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Multidisciplinary Pain Management Dr Yeo Sow Nam Director, The Pain Specialist, Mount Elizabeth Hospital President World Institute of Pain (SEA Chapter) MBBS (Singapore) MMED (Anesthesiology, S’pore) FANZCA (Anesthesiology, Aust/NZ) FFPMANZCA (Pain Medicine, Aust/NZ) Registered Acupuncturist

Multidisciplinary Pain Management · Persistent postsurgical pain is a common but under-recognized problem 21 1. Kehlet H, et al. Lancet 2006;367:1618-1625; 2. Durkin B, et al. Expert

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Page 1: Multidisciplinary Pain Management · Persistent postsurgical pain is a common but under-recognized problem 21 1. Kehlet H, et al. Lancet 2006;367:1618-1625; 2. Durkin B, et al. Expert

Multidisciplinary Pain Management

Dr Yeo Sow Nam

Director, The Pain Specialist, Mount Elizabeth

Hospital

President World Institute of Pain (SEA Chapter)

MBBS (Singapore)

MMED (Anesthesiology, S’pore)

FANZCA (Anesthesiology, Aust/NZ)

FFPMANZCA (Pain Medicine, Aust/NZ)

Registered Acupuncturist

Page 2: Multidisciplinary Pain Management · Persistent postsurgical pain is a common but under-recognized problem 21 1. Kehlet H, et al. Lancet 2006;367:1618-1625; 2. Durkin B, et al. Expert

As a doctor, our task is:

*To cure is sometime

*To treat is often, but …

*To comfort is always

A. Pare (1598)

Page 3: Multidisciplinary Pain Management · Persistent postsurgical pain is a common but under-recognized problem 21 1. Kehlet H, et al. Lancet 2006;367:1618-1625; 2. Durkin B, et al. Expert

Chronic pain – The burden

Page 4: Multidisciplinary Pain Management · Persistent postsurgical pain is a common but under-recognized problem 21 1. Kehlet H, et al. Lancet 2006;367:1618-1625; 2. Durkin B, et al. Expert
Page 5: Multidisciplinary Pain Management · Persistent postsurgical pain is a common but under-recognized problem 21 1. Kehlet H, et al. Lancet 2006;367:1618-1625; 2. Durkin B, et al. Expert
Page 6: Multidisciplinary Pain Management · Persistent postsurgical pain is a common but under-recognized problem 21 1. Kehlet H, et al. Lancet 2006;367:1618-1625; 2. Durkin B, et al. Expert

Prevalence of Chronic Pain

• Overall, 8.7% of the study population had

chronic pain. (ie about 392000 people)

• Incidence varies with gender and age.

• Female had a higher incidence.

– 9.9% or 1 in 10 women had chronic pain.

– 7.0% of men reported having chronic pain.

Page 7: Multidisciplinary Pain Management · Persistent postsurgical pain is a common but under-recognized problem 21 1. Kehlet H, et al. Lancet 2006;367:1618-1625; 2. Durkin B, et al. Expert

Prevalence of Chronic Pain

• Incidence increases with age:

16.7% 60 and above

12.7% 50 - 59

6.0% 18 - 49

% with Chronic Pain Age Group

慢性疼痛是一种疾病

Page 8: Multidisciplinary Pain Management · Persistent postsurgical pain is a common but under-recognized problem 21 1. Kehlet H, et al. Lancet 2006;367:1618-1625; 2. Durkin B, et al. Expert

Pain Management Services in

Singapore

• Rapid growth last 8 years

• Private and Public Hospitals

• Current challenges and Unmet Needs:

– Acute Perioperative Pain management

– Preventive Pain Management

– Chronic Pain Management

– Cancer Pain Management

– Special population: Paediatirics; Obstetrics; Elderly

(Drugs cleared by ?RES)

– Multimodal analgesia to improve NNT, NNH

Page 9: Multidisciplinary Pain Management · Persistent postsurgical pain is a common but under-recognized problem 21 1. Kehlet H, et al. Lancet 2006;367:1618-1625; 2. Durkin B, et al. Expert

Process of the pain disease

Acute pain + insufficient pain therapy

Central sensitization

Pain memory

Pain disease

Collapse of the body's pain defenses

Sandkühler, J.: Preventing Pain Memory. MMW 2002; Special edition 2

Page 10: Multidisciplinary Pain Management · Persistent postsurgical pain is a common but under-recognized problem 21 1. Kehlet H, et al. Lancet 2006;367:1618-1625; 2. Durkin B, et al. Expert

Cortical Reorganisation

in Central Sensitisation

At admission After 12 weeks functional treatment

Page 11: Multidisciplinary Pain Management · Persistent postsurgical pain is a common but under-recognized problem 21 1. Kehlet H, et al. Lancet 2006;367:1618-1625; 2. Durkin B, et al. Expert

Cortical Reorganization

Page 12: Multidisciplinary Pain Management · Persistent postsurgical pain is a common but under-recognized problem 21 1. Kehlet H, et al. Lancet 2006;367:1618-1625; 2. Durkin B, et al. Expert

What type of doctor did you first see, what type of doctor is most

responsible for treating the pain you just described?

