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• Rare in the cancer population.
Idiopathic Pain
• In the absence of evidence sufficient to label pain as either nociceptive or neuropathic, we may use the term “idiopathic.”
Syndrome: Definition
• A temporal and qualitative convergence of symptoms and signs, which conforms to a recognized pattern
• Associated with distinct etiologies, pathophysiologies, and prognostic and therapeutic implications
Temporal Classification • Acute • Chronic • Breakthrough Pain
Acute Cancer Pain
• Defined by a recent onset and a natural history characterized by transience.
• Metastatic bone disease, hollow viscous involvement and nerve compression or infiltration are most common causes
b) Pain syndromes associated with cancer therapy
Transmission
▪ Transfer and modulation of input from one neuron to another ▪ Substance P, Glutamate, Brain derived neurotropic factor ▪ Inhibitory interneurons
• May or may not be associated with overt pain behaviors.
• Usually caused by diagnostic or therapeutic interventions
Causes of Acute Cancer Pain
•Diagnostic Interventions •Acute postoperative pain •Therapeutic interventions •Analgesic Techniques •Associated with chemotherapy
Transmission Transfer and modulation of input from one neuron to another
Conduction Passage of action potential along the first order neuron to dorsal horn of spinal cord
• Due to cancer therapy (15-25%) • Pathology unrelated to either the cancer or its treatment (5-15%)
allodynia (pain induced by non-painful stimuli) and hyperalgesia (increased perception of painful stimuli).
Psychogenic Pain
• Refers to pain that is believed to be sustained predominantly by psychological factors.
• In patients with cancer, this term should lead to additional workup and a search for an underlying etiology and pathophysiology.
Basic Pathophysiology of Pain
Chronic Cancer Pain
• Persists for one month or more beyond the usual course of an acute illness or injury
• Most commonly due to direct effects of the tumor • Other causes:
Clinically, it is useful to determine both the etiology and inferred pathophysiology in the assessment of the pain complaint, as this may suggest the use of specific therapies.
Merskey, H., Bogduk, N, ed. Classification of Chronic Pain, Second Edition. IASP Task Force on Taxonomy. 1994, IASP Press: Seattle. 209-214.
Taxonomy of Pain
• Review the common causes of pain in cancer patients
• Review approach to managing pain
Defining Pain
Pain is defined as an unpleasant sensory and emotional experience associated with actual or potential tissue damage, or described in terms of such damage.
Transduction
▪ Conversion of thermal, chemical, mechanical stimulus to electrical activity at nociceptor ▪ Na channels
Conduction
▪ Passage of action potential along the first order neuron to dorsal horn of spinal cord
Neuropathic Pain
• Sustained by abnormal somatosensory processing in the PNS or CNS.
• Typically, described as “burning,” “shock-like,” “electrical.”
• May be paroxysmal in nature. • On physical examination, patients may have
d) Generalized pain in a dying cancer patient
Foley, KM. Pain syndromes in patients with cancer. Oxford Textbook of Palliative Medicine, 3rd Ed..
Cancer Pain Syndromes: Temporal Patterns
Cancer Pain Syndromes
Craig D. Blinderman, MD, MA Co-Director, MGH Cancer Pain Clinic
MGH Palliative Care Service
Objectives
• Review the definition of pain and basic pathophysiology
Cancer Pain Syndromes
a) Related to tumor involvement
• Accounts for 78% of pain problems in inpatient cancer population and 62% of outpatient cancer population in MSKCC survey
Taxonomy of Pain
• Nociceptive
▪ Somatic ▪ Visceral
• Neuropathic • Psychogenic • Idiopathic
Nociceptive Pain
• Nociceptive somatic pain
▪ Sustained predominantly by tissue injury or inflammation. ▪ Described as sharp, aching, stabbing, throbbing or pressure-like.
•Associated with radiotherapy
•Acute pain associated with hormonal therapy
•Acute pain associated with immunotherapy
•Acute pain associated with infection
Perception
▪ Awareness and meaning of pain
Modulation
▪ Descending pathways inhibit transmission of nociceptive impulses ▪ e.g. Periaqueductal grey matter in midbrain-->nucleus raphae in medulla ▪ Norepinephrine, serotonin, endogenous opioids
Peripheral and Central Pathways for Pain
Ascending Tracts
Descending Tracts
Modulation Descending pathways inhibit transmission of nociceptive impulses
Perception Awareness and meaning of pain
• 19% of pain problems in inpatient population and 25% in outpatient population
c) Pain unrelated to cancer or therapy
• Approx. 3% of inpatients have pain unrelated to their cancer and 10% in outpatient population
• Classification may be based on:
▪ Anatomy ▪ Body System ▪ Temporal Characteristics ▪ Severity ▪ Etiology ▪ Pathophysiology
▪ Defined pain syndromes
Taxonomy of Pain
Transduction Conversion of thermal, chemical, mechanical stimulus to electrical activity at nociceptor
Cortex Thalamus
Midbrain
Pons
Medulla Spinal Cowenku.baidu.comd
Cancer Pain Syndromes
• Nociceptive visceral pain
▪ Poorly localized; described as crampy pain (e.g. obstruction of hollow viscus), or as aching and stabbing (e.g. pain secondary to splenomegaly).
Idiopathic Pain
• In the absence of evidence sufficient to label pain as either nociceptive or neuropathic, we may use the term “idiopathic.”
Syndrome: Definition
• A temporal and qualitative convergence of symptoms and signs, which conforms to a recognized pattern
• Associated with distinct etiologies, pathophysiologies, and prognostic and therapeutic implications
Temporal Classification • Acute • Chronic • Breakthrough Pain
Acute Cancer Pain
• Defined by a recent onset and a natural history characterized by transience.
• Metastatic bone disease, hollow viscous involvement and nerve compression or infiltration are most common causes
b) Pain syndromes associated with cancer therapy
Transmission
▪ Transfer and modulation of input from one neuron to another ▪ Substance P, Glutamate, Brain derived neurotropic factor ▪ Inhibitory interneurons
• May or may not be associated with overt pain behaviors.
• Usually caused by diagnostic or therapeutic interventions
Causes of Acute Cancer Pain
•Diagnostic Interventions •Acute postoperative pain •Therapeutic interventions •Analgesic Techniques •Associated with chemotherapy
Transmission Transfer and modulation of input from one neuron to another
Conduction Passage of action potential along the first order neuron to dorsal horn of spinal cord
• Due to cancer therapy (15-25%) • Pathology unrelated to either the cancer or its treatment (5-15%)
allodynia (pain induced by non-painful stimuli) and hyperalgesia (increased perception of painful stimuli).
Psychogenic Pain
• Refers to pain that is believed to be sustained predominantly by psychological factors.
• In patients with cancer, this term should lead to additional workup and a search for an underlying etiology and pathophysiology.
Basic Pathophysiology of Pain
Chronic Cancer Pain
• Persists for one month or more beyond the usual course of an acute illness or injury
• Most commonly due to direct effects of the tumor • Other causes:
Clinically, it is useful to determine both the etiology and inferred pathophysiology in the assessment of the pain complaint, as this may suggest the use of specific therapies.
Merskey, H., Bogduk, N, ed. Classification of Chronic Pain, Second Edition. IASP Task Force on Taxonomy. 1994, IASP Press: Seattle. 209-214.
Taxonomy of Pain
• Review the common causes of pain in cancer patients
• Review approach to managing pain
Defining Pain
Pain is defined as an unpleasant sensory and emotional experience associated with actual or potential tissue damage, or described in terms of such damage.
Transduction
▪ Conversion of thermal, chemical, mechanical stimulus to electrical activity at nociceptor ▪ Na channels
Conduction
▪ Passage of action potential along the first order neuron to dorsal horn of spinal cord
Neuropathic Pain
• Sustained by abnormal somatosensory processing in the PNS or CNS.
• Typically, described as “burning,” “shock-like,” “electrical.”
• May be paroxysmal in nature. • On physical examination, patients may have
d) Generalized pain in a dying cancer patient
Foley, KM. Pain syndromes in patients with cancer. Oxford Textbook of Palliative Medicine, 3rd Ed..
Cancer Pain Syndromes: Temporal Patterns
Cancer Pain Syndromes
Craig D. Blinderman, MD, MA Co-Director, MGH Cancer Pain Clinic
MGH Palliative Care Service
Objectives
• Review the definition of pain and basic pathophysiology
Cancer Pain Syndromes
a) Related to tumor involvement
• Accounts for 78% of pain problems in inpatient cancer population and 62% of outpatient cancer population in MSKCC survey
Taxonomy of Pain
• Nociceptive
▪ Somatic ▪ Visceral
• Neuropathic • Psychogenic • Idiopathic
Nociceptive Pain
• Nociceptive somatic pain
▪ Sustained predominantly by tissue injury or inflammation. ▪ Described as sharp, aching, stabbing, throbbing or pressure-like.
•Associated with radiotherapy
•Acute pain associated with hormonal therapy
•Acute pain associated with immunotherapy
•Acute pain associated with infection
Perception
▪ Awareness and meaning of pain
Modulation
▪ Descending pathways inhibit transmission of nociceptive impulses ▪ e.g. Periaqueductal grey matter in midbrain-->nucleus raphae in medulla ▪ Norepinephrine, serotonin, endogenous opioids
Peripheral and Central Pathways for Pain
Ascending Tracts
Descending Tracts
Modulation Descending pathways inhibit transmission of nociceptive impulses
Perception Awareness and meaning of pain
• 19% of pain problems in inpatient population and 25% in outpatient population
c) Pain unrelated to cancer or therapy
• Approx. 3% of inpatients have pain unrelated to their cancer and 10% in outpatient population
• Classification may be based on:
▪ Anatomy ▪ Body System ▪ Temporal Characteristics ▪ Severity ▪ Etiology ▪ Pathophysiology
▪ Defined pain syndromes
Taxonomy of Pain
Transduction Conversion of thermal, chemical, mechanical stimulus to electrical activity at nociceptor
Cortex Thalamus
Midbrain
Pons
Medulla Spinal Cowenku.baidu.comd
Cancer Pain Syndromes
• Nociceptive visceral pain
▪ Poorly localized; described as crampy pain (e.g. obstruction of hollow viscus), or as aching and stabbing (e.g. pain secondary to splenomegaly).