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Neuro: Clin Med IIB > Chronic Pain > Flashcards

Chronic Pain Flashcards

1
Q

MC reason pts seek medical care; more than DM, heart dz and cancer combined

A

pain

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2
Q

difference between chronic vs acute pain?

A

The separation between the acute phase and chronic phase is usually at the 3 month point, or after 90 d of continued pain

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3
Q

Constant chronic pain will allow for ____, leading to normal BP, heart rate, respirations.

A

physiologic adaptation

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4
Q

Intermittent chronic pain will imitate _____, and physiologically cannot adapt.

A

acute pain

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5
Q

Imaging studies have shown that chronic pain is associated with changes in the brain, what are the main findings?

A
  1. decreases in gray matter —mainly in brainstem and somatosensory cortex
  2. altered brain chemistry
  3. structural changes in nerve tracts
  4. altered brain network connectivity

= altered behaviors

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6
Q

what is the relationship between time of intervention and chronic pain

A

earlier the intervention, the better success rate for tx

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7
Q

what are the three neurotransmitters that have an excitatory effect?

A
  1. substance P
  2. CGRP
  3. glutamate

everything else is inhibitory

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8
Q

40-50 m/sec; Thick myelination. Low threshold, mechanoreceptors. Fastest. Light touch, Pressure, hair movement. Not usually pain.

which primary afferent fiber?

A

A-beta

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9
Q

(>10 & <40 m/sec), Thinly myelinated. high & low threshold mechanical & thermal receptors. The first, ‘sharp’ and ‘intense’ pain sensation.

which primary afferent fiber

A

A-delta

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10
Q

(<2 m/sec), Unmyelinated. Free nerve endings, High threshold to thermal, mechanical or chemical insults. 75% of all afferent fibers. Prolonged, ‘burning’ that follows the initial A-delta stimulus.

which primary afferent fiber?

A

C

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11
Q

The cell body lies outside of the CNS in the ?

A

dorsal root ganglia?

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12
Q

The nerve then enters the spinal cord via the ?

A

dorsal (posterior) root.

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13
Q

First neuron synapse occurs at _____, and ______

A

spinal dorsal horn (nociception from primary afferents)
dorsal column nuclei (A-betas, light touch)

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14
Q

an instantaneous movement caused by the stimulus

A

reflex arc

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15
Q

what part of the brain releases NT and hormones to modulate and inhibit pain?

A

hypothalamus

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16
Q

difference between white vs gray matter?

A

white matter
- myelinated
- longitudinal tracts
- up and down
- signal conduction
gray matter
- segmentary structure
- side to side
- siganl process
- nerve roots are also gray matter

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17
Q

Regions of body where you might feel sensation
Related to spinal column and spinal cord

A

dermatomes

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18
Q

three main types of pain

A
  1. nociceptive (MC)
  2. neuropathic
  3. psychogenic
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19
Q

Aberrant activation of pain sensitive afferent peripheral nerves, due to noxious stimulation of somatic or visceral structures (i.e., celiac plexus.)

what type of pain?

A

nociceptive

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20
Q

nociceptive pain stems from activation of what type of fibers?

A

A-delta and C fibers by noxious stimuli

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21
Q

common nociceptive pain disorders

A
  1. Failed Back Surgery Syndrome
  2. Mechanical Spine disorders
  3. Arachnoiditis
  4. Degenerative Disk Disease
  5. Facet Joint Arthropathy
  6. Sacroiliitis
  7. Arthritis; OA, RA, Gout
  8. Cancer
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22
Q

Abnormal somatosensory processing in the PNS or CNS due to a primary lesion, neural injury or irritation, or
dysfunction.
Burning, stabbing, electrical sensations.

what type of pain?

A

neuropathic pain

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23
Q

Activation of what by glutamate increase spinal neuron sensitization
which increases perception of
pain?

A

NMDA receptors

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24
Q

When innocuous stimuli is painful; bedsheets, air, light touch.

what type of focal neurologic deficit?

A

allodynia

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25
Q

abnormal pain ‘like fire’

what type of focal neurologic deficit?

A

dysesthesia

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26
Q

increased perception of noxious stimulation; hurts worse than it should

what type of focal neurologic deficit?

A

Hyperalgesia

27
Q

6 focal neurologic deficits

A
  1. allodynia
  2. dysesthesia
  3. hyperalgesia
  4. edema
  5. vasomotor changes
  6. trophic changes
28
Q

common neuropathic pain disorders

A
  1. Diabetic neuropathy - Peripheral Nerve Injury, Reflex sympathetic dystrophy/CRPS I: No known obvious nerve injury.
  2. Complex Regional Pain Syndrome II/Causalgia
  3. phantom limb and post-amputation pain
  4. Post-herpetic neuralgia
  5. Central pain syndrome–CVA, MS, ALS, tumors, epilepsy, brain or spinal cord trauma, or Parkinson’s
    disease
  6. Trigeminal Neuralgia/tic doloureux/Atypical TN
  7. Occipital Neuralgia
  8. Ilioinguinal Neuritis
  9. Post-CA treatment pain; radiation/chemotherapy
29
Q

difference between nociceptive vs neuropathic pain?