Median #

MDs seen = 2

Visits in last year = 3

GPs Play a Pivotal Role in the Ongoing

Management of Neuropathic Pain

(n=1056) (n=1056)

. Neuropathic Pain Patient Flow Survey

Page 13: Multidisciplinary Pain Management · Persistent postsurgical pain is a common but under-recognized problem 21 1. Kehlet H, et al. Lancet 2006;367:1618-1625; 2. Durkin B, et al. Expert

GPs Play a Pivotal Role in the Ongoing

Management of Neuropathic Pain

Neuropathic Pain Patient Flow Survey

75%

46%

25% 29%

54%

Percentages of all patients surveyed in total (n=1056)

Page 14: Multidisciplinary Pain Management · Persistent postsurgical pain is a common but under-recognized problem 21 1. Kehlet H, et al. Lancet 2006;367:1618-1625; 2. Durkin B, et al. Expert

Recognizing most neuropathic pain is easy for me.

GPs are Most Challenged in Recognizing

Neuropathic Pain

Neuropathic Pain Patient Flow Survey

Page 15: Multidisciplinary Pain Management · Persistent postsurgical pain is a common but under-recognized problem 21 1. Kehlet H, et al. Lancet 2006;367:1618-1625; 2. Durkin B, et al. Expert

GPs Find Neuropathic Pain More Difficult to Recognize in

Some Conditions Than in Others

How challenging is it to recognize neuropathic pain in patients with

the following conditions? (n=428 GPs)

Neuropathic Pain Patient Flow Survey

Page 16: Multidisciplinary Pain Management · Persistent postsurgical pain is a common but under-recognized problem 21 1. Kehlet H, et al. Lancet 2006;367:1618-1625; 2. Durkin B, et al. Expert

Patient Concerns

Before Surgery

Warfield CA, Kahn CH. Anesthesiology 1995;83:1090-1094. (Survey of 500 U.S. adults)

Pain

after

Improvement Full

recovery

Pain

during Professional

Patient

Concerns

(%)

Page 17: Multidisciplinary Pain Management · Persistent postsurgical pain is a common but under-recognized problem 21 1. Kehlet H, et al. Lancet 2006;367:1618-1625; 2. Durkin B, et al. Expert

Undertreatment of Chronic Pain

• >40% to 50% of patients in routine practice

settings fail to achieve adequate pain relief

• In a recent study of 805 chronic pain sufferers,

>50% had to change physicians to achieve relief

because the physician:

– was unwilling to treat pain aggressively

– did not take the patient’s pain seriously

– had inadequate knowledge about pain treatment

(American Pain Society, 2001; Glajchen, 2001; Lister, 1996; Portenoy, 1996)

Page 18: Multidisciplinary Pain Management · Persistent postsurgical pain is a common but under-recognized problem 21 1. Kehlet H, et al. Lancet 2006;367:1618-1625; 2. Durkin B, et al. Expert

Persistent pain after surgery

Surgery Pain type Incidence

Limb amputation phantom limb pain 30-81%

Thoracotomy postthoracotomy pain >50%

Breast surgery chest wall, breast or scar 50%

pain; phantom breast pain

Cholecystectomy chronic abdominal pain 3-56%

Inguinal hernia groin pain 11.5%

Perkins F et al. Chronic pain as an outcome of surgery. Anesthesiology 2000; 93: 1123-1133.

Page 19: Multidisciplinary Pain Management · Persistent postsurgical pain is a common but under-recognized problem 21 1. Kehlet H, et al. Lancet 2006;367:1618-1625; 2. Durkin B, et al. Expert

Persistent postsurgical pain is a common but

under-recognized problem

21 1. Kehlet H, et al. Lancet 2006;367:1618-1625;

2. Durkin B, et al. Expert Opin Pharmacother 2010;11:2751-2758.

Estimated

incidence of

persistent

postsurgical pain

Estimated

incidence of

severe (disabling)

pain

Estimated US

surgical volumes

(1000s)

Inguinal hernia repair 10% 2–4% 600

Lower limb amputation 30–50% 5–10% 160

Breast surgery

(lumpectomy or

mastectomy)

