Chronic Pain Flashcards
Pain =
unpleasant sensory
and emotional experience
associated with actual or
potential tissue damage
multiple system output
activated by the brain
based on perceived
threat
Pain Metaphors & Examples:
- Alarm System
- Overflowing cup
- Phantom pain
- Virtual reality CROM
Alarm System:
Pain is like an alarm system in your body
When something is wrong, the alarm goes off to alert you to potential damage or danger
Overflowing Cup:
Your body can handle a certain amount of stress, pain, or discomfort (like a cup being filled with water)
Once that cup overflows, you experience pain or a flare-up of symptoms
Phantom Pain:
Phantom pain is the sensation of pain in a part of the body that is no longer there, often experienced after limb amputation
It’s as if the brain has a “map” of the missing limb, and even though it’s gone, the brain still perceives signals from it
Virtual Reality CROM (Cervical Range of Motion):
Virtual reality (VR) is used to help distract or retrain the brain’s perception of pain by immersing someone in a different environment.
In the context of cervical range of motion (CROM), VR can be used to help guide neck movements while distracting from the discomfort
Chronic Primary Pain =
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
CRPS
Signs/Symptoms
pain out of proportion to the inciting injury
movement disorder (weakness, spasms, dystonia, myoclonus, atrophy, decreased ROM)
insomnia, sleep disorder
neurogenic edema/swelling
changes in skin color
hyperemia
hyperesthesia
body temp asymmetry
symptoms spread to other limbs
visceral pain
hyperhidrosis
burning pain
tremor
nail changes
hair change
CRPS type I =
Occurs following trauma (fractures, surgery, sprains)
90% of cases
formerly known as Reflex Sympathetic Dystrophy or RSD
Includes pain, swelling, and changes in skin color and temperature, often out of proportion to the initial injury
CRPS type II =
related to direct injury to a nerve
formerly known as Causalgia
less common, making up a smaller portion of CRPS cases
Similar to CRPS I but typically with more defined nerve-related symptoms like burning pain, often in the distribution of the injured 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:
- Must display at least one sign at time of evaluation in two or more of the following categories:
- There is no other diagnosis that better explains the signs and symptoms
CRPS Budapest Criteria
symptoms: (need at least 1)
- 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)
CRPS Budapest Criteria
signs: (need at least 2)
- 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)
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
CRPS: clinical recommendations
B-level evidence
evidence suggests that biphosphonates and a short course of oral corticosteroids significantly improve pain in patients with CRPS
expert guidelines and systematic review of small clinical trials
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)
a patient satisfies diagnostic criteria for fibromyalgia if the following 3 conditions are met:
1) widespread pain index (WPI) >7 and symptom severity (SS) scale score >5 or WPI 3-6 and SS scale of >9
2) symptoms have been present at a similar level for at least 3 months
3) patient does not have a disorder that would otherwise explain the 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
German: Management tailored to severity
The European League Against Rheumatism
Tailored approach directed at key symptoms (pain, sleep disorders, fatigue, depression, disability)
German: Management tailored to severity
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
Vulvodynia:
Chronic pain or discomfort around the opening of the vagina (vulva) without an identifiable cause
Burning, stinging, irritation, or rawness, often aggravated by touch or pressure (e.g., during intercourse, tampon use)
Temporomandibular Disorders (TMD):
Conditions affecting the jaw muscles, temporomandibular joints, and nerves
Jaw pain, difficulty chewing, headaches, and clicking or locking of the jaw
Myalgic Encephalomyelitis/Chronic Fatigue Syndrome (ME/CFS):
A complex disorder characterized by extreme fatigue that doesn’t improve with rest
Fatigue, muscle pain, cognitive issues, unrefreshing sleep, and post-exertional malaise (worsening of symptoms after activity)
Irritable Bowel Syndrome (IBS):
A common disorder affecting the large intestine, characterized by abdominal pain and altered bowel habits
Abdominal pain, bloating, gas, diarrhea, constipation, or a mix of both
Interstitial Cystitis/Painful Bladder Syndrome (IC/PBS):
Chronic bladder pressure and pain, often without infection
