Amplified Pain Syndrome

Question 1

What is pain and how can it arise?

Answer 1

Unpleasant sensory and emotional experience associated with actual or potential tissue damage.
It’s subjective
It’s a real sensation, patients aren’t faking it.

Can arise from: injury, illness, psychological stress, idiopathic

Question 2

What happens in central centralization?

Answer 2

Inhibitory interneurons are inhibited causing an amplified sensation.

Question 3

What are some different amplified pain syndromes?

Answer 3

Chronic pain: diffuse, localized
Juvenile fibromyalgia
Complex regional pain syndrome

Question 4

Who is typically effected?

Answer 4

Females
Ages 9-18
Personality traits: mature, excels, pleaser, perfectionist, worrier, sensitive

Question 5

What is the pain history in amplified pain?

Answer 5

Long history of pain: mean duration of 1 year
Increasing pain over time
Pain has spread
Pain worsened with immobilization
Intermittent or constant pain
Diffuse or localized

Question 6

What is medical history for this patient population?

Answer 6

Seen by several providers
Underwent numerous procedures, tests, labs
Slow healer
May have history of multiple injuries
History of minor or major stressful events: often unable to identify event surrounding onset of pain
Failed prior therapies

Question 7

T/F: all other diagnoses have been ruled out by physician before diagnosis of amplified pain syndrome is made?

Answer 7

True

Question 8

What are exam findings for APS?

Answer 8

LEs affected more often than UEs
Weakness
Poor cardiopulmonary endurance
Poor muscle endurance
Allodynia: pain with non noxious stimulus
Positive review of systems
Patient has pain out of proportion to their exam findings

Question 9

What are symptoms associated with amplified pain syndrome?

Answer 9

Pain lasting >3 months
Absence of underlying medical condition
Normal lab results
5 or more tender points

Fatigue/sleep disturbances
Numbness or tingling of extremities
Pain modulated by stress
Depression/anxiety
Autonomic changes: temp, swelling, and/or skin color changes
Abdominal pain
Blurry vision
Chest pain
Diarrhea
Dizziness
Headaches
Memory deficits
Nausea/vomiting
Palpitations

Question 10

What psychological factors play a role in pain?

Answer 10

Positive and/or negative stress
School stressors
Family stressors
Stress increases pain pain increases stress

Question 11

What is CRPS?

Answer 11

Cold blue foot
Chronic condition affecting the nerves and blood vessels: generally no identifiable nerve damage
Pain disproportionate to initial event

Question 12

What sensory problems are found in CRPS?

Answer 12

Sensory disturbances: allodynia/hyperalgesia, autonomic dysfunction, motor dysfunction

Question 13

When and where does CRPS occur?

Answer 13

Typically occurs after trauma that is often trivial

More common in lower extremities in pediatrics

Question 14

What are clinical characteristics between CRPS in children versus adults?

Answer 14

Kids: LE more than UE, female, inciting injury is less often, skin cooler, neuro symptoms less pronounced, psych issues more common, prognosis is excellent

Adults: UE more than LE, females, inciting injury is more often, “stages” of change, psych issues less common, prognosis is variable, long term disability is common

Question 15

What is conversion disorder?

Answer 15

Inconsistent with any neurological or musculoskeletal injury
Symptoms are unconscious manifestations of psychological stressors
The patient cannot control the symptoms
Consistently inconsistent
Conversion and APS can co-exist

Question 16

What are examples of conversion disorder?

Answer 16

Limb locking, uncontrollable shaking, lack of ROM, foot drop, conversion gait/difficulty walking, fluctuating weakness, pseudoseizures, numbness/paralysis, blindness/deafness, astasia-abasis (inability to stand or walk, but ability to move legs when lying down)

Question 17

How do you address conversion disorder during treatment?

Answer 17

Downplay occurrences, avoid calling attention to symptoms, increase sped, alter activity, use distraction techniques, reinforce success with activity, reassurance that symptoms will improve, remain calm and act like it’s not a big deal, make sure the patient is safe, position yourself away from them so they will not collapse and rely on you to catch them

Question 18

What is treatment of APS?

Answer 18

No pain meds or sleep aides
Encourage patient to continue or start participating in functional activities
Initially pain my increase or spread
Focus on function rather than pain or limitation
Move through pain
Educate patient on APS and POC
Avoid focusing on or asking about pain

Question 19

How do you assess pain in APS?

Answer 19

Visual analog scale
FACES scale
Observable pain behaviors

Question 20

What are observable pain behaviors?