20–30% 5–10% 480

Thoracotomy 30–40% 10% 200

Total knee arthroplasty 12% 2–4% 550

Coronary artery bypass

surgery

30–50% 5–10% 598

Caesarean section 10% 4% 220

Page 20: Multidisciplinary Pain Management · Persistent postsurgical pain is a common but under-recognized problem 21 1. Kehlet H, et al. Lancet 2006;367:1618-1625; 2. Durkin B, et al. Expert

Risk factors for development of

persistent postsurgical pain

1. Genetic susceptibility

2. Moderate to severe preoperative pain

3. Psychosocial factors

4. Age and sex

5. Surgical approach with risk of nerve damage

6. Poorly controlled postoperative pain

22

1. Kehlet H, et al. Lancet 2006;367:1618-1625; 2. Durkin B, et al. Expert Opin Pharmacother 2010;11:2751-2758;

3. Schug SA, Pogatzki-Kahn EM. Pain: Clinical Updates 2011;19:1-5.

Page 21: Multidisciplinary Pain Management · Persistent postsurgical pain is a common but under-recognized problem 21 1. Kehlet H, et al. Lancet 2006;367:1618-1625; 2. Durkin B, et al. Expert

Assess the person, not just the pain

+ =

Mood

Attitude , Expectations

Coping efforts

Resources; Response of family

Impact of pain on life

Meaning of the pain in the situation

Culture Past experiences

Organic factors Patient’s perception

of pain

Page 22: Multidisciplinary Pain Management · Persistent postsurgical pain is a common but under-recognized problem 21 1. Kehlet H, et al. Lancet 2006;367:1618-1625; 2. Durkin B, et al. Expert

Chronic Pain Management

Modalities

• Pharmacological

• Non-pharmacological

• Surgical

• Interventional

• CBT

Page 23: Multidisciplinary Pain Management · Persistent postsurgical pain is a common but under-recognized problem 21 1. Kehlet H, et al. Lancet 2006;367:1618-1625; 2. Durkin B, et al. Expert
Page 24: Multidisciplinary Pain Management · Persistent postsurgical pain is a common but under-recognized problem 21 1. Kehlet H, et al. Lancet 2006;367:1618-1625; 2. Durkin B, et al. Expert

Chronic Back Pain Despite Surgery/ Failed

Back Surgery Syndrome

Page 25: Multidisciplinary Pain Management · Persistent postsurgical pain is a common but under-recognized problem 21 1. Kehlet H, et al. Lancet 2006;367:1618-1625; 2. Durkin B, et al. Expert

Differential

Diagnosis

• Internal Disk Disruption - 39% +

• DDD (with or without IDD)

• Facet syndrome - 15% to 45%

• Disc herniation - 4% to 6%

• Sacroiliac Joint Disorders - 19% to 30%

• Degenerative disorders & myofascial syndromes

- 5% to 10%

• Post laminectomy & spine fusion syndromes

Schwartzer Spine 19:801-806, 1994

Page 26: Multidisciplinary Pain Management · Persistent postsurgical pain is a common but under-recognized problem 21 1. Kehlet H, et al. Lancet 2006;367:1618-1625; 2. Durkin B, et al. Expert

Post Surgical Syndromes

• 20% - 40% of spinal surgeries are not

successful initially

• Less than 1 out of 4 of disc surgeries are

successful after 5 years

• Re-operation rate of 17-20%

Page 27: Multidisciplinary Pain Management · Persistent postsurgical pain is a common but under-recognized problem 21 1. Kehlet H, et al. Lancet 2006;367:1618-1625; 2. Durkin B, et al. Expert
Page 28: Multidisciplinary Pain Management · Persistent postsurgical pain is a common but under-recognized problem 21 1. Kehlet H, et al. Lancet 2006;367:1618-1625; 2. Durkin B, et al. Expert

Chronic Post Surgical Pain

Page 29: Multidisciplinary Pain Management · Persistent postsurgical pain is a common but under-recognized problem 21 1. Kehlet H, et al. Lancet 2006;367:1618-1625; 2. Durkin B, et al. Expert

Advanced Interventional Pain Management

Page 30: Multidisciplinary Pain Management · Persistent postsurgical pain is a common but under-recognized problem 21 1. Kehlet H, et al. Lancet 2006;367:1618-1625; 2. Durkin B, et al. Expert

Epidural Adhesiolysis and Neuroplasty

Page 31: Multidisciplinary Pain Management · Persistent postsurgical pain is a common but under-recognized problem 21 1. Kehlet H, et al. Lancet 2006;367:1618-1625; 2. Durkin B, et al. Expert
Page 32: Multidisciplinary Pain Management · Persistent postsurgical pain is a common but under-recognized problem 21 1. Kehlet H, et al. Lancet 2006;367:1618-1625; 2. Durkin B, et al. Expert

