A Brief Intro to:
PAIN CLASSIFICATION AND MANAGEMENT
JOSH LEIGH, SPT
Mission Statement:
Today we will discuss the prevalence, identification, measurement/documentation, and briefly touch on basic treatment of acute and chronic pain found in an inpatient setting.
IN-SERVICE OBJECTIVES: A NEURO REVIEW!
1. Prevalence of Pain in the inpatient settingIdentification of pain “Ouch that hurts…wait…what hurts?!”
Classification of pain “How do we feel pain?”
Quantitative Measurement of Pain “Documentation review!”
2. Review of Basic Acute Treatment Techniques
TABLE OF CONTENTS
Question 1: True or False, activation of A-Beta aff erents can relieve pain through the Gait Theory of Pain control.
Question 2: True or False, A verbal Pain rating Scale is as eff ective as a visual pain rating scale.
Question 3: True or False, Ice will cause inhibition of GTO’s and relax muscles through A-beta input.
PRE TEST
PR
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JCAHO standards (http://WWW.jcaho.org) that address the importance of pain assessment are:
PE.1.4: Pain is assessed in al l patients. RI.1.2.8: Patients have the r ight to appropriate
assessment and management of pain
Almost one fi fth of hospitalized patients in an do not receive adequate pain relief.
Jabusch et al. (2014)
1. Musculoskeletal (somatic) Pain Acute Recent Onset: short lived, limited to the proliferation
phase of tissue repair. Chronic Pain (Greater than 3-6 months)
Hyperalgesia: Painful stimuli present as far more painful Allodynia: React to a non-painful stimuli w/ painful response
2.Referred (Visceral) Pain: Pain is perceived on a body segment distant from source of pain
3. (Neuropathic) Phantom Pain
*(CRPS) Sympathetic Refl ex Dystrophy* Complex regional Pain Syndrome: Autonomic N. System
IDENTIFICATION: “OUCH THAT HURTS…WAIT…WHAT HURTS?!”
Specifi city Theory: Special receptor for each type of pain. Problem: Doesn’t account for the severity of pain
Pattern Theory: Not about receptor, its about coding for the stimulation Problem: Doesn’t account for the different types of perceived
pain
Gate Control Theory Pain Perception depends on a balance of sensory input from nonociceptive and nociceptive afferents Explains: Descending controls from the cortex, limbic system,
brainstem, and midbrain. Problem: Doesn’t fully explain differences in pain perception
between individuals. Placebo effect?
CLASSIFICATION: HOW DO WE FEEL PAIN?
Keep in mindExtent/Nature of InjuryEmotional states (positive, depression, relaxation,
rest)Cognitive states (focusing on pain, Boredom)Lack of ExercisePhysical Conditions (medication, Counterstimulation)
GAIT THEORY
Neuromatrix Theory: (Melzack and Wall) Physical, psychological, cognitive traits, and experience.
Central Biasing Theory: Personal learned behavior, conditive eff ects sensory discrimination, location of pain source and intensity/nautre of pain. Think reff erred pain/lbp Internal drive or external stimulation Think placebo effect
Endogenous Opiates Theory (6-8hrs of pain relief!)
FEW MORE THEORIES WE WILL INCLUDE
Anterolateral System (ALS): Conscious levels/touch/constant Direct
Lateral Spinothalamic Anterospinothalamic
Indirect Spinoreticulothalamic
A delta Fibers: 30m/sC Fibers 1-4m/sA beta Fibers: 20-90m/s
SPINAL CORD PAIN TRACTS
Paleospinothalamic/Archispinothalamic Tract More diffuse C fibers
ascend bilaterally, don’t reach the cortex
Terminate in brainstem/limbic system: not for conscious perception of pain, limbic system is emotional aspect of pain Reticulospinal tract:
Autonomic Nervous System response to pain fight/fl ight
PATHWAYS EMOTIONAL PAIN
Pain Neurotransmitters: Substance P, NGF, SHT (seratonin receptors), Aradaonic Acid,
HistamineAxon Refl ex
Mast Cells Release Histamine and cause substance P to be released
A-delta: Synapse I+V second order neurons, cross in anterior white
commissure, ascend contralaterally to VPL, 3 rd order to cortex.C-Fibers
Synapse at lamina II (substantia gelatinosa), ascends in ventral ventral spinal thalamic tract, ascends contrallaterally to VPL
As the neuron comes in before 2nd order synapse ascends and descends several segments ipsilaterally in the dorsal tip aka Lissauer’s tract.
