Brief description of some of chronic pain syndromes and treatment modalities.

1. CHRONIC
PAIN
MANAGEMENT

2. COMMON FORMS OF CHRONIC
PAIN
CANCER PAIN
NON-CANCER
PAIN
NEUROPATHIC
PAIN
MUSCLOSKELETAL
PAIN
INFLAMMATORY
ISCHEMIC

3. NEUROPATHIC PAIN
• Definition It is the pain that arises as a direct
consequence of a lesion or disease affecting the
somatosensory system.
• Prevalance : 3.3% to 8.2%
• It is the molecular and structural reorganization of
the pain pathway that is responsible for chronic
neuropathic pain.

4. Common causes of Neuropathic pain
1. Diabetes
2. Complex regional pain syndrome
3. Spinal injury
4. Lumbar radiculopathies
5. Trigeminal neuralgia
6. Amputation
7. Multiple sclerosis
8. Viral infection
9. Post surgical

5. MECHANISM OF NEUROPATHIC PAIN
1. Normal activity in PNS involves
a reciprocal balance between
excitation and inhibition.
2. At cellular level – increased
activity of NMDA receptors.
This leads to hyper excitability of
the neurons.
3. Genetic factor – GTP
cyclohydrolase 1 has been
specifically implicated.

6. SYMPTOMS AFFERENT
Burning C- fibres
Paresthesia A-ß Fibres
Shooting & Electrical shock like A fibres
Pinprick A-δ fibres

7. SYNDROMES SYMPTOMS
Diabetic Peripheral Neuropathy Burning, pricking (pins and needles),
shooting, numbness (dead feeling)
HIV assosiated Neuropathy Distal symmetrical polyneuropathy
Post-herpetic neuralgia Pain, burning sensation along the
affected dermatome
Phantom limb syndrome Phantom limb sensation, stump pain
Carpal tunnel syndrome Numbness, tingling, reduced sensation,
atrophy of the thenar muscles.
Trigeminal neuralgia Sudden, severe usually U/L stabbing
pain along the distribution of the
branches of V nerve
Glossopharyngeal neuralgia Pain along the posterior pharynx,
tonsillar fossa, base of the tongue

8. SYNDROMES SYMPTOMS
Spinal cord injury Burning, shooting, lancinating pain
along the nerve pathway
Central post stroke pain Pain over the body are that are
paralysed
Complex regional pain syndrome Pain, sensory and vasomotor
disturbances, tropic changes and
impaired motor function.

9. TRIGEMINAL NEURALGIA
• Also known as “tic
douloureux,”.
• The IASP defines TN as “a
sudden, usually unilateral,
severe, brief, stabbing,
recurrent pain in the distribution
of one or more branches of the
fifth cranial nerve.”

10. • Paroxysmal pain pattern
which may only last for a few
minutes or seconds, are
frequently triggered by non-
noxious stimuli or normal
activities such as talking,
chewing, shaving and
swallowing.
• V2 and V3

11. COMPLEX REGIONAL PAIN SYNDROME
• CRPS is characterized by severe, continuous pain in
the affected extremity, which is accompanied by
sensory, vasomotor, Pseudo-motor/edema, and
motor/trophic changes.
• CRPS 1 & 2
• The highest incidence was found in women aged 61–
70 yr

12. Causes
- Injuries to peripheral tissues(fractures, disclocations, postoperative
states)
- Inflammatory conditions (fascitis, bursitis, arthritis)
- Immobilization
- Peripheral nerve injury
- CNS involvements (head injury, brain tumor)
- Spinal cord lesions
- idiopathic

13. CRPS I
- History of initiating injury or immobilization
- Continuing pain, allodynia, or hyperalgesia out of
proportion to the initiating events
- No other causes of pain exists
CRPS II
- Differs by the presence of known nerve injury
- Burning pain is often of extreme severity
- Presence of significant vascular compromise.

