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Medicine Year 2 > HNN Topic 13 - Chronic Pain/Illness, Low Back Pain > Flashcards

HNN Topic 13 - Chronic Pain/Illness, Low Back Pain Flashcards

1
Q

List treatments of non-specific LBP

A
  • TENS
  • Physiotherapy
  • Accupuncture
  • Epidural injections - medial branch of dorsal primary ramus
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2
Q

Describe the difference between nociceptive and neuropathic pain and give examples

A
  • Nociceptive is due to tissue damage, e.g. osteoarthritis, rheumatoid arthritis
  • Neuropathic is due to nerve damage, e.g. post-herpetic neuralgia, painful diabetic neuropathy, post-stroke, lumbar radicular pain
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3
Q

List the factors which affect pain

A
  1. Biomedical
  2. Psychosocial
  3. Affective - cognition
  4. Ethnocultural
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4
Q

What factors can hinder management of low back pain?

A
  1. Progressive pathology
  2. Passive - belief that pain and activity are harmful, sickness behaviour (extended rest)
  3. Depression
  4. Problems - social, work, financial
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5
Q

List the afferent fibre types involved in chronic pain

A
  1. A beta
  2. A delta
  3. C fibres

A beta fibres usually not involved in pain, recruited in allodynia

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6
Q

How is pain assessed?

A
  1. History, examinations
  2. Characteristics - site, radiation, quality, severity, duration, frequency, exacerbating/relieving factors, associations
  3. Impact on physical and mental health/function and quality of life
  4. Verbal assessment of severity (0-10)
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7
Q

What does the ‘sick role’ include?

A
  • Rights - exempt from some social roles, not blamed for illness
  • Responsibilities - try to get better, seek help and cooperate with help given
  • Chronic illness? Blame e.g. smokers and lung cancer?
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8
Q

Define chronic pain

A
  • A sustained sensory abnormality/ongoing peripheral pathology (3+ months)
  • Maladaptive - no protective function
  • Induction is evoked or spontaneous
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9
Q

Define hyperalgesia

A

Heightened perception of pain - sensitisation of nociceptors

Can be caused by opoid use

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10
Q

List the sources of LBP

A
  • IVD
    • Bulge, rupture
  • Vertebrae
    • Osteoarthritis, lumbar instability
  • Joints
    • Facet, sacroiliac
  • Muscle
    • Paravertebral, gluteal
  • Ligaments
    • Anterior and posterior longitudinal
  • Initially may be focal lesion, over time grows to be multifactoral problem
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11
Q

List the obstacles which can prevent successful adaptation to living with a chronic illness

A
  • Intrapersonal, personality (dependent/paranoid/narcissistic/histrionic
  • Psychiatric illness, substance misuse
  • Characteristics of illness - pain, sleep disturbance
  • Characteristics of treatment - unpleasant, inconvenient
  • Finances, social support, culture, religion
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12
Q

What is important to consider when treating LBP?

A

Target treatment to patient depending on risk of chronicity

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13
Q

Describe use of opiods

A

RA/OA > neuropathic pain > LBP > visceral > fibromyalgia

Screen for risk of dependency, monitor for misuse/addiction

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14
Q

What are the symptoms of non-specific LBP

A
  • Tension
  • Pain
  • Stiffness
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15
Q

Define illness behaviour

A

Mechanic (1978)

  • Way in which symptoms and illness are perceived, evaluated and acted upon
  • Experience of symptoms and their meaning/consequences and the reaction to them
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16
Q

List the characteristics associated with coping badly with chronic illness

A
  • Reluctant to compromise/change
  • Passive approach, denial
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17
Q

Describe the neuropathic components of LBP

A
  • Pain due to compression of dorsal root ganglion
  • Abnormal impulses can over-stimulate ascending pathways to the brainstem, thalamus and limbic system
  • Pain awareness develops
18
Q

List the types of sensitisation to pain

A
  1. Primary - peripheral sensitisation, occurs directly in damaged tissues
  2. Secondary - centra sensitisation, occurs in surrounding undamaged tissues
19
Q

Define allodynia

A

Pain elicited by stimuli which normally only evoke innocuous sensation

20
Q

List adjuvants used with neuropathic analgesia

A
  1. Anti-depressants e.g. amitryptyline
  2. Anti-convulsants e.g. gabapentin, pregabalin
  3. Anti-arrhythmics e.g. lidocaine
  4. Others - ketamine, capsaicin, clonidine
21
Q

How does central sensitisation occur?

