Chronic pain syndrome Flashcards
What is the most common cause of long-term disability, with lost work days, in the US?
pain
What does persistent pain cause?
fxnal impairment and disability, psychological distress, and sleep deprivation. affects the quality of life
Define chronic pain
no biological value, has persisted beyond the normal tissue healing time
What does the DSM define chronic pain as?
persistent pain for six months
What are the three types of pain?
adaptive, inflammatory, maladaptive
Define adaptive pain
contributes to survival by protecting the organism from injury and promoting healing
Define inflammatory pain
preceded by injury at cellular level.
Define maladaptive pain
pain as a disease, abnormal sensory process, persisten or recurrent
Define hyperesthesia
increased sensitivity to stimulation, excluding the special senses
define dysethesia
an unpleasant abnormal sensation whether spontaneous or evoked
Describe psychogenic pain
physical pain that is caused, increased or prolonged by mental, emotional, or behavorial factors
What are some of the most common psychogenic pains?
headache, back pain, or stomach pain
Describe phantom pain
felt in a part of the body that has been lost or from which the brain no longer receives signals. a type of neuropathic pain
describe breakthrough pain
pain that comes on suddenly for short periods of time and isn’t alleviated by the patient’s normal pain management
What type of patient is likely to have breakthrough pain?
cancer patients
describe mixed chronic pain
may be mixed neuropathic/nociceptive pain present with advancing and changing disease.
What type of disease states are associated with mixed chronic pain?
migraines, cancer
What are the principles of chronic pain management?
An accurate diagnosis of pain syndromes, formation of a treatment plan
What are some goals of pain therapies?
reduction in intensity of pain, improvement of physical fxning, improvement of emotional fxning, improvement of quality of life, maintain dignity
What are the A’s of pain treatment outcomes?
analgesia, activities of daily living, adverse effects, aberrant behaviors
What are four types of pain therapies?
cognitive/behavioral, functional restorative, pharmacologic, interventional
Describe cognitive/behavioral aspects of pain management.
deals with the meaning of pain, the emotional background, and coping skills
When are invasive procedures used to treat pain?
when pain or SE persist despite comprehensive trials of pharmacologic therapy
What are some invasive procedures used to treat pain?
neurolytic blocks (celiac or hypogastric plexus), intra-spinal drug delivery, anesthesiologic
What are the different anesthesiologic pain treatments?
central nerve blocks (spinal, epidural), peripheral nerve blocks (femoral, intercostal, ect), autonomic nerve blocks (stellate ganglion, lumbar sympathectomy)
What are some special techniques of pain therapies?
facet block, cryolysis, radio frequency, ablative
What is a facet block used to treat?
back pain
What is cryolysis used for?
nerve damage
What is radio frequency used to treat?
facet jt/nerve damage
What are some nociceptive pain disorders?
low back pain, myofacial pain, visceral pain, headache, TMJ
What are some neuropathic pain disorders?
post herpetic neuralgia, trigeminal neuralgia, complex regional pain syndrome, phantom pain
What are some of the major causes of low back pain?
prolapse inter-vertebral disc, facet jt degeneration, sacroiliac jt arthritis, musculoskeletal disorder,
What are some red flags of low back pain?
loss of bowel/bladder control, fever, saddle parathesia
What are some musculoskeletal causes of myofascial pain?
abnormal muscle stress, poor posture or static position for prolonged period
What are some vitamin deficient causes of myofascial pain?
anemia, low Ca/Mg/K, low vitamins C, B-1/6/12
What are some miscellaneous disorders that can cause myofascial pain?
radiculopathy, visceral diseases, depression, hypothyroidism, hyperuricemia, hypoglycemia
What are some treatments for myofascial pain syndrome?
massage therapy using trigger-pt release, physical therapy, pharmaceuticals
What are some primary headaches?
migraines, cluster, tension, TMJ, Sinus, medication overuse
What are the causes of secondary headaches?
caused by other means-whiplash injury, subarachnoid hemorrhage, meningitis, neoplasm, stroke, acute HTN crisis
What are some danger signs associated with headaches?
Worst HA of life, new symptom, sensory or motor deficits preceding HA, unilateral HA, HA due to trauma, constant/unremitting
What are some dangerous tension symptoms associated with HAs?
steadily increasing, worse in the morning, accompanied by vomiting, H/O cancer, personality changes, older than >60
What are some dangerous family history diseases associated with HA?
cerebral aneurysm, other vascular anomalies, polycystic kidneys
Describe tension headaches.
most common type. pain can radiate from lower back of head, the neck, eyes or other muscle grps
What are some precipitating factors of tension HAs?
sleep deprivation, bad posture, eyestrain, muscle tension around the neck/head
What are the 3 main types of tension HAs?
infrequent episodic, frequent episodic, chronic
What is the duration of an infrequent episodic HA?
episodes less than one day a month
What is the duration of frequent episodic HA?
episodes 1-14 days a month
What is the duration of chronic HA?
episodes >15 days a month
What are some diagnostic characteristics of tension HA?
pain is bilateral, quality of pain is steady, intensity of pain is moderate, no aggravation with physical activity
What are some medications used to treat tension HAs?
aspirin, tylenol, NSAIDS, muscle relaxers (valium, robaxin), anti-anxiolytic (hyroxyzine)
What are some non pharmacologic treatments for tension HA?
behavioral health, chiropractic, massage therapy, biofeedback
Describe migraine HA
episodic disorder. characterized by severe HA associated with nausea, light/sound sensitivity
What are the 4 phases of migraine HAs?
premonitory, aura, HA, postdromal
What are some triggers of migraines?
skipping meals, too little/much caffeine, too little/much sleep, certain foods (red wine, chz), OCP, periods
What are some mild treatments of migraine HAs?
