Pain defenition

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Patyi ((ASP)
r Unpleasant sensory and
emotional experience
associated with actual or
potential tissue damage, or
describe in terms of such
damage.
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International for the study of Pain: Pain Definition.
Bonica JJ. The need of a taxonomy. Pain 1979;6(3):247-8.

Pain Management

BJD Psycho Social Culiurs

‘An 0 พ J e d SJ 9 Bk\W A1iJi น d 9
Pradit Prateepavanich, Assoc Prof
Dept PM&R, Siriraj Hospital
Past-President Thai Association for the study of Pain
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TIFF (Uncoi are neec

Classification

*By location (Topography)
■ Pathophysiology
■ By duration
acute,
subacute,
chronic
■ By behavior
Acute Pain,
Chronic Pain,
Cancer Pain

Classification
■ By location (Topography)
V Pathophysiology
■ By duration

acute,
subacute,
chronic
By behavior Acute Pain,
Chronic Pain, Cancer Pain
Inflammation
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Neuropathic
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Unknown

Basic Science
Perception
Transmission
Transduction
Deporalization

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Classification
■ By location (Topography)
■ Pathophysiology
/*TBy duration ( acuta —Mrtfacute, chronic
■ By behavior
Acute Pain,
Chronic Pain,
Cancer Pain

Acute Pain [Symptom]
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Physiological Pain

Warning Sign
Regress to Mean [Acute Injury]
R hnc MTQmiT’sJniI lO
losseiqmooeb (ช9889iqmoonU) ๆๆ!!
,9าฟ่อia sirti 998 ot เว่9ช99ท 916
Attitude

Classification
■ By location (Topography)
■ Pathophysiology
V By duration
ufe7
subacute,

By behavior Acute Pain,
Chronic Pain, Cancer Pain

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Classification
■ By location (Topography)
■ Pathophysiology
V By duration acute,
C
sttb^cute,
chrorac
ehstfior
Acute Pain,
Chronic Pain,
Cancer Pain

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Chronic Pain

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Insid i (A® ttfcR/l O^R) n se
Adjustment
[FA, Panic, OCPD, Depress]

Classification




By location (Topography)
By duration
acute,
subacute,
chronic
Pathophysiology
By behavior
Acute Pain,
Chronic Pa Cancer Pain

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Acute
Chronic Cancer

PAIN MEASUREMENT

Unidimensional
measures of painแผ่นแปะเท้า

MULTIDIMENSIONAL MEASURES OF PAIN
• Provide further information about the characteristics of pain and its impact on the individual.
• Brief pain inventory which assesses pain intensity and associated disability (Daut et al 1983)
• McGill pain questionnaire which assesses the sensory, affective and evaluative dimensions of pain

PAIN TREATMENT CONTINUUM
Diagnosis
Oral Medications
PT, Exercise, Rehabilitation
Behavioral Medicine
Corrective Surgery
Therapeutic Nerve Blocks
Oral Opiates
Implantable Pain Management Devices
Neurostimulation Intrathecal Pumps Neuroablation

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Although few people die of Pain
[eg.Acute Pain]
Many die in Pain
[eg.Cancer Pain]

An even more live with Pain
[eg.Chronic Non-cancer Pain]

Prevalence of Pain
□ Chronic non-cancer pain
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20%
□ Cancer pain [Terminal

□ Neuropathic Pain

30-45%
70-90%]
7-8%

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Drug
modulates hyperexcited neurons

straube ร, Derry ร, Moore RA, McQuay H. Pregabalin in fibromyalgia: meta-analysis of efficacy and safety from company clinical trial reports. Rheumatol 2010;49(4):706-15.
Ca++& Na+Channal Modulating Drugs
TCA, SNRI, Tramadol

Acute OA ^rrSSijr Chronic OA
Pharmacology
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EULAR 2005 Guideline for OA
Non-Pharmacology Level of evidence
Strength of Recommendation
Education Exercise Weight loss

Pharmacological
Acetaminophen NSAIDs – Conventional
– Coxibs
– Topical
Opioid Glucosamine Diacerein IA hyaluronic IA steroid
1A
IB
IB
IB
IA
IB
IA
IB
IA
IB
IB
IB
A
A
B
A
A
A
A
B
A
B
B
A
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f^^anized Medicine
Age

