Chronic Pain Flashcards
Pain definition
An unpleasant sensory and emotional experience associated with actual or potential tissue damage
- chronic pain lasts >12 weeks, can evolve from acute pain or have no know cause
- fatigue - insomnia - depression - anxiety - decreased appetite
Pain job
- withdraws us from danger
- protective to help prevent further injury and allow for healing
- teaches us to avoid particular behaviors in the future
- stimulated by thermal, chemical, and mechanical peripheral nerve fibers (A-delta and C-fibers)
- acute pain generally resolves when stimulus is removed or damage is healed
Why is pain a problem
- Most common reason for MD visits
- disability is as likely in the chronic pain population as it is in those with kidney failure, ephysema or stroke
- this is the reality or 11 million US adults with high impact chronic pain
- 4.8 percent of US adult population
- there is no test or imagining that can confirm a diagnosis of chronic pain
Tissue of origin
Pain arises from:
- MSK system: follows strict pattern of s/six, usually sharp pain, aching
- Visceral: usually a diffuse aching with referred pain patterns
- does not decrease with position change - Neuropathic: more vague, described usually as burning or aching
- CPRS, neuralgia, allodynia, sciatica, etc
Clinica presentaitons of pain
The more closely related the s/sx and functional disability fit together, the more likely the pain is acute and amenable to intervention
- conversely, lack of consistency between s/sx and functional disability points to more chronic pain, which may require additional interventions
Acute pain presentation
Elected by acute inflammation and has biological significance to protect wounded tissue
- pain is a symptom
- onset is well defined and pathology is found
- signs of autonomic activity and increased anxiety
- normal response to inflammation and tissue injury
- has biological funciton
- responds to pain treatment and medications
- affects the individual
- fits the medical model
Chronic pain presentation
Is maladaptive, has no beneficial biological significance and is characterized by spontaneous pain (burning) as well as evoked pain
- pain is a disease
- onset is I’ll defined and pathology is not often found
- no or adapted ANS response
- response to change in the NS
- unknow biological function
- less responsive to treatment/meds
- can be associated with depression
- involves other people
- multi-factorial
Neuronal plasticity
- generally believed that it is the pain-coding pathways and circuits resulting in chronic pain
- peripheral sensitization in primary sensory neurons of dorsal root ganglia and trigeminal ganglia
- central sensitization of pain-processing neurons in the spinal cord and brain
- amplification of neural signaling within the CNS that elicits pain hypersensitivity
Allodynia
Pain in response to normally no painful stimuli
Hyperalgesia
Increased pain in response to normally painful stimuli
Functional MRI
Increased activity in specific parts of brain, people with chronic pain with matched non-chronic pain subjects
Conditioned pain modulation
Stimulation with noxious input, cold treatment, then same noxious input
Osteoarthritis
Increased sensitivity to pressure both at OA hip AND on other non-effected side (example of general pattern of pain rather than just local)
Physiological responses to CPS
- neural changes and adaptations within the PNS and CNS lowers the pain threshold
- with prolonged episodes of pain, non-pain receptors may start transmitting pain to CNS
Up regulation
A process that makes cells more responsive to stimuli like hormones by increasing the number of receptors on the surface of the cell
- involves ion channels K, Na, Ca
(Ex: insulin receptors after exercise, oxytocin receptors with late-term pregnancy, nerve hypersensitivity after injury)
Physiological responses to CPS cont
- hormonal chagnes, altered chemical release of neurotransmitters
- decreased endorphin levels
- decreased serotonin levels
- changes in HR, RR, BP due to autonomic nervous system “fight or flight” overactivation
- identification of the initial cause of pain is difficult if not impossible to define: multiple compensations across many body systems
- insomnia - decreased or increased appetite
Physiological effects 3
Usually associated with depression, anxiety, fear, and anger
- pt may become isolated or withdrawn and exhibit self limiting behaviors
- excessive drug use to control pain
- **red flag: pain symptoms are out of proportion to objective findings
Behavioral changes
- difficulty assuming a balance between symptoms and activity with an exacerbation of symptoms trying to appear normal
- fear avoidance behavior / fear of further injury
- exaggeration of symptoms so care providers believe they are in pain
- poor effort with inconsistencies between subjective c/o and objective findings
- **red flag?