MAJOR PAIN COMPONENTS
You can Block Pain by Causing Pain A Beta input via gate theory A Delta Stim: Strong/fast stim for opiate production C Fiber Stim: Prolonged sub max endorphin release Maximize central biasing
Endogenous opiate theory/Descending Neurotransmitters Endorphins Enkephalins Serotonin Norepinephrine
Hyperirritability Decreased threshold, increased efferent,
viserosomatic/somatovisceral, spasm cycle
PAIN CONTROL RESPONSES
Reticular Formation*Raphe Nucleus (spinal tract): Production of Seratonin
*Pons: noepinephrine*Periaqueductal Grey Matter: PAGM: sends fibers down to dorsal grey horn
*Limbic System: Emotions, release opiodes
**stimulate Dorsal Grey Horn to release Enkephalin**
THE BRAIN: CENTRAL PAIN SUPPRESSION
Numerical Rating scale (0-10)
Verbal rating scale (4 levels)
Visual analogue scale (0-100)
Ransford Body Drawings
Pressure Algometers
Comparison to Pre-determined stimuli
Brief Pain Inventory (9)
McGil l Pain Questionaire
MMPI-2 (Minnesota Multiphasic Personality Inventory)
QUANTITATIVE MEASURE FOR PAIN
Hjermstad, M., Fayers, P., & Haugen, D. et al. (2011). Studies Comparing Numerical Rating Scales, Verbal Rating Scales, and Visual Analogue Scales for assessment of pain intensity in Adults: A Systematic Literature Review. Journal of Pain and Symptom Management, 41-6, 1073-1093.
NRS (Numerical Rating Scale)**
Ransford body diagrams
VRS (Verbal Rating Scale)**
Pressure Algometers
PGIC (Patient Global Impression of Change)
UNIDIMENSIONAL PAIN SCALES
McGill Pain Questionnaire (short form)** Sensory terms (sharp/stabbing) Affective Terms (sickening/fearful) 4 pt scale none-severe VAS for Intensity and Experiance
Brief Pain inventory Short form** (17 items) Sensory Intensity of Pain Degree which pain interferes in the Patients life Location, medications, response to past Rx
West Haven-Yale Multidimensional Pain Inventory LONG 52 items/12 subscales self perception
Classify patients dysfunctional, interpersonally depressed, or adaptive copers
Treatment Outcomes of Pain Survey
MMPI-2 (Hypochondriasis, depression, hysteria, psychopathic deviate, paranoia, psychasthenia, schizophrenia, hypomania)
MULTI-DIMENSIONAL PAIN SCALES
1. Manual Techniques for Pain Control Joint Mobilization (Grade I)Massage/Myofacial Release/Trigger Point Therapy
Positioning and Posture2. Stretching/Exercise for Pain Control
Dosing for pain control3. Physical Agents for Pain Control
Ice vs HeatKinesiotape
4. Physiological Component of Pain Control
BASIC TREATMENT TECHNIQUES
MA
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1. Joint Mobilization
2. Massage
3. Positioning and Posture
Possible tumor or infection Age >50YRS HX of Cancer Constitutional sx: Recent Fever, Chills, Unexplained weight-
loss Risk factors for spinal infection
Recent bacterial infection (UTI) IV drug abuse/immune suppression Steroids, Transplant, HIV
Pain that worsens when supine, severe nighttime pain Possible Fx
Major trauma, MVA Minor Trauma/Strenuous lifting in older/osteoporotic patient
Cauda Equina
GENERAL PAIN RED FLAGS
The “Bread and Butter” of PTDosing for Pain ControlPain free vs Pushing through pain
Appropriate POC Sequencing
STRETCHING & EXERCISE FOR PAIN CONTROL
Posture and LBP
POSITIONAL EFFECT ON PRESSURE
CARRY-OVER TO EXERCISE ACTIVITY
INTRADISCAL PRESSURES RELATED TO ACTIVITY
PH
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1. Ice Analgesia: suppressed nerve conduction
velocity Decreased metabolism: decreased release of
noxious chemicals
Vasoconstriction: Deceased edema
Histamine action on capillary permeability
