pain management

A Brief Intro to:

PAIN CLASSIFICATION AND MANAGEMENT

JOSH LEIGH, SPT

Mission Statement:

Today we will discuss the prevalence, identification, measurement/documentation, and briefly touch on basic treatment of acute and chronic pain found in an inpatient setting.

IN-SERVICE OBJECTIVES: A NEURO REVIEW!

1. Prevalence of Pain in the inpatient settingIdentification of pain “Ouch that hurts…wait…what hurts?!”

Classification of pain “How do we feel pain?”

Quantitative Measurement of Pain “Documentation review!”

2. Review of Basic Acute Treatment Techniques

TABLE OF CONTENTS

Question 1: True or False, activation of A-Beta aff erents can relieve pain through the Gait Theory of Pain control.

Question 2: True or False, A verbal Pain rating Scale is as eff ective as a visual pain rating scale.

Question 3: True or False, Ice will cause inhibition of GTO’s and relax muscles through A-beta input.

PRE TEST

PR

EV

AL

EN

CE

OF

PA

IN

JCAHO standards (http://WWW.jcaho.org) that address the importance of pain assessment are:

PE.1.4: Pain is assessed in al l patients. RI.1.2.8: Patients have the r ight to appropriate

assessment and management of pain

Almost one fi fth of hospitalized patients in an do not receive adequate pain relief.

Jabusch et al. (2014)

1. Musculoskeletal (somatic) Pain Acute Recent Onset: short lived, limited to the proliferation

phase of tissue repair. Chronic Pain (Greater than 3-6 months)

Hyperalgesia: Painful stimuli present as far more painful Allodynia: React to a non-painful stimuli w/ painful response

2.Referred (Visceral) Pain: Pain is perceived on a body segment distant from source of pain

3. (Neuropathic) Phantom Pain

*(CRPS) Sympathetic Refl ex Dystrophy* Complex regional Pain Syndrome: Autonomic N. System

IDENTIFICATION: “OUCH THAT HURTS…WAIT…WHAT HURTS?!”

Specifi city Theory: Special receptor for each type of pain. Problem: Doesn’t account for the severity of pain

Pattern Theory: Not about receptor, its about coding for the stimulation Problem: Doesn’t account for the different types of perceived

pain

Gate Control Theory Pain Perception depends on a balance of sensory input from nonociceptive and nociceptive afferents Explains: Descending controls from the cortex, limbic system,

brainstem, and midbrain. Problem: Doesn’t fully explain differences in pain perception

between individuals. Placebo effect?

CLASSIFICATION: HOW DO WE FEEL PAIN?

Keep in mindExtent/Nature of InjuryEmotional states (positive, depression, relaxation,

rest)Cognitive states (focusing on pain, Boredom)Lack of ExercisePhysical Conditions (medication, Counterstimulation)

GAIT THEORY

Neuromatrix Theory: (Melzack and Wall) Physical, psychological, cognitive traits, and experience.

Central Biasing Theory: Personal learned behavior, conditive eff ects sensory discrimination, location of pain source and intensity/nautre of pain. Think reff erred pain/lbp Internal drive or external stimulation Think placebo effect

Endogenous Opiates Theory (6-8hrs of pain relief!)

FEW MORE THEORIES WE WILL INCLUDE

Anterolateral System (ALS): Conscious levels/touch/constant Direct

Lateral Spinothalamic Anterospinothalamic

Indirect Spinoreticulothalamic

A delta Fibers: 30m/sC Fibers 1-4m/sA beta Fibers: 20-90m/s

SPINAL CORD PAIN TRACTS

Paleospinothalamic/Archispinothalamic Tract More diffuse C fibers

ascend bilaterally, don’t reach the cortex

Terminate in brainstem/limbic system: not for conscious perception of pain, limbic system is emotional aspect of pain Reticulospinal tract:

Autonomic Nervous System response to pain fight/fl ight

PATHWAYS EMOTIONAL PAIN

Pain Neurotransmitters: Substance P, NGF, SHT (seratonin receptors), Aradaonic Acid,

HistamineAxon Refl ex

Mast Cells Release Histamine and cause substance P to be released

A-delta: Synapse I+V second order neurons, cross in anterior white

commissure, ascend contralaterally to VPL, 3 rd order to cortex.C-Fibers

Synapse at lamina II (substantia gelatinosa), ascends in ventral ventral spinal thalamic tract, ascends contrallaterally to VPL

As the neuron comes in before 2nd order synapse ascends and descends several segments ipsilaterally in the dorsal tip aka Lissauer’s tract.

