Chronic Pain Management - Exam 4 Flashcards
What is acute pain? What is the associated timeframe?
A warning of pathology, threat, or direct insult and injury to the body.
lasts from a brief moment to 6 months
What is chronic pain? What is the associated timeframe?
Persistent pain that lasts longer than the course of healing, associated with a specific injury or disease process.
after 90 days of continued pain
What is the bodies response to constant chronic versus intermittent chronic pain?
constant chronic: the body adapts in terms of normal BP, HR, RR
intermittent chronic: pain will imitate acute pain and the body does NOT adapt
How does chronic pain affect the brain?
volume of gray matter decreases
What does time to intervention have to due with success rates?
quicker you intervene with pain control the higher the rate of success and vice versus is true
What are the 2 basic neurophysiologic pain mechanisms? give a brief explanation of both
somatosensation and nociception
somatosensation: Sensory neurons activated by physical stimulus. Perception of touch, pressure, pain.
nociception: Activation of specific neural pathways due to tissue-damage and/or
potential tissue damaging stimuli.
What is the basic understanding on how pain medication works?
Drugs decrease pain by antagonizing the effect of excitatory neurotransmitters or by stimulating production/preventing breakdown of inhibitory NT’s.
______ is the first step in the pain signal. What is it? What is a nociceptor?
Nociception
The perception of a potentially tissue-damaging stimulus
Neurologic receptor capable of differentiating between noxious and innocuous stimuli
What are the 3 different types of primary afferent fibers?
A-beta
A-delta
C
Which primary afferent fiber?________ Thick myelination. Low threshold, mechanoreceptors. Fastest. Light touch, Pressure, hair movement. NOT usually pain.
A-beta
Which primary afferent fiber?________ thinly myelinated. high & low threshold mechanical & thermal receptors. The first, ‘sharp’ and ‘intense’ pain sensation.
A-delta
Which primary afferent fiber?________ 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.
C
Where does a pain signal enter the spine cord?
pain enters at the dorsal root at the posterior portion of the spinal cord
The neurons of peripheral sensation begin in the ________. The cell body lies outside of the CNS in the _______. The nerve then enters the spinal cord via the _______.
sensory receptor
dorsal root ganglia
dorsal (posterior)root
First neuron synapse occurs at _______ (nociception from primary afferents), and _______ (A-betas, light touch)
spinal dorsal horn
dorsal column nuclei
Once in the spinal cord they make synaptic connections with ______ that may; cross the cord _______ & ascend (lateral spinothalamic tract), ascend ipsilaterally, descend, or take part in a _____
second order neurons
contralaterally
reflex arc
What is a reflex arc?
an instantaneous movement caused by the stimulus
watch youtube video on the anterolateral system!
do it!!
Where are 3rd order neurons found? What is the role?
thalamus
The thalamus processes sensory and complex motor signals; these in turn relay signals to the cortex in order to express the sensation of pain.
Also opioid receptors in ______area inhibits pain via endogenous or exogenous opiates.
periaqueductal gray
What are some major differences between white and gray matter?
What is nociceptive pain defined as?
Aberrant activation of pain sensitive afferent peripheral nerves, due to noxious stimulation of somatic or visceral structures (i.e., celiac plexus.) through activation of A delta and C fibers
What is neuropathic pain defined as? Activation of ______ by ______ increases spinal neuron sensitization which increases perception of pain.
Abnormal somatosensory processing in the PNS or CNS due to a primary lesion, neural injury or irritation, or dysfunction.like a burning, stabbing, electrical sensation
NMDA receptors
glutamate
**______ When innocuous stimuli is painful; bedsheets, air, light touch.
Allodynia
**______ Abnormal pain ‘like fire’
Dysesthesia
______ increased perception of noxious stimulation; hurts worse than it should
hyperalgesia
**vasomotor changes include _____ and ______. Trophic changes include ____ and _____
skin temp and color
skin and nail alternations
What is nociceptive pain mediated by? What makes it worse? Does this type of pain respond well to opiates?
Mediated by receptors in the viscera, bone, dermis, muscle and connective tissues
Exacerbated by positional change or activity
typically responds well to opiates
What is neuropathic pain due to? What is this type of pain a result from? Do they typically respond to opiates?
Damaged or dysfunctional nerve tissue or damage to the CNS
Resultant from tissue injury or pathology induced injury
Usually not opiate sensitive
What is nociplastic pain? do opioids help? give some examples
Pain that arises from altered nociception despite no clear evidence of actual or threatened tissue damage causing the activation of peripheral nociceptors or evidence for disease or lesion of the somatosensory system causing the pain
opioids typically do not help
Fibromyalgia, Restless Leg Syndrome, Chronic Fatigue Syndrome, TMJ, Irritable Bowel Syndrome
What is Pyschogenic pain/Somataform disorder? What is it commonly linked with?
