Pain (1) Flashcards
Pain assessment must focus on:
sensory, cognitive, emotional, behavioral and spiritual influences and effects.
An assessment of persistent pain that is solely focused on identifying the pain generator will likely lead to ___________ for both the patient and the provider.
Frustration
The goal of the pain interview is to:
Build trust
Gather information
Facilitate change
What are the rule out Red Flags?
Bowel/bladder dysfunction
Saddle anesthesia—perineal numbness
Bilateral leg weakness—motor lesion
Severe, sudden onset headache—aneurysm/cva /ICH
Fever, weight loss, night sweats—cancer
Recent injury
History of cancer—friable tissue, tried pain interventions
What is the goal of the patient centered interview?
Build the patients trust
What does OPQRSTU mnemonic for assessing pain?
Onset
Provocative/Palliative
Quality or Character
Region/Radiation
Severity
Timing/Treatment
U (You/Impact on Patient)
Why is it important to ask about previous consultations/treatments?
Tells us response to prior treatment (effects/side effects/ dose)
What is important about the psychosocial assessment?
Identifies coping strategies:
-anxiety, catastrophizing (, avoidance, internal locus of control
Catastrophizing: negative cascade of distressing thoughts—associated with higher pain intensity/poor Tx response
What do patient interviews sometimes become confrontational?
Doubt
Frustration
What should you do if a confrontation is unavoidable?
Remove yourself form the situation and seek assistance from a team member
WHat are the components of the clinical exam?
Inspection and General Appearance
Mental Status—usually patients in pain are taking multiple pain meds
Vital Signs
Posture and Gait
Palpation
Range of Motion (active and passive)
Neurological Examination
Special Tests
What is the goal of the physical exam?
Exclude red flags, complete psychosocial assessment , and quantify impairment
When is it appropriate to use diagnostic imaging?
Only when red flag signs and a physical exam suggest a red flag condition
Diagnostic imaging studies should only be performed in patients who have severe or progressive neurologic deficits or with features suggesting a serious or specific underlying condition
What is the cut off time when pain goes from being acute to chronic?
3 months
Why is multidimensional assessment scale for pain better to assess chronic pain?
(PEG) Assesses:
-average pain over past week
-Pain interference with QOL
-Pain interference with function
What screening tool is used for sleep apnea?
“STOP-BANG”
S Snoring?
T Tired?
O Observed apnea?
P High Blood Pressure?
B BMI > 35?
A Age > 50?
N Neck circumference > 40 cm (16 inches)?
G Gender is male?
Score >3 indicates presence and need to treat OSA
Screening tools for fibromyalgia:
WPI (widespread pain index)
SS (severity score)
What tool is used to screen patients prior to initiating opioids?
“ORT”
0-3: low risk
4-7: moderate risk
>8 : high risk
What would you do if a patient had a high score on the ORT screen?
Patient is high risk for abuse
Need more rigorous evaluation
How should you assess effectiveness of treatments?
Check 4 A’s:
Activity
Analgesia
Aberrant drug related behavior
Adverse effects
Consider 2 A’s:
Affect
Adjuncts
What does a low score on QoL screen indicate?
poor QoL
Neck pain is anywhere between ___________ and ___________
Base of the skull
The first thoracic spinous process
Which vertebrae separates upper and lower neck pain?
C4
Do you have headaches?
Just shove some 4% lidocaine on a cotton ball up your nose…problem solved sis
Mnemonic for red flag conditions:
“N SWIFT PICS”
Neuro – Progressive Neurological Deficit
Steroids – Prolonged Use
Weight Loss – Unexplained
Immunosuppression
Fever – Unexplained—meningitis
Trauma – Even mild if over 50
Porosis – Osteoporosis/Osteopenia
IVDU – Intravenous Drug Abuse—increased risk of fractures and infection
Cancer – History of Cancer
Severity – of Pain
What is the cause of chronic neck pain in the absence of trauma and red flags (normal exam)?
Cause for chronic neck pain is unknown
Moving the neck in which direction puts pressure on discs vs facets?
Neck forward puts pressure on disc
Neck backward puts pressure on facets
T/F: Osteoarthritis cannot be detected by imaging
True
Should you get imaging if neck pain is present with normal physical exam and no hx of red flags?
No need for imaging
Differentiate radiating vs referring:
Radiating: Pain that follows a dermatome and is accompanied with neurological signs (follows nerve distribution)
Referred: Follows myotome distribution and the neurological exam is normal (travels around muscular distribution)
What to do if neck pain persists despite attempted treatments?
Perform diagnostic testing (MRI)
If MRI normal then refer to specialist
What treatments provides the best long term outcome for neck pain?
Exercise, CBT are the best route
What area on the body qualifies as low back pain?
Anywhere between the tip of the last thoracic spinous process and the tip of the sacro-coccygeal joints
Where can back pain refer to?
The lower extremity above and below the knee
What are the different vertebral levels for Cauda Equina syndrome and Conus Medullaris?
Cauda Equina: L2 to sack-rum
Conus Medullaris: L1 to L2
Why is Cauda equina syndrome a red flag diagnosis?
There is damage to lumbar and sacral nerves and it can quickly progress to paralysis
- can be caused by an epidural hematoma
Acute low back pain is pain that is present for less than _____.
3 months
What is the prognosis of acute low back pain?
Favorable - following an acute low back pain episode, 80% can expect to recover rapidly
What are risk factors for developing chronic low back pain?
Stress at work, previous injuries, and litigation
Preferred tests for when a red flag is present:
What is a 59 year old male at risk for with osteopenia in vertebral bodies?
