NEURO-Chronic Pain Flashcards
Mr. Bruce is requesting increasing dose of meds, bc his symptoms are not changing. He is also experience agitation when he doesn’t have his meds. What is he experiencing?
Tolerance and Dependence
Mr. Bruce has seen multiple providers in order to fix his pain for TKR. After getting his pain stopped he stopped seeking. What is this condition?
Pseudo-addiction
no law broken
As with RX modalities what can the following TX option provide in term of Dec pain? Pharmacology ○ Physical Medicine ○ Behavioral Medicine ○ Neuromodulation ○ Interventional ○ Surgical
30% reduction
What is the workup for chronic pain lasting > 3mo
NO test for pain. Subjective ●Blood ● Imaging ● Neuro- mood ● Psych ● All usually benign if condition not previously known
What actually causes pain?
● Neuropathic- damaged nerve, gabapentin
● Musculoskeletal- trauma tear, nsaids
● Inflammatory- pressure on nerve, narcotics
● Mechanical/compressive- external
Neuropathic pain: accurate diagnosis, relieve nerve compression or medication effects. What RX is ideal?
antidepressants
Ca++ channel agents -Gabapentin and pregabalin -Changes neurotransmitter release via calcium channels
Carbamazapine
Narcotics- AVOID
Nociceptive pain: Pain *not from direct trauma on nerves but carried through peripheral nociceptors. What RX is ideal?
Acetaminophen- DEC prostaglandin NSAIDs- inhibit prostoglandin Tramadol antidepressants NO RX to relax a muscle. These are sedatives. *“Muscle relaxants” MOA – CNS Depression OPIODs- last resort
What theory supports small nerve in PNS can excite Neuron in PNS to signal pain the brain. However, another neuron can inhibited excited neurons in that signal Pain.
GATE theory
Substantia gelatinosa
What type of neurons excite nerunos in the substantia gelatinosa?
Mechanoreceptors Large Long Fast- mylinated A, delta fibers Recurrent neurons via neuron in the limbic system- endogenous analgesia
Which neuron excite the brain to produce pain?
Nociceptors
C fibers- slow, demylinated
Afibers
How do topical pain relievers works?
activates peripheral thermoceptors (Neuron S), interferes with transmission of pain signal at gate
Stimulate the gate theory via mechanorecepoters, stimulate neurons that can inhibit pain in the brain
42 yo male c/o acute exacerbation of LBP x 2 days since moving furniture. Reports L/S pain rad to right buttock worse with movement. H/o Degenrative Disc Dz, herniated disc L5-S1.
ROS consideration- incontinence, gait, foot drop sensation
PE- + SLR= lumbar radiculopathy
TX-ICE +/- heat. Acetaminophen and NSAIDs
NSAID 1-2wk
Tramadol prn, vicodin/xanax for sleep
PT
AVOID benzio, antieplitic,
NONRX- PT, yoga, stretch. MOVE
Surgery- little EBM Epidural inj+ SLR
What are DDX of LBP
Acute MSK lower back pain/strain
Right lumbar radiculopathy
Degenerative disc disease, lumbosacral
L5-S1 disc herniation without compression- d/t no gait abnormality
60 yo DM male c/o feet blisters x 3 days after using treadmill x 30 min. Previously sedentary. How would you treat?
Management of DPN
○ Glycemic control
○ Foot care
○ Treatment of pain
● *Amitriptyline (Elavil)-TCA
○ Neuromodulating agent for his neuropathy
● Other options: ○ Venlafaxine (Effexor) - SNRI ○ Duloxetine (Cymbalta) - SNRI ○ Pregabalin (Lyrica) - anticonvulsant ● NOT opiates (this is the key here)
48 yo F with knee pain related to long-standing damage to meniscus. Has advanced from OTC analgesia to Vicodin to control knee pain. Referred to orthopedics for evaluation and treatment. After arthroscopic procedure, patient reports significant, debilitating pain in extremity. Drug seeking d/t pain.
Management.
PE-general, skin, MSK
LABs- MRI +/-
Nerve conduction SNS
TX- TENs, biofeedback, spinal cord stim-implanted
TEAM approach
What syndrome is an uncommon form of chronic pain that usually affects an arm or a leg., develops after an injury, surgery, stroke or heart attack…out of proportion to the severity of the initial injury
Diagnosis of exclusion. Complex Regional Pain syndrome
● Sensitivity to touch or cold
● Swelling
● Changes in skin temperature, color, texture, hair and nail growth
● Joint stiffness damage
● Muscle spasms, weakness and loss (atrophy)
● Decreased ability to move the affected body part
35 yo female, new patient, requesting med refill for Oxycontin ER 10 mg po bid. She calls in 2 weeks stating her gym bag was stolen out of her car, including her meds, she is requesting refill;
states concern for w/d. How to manage?
ROS consideration- Why narcotics for HA? PE- no acute findings TX- Search CURES Psy- establish rules, contract MAT- reg. visit Percocet, Count pills, Discuss fire PT
What methods are used for Opiod mis use?
● Establish clear boundaries and “rules” ● Pain contracts ● Regular visits ● Pill counts ● Urine drug testing ● Prescription monitoring programs (CURES) ● Five AQ’s: analgesia, ADL, addiction, ADE, adherence ● Testing for DOA (drugs of abuse)
What is ideal management of Complex regional pain syndrome?
Body is responding to inflammation with damage Labs- NONE Image-NONE TX- Tens, Biofeedback, Team approach- Psych, MD, PT,
Will a DM patient respond to Tricyles Amitriptine if they have numbness or negative sx?
NO
Only for positive sx burning, tingling
What is the strongest evidence in managing pain?
Exercise therapy and Behavioral Therapy
Who is affected by pain more?
W elder Rural Newly employed w/ insurance Poverty Linked to GAD, childhood trauma,
What are risk factors for abuse?
mental illness
Multiple providers pharmacies
High daily dosage
When prescribing opioids what are the reccommendations?
follow standard of practice Build expectation for opioids, 30-40% of pain relief Functional goals- vs pain relief Contract- urine test, refill 1x/mo f/u Immediate release Low and slow 3-7d max Add naxolone AVOID Benzo w/ opioids
