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PAIN(types, pathways, pharma and non-pharma management)

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  2. 2. PAIN Is an unpleasant sensory and emotional experience associated with actual and potential tissue damage, or described in terms of such damage. (American Pain Society[APS],2003;Gordon,2002)
  3. 3. IMPORTANT IMPLICATIONS Pain is physical and emotional experience, not all in the body or all in the mind. It is in response to actual or potential tissue damage, so there may not be abnormal lab or radiographic reports despite real pain. Pain is described in terms of such damage.
  4. 4. LOCATION Classifications of pain based on where it is in the body may be useful in determining the client’s underlying problems or needs. Complicating the categorization of pan by location is the fact that some pains radiate(spread or extend) to other areas.
  5. 5. DURATION Acute pain- lasts only through the expected recovery period whether it has a sudden or slow onset and regardless of intensity. Chronic pain- is prolonged, usually recurring o persisting over 6 months or longer, and interferes with functioning. Mild to severe, constant or recurring without an anticipated or predictable end and a duration of greater than 6 months. (Ackley&Ladwig, 2006)
  6. 6. INTENSITY Classified using a standard 0(no pain) to 10 (worst possible pain) scale. Mild pain- rating of 1-3 Moderate pain- rating of 4-6 Severe pain- reaching 7-10 and is associated with worst outcome.
  7. 7. ETIOLOGY Physiological pain- experienced when an intact, properly functioning nervous system sends signals that tissue are damaged, requiring attention and proper care. Somatic pain- originates in the skin, muscles, bones or connective tissue with sharp sensation of a paper cut or aching of sprained ankle. Visceral pain- poorly located and may have cramping, throbbing, pressing, or aching quality. Often associated with feeling sick.
  8. 8. Neuropathic pain- experienced by people with damaged or malfunctioning nerves. Peripheral neuropathic pain- follows damage and/or sensitization f peripheral nerves. Central neuropathic pain- results from malfunctioning nerves in Central nervous system. Sympathetically maintained pain- occurs occasionally when abnormal connections between pain fibers and the sympathetic nervous system perpetuate problems with both the pain and sympathetically controlled function.
  9. 9. CONCEPTS ASSOCIATED WITH PAIN Pain threshold- least amount of stimuli that is needed for a person to label sensation as pain. Pain tolerance- maximum amount of painful stimuli that a person is willing to withstand without seeking avoidance of the pain or relief. Hyperalgesia and Hyperpathia- used interchangeably to denote heightened response to a painful stimuli. Allodynia-non-painful stimuli produce pain Dysesthesia- unpleasant abnormal sensation
  10. 10. PHYSIOLOGY OF PAIN How pain is transmitted and perceived is a complex in part because of the nature of the fully integrated constantly changing structure of the central nervous system, and the symphony of chemical mediators, only a fraction of which are understood.
  11. 11. NOCICEPTION The peripheral nervous system includes primary sensory neurons specialized to detect mechanical, thermal or chemical conditions associated with potential tissue damage. The signals, when these nociceptors are activated, must be transduced and transmitted to the spine and brain where signals are modified before they are ultimately understood or “felt”. 4 physiologic processed involved ( transduction, transmission, perception, and modulation)
  12. 12. TRANSDUCTION During this stage, noxious stimuli ( with potential to injure tissue) trigger the release of biochemical mediators (prostaglandins, bradykinin, serotonin, histamine, substance P) that sensitize nociceptors. Noxious or painful stimulation also causes movement of ions across cell membranes, which excites nociceptors.
  13. 13. Pain medication can work during this phase by blocking the production of prostaglandin(e.g., ibuprofen or aspirin) or by decreasing the movements of ions across the cell membrane (e.g., local anesthetic) . topical analgesic capsaicin ( Zostrix) depletes the accumulation of subtance P and blocks transduction.
  14. 14. TRANSMISSION Includes 3 segments. First segment- pain impulse travels from the peripheral nerve fibers to the spinal cord. Second segment- transmission from the spinal cord and ascension via spinothalamic tracts, to the brain stem and thalamus. Third segment- involves transmission of signals between thalamus to the somatic sensory cortex where pain perception occurs.
  15. 15. Pain control can take place during this second process. Opoids (narcotic analgesics) block the release of neurotransmitters, particularly substance P, which stops the pain at the spinal level. Capsaicin may also deplete substance P that could inhibit the transmission of pain signals.
  16. 16. MODULATION Often descibed as “descending System” Occurs when neurons in the thalamus and brain stem send signals down to the dorsal horn of the spinal cord. These descending fibers release substances such as endogenous opoids, serotonin, and norepinephrine which can inhibit the ascending noxious(painful) impulses in the dorsal horn.
  17. 17. PERCEPTION Is when the client becomes conscious of the pain. Pain perception is the sum of complex activities in the Central Nervous System that may shape the character and intensity of pain perceived and ascribe meaning to the pain.
