Pain-Lewandowski Flashcards
Who began the BPSS model?
George Engel-1977
T/F Chronic pain can be treated in a similar way to acute pain.
False. They are very different processes.
What are the biological, physical factors that affect the experience of chronic pain?
tissue damage tension guarding sleep problem fatigue
What are the psychological, emotional factors that affect the experience of chronic pain?
mood (including depression, anxiety, anger) inappropriate pain behavior non-productive beliefs about pain cognitive appraisal invisible nature of pain
What are the social factors that affect the experience of chronic pain?
cultural issues
past learning history
T/F Chronic pain is a learned response in some cases.
True.
T/F No two people’s pain experience is alike.
True.
Explain the role of inappropriate medication use as a biological factor of chronic pain.
People fear addiction to narcotics & wait to take their meds until their pain is bad. This reinforces the behavior of taking meds to alleviate pain, however.
Explain the role of non-restorative sleep as a biological factor of chronic pain.
A large percentage of people with chronic pain have sleep problems, such as sleep apnea. College students that were sleep deprived exhibited symptoms of fibromyalgia. It messes with you.
Explain the role of physical deconditioning as a biological factor of chronic pain.
When people experience pain, they exercise less & engage in less activity. This leads to deconditioning of muscles & therefore more pain upon activity.
Explain how dysfunctional activity patterns have a biological role in chronic pain.
As our society values being driven & overcoming pain, many people push too hard & over do it & increase their pain by their over-activity pattern.
What is the correct term for pain medications?
opioids. not narcotics. b/c those are associated with addiction & illicit drugs.
Explain the role of avoidance behaviors as a psychological factor of chronic pain.
These are fear-based behaviors. You are afraid that anything you do will increase your pain so you don’t do anything & your world starts to shrink. Can ask the question: What does your pain keep you from doing that you would have otherwise done? A 40% or higher reduction in activity is very concerning as an estimate of interference in a person’s life.
Explain the role of disturbed mood: anxiety, depression, anger as a psychological factor of chronic pain.
While these are very unpleasant, they can be motivators to encourage patients to manage chronic pain. Most difficult patients to treat: those who aren’t upset w/ their chronic pain.
Explain the role of past learning with pain & injury as a psychological factor of chronic pain.
You can ask patients about their views of pain & what they were taught about pain as a child. It will help you to assess where they are with their own chronic pain. Did their parents rush them to the ER with each cut & bruise or did they tell them to rub some dirt in it?
What is catastrophizing?
taking one piece of data & blowing it out of proportion. this factors into a person’s beliefs about pain & is a psychological factor of chronic pain.
What is the main social message about pain in the U.S.?
Pain is bad & it should be quickly eliminated & NOT endured. This paints a picture of our pain experience.
Explain the significant other influence as a social factor of chronic pain.
Often, the spouse will reinforce pain behaviors. If a husband groans in pain, she will tell him to sit down. She will take out the trash. It reinforces the pain behavior.
Other times, the spouse will criticize the pain behavior & the injured partner will either increase the pain behavior or become angry & jeopardize the relationship.
Data from 25 years ago showed that physicians most often were biased against what type of patient complaining of chronic pain?
Young
White
Female
Low SES
What is the #1 reason people go to see their physician?
PAIN
About how many Americans suffer from chronic pain? Is this more or less than patients in America with Diabetes?
100 million Americans
4X Diabetes patients in the U.S.
Which philosopher promoted the idea that the mind & body are completely separate (something against the concept of chronic pain)?
Rene Descartes
What is the classic view of pain?
It is secondary to disease. Cure the disease–cure the pain. Pain isn’t a primary problem.
What is the yo yo effect of chronic pain?
hop from doctor to doctor trying to find a cure for your pain. When your physician can’t help you completely–you switch docs.
What are the top 10 non-medical things that you need to know about your chronic pain patient?
1: Is your patient worried about not getting better?
2: Is your patient’s quality of life acceptable living with pain?
3: Does your patient live by an additive/multiplicative attitude or a subtractive/division attitude?
4: What is the personal meaning of your pain?
5: How much does pain interfere with your activity level?
6: What is your quality/quantity of sleep?
7: What is your history with pain & trauma?
8: Does your patient believe the mind & body interact?