KQ

6/12/01

Epiduroscope Tip

Catheter Tip

Page 33: Multidisciplinary Pain Management · Persistent postsurgical pain is a common but under-recognized problem 21 1. Kehlet H, et al. Lancet 2006;367:1618-1625; 2. Durkin B, et al. Expert
Page 34: Multidisciplinary Pain Management · Persistent postsurgical pain is a common but under-recognized problem 21 1. Kehlet H, et al. Lancet 2006;367:1618-1625; 2. Durkin B, et al. Expert

Permanent Implantable IPG

preventing%20chronic%20pain/crps.AVI
Page 35: Multidisciplinary Pain Management · Persistent postsurgical pain is a common but under-recognized problem 21 1. Kehlet H, et al. Lancet 2006;367:1618-1625; 2. Durkin B, et al. Expert
../../My%20Documents/My%20Pictures/Medical%20pics/CRPS/MVI_0115.THM
Page 36: Multidisciplinary Pain Management · Persistent postsurgical pain is a common but under-recognized problem 21 1. Kehlet H, et al. Lancet 2006;367:1618-1625; 2. Durkin B, et al. Expert

Acupuncture

Patel and Colleagues. All randomised controlled trials for chronic pain. J Epidemiol 1989. “Results favourable to acupuncture were obtained significantly more often than chance alone would allow”

TL Lee. Acupuncture and Chronic Pain Management. Ann Acad Med Singapore 2000. “ There are reasonable studies showing relief of pain in diverse pain conditions. “

Expert opinions and RCTs

Page 37: Multidisciplinary Pain Management · Persistent postsurgical pain is a common but under-recognized problem 21 1. Kehlet H, et al. Lancet 2006;367:1618-1625; 2. Durkin B, et al. Expert

APPROACH TO CRPS

MANAGEMENT

• Early diagnosis and treatment

• Interdisciplinary team approach

• Aggressive and comprehensive medical treatment

– Exercise therapy

– Pharmacotherapy

– Regional Anesthetic Techniques

– Neuromodulation

– Behavioral support Bonica JJ. Philadelphia: Lea & Febiger, 1953.

Stanton-Hicks M. Neuromodulation 1999; 194-210.

Page 38: Multidisciplinary Pain Management · Persistent postsurgical pain is a common but under-recognized problem 21 1. Kehlet H, et al. Lancet 2006;367:1618-1625; 2. Durkin B, et al. Expert
Page 39: Multidisciplinary Pain Management · Persistent postsurgical pain is a common but under-recognized problem 21 1. Kehlet H, et al. Lancet 2006;367:1618-1625; 2. Durkin B, et al. Expert

SURGERY

• surgical techniques may be indicated, eg.:

RFA / neurolysis sympathetic ganglia

Reconstructive surgery – foot, hand/wrist

Amputation – for severe infection or

palliation

MCS for refractory UE CRPS

DBS

Page 40: Multidisciplinary Pain Management · Persistent postsurgical pain is a common but under-recognized problem 21 1. Kehlet H, et al. Lancet 2006;367:1618-1625; 2. Durkin B, et al. Expert

Trophic Changes

Extreme

Page 41: Multidisciplinary Pain Management · Persistent postsurgical pain is a common but under-recognized problem 21 1. Kehlet H, et al. Lancet 2006;367:1618-1625; 2. Durkin B, et al. Expert

Cognitive Behavioural Therapy

Page 42: Multidisciplinary Pain Management · Persistent postsurgical pain is a common but under-recognized problem 21 1. Kehlet H, et al. Lancet 2006;367:1618-1625; 2. Durkin B, et al. Expert

CBT: Evidenced- Based Practice

• Turner and Clancy (1988)

• Bradley, Young, Anderson et al. (1987)

• Keefe, Caldwell, Williams et al. (1990)

• Syrjala, Donaldson, Davis et al. (1995)

• Morley et al. (1999)

Page 43: Multidisciplinary Pain Management · Persistent postsurgical pain is a common but under-recognized problem 21 1. Kehlet H, et al. Lancet 2006;367:1618-1625; 2. Durkin B, et al. Expert

Team Members

Pain specialists

• Doctors (Physicians/Oncol

Radiologist/Surgeons etc)

• Physiotherapists/ Rehab/OT

• Psychologists

• Nurses

• Pharmacist

Page 44: Multidisciplinary Pain Management · Persistent postsurgical pain is a common but under-recognized problem 21 1. Kehlet H, et al. Lancet 2006;367:1618-1625; 2. Durkin B, et al. Expert

