Lecture 17: Chronic Pain Management (Exam 3) Flashcards
T/F: Genetics and past experience are involved in how we handle pain
True
What happens to the movement when there is pain in an area of the body
- The kinesthetics of movement change
- See compensation for painful or stiff regions leads to additional probs
- ex. support limb OA, myofascial strain patterns, & Tendon & ligament injury
What is there a balance of in the body
Pro-inflammatory & anti-inflammatory mediators
What happens to inflammation as a px ages
It increases
What is fascia
- White connective tissue
- Directly under the skin
- Deeper & broader bands of connecting muscles & tendons
- The connection btw/ bones
- The “interstitium” around organs & vessels
How can we use myofascial to determine pain
- By palpating
- Hold alot of the pain
- Doesn’t give the exact location of pain but an area where it is located
T/F: Opioids play a very important role in chronic pain management
False it is very questionable b/c of neuro-inflammatory, poor long-term efficacy, increasing doses req, & poor bioavailability
_______ leads to modifications in pain pathways that are more complex than acute pain.
chronic pain
rehabilitation
certification provides fundamental skills for pain management.
_____ can make pain feel more intense and should be managed alongside pain
stress
What is a key advantage of regional nerve blocks in chronic pain?
They can help reset pain pathways
_____________ can help reset the nervous system in chronic pain cases.
regional nerve blocks
What is a key benefit of strengthening exercises in hip dysplasia?
Strengthening gluteal muscles helps stabilize the hip
What is a key consideration when using laser therapy?
It has a biphasic dose response
What is a potential concern with using Gabapentin in elderly patients?
Ataxia and sedation
________ only needs to be dosed ______ daily, unlike gabapentin.
pregabalin; 2X
A receptor in the spinal cord that becomes activated during chronic pain, leading to pain amplification
NMDA receptor
Which physical therapy modality is most beneficial for weight loss in patients with mobility issues?
Underwater treadmill
What is a key benefit of non-steroidal anti-inflammatory drugs in chronic osteoarthritis?
They can prevent joint degeneration
_____________ includes treatments that don’t put drugs into the body, such as acupuncture and laser therapy.
physical medicine
________ is more beneficial than passive stretching, especially in cats.
active exercise
What is a key advantage of Pregabalin over Gabapentin?
Less ataxia and twice daily dosing
Critical factor in reducing chronic pain and inflammation
weight optiization
Which drug is most appropriate for blocking NMDA receptors orally?
Amantadine
can be used to break the pain cycle in chronic cases.
ketamine
NSAIDS role
Anti-inflammatory medications that can provide disease-sparing effects when used long-term
Myofascial Palpation
Gentle examination technique to detect fascial abnormalities and pain sources
___________ is preferred over high-velocity adjustments in elderly patients.
joint mobilization
Period of intensive pain control to reset central wind-up and improve chronic pain management
pain vacation
Intrinsic immune imbalance that occurs in elderly patients
Inflemaging
support limb changes
Overuse of diagonal leg when compensating for osteoarthritis in one limb
What is the primary concern with underwater treadmill therapy in neurologic patients?
Risk of fatigue leading to loss of function
What is the recommended monitoring frequency for long-term NSAID use?
Every 6 months
What is a key advantage of Librela for osteoarthritis?
It targets nerve growth factor
What is the role of fascia in chronic pain?
It carries body awareness and can become sticky with disuse
What is the recommended approach for chronic pain in elderly patients?
Multimodal therapy including physical medicine
which nerve is important as an analgesic factor in pain management.
vagus
What is the recommended daily dosage of EPA and DHA for dogs?
5,200 mg per kg
What is the primary concern with using opioids for chronic pain?
They are neuroinflammatory
How often should blood work be checked initially when starting NSAIDs?
Within 3-4 weeks
Products like Adequan and Dasequin that help protect joint health
joint supplements
are important omega-3 fatty acids for pain management.
EPA and DHA
What is a key consideration when using herbal medicines?
