chronic pain Flashcards
what is pain
An unpleasant sensory
and emotional experience
associated with actual or
potential tissue damage,
or described in terms of
such damage.
“A multiple system output
activated by the brain
based on perceived
threat”
pain metaphors
Alarm System
* Overflowing cup
* Phantom pain
* Virtual reality CROM
chronic primary pain
“Chronic primary pain is pain in 1 or more anatomic
regions that persists or recurs for longer than 3
months and is associated with significant emotional
distress or significant functional disability
(interference with activities of daily life and
participation in social roles) and that cannot be
better explained by another chronic pain condition.
complex regional pain syndrome (CRPS)
Formerly referred to as reflex
sympathetic dystrophy (RSD)
* Etiology unknown, likely multifactorial
* Local inflammatory cascades
* Direct small fiber nerve injury
* Dysfunction of sympathetic nervous system
* Central pain processing
* Emotional responses to painful stimuli
* Possible autoimmune process
* Genetic factors may be involved
signs and sympotms of CRPS
pain out of proportion
movement disorder
insomnia
neurogenic swelling/edema
changes in skin color
hyperemia
hyperesthesia
body temp asymmetry
visceral pain
hyperhidrosis
burning pain
tremor
nail and hair changes
CRPS type 1
occurs following trauma 90% of cases
CRPS type 2
related to direct injury to a nerve
CRPS budapest criteria
- Continuing pain, which is disproportionate to any inciting event
- Must report at least one symptom in three of the four following categories:
- Sensory: reports of hyperesthesia and/or allodynia
- Vasomotor: reports of temperature asymmetry and/or skin color changes and/or skin color asymmetry
- Sudomotor/edema: reports of edema and/or sweating changes and/or sweating asymmetry
- Motor/trophic: reports of decreased range of motion and/or motor dysfunction (weakness, tremor, dystonia)
and/or trophic changes (hair, nail, skin) - Must display at least one sign at time of evaluation in two or more of the following categories:
- Sensory: evidence of hyperalgesia (to pinprick) and/or allodynia (to light touch and/or deep somatic pressure
and/or joint movement) - Vasomotor: evidence of temperature asymmetry and/or skin color changes and/or asymmetry
- Sudomotor/edema: evidence of edema and/or sweating changes and/or sweating asymmetry
- Motor/trophic: evidence of decreased range of motion and/or motor dysfunction (weakness, tremor, dystonia)
and/or trophic changes (hair, nail, skin) - There is no other diagnosis that better explains the signs and symptoms
allodynia testing
Assessed by brushing the skin with a
cotton whisp, paint brush, or graded
stimuli (von Frey filaments/Semmes
Weinstein monofilaments)
* Indicative of a central component to pain
chronic widespread pain (CWP)
“diffuse pain in at least 4 of 5 body regions
and is associated with significant emotional
distress (anxiety, anger/frustration or
depressed mood) or functional disability
(interference in daily life activities and
reduced participation in social roles)”
fibromyalgia FM
- Widespread pain
- Determined w/ Widespead Pain Index
and Symptom Severity Scale - Symptoms 3 mo. or more
- No other disorder would explain pain
FM etiology
Unknown
* Possibly a final common pathway leading from
different pathophysiologic mechanisms
*Central sensitization
* Sympathetic nervous system dysfunction
* increase proinflammatory & decrease anti-inflammatory
cytokine profiles
* Small fiber pathology
FM treatment
- Treatment should be individualized
*Consider Associated Conditions
*Mental Health Problems
*Chronic Overlapping Pain Conditions - Other somatic disease
*Consider disease severity
FM guidelines
The European League Against Rheumatism
* Tailored approach directed at key symptoms (pain, sleep
disorders, fatigue, depression, disability)
German
* Management tailored to severity
* Mild disease not requiring any specific treatment
* Severe disease multicomponent therapy (drug
treatment, aerobic exercise, psychological treatments)
chronic overlapping pain conditions
Vulvodynia
Temporomandibular disorders
Myalgic encephalomyelitis/chronic fatigue syndrome (ME/CFS)
Irritable bowel syndrome
Interstitial cystitis/painful bladder syndrome
FM
Endometriosis
Chronic tension-type headache
Chronic migraine headache
Chronic low back pain
post exertional malaise (PEM)
Worsening of symptoms following minor physical or mental
exertion that would have been tolerated previously.
