Transcript CHRONIC PAIN

CHRONIC PAIN
Chapter 25
Chronic Pain
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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
Definitions of Pain
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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
Acute Pain
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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
Chronic Pain
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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
Recurrent Pain
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Includes episodes of acute pain or chronic pain in
which symptoms are intermittent such as migraine
headache.
Chronic Pain Syndrome
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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 doctorshopping
considered a disease rather than a symptom
Models of Pain
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Biomedical: fix tissue damage > pain will resolve
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non-organic pain/ psychogenic
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pain whose physiological source could not be found
Biopsychosocial model of pain
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Physical factors interact with personal and environmental
factors to affect body, function and structure, activity and
participation in life activities
Pain Physiology
Pain Physiology
Gate Control Theory
Descending Inhibition
Peripheral sensitization
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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
Central sensitization
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Wind-up
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repeated low-frequency nociceptor stimulation results
in progressively increased action potential in dorsal
horn cells
Long term potentiation
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neural response is strengthened through increased
neurogenic inflammation
Classification of Pain
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Divided by body region
Pathology: Phantom limb pain, MS or malignant
(cancer)
Physiological process: nociceptive, inflammatory,
neurogenic, maladaptive
Dimensions: (sensory-discriminative, motivationaldiscriminative, cognitive-evaluated)/ (nociception,
pain cognition, suffering and pain behavior)
Classification of Pain (Dimensions)
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Sensory-Discriminative
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Motivational-affective dimension
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localization, intensity, duration and nature of pain
(burning, sharp and so forth)
emotional response, physiological manifestations
Cognitive-affective
 How
pain is interpreted in context of past and present
experience
Classification of Pain
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Nociceptive Pain
response to an immediate noxious stimulus (mechanical,
thermal or chemical)
 protective withdrawal response
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Inflammatory Pain
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increase sensory sensitivity after tissue damage
Maladaptive pain
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abnormally functioning nervous system relaying pain signals
unrelated or disproportional to tissue damage
Subjective and Objective Characteristics Associated with Different Types of Pain and Soft
Tissue Sources
Type of Pain Tissue Source
Subjective
Objective
Nociceptive:
Cutaneous/
Superficial
Skin and Subcutaneous tissues
(A fibers)
Well-localized,
stabbing, burning,
cutting
Clear, consistent
proportional pain
Nociceptive:
Deep
Somatic
Bone, muscle, blood vessels,
conncective tissue (C fibers)
Often referred to
other locations,
tearing, cramping,
pressing, aching
Vague, sometimes
referred pain
reproduced through
movement or
mechanical testing of
deeper tissues, trigger
points
Nociceptive
Visceral
Organs and linings of body
cavity (C fibers)
Often referred to
other locations; poorly
localized, diffuse,
deep cramping or
splitting sharp,
stabbing
Vague pain
reproduction on
movement or
mechanical testing of
visceral tissues
Subjective and Objective Characteristics Associated with Different Types of Pain and Soft
Tissue Sources
Type of Pain Tissue Source
Subjective
Objective
Peripheral
Neurogenic
Nerve fibers
Pain variously described as
burning, shooting, sharp,
aching, “electric like”
Pain symptoms
provocation with
movement or
mechanical tests that
move, load or compress
neural tissues
Central
Spinal Cord and Central
Nervous system
Disproportionate,
nonmechanical,
unpredictable pattern of
pain provication in response
to multiple nonspecific
aggravating or easing
factors
Disproportionate,
inconsistent,
nonmechanical or
nonanatomical pattern
of pain provocation in
response to movement
or mechanical testing
Causes and Risk Factors for Pain
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Genetic Factors
Women > Men
Post-traumatic stress disorder
Depression
Comorbid conditions
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Migraine
Fibromyalgia
CRPS
Low Back Pain
Irritable Bowel Syndrome
Lifestyle Factors
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Smoking
Alcohol Addiction
Obesity/ Overweight
Sleep disorders
Vitamin D deficiency
Psychosocial Factors
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Pain Beliefs and Coping
Anxiety and Fear Avoidance
Catastrophizing
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pessimism, helplessness to control symptoms, magnification,
and rumination (excessive focus on pain sensations)
Depression and Grieving
Stress
Non-organic Findings
Psychosocial Factors
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Non-organic Findings (Waddell signs)
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Personality disorders
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Superficial or Nonanatomical tenderness
Pain in response to simulation tests
Inconsistent response to distraction
Regional sensory and strength impairments
Overreaction
Borderline, Histrionic, OCD = poorer prognosis,
Social Support
Examination of Pain
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“Fifth Vital Sign”
Psychosocial aspects of pain should be examined
Examined both at rest and movement
Examination of Pain
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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
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Visual Analog Scale
Numeric Rating Scale
FACES
Body diagram
Pain Questionnaires and Outcome Measures
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McGill Pain Questionnaire (MPQ) / Short form MPQ
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Leads Assessment of Neuropathic Symptoms and Signs
(LANSS)
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examine sensory, affective, emotional, evaluative and
temporal aspects of pain
distinguishes between neurogenic and nociceptive pain
Neuropathic Pain Scale
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disinguishes between neuropathic and non-neuropathic pain
Pain Questionnaires and Outcome Measures
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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
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Tools for Specific Type of Pain
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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
Examination of Pain in Special Populations
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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
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Pharmacological Management of Chronic Pain
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Tx starts with acetaminophen and proceeds to
NSAIDs
Adjuvant Medications
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medications whose primary indication is a condition
other than pain, but which have demonstrated benefit
in pain management
Muscle Relaxants and Weak Opiates
Adjuvant Medications
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Anti-depressants
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TCA
SNRI
Anti-seizure
Muscle Relaxant
Sleep Medications
Serotonin Syndrome
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Potentially dangerous consequence of polypharmacy
Symptoms:
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Agitation, Anxiety, Confusion, Hypomania,
Hyperthermia, Tachycardia, Diaphoresis, Flushing,
Mydriasis, Hyperreflexia, Clonus, myoclonus, shivering,
tremor, and hypertonia
PT Examination
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Tests and Measurements
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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
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Local twitch response, transient contraction, jump response
 Examination
of balance
Algometer
PT Examination
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Activity and Participation Measures
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Revised Fibromyalgia Impact Questionnaire
Oswestry Low Back Pain Disability Questionnaire
Patient Specific Functional Scale (PSFS)
Activity Specific Balance Confidence Scale
Physical activity measures:
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30-second Sit to Stand Test
Timed up and go test
Short Physical Performance Battery Test
PT Management of Chronic Pain
Neuroblation
Implanted Spinal Analgesia
Most Invasive
Implanted Spinal Cord Stimulation
Strong Opioids
Weak Opioids
Cognitive and Behavioral Therapies
Adjuvant Medications
PT and OT
OTC Medications
Independent Exercise
Least Invasive
Procedural Interventions
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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
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Manual Therapy
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Manipulation, Muscle Energy Techniques
Procedural Interventions
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Neuromuscular Reeducation
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EMG Biofeedback
Yoga, Tai-chi, Qigong
Assistive Device
Physical and Electrotherapeutic Modalities
Thank you for listening