assessment and management of pain, physiotherapy pain management,

1. Assessment and Management of
Pain in the Elderly

2. Pain
An unpleasant sensory and emotional experience associated
with actual or potential tissue damage, or described in terms
of such damage.,
“or described in terms of such damage”. This was intended to
acknowledge complaints of people experiencing pain without
evidence of tissue stress or damage, despite thorough
investigation
(International Association for the Study of Pain).

3. • Pain is distressing experience associated with actual
or potential tissue damage with sensory, emotional,
cognitive and social components.
• (Amanda C de C Williams . Pain. 2016 Nov)

4. An unpleasant sensory and emotional experience associated with actual or
potential tissue damage, or described in terms of such damage.
Note:
• The inability to communicate verbally does not negate the
possibility that an individual is experiencing pain and is in need
of appropriate pain-relieving treatment.
• Pain is always subjective.
• Each individual learns the application of the word through
experiences related to injury in early life.
• Biologists recognize that those stimuli which cause pain are
liable to damage tissue.
• Accordingly, pain is that experience we associate with actual
or potential tissue damage.

5. • It is unquestionably a sensation in a part or parts of the body,
but it is also always unpleasant and therefore also an
emotional experience.
• Experiences which resemble pain but are not unpleasant, e.g.,
pricking, should not be called pain.
• Many people report pain in the absence of tissue damage or
any likely pathophysiological cause; usually this happens for
psychological reasons.
This definition officially adapted in 1979 was a slightly revised
version of a formulation first proposed by Harold Merskey.
International Association for the Study of Pain (IASP) , 1994
publication

6. Louisa Jones and John J. Bonica. It was taken in 1986 in Stockholm.
Professor John Bonica, chair of the Department of Anesthesiology at
the University of Washington in Seattle and author of the
groundbreaking book, The Management of Pain, published in 1953 by
Lea & Febiger.

7. John Loeser , in his model of pain, proposes four pain dimensions: nociception, pain,
suffering and pain behaviour.

8. Physiology and Anatomy of Pain
• Nociceptors : nociceptors, which derives from the
Latin word meaning injury.
• Ad (A delta) and C fibres (Cesare and McNaughton,
1997)
• Pain arises from chemical, thermal or mechanical
stimulus of the small-diameter sensory afferent
fibres found in the tissue.

10. • The fast-sharp pain signals are elicited by either mechanical
or thermal pain stimuli. They are transmitted in the peripheral
nerves to the spinal cord by small type Aδ fibers at velocities
between 6 and 30 m/sec.
• Conversely, the slow-chronic type of pain is elicited mostly by
chemical types of pain stimuli but sometimes by persisting
mechanical or thermal stimuli. This slow-chronic pain is
transmitted to the spinal cord by type C fibers at velocities
between 0.5 and 2 m/sec.

11. Nociceptors release the neurotransmitter (substance P or glutamate).

12. • Physiological pain: The pain response to high-intensity stimuli is
transient if the tissue damage is prevented by a simple spinal flexion
reflex arc (Willer, 1979). Consider striking a match and touching the
flame with your fingers you would drop the match instantly before
damage could occur.
• The speed with which this reflex occurs prevents deep tissue damage
and allows only a brief moment of discomfort. This is caused by a
simple spinal reflex mediated by the high-intensity thermal
stimulation of small sensory nerve endings in fingers.

13. Pathological pain
• This results from sensitization of
the nerves in the periphery and
the spinal cord.
• This can occur as a result of
inflammation.
• Peripheral nerve endings are made
more sensitive to noxious stimuli
through tissue damage, action of
local hormones such as
prostaglandins, histamine,
serotonin and bradykinin, and also
by direct nerve damage – this is
called peripheral sensitization.

14. Central sensitisation
• Central sensitisation describes the circumstances in
which there is an enhancement of the function of
neurons involved in nociception
• hypersensitivity to stimuli,
• responsiveness to non-noxious stimuli
• Increased pain response evoked by stimuli outside
the area of injury, an expanded receptive field.
• As a result the nerve fibres of the central nervous
system begin to respond to non-noxious stimuli such
as gentle touch as if they were pain impulses.

15. • Example, gentle stroking can become pain – this is
termed allodynia.
• Furthermore, an exaggerated response to
lowthreshold noxious stimuli can occur (hyperalgesia).

16. The pain gate theory
Second World Congress on Pain,
Montreal, 1978. Ronald Melzack, Chair
of the Local Arrangements Committee.
The pain gate was proposed by Melzack and
Wall back in 1965.
It is the most widely accepted theory of pain,
and explains a great many of the pain
phenomena.
The plasticity of the nervous system – its ability to become
desensitized and sensitized also adds an extra dimension.

