency
• Pacing
• Education
• Pain Behaviours
• Reinforcement www.londonpainconsultants.com

38. Functional Restoration
Programmes
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39. MRI scans

43. Other Imaging

45. Minimally Invasive Pain
Management

47. C-arm

48. Targets
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50. Spine Pain
Cervical/ Thoracic/ Lumbar
>65% workload

52. Radiofrequency

53. • DESTRUCTIVE- Radiofrequency
denervation
• Eg: medial branch (facet joint) blocks
• NON-DESTRUCTIVE- Pulsed
radiofrequency
• Eg: nerve roots

54. Botulinum Toxin A

55. Other Minimally Invasive
Techniques
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57. Musculoskeletal
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58. Shoulder
• Suprascapular nerve block
• Suprascapular pulsed radiofrequency
• Intra-articular
• Trigger point
• Botulinum Toxin A

59. Limbs
• Tenoperiostial injections
• Intra-articular
• Trigger points
• Intra-articular
• Botulinum Toxin A

61. Neuropathic Pain
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62. Complex Regional Pain
Syndrome (CRPS)
• Upper Limb
• Stellate ganglion block
• Intravenous guanethidine block (IVG)
• Lower Limb
• Lumbar Sympathectomy
• Intravenous guanethidine block (IVG)

63. Other Neuropathic Pain
• Coeliac plexus block
• Ganglion of Impar block
• Hypogastric plexus block
• Pulsed radiofrequency to nerves
• EG: intercostal/ obturator

64. Advanced Pain Management
Techniques
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65. Nerve Stimulation

66. Nerve Stimulation (2)

67. Intrathecal Pumps

68. Intrathecal Pumps (2)

69. The Future?
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70. The Future?
• Demographics
• Healthcare advances
• ↑ Patient expectations and involvement
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71. Summary
• Very common (1 in 7 UK)
• Time course- acute n chronic
• Nociceptive and neuropathic
• Multiple treatment modalities
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72. Medicolegal Case Histories
Dr. Christopher A. Jenner MB BS, FRCA
Consultant in Pain Medicine, Imperial Healthcare NHS Trust
Medical Director London Pain Consultants andSpinal Healthcare
11th November 2010

73. Anatomy of a Medicolegal
Report
• Pre Accident/ Incident
• Post Accident/ Incident
• Summary
• Pain History
• Pain Scores
• Previous Treatments

74. • Employment and ADL
• Examination
Opinion (including causation)
• Prognosis
• Treatment Plan (costed)
• Glossary and additional info

75. 49F Severe RTA
Cervical Facet Joint n Secondary
Myofacial Pain Syndrome
• Emotionally distressed
• Interim payment
• Clinical pain psychology
• Meds and MIPM
• Discharged
• Case concluded

76. 52 F School Secretary
• Poor working environment
• Cramped
• High stress
• WRULD
• Ongoing case

77. 32 F Post Spinal Surgery
• Medical Negligence case
• Unrecognised haematoma formation
• Complicated by infection
• Musculoskeletal pain
• Neuropathic leg pain

78. 34M Industrial Accident
• High pressure oil jet
• Traumatic amputation little/ middle/ ring
fingers
• Phantom limb pain
• Neuropathic stump pain
• Phantom sensations

79. 22M Industrial Accident
• Skip fell on foot
• Crush injury
• Traumatic amputation
• Surgical intervention
• Phantom limb pain
• Neuropthic stump pain
• Phantom sensations

80. 47 F Post Hysterectomy
• Medical Negligence case
• Genitofemoral neuralgia
•

81. 42F Cosmetic Filler
• Medical Negligence case
• Facial Neuropathic Pain
• Auriculotemporal nerve
• Improving on medication and local nerve
blocks
• ongoing

82. New Instructions
• Practice Manager for full details and TnC
• Competitive discounts for volume report
writing instructions

83. • www.londonpainconsultants.com
• www.spinal-healthcare.com

84. Any
Questions