Curriculum Vitae:

Staf pengajar Departemen Ilmu Penyakit Dalam FK UNPAD/ RS Hasan Sadikin Bandung

dr. Laniyati Hamijoyo SpPDKR. M.Kes

Pendidikan: 1994 : FK Universitas Atma Jaya, Jakarta 1996 : Internship di CWZ Nijmegen-Netherland 2005 : Spesialis Penyakit Dalam FK.UNPAD, Bandung 2005 : Magister kesehatan FK. UNPAD, Bandung 2007 : Subspesialisasi Reumatologi di Univ.Santo Tomas Manila 2008 : Adaptasi Konsultan Reumatologi FKUI,Jakarta Organisasi: Anggota: IRA, PAPDI, PRA, IDI, APLAR Penghargaan: JCR, APLAR, EULAR, TIR, PRA

Lanny

The Essentials of Pain Management

Laniyati Hamijoyo

Divisi Reumatologi Departemen Ilmu Penyakit Dalam FK Universitas Padjadjaran/ RS Hasan Sadikin Bandung

Lanny

Case # 1
Mr B 23/M Acute pain 2 hours ago On his right ankle History of falling during play basketball 2 hour ago

What is the diagnosis? What will you suggest?

Lanny

Case # 1
Ms. D 35/F Pain on both hands Since 2 months Swollen

What is the diagnosis? What medicine will you start on her?

Lanny

Case # 2
Mrs. L 55/F Sharp and burned like pain on her fingers especially right hand Since 3 months Worse in the morning History of type 2 DM What is her diagnosis? Therapy?

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Pain

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Pain
How to diagnose? Therapy?

Which medicine?

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Barriers to effective pain management

Problems related to healthcare professionals
Inadequate knowledge Poor assessment Concern about regulation of controlled substances Fear of patient addiction Concerns of side effects of analgesics Concerns about patients tolerant to analgesics

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Barriers to effective pain management

Problems related to patients
Reluctance to report Fear that pain means disease is worse Reluctance about taking pain medicines Concerns of being tolerant to medicines Poor adherence Worries about unmanageable side effects

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Barriers to effective pain management

Problems related to healthcare system Cost Reimbursement Restrictive regulation Availability

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Outline the essentials of pain management

Definition of pain Assessment and diagnosis of pain Management and monitoring of pain

1 2 3

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Definition of pain
An unpleasant sensory and emotional experience associated with actual or potential tissue damage, or described in terms of such damage IASP

In reality, its what the patient says it is.

Lanny

Merskey H, Bogduk N. 2nd ed Seattle, WA: IASP Press; 1994.

Physiology of Pain Perception

Injury Brain

Descending Pathway Dorsal Root Ganglion Ascending Pathways

Peripheral Nerve C-Fiber A-beta Fiber A-delta Fiber

Dorsal Horn
Lanny Adapted

with permission from WebMD Scientific American Medicine.

Spinal Cord

Injury-induced Pain: Patient Factors

Injury
Individual variation in response to injury: physiological, behavioral, and cultural Individual variation in response to treatment

Complaint of pain
McQuay H. BMJ 1997;314:1531.

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Outline

1 2 3

Definition of pain Assessment and diagnosis of pain Management and monitoring of pain

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Assessment of pain
Goals:
Achieve diagnosis of pain and underlying disorder Characterizing and quantifying the pain

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Achieve diagnosis and underlying disorder

History taking
Pattern : onset, duration, frequency Area Nature : location, topography : description, history of similar episodes, intervention & what helped Intensity: level

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Question to evaluate pain

P-Q-R-S-T format
Provocation How the injury occurred & what activities the pain, exacerbating and alleviating factors Quality Referral/ Radiation characteristics of pain (tingling, burning, dull) Referred site distant to damaged tissue that does not follow the course of a peripheral nerve. Radiating follows peripheral nerve; diffuse How bad is it? Pain scale When does it occur? p.m., a.m., before, during, after activity, all the time

Severity Timing

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Pain assessment tools

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Pain assessment tools

Brief pain inventory Patients rate pain intensity and its effect on general activity, mood, ability to walk, work, relationships, sleep, and enjoyment of life McGill Pain questionnaire Patients rank pain in words sets that are grouped in 4 main categories: sensory, affect, evaluative, and miscellaneous

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Physical examination
General PE: Vital sign

Regional examination

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Musculoskeletal examination
Inspection: look for redness, swelling, deformity Palpation : Test for warmness Test for deep/ superficial muscle tenderness Range of motion

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Neurological examination
Mental status Cranial nerves Motor function: weakness, ataxia Sensory function Reflexes

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Classify Pain
duration:
Acute Chronic

Recent onset Limited duration The cause is generally known resolution of underlying cause, self limited

Persist for > 3- 6 months Persist at least 1 month beyond the usual course of acute pain Associated with chronic pathologic process Recurs at relatively short interval

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http://www. medscape.org 2011

Classify the Pain

mechanism:
Neuropathic
Malfunction on peripheral / central nerves

Nociceptive

Irritation/ Tissue injury

Psychogenic

Psychologic factor

Mixed

Nociceptive & neuropathic

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Type of pain
Pain Nociceptive Neuropathic