Persistent and chronic pain at one or more sites in which psychological factors are thought to play a role.
commonly linked to depression and pts needs to see psych
What is the opioid risk tool? Do you want a higher or lower score?
questionnaire used to determine how likely the pt is to misuse opioids.
higher score is LESS likely to prescribe opioids
Why do office use a pain agreement?
To encourage patient compliance. To facilitate an understanding between the patient and the doctor regarding the use of scheduled medications.
T/F: pain agreement contracts are only used for schedule II medications
FALSE!! can be used for BZD and other class IV/V meds
T/F: The pt can request to change pain medications due to itching and the provider should comply.
FALSE!! Ensure a policy that unless patient has significant SE/allergy that the meds will not be changed until the next refill is due.
The pain agreement needs to be updated whenever a pt _______
changes pharmacies
What is the pain 1-10 scale called?
What are some additional pain questionnaires used in PM?
McGill pain questionnaire
Brief Pain Impact Questionnaire
What are the pros for using the brief pain impact questionnaire? When should you use it?
It’s quick, easy, and accurate.
Provides a baseline to review and accurately determines response over time.
at the initial visit and update every couple months
What is a lumbar discogram?
inject dye into discs and see how it looks
**_______ pain due to a stimulus which does not normally provoke pain
allodynia
**_____ a heightened response to a stimulus that causes pain
hyperalgesia
**______ diminished pain in response to a normally painful stimulus
hypoalgesia
What PE test would you use to check for a herniated disc? What is considered positive?
straight leg test: patient lays supine and raise leg 30-70 degrees
pain = positive test
What test when preformed on the asymptomatic leg and positive would make you think herniated disc?
if the asymptomatic straight leg test resulted in pain would create a high suspicion for herniated disc
What is the Patrick/FABER test? When would you use it?
crosses affected side, ankle on knee, compress
flexed knee to check for SI issues or hip joint pathology
What is zygomatic joint loading?
rotation and flexion of spine elicits pain at contralateral facet joints
What does foot drop/toe dragging make you think?
L5 root compression, peroneal nerve damage, sciatica, cauda equina syndrome
What is the piriformis stretch? What position does the pt need to be in?
Lat decubitus position,
flex hip and knee of upper leg; positive if downward pressure produces pain from buttock to leg.
What is the spurling test? What does it indicate?
extend, rotate and tilt head then compress head; if radicular to ipsilateral side, then possible nerve root compression in mid or lower C-spine.
What is the axial compression test? What does it indicate?
compression of C-spine by pressing on the head; positive neck pain or radiation=possible DJD or upper C-spine nn impingement.
What is the Waddell’s sign? What is it used for?
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
What is the Hoover’s test? When do you use it?
With patient 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.
What is the difference between ESI and TFESI?
ESI: steriods can float/coat multiple levels of nerve roots vs TFESI they stay at the nerve root level they were injected at, come in at the sides vs a midline approach with ESI
What are some pros of high frequency stimulation? what are some cons?
newer: over-rides previous limitations of stim.
Because pain action potentials vary, it may cover more pain.
cons: Pt can still feel the paresthesia.
It can over-ride other sensory nerves causing unwanted paresthesia.
Eats a lot of power
What are the pros of BURST stimulation?
Varies the waveform so it covers many different action potentials.
The patient doesn’t ‘feel’ the stimulation.
Gradually allows the pain to ‘disappear.’
Better coverage for more pathology types.
Longer battery life.
What is the sprint peripheral stimulator?
Stimulation of peripheral nerves, Outpatient surgery to implant the lead and pt wears the stimulator for 2 months with the goal of permanently modulating the nerve after the stimulator is removed
What is CRPS? What is a good pain relief option?
chronic regional pain syndrome
Dosal Root Ganglion stimulation (DRG)
What are limitations of conventional SCS?
unspecific pain: stimulating a broad range of nerve fibers versus pain or disease specific nerves
unstable leads, sometimes leads migrate
energy loss due to CSF which demand higher outputs and impact longevity of the battery life
Why is DRG a good therapy option to tx primary areas of pain?
Pain cells in DRG allow for activation without recruiting non-painful neurons
The DRG itself is a robust structure with a predictable intraforaminal location
Minimal CSF fluid and lower firing threshold of DRG neurons allow amplitudes set at the Micro-Amp level
What is the MILD procedure? What does it treat?
removes a layer of the spinal ligament to open the spinal canal
treatment for pain relief from symptomatic central lumbar canal stenosis
What are some common intrathecal medications? What is considered gold standard?
gold standard= morphine
other meds:
baclogen
hydromorphone
fentanyl
sufentanil
clonidine
bupivacaine
zyconotide
octreotide
_______ mimics morphine analgesic effects but is NOT an opioid
zyconotide (Prialt)
**What is the CDC recommended MME max for a pt with non-malignant pain? What are the 2 exceptions that do not have a limit?
50-90 MME is the MAX
pain associated with cancer and sickle cell crisis
According to the CDC opioid prescribing guidelines, ______ worth of opioids for acute pain. Need to avoid _____ and opioids
3-7 days worth of opioids for acute pain
avoid concurrent BZD and opioid use
