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CHRONIC PAIN

CHRONIC PAIN. Chapter 25. Chronic Pain. Pain is the m ost common reason why people visit health care providers and physical therapists Chronic pain affects more people than diabetes, heart disease and cancer combined. Definitions of Pain.

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CHRONIC PAIN

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  1. CHRONIC PAIN Chapter 25

  2. Chronic Pain • Pain is the most common reason why people visit health care providers and physical therapists • Chronic pain affects more people than diabetes, heart disease and cancer combined

  3. Definitions of Pain • Pain is defined as an unpleasant sensory and emotional experience associated with actual or potential tissue damage • More than merely firing of nociceptive neurons but also includes perception of pain, experience of suffering and pain behavior

  4. Acute Pain • Associated with tissue damage or threat of such damage and typically resolves once the tissue heals or threat resolves • Associated with physiological signs of distress (sweating, pallor, nausea, heart rate changes) • May become persistent if cause of pain is unresolved

  5. Chronic Pain • Pain persisting more than 3 or 6 months • Long-lasting, persistent, and of sufficient duration and intensity to adversely affect a patient’s well-being, function and quality of life • Persists past the healing phase following an injury with impairment greater than anticipated based on physical findings of injury, and occurs in the absence of observed tissue injury or damage

  6. Recurrent Pain • Includes episodes of acute pain or chronic pain in which symptoms are intermittent such as migraine headache.

  7. Chronic Pain Syndrome • When individuals have developed extensive pain behaviors such as pre-occupation with pain, passive approach to health care, significant life disruption, feelings of isolation, demanding, angry, or doctor-shopping • considered a disease rather than a symptom

  8. Models of Pain • Biomedical: fix tissue damage > pain will resolve • non-organic pain/ psychogenic • pain whose physiological source could not be found • Biopsychosocial model of pain • Physical factors interact with personal and environmental factors to affect body, function and structure, activity and participation in life activities

  9. Pain Physiology

  10. Pain Physiology

  11. Gate Control Theory

  12. Descending Inhibition

  13. Peripheral sensitization • Afferent nociceptive input is increased through decreased threshold, increased responsiveness, and/or increased receptive field • d/t inflammation of peripheral tissues or neural connective tissues

  14. Central sensitization • Wind-up • repeated low-frequency nociceptor stimulation results in progressively increased action potential in dorsal horn cells • Long term potentiation • neural response is strengthened through increased neurogenic inflammation

  15. Classification of Pain • Divided by body region • Pathology: Phantom limb pain, MS or malignant (cancer) • Physiological process: nociceptive, inflammatory, neurogenic, maladaptive • Dimensions: (sensory-discriminative, motivational-discriminative, cognitive-evaluated)/ (nociception, pain cognition, suffering and pain behavior)

  16. Classification of Pain (Dimensions) • Sensory-Discriminative • localization, intensity, duration and nature of pain (burning, sharp and so forth) • Motivational-affective dimension • emotional response, physiological manifestations • Cognitive-affective • How pain is interpreted in context of past and present experience

  17. Classification of Pain • Nociceptive Pain • response to an immediate noxious stimulus (mechanical, thermal or chemical) • protective withdrawal response • Inflammatory Pain • increase sensory sensitivity after tissue damage • Maladaptive pain • abnormally functioning nervous system relaying pain signals unrelated or disproportional to tissue damage

  18. Causes and Risk Factors for Pain • Genetic Factors • Women > Men • Post-traumatic stress disorder • Depression • Comorbid conditions • Migraine • Fibromyalgia • CRPS • Low Back Pain • Irritable Bowel Syndrome

  19. Lifestyle Factors • Smoking • Alcohol Addiction • Obesity/ Overweight • Sleep disorders • Vitamin D deficiency

  20. Psychosocial Factors • Pain Beliefs and Coping • Anxiety and Fear Avoidance • Catastrophizing • pessimism, helplessness to control symptoms, magnification, and rumination (excessive focus on pain sensations) • Depression and Grieving • Stress • Non-organic Findings

  21. Psychosocial Factors • Non-organic Findings(Waddell signs) • Superficial or Nonanatomical tenderness • Pain in response to simulation tests • Inconsistent response to distraction • Regional sensory and strength impairments • Overreaction • Personality disorders • Borderline, Histrionic, OCD = poorer prognosis, • Social Support

