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Nancy Wiedemer,CRNP Pain Management Coordinator Philadelphia VA Medical Center

Not all pain is the same: implications for assessment and treatment. Nancy Wiedemer,CRNP Pain Management Coordinator Philadelphia VA Medical Center nancy.wiedemer@med.va.gov. Assessment and Treatment of Pain:Issues and Challenges.

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Nancy Wiedemer,CRNP Pain Management Coordinator Philadelphia VA Medical Center

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  1. Not all pain is the same: implications for assessment and treatment Nancy Wiedemer,CRNP Pain Management Coordinator Philadelphia VA Medical Center nancy.wiedemer@med.va.gov

  2. Assessment and Treatment of Pain:Issues and Challenges • Underassessment and undertreatment • Interpatient variability • Patient not believed • OPIOIDS • Complex pathophysiology

  3. Defining Pain Arthritis Spinal Stenosis Failed Back Neuropathy DM,PHN,HIV,post CVA Cancer Acute Chronic < episodic < persistent End of life Pain Mechanisms

  4. Defining Pain By definition…… a disease process alters the way a system or organ system responds to different types of homeostatic processes within the body. • Hypertension Chronic Disease • Diabetes • Chronic Pain

  5. Biopsychosocial Model of Pain

  6. Suffering People suffer from what they have lost of themselves….. it continues until the threat of disintegration has passed or until the integrity of the person can be restored in some other manner. Eric J Cassel, NEJM , 1982

  7. Cascade of negative emotions experienced by health care providers Inadequacy Helplessness Frustration Anger Gallagher,2004

  8. PAIN is a sensory processing system with a known anatomy and physiology WHAT IS PAIN?

  9. Overview of Pain Perception

  10. Nociceptive Pain • Transient pain in response to a noxious stimuli • Key early warning – Alarm system • Announces the presence of a potentially damaging stimulus Woolf,CJ Ann Internal Med 2004;140:441-451

  11. Histamine Prostaglandin Substance P Serotonin Bradykinin Glutamate • Tissue damage  edema  activation of mechanoreceptors Release of chemicals from mast cells and injured nociceptors Woolf,CJ Ann Internal Med 2004;140:441-451

  12. SOMATIC Well-localized Aching,throbbing, gnawing bone joints soft tissue muscle skin VISCERAL Poorly localized Deep aching, cramping,pressure, Referred Bowel obstruction Biliary colic liver pain appendix Nociceptive Pain

  13. NEUROPATHIC PAIN

  14. Neuro- plasticity Ectopic discharge Central sensitization Ectopic discharge Alteration of modulatory systems Phenotypical Changes Spinal cord Afferent fibers Nerve injury C fiber A beta fiber Woolf & Mannion, Lancet 1999 Attal & Bouhassira, Acta Neurol Scand 1999

  15. Central Sensitization

  16. Overview of Pain Perception

  17. Modulation of Pain Perception Antinociceptive system Serotonin Neurepinephrine Endorphins Enkephalins Opioids GABA Opioids Endorphins Enkephalins Receptor sites

  18. Neuropathic Pain: injury to peripheral nerves and/or CNS • Burning • Stinging • Shooting • Lancinating • Pins and needles • Vicelike • Electric • Tingling

  19. Focus of medical attention is often centered on nerve/disc/bony relationship Little to no attention is given to the soft tissue that supports and binds the spine The Myofascial System • Guarded movements • Pelvic tilt when standing • Limited flexion and extension in • the spine • Paraspinal tenderness • Trigger points – active or latent

  20. Myofascial Pain • Deep aching pain • Burning or stinging sensation • Restricted movement in involved areas • Muscle spasms • Trigger points- feel indurated to palpation • Taut muscle bands

  21. VA Clinician 

  22. Pain Assessment • What is the pain generator ? • What is the pain mechanism ? • Nociceptive • Neuropathic • Myofascial • Mixed

  23. Pain Assessment • Are there pain amplifiers ? • Anxiety • Depression • PTSD • Substance Abuse Disorder

  24. Tumors Fractures Infection Cauda Equina Syndrome Factors that may impede recovery: Emotional state Fear-avoidance beliefs Poor coping strategies Are there RED FLAGS ????? Linton,SL & Boresma,K,2003

  25. History and Physical Exam • Events at pain onset • Pain: • site & radiation • quality • intensity (numeric score 0-10) • temporal pattern • provocations & sources of relief • Activities and functional limitations • Sleep disruption • Previous therapies

  26. Conclusions Chronic Pain ↔ Chronic Disease Chronic Disease Management Approach based on Biopsychosocial Model

  27. Conclusions • Not all patients with the same pain diagnosis have the same pain mechanisms • Different mechanisms can coexist • Treatment approaches that target each pain generator can improve outcomes

  28. Conclusions Secondary prevention depends on early and aggressive assessment and management of pain

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