Pain in Long Term Care: It Takes a Team
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Pain in Long Term Care:It Takes a Team
Department of Medicine, Anesthesiology & PsychiatryUniversity of Pittsburgh
Geriatric Research Education & Clinical Center VA Pittsburgh Healthcare System
Debra K. Weiner, M.D.
January 24, 2013
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DISCLOSURE
• No conflict of interest
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Learning Objectives
1. Understand the drivers of pain behaviors in long term care (LTC) residents.
2. Formulate an interdisciplinary approach to identifying, treating and tracking the LTC resident’s unique pain signature.
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Principles of Pain in LTC
• Principle #1: Most pain that nursing home residents experience is chronic.
• Chronic pain:– Lasts beyond the expected time of healing– > 3-6 months
• Corollary: Since chronic pain cannot be eradicated, residents will continue to report/manifest pain even after it is treated well.
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• 10 clinical trials, 2724 subjects• DPN, PHN, CLBP, FM, OA• “much improved” or “very much improved”
correlated with 30% or 2 point decrease
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Who are we evaluating/treating?
Impaired reporters
Impaired non-reporters
Intact
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Principles of Pain in LTC
• Principle #2: If a LTC resident can speak, (s)he can usually report pain reliably.
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Pain Thermometer(verbal descriptor scale)
NO PAIN
LITTLE PAIN
MODERATE PAIN
QUITE BAD PAIN
VERY BAD PAIN
THE PAIN IS ALMOST UNBEARABLE
Weiner 1998; Aging Clin Exp Res 10: 411-20
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Weiner 1998; Pain 76: 249-57
• N = 60 LTC residents• MMSE = 21 (6-30)• Test-retest: 1 hour• Kappa: 0.6-0.9
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Pain Behaviors
• Pain reporting• Body posturing or facial expressions that
imply a patient is experiencing pain• Interactive behaviors
– Social behaviors– Cooperation with staff
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Pain Behaviors: Those Unable to Report Pain
• Body posturing or facial expressions that imply a patient is experiencing pain
• Interactive behaviors– Social behaviors– Cooperation with staff
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PAINAD (Pain Assessment in Advanced Dementia)
1. Breathing independent of vocalization2. Negative vocalization3. Facial expression4. Body language5. Consolability
0-10 scaleSummary score based on 5 items, 0-2 each
Warden 2003; J Am Med Dir Assoc 4: 9–15
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PACSLAC(Pain Assessment Checklist for Seniors with
Limited Ability to Communicate)
• 60 items• 4 categories
– Facial Expression– Activity/Body Movement– Social/Personality/Mood– Other (Physiological Changes/Eating &
Sleeping Changes/Vocal Behavior)
Fuchs-Lacelle 2004; Pain Manage Nurs 5: 37-49
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Principles of Pain in LTC
• Principle #3: Behavioral indicators of “pain” may or may not indicate that a patient is experiencing pain.
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CLBP Pain-freeCognitively Intact 1 2
Mild-ModAlzheimer’s 3 4
Shega et al 2008; J Am Geriatr Soc 56: 1631-7
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Long leg sit
Bridging
Lying Prone
Supine to sit
Weiner et al 1996; Pain 67: 461
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Pain Behavior
Means (SD)Effect Size Univariate
PPain-free CLBP
Guarding 2.39(2.32)
3.83(2.84)
0.56 0.02
Bracing 4.78(5.29)
5.83(7.05)
0.17 0.42
Grimacing 1.02(1.48)
3.04(2.85)
0.93 <0.001
Sighing 0.54(0.89)
0.48(0.73)
0.07 0.77
Rubbing 0.72(1.54)
1.09(2.04)
0.21 0.32
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Pain Behavior
Means (SD)Effect Size Univariate
PCog. Intact
Dementia
Guarding 2.00(2.28)
3.58(2.62)
0.65 0.01
Bracing 6.39(7.17)
4.10(4.47)
0.39 0.03
Grimacing 1.67(2.49)
1.71(2.04)
0.02 0.72
Sighing 0.39(0.80)
0.63(0.85)
0.29 0.20
Rubbing 0.03(0.18)
1.50(2.10)
1.29 <0.001
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Principles of Pain in LTC
• Principle #4: The presence of pain should not be interpreted as the presence of suffering.
• Corollary: Treat pain if it is causing suffering (i.e., impairing function or quality of life).
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Case
• ID/CC: 80 year old LTC resident who “reports pain.”
• HPI: Patient without complaintsNo pain behaviorsCall placed to LTC staff: “Patient does not
talk about pain or appear to suffer from pain…..Just reports when we ask.”
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“Why was the consult placed?”“Resident continues to report pain.”“Is either he or the staff disturbed by this
reporting?”“No.”“Would the staff be comfortable with not
treating the resident as long as they know he is not suffering?”