  22. Examination of Pain • “Fifth Vital Sign” • Psychosocial aspects of pain should be examined • Examined both at rest and movement

  23. Examination of Pain • Standard Tools for Quantifying pain: • Visual Analogue Scale (VAS) • Numeric Rating Scale (NRS) • Verbal Rating Scale (VRS) • Faces Scale – children over 3 years old • Body diagram: pain location, radiation and character; more time consuming to administer

  24. Visual Analog Scale

  25. Numeric Rating Scale

  26. FACES

  27. Body diagram

  28. Pain Questionnaires and Outcome Measures • McGill Pain Questionnaire (MPQ) / Short form MPQ • examine sensory, affective, emotional, evaluative and temporal aspects of pain • Leads Assessment of Neuropathic Symptoms and Signs (LANSS) • distinguishes between neurogenic and nociceptive pain • Neuropathic Pain Scale • disinguishes between neuropathic and non-neuropathic pain

  29. Pain Questionnaires and Outcome Measures • Brief Pain Inventory (BPI) • initially designed for cancer-related pain • rates pain interference with functional activities such as walking, activity, normal work, relations with other people, mood, sleep and enjoyment of life

  30. Tools for Specific Type of Pain • Western Ontario and McMaster University Osteoarthritis Index (WOMAC) • Oswestry Low Back Pain Disability Questionnaire for LBP • Revised Fibromyalgia Impact Questionnaire (FIQR) • Headache Impact Test • Von Frey Filaments – pain treshold

  31. Examination of Pain in Special Populations • Children • FACES • Pieces of Hurt Scale • Crying, Requires increased oxygen administration, Increased Vital Signs, Expression, Sleeplessness (CRIES) Pain scale: 0-6 months • Face, Legs, Activity, Cry, Consolability Scale (FLACC): for infants and Children 2 months to 7 years • COMFORT Pain Scale – Unconscious ventilated infants, children, adolescents

  32. Pharmacological Management of Chronic Pain • Tx starts with acetaminophen and proceeds to NSAIDs • Adjuvant Medications • medications whose primary indication is a condition other than pain, but which have demonstrated benefit in pain management • Muscle Relaxants and Weak Opiates

  33. Adjuvant Medications • Anti-depressants • TCA • SNRI • Anti-seizure • Muscle Relaxant • Sleep Medications

  34. Serotonin Syndrome • Potentially dangerous consequence of polypharmacy • Symptoms: • Agitation, Anxiety, Confusion, Hypomania, Hyperthermia, Tachycardia, Diaphoresis, Flushing, Mydriasis, Hyperreflexia, Clonus, myoclonus, shivering, tremor, and hypertonia

  35. PT Examination • Tests and Measurements • Body Structure and Function Measure • Palpation for tenderness (tissue damage, muscle spasm, trigger points, hyperalgesia and allodyina) • Algometer: Measures palpation pressure • Pressure Pain Treshold(PPT): point at which pressure changes from comfortable pressure to slightly unpleasant pain • Trigger points: ropelike tautbands within a muscle fiber • Local twitch response, transient contraction, jump response • Examination of balance

  36. Algometer

  37. PT Examination • Activity and Participation Measures • Revised Fibromyalgia Impact Questionnaire • Oswestry Low Back Pain Disability Questionnaire • Patient Specific Functional Scale (PSFS) • Activity Specific Balance Confidence Scale • Physical activity measures: • 30-second Sit to Stand Test • Timed up and go test • Short Physical Performance Battery Test

  38. PT Management of Chronic Pain Neuroblation Implanted Spinal Analgesia Implanted Spinal Cord Stimulation Strong Opioids Weak Opioids Cognitive and Behavioral Therapies Adjuvant Medications PT and OT OTC Medications Independent Exercise Most Invasive Least Invasive

  39. Procedural Interventions • Therapeutic Exercise • Graded Exercise: decreasing fear avoidance • No one type of exercise is superior to others • Individual patients may tolerate and respond to some forms of exercise better than others • Manual Therapy • Manipulation, Muscle Energy Techniques

  40. Procedural Interventions • Neuromuscular Reeducation • EMG Biofeedback • Yoga, Tai-chi, Qigong • Assistive Device • Physical and Electrotherapeutic Modalities

  41. Thank you for listening

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