ASA, tylenol, NSAIDS, indomethacin
What are some stronger med treatments for migraine HAs?
zomig, maxalt, imitrex
What can you prescribe for nausea and vomiting with HA?
phenergan, zofran
What are some preventative meds for migraines?
tricyclic antidepressants (amitriptyline, nortriptyline), beta blockers (propanolol), calcium channel blockers
What is the pathophysiology of cluster headaches?
vascular headache disorder, primarily affects middle aged men
What is the periodicity of cluster headaches?
repetitive HA occurring regularly for weeks to months, usually at night. 1-2 attacks/day for 6-12 weeks, then 6-12 months free
What are some triggers of cluster headaches?
ETOH, stress, glare, foods
What are some clinical manifestations of cluster headaches?
unilateral pain initiating around eye, max intensity in minutes, deep/excruciating pain, ipsilateral lacrimation, redness of eye, nasal congestion, sweating, pallor
How long do cluster headaches usually last?
15 minutes to 3 hours
What are some acute treatments for cluster HA?
inhalation of O2, triptans, GH antagonists (sandostatin)
WHat are some prophylactic measures for cluster HA?
verapamil, prednisone, lithium, ergotamine, indomethacin
What is the periodicity of TMJ syndrome?
fairly constant pain usually in young women related to nocturnal bruxism and teeth clenchn
What are some manifestations of TMJ syndrome?
unilateral pain in mastication muscles, dull ache worsened by chewing, audible clicking during movt, jaw locking, pain can radiate to ear, jaw, post cervical area
What do you see on physical exam with TMJ?
tenderness inside the tragus of affected side
What are some differential diagnoses of TMJ syndrome
infection, RA, temporal arteritis, dental, trigeminal neuralgia, parotid gland disorder
What are some medications used to treat TMJ?
muscle relaxants, NSAIDS, tricyclic antidepressants, corticosteroid injections, botulinum toxin
What are some prophalactic treatments of TMJ?
jaw excercises, eliminate nocturnal jaw clenching, correct aggravating factors, dental care, avoid stimulants
What are some treatments of neuropathic pain?
pregabalin, capsaicin, controlling diabetes
What is the pathogenesis of post herpetic neuralgia?
nerves involved w/infection of acute herpes are inflamed, lies dormant
What are some signs/symptoms of post herpetic neuralgia?
thoracic, trigeminal, cervical sites. sharp, burning, stabbing pain, areas of anesthesia, impaired sleep, anorexia
What is the prevention for post herpetic neuraglia?
Herpes zoster vaccine
What are some medications used to treat post herpetic neuralgia?
tramadol, gabapentin, carbamazepine, TCAs
What is the surgical treatment used to treat post herpetic neuralgia?
peripheral nerve block
What is the pathogenesis of trigeminal neuralgia?
usually compression of nerve root by loop of artery or vein. cysts, neuroma, AV malformation. compression leads to demylination and ectopic transmission
What are some signs/symptoms of trigeminal neuralgia?
unilateral facial pain near mouth that shoots toward ear, asymptomatic at night, triggered by touch, movt drafts, eating, episodes become more frequent
When should an MRI be done with trigeminal neuralgia?
patients w/sensory loss, patients < 40 yr, patients with bilateral symptoms, patients that don’t respond to conservative treatment
What are some medications used to treat trigeminal neuralgia?
carbamazepine, valproic acid, baclofen, gabapentin
What are surgical treatments for trigeminal neuraglia?
microvascular decompression, radiofrequency rhizotomy
What do complex, regional, pain, syndrome represent in the CRPS acronym?
complex- varied/dynamic clinical presentation. regional- non dermatomal distribution of symptoms. pain- out of proportion to the inciting events. syndrome- constellation of symptoms and signs
Define CRPS
disorder of extremities characterized by pain, swelling, limited ROM, vasomotor instability, skin changes and patchy bony demineralization
Define type I CRPS
without definable nerve lesion, 90% of cases
Define type II CRPS
with definable nerve lesion, 10% of cases
What is the clinical presentation of CRPS?
triad of symptoms. spontaneous pain- burning, aching, throbbing, shooting or deep pressure. motor changes- weakness, distal tremors, dystonia, myoclonus
Describe stage I of CRPS?
with or without apparent cause, pt develops limb pain
Describe stage II of CRPS?
progession of edema, thickening of skin, muscle wasting, brawny skin. lasts 3-6 months
Describe III of CRPS?
limitation of movt, contracture of digits, waxy trophic skin changes, brittle ridged nails
What are some differential diagnoses of CRPS?
RA, thoracic outlet syndrome, scleroderma
What is prevention of CRPS?
treat underlying disorder, early mobilization after injury
What is management of CRPS?
physical therapy, antidepressants, prednisone, regional nerve blocks
What is the pathogenesis of phantom pain?
occurs when nerves that would normally innervate the missing limb cause pain
What are some symptoms of phantom pain?
tingling, itching, burning, aching
What are managements of phantom pain?
analgesic and antidepressants
