Pain Management after Spinal Cord Injury David R. Gater, Jr., MD, Ph.D., M.S. Rocco Ortenzio Chair & Professor Physical Medicine & Rehabilitation Penn State Milton S. Hershey Medical Center Penn State College of Medicine Hershey, PA [email protected]
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Pain Management after Spinal Cord Injury David R. Gater, Jr., MD, Ph.D., M.S. Rocco Ortenzio Chair & Professor Physical Medicine & Rehabilitation Penn.
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Pain Management after Spinal Cord Injury
David R. Gater, Jr., MD, Ph.D., M.S.Rocco Ortenzio Chair & ProfessorPhysical Medicine & Rehabilitation
Penn State Milton S. Hershey Medical CenterPenn State College of Medicine
Dr. Gater has no financial relationships to disclose.
Objectives
Review pathophysiological mechanisms of pain after SCI
Discuss current pain taxonomies for SCI
Consider pharmacological tiered management for pain associated with SCI.
Introduction
Definitions Anatomy Pathophysiology Taxonomy
Diagnosis Treatment
Practical Applications
Objectives
Review anatomy and pathophysiology of pain
Discuss pain taxonomy relevant to treatment intervention strategies
Provide a stepwise approach to managing SCI Pain
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Definitions
Pain: Unpleasant sensory & emotional experience associated with actual or potential tissue damage
Nociceptive: Pain in which normal nerves transmit information to the CNS about trauma to tissues
Neuropathic: Pain in which there are structural &/or functional nervous system adaptations due to injury
Allodynia: Pain due to a stimulus which does not normally provoke pain Causalgia: Burning pain, allodynia & hyperpathia, vasomotor &
sudomotor dysfunction after traumatic nerve lesion Central Pain: Initiated or caused by a 1 lesion in CNS Dysesthesia: An unpleasant abnormal sensation, whether spontaneous
or evoked Hyperesthesia: Increased sensitivity to stimulation, excluding the
special senses Hyperpathic: Painful syndrome characterized by an abnormally painful
reaction to a stimulus, especially a repetitive stimulus Neuralgia: Pain in the distribution of a nerve or nerves Paresthesia: An abnormal sensation, whether spontaneous or evoked
Nociceptive NeuropathicSiddall et al (1997), Spinal Cord 35(1):69-75
Bryce & Ragnarsson (2000), PM&R Clinics NA 11(11):157-168
2006 Pain Taxonomy for SCI
Nociceptive Musculoskeletal Visceral
Neuropathic Above LOI At LOI Below LOI
Siddall & Middleton (2006) Spinal Cord 44:67-77
2011 Pain Taxonomy in SCI
Tier 1: Pain Type Nociceptive
Neuropathic
Other Pain
Unknown Pain
Bryce et al (2011), International SCI Pain Classification. Spinal Cord Advance Online Publication
Tier 3: Pain Source E.g.Glenohumeral OA E.g. MI, appendicitis E.g. AD / Migraine HA E.g. Root compression E.g. Cord ischemia E.g. CTS E.g. Fibromyalgia,
CRPS 1 or 2, Trig. Neuralgia
?
Tier 2: Pain Subtype
Musculoskeletal Visceral Other At SCI Level Below SCI Level Other
Rx of Pain in SCI
Siddall & Middleton (2006) Spinal Cord 44:67-77
Treatment of Pain
Assessment Identify Pain Type Historical Assessment Identify Pain Sub-type Structural Assessment Identify Pathology Treat Cause Treat Symptoms
System Assessment
Is pain located in a region of normal sensation?
Yes: Noceceptive No: Neuropathic
Site Assessment
Position-dependent? Activity-related? Somatic-
tenderness? Viscera-related? Above level? At level? Below level?