(Exam I) Assessment of Pain Flashcards by Garrison Railsback

The goal of the pain interview is to

Build trust
Gather information
Facilitate change

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What are the pain assessment “Red Flags”?

Bowel/Bladder dysfunction (neurological compromise)
Saddle Anesthesia (perineal numbness, spinal cord compression)
Bilateral leg weakness (motor lesion)
Severe, sudden onset Headache (hemorrhagic stroke)
Fever, Weight loss, Night sweats (cancer or TB)
Recent Injury (could alter diagnosis & treatment)
Hx of Cancer (affects tissue integrity & pain management)

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What does the Pain Characteristics Mnemonic “OPQRSTU” stand for?

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What are some holistic treatments for pain?

Cold water immersion (releases Endorphins)
Acupuncture
Meditation
Exercise
Physical Therapy
Massage

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All pain has…

All pain has cognitive, sensory, spiritual, and emotional influences and behavioral manifestations.

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Why might pain assessment interviews be confrontational?

Doubt & Frustration

The patient has Doubts of there ever being a “fix” to their pain and they experience Frustration when their pain has not been “Fixed”. Patients dealing with chronic pain are often fearful, anxious, frustrated, angry, and have poor ability to self-regulate their emotions.

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What are the components of the clinical exam?

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What is a Myotome?

A Myotome is a group of muscles that are controlled by a single spinal nerve.

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What is a Dermatome?

A dermatome is a specific area of skin that is supplied by a single spinal nerve.

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What is a Sclerotome?

A Sclerotome is an area of bone that is supplied by a single spinal nerve.

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Unilateral foot drop is indicative of?

Peroneal nerve palsy

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When assessing Motor, how is it graded?

On a scale of 0-5

5- Normal
4- Full ROM against resistance
3- Full ROM against ONLY gravity
2- Full ROM with gravity eliminated
1- Palpable/Observable contraction
0- No palpable contraction

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When assessing Reflexes, how is it graded?

On a scale of 0-4

0- Absent
1- Diminished
2- Normal
3- Hyperactive
4- Hyperactive with Clonus (rhythmic involuntary contraction & relaxation)

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What is the Babinski reflex? And what does a (+) Babinski indicate?

When the sole of the foot is firmly stroked, and toes fan out.

A (+) Babinski indicated an issue with the CNS.

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What is the Hoffman sign? And what does a (+) Hoffman sign indicate?

A neurological reflex test where a doctor flicks the fingernail of a patient’s middle finger, and if the thumb and index finger involuntarily flex.

A (+) Hoffman’s sign indicates potential damage to the upper motor neurons in the spinal cord, often due to cervical cord compression.

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What is Clonus? And what is it indicative of?

Clonus is rhythmic involuntary contraction & relaxation of the muscles.

Clonus is indicative of: CVA, Brain tumor, TBI, Meningitis, Spinal cord injury, CP, MS, or ALS

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When do we use diagnostic imaging? What are the differences in diagnostic imaging? Xray, CT, MRI

Use diagnostic imaging only when the patient has Red Flag signs, or their physical exam suggests a Red Flag condition.

Xray- used to examine bone. Cheap.

CT- used for examining soft tissue and bone.

MRI- used for examining muscles, tendons, joints, and nerves.

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Do not obtain diagnostic imaging on a patient with uncomplicated headache unless…

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What are the causes and treatment of Post-Epidural Puncture Headache?

Causes: after spinal anesthesia and you sit up and get a headache because the loss of CSF volume starts to pull down on the meninges and cause pain.

Treatment: Positioning (lay flat), rest, severe cases may need an epidural blood patch.

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What is acute pain?

Most acute pain heals quickly, within 3 months.

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What is chronic pain?

Chronic pain persists beyond 3 months and may indicate an underlying issue.

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What are the differences between Widespread & Localized pain?

Osteoarthritis (Widespread)
Bone fracture (Localized)

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Nociceptive pain

Nociceptive pain occurs when body tissue is damaged by an injury (sprained ankle)

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Neuropathic pain

Neuropathic pain is caused by damage to the nerves themselves. (DM or RA)

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Why is it important to note the impact that pain has on a patient's functional status?

In order to receive reimbursement from Insurance companies they require evidence of a significant functional impact before approving pain treatment. This means demonstrating how the pain affects the patient's daily activities and quality of life.

What is the "STOP BANG" screening tool used for? And what does the mnemonic mean?

Screening tool for Obstructive Sleep Apnea (OSA) S: Snoring T: Tired O: Observed apnea P: High blood pressure B: BMI > 35 A: Age > 50 N: Neck circumference > 40cm (16in) G: Gender is male A score of 3 or more indicates the presence of OSA. A score of 5-8 indicates moderate to severe OSA.

What is Fibromyalgia?

Fibromyalgia is a chronic pain condition characterized by widespread musculoskeletal pain/tenderness, fatigue, and cognitive difficulties like brain fog. Usually a diagnosis of exclusion.

What are the screening tools, ORT and SOAPP-R used for?

They are Opioid risk assessment tools used to screen patients prior to initiating Opioids to see if the patient is at risk for potential substance abuse.

This is used to assess the effectiveness of your treatment and interventions

Neck pain that can cause arm pain or headaches is considered ______? (Myotomal or Dermatomal)

Myotomal

Myotomal Distribution

A group of muscles that are supplied by a single nerve root.

Dermatomal Distribution

A pattern of skin areas (called dermatomes) that are supplied by specific single spinal nerve.

When performing a physical exam, what pain behaviors should you pay attention to?