Natural doesn’t mean safer
can be particularly helpful for joint-specific pain.
shockwave therapy
know this
Kinesthetics of Movement
Compensation for
painful or stiff regions
leads to additional
problems
what other problems can occur from kinesthetic compensation
Support limb OA
* Myofascial strain
patterns
* Tendon and ligament
injury
* Altered body awareness
and increased tendency
toward additional injury
physical medicine examples
ouch/massage
* Acupuncture
* Laser or Photobiomodulation
* Therapeutic exercise
* Joint mobilization
* Heat/cold
* Exercise/motion
* Fascial Release
Emerging Evidence (Lascelles) that longer
durations of treatment with _________ (6 months)
are associated with less progression of arthritis
and pain in dogs with OA
NSAIDS
N-Methyl D-Aspartate
–Become activated by recurrent depolarization- loss of
Mg plug
–When activated- massively amplify calcium release
and thus nerve transmission
–Massive contributor to neuro-inflammation
–Excellent drug targets (receptors not constitutively
active)
N-Methyl D-Aspartate drug targets
Ketamine
* Amantadine
* Methadone
* +/- Tramadol (minor)
drugs of this classification antagonize central sensitization, glial activation, and decrease opioid tolerance, making a number of drugs more
effective
NMDA antangonists: amantadine and memantine
t/f: you should exercise caution when prescribing amantadine to a dog who has a pre-existing seizure condition
true, can cause more seizures
________ metabolized by the liver and cleared by the kidneys, so reducing the dose with liver or
kidney disease is recommended. Amantadine is available in tablets, capsules and a liquid solution
that is safe in animals. However,
amantadine
Fat is ____________
Reduction in weight is ___________
pro-inflammatory; Analgesic
Polysulfonated Glycosamino-Glycans
FDA approved (dogs) injectable drug
* For Non-infectious arthritis
* Decrease catabolic enzymes
* Enhance anabolic enzymes
Intra-Articular
Treatments for OA
Corticosteroids
* Hyaluronic acid
* Local anesthetics
* Platelet-rich plasma (PRP)
* Interleukin-1 receptor antagonist (IL-1ra,
IRAP, ACS)
* Mesenchymal or Bone Marrow stem cells
(MSC or BMAC)
* Botulinum A neurotoxin
* TRPV1 agonists (capsaicin)
* Radiation Therapy (Synovetin)
Corticosteroids
Reduction in pain from 1-4 weeks
* Not considered a long-term therapy alone
-three doses four weeks apart
regenerative therapy that augments natural healing process:
Platelet-Rich Plasma (PRP/ACP)
* Interleukin-1 Receptor Antagonists (IRAP)
* Mesenchymal Stem Cells
* Bone-marrow derived stem cells (BMAC
synovetin OA
breaks the vicious cycle of inflammation and chronic pain
Mechano-transduction from interaction with fascia networks
How fascia are associated with disease
* Modalities that interact with fascia for tissue deformation
neuomodulation can be
central
spinal
peripheral
visceral
tissue deformation is a powerful modulator of intrinsic healing in which soft tissues
skin, muscle
* ligaments, tendons
* fascia, cartilage
* periosteum
When the connective tissue complex
is deformed
growth factors and a variety of
proteins and neurotransmitters are released
Fibroblasts in loose connective
tissue respond to stretch
within minutes
* increasing ATP
* enhancing cytoskeletal relationships with neighboring cells
Therapeutic laser
Photons of light energy penetrate tissue and stimulate chromophores in the mitochondria
direct healing effects of electricity
-enhance bone and nerve repair mechanisms (nerves grow toward the cathode) at low intensity, but are destructive at high intensity
* PEMF- pulsed electrical magnetic field therapy (Assisi Loops, etc)
chemical healing effects of electricity
Receptor mediated effects (CGRP, NGF, Substance P)
mechanical healing effects of electricity
Mechanotransduction
thermal healing effects of electricity
increase local blood flow
which locations can you used electricity for healing
Cellular, Tissue, Segmental and Systemic
Important Promoters of De-Amplifying
Neuromodulation
Acupuncture
* Motion, Physiotherapy, Rehabilitation
* Vagal nerve stimulation
* System Modifying Pharmacology
Epi-genetic changes in humans