17. Aδ and C fibres synapse within the dorsal horn of the spinal cord
with both transmission fibres and interneurons
Rubbing the affected area will also stimulate the low-threshold Aβ
fibres which in turn synapse with the inhibitory interneuron which
decreases sensitivity of the transmission neuron to the nociceptors’
outputs.

18. Type of pain
• Acute pain
• Chronic pain
• Nociceptive pain
• Neuropathic pain

19. • Although no universally accepted definition exists for chronic
pain, it is often defined as pain that persists beyond the
expected time of healing (typically 12 weeks) and may or may
not be associated with an identifiable cause or actual tissue
damage. (IASP taxonomy. 2012).

20. Older people
• With ageing, sensory signals are slower, and the warning system of
pain may become less effective.
• Pain may be underreported as some elderly patients incorrectly
believe that pain is a normal process of aging.
• Approximately 66 % of people over the age of 65 report chronic
pain (Molton IR, Terrill AL.,2014).
• Most common types of pain in elderly adults are low back or neck
pain (65 %), musculoskeletal pain (40 %), peripheral neuropathic
pain (40 %), and chronic joint pain (20 %). (Denard PJ., et al. 2010)
• They do not seek medical management because they falsely believe
their chronic pain will not benefit from treatment. (Kaye AD., et al.
2010).

21. • Women are generally more likely to report chronic pain than
men (Molton IR, Terrill AL.,2014).
• Consequences of this pain include impaired activities of daily
living, depression, sleep disruption, cognitive impairment and
a burden on health care costs.

23. Elements of a comprehensive
geriatric pain assessment
Sensory:
• What does it feel like?
• What words come to mind?
Emotional impact:
• Has pain affected your mood, energy level?
Functional impact:
• Has pain affected your ability to do every day activities?
Sleep:
• Has pain affected your sleep?

24. Attitudes and beliefs
• Do you have any thoughts or opinions about specific pain
treatments that you believe would be important for me to
know?
Coping styles:
• What things do you do to help you cope with your pain?
Treatment expectations and goals:
• What do you think is likely to happen with the treatment I
have recommended?
Resources:
• Is there anyone at home or in the community that you can
turn to for help and support when your pain is really bad?

25. Assessing pain in older patients with major
cognitive impairment
Require modified approaches to assessment.
• Attempt to obtain self report data.
• Search for potential causes of the pain,
• Observing patient behaviour (for example, facial
expressions, vocalizations, guarding),
• Obtaining proxy data from family members or
caregivers who know the patient well and can report
on whether changes in behaviour or activity are very
different from baseline,
• Conducting an analgesic trial to see whether the
behaviour resolves with treatment.

26. Pain Assessment
• Geriatric pain assessment is typically followed by a good
history and physical exam.
• The elderly can experience multiple pain syndromes from
different areas of the body and this should be considered
while contemplating a differential diagnosis for pain.

27. • A comprehensive assessment of pain requires
• pain history,
• physical examination,
• specific diagnostic tests

28. Pain history
• A general medical history is an important part of the pain history, often
revealing important aspects of co-morbidities contributing to a complex
pain condition.
• The specific pain history must clarify location, intensity, pain descriptors,
temporal aspects, and possible pathophysiological and aetiological issues.
• It is more than just a sensory event.
• It has emotional responses to pain.
• Behaviors manifested in response to pain by patients and their family
members or caregivers)
• Attitudes and beliefs about pain.
• As well as sensory components (for example, quality, location, temporal
pattern).

29. (i) Where is the pain?
(ii) How intense is the pain?
(iii) Description of the pain (e.g. burning, aching,
stabbing, shooting, throbbing, etc).
(iv) How did the pain start?
(v) What is the time course of the pain?
(vi) What relieves the pain?
(vii) What aggravates the pain?

30. (viii) How does your pain affect
(a) your sleep?
(b) your physical functions?
(c) your ability to work?
(d) your economy?
(e) your mood?
(f ) your family life?
(g) your social life?
(h) your sex life?

31. (ix) What treatments have you received? Effects of
treatments? Any adverse effects?
(x) Are you depressed?
(xi) Are you worried about the outcome of your pain
condition and your health?
(xii) Are you involved in a litigation or compensation
process?

32. Physical examination
(i) General physical examination
(ii) specific pain evaluation
(iii) neurological examination;
(iv) musculoskeletal system examination
(v) assessment of psychological factors.