MAJOR PAIN COMPONENTS

You can Block Pain by Causing Pain A Beta input via gate theory A Delta Stim: Strong/fast stim for opiate production C Fiber Stim: Prolonged sub max endorphin release Maximize central biasing

Endogenous opiate theory/Descending Neurotransmitters Endorphins Enkephalins Serotonin Norepinephrine

Hyperirritability Decreased threshold, increased efferent,

viserosomatic/somatovisceral, spasm cycle

PAIN CONTROL RESPONSES

Reticular Formation*Raphe Nucleus (spinal tract): Production of Seratonin

*Pons: noepinephrine*Periaqueductal Grey Matter: PAGM: sends fibers down to dorsal grey horn

*Limbic System: Emotions, release opiodes

**stimulate Dorsal Grey Horn to release Enkephalin**

THE BRAIN: CENTRAL PAIN SUPPRESSION

Numerical Rating scale (0-10)

Verbal rating scale (4 levels)

Visual analogue scale (0-100)

Ransford Body Drawings

Pressure Algometers

Comparison to Pre-determined stimuli

Brief Pain Inventory (9)

McGil l Pain Questionaire

MMPI-2 (Minnesota Multiphasic Personality Inventory)

QUANTITATIVE MEASURE FOR PAIN

Hjermstad, M., Fayers, P., & Haugen, D. et al. (2011). Studies Comparing Numerical Rating Scales, Verbal Rating Scales, and Visual Analogue Scales for assessment of pain intensity in Adults: A Systematic Literature Review. Journal of Pain and Symptom Management, 41-6, 1073-1093.

NRS (Numerical Rating Scale)**

Ransford body diagrams

VRS (Verbal Rating Scale)**

Pressure Algometers

PGIC (Patient Global Impression of Change)

UNIDIMENSIONAL PAIN SCALES

McGill Pain Questionnaire (short form)** Sensory terms (sharp/stabbing) Affective Terms (sickening/fearful) 4 pt scale none-severe VAS for Intensity and Experiance

Brief Pain inventory Short form** (17 items) Sensory Intensity of Pain Degree which pain interferes in the Patients life Location, medications, response to past Rx

West Haven-Yale Multidimensional Pain Inventory LONG 52 items/12 subscales self perception

Classify patients dysfunctional, interpersonally depressed, or adaptive copers

Treatment Outcomes of Pain Survey

MMPI-2 (Hypochondriasis, depression, hysteria, psychopathic deviate, paranoia, psychasthenia, schizophrenia, hypomania)

MULTI-DIMENSIONAL PAIN SCALES

1. Manual Techniques for Pain Control Joint Mobilization (Grade I)Massage/Myofacial Release/Trigger Point Therapy

Positioning and Posture2. Stretching/Exercise for Pain Control

Dosing for pain control3. Physical Agents for Pain Control

Ice vs HeatKinesiotape

4. Physiological Component of Pain Control

BASIC TREATMENT TECHNIQUES

MA

NU

AL T

EC

HN

IQU

ES

F

OR

PA

IN C

ON

TR

OL

1. Joint Mobilization

2. Massage

3. Positioning and Posture

Possible tumor or infection Age >50YRS HX of Cancer Constitutional sx: Recent Fever, Chills, Unexplained weight-

loss Risk factors for spinal infection

Recent bacterial infection (UTI) IV drug abuse/immune suppression Steroids, Transplant, HIV

Pain that worsens when supine, severe nighttime pain Possible Fx

Major trauma, MVA Minor Trauma/Strenuous lifting in older/osteoporotic patient

Cauda Equina

GENERAL PAIN RED FLAGS

The “Bread and Butter” of PTDosing for Pain ControlPain free vs Pushing through pain

Appropriate POC Sequencing

STRETCHING & EXERCISE FOR PAIN CONTROL

Posture and LBP

POSITIONAL EFFECT ON PRESSURE

CARRY-OVER TO EXERCISE ACTIVITY

INTRADISCAL PRESSURES RELATED TO ACTIVITY

PH

YS

ICA

L A

GE

NT

S F

OR

PA

IN C

ON

TR

OL

1. Ice Analgesia: suppressed nerve conduction

velocity Decreased metabolism: decreased release of

noxious chemicals

Vasoconstriction: Deceased edema

Histamine action on capillary permeability

2. Heat

Analgesia: Increased nerve conduction velocity

Increased Metabolism: Increase in noxious chem

Vasodilation: Increases Edema but…

Also promotes Re-absorption

Viscoelastic Properties

Analgesia:GTO stimulation for muscle inhibition

3. Kinesiotape/Surface Taping

A-Beta input

Proprioceptive Feedback

Indications: Inflammation control, Pain control, spasticity control, facilitation (quick icing),