system modifying pharmacology (form of de-amplifying neuromodulation)
- Anti-inflammatories
- Gabapentin/Pregablin
- Cannabinoids (analgesia and inflammation)
- NMDA antagonists
- Pain Vacations
Epi-genetic changes in humans 9form of de-amplifying neuromodulation)
- Meditation
- Diet, supplements
- Medical interventions, in general
forms of Fascial
Modula,on
- Acupuncture
- Stretching
- Massage/touch
- Pressure waves
—– Tapping
—— ibration
—— Shock wave therapy
What are the sources of chronic pain
- Nervous System Sources (NMDA Receptor Mechanism): Located in spinal cord synapses, Becomes active with constant glutamate bombardment, Increases calcium binding, Activates surrounding glial cells
- Neurological Changes: Pain pathways modify and amplify over time, Potential for developing persistent pain syndromes, Nervous system becomes “wound up”
- Immune System Interactions: Disrupts normal inflammatory homeostasis; Can lead to: Hyperimmune responses, Autoimmune conditions, Reduced infectious disease response
- Fascial System’s Role: Largest organ system in body, Can become “sticky” with inactivity, Carries body awareness, Actively contracts and modulates body mechanics
- Aging-Related Sources: Multiple pain sources, Increased susceptibility to “inflammaging”, Aging immune system complications
Understand pain pathway amplification that accompanies chronic pain
- Pain Pathway Amplification Mechanisms (NMDA Receptor Mechanism): Located in spinal cord synapses, Normally plugged with magnesium, Becomes activated with constant glutamate bombardment
- Amplification Process : Tissue damage triggers constant nerve signal bombardment, NMDA receptor loses its magnesium plug, Increases calcium binding leads to, Presynaptic neuron becomes more active, Postsynaptic neuron becomes more active,Activates surrounding glial cells
- Example Illustration: Dr. Wright uses a toe-stubbing scenario to explain amplification the Initial injury causes pain Over hours, pain becomes more intense and throbbing Continuous stimulation “winds up” pain sensation
- Consequences of Amplification: Can transform from acute to chronic pain syndrome, Modifies pain pathways in complex ways, Involves multiple body systems (nervous, immune, fascial)
Understand immune imbalance that accompanies chronic pain
Understand kinesthetic/mobility changes that accompanies chronic pain
- Normal Immune Homeostasis: Typically maintains a balance of pro-inflammatory and anti-inflammatory mediators; Body expects inflammation to: Kick in during injury/illness & Resolve and return to normal state
- Chronic Pain Immune Disruption: Ongoing pain source makes it challenging to maintain immune balance; Potential consequences include: Difficulty balancing pro-inflammatory and anti-inflammatory effects & Complications with inflammation management
- Aging and Immune Imbalance: Dr. Wright introduces the term “inflammaging”; Elderly patients experience: Intrinsic immune system imbalance, Reduced immune system effectiveness, & Multiple pain sources compounding immune challenges
- Specific Immune Imbalance Outcomes: Hyperimmune responses, Potential autoimmune conditions, & Reduced infectious disease response
Understand fascia & soft tissue strain patterns that accompanies chronic pain
- Fascia Defined: Largest organ system in the body, White connective tissue under the skin, Connects muscles, tendons, bones, and organs, & Creates interstitial fluid space
- Fascia Functions: Body awareness, Immunity, Fluid balance, Connecting tissues, Surrounds all organs and vessels
- Soft Tissue Strain Patterns: Can become “sticky” with inactivity, Actively contracts and modulates body mechanics, Carries body awareness, Interrelates with muscle groups
- Pain Compensation Mechanisms: Injury causes changes in movement patterns, Compensation leads to additional soft tissue problems, Altered mobility changes body kinesthetics
- Fascial Characteristics in Chronic Pain: Becomes stiff with inflammation, Reduces tissue sliding and gliding, Can create stress across joints, Potentially leads to disc/joint stress
