Pain Management in Mixed Pain

Yudiyanta
Pain and Headache Sub.Dept
UGM/RSUP Dr Sardjito
 PAIN
ASSESSMENT AND MANAGEMENT

Yudiyanta
 Errors in Pain Treatment
Philosophy of Pain Goal in Pain Treatment
Assessment of Pain
Treatment Modality in Pain External Evidence
Comorbidity and Side Effects
Management Value & Expectation
1. Individual Clinical Expertise
 An unpleasant sensory and emotional experience
associated with actual or potential tissue damage, or
described in terms of such damage.
 Pain

Assessment of Disease Assessment of Pain

Diagnosis of Disease Diagnosis of Pain

Management of Disease Management of Pain

 Pain Assessment

Assessment of Disease Assessment of Pain

1. Pain Intensity 2. Type of Pain 3. Comorbidity

& Side Effects

Treatment
 NRS
PAIN
INTENSITY YES VRS Neonatal Infant Pain Scale (NIPS)
VAS 0 : No Pain
1-3 : Mild
4-5 : Moderate
6-7 : Severe
PATIENT ABLE
1-3 yo / Cognitive Disorder)
TO
FLACC (Face, Legs, Activity, Cry and
COMMUNICATE Consolability)
WELL? (Score: 0-10)

3-8 yo
WB/Faces Pain Scale Photographic
NO
(Score 0-10/no-Very Severe)

Sedation
Comfort Scale
9-17: Inadequate sedation and Pain Control
17-26 : Adequate Sedation and Pain
Control
26-45: Over Sedation
 TYPE OF PAIN

Superficial Somatic Pain

Somatic
Nocicepthic Deep Somatic Pain
Visceral

Peripheral NP Hyper-Excitability
TYPE OF PAIN Neuropathic
Hyper-Excitability
Central NP
Loss of Inhibitory
FM
MFPS etc
Dysfunctional
Somatoform etc
 Neuropathic pain: mechanisms and their clinical implications, Cohen SP., & Mao J., BMJ 2014;348:f7656 doi:
Injury 10.1136/bmj.f7656

Peripheral Spinal SupraSpinal

Mechanism Mechanism Mechanism

Nociceptor sensitization
Glu - regulation
(SP, CGRP, Mediator Inf.)
Glial activation-
Sensory denervation- Proinflammatory
NGF/sprouting cytokines
Expression of ion channel Disinhibition

Phenotypic switch
SP, CGRP Orioid-R

Expanded
SMP receptive fields

stimulation Provoke ectopic Trigger central exitability Hyper-

threshold discharge sensitization polarization

Pain
 SMP

Manifested as:
Temperature or color changes (or both) in an affected extremity
Swelling or atrophy
Pain worsened by cold weather or stress
 NEUROPATHIC PAIN

1. Pin Pricks
2. Electric Shock Like
3. Burning/Hot INTENSITY
4. Numbness
5. Alodinia

Gruccu G & Truini A, Tools for Assessing Neuropathic Pain, Plos Medicine, 2009
2. Best External Evidence
 Multimodal Analgesia
Non-
selective selective
COXIB COXIB
Ketamin

COXIB
parace NMDA
tamol antagonist

ANESTESI
LOKAL PAIN GABA
agonist

mu 5-HT
agonist Nadr Reuptake
inhibitor
Reuptake
inhibitor
OPIOID

TRAMADOL
TRAMADOL
Jin et al. J Clin Anesth;13:524, 2001
Kehlet et al. Anesth Analg;77:1048. 1998
Woolf CJ, Science, 288:1765-1768, 2000
 Treatment

Non Pharmacology Pharmacology Interventional PM

Pure Analgetics NSAIDs Adjuvant Analgetics Opioid

Acetaminophen Anti- Anti- Opioid Atypical

Metampiron Ns NSAIDs Coxib Convulsant Deppresant - Opioid
 Conventional Analgesia
Effective
Ceiling effect
Adverse drug reactions
Gastrointestinal bleeding
Cardiovascular events
Renal Issue
Respiratory depression Fatal
 COMORBIDITY & Side Effects

Gastrointestine

Cardiac
Vascular Brain
COMORBIDITY Peripheral

Renal

Respiratory

Contraindication And Side Effect

 GI RISK of NSAIDs: Classification by COX selection
Non-specific inhibition of COX-1 results in gastrointestinal and platelet side effects