“Yes.”
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• Rx: Staff reassurance
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Principles of Pain in LTC
• Principle #5: People with dementia process pain differently than those who are cognitively intact.
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sensory-dis criminative(nociceptiv e channel)motivationa l-affectivecognitiveprocessesdescendingmodulatory influences+/-skin
musclejointsviscera spinal cord
sensory-discriminative(nociceptive channel)
motivational-affective
cognitiveprocessesdescending
modulatoryinfluences
+/- NE , 5-HT, glut,NMDA, GABA
skin
muscle
joints
viscera spinal cord
What is Pain?
PCPRPittsburgh Centerfor Pain Research
Slide used with permission from Gerald F. Gebhart, PhD, Director, PCPR
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Pain-related brain activity: AD vs. controls
Cole et al 2006; Brain 129, 2957
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Facial Expression versus Verbal Rating of Pain
• Experimental pain (mechanical)• N = 96 (42 demented; 54 intact)• Verbal rating: none, mild, moderate,
strong, very strong, extremely strong• Facial expression: video, rated with Facial
Action Coding System
Kunz 2007; Pain 133: 221-228
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Kunz et al, Pain 2007; 133: 221-228
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Kunz et al, Pain 2007; 133: 221-228
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AD & Facial response to acute pain
General anxietyFear of needle sticksPre-venipuncture anxiety
Porter et al 1996; Pain 68, 413
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IMPLICATIONS
• Standard behavioral manifestations of pain may overestimate pain severity in those with dementia
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PAINBEHAVIORSe.g. verbal pain reports
grimacingcrying for help
General signalsof distress
Pain perseveration
Pain-related suffering
?
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Case
• ID/CC: 82 y.o., LBP/R leg pain X 2 yrs., SS on MRI
• HPI: Forced to retire 2 years ago. Pain is worse with standing, walking, OK at night, better with heat, no constitutional symptoms. Increasing trouble with heavy housework, afraid to go on bus by self. Reports passive suicidal ideations. Frequent near falls at home.
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• PE: – Poor balance– Impaired clock-drawing test– Kyphoscoliosis, SI/ paraspinal/ TFL pain– Leg strength impaired from pain.
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Medications• Gabapentin• Oxycodone CR• Celecoxib• Tramadol• Olanzapine• Escitalopram• Lorazepam
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What We Prescribed
• Short NH stay for detox. and balance/gait retraining.
• D/C’ed on tramadol + acetaminophen. • Did very well while in NH.• Recommendation to family: Assisted
Living placement, but family refused and continued to focus on pain
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Following Discharge…
• Immediate deterioration at home with frequent calls
• Escalation of need for analgesics.• Her condition continued to deteriorate
(eventual morphine pump trial), until she was admitted to an assisted living facility, where she did well.
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Case
• ID/CC: 85 y.o. veteran whose PCP notes, “Patient continues to report pain.”
• HPI: Obtained from wife of 60 years, as patient unable to provide history because of advanced dementia. Low back pain present for many years; as patient always acknowleged pain when asked by health care providers, analgesic trial ended with fentanyl.
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• Because of no change in clinical status, dose was escalated to 100 mcg/hr and patient became comatose and was hospitalized.
• In hospital, dose was weaned back to 50 mcg/hr and patient woke up and when asked about pain, he reported it.
• Presented to Pain Clinic. When wife asked whether patient was suffering from or reporting pain: “He’s just talking about it.”
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• PE: NAD, sitting in wheelchair with wife and daughter at side; pleasant, smiling. When asked if anything bothering him, he smiled widely: “No.”
• Rx: 1. Taper fentanyl to off; 2. Day care for distraction and caregiver respite.
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Principles of Pain in LTC
• Principle #6: Chronic pain is a multifactorial syndrome requiring multi-pronged management that is designed to optimize function and quality of life.
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The Pain Signature(cognitively intact)
Does pain affect your…
Not at all
A little Somewhat A lot As much as I can imagine
Energy XMood XAppetite XSleep XAbility to do daily chores
X
Ability to enjoy yourself
X
Ability to think clearly
X
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Follow-UpDoes pain affect your…
Not at all
A little Somewhat A lot As much as I can imagine
Energy X X
Mood XAppetite X X
Sleep XAbility to do daily chores
X
Ability to enjoy yourself
X X
Ability to think clearly
X
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Bad Poor Fair Good ExcellentEnergy X
Mood X
Appetite X
Sleep X
Cooperation with care
X
Ability to enjoy activities
X
Interaction with other residents
X
How to Evaluate Pain in LTC?
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Tips on Behavioral Observation
1. Multiple observers2. Multiple disciplines3. Multiple times of the day (i.e., all 3 shifts)
BE CREATIVE.BE FACILITY-FOCUSED.UTILIZE THE INTERDISCIPLINARY TEAM.
