Pain Management - Chronic Pain:

Background and Definitions:

  • It affects one out of every five Canadians.
  • It is defined as pain that persists beyond the usual course of an acute pain syndrome.
    • Usually >12 consecutive weeks
    • In addition to nociceptive and neuropathic pain, chronic pain includes
      • Hyperalgesia: increased painful response to a normally painful stimulus
      • Allodynia: pain due to a stimulus that does not normally provoke pain
  • It is a significant burden on the lives of patients, their families and the utilization of health resources.

Management:

  • A multidisciplinary approach is required to regain function while minimizing side effects.
    • Psychiatry, neurology, addiction medicine, physiotherapy, and psychology
  • Pharmacological Targets:
    • NSAIDs and opioids block noxious transduction (generation of action potentials)
      • NSAIDs and Tylenol remain first-line
      • Reserve high opioid doses for cancer-related pain
    • Local anesthetics from peripheral or neuraxial blocks inhibit transmission
    • Ketamine, intrathecal opioids, and clonidine modulate transmission
    • IV opioids block pain perception at the cerebral cortex
      • If starting opioids, first assess risk of addiction and ask patient to sign opioid contract.
  • It is a significant burden on the lives of patients, their families and the utilization of health resources.
  • TENS machine is thought to work through neuromodulation.
  • Activities such as aquafit and Tai Chi have proven to be beneficial.

Examples of various therapies for chronic pain management:

Medical therapy

Pharmacological:

  • Opioids
  • Anticonvulsants
  • Antidepressants
  • Topical agents
  • Membrane stabilizing agents

Interventional:

  • Epidural steroid injection
  • Peripheral nerve/joint injections
  • Spinal cord stimulation

Surgical:

  • Rotator cuff repair
  • Knee replacement surgery
  • Spine surgery

Physical therapy

  • Physiotherapy
  • TENS
  • Heat/cold therapy
  • Massage therapy
  • Strength exercise
  • Acupuncture

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