33. Specific diagnostic studies
(i) Quantitative sensory testing (QST)
with specific and well-defined
sensory stimuli for pain
thresholds and pain tolerance.
(ii) Diagnostic nerve blocks test.
(iii) Pharmacological tests.
(iv) Conventional radiography,
computerized tomography,
magnetic resonance imaging.

34. Pain Assessment Scales
• Verbal Descriptor Scales (VDS),
• Verbal Rating Scales (VRS)
• Visual Analogue Scales (VAS)
• Numerical Rating Scales (NRS)
• McGill Pain Questionnaire (MPQ)
• Brief Pain Inventory (Short Form)

35. Risk factors include advancing age,
• female sex
• lower socioeconomic status,
• Lower educational level,
• obesity, tobacco use,
• history of injury,
• History of a physically strenuous job,
• Childhood trauma
• Depression
• Anxiety

36. Verbal Rating Scales (VRS)
• The 0-to-3 Verbal Rating Scale (VRS)

37. Brief Pain Inventory (Short Form)
1991 Charles S. Cleeland, PhD Pain Research Group

38. The Brief Pain Inventory (BPI)
• The first version of our pain measure was the
Wisconsin Brief Pain Questionnaire (BPQ; Daut &
Cleeland, 1982; Daut, Cleeland, & Flanery, 1983).

39. The McGill Pain Questionnaire and the
short-form McGill Pain Questionnaire
• The McGill Pain Questionnaire (MPQ) and the short-form
MPQ (SF-MPQ) evaluate sensory, affective–emotional,
evaluative, and temporal aspects of the patient’s pain
condition.
• The SF-MPQ consists of 11 sensory (sharp, shooting, etc.) and
four affective (sickening, fearful, etc.) verbal descriptors.
• The patient is asked to rate the intensity of each descriptor
on a scale from 0 to 3.
• Three pain scores are calculated: the sensory, the affective,
and the total pain index. Patients also rate their present pain
intensity on a 0 – 5 scale and a VAS

42. Visual Analogue Scale (VAS)
• In clinical and research settings, VAS has proven to be a useful
measurement of pain because of its simplicity, reliability, and
ease of use (Kaye AD, Baluch A, Scott JT., 2010).

43. The Numeric Pain Rating Scale

44. Wong — Baker Faces Pain Rating Scale.
• This tool was originally created with children for children to help them
communicate about their pain.
Now the scale is used around the world with people ages 3 and older,
facilitating communication and improving assessment so pain management
can be addressed.
©1983 Wong-Baker FACES Foundation. www.WongBakerFACES.org

45. Verbal Descriptor Scale (Pain Thermometer)
An advantage of VDS is that
most elderly patients prefer
it because of its simplicity of
use, since it is suitable for
even mild to moderately
impaired patients.

46. Role of Emerging Technologies in Geriatric
Pain Management
• Geographic distance from health care centers.
• transportation services and increased mobility
difficulties.
• Significant cost savings in intervention delivery
but also improved quality of life and feelings
of control among patients.
Rachael Elizabeth Docking, PhD, MA (Hons 2016 Published by Elsevier Inc.

47. Evaluation of the iPhone Pain Assessment
Application for People with Dementia
• University of Greenwich collaborated with the Computing
and Mathematical Sciences department to develop an
iPhone pain assessment app. (Docking RE., et al. 2015)

48. Pharmacological management of pain
• Adverse drug reactions in the elderly are a significant
risk, but pharmacologic intervention for pain
management remains the principal treatment
modality for pain.
• Paracetamol: most popular and most commonly
used analgesic and antipyretic drugs around the
world.
• It was found by chance.

49. • Paracetamol can be used in the older person via a
variety of routes, from oral through to intravenous.
• Paracetamol should be regarded as the first-line
analgesic for mild to moderate pain and as an
important component of multimodal analgesia in the
management of moderate to severe pain.
• Co-administration of an NSAID or opioid, unless
contraindicated, with paracetamol may significantly
improve its analgesic effects
Provenance and Peer review: Commissioned; Peer reviewed; Accepted
for publication April 2015.

50. Nonsteroidal anti-inflammatory drugs
(NSAIDS)
• NSAIDs reduce pain and inflammation by inhibiting
the production of cyclo-oxygenase (COX) isoenzymes.
These enzymes are prostaglandins.
• Prostaglandins are produced at sites of injury or
damage, and cause pain and inflammation.
• By blocking the effect of COX enzymes, fewer
prostaglandins are produced, which means that pain
and inflammation are eased.
• NSAIDs including diclofenac and naproxen are
considered to be non-selective COX inhibitors.

