pain syndromes Flashcards
Affects more Americans than diabetes, heart disease and cancer combined
pain
the most common cause of long-term disability
chronic pain
Most common reason Americans access the health care system
pain
this kinda of pain alerts person to possible injury/condition
acute pain
this kind of pain is persistant, signals keep firing for weeks or years
There may be an initial trigger (injury or condition, serious infection, arthritis, cancer, etc.), but
many suffer w/o history of injury or condition
chronic pain
this kind of pain adversely affecting a person’s life physically, emotionally, and mentally
Can alter body at the cellular level
chronic pain
chronic pain includes
headaches, LBP, cancer, arthritis, neurogenic, and psychogenic (not due to past disease or injury)
pain classification
Can be based on pain physiology, intensity, temporal characteristics, type of tissue affected, or syndrome
Pain physiology (nociceptive, neuropathic, inflammatory)
Intensity (mild-moderate-severe; 0-10 numeric pain rating scale)
Time course (acute, chronic)
Type of tissue involved (skin, muscles, viscera, joints, tendons, bones)
Syndromes (cancer, fibromyalgia, migraine, others)
Caused by damage, injury, or inflammation to body tissue
Usually described as a sharp, aching, or throbbing pain
Usually associated with acute conditions
nociceptive pain
Associated with chronic pain
Occurs when there is damage, change, or problems to the peripheral nerves or CNS
Usually described as prickling, tingling or burning
Generally responds poorly to pain tx
neuropathic pain
A patient reports a pricking, tingling and burning sensation on the dorsum of her left hand. What type of pain is this patient describing?
a. Acute pain b. Nociceptive pain c. Chronic pain d. Neuropathic pain
neuropathic pain
what is gate control theory?
Pain impulses are “influenced” by a gating mechanism in the dorsal horn
Stimulating touch or movement sensation can close the gate, limiting pain impulse transmission
“non-painful sensations override painful sensations”
gating mechaniskm is controlled by
Gating mechanism is controlled by the activity in the large and small fibers
Large-fiber (A–alpha or proprioception/movement, A-beta or touch) activity inhibits (or closes) the gate
Whereas small fiber activity (pain) opens the gate
When gate is closed, small diameter pain fibers do not excite the dorsal horn transmission neuron
If pain information reaches a threshold that exceeds inhibition
It “opens the gate” and pathways to experience pain
Gating mechanism is influenced by nerve impulses that descend from the brain
3 influences on opening and closing the gate:
Amount of activity in the pain fibers
Amount of activity in other peripheral fibers
Messages that descend from the brain
neurophysiology of pain modulation: circles consist of what in the brain?
Circuit consists of periaqueductal gray (PAG) matter in the upper brain stem, locus coeruleus (LC), the nucleus raphe magnus (NRM) and nucleus reticularis gigantocellularis (Rgc)
neurophysiology of pain modulation: contribute to what pathway?
this inhibits what?
the descending pain suppression pathway,
inhibiting incoming pain
neurophysiology of pain modulation: opiods interact with what?
this causes what?
Opioids interact with the opiate receptors at different CNS levels, causing secondary changes which lead to neuronal electrophysiological change and modulation of ascending pain information
neuropathic pain causes
Infections & viral conditions
Compressive
Autoimmune
Congenital/hereditary
chronic pain treatment
Medications, acupuncture, local electrical stimulation, and brain stimulation, as well as surgery, etc.
Some physicians use placebos
Psychotherapy, relaxation and medication therapies, biofeedback, and behavior modification
Chronic pain sufferers found to often have lower than normal levels of endorphins in spinal fluid
acupuncture activates what systems?
Acupuncture & electro-acupuncture may activate endorphin systems
acupuncture is believed to stimulate what fibers? what do these fibers inhibit and enhance?
Believed to stimulate A-delta fibers mediating inhibition of pain impulses, and enhance descending pathway inhibition from midbrain
post-acupuncture treatment has shown increased levels of what in CSF?
Post-acupuncture Tx shown to increase levels of endorphins in cerebrospinal fluid
What is CRPS?
Complex Regional Pain Syndrome (CRPS) type I and II is a multifactorial disorder that is associated with an aberrant host response to tissue injury
30% of CRPS sufferers experience persistent pain and impairment for 2-6years following onset
CRPS can be resistant to therapies making management challenging for clinicians
mechanism of CRPS
1) original injury initates a pain impulse carried by sensory nerves to CNS
2) pain impulses trigger impluses in sympathetic system which returns to the original site of injury
3) sympathetic impluse triggers inflammatory response causing the vessels to spasm leading to swelling and increased pain
4) pain triggers another response, establishing a cycle of pain and swelling
Formerly known as Reflex Sympathetic Dystrophy (RSD)
Pain characterized as constant, extremely intense, and out of proportion to the original injury
CRPS
Typically accompanied by swelling, skin changes, extreme sensitivity, and can often be debilitating
Usually affects one or more of the four limbs but can occur in any part of the body
In over 70% of the victims it spreads to additional areas
CRPS
Progressive disease of the ANS, and more specifically, the Sympathetic Nervous System
CRPS
75% of those affected are women
Pain is primary component:
CRPS
Described as the most pain ever experienced
“Imagine your hand was doused in gasoline, lit on fire, and then kept that way 24/7, and you knew it was never going to be put out”
CRPS
2nd component is Allodynia - extreme sensitivity to touch, loud or deep sounds, and/or vibration, where normal touch become pain
CRPS
CRPS SIGNS AND SYMPTOMS
Constant chronic burning pain, usually significantly greater than original event/injury
Inflammation
prevention of CRPS
Multiple cast changes
Neglect of limb/ anger with limb
Reports “claustrophobia in cast”
Reports “limb does not feel like my own”
Allodynia
Uncontrolled pain while in cast by two weeks
Restricted unaffected joint motion while in cast
prognosis of CRPS
Varies from person to person
Most children and teenagers have a good recovery
Evidence suggests prevention is key
Early treatment, particularly rehabilitation, helpful in limiting the disorder, but not yet been proven in clinical studies
More research needed to understand the causes of CRPS, how it progresses, and the role of early treatment
OT Intervention in Pt’s with CRPS
Compensatory Approaches
Use clinical-decision making skills to determine if compensatory approach is better fit for patient.