9: Recognize that your patient has invisible pain.
10: Does your patient know the difference b/w acute & chronic pain?
Explain acute pain. Specifically: span underlying cause treatment cognitive expectation level of life disruption
warning signal lasts 0-12 weeks then ceases symptom for underlying tissue damage Treatment: correct damage, rest, meds Ex: appendicitis, broken leg Cognitive Expectation: cure, fix, eliminate pain Moderate level of life disruption
Explain chronic pain. Specifically: span underlying cause treatment cognitive expectation level of life disruption
pain signal is the problem–not indicative of underlying damage
span is 13 weeks to many years
Treatment: movement in a graded fashion
Cognitive expectation: manage, cope, accept
significant level of life disruption
Soft tissue injuries usu take an average of how many months to heal?
3 mo
Fractures usu take an average of how many months to heal?
6 mo
What does it mean that hurt doesn’t equal harm?
harm is what always requires a doctor; hurt could be chronic pain. can’t adopt the attitude that you are only cured when all of your pain is gone.
Why is it essential for a physician to recognize that a patient has invisible pain?
b/c deep down patients are worried that you don’t believe them. Sometimes they spend a lot of time just trying to establish their credibility.
Do some patients believe that the mind & body don’t interact?
Yes! about 40% of patients. changes their treatment options.
Explain what it means when someone says that tissue damage doesn’t always equate with pain?
People process pain differently. Soldier on the front lines survived battle & is going home & requests less pain medication. A person going to the theatre & is mugged with minor injuries & request a greater amount of pain meds. Sometimes circumstances paint your pain.
Explain Cartesian thinking when it comes to chronic pain.
If you can't see it on an MRI--it doesn't exist. Pain ends when healing is complete. We need to fix & cure. Pain = Harm. Hurt = Harm. Man is a machine.
What are the 5 factors that predict bad outcomes with lumbar vertebrae surgery? Which of the 10 essential questions would reveal this info?
- physical abuse as child
- sexual abuse as child
- emotional abuse as child
- Parental substance abuse
- Neglect & abandonment
#7: History with pain & trauma
T/F Patients tend to have better recovery outcomes when dealing with chronic pain management when they blame someone else for their pain b/c it gives them somewhere to focus their anger. Which of the 10 essential questions deals with this?
FALSE. They have worse outcomes. #4: What is the meaning of your pain to you?
What is question #1 of the 10 essential questions? What is the most concerning response?
#1: Are you worried about not getting better? Worst response: no.
What are 4 validated treatment approaches for chronic pain?
physical therapy–try to increase activity slowly
cognitive-behavioral pain management
biofeedback & relaxation training
medications
What is the response rate to pain meds?
only works on 1/2 the people. Reduces their pain by 30%.
If you get thru therapy with a patient & they can answer “yes” to these 2 questions–you have been successful. Which 2 questions?
#1: Is your quality life at an acceptable level right now? #2: Is your ability to do things that you want to do at an acceptable level right now?
What are the 5 goals of cognitive behavioral therapy?
- problem solving orientation
- developing a sense of resourcefulness
- reconceptualization of attitudes & beliefs
- management rather than cure or fix
- pacing & modification of activities
CBT is a ____ _____ model.
control-based model
gaining control over your pain
reducing non-productive thoughts
getting away from your pain
What are 2 potential problems with CBT?
- could lead to a patient vulnerable to frustration
2. could demoralize patient & lead to preoccupation w/ pain
What is 3rd generation CBT?
- *doesn’t try to change content of thoughts, but relationship to your thoughts.
- *also called mindfulness-based cognitive therapy or acceptance therapy
What should psychologists be called when a referring a patient with chronic pain?
behavioral medicine specialists
Who is your quarterback & coordinator of care in each case?
Moderate Chronic Pain Case
Complex Chronic Pain Case
Moderate: Primary Care Physician
Complex: pain specialist
T/F Addiction to opioid prescribed for pain is common.
FALSE. It is uncommon.
What are the 2 main dimensions of pain?
Emotional & Sensory
T/F There is somatogenic pain and psychogenic pain.
False. Now, all pain should be considered real b/c of the complex interactions involved.
T/F Neuropathic pain often occurs in the absence of tissue damage.
