Chronic pain

Question 1

Chronic pain

Answer 1

chronic pain commonly persists beyond the time of healing of an injury and frequently there may not be any clearly identifiable causes

Question 2

consequence of chronic pain

Answer 2

physical

• sensitisation
• sleep abnormalities
• disuse/posture abnormalities

psychological

• frustration
• hopelessness
• low self esteem

social/occupational

Question 3

Sicca syndrome

Answer 3

• look up brown sequard syndrome

Question 4

neuropathic pain

Answer 4

pain caused by damage or disease affecting the somatosensory nervous system

examples
diabetic retinopathy
phantom limb pain
sciatic
merlagia
carpal tunnel
trigeminal neuralgia
lumbosacral radicular pain
postherapatic pain

Question 5

neuropathic pain clinical features

Answer 5

burning
shooting
dysaesthesia
occurs spontaneously with non painful stimuli greater than expected response/increases with repetitive stimuli

presence o a neurological deficit
unaccompanied by on going tissue damage
area of sensory loss

Question 6

trigeminal neuralgia

Answer 6

‘tic douloureux’ / suicide pain
unilatera lancinating pain affecting V nerve.
bilateral <3%
V2 and V3 are commonest
increases with age, rarely below 40 years
triggering factors
atypical presentations with background pain

cause:
blood vessel at root entry of trigeminal nerve. superior cerebellar artery / inferior.

neurovascular conflict at V root entry zone.

exclude other causes- MS (V1), tumour, AV malformations. need an MRI with root entry views

Question 7

post herpetic neuralgia (PHN)

SHINGLES

Answer 7

pain >3 months after herpes zoster eruption

unilateral neuropathic pain: hyperalesia, allodynia, itching

risk higher if severe immunosuppression + DM + age

T7/T8 dermatome

Question 8

who needs referral to pain cinic

Answer 8

procedure with evidence based benefit
diagnostic conundrum
patient fails to improve in function
difficult to control neuropathic pain
stronger opioid analgesia/hx o medication misuse
complex psychosocial influences.

Question 9

how will we manage the pain?

Answer 9

chronic pain:
1) non pharmacological
- heat, massage, hydrotherapy, physiotherapy, TENS machine, acupuncture
normalising function most important factors
active vs passive therapeutic modalities
key difference between acute/chronic

2) pharmacological
TCA, gabapentinoids for neuropathic pain

3) conservative
4) invasive

Question 10

how will we manage the pain?

Answer 10

chronic pain:
1) non pharmacological
- heat, massage, hydrotherapy, physiotherapy, TENS machine, acupuncture
normalising function most important factors
active vs passive therapeutic modalities
key difference between acute/chronic

2) pharmacological
TCA, gabapentinoids for neuropathic pain. membrane stabilisers. opioid. muscle relaxants/BZD, NSAIDs, topical lidocaine IV and capsaicin cream, bisphosphonate/clonidine.
ketamine.

3) conservative
4) invasive

Question 11

complex regional pain syndrome

Answer 11

severe pain/swelling changes that is disproportionate/not line with the mechanism of injury e.g spraining of the ankle.

Question 12

central sensitivity syndrome

• more common in female
• genetic link

Answer 12

FMS- fibromyalgia (140 different symptoms)
chronic fatigue syndrome
IBS
POTS (tachycardia on standing)
hypermobile ehlers danlos syndrome

? other functional syndrome

a new narrative for fibryomyalgia body reprogramming davies 2020