14. Pathophysiology :
• Sensory abnormalities- Due to changes
in the thalamus and cortex
• Dysesthesia/ hyperalgesia throughout the
affected half of the body
• Autonomic Dysfunction - after nerve
injury, surviving cutaneous afferents
develop noradrenrgic sensitivity
• Catecholamines can activate peripheral
nociceptors after thermal or chemical
sensitization in the absence of nerve
injury

15. • Neurogenic Inflammation – Increased systemic
CGRP in the acute phase, increased levels of TNF-
alpha and IL-6.
• Increased production of NO.
• Motor Abnormalities - Decreased range of
movements, physiological tremor, reduction in active
motor force.
• Dystonia in the affected extremity

17. PATIENT
ASSESME
NT
DOCUMENTA
TION
DRUG
THERAPY
AND
DOSE
TITRATIO
N
REASSES
SMENT
DOCUME
NTATION
DOSE
TITRATION
AND
TAPERING
RECOMMENDED CLINICAL APPROACH

18. MULTIDISCIPILNARY
&MULTIMODAL
APPROACH
NON-
PHARMACOTHERAPY
PHARMACOTHERAPY
INTERVENTIONAL
METHODS

19. TREATMENT MODALITIES
• PHARMACOLOGIC : Antidepressants, Anticonvulsants,
opioids, non- opioid analgesic, Topical agents.
• NON-PHARMACOLOGIC:
1. Physical modalities- TENS.
2. Psychological and behavioral modalities- cognitive
behavioral therapy (CBT).
3. Alternative and complementary therapies- Acupuncture,
Acupressure, yoga, Massage, Tai chi, Chiropractic,
Meditation, Therapeutic touch, homeopathy, Prayer.

20. ALGORITHM FOR THE MANAGEMENT OF
NEUROPATHIC PAIN
• STEP 1- Pain assesment, history and physical examination, previous
treatment and diagnostic records.
• STEP 2- consider Non- pharmacologic modalities
• STEP 3- Initiate first line monotherapy- Gabapentin, TCA, SNRI.

21. Ineffective or not tolerated Partial treatment response
Switch to alternative first-line drug
monotherapy
Consider adding another first line
drug.
STEP 4
Ineffective or not tolerated Partial treatment response
Initiate monotherapy with tramadol or
opioid analgesic.
Consider adding tramadol or opioid
analgesic.
STEP 5
Ineffective or not tolerated Ineffective or not tolerated
Third line drug, interventional
treatments and pain rehablitation
programs.
Third line drug, interventional
treatments and pain rehablitation
programs
STEP 6

22. ISCHEMIC PAIN
• Ischemic pain is a distinct type of pain associated
with decreased or complete cessation of blood flow.
PATHOPHYSIOLOGY:
• Tissue hypoxia and resultant acidosis seems to be
the main trigger.
• An acid sensing ion channel and accumulation of
substance P are the involved in ischemic pain.

23. SYNDROMES SYMPTOMS
Atherosclerosis obliterans &
Buerger’s disease
Claudication, critical limb ischemia pain
Raynaud’s phenomenon Severe pallor and painof fingers, toes,
nose, ears.
Deep venous thrombosis Tenderness along the course of major
veins, leg pain of foot
dorsiflexion(hoffman sign)
Polyarteritis nodosa Polymorphic skin rashes, persistent
livedo reticularis.
Sickle cell anemia Bone pain caused by pressure in marrow
and vascular occlusion.
Visceral pain caused by
ischemia(splenic infarction, appendicitis,
pancreatitis, bowel ischemia)
Painful opthalmoplegia Pain and restriction of extraoccular eye
movements, proptosis.
Erythromelalgia Ischemic ulcers causing pain and
gangrene.

24. TREATMENT MODALITIES
Pharmacological treatment
SYMPATHECTOMY : Sympathectomy with RF OR
Chemical ablation are effective for severe refractory
ischemic pain.
PERIPHERAL NERVE BLOCK : Continuous PNB is
effective and safe modality for long-term used in home
setting for intractable chronic lower limb pain.

25. VISCERAL PAIN
• Visceral pain is the pain that
results from the activation of
nociceptors of visceras.
• It is often a poorly localized and
often originates as a midline
sensation.
CLASSIFICATION: divided into two
categories

26. 1. True visceral pain- it is
the first pain sensation
felt, mostly at the
epigastric and lower
thoracic region.
It is associated with
marked autonomic
phenomena like pallor,
profuse sweating,
nausea, vomiting,
diarrhoea changes In HR
and BP .