51. Pharmacological management of
moderate pain
• Codeine:
• Tramadol

52. Pharmacological management of
moderate to severe pain
• Opioids
• Local anaesthetics
• Epidural and spinal anaesthesia:

53. • The optimal approach to the management of pain in
older persons considers pharmacological and non-
pharmacological options
• Balances pain relief with side effects of therapy.
• Pharmacological management is made more difficult
because of age-related physiological changes, co-
morbidity, polypharmacy, disability and frailty.
37th Annual Scientific Meeting of the Australian Pain Society, in Adelaide South Australia
9-12 April, 2017

54. Acute pain management
in the older person
Non-pharmacological management of pain
• Superficial or topically applied cold therapy is used to
reduce inflammation, pain, and swelling and to
increase pain tolerance.
• Cold application decreases skin and joint temperature,
decreases blood flow and has a direct analgesic effect.
• The first mention of cold treatment dates back to
ancient Egypt, 2500 BC.
• Hippocrates also recommended the use of cold water,
flour mush, ice and snow to treat fresh injuries.
Provenance and Peer review: Commissioned; Peer reviewed;
Accepted for publication April 2015.

56. • Fibromyalgia is characterised by persistent, widespread pain;
sleep problems; and fatigue.
• Transcutaneous electrical nerve stimulation (TENS) is the
delivery of pulsed electrical currents across the intact surface of
the skin to stimulate peripheral nerves and is used extensively to
manage painful conditions.
• TENS reduces pain during movement in some people so it may
be a useful adjunct to assist participation in exercise and
activities of daily living.

57. • Objectives: To assess the analgesic efficacy and adverse events
of TENS alone or added to usual care (including exercise)
compared with placebo (sham) TENS, for fibromyalgia in
adults.
• Search methods: Searched the following electronic databases
up to 18 January 2017: CENTRAL (CRSO); MEDLINE (Ovid);
Embase (Ovid); CINAHL (EBSCO); PsycINFO (Ovid); LILACS;
PEDRO; Web of Science (ISI); AMED (Ovid); and SPORTDiscus
(EBSCO).
• Selection criteria: included randomised controlled trials (RCTs)
or quasi-randomised trials. TENS administered using
noninvasive techniques, TENS administered as a sole
treatment or TENS in combination with other treatments,.
• Main results: There was insufficient high-quality evidence to
support or refute the use of TENS for fibromyalgia.

59. • Objectives: To determine the analgesic effectiveness of TENS
versus placebo (sham) TENS, TENS versus usual care, TENS
versus no treatment and TENS in addition to usual care versus
usual care alone in the management of neuropathic pain in
adults.
• Search methods: Searched CENTRAL, MEDLINE, Embase,
PsycINFO, AMED, CINAHL, Web of Science, PEDro, LILACS (up
to September 2016) and various clinical trials registries.
• Selection criteria: Included randomised controlled trials
where TENS was evaluated in the treatment of central or
peripheral neuropathic pain

60. • Data collection and analysis: Two review authors
independently screened all database search results and
identified papers requiring full-text assessment.
• Main results:We included 15 studies with 724
participants
• Found a range of treatment protocols in terms of
duration of care, TENS application times and intensity
of application.
• Briefly, duration of care ranged from hour days through
to three months.
• Similarly, variation of TENS application times; from 15
minutes up to hourly sessions applied four times daily.

61. • Authors’ conclusions:
• The quality of the evidence was very low meaning
and unable to confidently state whether TENS is
effective for pain control in people with neuropathic
pain.

62. Exercise and physical activity
• Increasing and maintaining physical activity is
important in the management of persistent pain
in older people.
• There is also RCT evidence of improvement in
function and pain with exercise for older people
over 65 with chronic pain.
• Persistent pain is also a strong risk factor for falls
in older people
• Exercise should involve strengthening, flexibility,
endurance and balance

63. Management of chronic pain in older adults

64. Objectives:
• Effectiveness of different physical activity and exercise
interventions in reducing pain severity and its impact on
function, quality of life, and healthcare use
• The evidence for any adverse effects or harm associated with
physical activity and exercise interventions.
Methods:
• Searched the Cochrane Database of Systematic Reviews
(CDSR) on the Cochrane Library (CDSR 2016, Issue 1) for
systematic reviews of randomised controlled trials (RCTs).

65. • Extracted data for (1) self-reported pain severity, (2)
physical function (objectively or subjectively measured),
(3) psychological function, (4) quality of life, (5) adherence
to the prescribed intervention, (6) healthcare
use/attendance, (7) adverse events, and (8) death.
Main results:
• Included 21 reviews with 381 included studies and 37,143
participants. Of these, 264 studies (19,642 participants)
examined exercise versus no exercise/minimal
intervention in adults with chronic pain and were used in
the qualitative analysis.

