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INTRODUCTION TO PAIN CONCEPTS

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Mechanical in nature (varies with time and activity, & position) Patient well ... Motor, sensory and reflex changes limited to 1 nerve root. Most common is C6 ... – PowerPoint PPT presentation

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Title: INTRODUCTION TO PAIN CONCEPTS


1
INTRODUCTION TO PAIN CONCEPTS
  • Ali A. Alhimiri, MD
  • PMR Clinical Instructor
  • WSU School of Medicine

2
PAIN
  • A physical or mental suffering caused by injury,
    disease, grief, anxiety, etc (… )

3
Allegory of Pleasure Pain
  • Twins
  • Never one without the other..!
  • Same foundation.
  • Contrary to each other.

4
Nociceptors induced inflammation
  • Tissue damage? H, K ?PG, BK
  • Signal propagation? Substance P? Histamine,
    sertonine

5
Primary afferent nociceptors
6
Pain pathways
  • Peripheral nociceptors
  • Nerve fibers myelinated A-delta unmyelinated C
  • Spinal cord
  • Thalamus
  • Sensory brain cortex.

7
Gate Control Theory
  • Ronald Melzack Patrick Wall

8
2002 Giro d'Italia
  • "I crashed and broke my shoulder early, but the
    doctors didn't really know it was broken, so I
    just kept riding
  • Tyler Hamilton

9
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12
Variables of pain
  • Time (immediate, acute, chronic)
  • Pathology (tissue, nerves, central processing)
  • Nature, (shocking/burning, dull/achy)
  • Function, (protective, maladaptive)
  • Psychology

13
Physiologic Classification of Pain
14
Physiologic Classification of Pain
15
Douleur damour
  • William Bouguereau

16
Psychosomatic pain
  • Stress Induced
  • Transient Episodic
  • Headaches
  • Neck shoulders pain (swelling)
  • Heart burn
  • lower back pain

17
Somatoform Pain Disorders
  • Somatization disorder (Hysteria) before 30 y
    old, pain, psudo-neurological, GI, sexual
    symptoms.
  • Intentional production of symptoms and sings
    Factitious disorder / Malingering
  • Easier Acceptance less accountability

18
Chronic pain patient
19
Not a Differential Diagnosis
20
Clinical Anatomy
21
Simple Neck Pain
  • Middle Age
  • Neck, Headache, Shoulder
  • Mechanical in nature (varies with time and
    activity, position)
  • Patient well
  • Duration few several days

22
Radiculopathy
  • Unilateral neck upper limb pain
  • Radiating symptoms
  • Parathesia numbness
  • Reproduced with positioning
  • Motor, sensory and reflex changes limited to 1
    nerve root
  • Most common is C6

23
Radiculopathys Etiology
  • HNP
  • Spinal stenosis
  • Radiculitis
  • Spondylolisthesis
  • Infection
  • Tumor
  • Facet Synovial cyst
  • DM, AIDP

24
Herniated Nucleus Pulposus
25
Mimicking Conditions
  • Entrapment neuropathy, ulnar, median
  • Brachial plexopathy, multifocal neuropathy
  • Bursitis, tendinitis

26
Cervical Melopathy
  • Slowly progressive spinal stenosis
  • Gait abnormality apraxia, ataxia, hemipleagia
  • Frequent falls and fractures
  • Painless vs. radiating pain numbness
  • Motor weakness, loss hand dexterity
  • Bladder urgency, sphincters incontinent
  • With without radiculopathy
  • Hyperreflexia Spasticity

27
Cervical Mylopathy
28
RED flags
  • Vilolent Trauma
  • Constant progressive pain
  • Age lt20, gt55
  • Systemic illness (Ca, Steroids,HIV, IVDA, weight
    loss, fever)
  • Thoracic pain

29
Managment
  • Limit nerve irritation (soft caller)
  • Immobilization
  • Anti-Inflamatory
  • Mild narcotics
  • Imaging / EMG
  • Epidural steroids
  • Surgery

30
Role of Electodiagnosis
  • Exclude and confirm clinical suspesion
  • Identify nerve root level
  • Prognosis
  • Sensitivity varies (50-70) clinical and imaging
    studies.

31
Clinical Relevance for Diagnostic Testing
32
National Health Service/UK LBP Data
  • Pathology unchanged
  • Technology changed
  • Longer time off less chance of work return
  • 6 Months 50
  • 1 Year 25
  • 2 years 10

33
Avoid narcotics
  • Enkephalins.
  • Opiates.
  • Reduction in the sensitivity.
  • Tolerance addiction.

34
Thank you
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