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Principles of Pain in LTC
• Principle #7: Treatment of pain in LTC residents should utilize a multidisciplinary stepped-care approach.
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Prescription of Analgesia in the Nursing Home: A Stepped-Care Approach
STEP 1: NON-PHARMACOLOGIC MODALITIES
STEP 2: TOPICAL PREPARATIONS
STEP 3: LOCAL &MINIMALLY INVASIVE RX.
STEP 4: LOCAL &MORE INVASIVE RX.
STEP 5: SYSTEMICORAL ANALGESICS
ADJUNCTIVENON-PHARMACOLOGIC
MODALITIES
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Prescription of Analgesia in the Nursing Home: A Stepped-Care Approach
ADJUNCTIVENON-PHARMACOLOGIC
MODALITIES
Should treatment focus on pain or dementia-related behaviors or fear or……?
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Painperseveration
Underminedementia
Falsely escalate pain severity &impact
DISTRACTION
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FEAR
Activity Avoidance
Pain
ReassuranceSupportDesensitizationPATIENCE
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Step 1: Non-Pharmacological Modalities
• Distraction (i.e., CBT)• Positive communication• Alleviation of fear• Gentle touch• Massage• Assistive devices
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Non-Pharmacological (cont.)
• Behavioral approaches for the treatment of dementia-associated fear/agitation
• Address all sources of discomfort (positioning, toileting, treatment of other conditions causing suffering such as depression)
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How effective is non-pharmacological treatment of pain in LTC?
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Evidence – Study 1
• Randomized controlled trial • 9 LTC facilities• 89 intervention residents, 36 control• Agitation = Unmet Needs (loneliness/
depression, boredom, discomfort)• Unmet needs evaluated and customized
intervention developed• Loneliness/depression, boredom, discomfort
Cohen-Mansfield et al 2012; J Clin Psychiatry 73(9): 1255-61
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Outcomes
• Significant reduction in agitation, both verbal and physical
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Interventions Utilized (2 weeks)Simulated social 27.2%
One-on-one interaction 16.4%
Magazine/reading/book on tape 12.7%
Music 10.3%
Videos and television 6.3%
Physical activity 4.9%
Arts and crafts 4.6%
Worklike activities 4.3%
Sensory stimulation 2.7%
Care 2.6%
Puzzles and games 2.3%
Food or drink 1.8%
Sorting 1.6%
Group activity 1.5%
Other 0.7%
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Evidence – Study 2
• PARTICIPANTS: 21 NH in Rhode Island• INTERVENTION: Multi-faceted intensive
intervention to improve pain management (education, coaching, rapid cycle QI, inter-NH collaboration)
Baier R, et al. J Am Geriatr Soc 2004; 52: 1988-1995
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• OUTCOMES: Chart review, MDS• RESULTS: Significantly more pain
evaluations and non-pharmacological Rx, but not pain meds.
PAIN PREVALENCE DECREASED!
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Prescription of Analgesia in the Nursing Home: A Stepped-Care Approach
STEP 2: TOPICAL PREPARATIONS
• lidocaine• capsaicin• NSAIDs
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HoPrescription of Analgesia in the Nursing Home: A Stepped-Care Approach
STEP 3: LOCAL &MINIMALLY INVASIVE RX.
• Trigger point injections
• Joint injections
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HPrescription of Analgesia in the Nursing Home: A Stepped-Care Approach
STEP 4: LOCAL &MORE INVASIVE RX.
• Spine injections
• Hip/SI injections
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STEP 5: SYSTEMIC ORAL ANALGESICS
How effective are they?
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Evidence
• Cluster randomized clinical trial• 352 LTC residents, ½ intervention, ½
control• Intervention: stepped care pain rx X 8 wks
– acetaminophen, morphine, buprenor-phine transdermal patch, pregabalin
• Control: usual care
Husebo et al 2011; BMJ 343
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Do these results reflect the impact of pain treatment or the rule of double-effect?
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Pharmacodynamics
Site of action
Effects TREATMENT EXPECTANCY
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Dementia: Impact on Pain Processing & Treatment Implications
Analgesic
Treatment Expectation
PAIN+
PAIN
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Benedetti et al 2006; Pain 121: 133
Dementia and Expectancy
Benedetti et al 2006; Pain 121: 133
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IMPLICATIONS
• Because of reduced treatment expectancy, patients with advanced dementia may require larger analgesic doses to achieve similar treatment outcomes.
• “Start low….Go slow….Keep going!”