Symptoms may be worsened by stress loading patients with CRPS
Packman & Holly (2018) suggest unloading:
Providing supportive wrist orthosis permitting functional use while minimizing pain
Increasing physical demands when monitoring responses of clinical signs and patient symptoms
OT Intervention in Pt’s with CRPS
Remedial Approaches
Management of allodynia, edema, ROM, and strength along with engagement in activities of daily living (ADLs)
Exercise program to keep the painful limb moving to
Improve blood flow and reduce circulatory symptoms,
Improve the affected limb’s flexibility, strength, & function
Prevent or reverse the secondary brain changes associated with chronic pain
Management of psychological symptoms
Addressing Sensory Stimulation/Neuroplasticity in Pt’s with CRPS
Sequential activation of the cortical networks involved in sensory and motor processing corrects sensorimotor incongruence in afferent signaling from the affected limb.
N = 51 single blind RCT with persons with CRPS1 and phantom limb pain. Slowly and smoothly adopt the movement portrayed in a card in each hand while looking in the mirror and repeated 2 times
Decrease in pain
Addressing Sensory Stimulation/Neuroplasticity in Pt’s with CRPS
3-D augmented virtual reality using mirror visual feedback principles can correct sensorimotor incongruence to reduce neuropathic pain.
N = 22; Patients see a projected image of themselves. When they move the unaffected limb, they see their affected limb moving. Patients had to reach for specific targets and the difficulty level of the task increased. 5 sessions (20 min each) over 1 wk
Significant effect on pain reduction (while pain relief was not maintained in total between sessions, it never returned to baseline of previous session)
Addressing Psychological Distress Along with CRPS
Psychotherapy
CRPS is often associated with profound psychological symptoms for affected individuals and their families
May develop depression, anxiety, or post-traumatic stress disorder, all of which heighten the perception of pain and make rehab efforts more difficult
Acceptance-based coping is reflected by increased activity
N = 30, Observational cohort (i.e. no intervention); “proof of principle study”
Those with good coping mechanisms has lower pain and increased participation in activity; suggesting acceptance-based coping may be beneficial to those with CRPS.
CRPS medications
Medications
Sympathetic Nerve Block
Surgical Sympathectomy
CRPS medical treatment
Neurostimulation
Along the pain pathway, include near injured nerves (peripheral nerve stimulators)
Outside the membranes of the brain (motor cortex stimulation with dural electrodes)
Within the parts of the brain that control pain (deep brain stimulation)
Recent option involves the use of repetitive Transcranial Magnetic Stimulation (rTMS)
Magnetic currents applied externally to the brain
placebo effect for CRPS
Placebo – substance or inactive treatment made to appear as active treatment
Often used in clinical trials (research) to compare differences in effect between the active treatment and inactive treatment
The “effect” seems to affect how a person feels, and may change symptoms as a result
Usually refers to relieving symptoms
Nocebo effect refers to worsening of symptoms after a placebo
Common and complex chronic pain disorder that affects people physically, mentally and socially
Can be extremely debilitating and interfere with basic daily activities
fibromyalgia
A syndrome rather than a disease
Also called fibromyositis and fibrositis
fibromyalgia
Characterized by chronic widespread pain, multiple tender points, abnormal pain processing, sleep disturbances, fatigue and often psychological distress
fibromyalgia
symptoms of fibromyalgia
Pain
Is profound, chronic and widespread can migrate to all parts of the body and vary in intensity
Has been described as stabbing and shooting pain and deep muscular aching, throbbing, and twitching
Fatigue
All-encompassing exhaustion that can interfere with occupational, personal, social or educational activities
Profound exhaustion and poor stamina
fibromyagia diagnosis
Doctors must rely on patient histories, self-reported symptoms, physical examination
No laboratory tests available for diagnosing fibromyalgia
Takes an average of five years for an FM patient to get an accurate diagnosis
what must a FM patient do to receive a diagnosis of FM?
the patient must meet the following diagnostic criteria:
Pain in all four quadrants of the body for at least 3 months
Tenderness or pain in at least 11 of the 18 specified tender points when pressure is applied
fibromyalgia trigger points
cervical vertrabae, 2nd rib, lateral epicondyle, knee
back of head, supraspinatus, traps, hip, and butt
a disorder characterized by widespread musculoskeletal pain accompanied by fatigue, sleep, memory and mood issues.
fibromyalgia