Visceral

Somatic

Poorly localized Cramping, dull Pleurisy Appendicitis cholecystitis

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well localized Variably

Abn neural activity due to injury or disease of the nervous system

Skin, muscle Soft tissue, bone

Thalamic pain Trigeminal neuralgia Diabetic neuropathy

Nociceptive VS neuropathic pain

Nociceptive pain
Caused by activity in neural pathway in response to potentially tissue- damaging stimuli

Mixed pain
Caused by a combination of both primary injury or secondary effects

Neuropathic pain
Initiated or caused by primary lesion or dysfunction in the nervous system

Postoperative pain Mechanical LBP

ARTHRITIS

PHN

CRPS

Sickle cell crisis

Neuropathic LBP Distal polyneuropathy (e.g. diabetic)

Trigeminal neuralgia Central post stroke pain

Sport / exercise injuries

Lanny

International Association for the Study of Pain. IASP Pain Terminology. Raja et al. in Wall PD, Melzack R (Eds). Textbook of pain. 4th Ed. 1999.;11-57

Pain characteristic
Nociceptive Neuropathic

Focal/ diffuse pain Sharp, dull, ache with sign of inflammation usually acute Often decrease over time

Regional/ dermatomal Burning, tingling, numbness, needle prick pain Often persists / worsen over time

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Pain characteristic
Nociceptive
Alodinia/ hyperalgesia MS regional pain (arthritis, bursitis, tenosynovitis, etc) Post traumatic pain , fracture Inflammation pain Bone metastases NSAIDs often work, opiods effective, adjuvant and topical analgesics somewhat effective
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Neuropathic
Peripheral neuropathic pain: - post herpetic neuralgia - diabetic neuropathic - radiculapathic pain etc - metastases on plexus Central neuropathic pain NSAIDs not effective, opioid less effective, adjuvant and topical analgesics somewhat effective

Evaluate the functional status

How does it affect physical function and work (ADLs)? How does it affect social and mental functioning?

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Evaluate the pain

Identify comorbid conditions Identify past medical history Family history

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Additional examination
Imaging Laboratory Psychosocial

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Identify Pain Treatment Options

Non-Drug Therapies Drug Therapies More Invasive Therapies

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Pain Treatment Continuum

Least invasive Most invasive

Continuum not related to efficacy

Psychological/physical approaches Topical medications Systemic medications* Interventional techniques*

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*Consider referral if previous treatments were unsuccessful.

Non-Drug Therapies
Ice/Heat Exercise/Rest Physical Therapy Chiropractic Care Acupuncture TENS Units Behavioral Therapy And Many More.

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Drugs for Pain

Non-Opioid Analgesics
Acetaminophen Salicylates and Non-Selective NSAIDS Selective COX-2 Inhibitors

Adjuvant Analgesics
Antidepressants Anticonvulsants Topicals, Muscle Relaxants, and Others

Opioids
Short- and long-acting formulations

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WHO (World Health Organization) ThreeStep Analgesic Ladder

Satisfactory Symptom Management
Opioid for moderate to severe pain + Non-opioid + Adjuvant

Pain persisting or increasing

Opioid for mild to moderate pain + Non-opioid + Adjuvant

Pain persisting or increasing

Non-opioid + Adjuvant

Pain
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WHO 3 -STEP LADDER

3 SEVERE Morphine Hydromorphone Methadone Oxycodone Fentanyl +/- Adjuvants 3 MODERATE A/Codeine A/Hydrocodone A/Oxycodone Tramadol +/- Adjuvants

3 MILD ASA/NSAIDS Acetaminophen Cox-3 +/- Adjuvants

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Bio-psycho-social in pain management

Cognitive therapies Functional restoration
Pain Behaviors Suffering

Anti-depressants / psychotropics Relaxation Spiritual

Opioid Adjuvants NSAIDs? Acetaminophene Neural augmentation Ablative surgery

Pain Perception

Local block Nociception

NSAIDs
Surgery Physical modalities

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Some More Invasive Therapies

Trigger Point Injections Intra-arthricular Injections Regional Nerve Blocks Epidural Injection Various Surgeries

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Evaluation of pain management

Follow up: - reassessed pain - functional improvement - side effect therapy - adherence to therapy Educate patients: - about the cause of pain - set appropriate expectations of treatment
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Case # 1
Mr B 23/M Acute pain 2 hours ago On his right ankle History of falling during play basketball 2 hour ago

What is the diagnosis? PE: Warmth, swelling, pain limited range of motion What will you suggest?

Pattern : onset, duration, frequency Area Nature : location, topography : description, history of similar episodes, intervention & what helped Lanny Intensity: level

Case # 1
Ms. D 35/F Pain on both hands Since 2 months Swollen, tender. Warm, morning stiffness Lab: RF (+), ESR What is the diagnosis? What medicine will you start on her?
Pattern : onset, duration, frequency Area Nature Lanny : location, topography : description, history of similar episodes, intervention & what helped Intensity: level

Case # 2
Pattern : onset, duration, frequency Area Nature : location, topography : description, history of similar episodes, intervention & what helped Intensity: level

Mrs. L 55/F Sharp and burned like pain on her fingers especially right hand Since 3 months Worse in the morning History of type 2 DM Test: Tinel (+), Phallen (+) What is her diagnosis? Therapy?

Lanny

Summary of a Practical Approach to Pain Management

1. Evaluate and treat the underlying cause. 2. Evaluate and treat the pain itself. 3. Listen to and trust your patients. 4. Use all the resources at your disposal. 5. Re-evaluate the treatment 6. Refer if you get stuck

Lanny

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