Pain Management

1
Pain Management
2
Pain Classification

• Acute Pain
• up to 3 days after injury
• also defined as up to several months after an
  injury

• Chronic Pain
• gt several months

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Substance P

• Chemical mediator thought to be involved with
  transmission of pain.
• Associated with inflammatory pain
• It excites pain transmitting neurons when
  released
• Its mechanism is not fully understood

4
Gate Control Theory - Melzack Wall 1965

• severity of pain sensation determined by balance
  between excitatory and inhibitory inputs to T
  cells in spinal cord
• C A-delta nociceptor afferents give excitatory
  input
• Substantia gelatinosa, large diameter A-beta
  non-nociceptor afferents give inhibitory input
• Increased firing of non-nociceptor afferents
  causes presynaptic inhibition of T cells and the
  spinal gate from excitatory cells to the brain is
  closed.
• Physical agent modalities and physical activities
  believed to close the gate by activating the
  non-nociceptor afferents
• The theory does not explain pain modulation
  descending from brain

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Endorphins

• Pain perception modulated by these opiate like
  neurotransmitters
• The endorphins bind to certain sites on the
  nervous system including peripheral nerves
• They suppress pain transmission at the spinal
  cord level by inhibiting the release of the
  neurotransmitter gamma aminobutyric acid (GABA)
  in the periaqueductal gray matter (PAGM) raphe
  nucleus of the brain
• High concentration of opiate receptors in limbic
  area of brain explains the stress relief and
  euphoria associated with opiates
• Limbic system involved with emotional component
  of pain

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Pain Scales

• 0 to 10 scale
• these scales may not be reliable since pain
  perception differs in various people
• Observable characteristics of pain
• palpation
• mild, moderate, severe
• anesthesiometer
• Ability to complete ADLs such as makeup

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Psychological aspects of pain

• learned responses
• emotional components
• associated pain
• random pains attributed to injury
• Reaction to stressors
• work
• family
• marriage

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Autonomic nervous system

• parasympathetic
• activates smooth muscles, cardiac muscles, and
  glandular secretions
• Sympathetic
• involved in flight or fight response
• manages blood pressure, heart rate, constricts
  blood vessels, increases sweating
• this system responds to injury temporarily
• stimulation here does not usually cause pain
• over reactive sympathetic response can cause
  continued pain
• Stressors and emotional events seem to affect a
  person at this level

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Pain Syndromes

• RSD
• involves sympathetic nervous system over
  activation
• Shoulder hand syndrome
• Somatization disorders
• psychological response
• dependent person
• sick role
• external locus of control
• frequently seeks medical attention
• no desire to get better

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Acute pain management

• NSAIDs - Non-steroidal anti-inflammatory drugs
• aspirin, ibuprofen, Naprosin, Feldene
• may cause kidney damage, bone marrow suppression,
  rashes, decrease renal blood flow in dehydrated
  pts
• Acetaminophen (Tylenol)
• has analgesic antipyretic effect, but no
  anti-inflammatory effect
• prolonged use can cause liver damage
• physical agents
• light exercise
• corticosteroid injections

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Chronic Pain Management

• No physical agent modalities
• develop internal locus of control
• train them to take control of their
  responsibilities
• occupationally relevant activities
• no passive treatments
• require them to resume responsibilities
• stressor management
• marriage or family counseling
• change jobs

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(Chronic Pain Management Cont.)

• Distraction techniques
• relaxation techniques
• problem solving training
• behavior modification

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Handling your emotions

• Realize that these are difficult patients
• Realize that they need help even though it
  doesnt seem that way
• Dont take it personally
• Realize that most of these patients you will not
  cure. Your goal is to manage them.
• Dont talk about how they feel. You already know
  that.