Cognitive behavioral therapy
- the idea that our thoughts cause our feelings and behaviors, not external things, like people, situations, and events
- the benefit of this is that we can change the way we think to feel/act better even if the situation does not change
Musculoskeletal common chronic pain syndromes
- fibromyalgia (neuro-endocrine immunologic)
- myofascial pain syndromes
- headaches (cervicogenic)
- chronic neck and lower back pain (arthritics inflammatory, MSK)
Neuropathic common chronic pain syndromes
- neuropathies
- chronic regional pain syndrome
- phantom limb pain
Fibromyalgia
- systemic problem with diffuse and 11/18 tender points
- migraine type pain of the muscles which can be variable, fluctuating
- can occur anywhere in the body, but usually greater above the waist, scapula, head, neck, chest, diaphragm, LB
- fatigue with decreased activity tolerance, likely due to poor sleep
- higher incidence of tendinitis, HA, IBS, TMD, restless leg syndrome, mitral valve prolapse, anxiety, depression, and memory problems
Fibromyalgia 2
- research found pts with fibromyalgia have abnormal C nocioceptors, likely resulting in increased mechanical sensitivity
- increased ion channel
- implied regulation of stress chemicals
- typically aggravated with stress - illness - increases in or too little activity - changes in weather
- typically associated with lack of restorative REM sleep
Fibromyalgia common treatment
- pt edu on ergonomics and body mechanics, stress management, activity modification/pacing, symptom management and care, diet modification, decrease caffeine and alcohol consumption
- regular low intensity exercise and conditioning
- aquatic therapy (neutral-warmer temps)
- meds
- multidisciplinary approach
Fibromyalgia meds
- tricyclics antidepressants: elavil, sinequan
- serotonin norepinephrine reputable inhibitors: Effexor, cymbalta
- alpha 2 delta ligands: lyrica
Myofascial pain syndrome
- symptoms usually isolated to 1 area of the body, unilateral
- characterized by tender/trigger points that have a specific referral patterns when palpated
- occurs secondary to repetitive overuse which can cause: muscle imbalance, lateraled posture and alignment, loss of ROM and strength within involved mm, lupus like disease
- associated with stress, fatigue, and sleep disturbances
Cervicogenic headaches
- prevalence of cervicogenic headaches is estimated to be between 0.4-2.5% among the general population but as high as 20% in patients with chronic headaches presenting in pain management clinics
- 4x more prevalent F > M
- referred pain perceived in any part of the head caused by a primary nociceptive source in MSK tissue innervated by a C nerve
Cervicogenic HA s/sx
Pattern of symptoms start in the posterior aspect of the neck (occiput) and progress to the fronto-ocular, temporal, and/or orbital region
- loss of cervical A/PROM with myofascial trigger points through cervical mm
- symptoms may fluctuate or can be continuous
- can have associated vague ipsilateral shoulder, neck or arm pain without radicular pattern/neurological symptoms
- can be associated with N&V, dizziness, visual blurring, tinnitus and irritability on the side of the HA
Cervicogenic HA
Pain is triggered by cervical motion or positioning: usually into extension or extension/rotation to the involved side
- pain is elicited with palpation to cervical structures on the effected side
- pt will often complain of deep, non-throbbing type pain of moderate-severe intensity
common causes of cervicogenic headaches
- MVA: 8mph and 140 degrees
- postural dysfunctions (micro trauma)
- arthritic changes or spondylosis
- stiffness upon palpation of C1, C2: observed in 80% of patients presenting with chronic headaches
cervicogenic HA treatment
- manual therapy: low grade, low intensity joint mobs and gentle STM
- exercise: spinal stabilization, endurace training, and postural re-ed
- patient education
chronic neck and LBP
- arthritic changes - myofascial involvement - neurological (dermo, myotome) - repetitive overuse - inflammatory - recurrent - fracture - post surgical
peripheral neuropathy
2/3 cases related to diabetes, soaring epidemic
- progressive but reversible disease
- > 45yo
- DMII - HIV/AIDS, RA, SLE, organ failure - environmental exposure and toxins - trauma - hereditary
- management: pt ed on foot checks, fall prevention, appropriate foot/shoe wear, monofilament testing; LASER; improvement of deficient ROM, strength/conditioning; balance training and fall prevention activities
peripheral neuropathy differs from radiculopathy
- stocking or glove effect, usually bilateral but can be asymmetric
- distal to proximal loss of sensation
- pt may c/o sharp, burning type pain, band/compression pressure, progresses to eventual numbness
- loss of sensation, ROM, stability, reflexes and function
Complex regional pain syndrome
chronic neurological syndrome caused by an injury to a nerve or soft tissue that does not follow the normal healing path; can occur as a result of immobilization
- does not appear to depend on the magnitude or severity of the injury. The sympathetic nervous system seems to assume in abnormal function after an injury adn can spread beyond area of injury
1. “fight or flight” increased sympathetic nervous system activity with acute injury, or in response to pain - increased HR and BP, increased sweating, increased anxiety
- abnormal heightened activity o the failure to subside = generalized hypersensitivity and exaggerated response to noxious and non-noxious stimuli
CRPS type I
RSD
- occurs after an illness or injury that didnt directly damage the nerves in the affected limb
- about 90% of peaople with complex regional pain syndrome have type I
CRPS type II
Causalgia
- cases in which a distinct “major” nerve injury has occurred
- ex: forceful trauma such as a crush injury, fracture or amputation
CRPS s/sx
- severe burning, throbbing, aching pain - pathological changes in bone and skin (thin, shiny) - excessive sweating and altered vasomotor responses - tissue swelling and discoloration - extremes sensitivity to touch and cold - changes in hair and nail growth - joint stiffness, swelling, and damage - mm spasms, weakness, and loss of strength (atrophy) - decreased ability to move the affected body part
CRPS treatment options
- early section and management
- biofeedback and other modalities
- desensitized techniques
- early WB
- ROM, functional training, goal-directed PT, graded exposure to fearful activities
- pacing activities
- pharmacological
- multi disciplinary approach
Phantom limb pain
Characterized by pain in an area of the body that is no longer there
- actual phenomenon due to neural connections in the brain and spinal cord
Phantom limb pain s/sx
- onset within first few days on amputation
- tendency of sx to be intermittent rather than constant
- seems to come from the part of the limb farthest away from the body, such as the foot of an amputated leg
- may be described as shooting, stabbing, boring, squeezing, throbbing, or burning
- may be triggered by weather changes, pressure on the remaining part of the limb or emotional stress
Phantom limb pain treatment
Early detection and management- should resolve in <6 months, if persists, poor prognosis for resolution
- desensitization of limb
- pharmacological management
- appropriate prosthetic fit
Conversion disorder
- psychological response characterized by the inability to verbally express and emotion
- emotion transforms into physical manifestations, without a physical explanation or finding
- preceded by stress, anxiety which activates the ANS