Pelvic pain, urinary urgency and frequency, discomfort with bladder filling
Fibromyalgia (FM):
A disorder characterized by widespread musculoskeletal pain, often accompanied by fatigue, sleep, memory, and mood issues
Chronic pain, tenderness, cognitive dysfunction (“fibro fog”), and sleep disturbances
Endometriosis:
condition where tissue similar to the lining of the uterus grows outside the uterus, causing pain
Pelvic pain, painful menstruation, pain during intercourse, and infertility
Chronic Tension-Type Headache:
common type of headache characterized by a dull, aching head pain, often related to muscle tension
Bilateral, mild to moderate pain that feels like pressure or tightness around the head
Chronic Migraine Headache
Migraine headaches that occur 15 or more days per month, lasting for at least 4 hours per day
Throbbing or pulsating pain, often on one side of the head, sensitivity to light and sound, nausea, and sometimes aura (visual disturbances)
Chronic Low Back Pain:
Persistent pain and discomfort in the lower back lasting longer than 3 months
Dull, aching pain in the lower back, radiating pain down the legs (sciatica), stiffness, and difficulty with mobility
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 week
First described in ME/CFS
Linked to Long COVID & FM
PEM & 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
“Boom and Bust Cycle”
happens when people with chronic conditions, such as ME/CFS or fibromyalgia, overexert themselves on “good” days (the boom) by doing more than they can handle, leading to a bust—a period of severe symptoms and exhaustion (PEM)
After the bust, they may need extended rest, and once they feel slightly better, they may “boom” again, repeating the cycle
Breaking the Boom-Bust Cycle:
Pacing is the key to breaking this cycle.
By learning to listen to the body, set realistic limits, and gradually increase activity within a manageable range, a person can avoid the extremes of “boom” and “bust.”
The focus is on maintaining a consistent level of energy expenditure and reducing symptom flare-ups.
Pacing Strategies:
Plan activities: Break tasks into smaller steps and spread them out over time.
Set limits: Stop activities before reaching the point of fatigue, even if you feel capable of doing more.
Rest: Schedule regular rest periods, even when not feeling tired, to avoid overexertion.
Track energy: Keep a diary to monitor activity levels and symptom patterns to identify limits.
Myofascial Pain Syndrome (MPS): Characterized by ___
trigger points (TrP)
Reproduction of painful symptoms is the
diagnostic criterion differentiating between the two
Active TrP =
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 patient
Myofascial Pain Syndrome (MPS) =
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
Keep your bedroom quiet, relaxing, and at a cool temperature
Turn off electronic devices 30
minutes before bedtime
Avoid large meals and alcohol
Avoid caffeine in the afternoon or
evening
Exercise regularly and maintain a healthy diet
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 patient’s goals
Make it optional
*It’s not a requirement, just a thought
Make it conditional
*Only committing to one visit
*Being clear length of treatment and level of commitment is up to them
Don’t make promises
Graded motor imagery
3 sequential parts
1) laterality training
2) imagery
3) mirror box therapy
Laterality Training:
This involves identifying images of the affected body part as being either left or right
This step helps improve the brain’s ability to recognize the limb’s position and distinguish between left and right
It stimulates the brain areas responsible for movement without actually moving the body
Imagery (Motor Imagery):
The patient visualizes themselves moving the affected body part without actually performing the movement
The goal is to activate the motor networks in the brain, which improves motor planning and reduces pain perception
Mirror Box Therapy:
In this stage, the patient performs movements of the unaffected limb while watching its reflection in a mirror
The brain perceives the reflection as the affected limb moving, which can help reduce pain, improve motor control, and restore movement in the affected limb
Graded motor imagery:
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
Patients practice hourly (frequency of practice is critical)
Return to graded activity should be included when symptoms are controlled
Mirror movements guidelines:
- 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 sequence:
L/R discrimination
explicit motor imagery
mirror therapy