68. • Pain conditions included rheumatoid arthritis, osteoarthritis,
fibromyalgia, low back pain, intermittent claudication,
mechanical neck disorder, spinal cord injury, postpolio
syndrome, and patellofemoral pain.
• Interventions included aerobic, strength, flexibility, range of
motion, and core or balance training programmes, as well as
yoga, Pilates, and tai chi.

69. Authors’ conclusions:
• There were some favourable effects in reduction in pain
severity and improved physical function, though these
were mostly of small to- moderate effect, and were not
consistent across the reviews.
• The available evidence suggests physical activity and
exercise is an intervention with few adverse events that
may improve pain severity and physical function, and
consequent quality of life.

70. Nonsurgical Management of Osteoarthritis Knee
Pain in the Older Adult
• Older adults opting for knee replacement are likely to suffer
longer hospital stays and higher risks of both intensive care
unit admission and postoperative complications as compared
with younger patients. (Fang M, Noiseux N, Linson E, et al.
2015)
NONPHARMACOLOGIC TREATMENT OPTIONS
• Focus on exercise and achieving a healthy weight.
• A 7% to 10% weight loss in obese elderly patients with
symptomatic knee osteoarthritis should be the aim to achieve
pain relief.
• Exercise should be tailored to the individual functional level
with progressive programs favored.

71. Muscle mass and strength are lost in
the natural aging process with a
decline in strength appreciable even
when muscle mass is maintained.
Strength training is one mechanism
to achieve this end

72. Massage
• Massage therapy has a long history of demonstrating
positive effects on musculoskeletal pain and chronic
pain in general.
• Proposed that massage can increase serotonin and
dopamine levels, and enhance the local blood flow
while ‘closing the pain gate’.
• Ten minutes of slow stroke back massage has been
shown to reduce shoulder pain and anxiety in older
adults with a stroke, and this effect continues for 3 days
after the massage. (Mok E, Woo CP. 2004)
British Geriatric Society (2013)

73. Psychological interventions
• The biopsychosocial model reinforces how
psychological factors may influence the way in
which people interpret, respond to and cope
with pain.

74. Cognitive behavioural therapy
• Cognitive and behavioural therapies use a broad
range of psychological techniques to alter
dysfunctional ways of thinking, modify beliefs and
attitudes and increase a person’s control over
pain and how they interpret and manage this.
• This intervention consists of a comprehensive
initial evaluation of a range of domains, including
level of dementia, emotional distress and pain.
• Therapist worked collaboratively with the
residents, their families and others involved in
their care
British Geriatric Society (2013)

75. Guided imagery and biofeedback
• Guided imagery is an approach whereby the
attention is focused on sights, sounds, music
and words to create feelings of empowerment
and relaxation.
• Relaxation and guided imagery may be
effective strategies for pain management
British Geriatric Society (2013)

76. Self-management of pain
• Self-management covers a wide range of techniques,
including relaxation, coping strategies, exercise, adaptations
to activities and education about pain and its effects. (Kemp
CA 2005)
• By definition, the person with pain takes the lead role in
carrying out the intervention, independently or with varying
levels of support from health professionals.

78. References
• Molton IR, Terrill AL. Overview of persistent pain in older
adults. Am Psychol. 2014;69:197–207.
• Kaye AD, Baluch A, Scott JT. Pain management in the elderly
population: a review. Ochsner J. 2010;10(3):179–87.
• Denard PJ, Holton KF,Miller J, Fink HA, KadoDM,Marshall
LM. Back pain, neurogenic symptoms, and physical function
in relation to spondylolisthesis among elderly men. Spine J.
2010;10:865–73. doi:10.1016/j.spinee.2010.07.004.
• Docking RE, Lane M, Schofield PA. Developing an iPhone
APP for the assessment of pain in older adults with
dementia. Presented at the 7th International Congress of
Pain in Dementia, Bergen, Norway, April 24–25, 2015.

79. • . Fang M, Noiseux N, Linson E, et al. The effect of
advancing age on total joint replacement outcomes.
Geriatr Orthop Surg Rehabil 2015;6(3):173–9.
• Mok E, Woo CP. The effects of slow-stroke back
massage on anxiety and shoulder pain in elderly stroke
patients. Complement Therap Nurs Midwifery 2004;
10: 209–16.
• Kemp CA, Ersek M, Turner JA. A descriptive study of
older adults with persistent pain: use and perceived
effectiveness of pain management strategies. BMC
Geriatr 2005; 5: 12.