Details of Programme

• Eight days

• 9 am to 5 pm

• Mon-Thu the first week

• Tue- Fri the following week

Page 45: Multidisciplinary Pain Management · Persistent postsurgical pain is a common but under-recognized problem 21 1. Kehlet H, et al. Lancet 2006;367:1618-1625; 2. Durkin B, et al. Expert
Page 46: Multidisciplinary Pain Management · Persistent postsurgical pain is a common but under-recognized problem 21 1. Kehlet H, et al. Lancet 2006;367:1618-1625; 2. Durkin B, et al. Expert
Page 47: Multidisciplinary Pain Management · Persistent postsurgical pain is a common but under-recognized problem 21 1. Kehlet H, et al. Lancet 2006;367:1618-1625; 2. Durkin B, et al. Expert
Page 48: Multidisciplinary Pain Management · Persistent postsurgical pain is a common but under-recognized problem 21 1. Kehlet H, et al. Lancet 2006;367:1618-1625; 2. Durkin B, et al. Expert
Page 49: Multidisciplinary Pain Management · Persistent postsurgical pain is a common but under-recognized problem 21 1. Kehlet H, et al. Lancet 2006;367:1618-1625; 2. Durkin B, et al. Expert

Distraction TechniquesDistraction Techniques

Pain Management Programme

Singapore General Hospital

Pain Management Programme

Singapore General Hospital

PacingPacing

Pain Management Programme

Singapore General Hospital

Challenging YourChallenging Your

Thought ProcessesThought Processes

Pain ManagementPain Management

ProgrammeProgramme

Singapore General HospitalSingapore General Hospital

MakingMaking

Changes toChanges to

Achieve GoalsAchieve Goals

Pain Management Programme

Singapore General Hospital

Maintaining

Changes

Page 50: Multidisciplinary Pain Management · Persistent postsurgical pain is a common but under-recognized problem 21 1. Kehlet H, et al. Lancet 2006;367:1618-1625; 2. Durkin B, et al. Expert
Page 51: Multidisciplinary Pain Management · Persistent postsurgical pain is a common but under-recognized problem 21 1. Kehlet H, et al. Lancet 2006;367:1618-1625; 2. Durkin B, et al. Expert
Page 52: Multidisciplinary Pain Management · Persistent postsurgical pain is a common but under-recognized problem 21 1. Kehlet H, et al. Lancet 2006;367:1618-1625; 2. Durkin B, et al. Expert
Page 53: Multidisciplinary Pain Management · Persistent postsurgical pain is a common but under-recognized problem 21 1. Kehlet H, et al. Lancet 2006;367:1618-1625; 2. Durkin B, et al. Expert

