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year 4 CDM 2 > Case 18: chronic pain > Flashcards

Case 18: chronic pain Flashcards

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1
Q

Complex regional pain syndrome (CRPS) diagnosis

A
  • At least 1 symptom from 3 out of the 4 categories
  • Sensory: Allodynia (pain from non-painful stimuli i.e. light touch, movement), Hyperalgesia (increased/disproportionate pain from a painful stimuli i.e. pinprick)
  • Vasomotor: temperature change, colour change
  • Sudomotor: oedema, reduced/increased sweating
  • Motor/trophic: reduced motor function, nail, hair, skin change
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2
Q

CRPS investigations

A
  • Clinical diagnosis
  • Imaging: Nerve conduction studies and MRI can show nerve damage but normal scan does not rule out CRPS
  • Pain so severe limb can be non-functional, patients may request amputation but this can cause phantom limb syndrome
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3
Q

Pain history

A
  • Current pain symptoms: SOCRATES
  • Impact of the pain: activities of daily living, social and psychological
  • Screen for red flags
  • Systems inquiry: associated conditions e.g. depression, IBS, connective tissue disease signs
  • Past medical history and other pain conditions
  • Drug history including opioid use and illicit drugs
  • Social history: support networks, job, finance
  • Ideas, concerns and expectations
  • McGill pain questionnaire
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4
Q

Managing pain

A
  • Approaches to pain management: Medication, Physiotherapy, Education and self care, Psychological (CBT)
  • Identify features which predispose, precipitate and perpetuate. Pain at night can cause poor sleep which increases pain perception
  • Chronic pain factors: poor quality sleep, adopting negative health behaviours, fear of pain, de-conditioning, depression, stress.
  • Make it a positive diagnose i.e. you have fibromyalgia as its in keeping with the symptoms not because you rules everything else out
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5
Q

Why might patients be upset with fibromyalgia diagnosis

A
  • Lack of understanding on behalf of patient
  • Unclear or unempathetic explanation from clinician
  • Felt stigma surrounding a diagnosis - feeling of stigma from clinicians/society
  • Feeling of being accused of “making it up” or “saying it’s all my head”
  • Feeling that symptoms are “just being put down to being depressed”
  • Feeling that pain/symptoms are not being validated as real/significant
  • Feeling that another diagnosis is being missed
  • Lack of cure/treatment
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6
Q

Pain definition

A
  • Pain: an unpleasant sensory and emotional experience associated with actual or potential tissue damage
  • Chronic pain: pain that persists or recurs for more than 3 months
  • Chronic primary pain: Chronic pain in one or more anatomical regions, characterised by significant emotional distress or functional disability.
  • Chronic primary pain includes: chronic widespread pain, complex regional pain syndrome, chronic primary headache or orofacial pain, chronic primary visceral pain and chronic primary musculoskeletal pain
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7
Q

Total pain

A
  • Total pain recognises that the physical element of pain is a very small component of the persons experience of their pain
  • Physical: due to illness, due to treatment, due to comorbidities
  • Psychological: depression, anxiety, fear of suffering, past experience
  • Spiritual: anger with God, loss of faith, loss of purpose, fear of unknown
  • Social: loss of role, social status, loss of job, financial concerns, worries for future
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8
Q

Taking a pain history

A
  • Pain history
  • Pain treatment history
  • Home environment and support structure
  • Other social support including carers
  • Relevant educational and employment details
  • Finance and benefit support
  • Social and leisure interests or activities
  • Emotional and psychological distress factors including legal issues
  • Impact of pain on quality of life
  • Other pre-existing risk factors for the development of chronic pain
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9
Q

Questions to ask specifically about pain

A
  • SOCRATES
  • Duration: acute (self limiting), chronic (>3 months)
  • Cause: cancer, visceral, musculoskeletal, central
  • Mechanism: Nociceptive, Neuropathic, Nociplastic
  • Affect on patient: Bio-psycho social factors i.e. stops ability to work, stress, de-conditioning, worse on exercise
  • Other factors: associated depression, organic co-morbidities
  • McGill Pain Questionnaire
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10
Q

Non pharmacological pain management

A
  • Psychological: Explanation, Reassurance, Psychological therapies i.e. CBT, distraction techniques, Mindfulness, exercise
  • Physical: RICE, Acupuncture, Massage, Physiotherapy, TENS machine
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11
Q

Principles of psychological interventions for pain management

A
  • Work by reducing the anxiety attributed to the experience of pain. Help people to live with the pain and avoid catastrophising
  • Analgesia is unlikely to completely remove the pain and majority will live with chronic pain for there whole life
  • Help people manage their pain and re-address ideas and expectations
  • Graded exercise: beneficial to some
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12
Q