Disc Findings in Normal Subjects
(10(
Disc Cracks
X-RAY I
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CT/ MRI-Hern
Mix-Diagnosis
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Mis-Diagnosis
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False-positive rites for HNP with various imaging modalities.
Bigos ร, Muller G. Primary care approach to acute and chronic back problems. Definition and care. In: Loeser JD, ed. Bonica’s Management of Pain, 3rd ed. 2001

[More than one symptoms is the most common of cervical MPS] Q Myofascial Pain is a Syndrome

[Office Syndrome]

Each TrP has specific referred pain pattern
น Referred to Head
[upper trapezius, posterior cervical]
เ^ Referred from neck to Arm
[Scalence ะ Clinical TOS]
น Referred deep inside Scapular + chest
[serratus superior posterior]

A

๚เฒพ^-”

r พ

Sikdar ร, Shah JP, Gebread T, et al. Novel applications of ultrasound technology to visualize and characterize myofascial trigger points and surrounding soft tissue. Arch Phys Med Rehabil Vol 90, November 2009; 1829-38.

; Neurovasoactive Substances such as bradykinin,
Substance P, Serotonin, and histamine

Pathophysiology
Trigger Point
Shah JP, Gilliams EA. Uncovering the biochemical milieu of myofascial trigger points using เท vivo microdialysis: An application of muscle pain concepts to myofascial pain syndrome. J Bodywork and Movement Therapy (2008) 12, 371-84.

Che *
Stretching
x^S^Massage x^E^Dry Needling

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And Acupuncture ^E^Trigger Point Injection
Local anesthetic

CWP with associated symptoms
Characterized by increase pain sensitivity ะ the extreme end of a spectrum of abnormal pain
sensation/processing [Wolfe F, et al. Arthritis [ICD M 79.0: Non-specific rheumatic conditmn (Fibromyalgia)]
2% population F/M = 8-10/1 30-50 Years

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^Psychologic symptoms ^Rheumatic symptoms ^Orthopedic symptoms ^Neurologic symptoms ^Gynecologic symptoms ^Uroiogic symptoms ^Rehabilitation
Perrots. Fibromyalgia syndrome: a relevant recent construction of an sncient condition? CurrOpin Support Palliat Care 2008;2(2): 122-7.

Pathophysiology
Central Sensitization (Imbalanced of Nociception)

Glutamate, substance p, IL-1B, IL-6, 8, TNF-a

Hybrid
Glutamate, Substance p
staud R. Biology and therapy of fibromyalc
Gracely et al. Arthritis Rheum. 2002;46:1333-1343.

Serotonin, Noradrenaline, Dopamine IL-4,10

Serotonin, Noradrenaline
syndrome. Arthritis Res Ther 2006;8:208-14.

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Assess Key Symptom(s) Clinical-Based
Acetaminophen Weak-Opioid (Reacutization)
Pain or others
Glutamate Substance p
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DOSE
TCAs
Insomnia/Anxiety
Hypnotics
Serotonin
NE
Anxiety/Depress
SSRIs
Russell ม. Fibromyalgia syndrome: approach to management. Primary Psychiatry 2006; 13(9):76-84.

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Coping strategy

How many common coping strategies [psychosocial subgroups] in Fibromyalgia patient?
Bennett R, Nelson D. Cognitive behavioral therapy for fibromyalgia.
เท: Nature Clinical Practice Rheumatology. Aug 2006 Vol 2 No 8, p 416-24.

What is the common cognitive error from the therapist side in each subgroup?

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Bennett R, Nelson D. Cognitive behavioral therapy for fibromyalgia.
เท: Nature Clinical Practice Rheumatology. Aug 2006 Vol 2 No 8, p 416-24.

Stress Reduction
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Trigger or Co-morbid
32.3% Anxiety 3
22% in SLE1 22.2% in Migraine2 14.6% in MDD 3
23 3% OCPD 3
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Rheumatologist Neurologist Psychiatrist
14% in Arthritis4 4

Rehabilitation
1. Journal of Clinical Rheumatology 1995; 1:158-64. 2. Cephalalgia 2006; 26(4): 451-56.
3. General Hospital Psychiatry 2010;32:105-07.4 Wolfe F, et al. Arthritis Care Res (Hoboken) 2010;62:600-610.