27. 2. REFFERED PAIN – if the visceral sensation recurs or
intensifies the pain evolves.
- the area is often remote from the primary source of
stimulus.
- Two types of visceral pain- with hyperalgesia and without
hyperalgesia.
• PAIN WITHOUT HYPERALGESIA – also called as
irradiated segmental pain.
.
• PAIN WITH HYPERALGESIA - called true parietal pain,
as it includes skin, subcutaneous tissue and muscle
overlying it.

29. TREATMENT
NON-INVASIVE
THERAPIES
INVASIVE THERAPIES
Exercise Pharmacologic pain medicine
Cognitive behavioral therapy Anesthetic blocking technique
Physical and occupational therapy Neuromodulatary technique
Nutritional and psychotherapy Surgery
Alternative therapies neuroablation

30. HEADACHE

31. Headache is one of the common reasons for
seeking medical attention. It encompasses all
aches and pains ed in the head.
PATHOPHYSIOLOGY
• Vascular theory, abnormal synthesis of
vasoactive amines such as NE, DA and
serotonin cerebral vasoconstriction followed
by compensatory vasodilatation.
• Inflammatory theory, substance P a vasodilator
released causes neuro-inflammatory changes.
• Genetics
• Physical abnormalities such as tumors, stroke,
aneurysms.
• Psychological abnormalities like anxiety,
stress and mood disorders and drug abuse.

32. TYPES OF
HEADACHE
PATHOLOGY PRESENTATION TREATMENT
Migraine headache Vascular or
inflammation
May present with or
without aura
Triptans, ergotamine,
NSAIDS, steroids,
benzodiazepines
Cluster headache Neurovascular or
histamine or mast
cell mediated
Severe unilateral
headache inn
temporal&periorbital
region.
Oxygen therapy,
triptans, capsaicin,
opioids , steroids.
Tension headache Vascular and
psychogenic factors
are suggested
Constant, tight band-like
pressing pain in temporal,
frontal, occiptal or parietal
areas
NSAIDS,
Acetaminophen +
codeine or caffeine,
anti-depressants,
TCAs, TENS, hot and
cold massage
relaxation technique
Temporal arteritis Idiopathic
autoimmune etiology
to elastin component
of the arteries
Unilateral, intense
throbbing usually in areas
of affected cranial
arteries
Steroids,
immunosuppressant’
s like azathioprine,
methotrexate,
cyclophosphamide.

33. DRUGS USED FOR PREVENTION OF MIGRAINE
HEADACHES
DRUG CLASS DRUGS SIDE EFFECTS
Antidepressants Amitriptyline, fluoxetine Drowsiness, headache
B- receptor antagonists Propanalol, metaprolol,
nadolol, timolol
Reduced energy,
tiredness, postural
hypotension
Calcium channel
lblockers
Diltiazem, verapamil Constipation, cardiac
conduction abnormalities,
edema
Anticonvulsants Gabapentin, topirmate Drowsiness, weight gain,
tremors, somnolence
Serotonin antagonists Methysergide Drowsiness, leg cramps,
hairloss.

35. BACK PAIN
- Back pain is a common ailment, is one of the leading cause
of disability and work loss, incurring huge costs to society.
Sources of low back pain :
1. Lumbar strain or sprain- 70%
2. Degenerative changes-10%
3. Herniated disk- 4%
4. Osteoporosis compression fractures – 4%
5. Spinal stenosis- 3%
6. Spondylolistheis- 2%
7. Myofascial pain, cancer, infections.

36. - 90% of cases of low back pain resolves without treatment
within 6-12 weeks.
- 75% of cases with nerve root involvement can resolve in
6 months
Acute low back pain : lasts for 4-6 weeks
- Treatment is mainly conservative- hot or cold packs and
anti-inflammatory drugs.
Subacute and chronic back pain : lasting > 4-6 weeks.
- CT, MRI and X-rays should be done for pathology
identification.