TENS (transcutaneous electrical nerve stimulation) machine

A
  • Manage acute and chronic pain but more effective for acute
  • Give small electrical currents like a buzz or tingling sensation which interrupts painful signals reducing pain intensity by activating inhibitory neurones
  • painful stimuli is transmitted from the periphery by C fibres and A delta fibres which are unmyelinated and therefore slow
  • mechanical stimulation is transmitted by A beta fibres which are myelinated and therefore fast
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13
Q

WHO pain ladder

A
  • Non-opioids: paracetamol, NSAIDs +/- adjuvants
  • Opioids for mild to moderate pain: Codeine, Dihydrocodeine, Tramadol
  • Opioids for moderate to severe pain: Morphine, Oxycodeine, Fentanyl
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14
Q

Renal WHO pain ladder

A
  • Mild pain: Paracetamol, avoid NSAIDS
  • Moderate: Hydrocodeine, Oxycodone, Tramadol
  • Severe pain: Hydromorphine, Alfentanil
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15
Q

Amitryptyline

A
  • Given for neuropathic pain
  • Cautions: arrhythmias, IHD, HF
  • Side effects: dry mouth sedation
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16
Q

Gabapentin

A
  • Controlled drug
  • Given for neuropathic pain (particularly diabetic neuropathy and post herpetic neuralgia)
  • Cautions: absence seizures, psychosis
  • Side effects: sedation, dizziness
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17
Q

Pregabalin

A
  • Controlled drug
  • Given for neuropathic pain (first line)
  • Cautions: heart failure, renal impairement
  • Side effects: prolonged QTc, blurred vision
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18
Q

Duloxetine

A
  • Indications: diabetic peripheral neuropathic pain
  • Cautions: bleeding disorders, cardiac disease, elderly
  • Side effects: anxiety, decreased appetite
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19
Q

Carbamazepine

A
  • Indications: trigeminal neuralgia
  • Cautions: arrhythmias, previous bone marrow suppression
  • Side effects: dizziness
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20
Q

Other options for pain killers in specialist pain clinics

A
  • Local anaesthetic. Often used in nerve blocks or epidurals by anaesthetists with a special interest in pain management
  • Ketamine, Clonidine, NSAIDs
  • Capsaicin cream (specialist use): rubbed into the painful area and causes interference with the pain signals, in a similar way to TENS machines. Can be used in neuropathic pain management.
  • Facet joint injections for OA spine
  • Spinal cord stimulators. Inserted under the skin and deliver small electrical signals to interrupt pain signals.
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21
Q

Harmful effects of chronic opioid use and how to manage

A
  • Sedation, dizziness, N+V, constipation, respiratory depression, physical dependence and tolerance, delayed gastric emptying, Immune + Hormone suppression, muscle rigidity
  • Provide regular laxatives and a small supply of anti-emetics
  • Patches can manage stable, chronic nociceptice pain but not acute or changing
  • Opioids shouldnt be used for chronic primary pain
22
Q

When not to prescribe opioids

A
  • Patients who do not achieve useful pain relief from opioids within 2-4 weeks are unlikely to gain benefit in the long term.
  • Short-term efficacy does not guarantee long-term efficacy
  • No good evidence for dose response with opioids up to 120mg
  • No evidence of effectiveness of high dose steroids in long term pain
23
Q

What to prescribe in Chronic Primary Pain

A
  • The following antidepressants: duloxetine, fluoxetine, paroxetine, citalopram, sertraline or amitriptyline
  • Dont prescribe opioids for neuropathic pain (better suited for nociceptive)
24
Q

Acute to chronic pain

A
  • The acute pain can cause physical and mental deconditioning leading to more chronic pain
  • Initial psychological distress can get worsened and lead to acceptance of the ‘sick role’ and consolidation of abnormal illness
25
Q

Management of chronic pain

A
  • Refer to psychology to commence CBT/ACT
  • Commence an antidepressant i.e. duloxetine, fluoxetine
  • Wean off opioids
  • Consider acupuncture: offer up to 5 treatment hours, if no benefit after first 1 or 2 sessions discontinue
  • Local exercise groups for chronic pain
  • Physio
  • Education and self care
26
Q

How do psychological therapies help with chronic primary pain

A
  • they reduce the psychological factors (e.g. anxiety, depression) that contribute to the experience of pain
  • they address ways in which the person thinks about and manages their pain
27
Q

Red flag features for GI disease

A

change to bowel habit, unexplained anaemia, weight loss, PR blood loss

28
Q

Medically unexplained symptoms

A
  • physical symptoms which cant be explained by somatic (bodily) or psychological cause after appropriate examination and investigation
  • Most are transient and self limiting but some become longer lasting and cause functional impairment
  • Longer lasting cases tend to resolve over 6-15 months, improved by early recognition, continuity of care and a strong doctor-patient relationship
  • Tend to have symptoms clusters i.e. IBS, fibromyalgia. Medically unexplained symptoms is an umbrella term for this
29
Q

