PH1122 - Pain & CNS Flashcards
What is the time frame for acute and chronic back pain ?
Acute back pain is classified as episodes lasting 6 weeks or less and chronic if symptoms persist beyond 6 weeks.
What are some clinical features of acute low back pain ?
Pain in the lower lumbar or sacral area is usually described as aching or stiffness. Depending on the cause, pain might be localized (e.g., lumbosacral strains after physical activity) or more diffuse (e.g., from postural backache after sitting incorrectly for a prolonged period). In cases of acute injury, the symptoms come on quickly, and there will be a reduction in mobility.
Bad posture when seated and poor lifting technique when performing daily tasks, such as cleaning or gardening, are very common predisposing factors.
What are symptoms of sciatica ?
Sciatica typically occurs in healthy, middle-aged adults. Pain is acute in onset and radiates to the leg. Pain starts in the lower back and, as it intensifies, radiates into the lower extremities.
If the disc ruptures or herniates under strain, pain is usually lancinating in quality, shooting down the leg like an electric shock. Valsalva movements – for example, coughing, sneezing or straining at stool – often aggravate pain. Numbness, tingling, and muscle weakness in the distribution of a nerve root suggests nerve root compression.
Referral is needed for confirmation of the diagnosis.
what are clinical features of osteoarthritis ?
It is characterized by pain of insidious onset that progressively increases over months or years, is exacerbated by exertion, and is relieved by rest. The affected joints are painful when used and may show a restricted range of motion. Stiffness in the affected joint occurs typically in the morning and after rest, but usually only lasts for 15 to 30 minutes.
What are some trigger points for referral when dealing with lower back pain ?
Numbness
Fever
Persistent and progressively worsening pain
Weight loss
Systemically unwell- Possible sinister spinal pathology- Immediate to general practitioner
Bowel or bladder incontinence Cauda equina syndrome (rare and very unlikely to be seen by a pharmacist)
Pain that radiates away from lower back area Sciatica As soon as practicable
Back pain from structures above the lumbar region Outside scope of community pharmacist
Failure of symptoms to improve after 4 weeks Requires further investigation as pain that becomes subacute/chronic requires medical intervention
Younger and older people (55 years old) with no identifiable cause Suggests more sinister pathology
Whats the OTC treatment for lower back pain and sprains ?
The goal of treatment is to provide relief of symptoms and a return to normal mobility.
Conservative treatment
Bed rest was once widely prescribed for patients with low back pain. However, systematic reviews have now proven that prolonged bed rest is counterproductive (Dahm et al., 2010). The authors concluded that ‘Moderate quality evidence shows that patients with acute LBP may experience small benefits in pain relief and functional improvement from advice to stay active compared with advice to rest in bed’.
Exercise programmes can help with acute back pain and have been shown to reduce recurrence.
Analgesics
Nonsteroidal anti-inflammatory drugs (NSAIDs) for 7 to 10 days is widely advocated. A systematic review of NSAIDs in acute or chronic LBP found that treatment with an NSAID produced significant short-term improvement compared with placebo (Roelofs et al., 2008). The review identified 65 trials, 28 of which were rated as high quality. The study failed to find any difference among the various NSAIDs. A further Cochrane review (involving 13 trials, of which 10 were rated high quality) looking at chronic LBP only found that NSAIDs were more effective than placebo in terms of pain intensity and, to a smaller extent, disability (Enthoven et al., 2016). Like Roelofs et al., the study failed to find any difference among the various NSAIDs.
Paracetamol when used for LBP has also been subject to a review (Saragiotto et al., 2016), which identified three trials involving 1825 patients. They found that paracetamol was no more effective than placebo in terms of pain reduction and improving quality of life. The authors concluded that paracetamol should not be used to manage acute LBP.
what are some key questions when investigating a possible sprain?
When did it happen, and when did the patient present The closer these two events are, the more likely the patient will be suffering from a problem that is outside the remit of the pharmacist (unless the injury was sustained in close proximity to the pharmacy and the patient has asked for first aid).
Presenting symptoms Marked swelling, bruising, and pain occurring right after injury are suggestive of more serious injury, and referral to casualty for x-rays and further tests is needed.
Nature of injury If the injury occurred in which impact forces were great, then fracture becomes more likely.
Sudden onset associated with a single traumatic event suggests a mechanical problem such as tendon or ligament tearing.
If the person has a foot injury and is unable to bear full weight while walking, then referral is needed.
Range of motion If the affected joint shows marked reduction in normal range of motion, this requires referral for fuller evaluation.
Nature of pain Referred pain suggests nerve root compression – for example, a shoulder injury in which pain is also felt in the hand.
Pain that is insidious in onset and progressive is more likely to be due to some form of degenerative disease and requires referral.
Age of patient Children: Bones are softer in children and therefore more prone to greenstick fractures (fracture of the outer part of the bone) and should be referred to exclude such problems.
Older adults: Risk factors for fracture, such as osteoarthritis and osteoporosis, should be established.
what is the non pharmacological advice for treating a sprain ?
R EST- Rest allows immobilization, enhancing healing and reducing blood flow.
I CE- Ice should be applied while the injury feels warm to the touch. Apply until the skin becomes numb, and repeat at hourly intervals. Bags of frozen peas wrapped in a towel are ideal to use on the injury because they conform to body shape and provide even distribution of cold.
C OMPRESSION- A crepe bandage provides a minimum level of compression. Tubular stockings (e.g., Tubigrip) are convenient and easy to apply, but fail to give adequate compression.
E LEVATION Ideally the injured part should be elevated above the heart to help fluid drain away from the injury.
What are symptom specific questions to ask about insomnia ?
Pattern of sleep An emotional disturbance (predominantly anxiety) is commonly associated in patients who find it difficult to fall asleep; patterns that include patients who fall asleep but wake early and cannot fall asleep again, or who are then restless, are sometimes associated with depression.
Daily routine Has there been any change to the work routine, such as changes to shift patterns and additional workload, resulting in longer working hours and greater daytime fatigue?
Too much exercise or intellectual arousal before going to bed can make sleep more difficult.
Underlying medical conditions Medical conditions likely to cause insomnia are gastro-oesophageal reflux disease (GORD) pregnancy, pruritic skin conditions, asthma, Parkinson disease, painful conditions (osteoarthritis), hyperthyroidism (night sweats), menopausal symptoms (hot flushes) and depression.
Recent travel Time zone changes will affect the person’s normal sleep pattern, and it can take a number of days to re-establish normality.
Daytime sleeping Older adults might nap throughout the day, which results in less sleep needed in the evening, making patients believe they have insomnia.
What are key steps to good sleep hygiene ?
Maintain a routine, with a regular bedtime and awakening time.
Food snacks, alcoholic- and caffeine-containing drinks should be avoided.
Avoid sleeping in very warm rooms.
Avoid stimulants and alcohol within 6 hours of going to bed.
Avoid exercise within 4 hours of bedtime.
No daytime naps.
No sleeping in to catch up on sleep.
No strenuous mental activity at bedtime (e.g., doing a crossword in bed).
Solve problems before retiring.
Associate bed with sleep; try not to watch TV or listen to music.
If unable to get to sleep, get up and do something and return to bed when sleepy.