In vitro assessment
of COX-1 COX-2 activity

Sleisenger & Fordtran's Gastrointestinal and Liver Disease, 8th ed., Copyright 2006 Saunders, An Imprint of Elsevier
 Neurological properties of B vitamins
B1 B6 B12
Formation of ACh Modulates GABA Biosynthesis of
Transmission of impulses from release from pre- neurotransmitters
nerves to muscles synaptic cells Methionine
Regeneration of the nervous Influences synthesis (myelin
system after strain biosynthesis of sheath formation)
B1: of
Reduction Neurodegeneration
hyperexcitability neurotransmitters: Vitamin B12 deficiency
Suppressing thermal serotonin, Increased
B6: Clinical manifestation
hyperalgesia of neurological
epinephrine, GABA symptoms
production of TNF-a,
(numbness,
Reduction paraesthesia)
of hyperexcitability Vitamins B1 and B6 IL-1, IL-6, NF-kB,
and Na+ current alterations in activate cGMP, NGF
B12:
injured DRG Neurodegeneration
neurons; involved in the Noxious role in the
suppression of thermal inhibition of progression of
hyperalgesia thermal neuropathy
Reduction of inflammatory hyperalgesia
and nociception,
Reduction of tactile allodynia
in non- diabetic and diabetic
DICLOFENAC
Inflamasi pd RA Rendahnya kadar B6
+ B6 penurunan IL-6 dan TNF a
 RCT Kronik LBP:
B12 1mg IM penurunan Pain Score >>

Mauro GL, Martorana U, Cataldo P, Brancato G, Letizia G. Vitamin B12 in low

back pain: a randomised, double-blind, placebo-controlled study.
Eur Rev Med Pharmacol Sci. 2000 May-Jun;4(3):53-8.
effect of 14 daily 1000 g vitamin B12 IM injection on chronic low back pain
 Maladkar M, et al. Efficacy, safety, and tolerability of
Epalrestat compared to cobalamine in patients with
diabetic neuropathy.
Int J Diabetes Dev Ctries. 2009 Jan-Mar; 29(1): 2834.

Neuropati DM:
% o f ca se s in p a in w ith co b a la m in e

Cobalamin 3x500 mcg/3 bln Gejala Neuropati

Causatif
5 0 0 g t.i.d fo r 1 2 w e e ks o n
D ia b etic N eu ro p athy
 Kuhlwein Study - 1990

Reduced need for Diclofenac with

concomitant B-vitamin therapy
Therapuetic success
Diclofenac + Vitamin B Diclofenac
49% Terapetic Success Dicl + B >> Dicl

34%
29.5%
23% 24.5% 23%

10%
7%

Very good Good Moderate Poor

The Role of B-Vitamins in Pain

Tonsilektomi:
+Vit B Pengurangan kebutuhan Dicl
 Lettko Study - 1986

Diclofenac + B vitamins vs
diclofenac monotherapy in LBP
Proportion of patients terminating their
participation due to freedom of pain
Diclofenac + Vitamin B Diclofenac
LBP:
20% Bebas Nyeri Dicl+B6 >> Dicl

7%
P < 0,05

Day 7
The Role of B-Vitamins in Pain
 Vetter Study - 1988

The shortening of diclofenac treatment by

means of B-complex vitamins
Day 7
Diclofenac + Vitamin B Diclofenac

40.6%

28.3% 29%

P < 0,05 16% 19%

8%

Treatment success VAS Reduction Improvement

(Persistent to
Intermitten)
Com bination benefit:
Reducing the daily NSAID dosage in painful spinal disease
 The DOLOR Study - 2009

Diclofenac + B vitamins vs
diclofenac monotherapy in lumbago
Proportion of subjects terminated the study due
to treatment success
Diclofenac + Vitamin B Diclofenac
Lumbago : Treatment Success
82%

47% 43%
29%

Day 3 Day 5
Time course of the effect of diclofenac alone
or diclofenac plus B vitamins for the
treatment of pain

Sustainability Respons (jam)

 Vitamins B in Pain Management
Have anti-nociception and anti inflamatory effect
Augment the effect of NSAIDs
Support Physiological mechanism anti
Neuropathic effects
Diclofenac + Vit B Multimodal