Diagnosis and treatment  of Pain Introduction Introduction Intruduction ◆Every person may experience pain at some time, in some extent, for some reason. ◆Pain is one of the most important part of our sensation, which warn us of kinds of injuries/risks so that we can avoid or deal with these injuries/risks. ◆Pain also cause us unpleasant feeling, influence on our physiological function and life quality, even threat on our lives. This make pain an important problem to be treated clinically. ◆It is necessary for us medical students to have a good understanding of pain. Intruduction 每一个人生命过程中会由于不同原因在不同时期不同程度受到疼痛的折磨，严重时会影响生理机能和生命质量，甚至危及生命安全。有的时候疼痛本身就是一种病（如三叉神经痛），或者引起疼痛的原发疾病已不那么重要（如晚期癌痛），使疼痛治疗成为唯一的选择The development of pain management The development of pain management 在埃及、印度等国很早就采用大麻、罂栗碱、曼陀罗(mandala, stramonium) 等止痛在巴比伦用莨菪果实(scopola) 等制成粘土胶涂于龋齿止痛在希腊和罗马用鸦片制剂缓解关节痛和胸痛古代秘鲁土人用古卡叶涂于伤口止痛The development of pain management 1654,Pare,local analgesia with press 1611,Katz,local analgesia with opioid ointment 1844, Well,N2O for tooth extraction pain 1946, Serverino, local analgesia with ice 1947,Simpson,labor pain control with halothane 1884,Koller,topical anesthesia with cocaine 1899,Bier,spinal anesthesia 1912,Harris,trigeminal neuralgia injection 。1931,Dogliotti,long-term analgesia for cancer patients by subarachnoid absolute alcohol The development of pain management 1936,www.book118.comnstine, nerve block clinic 1961,Bonica,pain clinic 1962, 山村秀夫《麻醉科门诊》1965, 《疼痛研究会》1966, 《疼痛临床杂志》1975, 佛洛伦萨,1st IASP 1976, 若杉文吉,疼痛科1982 ，Milan,cancer pain conference 1984, 《疼痛研究会》改为《日本疼痛学会》1985, 鹿特丹,疼痛临床国际学术交流会and 《Pain clnic 》The development of pain management Thousands of pain management unit Tens of pain related journals Hundreds thousands of members Advance in the field of pain Basic research More targeting,less toxic drugs PCA Microinvasive techniques The history of pain management Definition of Pain pain as "an unpleasant sensory and emotional experience associated with actual or potential tissue damage, or described in terms of such damage." Teaching Outline Basic aspect Anatomy Injury and pain Processing of pain Teaching Outline Basic aspect Anatomy Injury and pain Processing of pain Teaching Outline Basic aspect Anatomy Injury and pain Processing of pain Injury and pain Teaching Outline Basic aspect Anatomy Injury and pain Processing of pain The Model of Pain by Descartes Pain process stages Stimulation transduction Transmission modulation perception Internal biochemical mechanism NMDA system GABA system Opioid system  Teaching Outline Basic aspect Anatomy Injury and pain Processing of pain 疼痛的流行病学epidemiology of pain 五分之一癌痛未受到控制(3) 70% 以上晚期癌症病人有中重度疼痛(1,2) 一项1,308 例门诊转移癌病人研究中, 虽经一些疼痛治疗，但大多数(62%) 病人疼痛严重，影响功能(4) 20%-30% 美国人口受急慢性疼痛严重困扰(1) 1999 年805 项调查中，五分之二中重度痛病人认为其疼痛未受控制，需要寻求足够的治疗(5) 三百多万美国人有慢性非恶性痛（CNMP ）(6) 每年四百万美国人因慢性痛看医生(7) Epidemiology 81 ％from average population reported experience pain at least once in their life time In a randomized survey of 827 persons, 66% complained pain in their body Teaching Outline Basic aspect Anatomy Injury and pain Processing of pain classification Good gain pain ：physiological pain （‘good pain’）“good pain”——alarming——protection No good gain pain ：pathophysiological pain （bad pain ）bad pain ——except alariming ，pain is of no good We would like with no pain system if we had other alarming systems Sensitization classfication 从病程分acute pain chronic pain 从人体的部位分headache cervical-shouder pain thoracico-abdominal pain low back pain 从疼痛的来源分皮肤痛muscles pain 、tendons pain 、ligaments pain arthralgia bone pain visceral pain neuropathic pain （central pain ）pathogenic classfication 无菌性炎症(inflammation pain)——椎管内外或关节内外软组织因急性损伤后遗或慢性劳损而引起的损害性疼痛。