37. SYNDROMES SYMPTOMS
Herniated Disc Radicular symptoms
Discogenic pain Deep, aching, axial midline
pain extd. Into buttock, hip,
LL
Spinal canal stenosis B/L axial low back and leg
pain, pain more severe when
walking downhill
Myofascial pain Deep aching pain aggravted
by activity, tender taut bands
of muscle(trigger points)

38. Non- pharmacological
Pharmacological
Interventions

40. Non- Pharmacological
Interventions
- Life style modifications- healthy
diet, regular sleep
- Physiotherapy & Exercises
- Orthotics – belts, foot orthotics
- Manual therapies- spinal
manipulation, mobilisation or
massages.
- Acupuncture
- Electrotherapies – IFT
- Psychological therapy

41. Pharmacological Therapy
- NSAIDS – Diclofenac, ketorolac,
indomethacin, meloxicam,
piroxicam , ibuprofen, aspirin,
celecooxib
- Weak opioids- tramdol,
tapentadol
- Muscle relaxants- tizanidine,
thiocolchicoside

42. Interventional methods
- Epidural steroid injections
- Facet joint injection
- SI JOINT injection
- Intrathecal drug delivery
system

43. CANCER PAIN
• Cancer pain can
develop from tumor
invasion,
musculoskeletal pain,
visceral pain, radiation
treatment effect, or
neuropathy from
chemotherapy.

44. TREATMENT OF CANCER PAIN
• World Health Organization
(WHO) developed guidelines
for treatment of cancer pain.
• It includes three-step
“analgesic ladder” for
pharmacologic management
of cancer pain.

45. Interventional procedures are added as Step 4 in the modified
analgesic ladder

46. - The first line of treatment includes non-opioid
analgesics.

47. Opioid Therapy in the Treatment of Cancer Pain
• When non-opioid analgesic fails.
• Combining short- and long-acting opioids in
moderate to severe pain can be effective if the pain
is not well-controlled

49. • Breakthrough pain
• overmedication.
• Evaluation of the patient on a regular basis is must.

50. • Breakthrough Pain
A transitory increase in pain that occurs on a background of
otherwise controlled persistent pain.
Treatment – 10% of the provided total daily dose as an
immediate release formulation.
How to calculate breakthrough dose?
For example patient receiving controlled release Oxycodone
40mg every 12hrs will have ,
• 40mg*2= 80mg/day
• 80mg/10 = 8mg oxycodone as needed.

52. • Management of side effects of opioids
• Constipation- Add fibre to the patient’s diet, laxatives.
• Nausea & vomiting- antiemetics routinely when starting
opioids.
• Sedation – Mild sedation usually occurs when first starting
opioids or with dosage titration
• Respiratory Depression occurs if too high a starting dose,
too rapid titration or too large increments especially in
patients with COPD, severe sleep apnea, renal failure.

53. INTERVENTIONAL PAIN MANAGEMENT
- Interventional procedures are indicated for a variety of
acute, chronic, non-cancer and cancer pain patients.
- The modalities include antitumor therapy, neural
blockade with or without neurolytic drugs, infusion
therapy with opioids and/or local anesthesia with neuro-
axial or peripheral nerves, central nervous system
(CNS) opioid therapy, neurosurgery, or electrical
stimulation.

55. THERAPUETIC NERVE BLOCK
- Neurological examination is mandatory before
performing neurolytic blocks in order to identify any
preexisting neurological deficit.
- obtain coagulation profile including PT, INR,PTT, and
platelet count because some of the cancer medications
can affect platelets function and coagulation factors.
- Performance of local anesthetic block prior to neurolytic
block is essential.

56. NEUROLYTIC AGENTS
- Local anesthetic and neurolytic solutions are used for therapeutic blocks.
- Bupivacaine 0.25% -0.5% is often preferred for block.
- Phenol and alcohol are commonly used neurolytic solutions.
- Phenol destroys both sensory and motor fibres by protein denaturation. 2-3%
conc. spares motor fibres.
- Alcohol is more potent than phenol.
- Local anaesthetic commonly used as diluent.
- Neuritis and systemic toxic reactions are common side effects.

