World Congress on Pain Medicine and Management September 9-10, 2019 Singapore

While acute pain is a normal sensation triggered in the nervous system to alert you to possible injury and the need to take care of yourself, chronic pain is different.

Chronic pain persists. Pain signals keep firing in the nervous system for weeks, months, even years. There may have been an initial mishap sprained back, serious infection, or there may be an on-going cause of pain arthritis, cancer, ear infection, but some people suffer chronic pain in the absence of any past injury or evidence of body damage.

A person may have two or more co-existing chronic pain conditions.  Such conditions can include chronic fatigue syndrome, endometriosis, fibromyalgia, inflammatory bowel disease, interstitial cystitis, temporomandibular joint dysfunction, and vulvodynia.  It is not known whether these disorders share a common cause.

The various neuropathic pains can be difficult to treat. However, with careful diagnosis and often a combination of methods of treatments, there is an excellent chance of improving the pain and return of function. Medications are a mainstay of treatment of neuropathic pain.

Most pain information is filtered out by the central nervous system, usually at the level of the spinal cord. Many medications to treat neuropathic pain operate on this filtering process. The types of medications used for neuropathic pain include antidepressants, which influence the amount of serotonin or norepinephrine, and anti-seizure medications, which act on various neurotransmitters, such as GABA and glycine.

One of the most powerful tools in treating neuropathic pain is the spinal cord stimulator, which delivers tiny amounts of electrical energy directly onto the spine. Stimulation works by interrupting inappropriate pain information being sent up to the brain. It also creates a tingling in the pain extremity, which masks pain.

Headache is our most common form of pain and a major reason cited for days missed at work or school as well as visits to the doctor.  The International Classification of Headache Disorders, published by the International Headache Society, is used to classify more than 150 types of primary and secondary headache disorders. Primary headaches occur independently and are not caused by another medical condition. Migraine, cluster, and tension-type headache are the more familiar types of primary headache.

Migraines are severe, recurring, and painful headaches. They can be preceded or accompanied by sensory warning signs and other symptoms.

The extreme pain that migraines cause can last for hours or even days.According to the American Migraine Association, they affect 36 million Americans, or approximately 12 percent of the population. Migraines can follow an aura of sensory disturbances followed by a severe headache that often appears on one side of the head. They tend to affect people aged 15 to 55 years.

To a certain extent, medical practitioners have always been specialized. Specialization was common among Roman physicians. The particular system of modern medical specialties evolved gradually during the 19th century. The particular subdivision of the practice of medicine into various specialties varies from country to country, and is somewhat arbitrary. Pain management specialists are most commonly found in the following disciplines: Physiatry (also called Physical medicine and rehabilitation), Anaesthesiology, Interventional radiology, Physical therapy. Specialists in psychology, psychiatry, behavioural science, and other areas may also play an important role in a comprehensive pain management program.

Orofacial pain disorders are highly prevalent and debilitating conditions involving the head, face, and neck. These conditions represent a challenge to the clinician since the orofacial region is complex and therefore, pain can arise from many sources. The clinician needs to have solid knowledge of the pain conditions that arise from these structures for proper diagnosis and a multidisciplinary approach of management is strongly recommended.

Neuropathic pain is often described as a shooting or burning pain. It can go away on its own but is often chronic. Sometimes it is unrelenting and severe, and sometimes it comes and goes. It often is the result of nerve damage or a malfunctioning nervous system. The impact of nerve damage is a change in nerve function both at the site of the injury and areas around it.

Neuro-orthopaedic service offers the latest advances in diagnosis and treatment to patients whose arms or legs are impaired by brain injury, stroke, anoxia, central nervous disorders, or orthopaedic conditions.

Arthritis means joint inflammation, but the term is used to describe around 200 conditions that affect joints, the tissues that surround the joint, and other connective tissue. It is a rheumatic condition.

The most common form of arthritis is osteoarthritis. Other common rheumatic conditions related to arthritis include gout, fibromyalgia, and rheumatoid arthritis (RA).

