Lecture 5: Pain Management Flashcards
5th vital sign
pain
goals for clinicians in terms of pain management
eliminate source
teach function within limitations
improve pain control with physical/physiological questions
treat overall well being
improve support systems
optimal pain management does what
helps pt understand their symptoms, adhere to treatment plan, and return to normal lives
problem with passive meds
opioid crisis
doctors now prescribing less
problem with passive modalities
often waste of time for only short term relief
some clinicians dont use any modalities
helpfulness of subjective vs objective pain report
subjective = self report; most reliable
pain scales = quantitative rating of intensity
objective measures for pain
verbal rating
numerical rating
visual analogue scale
picture or face scale
what should you consider when choosing a type of objective pain measure
symptom duration
pt cognitive abilities
time needed
complexity of measure/sensitivity to change
nonverbal pain indicators
facial expression
sounds; i.e. groans, cries, etc
bracing/guarding
restlessness
rubbing area
vital sign response
the anterolateral spinothalamic pathway provides primary sensation for what
nondiscriminative/crude touch, pain, and temp
what is acute pain
less than 30 days
well localized and defined
what is chronic pain
longer than 3-6 month duration
nociceptive, neuropathic
CNS PNS SNS
what is referred pain
perceived as coming from a site different from source
i.e. visceral pain
anterolateral spinothalamic pathway receives signals from
mechanoreceptors
nociceptors
thermoreceptors
type of fibers in the anterolateral spinothalamic pathway
C fibers (peripheral n)
small/unmyelinated
what is nociception
neural process of encoding noxious stimuli
pain is NOT nociception
transmission can be facilitated or inhibited along the way before it reaches the brain (i.e. modalities can inhibit)
pain is an output of the brain triggered by the action potential of what and converted to what
triggered by action of a potential nociceptor and converted to conscious understanding of that stimulus
what is the perception of nociception by the cerebrum
pain
questions to ask pt about pain
location
intensity
type (can help determine structure)
radiates
duration
aggravating/relieving
effects on daily activities
sleep patterns
psychosocial effects
what are the 3 dimensions of the experience of pain
sensory discriminative = where pain is and what it feels like
motivational affective = how pt feels about P! emotionally
cognitive-evaluative = what pt thinks about pain intellectually and what they expect
characteristics of sensory receptors
at distal ends of afferent n
specific and sensitive for the type of stimulus they were designed to sense
free nerve endings are
type of nociceptor/mechanoreceptor that “sense” pain
nociceptors are triggered by
intense thermal, mechanical, or chemical stimuli
exogenous source: brick, acid, bleach, fire
endogenous source: fx bone, inflammation, etc
types of nociceptors for afferent neurons
C fibers (80%)
A delta fibers (20%)
characteristics of C fibers
small/unmyelinated (slow)
pain = dull/throbbing/aching/burning
respond to noxious levels of stimulus
slow onset, long lasting symptoms and diffusely local
blocked by opioid meds at receptor
emotional involvement
characteristics of A delta fibers
larger/myelinated (faster)
more sensitive at high intensity mechanical stimulus
pain = sharp, stabbing, pricking
quick onset, short duration
localized to where stimulus arose
not blocked by opiods
no emotional involvement
where are 1st and 2nd order neural cell bodies housed
1 = dorsal root ganglion
2 = dorsal horn
what neuro path does pain sensory travel
spinothalamic tract
where does the 3rd order neuron on the spinothalamic tract terminate in the brain to be percieved as pain
primary somatosensory cortex
describe the multifaceted preprogrammed response of the pain matrix
1- conscious perception of pain
2- motor responses (physical rxn)
3- homeostatic system respons (ANS, endocrine, and immune systems)
explain the gate control theory
stimulation of non-nociceptive fibers simultaneously with pain
A beta fibers (inhibit pain transmission to higher centers) trump the other slower signals from C fibers
brain only recieves A beta signals
“closes the gate” to the pain signal
how do modalities follow the gate control theory
thermoreceptors send signal on A beta fibers to brain
estim = electrical impuslse felt instead
examples of gate control theory that are often unconsciously preformed
rubbing a contusion, strain, sprain
applying moist heat
massaging sore muscles
how do opioids and opiopeptins (endorphins) work in the central and peripheral nervous systems
peripheral = have inhibitory actions causing presynaptic inhibition of nociceptive signal
central = relieve pain naturally as they attach to reward centers in the brain
explain the endogenous opioid systems theory
act as neuromodualtors and have inhibitory actions on pain pathways
release of opiopetins plays important role in controlling pain during emotional stress
act of C fibers peripherally but NOT A delta
explains paradoxical pain relieving effects of painful stimulation like acupuncture and TENS
pain management appraches act physiologically by doing what
controlling inflammation
altering nociceptor sensitivity
increased binding to opioid receptors
modifying n conduction
modulating pain transmission
altering higher level aspects of pain perception
management of psychological and social aspects
drawbacks to pharmacologial agents for pain management
adverse side effects
may not be sufficient
risk of dependence
may need multidisciplinary treatment
pt adherence
what are systemic analgesics and examples
primary method of pain management
i.e. NSAIDs, acetaminophen, opiates, antidepressants, sedatives
what are spinal analgesia drugs and examples
epidural or subarachnoid space of spinal cord; bypass brain blood barrier and reduce systemic side effects
opiods, local anestheics, corticosteroids
what are local injections/benefits
into structures or painful/inflamed areas
short term pain relief used mainly for procedures
all pharmacological agents control pain by
modifying antiinflammatory mediators at periphery
altering pain transmission from periphery to cortex
altering central perception of pain
pt edu for pain management should include
info about neuophysiology of pain
reassurance that pain with mvmt isn’t a sign of further damage
reassure that pain is normal post trauma
complete elimination of pain is not generally achievable in short term
pain is multifactorial
pain almost always resolves with time
what modalities assist in pain management
thermo = cold/hot pack
mechanical = US, traction, compresison
EMT = ESTIM, laser light
what are the benefits of physical agents
reduce intensity (prevents acute turning chronic)
give pt some control over symptoms
pt can have autonomy
reduced medical cost
minimal risk of adverse side effects
no risk of dependence
no sedation
opportunity to practice related pain management skills
give pt therapeutic window
how does TENS control pain
stimulates A beta fibers
and
stimulates release of opiopeptins at spinal cord and higher levels