Lita Chew

Tan Seng Huat

Leela Nair

Wong Loon Tat

Daphne Koh

Gregory Meredith

Jane George

Yeo Sow Nam

Tan Kian Hian

Michelle Tan

1 9 8 4 2 0 0 4 20 years of service to our community

Ng Beng Yeong

Yap Huei Ling

Jennifer Liaw

Loh Moh Huan

Kaldip Kaur

Tan Ai Muay

Esther Tan

Evangaline Tan

Cui Shuli

Lita Chew

Tan Seng Huat

Leela Nair

Wong Loon Tat

Daphne Koh

Gregory Meredith

Jane George

Yeo Sow Nam

Tan Kian Hian

Michelle Tan

Lita Chew

Tan Seng Huat

Leela Nair

Wong Loon Tat

Daphne Koh

Gregory Meredith

Jane George

Yeo Sow Nam

Tan Kian Hian

Michelle Tan Ng Beng Yeong

Yap Huei Ling

Jennifer Liaw

Loh Moh Huan

Kaldip Kaur

Tan Ai Muay

Esther Tan

Evangaline Tan

Cui Shuli

Lita Chew

Tan Seng Huat

Leela Nair

Wong Loon Tat

Daphne Koh

Gregory Meredith

Jane George

Yeo Sow Nam

Tan Kian Hian

Michelle Tan Ng Beng Yeong

Yap Huei Ling

Jennifer Liaw

Loh Moh Huan

Kaldip Kaur

Tan Ai Muay

Esther Tan

Evangaline Tan

Cui Shuli

Ng Beng Yeong

Yap Huei Ling

Jennifer Liaw

Loh Moh Huan

Kaldip Kaur

Tan Ai Muay

Esther Tan

Evangaline Tan

Cui Shuli

Lita Chew

Tan Seng Huat

Leela Nair

Wong Loon Tat

Daphne Koh

Gregory Meredith

Jane George

Yeo Sow Nam

Tan Kian Hian

Michelle Tan

Lita Chew

Tan Seng Huat

Leela Nair

Wong Loon Tat

Daphne Koh

Gregory Meredith

Jane George

Yeo Sow Nam

Tan Kian Hian

Michelle Tan

Ng Beng Yeong

Yap Huei Ling

Jennifer Liaw

Loh Moh Huan

Kaldip Kaur

Tan Ai Muay

Esther Tan

Evangaline Tan

Cui Shuli

Ng Beng Yeong

Yap Huei Ling

Jennifer Liaw

Loh Moh Huan

Kaldip Kaur

Tan Ai Muay

Esther Tan

Evangaline Tan

Cui Shuli

Lita Chew

Tan Seng Huat

Leela Nair

Wong Loon Tat

Daphne Koh

Gregory Meredith

Jane George

Yeo Sow Nam

Tan Kian Hian

Michelle Tan

Ng Beng Yeong

Yap Huei Ling

Jennifer Liaw

Loh Moh Huan

Kaldip Kaur

Tan Ai Muay

Esther Tan

Evangaline Tan

Cui Shuli

Ng Beng Yeong

Yap Huei Ling

Jennifer Liaw

Loh Moh Huan

Kaldip Kaur

Tan Ai Muay

Esther Tan

Evangaline Tan

Cui Shuli

Lita Chew

Tan Seng Huat

Leela Nair

Wong Loon Tat

Daphne Koh

Gregory Meredith

Jane George

Yeo Sow Nam

Tan Kian Hian

Michelle Tan

Lita Chew

Tan Seng Huat

Leela Nair

Wong Loon Tat

Daphne Koh

Gregory Meredith

Jane George

Yeo Sow Nam

Tan Kian Hian

Michelle Tan

Lita Chew

Tan Seng Huat

Leela Nair

Wong Loon Tat

Daphne Koh

Gregory Meredith

Jane George

Yeo Sow Nam

Tan Kian Hian

Michelle Tan

Lita Chew

Tan Seng Huat

Leela Nair

Wong Loon Tat

Daphne Koh

Gregory Meredith

Jane George

Yeo Sow Nam

Tan Kian Hian

Michelle Tan

Lita Chew

Tan Seng Huat

Leela Nair

Wong Loon Tat

Daphne Koh

Gregory Meredith

Jane George

Yeo Sow Nam

Tan Kian Hian

Michelle Tan

Lita Chew

Tan Seng Huat

Leela Nair

Wong Loon Tat

Daphne Koh

Gregory Meredith

Jane George

Yeo Sow Nam

Tan Kian Hian

Michelle Tan

Lita Chew

Tan Seng Huat

Leela Nair

Wong Loon Tat

Daphne Koh

Gregory Meredith

Jane George

Yeo Sow Nam

Tan Kian Hian

Michelle Tan

Lita Chew

Tan Seng Huat

Leela Nair

Wong Loon Tat

Daphne Koh

Gregory Meredith

Jane George

Yeo Sow Nam

Tan Kian Hian

Michelle Tan

Ng Beng Yeong

Yap Huei Ling

Jennifer Liaw

Loh Moh Huan

Kaldip Kaur

Tan Ai Muay

Esther Tan

Evangaline Tan

Cui Shuli

Lita Chew

Tan Seng Huat

Leela Nair

Wong Loon Tat

Daphne Koh

Gregory Meredith

Jane George

Yeo Sow Nam

Tan Kian Hian

Michelle Tan

Lita Chew

Tan Seng Huat

Leela Nair

Wong Loon Tat

Daphne Koh

Gregory Meredith

Jane George

Yeo Sow Nam

Tan Kian Hian

Michelle Tan

Lita Chew

Tan Seng Huat

Leela Nair

Wong Loon Tat

Daphne Koh

Gregory Meredith

Jane George

Yeo Sow Nam

Tan Kian Hian

Michelle Tan

Lita Chew

Tan Seng Huat

Leela Nair

Wong Loon Tat

Daphne Koh

Gregory Meredith

Jane George

Yeo Sow Nam

Tan Kian Hian

Michelle Tan

Lita Chew

Tan Seng Huat

Leela Nair

Wong Loon Tat

Daphne Koh

Gregory Meredith

Jane George

Yeo Sow Nam

Tan Kian Hian

Michelle Tan

Page 54: Multidisciplinary Pain Management · Persistent postsurgical pain is a common but under-recognized problem 21 1. Kehlet H, et al. Lancet 2006;367:1618-1625; 2. Durkin B, et al. Expert
Page 55: Multidisciplinary Pain Management · Persistent postsurgical pain is a common but under-recognized problem 21 1. Kehlet H, et al. Lancet 2006;367:1618-1625; 2. Durkin B, et al. Expert
Page 56: Multidisciplinary Pain Management · Persistent postsurgical pain is a common but under-recognized problem 21 1. Kehlet H, et al. Lancet 2006;367:1618-1625; 2. Durkin B, et al. Expert

