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Year 3 Clinical > Management of Chronic Pain > Flashcards

Management of Chronic Pain Flashcards

1
Q

What is pain?

A

An unpleasant sensory and emotional experience, associated with actual tissue damage, or described in terms of such damage

It is a construction of our brains and is not a physiological parameter; there is no single entity of pain

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2
Q

How does pain affect an individual?

A

Sensory - discriminative

Cognitive - evaluative

Affective - emotional

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3
Q

What factors influence the variable relationship that exists between input and experience of pain?

A

3 main categories:
• Biological variables
• Psychological variables
• Sociocultural variables

Examples of these are below:

Genetics, demographics

Emotional context and psychological state

Previous damage and dysfunction

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4
Q

Characteristics of acute pain?

A

Usually there is obvious tissue damage and the pain is a consequences of protective functions

Increased NS activity

Pain resolves upon healing

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5
Q

Characteristics of chronic pain?

A

Pain extends beyond the period of healing and thus no longer has a useful purpose; it degrades health and function

Individuals have changes in pain signalling and detection

NOTE - chronic pain can be broadly divided into:
• Chronic cancer pain
• Chronic non-cancer pain

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6
Q

How can pain be measured?

A

Verbal rating scale - no pain (0), mild (1), moderate (2), severe (3)

Numeric rating scale - 0-10 with 0 being no pain and 10 being the worst pain imaginable

Visual analogue scale (uses emoticon faces)

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7
Q

Behavioural observations of a patient in pain?

A

Grimacing, frowning, crying

Rigid body posture

Limping

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8
Q

Physiological responses to pain?

A

Increased HR and BP; these are not sensitive or specific as indications of pain

NOTE - behavioural observations and physiological responses should not be used instead of self-reporting on a pain scale

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9
Q

How does pain become an emotion?

A

A painful stimulation on the skin passes, via Aδ-fibre and C-fibres, to the spinal cord (lamina I)

From here, the signal passes to the parabrachial nucleus and then to the amygdala hypothalamus; this is processed in the brain and attention is given to the stimulus

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10
Q

How is pain interpreted as a sensation?

A

A painful stimulation on the skin passes, via Aδ-fibre and C-fibres, to the spinal cord (lamina I)

From here, the signal passes to lamina V in the spinal cord; this is followed by the thalamus and primary somatosensory cortex

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11
Q

2 types of pain?

A

Nociceptive pain - appropriate physiologic response to painful stimuli, via an intact NS

Neuropathic pain - inappropriate response caused by a dysfunction in the NS

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12
Q

Description of neuropathic pain?

A

Burning, shooting, tingling, sensitivity

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13
Q

Examination of neuropathic pain?

A

Allodynia - pain from a stimulus that is not normally painful, e.g: cotton wool

Hyperalgesia - more pain than expected from a painful stimulus, e.g: pinprick

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14
Q

Common causes of neuropathic pain?

A

Shingles and post-herpetic neuralgia

Surgery

Trauma

Diabetic neuropathy

Amputation

Many types of neuropathic pain have unknown origin

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15
Q

At which locations does the NS change?

A

At the periphery, the nerve axons, spinal cord and brain

This is referred to as neuroplasticity

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16
Q

Importance of early and effective treatment of pain?

A

Assoc. with better outcomes:
• A lower degree of chronicity relates to a better therapy result, i.e: not treating adequately at an early stage is assoc. with pain becoming more difficult to treat
• Chronic pain assoc. with morphological change in the CNS
• Once present, pain is often persistent and seldom totally resolves, even with treatment
• Chronic pain causes a lot of suffering and marked -ve effects on wellbeing and QoL

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17
Q

WHO ladder for pain Mx?

A

ADD IMAGE

Non-opioid analgesics, e.g: NSAIDs, paracetamol

Opioid analgesics, e.g: tramadol, codeine, morphine and oxycodone

Adjuvants:
• Anti-depressants, e,g: amitriptyline, dyloxetine
• Anti-convulsants, e.g: gabapentin, pregabalin
• Topical analgesics, e.g: capsaicin, lidocaine 5% plaster

Local anaesthesia (peripheral nerve or nerve plexus)

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18
Q

Efficacy and mode of action of NSAIDs (non-opioid analgesics), e.g: aspirin, ibuprofen?

A

Mainly act on nociceptive pain:
• Inhibit COX
• PG synthesis decreases

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19
Q

Side effects of NSAIDs?

A

GI irritation / bleeding

Renal toxicity

Potential drug-drug interactions

CV side effects

20
Q

Efficacy and mode of action of paracetamol (non-opioid analgesics), e.g: panadol?

A

Has analgesic and anti-pyretic effects:
• Inhibit CENTRAL PG synthesis (complete mode of action is unclear); it differs from NSAIDs due to its predominantly central action

Does not possess any anti-inflammatory action

21
Q

Side effects of paracetamol?