Vertebral fracture
What kind of symptom management can you prescribe for minimal to modest relief of back pain?
- encourage activity
- acupuncture, stretch and spray, heat packs
- NSAIDs and muscle relaxants are not particularly effective
- Opioids are not indicated
- Bed rest should not be prescribed
The shoulder and pectoral girdle are comprised of the _____, _____, and _____.
Scapula, clavicle, and humerus
The shoulder and pectoral girdle are stabilized by the _____.
Rotator Cuff
Where can shoulder pain be referred from?
Neck, heart, and gallbladder
What is the Apley scratch test?
Pain when reaching to opposite scapula
What is the Neers test?
Pain with shoulder flexion
What is the Hawkin’s test?
Pain with shoulder internal rotation
What is the drop arm test?
Pain with shoulder abduction
What is the Lift off test?
Pain with rotation and abduction
What is the O’Brian’s test?
Pain with rotation and abduction
What is Speed’s and Yerguson test for?
To test the biceps with elbow flexion - can detect biceps tendonitis
What is the apprehension test for?
Pain on pushing the humeral head - to detect a tear in the labrum
What are the most common shoulder pain conditions?
- Rotator cuff impingement or tear
- Gleno-humeral/sub-acromial bursitis
- Gleno-humeral instability
- Bicep tendonitis
Shoulder pain conditions in the elderly:
- mostly arthritis
- less frequently due to adhesive capsulitis
- always review red flags: metastases, infection, and systemic disease
- tend to respond less to intra-articular injections and rehabilitation
- if there’s limited functionality, discuss surgery or palliation
- Platelet rich plasma for treatment
Imaging has ____ utility in shoulder pain.
When would you consider it?
Limited
Consider it only if rehab fails or weakness and loss of function progress
MRI in asymptomatic patients reveal a high prevalence of _____, _______ and other structural abnormalities. (shoulder)
Rotator cuff tears, acromio-clavicular joint arthropathy
These findings most often are not the source of the patient’s pain
Who do you consult for the diagnosis of a rotator cuff tear?
What is usually required to correct any shoulder instability?
A surgeon
Arthroscopic surgery
What is the difference in mechanical hip pain and referred hip pain?
Mechanical = musculoskeletal origin - localized and aggravated by loading
Referred = poorly localized and may not increase by loading
What would pain at rest or without physical provocation indicate?
Rheumatologic, infectious, or cancer
Where can hip pain be referred to/from?
Low back, thigh, buttocks, or groin
Hips are surrounded by muscle groups that are important in _____ .
Normal gait
Where is blood supply most vulnerable in the hip?
Femoral neck
- important to perform imaging when the history and exam suggests avascular necrosis
What hip disorder is common in the elderly?
Hip osteoarthritis
What congenital hip disorders appear in children?
Slipped Capital Femoral Epiphysis (SCFE)
Legg-Clave-Perthes Disease (LCP)
When can trochanteric bursitis appear?
At all ages
What disease in the hip can be idiopathic but more frequently associated with corticosteroids, alcoholism, and systemic disease (Lupus, RA)
Avascular necrosis
What can steroids cause?
Arthritis and avascular necrosis
Plain films are valuable for _____, especially in children.
Most hip disorders
What are MRIs useful for in hips?
Early diagnosis of inflammatory, infectious or AVN
What are treatments for hip disorders?
- Exercise therapy is the foundation treatment for hip pain
- Active physical therapy is better than passive in hip Osteoarthritis
- Intra-articular steroid injection may offer transient relief for trochanteric bursitis
- Hip replacement is indicated in trauma and must be used judiciously for osteoarthritis
Where can knee pain refer to?
Lower back and leg
_____ into the knee is typically poorly localized and will often not increase with mechanical loading
Referred pain
What are the 3 components of the knee?
- Tibiofemoral
- Patellofemoral
- Proximal tibiofibular
How would you assess a knee?
- Best performed with knee in slight flexion
- Palpate medial, lateral, and anterior joint lines; patella, fibular head
- Assess for variations in skin temperature
- Assess for effusion - knee is enlarged or lacks full flexion
____ appears twice as often in women and does not require referral to surgery (knee)
Patellofemoral pain - pain is aggravated by squatting, climbing stairs, prolonged sitting, running or lifting
_____ of the knee presents with morning stiffness, knee crepitus, bony tenderness, bony enlargement and no palpable warmth of the knee
Osteoarthritis - treatment should focus on maintaining or improving function. Encourage activity and general exercise with PT and short term NSAIDs as first line treatment
____ is common in osteoarthritis after twisting the knee with a fixed foot.
Meniscal tear - it can lead to knee “locking”, effusion, and pain with loading activity
_____ is most commonly at the pre-patellar once it becomes infected and may require aspiration.
Bursitis
What knee injuries are common with trauma?
Ligamentum injuries
- Early bracing may be warranted to prevent further injury
- Early rehab should be utilized to maintain ROM and improve function
Most acute knee injuries are ____ tissue injuries.
Soft
Ottawa Rules for knee imaging:
- Age > 55
- Tenderness at the head of the fibula
- Isolated tenderness of the patella
- Inability to flex knee to 90 degrees
- Inability to walk 4 weight bearing steps
- Plain radiography is an appropriate first line
- If unrevealing MRI is useful for the detection of ongoing knee instability
What treatments are available for knee pain?
- Exercise therapy and weight loss are the foundational treatments
- Active physical therapy is better than passive
- Intra-articular aspiration or steroid injection may offer transient relief for pre-patellar bursitis
- While knee surgery is indicated in trauma, it must be discussed for OA
How can facet pain in the neck be ruled out?
Medial branch block
