Post on 14-Jan-2016
CHRONIC PAINChapter 25
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
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
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
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
Recurrent Pain
Includes episodes of acute pain or chronic pain in which symptoms are intermittent such as migraine headache.
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
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
Pain Physiology
Pain Physiology
Gate Control Theory
Descending Inhibition
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
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
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)
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
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
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 Genetic Factors Women > Men Post-traumatic stress disorder Depression Comorbid conditions
Migraine Fibromyalgia CRPS Low Back Pain Irritable Bowel Syndrome
Lifestyle Factors
Smoking Alcohol Addiction Obesity/ Overweight Sleep disorders Vitamin D deficiency
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
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
Examination of Pain
“Fifth Vital Sign” Psychosocial aspects of pain should be
examined Examined both at rest and movement
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
Visual Analog Scale
Numeric Rating Scale
FACES
Body diagram
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
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
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
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
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
Adjuvant Medications
Anti-depressants TCA SNRI
Anti-seizure Muscle Relaxant Sleep Medications
Serotonin Syndrome
Potentially dangerous consequence of polypharmacy
Symptoms: Agitation, Anxiety, Confusion, Hypomania,
Hyperthermia, Tachycardia, Diaphoresis, Flushing, Mydriasis, Hyperreflexia, Clonus, myoclonus, shivering, tremor, and hypertonia
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
Algometer
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
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 ExerciseLeast Invasive
Most Invasive
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
Procedural Interventions
Neuromuscular Reeducation EMG Biofeedback Yoga, Tai-chi, Qigong
Assistive Device Physical and Electrotherapeutic
Modalities
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