  18. 18. GATE-CONTROL THEORY According to Melzack and Wall’s gate theory, small diameter(A-delta,or C) peripheral nerve fibers carry signals of noxious stimuli to dorsal horn , where these signals are modified when they’re exposed to substantia gelatinosa. Peripherally, large diameter (A-delta) nerve fibers, which typically send messages of touch, or warm or cold temperature, have am inhibitory effect on substantia gelatinosa and may activate descending mechanism or inhibit transmission of pain impulses.
  19. 19. Higher centers in the brain, esp. those associated with affect and motivation, are capable of modifying the substantia gelatinosa and influence the opening or closing of gates.
  20. 20. RESPONSE TO PAIN The body’s response to pain has both physiologic and psychological aspects. The sympathetic Nervous System responds, resulting in fight-or-flight response, with noticeable increase in pulse and blood pressure. The person may hold his breath or have short, shallow breathing,
  21. 21. Pain interferes with sleep, affects appetite and lowers quality of life for clients and their family members. Natural response is to stop activity, tense muscles, and withdraw from the pain-provoking activities which reduced mobility that may produce muscle atrophy and painful spasm.
  22. 22. Uncontrolled pain impairs immune function, which slows healing and increase susceptibility to infections and dermal ulcers. This short, shallow breathing that accompanies pain produces atelectasis , lowers circulating oxygen and increase cardiac load.
  23. 23. Factors affecting Pain Ethnic and cultural values Developmental stage Environment and support people Past-pain experience Meaning of pain
  24. 24. NURSING MANAGEMENT ASSESSING- pain history, location, pain intensity with pain scale, pattern. Precipitating factors, alleviating factors, associated symptoms, effect on daily activities, coping resources, affective response. DIAGNOSING- acute or chronic pain.
  25. 25. BARRIERS TO PAIN MANAGEMENT Attitude of nurses or clientsand knowledge deficits. Clients may not report pain because they expect nothing can be done. Fear of becoming addicted especially in long-term opoid use is prescribed. Pseudoaddiction- results from undertreatment of pain where clients may become focused on obtaining medication.
  26. 26. KEY STRATEGIES Acknowledge and accepting client’s pain. Acknowledge possibility of pain, listen attentively, convey that you need to ask about pain, attend to client’s need promptly. Reducing misconceptions about pain. Assisting support persons. Reducing fear. Preventing pain.
  27. 27. Mild pain Paracetamol (acetaminophen), or a non steroidal anti-inflammatory drug (NSAID) such as ibuprofen or aspirin. NSAIDS have antiinflammatory, analgesic and antipyretic effects. The antiinflammatory action relieves pain by interfering with cyclooxygenase.
  28. 28. Mild to moderate pain Paracetamol, an NSAID and/or paracetamol in a combination product with a weak opioid such as hydrocodone, may provide greater relief than their separate use. Also combination of opioid with acetaminophen can be frequently used such as Percocet, Vicodin, or Norco.
  29. 29. Moderate to severe pain When treating moderate to severe pain, the type of the pain, acute or chronic, needs to be considered. The type of pain can result in different medications being prescribed. Certain medications may work better for acute pain, others for chronic pain, and some may work equally well on both. Acute pain medication is for rapid onset of pain such as from an inflicted trauma or to treat post-operative pain. Chronic pain medication is for alleviating long-lasting, ongoing pain.
  30. 30. Morphine - is the gold standard to which all narcotics are compared. Fentanyl - has the benefit of less histamine release and thus fewer side effects. Oxycodone - is used across the Americas and Europe for relief of serious chronic pain. Pethidine - known in North America as meperidine, is not recommended for pain management due to its low potency, short duration of action, and toxicity associated with repeated Pentazocine- dextromoramide and dipipanone are also not recommended in new patients except for acute pain where other analgesics are not tolerated or are inappropriate, for pharmacological and misuse-related reasons. Amitriptyline- is prescribed for chronic muscular pain in the arms, legs, neck and lower back. While opiates are often used in the management of chronic pain, high doses are associated with an increased risk ofopioid overdose.
  31. 31. Opioids Opioid medications can provide a short, intermediate or long acting analgesia depending upon the specific properties of the medication and whether it is formulated as an extended release drug. Opioid medications may be administered orally, by injection, via nasal mucosa or oral mucosa, rectally, transdermally, intravenously, epidurally and intrathecally
  32. 32. Although opioids are strong analgesics, they do not provide complete analgesia regardless of whether the pain is acute or chronic in origin. Opioids are efficacious analgesics in chronic malignant pain and modestly effective in nonmalignant pain management. However, there are associated adverse effects, especially during the commencement or change in dose. When opioids are used for prolonged periods drug tolerance, chemical dependency, diversion and addiction may occur
  33. 33. Commonly-used long-acting opioids: Oxycontin (oxycodone) Exalgo (hydromorphone) Opana ER (oxymorphone) Duragesic patch (fentanyl) Nucynta ER (tapentadol) Methadone (methadone)*
  34. 34. Non-steroidal anti-inflammatory drugs The other major group of analgesics are non-steroidal antiinflammatory drugs (NSAID). Acetaminophen/paracetamol is not always included in this class of medications. However, acetaminophen may be administered as a single medication or in combination with other analgesics (both NSAIDs and opioids). The alternatively prescribed NSAIDs such asketoprofen and piroxicam, have limited benefit in chronic pain disorders and with long-term use is associated with significant adverse effects. The use of selective NSAIDs designated as selective COX-2 inhibitors have significant cardiovascular and cerebrovascular risks which have limited their utilization.