TRUE
As opposed to nociceptive pain
What theory did Wall & Melzack develop for pain?
Gate Control Theory of Pain
gate in the dorsal horn of the spinal cord
large diameter nerve fibers inhibit transmission
small diameter nerve fibers facilitate transmission
Who developed the BPSS model & when?
Engel in the 1970s.
What is the operant conditioning model of pain & who developed it?
Developed by Fordyce in 1976
said that acute pain behaviors reinforced by interpersonal & environmental factors
Goal: extinguish bad pain behaviors (asking for meds & rest)
& promote good pain behaviors (resuming activity)
What is the cognitive behavioral model?
it adds to the operant conditioning model cognitive theory & tries to challenge bad beliefs & restructure the way a person views their circumstances.
What are frequent comorbidities to find in the chronic pain community?
depression
alcohol abuse
substance abuse
T/F Rates of suicide are higher in the general population than in patients with chronic pain.
False at least 2-3 X higher rates in patients w/ chronic pain.
What is anhedonia?
loss of interest in daily activities
What is pseudo addiction?
this is when a patient exhibits drug seeking behavior when pain is the central problem, not addiction.
May get pain meds from multiple providers or exceed the recommended dose.
What is opioid tolerance hyperalgesia?
worsening pain & side effects associated w/ long-term use of opioids
Why, under the old criteria, did so many patients categorize as addicted to opioids when they had been prescribed opioids for long-term pain management?
b/c they only have to meet 3/7 criteria in the DSM. Tolerance & dependence are present in almost everyone using opioids long-term. Difficulty withdrawing b/c of withdrawal symptoms easily counts as the 3rd symptom.
What is involved in operant conditioning & behavioral therapy?
it is based on the idea that the frequency of a behavior is modified by environmental contingencies
A behavior can be increased by: pos & neg reinforcement
A behavior can be decreased by: extinction & punishment
According to operant conditioning & behavioral therapy, how should pain medication be administered?
on a scheduled basis, so as to not act as a positive reinforcement of pain behaviors
What is extinction? What is an example?
It decreases the frequency of a behavior by discontinuing reinforcers.
Ex: staff ignores patient’s pain behaviors
What are some examples of self-regulatory behaviors? What is the main goal of this?
Main Goal: counteract physiological response to stress diaphragmatic breathing progressive & passive relaxation imagery meditation autogenic phrases hypnosis self-hypnosis biofeedback
What is biofeedback? How does this relate to treatment of migraine headaches & reflex sympathetic dystrophy?
biofeedback treatment shows a patient their muscle tension or other numbers so they can adjust their behaviors accordingly…
Ex: to treat migraines & dystrophy: modify peripheral skin temp & employ thermal biofeedback
What is the main goal of CBT? What must a good CBT program include?
Main Goal: change how patients perceive & understand their pain & address their emotional pain & losses Should Include: Education Goal-Setting Self-Regulatory Techniques Skill Acquisition Cognitive Restructuring Maintenance Exercise
What should a good physical therapy program include?
learning to maintain postural alignment relaxation to reduce muscle tension flexibility exercises resistance training to increase strength aerobic exercise to improve endurance TENS training (transcutaneous electrical nerve stimulation--stimulates unmyelinated nerve fibers)
What are the 3 classes of analgesics used in chronic pain management?
Nonopioid: Salicylates–Acetaminophen, Aspirin
Opioid: morphine-like
Adjuvant: anticonvulsants, antidepressants
What are the bad side effects of opioids that can be overcome if used for chronic pain use?
resp depression sedation nausea pruritus urinary retention
What are the bad side effects of opioids that aren’t overcome when used for chronic pain management?
constipation impotence or decreased libido sweating/chills depression physical dependence tolerance (limits effectiveness) opioid addiction Opioid tolerance hyperalgesia
What are adjuvants particularly helpful for?
neuropathic pain particularly w/ symptoms of: insomnia irritability depression anxiety
What are some examples of anti-convulsants & what are they used to treat?
Gabapentin–postherpetic neuralgia
Pregabalin (Lyrica)-postherpetic neuralgia, diabetic neuropathy, fibromyalgia
What is a serotonin NE reuptake inhibitor that is often used to treat fibromyalgia?
milnacipran
