Chronic Pain

Chronic Pain
Dr. MC Chu
Anaesthesia and Intensive Care
PWH
Agenda
Start at acute pain
Un-veil the complexity of chronic pain
In second part we will try to treat them

Let’s start with acute pain
Tissue damage
Site and intensity correlation
Gets better with healing (self limiting)
Case 1
A man with a pain in his right leg
“Are you sure it is the right leg?”

Case 1
How does it feel like?

Case 1
And any other abnormalities?

Case 1
What causes it?

Remarks from Case 1
Chronic pain is not prolonged acute pain
Remarks from Case 1
Pathophysiology is different from acute pain
Sensitization
Reduced pain threshold (hyperalgesia)

Non-painful stimulus (allodynia)
Remarks from Case 1
Pathophysiology is different from acute pain
Neuropathic pain
Site
Character
Timing
More than that…

Case 2
A man with fracture forearm, compartment syndrome
Fracture fixed, fasciotomy healed
Neurovascular integrity OK
But he has pain and other things
Case 2
What else do you noticed?

Case 2
What are the differentials?

Case 2
He want to chop his forearm off. Useful?

Remarks from Case 2
Impairment is different from acute pain
Pain can come without obvious pathology

Pain, motor, sudomotor or sensory changes
Trophic changes
Exclude differentials
One more example…

Case 3
A lady with difficulty in her dress
Diagnosis?
Case 3
Does physiotherapy help?

Case 3
Does topical therapy help?

Case 3
Does NSAID help?

Case 3
Does opioids help?

Remarks from Case 3
Treatment are different from acute pain
Partial response to “common” analgesics

Long term side effects
Tolerances, organ damages
Not all chronic pains are neuropathies…

King Mongkut
Lung cancer with pain in his chest, arm and abdomen
Case 4
Why does he has a chest pain?

Case 4
Why does he has an arm pain?

Case 4
Why does he has an abdominal pain?

Case 4
What bother him most?

Remarks from Case 4
Pain is common source of distress
Multiple etiologies
Iatrogenic
Other somatic symptoms
Other psychosocial factors
Role of palliative medicine
Now, the classical onion…

Ms. Unhappy
Why can’t you fix my

neck and fxxk off
Ms. Unhappy
33 year old woman, traffic accident
“whiplash injury”
MRI: unremarkable
Nociception
Ms. Unhappy
She felt so bad that he cannot sleep, cannot eat, and
became irritable
Affect
Ms. Unhappy
She cannot work, cannot go out, cannot do housework,
cannot….
Social
Ms. Unhappy
She insisted to use a neck collar, visited 4 doctors for the
“right diagnosis”, alcohol to “knock me off the pain”
Behavior
Remarks from Case 5
Multi-facet problems of chronic pain
Nociception is different
Mood is altered
Behavior and thoughts are changed
Function is impaired
They are a different person altogether

Chronic pain is a disease of its own
Pain Management is a specialty of its own
Want to have a break?
Chronic pain as a disease
Definitions
“Pain extending for a long period of time, represents low

levels of underlying pathology that does not explain the
presence and extent of pain, or both”
Turk in: Bonica’s Management of Pain 3rd Ed.
“Pain without apparent biological value that persists beyond

normal tissue healing (usually taken to be 3 months)”
IASP 1986
Impact of chronic pain
Elliott et al Lancet
1999
10.8% of local adult Chinese

38% work affected
34% daily activities affected
30% on long term analgesics
Ng et al Clin. J. Pain 2002

38 Billion Euro per year in Germany

62 Billion US$ per year in US
Zimmermann Orthopade
2004
Steward et al JAMA 2003
How much is this?

How much is this?
Cost: 7 billion US$

How much is this?
Cost: 4 million US$ per year

White et al J. Occu. & Environ. Med. 2005

Clinical aspect
Scope of pain medicine
Etiology
Trauma (including iatrogenic)

Cancer (and its treatment)
Infections / inflammations
Mechanical / functional
Idiopathic
Etiology

Idiopathic
Complex Regional Pain Syndrome (CRPS)
Type I and II (with obvious nerve injury)
Which type is this one?

Complex Regional Pain Syndrome (CRPS)
Pathophysiology is unknown
Diagnosis is clinical
Investigations are not diagnostic
Treatment is empirical
Prognosis: 30% loss of work at 1 year
“early intervention to prevent disability”
Atkins J. Bone & Joint Surg 2003

Persistent post-operative pain
Bay-Nielson Annals of Surgery 2001

Persistent post-operative pain
Predictive factor: intensity of early post-op. pain

Most will resolve slowly
Is it preventable?
Role of pre-emptive analgesia still uncertain
Should be part of the surgical consent

Etiology

Idiopathic
Cancer pain
Over 50% cancer patients have severe pain at their end
What contribute to this un-desirable outcome?

