Chronic Pain

Question 1

Chronic pain definition and timeframe

Answer 1

Pain that endures as a result of unresolved local injury or perpetuation of pain after apparent resolution of local injury

> 3 months

Question 2

Branches of pain

Answer 2

Organic or idiopathic (psychogenic)

Organic pain= nociceptive or neuropathic

Nociceptive pain=somatic or visceral

Question 3

Somatic pain

Answer 3

Activation of nociceptors in peripheral tissues, well localized stabbing/aching/throbbing

Question 4

Visceral pain

Answer 4

Poorly localized, not attributable to involved organ, dull/achy/crampy/deep

Can be referred in dermatomal distribution as the autonomic fibers innervate organs or hollow viscera found in the dermatome

Question 5

Dysethesia

Answer 5

Altered or abnormal sensations

Question 6

Paresthesia

Answer 6

Sensation of electrical shock

Question 7

Hyperalgesia

Answer 7

Increased sensitivity to painful stimulation

Question 8

Allodynia

Answer 8

Pain resulting from ordinarily nonpainful causes like cool air or light touch

Question 9

Clinical presentation of chronic pain

Answer 9

Disparity between objective and subjective because autonomic nervous system adapts to chronicity of pain resulting in lack of signs of heightened sympathetic activity

Concomittant anxiety, depression or other psychiatric conditions

Chronic pain syndrome dx if chronic pain is compunded by psychological and behavioral changes that lead to functional impairment and emotional distress; may manifest distress through relationship difficulties, decreased coping abilities or inability to work

Pattern of excessive health care system use

H/o prolonged or excessive use of opiates

Question 10

Pain assessment

Answer 10

1 past relevant health issues
2 psychiatric hx
3 psychosocial factors
4 addiction risk
5 functional assessment
6 goals of treatment
7 current meds OTC/herbal remedies
8 s/sx of depression (fatigue, insomnia, decreased appetite, decreased activities)
9 ADLs
9 functional capacity
10 how would easing or absence of pain improve QOL

Question 11

PQRST pain assessment

Answer 11

Provocative-palliative factors
Quality
Region or site
Severity
Temporal or timing

Question 12

Diagnostics for chronic pain

Answer 12

EKG, xray, CBC, SMA 20, UA, EMG

Question 13

Three step analgesic ladder

Step 1

Answer 13

Step 1 nonopioids + adjuvant

NSAIDs, TCAs, SSRIs, anticonvulsants, antiarrhythmics

NSAIDs not proven alone in chronic pain, but proven in acute pain (ibuprofen, naproxen, celecoxib)

TCAs treat depressive aspects and physiologic nerve pain; lower dose in elders; primary SE=sedation; ALWAYS try a second drug if one fails in this class; other SEs=dry mouth, constipation and grogginess

SSRIs for patients not responsive to TCAs; SEs=rash, urticaria, dizzy, drowsy

Anticonvulsants treat neuralgia and paresthesia; low dose at HS; blood levels should be same as treatment for sz; consider lidocaine patch

Question 14

Three-step Analgesic Ladder

Step 2

Answer 14

Step 2 mixed opiate products

Hydrocodone and acetaminophen (vicodin, lortab)

Oxycodone and acetaminophen (percocet),

Codeine phosphate and acetaminophen (tylenol #3)

Codeine

Tramadol (ultram) synthetic opioid may initiate addiction

Ultracet (tramadol with acetaminophen)

SEs=drowsy and constipation

Question 15

Three-step analgesic ladder

Step 3

Answer 15

Step 3 pure opioid components

Morphine, fentanyl, oxycodone, methadone, hydromorphone

DO NOT USE meperidine (demerol) for chronic pain d/t long-acting metabolites r/o CNS toxicity and repetitive injections can cause skin problems

Question 16

Nonpharmacologic intervention

Answer 16

Nutritional supplements, spiritual healing, massage, meditation, acupuncture, biofeedback, guided imagery

Question 17

Consultations

Answer 17

Social work, psychology, psychiatry, substance abuse counselor, specialist; ensure prescriptions go through one provider

Question 18

Rehabilitation assessment

Answer 18

Functional history: ADLs (current and before illness), home and community mobility, degree of assistance required, use of assistive devices (wheelchair, walker, canes, prosthetics, orthotics), architectural barriers in patient’s environment, family/social support, use of community support services

Functional assessment: self-care act (dress, bathe, toilet, groom, hygiene, eat), mobility (ambulation, transfers, bed and wheelchair mobility), social and cognitive functioning and safety awareness

Question 19

Functional Independence Measure (FIM)

Answer 19

Tool used to establish baseline functional abilities, measure treatment outcomes, facilitate communication with rehab team

Question 20

Goal of rehab therapeutic exercise

Answer 20

Mobilization, prevent skin breakdown/pneumonia/atrophy/contractures/deconditioning from immobility

Question 21

Home evaluation

Answer 21

Performed by OT, PT, home health nurses to ID equipment needs, environmental and architectural barriers or other safety hazards