A
  • Changes in CNS - modification of neurons, amplification of the excitability of neurons within the CNS
  • Interneurons - decreased GABA and glycine (inhibitory)
  • CPM - decreased noradrenaline and serotonin (modulate pain)
22
Q

List the symptoms which can be caused by nerve damage

A
  • Positive symptoms - spontaneous pain and tingling, radiating to lower legs
  • Negative symptoms - weakness or loss of sensation, radiating to lower legs
23
Q

Describe the types of pain

A
  1. Acute (e.g. trauma, post-operative) vs. chronic (LBP)
  2. Cancer vs non-cancer
  3. Nociceptive vs neuropathic
24
Q

List the aspects of treatment of LBP

A
  1. Prevention - back care, exercise, good acute pain control
  2. Pathology - treat
  3. Physical therapies - maintain activity, physio, TENS
  4. Pharmacotherapies
  5. Procedural - regional analgesia, injections
  6. Psychologically based - eduction, relaxaton, distraction
25
Q

What are the risk factors for not returning to work following LBP

A
  • Poor job satisfaction
  • Smoker
  • Work injury
  • Unemployed
26
Q

How are cytokines involved in chronic illness?

A
  • Mediate many non-specific symptoms - weakness, fatigue, poor concentration, anhedonia
  • Cognitive and behavioural interventions should target this - exercise, activity scheduling
27
Q

Describe the ladder of analgesia used to treat LBP

A
  1. Paracetamol/NSAIDs (NSAIDs have more side effects)
  2. Codeine, dihydrocodeine (CP450 CYP 2D6 - genetic deficiency), dextropropoxyphene (OD risk)
  3. Tramadol
  4. Morphine, oxycodone, fentanyl, bupenorphine, methadone, hydromorphone, diamorphine, pethedine
28
Q

Which causes should be ruled out before diagnosis of non-specific LBP?

A
  • Malignancy
  • Infection
  • Fracture
  • Inflammatory - ankylosing spondylitis
29
Q

How does introspection effect perception of health?

A

Introspective individuals experience more physical/psychological distress, use health services more and are more likely to define common bodily sensations as symptoms

30
Q

How does the idea of locus of control contribute to health and illness?

A
  • Internal locus of control = decisions made for yourself
    • Take responsibility for actions and health
    • More likely to adapt successfully to chronic illness
  • External locus of control = decisions made by outside force
    • Passive, don’t take responsibility
    • Negative implications for disease
  • Spectrum - people are usually somewhere between the two extremes
31
Q

How is nociceptive pain classified?

A

Somatic (skin, muscle, bone) or visceral (internal organs)

32
Q

What are the common problems associated with chronic pain?

A

Problems with sleep and anxiety/depression - all are interlinked

33
Q

List the characteristics associated with coping well with chronic illness

A
  • Flexible, open to suggestions/change
  • Optimistic
  • Interal locus of control
  • Appropriate emotional expression - feelings of anxiety/depression common, not necessarily pathological
  • Self management
  • Finding benefit
34
Q

How does peripheral sensisation occur?

A
  • Release of mediators creates ‘inflammatory soup’ which changes nociceptors to low threshold
  • Mediators which activate nociceptors
    • Potassium, serotonin, bradykinin, histamine
  • Mediators which sensitise nociceptors
    • Prostaglandins, leukotrienes, substance P, cGRP, noradrenaline
35
Q

Describe the nociceptive components of LBP

A
  • At site of problem
  • Caused by release of inflammatory mediators from damaged tissue
  • Activates peripheral nociceptors, which activate afferent sensory fibres to the dorsal horn and up to the brain
36
Q

List the ‘red flags’ which indicate a serious cause of LBP

A
  • Weight loss
  • PMH of malignancy
  • Fever
  • Signs of systemic inflammatory disease
  • Anatomical change
  • History of trauma
  • Loss of bowel/bladder control - cauda quina syndrome
  • Neurological signs (radiculopathy)
37
Q

Describe the radicular pain of LBP

A
  • Travels to lower limbs in narrow band
  • Below knees - neuropathic pain
    • Burning, stabbing, dysaesthesias
  • Associated with sensory/motor deficits
  • Provocation by straight leg raise
38
Q

List the characteristics of neuropathic pain

A

Shooting, electric shock-like, burning, tingling, numbness

39
Q

Compare somatic to visceral nociceptive pain

A
  • Somatic
    • Well localised
    • Dermotomal radiation
    • Sharp, aching, gnawing
    • Constant/periodic
    • Associations rare
  • Visceral
    • Vague distribution
    • Diffuse radiation, to body surface
    • Dull, cramp, dragging pain
    • Often periodic
    • Associations - nausea, sweaty, increased HR/BP
40
Q

What kind of pain is LBP?

A
  1. Nociceptive
  2. Neuropathic

Medicine Year 2 (41 decks)

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