神经病理性疼痛neuropathic pain__ 机械性压迫(mechanic pressure)——机体生物力学失去平衡，解剖位置改变，肌应力异常引起的神经血管受压性疼痛。（neuropathic pain 神经病理性疼痛）癌痛(cancer pain ) 部位分类position classfication 浅表痛(superficial pain)——由机械性、化学性、物理性的不良刺激引起皮肤、黏膜部位的疼痛。程度剧烈、定位精确多呈局限性如刀割、针刺。Adelta 神经传递。深部痛(deep pain)——内脏、关节、胸膜、腹部受刺激而产生的疼痛，常为灼痛，无明显疼痛部位，不呈局限性。C神经传递中枢痛(central pain)--- 疼痛强烈、持久、难忍疼痛的性质分类刺痛(pricking pain) 灼痛(burning pain) 胀痛(distending pain) 酸痛(aching pain) 绞痛(colicky pain) Acute pain Signals of diseases For insult of tissue intact Adaptive,of good Alarm for early treatment Chronic pain More than 3/6 months Nervous modulation after month’s pain insult complicated with some intractable disease still pain even the origional disease cured Pain: Acute vs. Chronic Acute pain Psychological status ：exciting, agitation,sc-reaming, depression if at pain state for a long time Neuroendocrine system ：increased secretion of catecholamine Circulation system ：rapid or slow P related to intensity of pain,even cardiac arrest. BP increase or decrease, collapse, shock or cardiac vascular accident Respiratory system ：rapid with small VT Digestive system ：nausea and vomiting, malfunctioning Immuno system ：Delayed healing Chronic pain physical suffering disability noxious 、low appetite Low quality of sleep Side effects of drugs psychological Lower living happiness Anxiety, fairness depression Hard to concentrate and memorize Depending on others social Lower social relationship quality Can’t join social/family activity Lower sexual ability Self configuration changes Increase other’s burden Forced to deal with adversarial system. Loss income spiritual suffering Meaning of life changes Sense of delusion Religion and believe Acute pain is harmful to body, and may transforms to chronic pain. It is necessary to initiate early and whole range treatment Chronic pain is even harmful, need effective and comprehensive control Teaching Outline Basic aspect Anatomy Injury and pain Processing of pain Quantization of pain intensity 疼痛测定和评估的意义准确判定疼痛特征,指导用药和治疗方法. 及时调整治疗方案判断治疗效果判断预后If you don’t measure it, you can’t improve it Single dimension of pain assessment visual analogue scale, VAS numeric rating scale, NRS verbal rating scale, VRS faces pain rating scale Multi-dimension tools McGill Pain Questionnaire, MPQ Brief pain inventory, BPI Visual analogue scale(VAS) Numeric pain intensity scale Verbal descriptive rating scale （VRS ）0 no pain 1 slight pain 2 moderate pain 3 severe pain Verbal rating scales,VRS( 口述描绘评分法) 无痛轻微痛中度痛重度痛极重度痛Wong-Baker faces pain rating scale McGill pain questionnaire Objective pain assessment ◆Pain threshold 	Thermal radiation,TR 	Electrical stimulation,ES 	cold stimulation 	drug stimulation ◆Physiological parameters 	tidal volume 	heart rate and blood pressure hormone examination 	Evoked potential,EP ◆Image examination ◆Psychological examination	 行为测定法6点行为评分法(behavioral rating scale,BRS-6) 疼痛日记评分法(pain diary scale,PDS) 生理指标和生化指标Teaching Outline Basic aspect Anatomy Injury and pain Processing of pain Objective of life ？Painless ，无痛Happiness ，快乐Pain assessment and diagnosis Diagnosis procedure of pain patients Source of patients Direct to clinic Introduced by appointed Assessment in clinic Clinical medical history Physical exam. Pain assessment Psychological depression anxiety cognitive Social support Lab exam. （X-ray 、CT 、MRI 、etc ）Treatment of pain Significance of pain treatment Control pain and facilitate rehabilitation （消除疼痛，促进恢复）Improve body function and life quality （改善机体功能和生活质量）Treat original disease （治疗原发病）疼痛治疗的原则明确诊断除痛与病因治疗相结合综合治疗确保安全有效Principle of treatment Clear diagnosis