MS management, Cryokinetics

Contraindications: Cold Hypersensitivity (urticaria), Cold Intolerance, Cryoglobulinemia,

Hemoglobinuria, raynaud’s disease, Regenerating peripheral nerve, PVD Precautions

Superficial Branch of a Nerve, Open Wound, HTN, Poor Sensation, Poor Mentation, Age (poor temp control)

Adverse Rxn’s Frostbite, Nerve damage Hunting Reaction (rapid vasodilation, systemic shock)

Physiological eff ects Hemodynamic Neuromuscular Metabolic

ICE: THE COLD STUFF

Rate of Transfer= (area in contact)(temp diff )(Thermal Condu)

---------------------------------------------------------------------------------------------------------------------------------------------------------------

(Thickness of the tissue)

Conduction/Convection/Conversion/Radiation

Contraindications: Acute Stage( inflammation, hemorrhage, thrombophlebitis),

impaired sensation/mentation, malignancy, fever Precautions

Acute stage, pregnancy, impaired circulation, poor thermal regulation, edema, cardiac insuffi ciency, metal, open wound, demyelinated nerves

Adverse eff ects Burns, Bleeding, Fainting

HEAT: THE HOT STUFF

PS

YC

HO

LO

GIC

AL

CO

MP

ON

EN

T O

F P

AIN

CRPS

Back-Pain

Fibromyalgia

Chronic pain

ETOH/Substance Abuse Patients

Question 1: True or False, activation of A-Beta aff erents can relieve pain through the Gait Theory of Pain control.

Question 2: True or False, A verbal Pain rating Scale is as eff ective as a visual pain rating scale.

Question 3: True or False, Ice will cause inhibition of GTO’s and relax muscles.

POST TEST

Hj e rmstad , M . , Fayers , P. , & Haugen , D . e t a l . ( 2011 ) . S tud i es Compar i ng Numer i ca l Ra t i ng Sca l es , Ve rba l Ra t i ng Sca les , and V i sua l Ana logue Sca l es f o r a ssessment o f pa in i n tens i t y i n Adu l t s : A Sys temat i c L i t e ra tu re Rev iew. J ou rna l o f Pa i n and Symptom Management , 41 -6 , 1073 -1093 .

Daut RL , C l ee l and CS , F l ane ry RC . Deve lopment o f the Wi scons in B r i e f Pa in Ques t i onna i re t o assess pa in i n cancer and o ther d i seases . Pa i n 1983 ;17 :197e210 .

Me l zack R. The McG i l l Pa in Ques t i onna i re : ma jo r p roper t i es and sco r i ng methods . Pa in 1975 ;1 : 277e299 .

Neurosc i ence : Fundamenta l s f o r Rehab i l i t a t i on . Lundy-Ekman, L . W. B . Saunders Company.

Pr i nc i p l es o f Neura l Sc i ence . Kande l , K . R. , Schwar t z , J . H. , & B . J e sse l . McGraw H i l l , 2000 .

Neurosc i ence f o r Rehab i l i t a t i on . Cohen , H. L i p i nco t t Wi l l i ams & Wi l k i ns , 1999 .

C l i n i ca l Neuroana tomy f o r Med i ca l S tudents . Sne l l , R. L i p i nco t t Wi l l i ams & Wi l k i ns . 2001 .

C l i n i ca l Neuro l ogy.S i mon , R. P. , Aminoff , M . J . , & Greenberg , D . A . Lange / McGraw H i l l , 1999 .

Younger , J . , McCue , R. , & Mackey , S . ( 2009 ) Pa i n outcomes : A B r i e f rev i ew o f I ns t ruments and Techn i ques , Curr Pa in Headache Rep , 13 (1 ) : 39 -43 .

Cameron , M . H. ( 2013 ) . Phys i ca l agent s i n rehab i l i t a t i on . F rom resea rch to p rac t i ce ( 4 th ed . ) . S t . Lou i s , MO: Saunders E l sev i e r.

REFERENCES