A
  1. nociceptive
    - Mediated by receptors in the viscera, bone, dermis, muscle and connective tissues
    - Exacerbated by positional change or
    activity
    - Usually opiate sensitive
  2. neuropathic
    - Damaged or dysfunctional nerve
    tissue or damage to the CNS
    - Resultant from tissue injury or pathology induced injury
    - Usually not opiate sensitive
30
Q

Persistent and chronic pain at one or more sites in which psychological factors are thought to play a role.

what type of pain?

A

Pyschogenic pain/Somataform disorder, defined

No nociceptive or neuropathic mechanisms
Not necessarily associated with secondary gain
Commonly linked with depression
Psychiatric and behavior management a must
Low rate of recovery

31
Q

purpose of Pain Agreement?

A

To encourage patient compliance.
To facilitate an understanding between the patient and the doctor regarding the use of scheduled medications.

32
Q

what is the pain agreement?

A
  1. not a legal doc
  2. DEA still breathes down your neck
  3. will help as long as YOU follow terms of the agreement
    - frequent UDS
    - pill counts
    - communication with PCP
    - pharmacists, consultants, and the local authorities.
  4. ensure policy that unless pt has SE/allergy that the meds will not be changed until next refill is due
  5. insist f/u visits for med changesl avoid extensive use of phone-ins
33
Q

With the pain agreement, the pt must:

A
  1. agree to one prescriber for meds
  2. must agree to undergo screening for compliance; UDS, saliva tests, serum testing
  3. agree that lost/stolen meds will not be replaced
    - don’t forget to raper if necessary to avoid withdrawal. agree to replace only if pt provides police report
  4. report one pharmacy for meds and should report if they change pharmacies
  5. bring back unfilled scripts and unused meds back for destruction
34
Q

what adjuvant meds have a pain agreement?

A
  1. benzo
  2. class IV/V meds
35
Q

Quick and good for acute pain, but
doesn’t demonstrate progressive
response to treatment accurately
for chronic pain.

A

Wong-Baker FACES scales

36
Q

which pain questionnaire is for assessing the whole body?

A

McGill pain questionnaire

37
Q

Provides a baseline to review and
accurately determines response
over time.

A

Brief Pain Impact Questionnaire

38
Q

common diagnostic testing for pain

A

imaging: MRI/CT, xray, motion XR, US
NCS/EMG (electromyography)
bone scan
serum - CMP, thyroid, B12, DM, HgbA1C, RA panel, Lupus panels
Discography

39
Q

a heightened response to a stimulus that causes pain

what is this term

A

hyperalgesia

diminished pain in response to a normally painful stimulus = hypo

40
Q

what spinal PE test is used to test for HNP of the L-spine

A

SLR
Must be supine, reproduction of sciatica 30-70 degrees = Positive

Crossed SLR: +SLR on asx leg = high suspicion for HNP

41
Q

crosses affected side, ankle on knee, compress flexed knee to check for SI issues or hip joint pathology

what is this spinal PE test?

A

patrick’s/faber

42
Q

how to do zygomatic joint loading?

A

rotation and flexion of spine
elicits pain at contralateral facet joints

43
Q

foot drop-toe dragging (steppage gait) is indicative of what?

A

inability to walk on heels; think L5 root compression, peroneal nerve damage, sciatica, cauda equina syndrome

44
Q

what is the piriformis stretch?

A

Lat decubitus position, flex hip and knee of upper leg; positive if downward pressure produces pain from buttock to leg.

45
Q

what is spurling’s test?

A

extend, rotate and tilt head then compress head; if radicular to ipsilateral side, then possible nerve root compression in mid or lower C-spine.

46
Q

what is the axial copmression?

A

compression of C-spine by pressing on the head; positive neck pain or radiation=possible DJD or upper
C-spine nn impingement.

47
Q

what is the Waddell’s Signs-malingere

A

Nonsensical/non-anatomical pain
Axial loading of skull producing low back pain
Rotation of shoulders and hips simultaneously with feet planted causing low back pain
SLRs differ when sitting or supine
Unexplained sensory pain or motor
weakness non-dermatomally

48
Q

what is the hoover’s test?

A

supine, ask to lift weak leg. With both hands on heels, true ataxia will cause good leg to press down against your hand. Feigned weakness will not show that the good leg is supportive.

49
Q

what is Embellishment of arm weakness

A

when testing for UE strength, a ratcheting ‘give-way’ weakness is elicited in the ‘bad’ arm. Testing both at same time you will notice that both arms ‘give-way.’

50
Q

initial tx for pain

A
  1. PT/OT, return-to-work programs
  2. Surgical evaluation/treatment
  3. wt loss and lifestyle changes
  4. PO steroids, NSAIDs and other OTCs
  5. Antidepressants
  6. Membrane stabilizers/Anticonvulsants
  7. Antispasmodics
  8. Transcutaneous electrical nerve stimulation; TENS unit or newer E-stim units.
  9. Bracing/orthotics
  10. Anxiolytics (*cautionary)
  11. psychiatric care
51
Q

when to refer for pain?