Bodily distress disorder

A
  • Encompasses ‘explained disease’ as well as isolated medically unexplained symptoms i.e. Fibromyalgia
  • Its the presence of one or more chronic, distressing bodily symptoms (which can be medically unexplained or caused or exacerbated by a general medical condition) and ‘excessive attention’ or disproportionate or maladaptive thoughts, feelings or behavioural responses to the symptoms
30
Q

Investigations for GI medically unexplained symptoms

A
  • Bloods: FBC, U&Es, LFTs, TSH, CRP/ESR, anti-ttg
  • Special tests: Faecal calprotectin, consider stool sample for H pylori
  • In order to rule out IBD, coeliac disease, thyroid disease
31
Q

Different categories of medically unexplained symptoms

A
  • Neurological: poor concentration/memory, headaches, dizziness, paraesthesia
  • Urogenital: urinary urgency, urinary frequency, chronic pelvic pain
  • Systemic: fatigue, weight gain, sensitive to hot/cold
  • Musculoskeletal: muscle/joint aches and pain, subjective weakness, non-specific lower back pain
  • Cardiopulmonary: palpitations, precordial discomfort, breathlessness/hyperventilation, light headedness
  • GI: abdo pain, loose stools/constipation, bloating, nausea, reflux
32
Q

How to categories medically unexplained symptoms

A
  • Symptoms can be combined into syndrome i.e. IBS, patients may have multiple syndromes or the patient experiences just a couple of the symptoms and never receive a diagnosis of a syndrome.
  • Medically unexplained symptoms can co-exist and be exacerbated by an organic disease
33
Q

Theories for different causes of medically unexplained symptoms

A
  • Sensory sensitisation:Sensory processing in the CNS becomes hyper-reactive to ‘normal’ signals. For example, normal peristalsis of the bowels becomes painful and distressing, in turn leading to stress response and autonomic reaction.
  • HPA axis dysfunction:A neuroendocrine feedback system involved in the cortisol and immune system response. Dysfunction could cause: several mental health disorders, chronic fatigue syndrome, fibromyalgia and IBS.
  • Somatisation:Mental health disorders e.g. anxiety/depression/stress manifesting as physical symptoms. Symptoms are not a direct consequence of the mental health condition e.g. panic disorder causing an episode of dyspnoea.
34
Q

The 3 P’s of medically unexplained symptoms

A
  • Predisposing: FH, organic disease, childhood trauma/neglect, health beliefs and behaviours
  • Precipitating: illness/injury, acute life stressors, significant life events
  • Perpetuating: Central sensitisation, symptom hypervigilance, mental ill health, Maladaptive health beliefs and behaviours, social support network behaviours
35
Q

Illness anxiety disorder

A
  • A cycle of recurrent anxiety surrounding fears of ill health.
  • Can cause healthcare avoidance or recurrent presentation to health services despite reassurance
  • May be experiencing organic physical symptoms, medically unexplained symptoms or no symptoms at all
  • Hyper-vigilance can cause patients to develop new physical symptoms
  • People with medically unexplained symptoms may not have any illness anxiety and are often concerned about a specific disease but react well to reassurance and explanation
36
Q

What issues do patients with Medically unexplained symptoms have

A
  • Difficulty accepting explanation may continue to seek a ‘biomedical explanation
  • Searching for alternative diagnosis can delay acceptance and treatment
  • Can cause loss of trust in doctors when expectations aren’t filled
  • Stigma- doctors may incorrectly assume its due to mental health issue
  • Friends and family thinking they are lazy its in there heads
  • Disjointed care if under multiple different specialities and receive multiple diagnoses
37
Q

How to describe medically unexplained symptoms to a patient

A
  • Use examples to explain the mind brain connection i.e. the feeling of a lump in your throat when sad
  • Requesting investigations - explain that they may be normal but that this is common and you have a diagnosis in mind if that’s the case
  • Empower patients to feel in control of their bodies. Can trial symptom diaries including tracking effects of mood, stress and coping strategies such as mindfulness or CBT.
  • Don’t assume all patients have MH disorder and if they do don’t attribute all their symptoms to it
  • MDT approach: physiotherapy, psychiatry, psychology, social prescriber, pharmacist etc
38
Q

Harms of over investigation

A
  • Delay in reaching a diagnosis, patient acceptance and management
  • Precipitate or perpetuate illness anxiety, or put patients through stress of awaiting results which may reveal a serious diagnosis e.g. cancer, despite being extremely unlikely.
  • Dis-empower patients and lead to an increased external locus of control, increasing dependence on healthcare and clinicians.
  • Repeated scans can increase radiation exposure.
  • Iatrogenic harm through invasive investigations e.g. biopsies, surgery.
  • Unnecessary costs to the NH
39
Q