59. ISSP UNIFORM CONSENT FORM
FOR INTERVENTIONAL PAIN
PROCEDURES

60. FLUROSCOPY SUITE
• Fluroscopy has revolutionised the interventional
procedures.
• Unit consists of C-arm with double screen facility.
PROTECTION FROM RADIATION
1. Protective lead apron along with thyroid shield.
2. Dosimeter
3. Stand at 90˚ to receive minimum scattered radiation.
4. Shield the patient by placing lead sheets under the
unrequired parts.
5. Decrease patient exposure by using higher range
kV(85-120) and low miliamperage (1.5 to 2.0 mA)

62. THERAPUETIC NERVE BLOCK
HEAD AND NECK REGION
1. Supra and infraorbital and supratrochlear nerve
blocks:
- Performed for herpes zoster pain
- Local anesthetic and steroid are used for block
- Most common complication are hematoma and
compression neuropathy.

63. 2. Trigeminal neurolysis
- Performed to treat chronic facial pain like trigeminal neuralgia.
- It can be done using alcohol injection or radiofrequency(RF)
- The commom complication of this block is facial numbness, some
find this more unpleasant than pain.

64. 3. Sphenopalatine ganglion
block(SPG)
- SPG or meckel’s ganglion
block is used for the Rx of
migraine, cluster headache,
atypical facial pain and
trigeminal neuralgia.
- Transnasal approach

65. • Lateral approach

66. • Greater palatine foramen approach
• Local anesthetic injection 0.5-2ml or RF can be used.
• Complication include local anesthetic toxicity, orthostatic
hypotension, bradycardia and epistaxis.

67. THORAX REGION
1. Intercostal nerve block
- Used to improve postoperative analgesia,
postherpectic neuralgia, chestwall metastasis and rib
fracture.
- It arises from ventral rami of T1-T11.
- 2-4 ml of drug is injeccted.

68. complications
- pneumothorax and local anesthetic toxicity.
- Post-procedure intercostal Neuropathy may occur.

69. VISCERAL NERVE BLOCK
1. Celiac plexus block
- Located at T12-L1, receives
fibres from greater, lesser
and least splanchnic
nerves.
- It is performed for pain
secondary to malignancy of
the abdominal organs,
pancreatitis etc,.
- Block is performed in prone
position and bilaterally to
block both the ganglia.

71. - For a neurolytic block, 15 ml of alcohol 50-100%
mixed with 5 ml of lidocaine 2% (to avoid pain on
injection) in each needle is injected. As an alternative,
phenol 10% 10 ml can be injected in each needle
without associated pain.
- It causes sympathetic blockade causing
hypotension.
- Diarrhoea, kidney, aorta or IVC injury.
- Paraplegia if drug injected into arteries that supply
spinal cord

72. 2.Hypogastric plexus
block
- It provides sympathetic
innervation to pelvic
organs.
- It is used to treat chronic
pelvic pain, malignancy,
postsurgical, and
intestinal pathologies.

73. -One of the serious complications is retroperitoneal hematoma.
- Another common complaint is back pain which can be
differentiated from back pain due to hematoma by the severity
of pain

74. 3. Ganglion impar block
- It is used for treatment of
perineal pain due to vaginal
and rectal malignancies and
other pathologies.
- It is a solitary structure at
end of the sympathetic chain
just anterior to
sacrococcygeal junction. 4-
10ml injected.
- Complication include
perforation of rectum.

75. -Retroperitoneal hematoma,perforation of the rectum or
anus can occur.
- Another potential complication is injection of the
neurolytic medication in the rectum or the sacrum.
- Injection of contrast dye before injection of drug is
necesasary.

76. • Perforation of the rectum or anus can occur. Another
• potential complication is injection of the neurolytic medication in the
rectum or the sacrum.
• Injection of contrast dye before injection of neurolytic substances is
therefore essential.