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Stepped-Care Oral Analgesics
Acetaminophen
Non-Acetylated Salicylates
Strong Opioids
Other NSAIDs, Weak Opioids
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Beers Criteria for Potentially Inappropriate Medication Use in Older Adults (2012)
• Tertiary TCAs (anticholinergic)– amitriptyline– clomipramine– doxepin > 6mg/d– imipramine– trimipramine
• Meperidine (inefficacy, neurotoxicity)
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• Non-COX-selective NSAIDs, oral (GI bleeding, PUD)– aspirin > 325 mg/d– diclofenac– diflunisal– etodolac– fenoprofen– ibuprofen– ketoprofen– meclofenamate– mefenamic acid
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– meloxicam– nabumetone– naproxen– oxaprozin– piroxicam– sulindac– tolmetin
• indomethacin• ketorolac (+ parenteral)
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• Pentazocine (CNS toxicity)• Skeletal muscle relaxants (anticholinergic,
sedation, fracture risk)– carisoprodol– chlorzoxazone– cyclobenzaprine– metaxalone– methocarbamol– orphenadrine
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Pre-Emptive Analgesia
• Pre-medication prior to anticipated painful episodes (e.g., prior to care that requires movement of painful areas, physical therapy).
• Use in combination with strategies to alleviate dementia-associated fear when appropriate.
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Non-NSAID
Drug Recommended Dose
Special Considerations
Acetaminophen 325-1000 mg q 4-6h;Maximum dose 3000-4000 mg
SafeAcute overdose of 10 gm can be fatal
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Methadone Dosing ConversionDaily Oral Morphine Dose Equivalents
Conversion Ratio of Oral Morphine to Oral Methadone
< 100 mg 3:1101-300 mg 5:1301-600 mg 10:1601-800 mg 12:1801-1000 mg 15:1> 1000 mg 20:1
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Opioids: Potential Side Effects• Gastrointestinal: Constipation, Nausea,
Vomiting• Cognitive: Delirium, sedation, agitation,
depression• Mobility: Falls, hip fractures• Respiratory: Sleep-disordered breathing
(sleep apnea, resp. depression)• Genitourinary: Urinary retention• Pain: Worsening
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DRUG EFFECTS
PAINEFFECTS
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Principles of Pain in LTC
• Principle #8: If a patient is not responding to treatment, take a step back and re-evaluate your treatment strategy.
• Corollary 1: Make sure that you are treating all contributors to impaired function and quality of life.
• Corollary 2: Re-evaluate drug effects and appropriateness.
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Case
• ID: 86 yo female LTC resident with multiple sources of pain (recent hip fracture, stage III pressure sore, CLBP, depression)
• HPI: Following hip fracture hospitalization, resident became agitated and restless. Baseline behavior without agitation.
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• Medications on discharge:– Propoxyphene prn– Tramadol prn– Hydrocodone/acetaminophen prn
• Post-discharge course:– All prn analgesics d/c’ed and fentanyl started
and titrated– Agitation continued until…
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Principles of Pain in LTC
• Principle #9: Apply principles of rational drug prescribing to avoid excess polypharmacy
• Corollary: If one medication has dual effects, prescribe it.– e.g. gabapentin for anxiety and peripheral
neuropathy– duloxetine for fibromyalgia or peripheral
neuropathy and depression
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Principles of Pain in LTC
• Principle #10: Myofascial pain should be assessed routinely in LTC residents with pain, and treated specifically when identified as a contributor to impaired function or quality of life.
Travell & Simons’ Myofascial Pain and Dysfunction, The Trigger Point Manual, 1999
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Epidemiology
• Majority of chronic pain patientsBorg-Stein 2006; Phys Med Rehabil Clin N Am 17: 491
• >95% of older adults with CLBPWeiner et al 2006; J Am Geriatr Soc 54: 11-20
• >30% of patients in general practiceSkootsky et al 1989; West J Med 151: 157-60
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www.innertraditions.com
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Myofascial Pain Treatment Perpetuating factors
• Leg length discrepancy• Hip/knee arthritis• Postural abnormalities• Axial spondylosis (neuropathic MP)• Psychological & environmental stressors
• Trigger point deactivation• Local twitch response
• Resilience building• Gentle stretching• Strengthening
Borg-Stein 2006; Phys Med Rehabil Clin N Am 17: 491 Cummings & White 2001; Arch Phys Med Rehab 82: 986
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Neuropathic Myofascial Pain
Gunn CC 2001; Bonica’s Management of Pain, p. 522
NeurotrophicFactors
+/- PAINRx: Low dose gabapentin?(e.g. 300-600 mg qd-bid)
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Summary
1. Chronic pain cannot be cured. Patients who are well treated will continue to report/manifest some pain.
2. Defining patient-centered pain treatment outcomes (the pain signature) is critical; treatment should focus on improving function and quality of life.
3. Interdisciplinary pain evaluation and treatment is the gold standard.