2. Heat
Analgesia: Increased nerve conduction velocity
Increased Metabolism: Increase in noxious chem
Vasodilation: Increases Edema but…
Also promotes Re-absorption
Viscoelastic Properties
Analgesia:GTO stimulation for muscle inhibition
3. Kinesiotape/Surface Taping
A-Beta input
Proprioceptive Feedback
Indications: Inflammation control, Pain control, spasticity control, facilitation (quick icing),
MS management, Cryokinetics
Contraindications: Cold Hypersensitivity (urticaria), Cold Intolerance, Cryoglobulinemia,
Hemoglobinuria, raynaud’s disease, Regenerating peripheral nerve, PVD Precautions
Superficial Branch of a Nerve, Open Wound, HTN, Poor Sensation, Poor Mentation, Age (poor temp control)
Adverse Rxn’s Frostbite, Nerve damage Hunting Reaction (rapid vasodilation, systemic shock)
Physiological eff ects Hemodynamic Neuromuscular Metabolic
ICE: THE COLD STUFF
Rate of Transfer= (area in contact)(temp diff )(Thermal Condu)
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(Thickness of the tissue)
Conduction/Convection/Conversion/Radiation
Contraindications: Acute Stage( inflammation, hemorrhage, thrombophlebitis),
impaired sensation/mentation, malignancy, fever Precautions
Acute stage, pregnancy, impaired circulation, poor thermal regulation, edema, cardiac insuffi ciency, metal, open wound, demyelinated nerves
Adverse eff ects Burns, Bleeding, Fainting
HEAT: THE HOT STUFF
PS
YC
HO
LO
GIC
AL
CO
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ON
EN
T O
F P
AIN
CRPS
Back-Pain
Fibromyalgia
Chronic pain
ETOH/Substance Abuse Patients
Question 1: True or False, activation of A-Beta aff erents can relieve pain through the Gait Theory of Pain control.
Question 2: True or False, A verbal Pain rating Scale is as eff ective as a visual pain rating scale.
Question 3: True or False, Ice will cause inhibition of GTO’s and relax muscles.
POST TEST
Hj e rmstad , M . , Fayers , P. , & Haugen , D . e t a l . ( 2011 ) . S tud i es Compar i ng Numer i ca l Ra t i ng Sca l es , Ve rba l Ra t i ng Sca les , and V i sua l Ana logue Sca l es f o r a ssessment o f pa in i n tens i t y i n Adu l t s : A Sys temat i c L i t e ra tu re Rev iew. J ou rna l o f Pa i n and Symptom Management , 41 -6 , 1073 -1093 .
Daut RL , C l ee l and CS , F l ane ry RC . Deve lopment o f the Wi scons in B r i e f Pa in Ques t i onna i re t o assess pa in i n cancer and o ther d i seases . Pa i n 1983 ;17 :197e210 .
Me l zack R. The McG i l l Pa in Ques t i onna i re : ma jo r p roper t i es and sco r i ng methods . Pa in 1975 ;1 : 277e299 .
Neurosc i ence : Fundamenta l s f o r Rehab i l i t a t i on . Lundy-Ekman, L . W. B . Saunders Company.
Pr i nc i p l es o f Neura l Sc i ence . Kande l , K . R. , Schwar t z , J . H. , & B . J e sse l . McGraw H i l l , 2000 .
Neurosc i ence f o r Rehab i l i t a t i on . Cohen , H. L i p i nco t t Wi l l i ams & Wi l k i ns , 1999 .
C l i n i ca l Neuroana tomy f o r Med i ca l S tudents . Sne l l , R. L i p i nco t t Wi l l i ams & Wi l k i ns . 2001 .
C l i n i ca l Neuro l ogy.S i mon , R. P. , Aminoff , M . J . , & Greenberg , D . A . Lange / McGraw H i l l , 1999 .
Younger , J . , McCue , R. , & Mackey , S . ( 2009 ) Pa i n outcomes : A B r i e f rev i ew o f I ns t ruments and Techn i ques , Curr Pa in Headache Rep , 13 (1 ) : 39 -43 .
Cameron , M . H. ( 2013 ) . Phys i ca l agent s i n rehab i l i t a t i on . F rom resea rch to p rac t i ce ( 4 th ed . ) . S t . Lou i s , MO: Saunders E l sev i e r.
REFERENCES
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