Answer 20

Facial grimacing, crying, decrease movement, withdrawal from stimulus, muscle guarding, vocalizing discomfort, rubbing affected area, decreased weight bearing on affected extremity, protective positioning, continual movements, quick movements, compensatory positioning, holding breath, altering task/activity, stalling, laughing

Question 21

What are treatment recommendations for APS?

Answer 21

4 prong approach: Physical activity, desensitization, stress management, decrease attention to pain

Stop use of AD for mobility
Discharge CAM walker if present
Focus on improving function

If it hurts to do something, that’s what you should do
Function will return before pain fully resolves

Question 22

What are physical activity recommendations?

Answer 22

At least 45 minutes of intense non stop exercise per day: 15 minutes of aerobic, 30 minutes of strengthening focusing on affected area
Patients should be out of breath and sweating
Recommend return to sports and age appropriate activities
Provide a HEP of about 20 exercises

Question 23

What are types of sensation kids have trouble with in APS?

Answer 23

Light touch, deep pressure, vibration, temperature

Allodynia: pain response to non noxious stimulus
Hyperalgesia: increased pain response to a noxious stimulus
Variable borders: start and end points may change up to 12 cm within seconds

Question 24

What are recommendations for desensitization?

Answer 24

5x/day for 5-10 minutes at a time

Examples: brushing, lotion massage, towel rub, tennis ball massage, audible taps, vibration, contrast baths, ice massage, painting, tubigrip

Question 25

What are recommendations for stress management?

Answer 25

Inquire about current use of strategies: counseling, self regulation, journaling, yoga, deep breathing
Most patients with unresolved pain have not addressed the stress component

Question 26

What is RAPS?

Answer 26

Intensive rehab program
Exercise based
Drug free
Admission: adolescents with disability, severe pain, failure of outpatient interventions
Rolling admission
Typical duration: 3-6 weeks

Question 27

What disciplines are involved in RAPS?

Answer 27

Multidisciplinary
Physician/NP: daily exam
Psych: IQ and school testing, individual talk times 2x/wk, parent groups 2x/wk
Aquatic: 1 hr/day, Mon-Thurs
OT: 2 hr/day
PT: 2 hr/day
Child life and art therapy: individual and group sessions weekly
Music therapy: individual and group sessions weekly
Yoga: 1.5 hr sessions, 3x/wk
Self regulation/mindfulness: 0.5 hr sessions, 2x/wk

Question 28

What are goals while in RAPS?

Answer 28

Become fully functional
Return to school w/o physical accommodations
Provide tools to continue treatment following discharge: variety of exercises, desensitization activities, self regulation activities, understand what info is important to share with counselor
Reduce pain
Decrease associated symptoms/conversion episodes

Question 29

What test and measure showuld be used with APS?

Answer 29

MMT: may find inconsistent measurement compared to functional abilities
Sensory testing: assess allodynia to light touch, deep pressure, vibration, temperature
Functional disability inventory
Canadian occupational performance measure
Bruininks-Oseretsky Test of Motor proficiency
6 MWT

Question 30

What is the functional disability inventory? What’s is reliability?

Answer 30

Measures patients perception of functional abilities.
15 item self report inventory.
5 point scale from 0-4
Total score= 0-60, higher score indicates greater disability

High internal consistency, moderate to high test-retest reliability, moderate cross informant reliability, reliable and valid measure for functional assessment of children with acute illness and recurrent pain

Question 31

What is the Canadian occupational performance measure?

Answer 31

Measures patient’s personal goals and their satisfaction with their performance on these goals.
Patients determine goals and rate level of importance, current importance, and satisfaction
1-10 scale
Change of 2 points is considered clinically and statistically significant.
Using this will help keep patients motivated by referring to their goals

Question 32

What is purpose of using 6 MWT?

Answer 32

Assesses sub maximal level of functional capacity.

Reliable and valid for submaximal exercise in patients with chronic pain, fibromyalgia, and chronic fatigue

Question 33

What is the BOT2?

Answer 33

Assesses motor performance- fine motor control, manual coordination, body coordination, strength, agility
Standardized, norm referenced
Norms based on kids 4-21 years old
Reliable and valid measure

Question 34

What are the subsections of fine motor, manual coordination, body coordination, strength and agility on the BOT?

Answer 34

Fine: fine motor precision, fine motor integration
Manual: manual dexterity, upper limb coordination
Body coordination: bilateral coordination, balance
Strength and agility: running speed and agility, strength

Question 35

What are tools needed for the BOT?

Answer 35

Tape off start ands top line 50 ft apart of shuttle run.
Tape straight line (10 ft) for balance
Get test kit: manual, easel, block, balance beam
Gather any additional objects needed: stopwatch, table, chair, tape measure