What are the challenges for clinicians who diagnose medically unexplained symptoms

A
  • accepting uncertainty and fear of missing serious disease
  • difficulty differentiating with co-existing organic pathology
  • multi-system problems raised at once which can be overwhelming in a time limited consultation
  • own assumptions can affect patient assessment
  • effect on doctor-patient relationship e.g. pressure to meet patient expectation of clear diagnosis, dealing with a patient with pre-existing frustration or mistrust due to previous experience
  • disjointed care due to involvement from multiple specialities with contradicting care plans and multiple diagnostic labels
40
Q

The 2 causes of abdo pain

A
  • Organic: can be explained by a structural or biochemical cause. Can be identified on investigations i.e. scans or blood tests
  • Functional: symptoms of GI dysfunction or pain without a known underlying pathophysiology. Investigation results are normal
41
Q

Challenges the patient may face with medically unexplained symptoms

A
  • Conditions can be challenging to treat/gain symptomatic relief
  • Difficulties with diagnosis acceptance
  • Possible co-morbid psychiatric/psychological/social issues
  • Bias from clinicians/society
  • Harms from over-investigation and under-investigation
  • Time-stretched clinical services
42
Q

Functional causes of persistent abdo pain

A
  • IBS: pain relieved by defecation. Change in bowel habit, constipation, bloating may be present
  • Functional dyspepsia: fullness after eating and early satiety. Epigastric pain and N+V may be present
  • Centrally mediated abdo pain syndrome: pain is the principle feature. Eating and defecating do not change pain
  • Abdominal migraine: mostly in childhood. Recurrent pain attacks lasting up to 72 hours.
43
Q

IBS

A
  • Functional bowel condition causing altered bowel habit and pain
  • Also associated with lethargy, nausea, backache and bladder dysfunction
  • Can develop after an episode of gastroenteritis
  • Depression and anxiety are more common among IBS patients
  • IBS patients tend to have a predominant constipation type, diarrhoea type or mixed
  • No known cause
  • Examination and investigations are generally normal
44
Q

IBS diagnosis

A
  • Characterised by 6+ months of either:
  • A: Abdominal pain (cramping) often relieved by defecation
  • B: Bloating
  • C: Constipation (+/- diarrhoea) - altered bowel frequency or form, mucous may be present in the stool
  • Associated with lethargy, nausea, backache and bladder dysfunction
  • Depression and anxiety are common among IBS symptoms
  • IBS co-exist among GI disease
45
Q

Red flags for further investigations in functional abdo pain

A
  • Rectal bleeding
  • Unexplained weight loss
  • FH of bowel/ovarian cancer
  • Age >60 + >6 weeks change to bowel habit
  • Anaemia
  • Abdominal/rectal masses
  • Raised inflammatory markers
46
Q

Recommended tests for IBS

A
  • Bloods: FBC, CRP, LFT, ESR, Anti-ttg (coeliac), faecal calprotectin (if symptoms can be explained by IBD)
  • Tests which are only indicated if red flags present: Sigmoidoscopy, Colonoscopy, US, TFT, faecal occult blood, Hydrogen breath test
47
Q

Functional dyspepsia

A
  • Issue with upper GI pain and delayed gastric emptying
  • Symptoms include dyspepsia, nausea, early satiety, bloating, increased burping, fullness after eating, epigastric pain
  • Investigations: bloods, H.pylori testing, endoscopy (looking for ulcers, inflammation and malignancy)
  • Screen for red flags and ALARM symptoms in dyspepsia
  • Diagnosed once organic diseases are ruled out
  • May have IBS as well
48
Q

Centrally mediated (functional) abdominal pain

A
  • > 6 months of abdominal pain with no explained organic cause
  • Rome III criteria defines: pain is nearly continuous for at least 3 months. Not or minimally relating to eating/defecation/menses. Impairs daily functioning. Not attributable to another medical condition
  • Around 2% prevalence, more common in females and younger adults/adolescents
  • Increased prevalence in patients with life/social stressors, which can be a precipitating or perpetuating factor.
49
Q

Abdominal migraine

A
  • Primary found in children
  • Paroxysmal episodes of central abdominal pain, lasting >1 hour.
  • Associated with: nausea, vomiting, loss of appetite and sometimes headache/photophobia.
  • Long symptom-free periods in between episodes.
  • Children with abdominal migraines may go to develop headache migraines in adolescence/adulthood.
50
Q

Functional abdo pain pathophysiology

A
  • Include gut function, motility disruption, gut microbiota alteration, biochemical changes and psychological factors
  • A combination of factors can lead to hypersensitivity to pain from the gut
  • Increased rates of mental health i.e. depression and anxiety
  • Particularly noted in paediatrics i.e. butterflies in stomach when anxious

year 4 CDM 2 (39 decks)

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