Cancer Pain [Mix Nocicepors]
Cancer Pain
Tumor itself
Bone Metastsis Obstruction Invade nerve
Acute Pain
Chronic Pain
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Treatments Psychological Co-morbid
Post-op Pain
CMT
RT
Coper
Stress [Fear]
M I o stress [\
T e—.—>■—^Depress
^Mental Met^asis

WHO 3 Steps Ladder [Cancer Pain Only]

opioid for moderate to severe pain +/-non opioid +/- adjuvant
pa//7 pers/sf//7<7 or //7creas//7c?
opioid for miid to moderate pain +/-non opioid +/- adjuvant
P&//7 pprs/s///yp or //ref&#£//?&
non opioid +/- adjuvant
Sedation Score

Palliative Care FactSiOf Life

Tjr ,
*Birth
Jl
m lfc V
Ageing

/< ri

■JC ■1 jW
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John H Turney BMJ 1998;317:142
“Doctors who changed a patient’s life,

I

Today’s dogma may by toir/iorrโ)พ’ร joke.”
yesterday’s joke may be today’s dogma”

After พพ II
1960 ะ Quackery
1970 ะ Unproven remedies
1980 ะ Questionable remedies
1990 ะ CAM

2004 ะ Placebo Analgesia & Nocebo Hyperalgesia

Culture [Attitude] & Dynamic
Vietnamese American
Acute Pain
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Consumpttoft Mb eq น i
0.9 mg. \ 30.2 mg
Inadequate pain control reported
8% J 80%

Lasch KE. Culture and Pain. Pain Clinical Updates. 2002;10(5):1-9.
Carragee EJ, Kim อ, van der VlugtT,et al. Pain control aricfcultural norfhc and expectations after closed femoral shaft fractures. Am J c(thop 1999;28(2):^-102.
,011

Is there any cross culture effect on coping strategy?
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Distressed Dysfunction
Epidemiology ะ Prevalence? Subgroup Proportion?
Vietnamese
Lasch KE. Culture and Pain. Pain Clinical Updates. 2002;10(5):1-9.
Carragee EJ, Kim อ, van der Vlugt T,et al. Pain control and cultural norms and expectations after closed femoral shaft fractures. Am ป Orthop 1999;28(2):97-102.

Cancer Pain [Mix Nocicepors]
Cancer Pain
Acute Pain
Chronic Pain CAM
are needed to sei
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Tumor itself
Bone Metastsis Obstruction Invade nerve

Treatments Psychological Co-morbid
Post-op Pain
CMT
RT
Coper
Stress [Fear] Depress

Believe
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Placebo Mechanisms
Drug
Placebo
Expectations
m-Opioid
Pain Relief
Conditioning
Active Ingredient (บร)
Pill Shape, Color, Taste etc. (CS)
Pain Relief (UR)
Repeated Associations
Inactive Pill: Shape, Color, Taste
Pain Relief (CR)
Benedetti and Amanzio Prog Neuro 1997

Pain Effect
DACmg

fev
DACing

Physiological Basis for the “Placebo Effect” in Pain
MPFC Zubieta et al. JNeurosci 2005

z scores
Placebo Effect and BP
1 4 Placebo Regions
RACing
— เกร 1
DLPFC
NAcc
Rostral Anterior Cingulate (RACing), Dorsolateral Prefrontal Cortex (DLPFC), Nucleus Accumbens (NAcc), Insula (เทร)
RACing
PET and MRI brain scans were combined to make these images, illustrating activity in the brain’s mu opioid system. On top, study participants were experiencing pain. On the bottom, they thought they were receiving an inj ection of painkiller medicine that was actually a placebo. Image Courtesy of University of Michigan.

What causes the placebo/nocebo effect?

Naloxone

Symbolic

Expectation (Belief)
I
IAST * .jUgy
RALPH AOKEfe

Culture [Attitude] & Dynamic

Psychosocial <=! \>
Of
ill
[Chronic Pain’
fs li. sd Ln Attitude
Culture <^ t»re 11
[Spiritual Pain]

Foot Patch มีอย.ต้อง mamae

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