* Symptoms typically worsen 12 to 48 hours after activity
* can last for days or weeks
* First described in ME/CFS
* Linked to Long COVID & FM
PEM and pacing
Patients determine individual limits for mental and
physical activity.
* Use of activity and symptom diaries may help patients
identify their “energy envelope.”
- “Healthcare providers need to be aware that their
patients’ ability to function may seriously deteriorate if
they exceed their individual capacities. In general, patients
should not push themselves beyond their capacities as
this may exacerbate their symptoms and trigger PEM.”
myofascial pain syndrom (MPS)
Characterized by trigger points (TrP)
* Active TrP is any point that causes tenderness
and referred pain on palpation. Palpation may
also cause autonomic symptoms such as skin
redness, sweating, and dizziness.
* Latent TrP does not evoke pain spontaneously,
and local or referred pain occurs only with
strong digital pressure. They may change
muscle activation patterns or cause muscle
weakness in pain
-free patients.
* Reproduction of painful symptoms is the
diagnostic criterion differentiating between the
two
Definition varies
* Reported lifetime incidence of 85%
* 77.7% of asymptomatic individuals have
Latent TrP in LEs
* Intervention directed at trigger points
sleep hygiene
Go to bed and get up at the same
time every day
* Keep your bedroom quiet, relaxing,
and at a cool temperature
* Turn off electronic devices 30
minutes before bedtime
* Avoid large meals and alcohol
before bedtime
* Avoid caffeine in the afternoon or
evening
* Exercise regularly and maintain a
healthy diet
a sleep diary
- A sleep diary should include when you:
- Go to bed
- Wake up during the night
- Wake up in the morning
- Take naps
- Exercise
- Drink alcohol or caffeinated drinks
- Take medications
how to refer someone to a mental health provider
make it about the patienns goals
- “Seems like the headaches you are getting are really
hassling you at work, and it seems like they get worse
with stress. Therapy can help with that and it might
make you less miserable at work and home.”
make it optional
* “It’s not a requirement, just a thought.”
* “It’s really up to you,”
make it conditional
- only commiting to one visit
- being clear length of tx and level of commitment is up to them
don’t make promises
how to practice graded motor imagery 3 sequential parts
Practice in each stage lasts from 1
visit up to about two weeks
- Progress to next stage when affected
limb is performing near equal to
unaffected without elevated pain sensations
the therapist working with the patient is more like a coach or supervisor
- Patients practice hourly (frequency
of practice is critical) - Return to graded activity should be
included when symptoms are
controlled
mirror movements
- Sit comfortably
- Jewelry and clothing off both limbs
- Affected limb in the box and forget about it
- Move unaffected hand in various ways while
looking in the mirror - Progress to replicating movements of the
unaffected hand with affected hand (while still
in mirror) - Vary speed, size, intensity of movements with
unaffected hand, replicate with affected hand - Accuracy important, illusion must be complete,
movement of the unaffected limb must be
accurate
graded motor imagery
left/right discrimination
explicit motor imagery
mirror therapy
graded motor imagery
a treatment for CRPS
- strong evidence of effficacy
- no known risks
- minimal side effects
it is a sequential process of laterality recontruction, motor imagery and mirror therapy (think graded exercise)
it gives people who have pain when just thinking about moving something positive to work on
3 sequential parts to graded motor imagery
laterality training
- recognizing pictured hands or feet as being left or right
imagery
- imagined movements or postures of affected limb
mirror box therapy
- mirror movements