A
  1. outcomes aren’t successful.
  2. ‘complicated’ pt
  3. clear-cut pathology needs addressed interventionally.
  4. you aren’t comfortable with the tx needed; ie, injections.
  5. maintain a pt in good standing with chronic Rx therapy.
52
Q

interventional pain management injectable options

A
  • myofascial/trigger point injections (also w/ myobloc/botox)
  • peripheral nerve blocks
  • spinal nerve blocks
  • sympathetic nerve blocks/plexus blocks
  • epidurals: transforaminal and interlaminar
  • intra-articular injections
  • facet injections/median nerve blocks
53
Q

Advanced Interventional Pain Management Strategies

A
  • Radiofrequency Ablation (RFA)
  • Chemodenervation
  • Minimally Invasive Lumbar Decompression-MILD
  • Interdiscal radiofrequency ablation
  • Mechanical Spacers for stenosis, SI fusion
  • Spinal Cord Stimulation
  • Peripheral Nerve Stimulation
  • Dorsal Root Ganglion stimulaton
54
Q

what is spinal cord stimulation

A
  1. Stimulation of dorsal column of the spinal cord, dorsal root ganglion, or dorsal root entry zone
  2. For lumbar radiculopathy, peripheral neuropathy, CRPS of the extremities
  3. Used to be difficult to relieve low back pain, but getting much better with higher frequency stimulators
55
Q

ways for peripheral nerve stimulation

A
  1. ilioinguinal neuralgia - ilioinguinal region in the abdomen
  2. somatic peripehral nerves
    - median, ulnar, genicular, etc
    - Causalgia, single nerve RSD,
    post-CVA pain
    - Intercostal nerve; intercostal neuritis, PHN
  3. Occipital nerve
    - Occipital neuralgia, cervicogenic HA
    - Cluster HA, Migraines
  4. Cranial nerves - Trigeminal neuralgia
56
Q

Indications for Motor Cortex Stimulation

A
  • Post-stroke pain
  • Thalamic pain
  • Anesthesia dolorosa “numb pain” 2nry to neurolysis
  • Trigeminal pain
  • Brachial plexus avulsion
  • Stump pain
  • Phantom pain
  • Spinal cord injury pain
  • CRPS Type I (RSD)
  • CRPS Type II (causalgia)
  • Post-herpetic neuralgia
57
Q

indications for deep brain stimulation

A
  1. neuropathic pain
    - anesthesia dolorosa
    - trigeminal nuropathic pain
    - post-strok pain
    - thalamic pain
    - post herpetic neuralgia
    - spinal cord injury
    - peripheral neuropathy
  2. nocioceptive pain
    - failed back syndrome
    - cancer
    - osteroarthritis
58
Q

what is the sprint peripheral stimulator?

A
  • stimulates peripheral nerves
  • outpatient surgery to implant the lead
  • wears stimulator for 2 months
  • then stimulator is removed
  • goal: permanently modulate the nerve after the stimulator is removed
59
Q

limitations of conventional SCS

A
  1. unspecific - stimulation of broad range of nerve fibers versus pain- or disease-specific nerves
  2. unstable
    - postural effects on stimulation
    - lead migration
  3. consuming
    - energy loss to CSF demnds higher output, thereby impacting longevity
60
Q

what is the MILD procedure?

A

tx for pain relief from symptomatic central lumbar canal stenosis

61
Q

common intrathecal meds

A

Morphine
Baclofen
Hydromorphone
Fentanyl
Sufentanil: 7x stronger than fentanyl
Clonidine: decreases sympathetic response and vasomotor associated with neuropathic pain
Bupivacaine: Increases efficacy of
analgesics and for neuropathic pain.
Prialt (zyconotide): from sea snails
Octreotide: synthetic sandostatin (growth hormone)

62
Q

alternative

A
  • Chiropractic
  • Biofeedback and hypnotherapy
  • Dry needling
  • Accupuncture
  • Massage Therapy
  • Non-FDA approved tx, research, and experimental tx (DREZ, brain mapping)
63
Q

CDC Guidelines for Prescribing Opioids for Chronic Pain 2016

A
  1. Nonopioids should be first line therapy
  2. Establish treatment goals,
    discontinuance
  3. Discuss risks and realistic outcomes first
  4. Start immediate-release opioids first
  5. Prescribe lowest effective dosage 50-90 MME
  6. 3-7 days worth of opioids for acute pain
  7. Re-evaluate patient in 1-4 weeks for
    benefit vs harm; q3 months to check
    efficacy and DC or lower dose if no
    positive outcomes
  8. Evaluate risk factors prior to starting opioids; offer naloxone if past risk factors (previous OD, substance disorder) or if benzo use
  9. Review state drug monitoring program to ensure proper dispensing of medications
  10. Urine Drug Testing prior to starting opioids and minimum of annual UDS
  11. Avoid concurrent benzodiazepines and opioids
  12. Arrange tx for pts with opioid use disorder; consider buprenorphine or methadone (suboxone and methadone clinic) in combo with behavioral therapies

Neuro: Clin Med IIB (13 decks)

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