Everything is pain; Delivery is pain, disease

is pain, aging is pain.death is pain, to be

away from your beloved is pain, even hatred

is pain Buddha

Page 57: Multidisciplinary Pain Management · Persistent postsurgical pain is a common but under-recognized problem 21 1. Kehlet H, et al. Lancet 2006;367:1618-1625; 2. Durkin B, et al. Expert

Thank You

Dr Yeo Sow Nam

[email protected]

www.pain.org.sg

mailto:[email protected]

MANAGING POSTSURGICAL PAIN WITH OPIOID-REDUCING … · 2019-07-24 · MANAGING POSTSURGICAL PAIN WITH OPIOID-REDUCING STRATEGIES II ... Chondrolysis: There have been reports of chondrolysis

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Advancing Orthopedic Postsurgical Pain Management

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Obstructive jaundice secondary to postsurgical persistent ... · Maulana M. Ansari, ... A 30-year-old female complained of persistent abdominal pain for eight months ... Dr. Maulana

Obstructive jaundice secondary to postsurgical persistent ... · Maulana M. Ansari, ... A 30-year-old female complained of persistent abdominal pain for eight months ... Dr. Maulana

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PAIN & PAIN

PAIN & PAIN

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Jacob Binzer Signature - Kehlet Guitars

Jacob Binzer Signature - Kehlet Guitars

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(VPIA) for postsurgical pain patient-assisted intravenous

(VPIA) for postsurgical pain patient-assisted intravenous

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Neck of Femur Enhanced Recovery - Hip Fracture · Enhanced Recovery Programmes in elective surgery Professor Henrik Kehlet, Copenhagen Multimodel approach to control postoperative

Neck of Femur Enhanced Recovery - Hip Fracture · Enhanced Recovery Programmes in elective surgery Professor Henrik Kehlet, Copenhagen Multimodel approach to control postoperative

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Pain Pain Pain

Pain Pain Pain

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Genetic and Clinical Factors Associated with Chronic ... · Anesthesiology, V 122 • No 5 1123May 2015 S INCE the discussion of chronic postsurgical pain (CPSP) commenced in 1998,

Genetic and Clinical Factors Associated with Chronic ... · Anesthesiology, V 122 • No 5 1123May 2015 S INCE the discussion of chronic postsurgical pain (CPSP) commenced in 1998,

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ACaseofLate Postsurgical Hypoparathyroidism

ACaseofLate Postsurgical Hypoparathyroidism

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Rehabilitation For The Postsurgical Orthopedic Patient Mitchell Goldflies, MD

Rehabilitation For The Postsurgical Orthopedic Patient Mitchell Goldflies, MD

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Immunology: The Selenium Metabolite Methylselenol Regulates … · 2019-11-17 · Gammelgaard and Søren Skov Charlotte Gabel-Jensen, Lars Ellgaard, Bente Uhlenbrock, Stephanie Kehlet,

Immunology: The Selenium Metabolite Methylselenol Regulates … · 2019-11-17 · Gammelgaard and Søren Skov Charlotte Gabel-Jensen, Lars Ellgaard, Bente Uhlenbrock, Stephanie Kehlet,

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UCSF Dept of Anesthesia - Pain Management in Pediatric ......Pain Management in Pediatric Postsurgical Patients at MulagoHospital Kyle Sanders1, Michael Lipnick1, Mary T. Nabukenya2,

UCSF Dept of Anesthesia - Pain Management in Pediatric ......Pain Management in Pediatric Postsurgical Patients at MulagoHospital Kyle Sanders1, Michael Lipnick1, Mary T. Nabukenya2,

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The Different Types of Flaps in the Surgical Relations of the Third … · 2019-06-24 · Among the most common complications are; anxiety pre and postsurgical [100-101], pain, trismus,

The Different Types of Flaps in the Surgical Relations of the Third … · 2019-06-24 · Among the most common complications are; anxiety pre and postsurgical [100-101], pain, trismus,

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Early Cardiac Tamponade in a Patient with Postsurgical

Early Cardiac Tamponade in a Patient with Postsurgical

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Clinical Study Pain Sensation and Postsurgical ...downloads.hindawi.com/journals/isrn/2013/134210.pdf · One of the most serious complications is the alteration of sensation a er

