Nancy Wiedemer,CRNP
Pain Management Coordinator
Philadelphia VA Medical Center [email protected]
Not all pain is the same: implications Not all pain is the same: implications for assessment and treatment for assessment and treatment
Assessment and Treatment of Pain:Issues and Challenges
Underassessment and undertreatment
Interpatient variability Patient not believed OPIOIDS Complex pathophysiology
Defining Pain
Arthritis
Spinal Stenosis
Failed Back
Neuropathy DM,PHN,HIV,post CVA Cancer
Pain Mechanisms
Acute
Chronic < episodic < persistent
End of life
Defining Pain
By definition…… a disease process alters the way a system or organ system responds to different types of homeostatic processes within the body.
Hypertension
DiabetesChronic Pain
Chronic Disease
Biopsychosocial Model of Pain
Suffering
People suffer from what they have lost of themselves…..
it continues until the threat of disintegration has passed or until the integrity of the person can be restored in some other manner.
Eric J Cassel, NEJM , 1982
Cascade of negative emotions experienced by health care providers
Inadequacy
Helplessness Frustration Anger
Gallagher,2004
PAIN is a sensory processing system with a known anatomy and physiology
WHAT IS PAIN?
Overview of Pain Perception
Physiology of Pain Perception
• Transduction
• Transmission
• Modulation
• Perception
• Interpretation
• Behavior
Injury
Descending Pathway
PeripheralNerve
Dorsal RootGanglion
C-Fiber
A-beta Fiber
A-delta Fiber
AscendingPathways
Dorsal Horn
Brain
Spinal CordAdapted with permission from WebMD Scientific American® Medicine.
Transient pain in response to a noxious stimuli Key early warning – Alarm system Announces the presence of a potentially
damaging stimulus
Nociceptive Pain
Woolf,CJ Ann Internal Med 2004;140:441-451
Tissue damage edema activation of mechanoreceptorsRelease of chemicals from mast cells and injured nociceptors
Woolf,CJ Ann Internal Med 2004;140:441-451
Glutamate
HistamineProstaglandinSubstance PSerotoninBradykinin
Nociceptive Pain
SOMATIC Well-localized Aching,throbbing, gnawing
bone joints soft tissue muscle skin
VISCERAL Poorly localized Deep aching,
cramping,pressure, Referred
Bowel obstruction Biliary colic liver pain appendix
NEUROPATHIC PAIN
Afferent fibers
C fiber
A beta fiber
Nerve injury
PhenotypicalChanges
Spinal cord
Neuro-plasticity
Central sensitization
Alteration of modulatory
systems
Ectopic discharge
Ectopic discharge
Woolf & Mannion, Lancet 1999Attal & Bouhassira, Acta Neurol Scand 1999
Central Sensitization
Overview of Pain Perception
Physiology of Pain Perception
• Transduction
• Transmission
• Modulation
• Perception
• Interpretation
• Behavior
Injury
Descending Pathway
PeripheralNerve
Dorsal RootGanglion
C-Fiber
A-beta Fiber
A-delta Fiber
AscendingPathways
Dorsal Horn
Brain
Spinal CordAdapted with permission from WebMD Scientific American® Medicine.
Modulation of Pain Perception
Antinociceptive system
Endorphins Enkephalins Receptor sites
GABA
OpioidsSerotoninNeurepinephrine
Endorphins Enkephalins
Opioids
Neuropathic Pain: injury to peripheral nerves and/or CNS
Burning Stinging Shooting Lancinating Pins and needles Vicelike Electric Tingling
Focus of medical attention is often centered
on nerve/disc/bony relationship
Little to no attention is given to the soft tissue that supports and binds the spine
The Myofascial System
• Guarded movements• Pelvic tilt when standing• Limited flexion and extension in the spine• Paraspinal tenderness•Trigger points – active or latent
Myofascial Pain
Deep aching pain Burning or stinging sensation Restricted movement in involved areas Muscle spasms Trigger points- feel indurated to
palpation Taut muscle bands
VAClinician
Pain Assessment
What is the pain generator ?
What is the pain mechanism ? Nociceptive Neuropathic Myofascial Mixed
Are there pain amplifiers ?
Anxiety Depression PTSD Substance Abuse Disorder
Pain Assessment
Tumors Fractures Infection Cauda Equina
Syndrome
Factors that may impede recovery:
Emotional state Fear-avoidance
beliefs Poor coping
strategiesLinton,SL & Boresma,K,2003
Are there RED FLAGS ?????
History and Physical Exam Events at pain onset Pain:
site & radiation quality intensity (numeric score 0-10) temporal pattern provocations & sources of relief
Activities and functional limitations Sleep disruption Previous therapies
Conclusions
Chronic Pain ↔ Chronic Disease
Chronic Disease Management Approach
based on
Biopsychosocial Model
Conclusions
Not all patients with the same pain diagnosis have the same pain mechanisms
Different mechanisms can coexist Treatment approaches that target
each pain generator can improve outcomes
Conclusions
Secondary prevention depends onearly and aggressive assessment
and management of pain