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
A man with a pain in his right leg

How does it feel like?

 Case 1
A man with a pain in his right leg

And any other abnormalities?

 Case 1
A man with a pain in his right leg

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
A man with fracture forearm, compartment syndrome

What else do you noticed?

 Case 2
A man with fracture forearm, compartment syndrome

What are the differentials?

 Case 2
A man with fracture forearm, compartment syndrome

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
A lady with difficulty in her dress

Does physiotherapy help?

 Case 3
A lady with difficulty in her dress

Does topical therapy help?

 Case 3
A lady with difficulty in her dress

Does NSAID help?

 Case 3
A lady with difficulty in her dress

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
Lung cancer with pain in his chest, arm and abdomen

Why does he has a chest pain?

 Case 4
Lung cancer with pain in his chest, arm and abdomen

Why does he has an arm pain?

 Case 4
Lung cancer with pain in his chest, arm and abdomen

Why does he has an abdominal pain?

 Case 4
Lung cancer with pain in his chest, arm and abdomen

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
 Chronic pain as a disease
Impact of chronic pain

Elliott et al Lancet
1999
Chronic pain as a disease
Impact of chronic pain

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

 Chronic pain as a disease
Impact of chronic pain

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?

Chronic pain as a disease
How much is this?

Cost: 7 billion US$

Chronic pain as a disease
How much is this?

Cost: 4 million US$ per year

Chronic pain as a disease
Impact of chronic pain

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
Scope of pain medicine
Etiology

Trauma (including iatrogenic)

Cancer (and its treatment)
Infections / inflammations
Mechanical / functional
Idiopathic
Scope of pain medicine
Complex Regional Pain Syndrome (CRPS)
Type I and II (with obvious nerve injury)

Which type is this one?

Scope of pain medicine
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

Scope of pain medicine
Persistent post-operative pain

Bay-Nielson Annals of Surgery 2001

 Scope of pain medicine
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

Scope of pain medicine
Etiology

Trauma (including iatrogenic)

Cancer (and its treatment)
Infections / inflammations
Mechanical / functional
Idiopathic
 Scope of pain medicine
Cancer pain

Over 50% cancer patients have severe pain at their end

What contribute to this un-desirable outcome?

Scope of pain medicine
Cancer pain

Difficulties with treatment

Side effects may be intolerable

Oral intolerance
Fatigue or impaired consciousness
Scope of pain medicine
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”
Scope of pain medicine
Etiology

Trauma (including iatrogenic)

Cancer (and its treatment)
Infections / inflammations
Mechanical / functional
Idiopathic
Scope of pain medicine
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?

 Scope of pain medicine
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
Scope of pain medicine
Acute low back pain

Most important: to exclude organic pathology

“Red flags”
Scope of pain medicine
Acute low back pain

NSAID, paracetamol
Avoid opioids / muscle relaxants
Avoid aggressive physio
Avoid bed rest

Live a normal life

 Scope of pain medicine
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

Scope of pain medicine
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

Scope of pain medicine
Chronic low back pain

We all pay if pain allowed to progress

 Scope of pain medicine
Chronic low back pain

Structures potentially involved

Bone, disc, facet joints, ligaments, muscle, nerves

How can we tell?

Scope of pain medicine
Chronic low back pain

Musculoskeletal Examination value

Tenderness 0.24
Muscle spasm < 0.2

Deyo JAMA 1992

Scope of pain medicine
Chronic low back pain

Neurological Examination value

Weak ankle dorsiflexion 1.0

Normal ankle reflexes 0.39
Straight leg raising 0.6

Deyo JAMA 1992

 Scope of pain medicine
Chronic low back pain

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
 Scope of pain medicine
Chronic low back pain

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
Scope of pain medicine
Chronic low back pain

Mis-interpretation of non-organic signs

Malingering
Secondary gain
Exclude pathology
False positives
Scope of pain medicine
Chronic low back pain

Investigations
Poor correlation with imaging findings

This is obvious
Scope of pain medicine
Chronic low back pain

Investigations
Poor correlation with imaging findings

This is less obvious

Scope of pain medicine
Chronic low back pain

Investigations
Diagnostic nerve / joint blocks

Under-utilized
Scope of pain medicine
Chronic low back pain

Surgery is indicated if

Failed conservative treatment

Demonstrable pathology
Correlation with clinical findings
Minimal psychosocial complications

Why are we so cautious?

Scope of pain medicine
Chronic low back pain

Failed back surgery syndrome (FBSS)

More MRI, more surgery

Therefore…
Scope of pain medicine
Chronic low back pain

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