A

Risk of toxic liver damage (at high doses)

22
Q

Efficacy of opioid analgesics e.g:
• Tramadol and codeine (weak opioids)
• Morphine and oxycodone (strong opioids)

A

Mainly effective in nociceptive pain and only partially effective in neuropathic pain

Less effective in chronic states

23
Q

Mode of action of opioid analgesics?

A

Activate the endogenous analgesic system:
• Stimulate receptors in the limbic system to eliminate the subjective feeling of pain
• Affect descending pathways that modulate pain perception
• Reduce ascending pain signal transmission in the spinal cord

24
Q

Side effects of opioid analgesics?

A

N&V

Constipation

Dizziness or vertigo

Somnolence

Dry skin and pruritus

25
Q

Efficacy of tricyclic anti-depressants (TCAs), e.g: amitriptyline, imipramine?

A

Mainly effective for neuropathic pain, complex regional pain syndrome (CRPS) and tension headaches

26
Q

Mode of action of TCAs?

A

Inhibit neuronal uptake of noradrenaline and serotonin (5-HT), which are key neurotransmitters in pain signalling

27
Q

Side effects of TCAs?

A

Constipation

Dry mouth

Somnolence
Insomnia

Abnormalities in HR or rhythm

Increased appetite

28
Q

Drug-drug interactions with TCAs?

A

With cimetidine, phenothiazine and some anti-arrhythmic drugs

29
Q

Efficacy of selective serotonin and noradrenaline reuptake inhibitors (SSRIs and SNRIs), which are anti-depressants?

A

Used for neuropathic pain; SNRIs are better than SSRIs

30
Q

Mode of action of SSRIs and SNRIs?

A

Selectively inhibit the reuptake of noradrenaline or serotonin or both

Provide analgesia by intensifying descending inhibition

31
Q

Side effects of duloxetine?

A

N&V

Constipation

Somnolence

Dry mouth

Increased sweating

Loss of appetite

32
Q

Efficacy of anti-convulsants?

A

Used for neuropathic pain

33
Q

Mode of action of the different types of anti-convulsants?

A

Gabapentin - binds to pre-synaptic, voltage-dependent Ca2+ channels

Pregabalin - interacts with special N-type Ca2+ channels

Carbamazepine - blocks Na+ and Ca2+ channels

34
Q

Side effects of anti-convulsants?

A

Sedation and dizziness

Ataxis

Peripheral oedema

Nausea and weight gain

35
Q

Main categories of topical analgesics?

A

Rubefacients - traditional formulations based on salicylate and nictinate esters

Capsaicin and capsicum extracts and derivatives:
• Capsaicin 0.025%
• Capsaicin 8% patch

NSAIDs - diclofenac, felbinac, ibuprofen, ketoprofen, piroxicam, naproxen, flurbiprofen and other NSAIDs

Lidocaine 5% medicated plaster

Levomenthol 0.5-2%

36
Q

Mode of action of topical analgesics?

A

Reduce pain impulses transmitted by Aδ-fibre and C-fibres

37
Q

Main side effects of topical analgesics?

A

Pruritus, erythema and rash (localised application site reactions)

38
Q

Why is pharmacological treatment of chronic pain often limited?

A

By lack of efficacy and / or side effects (vicious circle), which may lead to treatment discontinuation

39
Q

Aim of using complementary therapies?

A

Aim to work in conjunction with and alongside conventional treatment and can aid in pain control

40
Q

Types of complementary therapies?

A 
Physical therapy - direct intervention on the body, e.g:
• Massage
• Aromatherapy
• Reflexology
• Acupuncture 
Mind therapy - focus is on psychological aspect of disease and assisting coping mechanisms, e.g:
• Relaxation, breathing techniques
• Visualisation, art and music therapies
• Reiki
• Stress and anger management
• Sleep hygiene
• Activity pacin
• Hypnosis
• Biofeedback
• Mindfulness
41
Q

Types of psychological therapy?

A

Cognitive behavioural therapy (CBT) - challenge -ve thoughts, feelings and behaviour; encourages patients to take an active part in changing outcome of a situation, emotional and physical response to a situation

Solution focused brief therapy - focuses on what the patient would like to achieve in the present or the future

42
Q

Guidelines for Mx of chronic pain?

A
  1. Assessment and planning of care
  2. Supported self Mx
  3. Pharmacological Mx
  4. Psychological based interventions
  5. Physical therapies
43
Q

What other therapies and procedures can be added by a pain clinic?

A

TENS

Procedures like SCS and ITDD????

44
Q

What topics are patients with chronic pain, and their relatives, educated on?

A

Beliefs and aims

Goal setting

Fear avoidance, pacing, sleep, mood-pain cycle, stress-tension-pain cycle

Weight Mx

45
Q

Why is a biopsychosocial perspective important for a patient with chronic pain?

A

Chronic pain is multifaceted and involves the interaction of physical, psychological and social factors

Year 3 Clinical (100 decks)

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