Pain And Nociception

Question 1

Pain definition

Answer 1

An unpleasant sensory and emotional experience associated with actual or potential tissue damage

-it is a physiological process, not an anatomical process (but changes in anatomy can lead to physiological mechanism of pain)

Question 2

Why assess pain?

Answer 2

-pain is recognized as the 5th vital sign and is considered a key feature of the PT interview
-it is the #1 reason why someone is seeking your services

Question 3

Why is not all pain bad?

Answer 3

-pain is a protective mechanism
-helps us with drawl from dangerous situations (reflexes)
-pain allows us to know if there is actual tissue damage

*uncontrolled pain is bad
*People who can’t feel pain are in danger of many complications

Question 4

5 characteristics of pain

Answer 4

Location, description, intensity, duration, frequency

Question 5

Characteristics of pain: location

Answer 5

-Where does it hurt? (This can be more complicated)
-Does the person have any other pains or symptoms elsewhere? (Isolated spot vs whole extremity)
-characteristics and location can change over time

Question 6

Characteristics of Pain: Description

Answer 6

-What does the pain feel like?
-Boring, knifelike, comes in waves, deep aching-could indicate a systemic origin this is a red flag
-dull, achy, sore - could indicate musculoskeletal
-Has the pain changed?
-if different positions don’t make it better, then this is a red flag

Question 7

Characteristics of pain: intensity

Answer 7

-very important, but hard to assess (can vary person to person)
-highly subjective
-psychological factors can play a role (stress, anxiety, depression, tiredness all impact the perception of pain)

Question 8

Characteristics of pain: frequency and duration of pain

Answer 8

-how often does pain occur?
-is it constant or intermittent?
-Does it decrease (or increase) with rest or change in position- characteristic of musculoskeletal issue

Question 9

Medication consideration

Answer 9

-need to take into consideration any medications persons may be on (ex. NSAID, Anti depressants, opioids, etc)
-This is often over looked

Question 10

5 sources of pain

Answer 10

-cutaneous sources
-somatic sources
-visceral sources
-neuropathic pain
-referred pain

Question 11

Cutaneous and somatic pain

Answer 11

-Cutaneous pain: localized to the skin and subcutaneous tissues (somatotopically organized, can put your finger on it)

-somatic pain: refers to pain arising from muscles, bone, tendons, ligaments fascia (musculoskeletal pain or neuromuscular pain)

Question 12

Chemical pain

Answer 12

-pain arising from actual tissue damage (will encounter this mostly in the acute setting)
-activation and sensitization of specialized receptors by algogenic substances
-reaction to an inflammatory type response

Question 13

mechanical pain

Answer 13

-Pain arising (in theory) by stretching of collagen fibers and thus squeezing nerve endings between them (swelling can lead to this)
-occurs in the absence of actual tissue damage, but when tissue is excessively strained or overused

*both mechanical and chemical pain can work together

Question 14

Neuropathic pain

Answer 14

-direct consequence of a lesion or disease affecting the:

~Central nervous system (CNS; brain or spinal cord) Origins can include: MS, SCI, Stroke, TBI

~Peripheral Nervous system (PNS) Origins can include: Nerve compression, diabetes, cancer, crush injury, Guillain-Barré syndrome

Question 15

Visceral pain

Answer 15

-Pain arising from the internal organs and the heart muscle
-pain is poorly localized and diffuse
-is well known for its ability to produce referred pain

Question 16

Referred Pain

Answer 16

-pain that is perceived as coming from a site distinct from the actual site of origin

Could be due to:
-different nerve branches that originate in different areas converge on the same dorsal horn cell
-the same nerve may have 2 peripheral axons, one in skin and one on the viscera
-nerve impingement

Question 17

Acute pain

Answer 17

-an essential biological signal of the potential for the extent of injury
-lasts or is expected to last a short time (self limited)
-the pain is proportional and appropriate to the problem and is treated as a symptom

Question 18

Chronic Pain syndrome

Answer 18

-Pain that persists past the expected time of healing
-it has no adaptive biological role: it is no longer a warning about tissue damage (has no recognizable endpoint)

-is characterized by a collection of life changes and altered behavior (the pain becomes a disease itself, is complex and multidimensional)

Question 19

Chronic pain syndrome: Therapy

Answer 19

-requires a focus towards maximizing functional abilities rather than treatment of pain
-therapy approach is to assess how the pain has affected the person
-interventions may be aimed at: managing stress, decreasing emotional response to pain, movement (release of endocannabinoids)

Question 20

Measures of Pain

Answer 20

-Visual analog scales
-numeric rating scale (NRS)
-faces pain scale (good for kids)
-McGill pain Questionnaire
-short form (36) health survey assessment pain scale
-nursing assessment of pain
-pain assessment in advance dementia scale

*important to also ask about things influencing this pain rating (stress, anxiety, depression, time of day)

Question 21

Pain assessment in older adults

Answer 21

-may just accept pain as part of growing older and will not report (they will suck it up mentally)
-May not report for fear of losing independence
-may not be able to report pain level (cognitive impairments)

*look at body language (that will be the true test)

Question 22

pain assessment in children

Answer 22

-Need to be language appropriate when talking with children
-face scale works well with this population

Question 23

Why physical therapist should be dealing with pain

Answer 23

-surgeon general addressed in the ATPA leadership meeting that the PT profession is well positioned to change the culture around pain management in the US
-we know that physical therapy is going to be part of the evolution to value based care
- studies have established the efficacy of PT in treating and reducing pain as well as preventing chronic pain

Question 24

Prevention of opioid Abuse

Answer 24

research on the efficacy of opioids for long term pain management show:
-low back pain- opioids do not expedite return to work or improve functional outcomes
-after surgery- patients prescribed opioids are at increased risk for chronic opioid use
-arthritis opioids lead to higher risk of bone fractures