Case 18: chronic pain Flashcards
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
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
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
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
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
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
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
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
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
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
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
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
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
14
Q
Renal WHO pain ladder
A
- Mild pain: Paracetamol, avoid NSAIDS
- Moderate: Hydrocodeine, Oxycodone, Tramadol
- Severe pain: Hydromorphine, Alfentanil
15
Q
Amitryptyline
A
- Given for neuropathic pain
- Cautions: arrhythmias, IHD, HF
- Side effects: dry mouth sedation
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
17
Q
Pregabalin
A
- Controlled drug
- Given for neuropathic pain (first line)
- Cautions: heart failure, renal impairement
- Side effects: prolonged QTc, blurred vision
18
Q
Duloxetine
A
- Indications: diabetic peripheral neuropathic pain
- Cautions: bleeding disorders, cardiac disease, elderly
- Side effects: anxiety, decreased appetite
19
Q
Carbamazepine
A
- Indications: trigeminal neuralgia
- Cautions: arrhythmias, previous bone marrow suppression
- Side effects: dizziness
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.
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