Inflammation is a defense mechanism in the body. The immune system recognizes damaged cells, irritants, and pathogens, and it begins the healing process.

When something harmful or irritating affects a part of our body, there is a biological response to try to remove it. The signs and symptoms of inflammation can be uncomfortable but are a show that the body is trying to heal itself.

Cancer pain takes many forms. It can be dull, achy, sharp or burning. It can be constant, intermittent, mild, moderate or severe. How much pain you feel depends on a number of factors, including the type of cancer you have, how advanced it is, where it's situated and your pain tolerance.

Differently from the adult patients, in pediatric age it is more difficult to assess and treat efficaciously the pain and often this symptom is undertreated or not treated. In children, selection of appropriate pain assessment tools should consider age, cognitive level and the presence of eventual disability, type of pain and the situation in which it is occurring. Improved understanding of developmental neurobiology and paediatric analgesic drugs pharmacokinetics should facilitate a better management of childhood pain.

The current evidence supports infusions of local anaesthetics at the surgical site, continuous peripheral nerve blocks, and neuraxial analgesia for major thoracic and abdominal procedures. Ultrasound guidance can improve the performance of the blocks and different patient outcomes, although the incidence of peripheral nerve damage is not decreased. For chronic pain, the best available evidence is on nerve blocks for the diagnosis of facet joint pain. Further research is needed to validate diagnostic nerve blocks for other indications. Therapeutic blocks with only local anaesthetics (greater occipital nerve and sphenopalatine ganglion) are effective in headache. A possible mechanism is modulation of central nociceptive pathways. Therapeutic nerve blocks for other indications are mostly supported by retrospective studies and case series.

Education and psychological conditioning:-

• Ask for an explanation of each step of a procedure in detail, utilizing simple pictures or diagrams when available.
• Meet with the person who will be performing the procedure and write down answers to questions

Hypnosis:-

• With hypnosis, a psychologist or doctor guides you into an altered state of consciousness.
• Methods for hypnosis include: Imagery, Distraction, Relaxation/guided imagery
• Comfort therap

Comfort therapy:-

• Companionship
• Exercise
• Heat/cold application
• Lotions/massage therapy
• Meditation
• Music, art, or drama therapy

Physical and occupational therapy :-

• Psychosocial therapy/counseling
• Neurostimulation

Neurostimulation may involve the following:

• Transcutaneous electrical nerve stimulation (TENS)
• Acupuncture
• Acupressure

OTC (over the counter drugs) includes the following :-

• Acetaminophen (Tylenol)
• Nonsteroidal anti-inflammatory drugs (NSAIDs), including ibuprofen (Motrin, Advil) or naproxen (Aleve, Naprosyn)

Prescription Pain Relievers includes the following:-

Corticosteroids:-  Prescription corticosteroids provide relief for inflamed areas of the body by easing swelling, redness, itching and allergic reactions. Corticosteroids can be used to treat allergies, asthma and arthritis. When used to control pain, they are generally given in the form of pills or injections that target a certain joint.

Examples include: prednisone, prednisolone, and methylprednisolone.

Side effects:-

• Weight gain
• Trouble sleeping
• Weakened immune system
• Thinning of the bones

Opioids:-

Opioids are often used for acute pain, such as short-term pain after surgery.

Some examples of opioids include:- Morphine, Fentanyl, Oxycodone, Codeine

Side effects:-

• Nausea
• Constipation
• Itching
• Breathing problems
• Addiction

Anti convulsants:-

Anticonvulsants are drugs typically used to treat seizure disorders. Some of these medications are shown to be effective in treating pain as well. The exact way in which these medicines control pain is unclear but it is thought that they minimize the effects of nerves that cause pain.

Some examples include carbamazepine (Tegretol), gabapentin (Neurontin), and pregabalin (Lyrica).

Side effects:-

• Drowsiness
• Dizziness
• Fatigue
• Nausea

Other Pain Treatments:-

Topical pain relief comes in the form of a lidocaine (Lidoderm) patch.

TENS, a procedure that uses patches placed on the skin to send signals that may help stop pain.