Describe therapy for chronic pain involving medications & supplements
- Opioids: Limited use in chronic pain, Not recommended long-term, Neuroinflammatory effects, Poorly absorbed in dogs and cats
- Non-Steroidal Anti-Inflammatory Drugs (NSAIDs): Effective for both acute and chronic pain, Potential disease-modifying effects, Require regular blood work monitoring; Examples: Carprofen, Meloxicam, Galliprant (EP4 receptor antagonist)
- Gabapentin: De-amplifies nervous system, Can cause sedation
- Pregabalin: Similar to Gabapentin, Fewer side effects, Twice-daily dosing
- NMDA Antagonists: Ketamine, Amantadine, Help de-amplify pain sensing system, Neuroprotective properties
- Omega-3 fatty acids: Joint support supplements, Antioxidants, Adaquin, Collagen-based supplements
- Injection Therapies: Nerve growth factor inhibitors (Librela, Solensia); Joint injections: Steroids, Hyaluronic acid, Biological treatments, Platelet-rich plasma, Stem cells
- Supplement Selection Criteria: Scientifically validated products, Check EPA/DHA concentrations, Prefer sustainably sourced options
- Recommended Supplement Brands: Nordic Naturals, Look for specific EPA/DHA milligram concentrations
- Key Therapeutic Approach: Holistic, integrative treatment, Combine pharmacological and non-pharmacological interventions, Individualized treatment plans, Regular monitoring
Describe therapy for chronic pain involving Diet, nutrition, & weight
- Weight Management: Highly correlated with pain management, Obesity is pro-inflammatory, Weight reduction is analgesic, Can have greater impact than anti-inflammatory medications, Veterinary studies show weight loss can improve pain more effectively than NSAIDs
- Food Choices: Focus on less inflammatory foods, Debate between fresh vs. dried foods, Consider foods with lower inflammatory potential
- Nutritional Strategies: Choose foods that reduce inflammatory state, Improve overall metabolic outlook, Support patient comfort
- Supplement Recommendations: Omega-3 fatty acids, Joint support supplements, Antioxidants, Careful selection of scientifically validated products
- Specific Dietary Recommendations: Arthritis-specific diets from major food companies, High omega-3 fatty acid concentrations, Recommended EPA/DHA intake: 5,200 mg per day
Describe therapy for chronic pain involving Physical medicine modalities
- Thermal Therapies : Ice and heat treatments, Scientific methods causing chemical tissue changes
- Manual Therapies: Tissue deformation, Acupuncture, Massage, Manual therapy, Joint mobilization, Soft tissue manipulation
- Exercise-Based Interventions: Rehabilitation, Hydrotherapy, Underwater treadmill, Balance work, Specific muscle group strengthening
- Advanced Treatment Techniques: Laser therapy, Shockwave therapy, Electrical stimulation, Magnetic field therapies, Hyperbaric oxygen therapy
- Physiological Mechanisms: Activates endogenous (Opioid system, Serotonergic system, Noradrenergic system, Endocannabinoid system); Key Benefits: Analgesic effects, Improves body awareness, Reduces pain signaling, Enhances overall mobility
Describe therapy for chronic pain involving movement & exercise
- Importance of Movement: Crucial for pain management, Helps reset pain sensing system, Improves overall body function
- Exercise Benefits: Inherently analgesic, Improves body awareness, Strengthens supporting muscle groups, Reduces pain signaling
- Specific Exercise Approaches: Balance work, Underwater treadmill, Targeted muscle group exercises, Rehabilitation-focused movements, Gentle controlled motion
- Rehabilitation Strategies: Every other week intensive sessions, Laser therapy during exercise, Acupuncture support, Muscle building, Proprioception improvement
- Special Considerations: Active stretching preferred over passive, Lifestyle modifications to encourage movement, Creating engaging exercise games, Tailored to individual patient needs
- Practical Implementation For cats: Acupuncture, Lifestyle changes, Food placement strategies, Interactive movement games
- Caution Points: Avoid overexertion, Careful with neurologic patients, Underwater treadmill can be risky for some conditions