Cancer pain
Difficulties with treatment
Side effects may be intolerable

Oral intolerance
Fatigue or impaired consciousness
Cancer pain
Difficulties with treatment
Patients and doctors refuse treatment

Denial of disease progression
Hope of curing the incurable
Myths of analgesics, including addiction
“Opio-phobia”
Etiology

Idiopathic
Acute low back pain
Leading cause for GP consultations

Most (>90%) gets better in 2 weeks
Blind investigation yield is very low (< 5%)
How many of you have this?

Acute low back pain
Most important: to exclude organic pathology

“Red flags”
Fever
History of trauma
Constitutional (weight / appetide loss)
Neurological (cauda equina /radiculopathy)
Non-spine pathology eg: pulsatile abdominal mass
Acute low back pain
Most important: to exclude organic pathology

“Red flags”
Acute low back pain
NSAID, paracetamol
Avoid opioids / muscle relaxants
Avoid aggressive physio
Avoid bed rest
Live a normal life

Acute low back pain
Predictive of chronicity and disability

“Yellow flag”
Fear avoidance behavior

Negative belief that pain is harmful or disabling
Excessive focusing on pain
Expectation on passive pain management
Linton Spine 2000

Acute low back pain
Predictive of chronicity and disability

“Yellow flag”
Depressed mood, social withdrawal

Co-existing financial and social problems
Poor job satisfaction
Linton Spine 2000

Chronic low back pain
We all pay if pain allowed to progress

Structures potentially involved

Bone, disc, facet joints, ligaments, muscle, nerves
How can we tell?

Musculoskeletal Examination value
Tenderness 0.24
Muscle spasm < 0.2
Deyo JAMA 1992

Neurological Examination value
Weak ankle dorsiflexion 1.0

Normal ankle reflexes 0.39
Straight leg raising 0.6
Deyo JAMA 1992

Non-organic signs
“find ways of predicting surgical failure to treat back pain”
8 physical signs associated with higher personality score

abnormalities, multiple surgeries and surgeon’s
suspicion.
Waddell 1980
Non-organic signs
Non-anatomical motor / sensory loss

Superficial / non-anatomical tenderness
Simulation (pelvic rotate, axial load, distraction SLR)
Over-reaction
3 out of 8
Mis-interpretation of non-organic signs
Malingering
Secondary gain
Exclude pathology
False positives
Investigations
Poor correlation with imaging findings
This is obvious
Investigations
Poor correlation with imaging findings
This is less obvious

Investigations
Diagnostic nerve / joint blocks
Under-utilized
Surgery is indicated if
Failed conservative treatment

Demonstrable pathology
Correlation with clinical findings
Minimal psychosocial complications
Why are we so cautious?

Failed back surgery syndrome (FBSS)
More MRI, more surgery

Therefore…
Failed back surgery syndrome (FBSS)
Fritsch Spine 1996

Try this one
37 year old kindergarten teacher
Sprained her back while lifting a child 2 years ago

Seen GP and several Orthopediac surgeons
Had a few spine X-rays and an MRI
“Bone spurs everywhere”
Scheduled for spinal fusion
Patient next bed: “I have that 3 times, and I’m still here”
You are consulted: “for better analgesics”
Try this one
37 year old kindergarten teacher
How would you assess her?

Any “better analgesic” to offer?
We will split the onion next time

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In second part we will try to treat them

“Are you sure it is the right leg?”

How does it feel like?

And any other abnormalities?

What causes it?

Reduced pain threshold (hyperalgesia)

More than that…

What else do you noticed?

What are the differentials?

He want to chop his forearm off. Useful?

Pain can come without obvious pathology

One more example…

Does physiotherapy help?

Does topical therapy help?

Does NSAID help?

Does opioids help?

Partial response to “common” analgesics

Not all chronic pains are neuropathies…

Why does he has a chest pain?

Why does he has an arm pain?

Why does he has an abdominal pain?

What bother him most?

Now, the classical onion…

Why can’t you fix my

They are a different person altogether

“Pain extending for a long period of time, represents low

Turk in: Bonica’s Management of Pain 3rd Ed.

“Pain without apparent biological value that persists beyond

10.8% of local adult Chinese

Ng et al Clin. J. Pain 2002

38 Billion Euro per year in Germany

How much is this?

Cost: 7 billion US$

Cost: 4 million US$ per year

White et al J. Occu. & Environ. Med. 2005

Trauma (including iatrogenic)

Trauma (including iatrogenic)

Which type is this one?

Atkins J. Bone & Joint Surg 2003

Bay-Nielson Annals of Surgery 2001

Predictive factor: intensity of early post-op. pain

Should be part of the surgical consent

Trauma (including iatrogenic)

Over 50% cancer patients have severe pain at their end

What contribute to this un-desirable outcome?

Difficulties with treatment

Side effects may be intolerable

Difficulties with treatment

Patients and doctors refuse treatment

Trauma (including iatrogenic)

Leading cause for GP consultations

How many of you have this?

Most important: to exclude organic pathology

Most important: to exclude organic pathology

Live a normal life

Predictive of chronicity and disability

Fear avoidance behavior

Linton Spine 2000