77. EXTREMITIES
1. Stellate Ganglion Block
- It is effective for treatment of CRPS, malignancy pain
of head and neck and upper extremities, vascular
insufficiency and hyperhydrosis.
- Formed by fusion of inf.cervical ganglion(C7) and
first thoracic ganglion(T1)

78. • Skin temperature in the blocked extremity should
elevate a few degrees due to vasodilatation.
• Horner’s syndrome and recurrent laryngeal nerve
paralysis and hoarseness are common side effects.
Complications
• Complications include pneumothorax, and intravascular
and subarachnoid injection.

79. 2. Lumbar sympathetic block
- It is used to treat complex regional pain syndromes of lower limb,
increasing blood flows in PVD and to treat pain of lower limb
malignancies.
- 10-15 ml is injected.
- Complications include intravascular injection and viscus
perforation.

80. 3. Epidural steroid injection
- They are the most commonly
performed injection for back
pain.
- Can be performed in all
segments but commonly
done in lumbar and cervical
regions.
- Complication include dural
puncture, headache, epidural
abscess, bleeding, sensory
deficit and catheter shearing.

81. NEUROMODULATION
1.Spinal cord stimulation(SCS)
- Electrical stimulation is applied to the dorsal columns of
spinal cord by placing temporary electrodes in
post.epidural space and connected to an ext.generator.
- It is based on gate control theory.
- It is used to treat pain after back surgery, post-
laminectomy pain syndrome, CRPS, ischemic pain
from PVD, limb amputation pain and diabetic
neuropathy.
- Complication include epidural hematoma , abscess,
dural puncture and lead migration.

83. RADIOFREQUENCY LESIONING
• Radiofrequecy procedures use
high-frequecy alternating current
to interrupt nociceptive pathways
at various sites.
• RF is a low-energy, high
frequecy(50-500 kHz) , it causes
molecules within the tissues to
oscillate thus causing friction and
heat which in turn causes
coagulation within the target
tissue.
• Two types continuous RF and
pulsed RF

84. Continuous RF
- Alternating current in range of
100-500 kHz is continuously
applied to a target nerve.
- Non selective destruction of
nerve fibres.
- Heat energy is produced
transversely along the active
tip and not distal to it.
- So tip should be aligned
alongside not perpendicular to
nerve.

85. Pulsed RF
- In PRF a 50kHz is delivered in 20ms at frequency of 2Hz
for a period of 120s.
- Long pause between pulses allow for heat dissipation.
- In PRF current is delivered distal to active tip hence
electrode to be placed perpendicular to the nerve.
- PRF acts by altering the signal transduction in pain
pathway.

86. INTRATHECAL DRUG DELIVERY
DEVICES
- An ITDD system consists of a catheter connected
to a pump.
- The major advantage is that they give the flexibility
necessary for complex pain problems.
- The aim is to deliver the chosen drug to its receptor
sites in the dorsal horn of the spinal cord in
sufficient quantity to have a clinical effect.

91. • Ziconotide is a new class of IT drug—an n-type
calcium-channel blocker and non-opioid analgesic.
• a selective inhibitor of pre-synaptic n-type channels.
• Tolerance does not develop with ziconotide unlike
opioids.
Surgical Treatment of Cancer Pain
• Surgical treatment of cancer pain is rarely used now
because of the development of intrathecal opioid
infusions.
• These procedures include neurectomy, cordotomy,
rhizotomy, or cingulotomy.

92. ALTERNATIVE THERAPIES

93. ACUPUNCTURE
-Acus- needle, puncture – to penetrate.
-Acupuncture involves the insertion of very thin needles
through your skin at strategic points on your body.
MEDITATION - the art of living in the present moment.
HYPNOSIS - An altered state of awareness during which
the patient experiences increased suggestibility and
during which the patient mind is more likely to accept
ideas uncritically.
TENS - Electrodes are applied to the same dermatome
as the pain and are stimulated periodically by direst
current from a generator

95. COGNITIVE BEHAVIOURAL THERAPY
CBT is a talking therapy that can help you manage your
problems by changing the way you think and behave.
Although CBT can't cure the physical symptoms of these
conditions, it can help people cope better with their
symptoms.

96. Non- pharmacological
Pharmacological
Interventions

97. THANK YOU