Clinical Study Pain Sensation and Postsurgical ...downloads.hindawi.com/journals/isrn/2013/134210.pdf · One of the most serious complications is the alteration of sensation a er

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Regional Anesthesia in the Prevention of Persistent Postsurgical Pain

Regional Anesthesia in the Prevention of Persistent Postsurgical Pain

Health & Medicine
A Middle Range Theory: Chronotherapeutic Intervention for Postsurgical Pain

A Middle Range Theory: Chronotherapeutic Intervention for Postsurgical Pain

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Identifying Patients at Risk for Postsurgical Opioid-Related ......of orthopedic and gastrointestinal procedures only. Perioperative Nursing Implications: Postsurgical ORADEs are common,

Identifying Patients at Risk for Postsurgical Opioid-Related ......of orthopedic and gastrointestinal procedures only. Perioperative Nursing Implications: Postsurgical ORADEs are common,

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Short postsurgical antibiotic therapy for spinal infections ......STUDY PROTOCOL Open Access Short postsurgical antibiotic therapy for spinal infections: protocol of prospective, randomized,

Short postsurgical antibiotic therapy for spinal infections ......STUDY PROTOCOL Open Access Short postsurgical antibiotic therapy for spinal infections: protocol of prospective, randomized,

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Pain Management in Oro Valley, Tucson | Arizona Pain Care ...€¦ · Neck Pain / Shoulder Pain / Arm Pain / Hand Pain / Chest Pain / Upper Back Pain / Low Back Pain / Buttock Pain

Pain Management in Oro Valley, Tucson | Arizona Pain Care ...€¦ · Neck Pain / Shoulder Pain / Arm Pain / Hand Pain / Chest Pain / Upper Back Pain / Low Back Pain / Buttock Pain

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Cancer Pain: Etiology, Barriers, Assessment, and Treatment cancer.pdf · pain, postsurgical incisional pain, and musculoskeletal inflammation and spasm. Visceral pain is described

Cancer Pain: Etiology, Barriers, Assessment, and Treatment cancer.pdf · pain, postsurgical incisional pain, and musculoskeletal inflammation and spasm. Visceral pain is described

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©Copyright 2020 International Association for the …s3.amazonaws.com/rdcms-iasp/files/production/public/3_GY...[11] Kehlet H, Jensen TS, Woolf CJ, Persistent postsurgical pain: risk

©Copyright 2020 International Association for the …s3.amazonaws.com/rdcms-iasp/files/production/public/3_GY...[11] Kehlet H, Jensen TS, Woolf CJ, Persistent postsurgical pain: risk

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1.01.28 Postsurgical Home Use of Limb Compression Devices for Venous Thromboembolism ... · 2020. 7. 2. · Postsurgical home use of limb compression devices for VTE prophylaxis Postsurgical

1.01.28 Postsurgical Home Use of Limb Compression Devices for Venous Thromboembolism ... · 2020. 7. 2. · Postsurgical home use of limb compression devices for VTE prophylaxis Postsurgical

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Clinical Study Pain Sensation and Postsurgical …downloads.hindawi.com/archive/2013/134210.pdf · Panoramic Radiography, and Infiltration Anesthesia AliSaadThafeedAlGhamdi Faculty

Clinical Study Pain Sensation and Postsurgical …downloads.hindawi.com/archive/2013/134210.pdf · Panoramic Radiography, and Infiltration Anesthesia AliSaadThafeedAlGhamdi Faculty

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Reducing Postsurgical Wound Complications: A Critical Reviewbursement system, avoiding these postsurgical complications and their progression to chronic wounds is paramount. This article

Reducing Postsurgical Wound Complications: A Critical Reviewbursement system, avoiding these postsurgical complications and their progression to chronic wounds is paramount. This article

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Reducing Postsurgical Wound Complications: A Critical Reviewnursing.ceconnection.com/ovidfiles/00129334-201706000-00007.pdfReducing Postsurgical Wound Complications: A Critical Review

Reducing Postsurgical Wound Complications: A Critical Reviewnursing.ceconnection.com/ovidfiles/00129334-201706000-00007.pdfReducing Postsurgical Wound Complications: A Critical Review

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Esthetic and Functional REHABILITATION: A Case Report · 2/15/2016  · Ukraine) for five days, analgesics to control postsurgical pain (Nimesil, Berlin-Chemie AG, Menarini Group;

Esthetic and Functional REHABILITATION: A Case Report · 2/15/2016  · Ukraine) for five days, analgesics to control postsurgical pain (Nimesil, Berlin-Chemie AG, Menarini Group;

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