Amplified Pain Syndrome Flashcards
What is pain and how can it arise?
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
What happens in central centralization?
Inhibitory interneurons are inhibited causing an amplified sensation.
What are some different amplified pain syndromes?
Chronic pain: diffuse, localized
Juvenile fibromyalgia
Complex regional pain syndrome
Who is typically effected?
Females
Ages 9-18
Personality traits: mature, excels, pleaser, perfectionist, worrier, sensitive
What is the pain history in amplified pain?
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
What is medical history for this patient population?
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
T/F: all other diagnoses have been ruled out by physician before diagnosis of amplified pain syndrome is made?
True
What are exam findings for APS?
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
What are symptoms associated with amplified pain syndrome?
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
What psychological factors play a role in pain?
Positive and/or negative stress
School stressors
Family stressors
Stress increases pain pain increases stress
What is CRPS?
Cold blue foot
Chronic condition affecting the nerves and blood vessels: generally no identifiable nerve damage
Pain disproportionate to initial event
What sensory problems are found in CRPS?
Sensory disturbances: allodynia/hyperalgesia, autonomic dysfunction, motor dysfunction
When and where does CRPS occur?
Typically occurs after trauma that is often trivial
More common in lower extremities in pediatrics
What are clinical characteristics between CRPS in children versus adults?
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
What is conversion disorder?
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
What are examples of conversion disorder?
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)
How do you address conversion disorder during treatment?
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
What is treatment of APS?
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
How do you assess pain in APS?
Visual analog scale
FACES scale
Observable pain behaviors
What are observable pain behaviors?
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
What are treatment recommendations for APS?
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
What are physical activity recommendations?
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
What are types of sensation kids have trouble with in APS?
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
What are recommendations for desensitization?
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
What are recommendations for stress management?
Inquire about current use of strategies: counseling, self regulation, journaling, yoga, deep breathing
Most patients with unresolved pain have not addressed the stress component
What is RAPS?
Intensive rehab program Exercise based Drug free Admission: adolescents with disability, severe pain, failure of outpatient interventions Rolling admission Typical duration: 3-6 weeks
What disciplines are involved in RAPS?
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
What are goals while in RAPS?
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
What test and measure showuld be used with APS?
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
What is the functional disability inventory? What’s is reliability?
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
What is the Canadian occupational performance measure?
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
What is purpose of using 6 MWT?
Assesses sub maximal level of functional capacity.
Reliable and valid for submaximal exercise in patients with chronic pain, fibromyalgia, and chronic fatigue
What is the BOT2?
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
What are the subsections of fine motor, manual coordination, body coordination, strength and agility on the BOT?
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
What are tools needed for the BOT?
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