Look for: Grimacing Groaning Guarding Over reactions Inconsistencies Give-way weakness Shaking

The Red Flag mnemonic "N SWIFT PICS" means?

Steroid injections are often used to manage pain, but can have adverse effects such as...

Mask some underlying symptoms, causes tissue degeneration, and suppresses the immune system.

What are some alternatives to steroid injections?

Sugar Injections- stimulate the body's healing process. Stem Cell Treatments- gaining popularity but is heavily regulated by the FDA. You may have to go to Mexico, but it is a lengthy process for this treatment. Platelet Rich Plasma (PRP)- enhances tissue growth

What serious medical condition presents with severe neck pain and fever?

Meningitis

This patient population is at increased risk for fractures and infections including Myocarditis.

IV drug users

Neck pain with forward flexion indicates?

Disk pain, because you are putting additional pressure on the Disk.

Neck pain with extension indicates?

Facet pain, because you are putting additional pressure on the Facet joint.

Type of pain that follows Myotomal distribution and usually has a normal neurological exam

Referred Pain

Type of pain that follows Dermatomal distribution and can have an abnormal neurological exam (paresis, hyper-reflexia, hypoesthesia)

Radiating Pain

With neck pain of unknown origin, with no Red Flags, and a normal physical exam should you obtain diagnostic imaging? (Y/N)

No.

What is Paresis?

Partial loss of voluntary movement or muscle weakness

What is Hypoesthesia?

Partial or total loss of sensation in a part of the body.

What are some basic interventions for Neck pain?

NSAIDs Physical Therapy Warm compress Acupuncture

Why should we try to avoid Opioids in patients with neck pain?

Neck pain is generally easy to treat, and by providing Opioids it can lead to tolerance and hinder their effectiveness when truly needed.

Which type of regional block is effective at treating referred or radiating neck pain?

Medial branch block

A minimally invasive procedure that involves injecting cement into a weak vertebrae to strengthen it.

Kyphoplasty

This syndrome involves damage to the lumbosacral nerve roots and causes Saddle anesthesia, loss of bowel/bladder, and paralysis.

Cauda Equina Syndrome Causes: Metastasis, Trauma, or complications from Epidural anesthesia (secondary to epidural hematoma) Pt needs prompt CT imaging

Preferred diagnostic imaging for spinal pain. (See Chart)

Someone with the complaint of tearing/stabbing back pain may mimic musculoskeletal back pain but in reality, might have?

Aortic Aneurysm Can be detected on plain films and CTs.

A condition of low bone mineral density

Osteopenia Can be see with diagnostic imaging. If you have it in your back, you have it everywhere.

Treatment for back pain:

Encourage general activity, but avoid strenuous activity Heat therapy Stretching Acupuncture Lateral inhibition *bed rest is discouraged

Treatment for shoulder pain:

HAHAHAHA Peptide injections Synovial fluid injections Stem Cell injections Steroid injections- use with caution Platelet rich plasma injections

What procedures can cause abdominal pain to be referred to the shoulder?

Laparoscopic abdominal procedures

Shoulder pain exams:

Tests for Rotator Cuff injury: Apley, Neer, Hawkin's, Drop arm, Lift off, and O'Brian Detects Bicep tendonitis: Speed's & Yerguson Detects Labral tear: Apprehension test

Who should we consult in the event of a Rotator Cuff tear?

Consult a surgeon. Arthroscopic surgery is usually required to correct any shoulder instability like with Rotator Cuff tears.

What type of pain can be referred to/from the lower back, thigh, buttocks, or groin?

Hip Pain

A condition that can occur in young people that causes hip pain and is characterized by the head of the Femur losing blood supply and dying.

Avascular Necrosis

Patients with this type of joint pain have difficulty with sitting and may adopt a half-sitting/half-standing position.

SI joint pain

Excruciating pain within the hip that occurs when a ligament passes over a bony structure causing a popping sensation. Can often mimic a hip dislocation.

Snapping hip syndrome

The hip has how many planes of direction, with 2 motions with each plane.

3 planes of motion: Flexion & Extension External & Internal rotation Abduction & Adduction

Which tests are used to detect Labral injury or Sacroiliac joint problem by crossing a leg, applying pressure to the knee to separate the SI Joint.

FABER (Flexion, ABduction, External Rotation) & Patrick's test

What are some hip tests other than FABER & Patrick's?

Pediatric Hip disorders:

Slipped Capital Femoral Epiphysis (SCFE)- condition where the femoral head slips off of the neck of the femur Legg-Calve-Perthes Disease (LCP)- condition that affects the blood supply to the femoral head

An injection therapy that injects Dextrose & Procaine which allows platelets to come from nearby tissue and remodel the collagen in tendons.

Prolotherapy

This type of pain can refer to the thigh, lower back, or leg

Knee pain

Which muscle acts to both extend the knee and flex the hip?

Rectus Femoris M. It crosses both the knee and the hip

This muscle of the leg is the main plantarflexor of the ankle, but also helps to flex the knee

Gastrocnemius M.

What diagnostic tool can be used for visualizing a joint space for an effusion drainage?

What else should we be concerned with in a patient who has hyperextended their knee?

Vascular injuries

Treatment for knee pain:

Physical Therapy Weight loss- pt may need dietary consult Rest Bracing Knee replacement

This pain is aggravated by squatting, climbing stairs, prolonged sitting, running or lifting. It also appears twice as often in women.

Patellofemoral pain (PFPS) Does NOT require surgical consult

For knee injuries, follow Ottawa Rules for diagnostic imaging: