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Referral pain and phantom pain
- 1. Pain facts â3 Dr. S. Parthasarathy MD., DA., DNB, MD (Acu), Dip. Diab. DCA, Dip. Software statistics PhD (physio) Mahatma Gandhi medical college and research institute â puducherry, India
- 2. Referred pain âą Painperceived at a location other than the site of the painful stimulus âą What is radiating pain ?? âą What is referred pain ??
- 3. Radiation or referral âąPain of myocardial infarction is located in the mid or left side of the chest where the heart is actually located. The pain can radiate to the left side of the jaw and into the left arm. âą Referred pain is when the pain is located away from or adjacent to the organ involved. Referred pain would be when a person has pain only in their jaw or left arm, but not in the chest
- 4. âą Confusion stillâą ISSP does not clarify ??
- 5. Visceral pain âą Doesit respond to clamp?? âą No âą Ischemia âą Distension âą Active contractions âą Diffuse, referred, autonomic
- 6. Organs and siteof referred pain
- 7. Characteristics 1. segmental Renal colicâ loin and scrotum 2. area of referral â tender hyperalgesic, 3. develops after sometime.
- 8. Mechanisms âą Morley âs theory âą Axon reflex -= Sinclair âą Convergent-projection- Ruch âą Convergence-facilitation âą Hyperexcitability âą Thalamic-convergence
- 9. Morley â stheory âą It states that the involvement of adjacent somatic structures caused pain !! âą Simultaneous ? âą Can be the only symptom ? âą Put to disuse
- 10. Axon reflex theory âąprimary sensory neurones have widely bifurcating axons and innervate both somatic and visceral targets, thus obscuring the source of afferent activity, and explaining the segmental nature of referred sensations.
- 11. Questions about axontheory âą No such axons âą No explanation to time delay No explanation to referred hyperalgesia
- 12. Convergent-projection- Ruch âą visceraland somatic primary sensory neurones converge onto common spinal neurones âą This theory proposes that the activity in ascending spinal pathways is misconstrued as originating from somatic structures ready explanation for the segmental nature but issue of referred hyperalgesia.??
- 13. convergence-facilitation theory âą viscerawere wholly insensitive and therefore that visceral afferent activity never of itself gave rise to pain. âą He proposed instead that this activity was capable of creating an âirritable focusâ within the spinal cord, so that other, segmentally appropriate, somatic inputs could now produce abnormal and, of course, referred pain sensations. âą MacKenzie
- 14. convergence-facilitation theory âą NOgeneral acceptance, in part because it implicitly denied the existence of âtrueâ visceral palm. However, the theory offers an explanation for referred hyperalgesia and, perhaps, the delay of referred sensations. âą The concept of an irritable focus has more recently been resurrected with another labelâcentral sensitization, which appears to be of major importance in hyperalgesia from somatic and visceral structures.
- 15. Supraspinal â theobald âąinteractions at supra spinal levels lead to the phenomenon. âą But are there separate systems ??
- 16. What happens ifwe block area referred hyperalgesia lost tenderness lost , pain- loss â controversial
- 17. Summary âą Referred pain âąFeatures âą Theories
- 18. Phantom pain âą Aphantom limb is the sensation that an amputated or missing limb (even an organ, like the breast) is still attached to the body and is moving appropriately with other body parts âą Approximately 60 to 80% of individuals with an amputation experience phantom sensations in their amputated limb, and the majority of the sensations are painful
- 19.
- 20. Or simply!! âą Painfulsensations experienced in a missing limb . âą Tooth and eye also possible âą Stump pain is different.
- 21. âą phantom painscan also occur in people who are born without limbs and people who are paralyzed. âą So phantom limb, phantom pain, stump pain
- 22. History âą Ambrose Paire(1510) âą Military surgeon âą First explained âą Mitchell (1979) coined the term â phantom pain
- 23. How frequent isit ?? âą 4 â 90 % âą Innumerable studies âą Onset âą Usually first week after amputation âą Rarely months to years
- 24. Where is it?? âą Entire â 6% âą Proximal â 10% âą Distal â around 80 % âą Approx figures changes with duration !!
- 25. Quality - Noproper studies âą Varied âSqueeze ,Clenching toes ,Nails digging âą The missing limb often feels shorter âą feel as distorted âą can be made worse by stress, anxiety, and weather changes. âą usually intermittent. âą The frequency and intensity of attacks usually declines with time 70 % ----35 % in 2 years
- 26. Preamputation pain âą Strikingcase reports âą Location and character similar â âą Vascular and traumatic amputees âą Pain memory ? âą Melzack (1990) â questioned the fact ?? âą CNS lesions made pain disappear
- 27. Possible no relation âąMilitary Vs civilian âą Age, side, âą Sex âą Level of amputation
- 28. Etiology âą Peripheral âą Spinal âąSupraspinal
- 29. Peripheral âą Irritation inthe severed nerve endings (called "neuromas"). âą Gallamine and Local injection âą Percussion of stump â increases pain âą Stump end pathology ends pain ends
- 30. Spinal and thereon âąDisinhibition of neurons at spinal level âą Nerve injury â sensitization â spinal plasticity âą In his 1989 paper,"Phantom Limbs, The Self And The Brainâ Melzack proposed the theory of the "neuromatrix.â
- 31. Mechanisms âą the experienceof the body is created by a wide network of interconnecting neural structures âą the primary somatosensory cortex undergoes substantial reorganization after the loss of sensory input. âą due to this reorganization in the somatosensory cortex, which is located in the postcentral gyrus, and which receives input from the limbs and body. âą Stroke the Face â phantom pain
- 32. Etiology âą Peripheral âą Spinal âąSupraspinal
- 33. Treatment âą Yes ita form of chronic pain âą Difficult to treat âą 68 treatment , 50 still in use !! âą TENS, massage, acupuncture,capsaicin ECT âą 75% Vs 44 % placebo âą mirror box visual feedback
- 34. Drugs âą Carbamazepine andnewer anticonvulsants âą Antidepressants âą IV calcitonin âą Beta blockers âą Depression or original which is treated ??
- 35. Invasive techniques âą Stumprevisions âą Neuroma excision âą Sympathectomy âą Dorsal root entry â zone lesions âą Spinal stimulation âą Brain stimulation âą Preemptive â role ??
- 36. What I do âąA very low dose IV ketamine as premed âą Always regional âą Add opioids
- 37. Villiyanur Ramachandran !! Statementby an international phantom pain authority The fingers were illusory, but the pain was real
- 38. If we givepain relief then
- 39. Is this phantomor real ? âą Thank you all