Conservative pain management for the older adult

Question 1

4 Pain Types

Answer 1

1. Transient: Minor and rarely requires medical intervention
2. Acute: Typically associated with direct tissue trauma and generally resolves predictably through the healing process. (Post surgical, fractures, tissue trauma…). Often results in either self administered or other administered medical interventions (Thermal therapies, medications, wrapping, & splinting/casting)
3. Chronic cancer pain: issue damage secondary to disease process &/or treatment interventions (Bone pain/pressure chemo & radiation therapy).
4. Chronic non-cancer pain: Unresolved and persistent pain extending beyond the normal timeline for tissue healing

Question 2

PREVALANCE

Answer 2

• 76 million annually in US experience pain
• Peak incidents in middle age (45-64 years)
• Nearly 50% of those 65 and older reported joint pain (excluding the spine)
• Older adults typically have more pain sites with longer duration of pain
• Incidence of acute pain is higher in middle aged adults
• Prevalence of chronic health issues with associated persistent pain higher in older adults
• Prevalence of rheumatic diseases including: Polymyalgia Rheumatica, giant cell arteritis, and gout are significantly increased in those 65 and older
• Approx 50% of those 65 and older suffer from osteoarthritis

Question 3

PAIN MANAGEMENT CHALLENGES

Answer 3

• Increased prevalence of medical conditions positively correlated with decreased levels of physical activity and higher pain intensity as well as elevated levels of depressive and anxiety symptoms.
• Treating symptoms of depression alone can produce a small but significant effect for pain related disability.
• Socio-economic factors impact pain management such that those with lower levels of education and income report a higher incidence of pain related disability.
• Gender differences play a role in pain experience.
• Women reportedly experience both increased intensity and multiple locations of pain impacting function to a greater extent than men

Question 4

COSTS

Answer 4

• Greater than 50 million individuals seek medical intervention for chronic pain every year
• The annual cost for those seeking intervention & from lost productivity is in excess of $70 billion
• Nationwide between 1997 and 2004 there was a 423% increase in Medicare payments for opiates for those with low back pain!
• Between 2000 and 2003 in the state of Pennsylvania, Medicare payments for physical therapy services increased 0.2%, however an increase of 59% for steroid injections and nearly a 42% increase in the cost of MRI/CT scans occurred during that same time frame

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Question 5

BIOPSYCHOSOCIAL MODEL OF PERSISTENT PAIN

Answer 5

• Pain is a multi-dimensional experience including biological, psychological, and sociological factors
• All 3 of these major factors are linked in complexity, making the experience and perception of pain multi-dimensional.
• Pain intensity fluctuates under the influence of patients various moods, which impacts upon neurotransmitters through the hormonal systems.
• An undeniable link exists between persistent/chronic pain and depressive disorder’s.
• Psychosocial factors directly impact the pain experience
• A more supportive social system improves pain coping mechanisms, where as conflict in one’s social systems results in elevated pain levels

Question 6

AGE RELATED CHANGES

Answer 6

1) Decreased nociceptive density
2) Conductivity of nociceptive afferents (slower response in the A-delta fibers which are responsible for transmission of the “first pain” perception). No delay in transmission of the unmyelinated C fibers which are responsible for perception of longer term/ongoing pain.
3) Central coding of pain
4) Segmental nociceptive reflexes
5) Alterations in descending inhibition of pain
6) Psycho social influences altering both the meaning and impact of pain

•Although persistent pain in older adults results in increased physical and functional limitations, overall the older adult shows better mental health and pain coping mechanisms than do younger adults.

Question 7

PROGNOSIS & PLAN OF CARE

Answer 7

• Acute> Sub-Acute> Chronic/Persistent
• Some generally excepted predictable timelines for postsurgical and spine pain.
• Rehab potential “IF“

“Identified impairments and relevant functional deficits will respond favorably to skilled PT intervention, IF patient is compliant with the recommended home exercise program and postural/biomechanical principles”.

Question 8

PT Interventions

Answer 8

• Thermal Agents
• Manual Therapy
• TENS (For Acute & Persistent Pain)
• Low Level Laser Therapy (LLLT)
• Functional Dry Needling (FDN)
• EXERCISE!!!!!!
  
  • Flexibility, Aerobic, Strength Training, Relaxation
• Establish Self -DirectedPrograms

Question 9

COGNITIVE BEHAVIORAL THERAPY

Answer 9

• Given the complex & multi-dimensional aspects of pain, we must recognize and address the psychological component which may often generate referrals to other mental health practitioners.
• Factors such as: Emotional, Physical, & Sexual Abuse can significantly impact ones pain experience.
• Previous Traumas
• PTSD
• NATURAL DISASTERS
• LOSS OF A LOVED ONE
• FEAR
• ANTICIPATION OF PAIN