  35. 35. Antidepressants and antiepileptic drug Some antidepressant and antiepileptic drugs are used in chronic pain management and act primarily within the pain pathways of the central nervous system, though peripheral mechanisms have been attributed as well. These mechanisms vary and in general are more effective in neuropathic pain disorders as well as complex regional pain syndrome. Drugs such as gabapentin have been widely prescribed for the offlabel use of pain control. The list of side effects for these classes of drugs are typically much longer than opiate or NSAID treatments for chronic pain, and many antiepileptics cannot be suddenly stopped without the risk of seizure.
  36. 36. Cannabinoids Chronic pain is one of the most commonly cited reasons for the use of medical marijuana. A 2012 Canadian survey of participants in their medical marijuana program found that 84% of respondents reported using medical marijuana for the management of pain.
  37. 37. Other analgesics Other drugs are often used to help analgesics combat various types of pain, and parts of the overall pain experience, and are hence called adjuvant medications. Gabapentin — an anti-epileptic — not only exerts effects alone on neuropathic pain, but can potentiate opiates. While perhaps not prescribed as such, other drugs such as Tagamet (cimetidine) and even simple grapefruit juice may also potentiate opiates, by inhibiting CYP450 enzymes in the liver, thereby slowing metabolism of the drug. In addition, orphenadrine,cyclobenzaprine, trazodone and other drugs with anticholinergic properties are useful in conjunction with opioids for neuropathic pain. Orphenadrine and cyclobenzaprine are also muscle relaxants, and therefore particularly useful in painful musculoskeletal conditions. Clonidine has found use as an analgesic for this same purpose, and all of the mentioned drugs potentiate the effects of opioids overall.
  38. 38. NON - PHARMACOLOGIC Non-pharmacological pain management is the management of pain without medications. This method utilizes ways to alter thoughts and focus concentration to better manage and reduce pain. Methods of non-pharmacological pain include:
  39. 39. Bed Rest The use of prolonged bed rest in the treatment of patients with neck and low back pain and associated disorders is without any significant scientific merit. Bed rest supports immobilization with its deleterious effects on bone, connective tissue, muscle, and psychosocial well-being. For severe radicular symptoms, limited bed rest of less than 48 hours may be beneficial to allow for reduction of significant muscle spasm brought on with upright activity. Patients should be instructed to avoid resting with the head in a hyperflexed or extended position. The proactive approach emphasizes activity modification as opposed to bed rest and immobilization.
  40. 40. Manipulation and Mobilization Manipulative treatment is commonly used in the treatment of patients with neck pain and associated disorders. Many different types of manual treatment exist, including soft tissue myofascial release, muscle energy/contract-relax, and high-velocity low-amplitude manipulation. Soft tissue myofascial release may include various techniques, including effleurage, pétrissage, friction, and tapotement. It has been shown to improve flexibility, decrease the perception of pain, and decrease the levels of stress hormones.
  41. 41. Traction Cervical traction is a therapeutic modality that can be administered with the patient in the supine or seated position. Traction may reduce neck pain and works through a number of mechanisms including passive stretching of myofascial elements, gapping of facet joints, improving neural foraminal opening, and reducing cervical disc herniation. It has been found to reduce radicular symptoms in individuals with confirmed radiculopathy and localized neck pain in individuals with cervicogenic pain and spondylosis. Cervical traction may be initiated during physical therapy with the patient properly instructed in home use. It is not a stand-alone treatment modality and should be done in conjunction with range-ofmotion (ROM) exercises, appropriate strengthening, and correction of postural issues.
  42. 42. Therapeutic Modalities Therapeutic modalities should be considered an adjunct to an active treatment program in the management of acute low back pain. They should never be used as the sole method of treatment. The prescribing physician should first be aware of all indications and contraindications for a prescribed modality and have a clear understanding of each modality and its level of tissue penetration.
  43. 43. Transcutaneous Electrical Nerve Stimulation Transcutaneous electrical nerve stimulation (TENS) has been used to treat patients with various pain conditions, including neck and low back pain. Success may be dictated by many factors, including electrode placement, chronicity of the problem, and previous modes of treatment. TENS is generally used in chronic pain conditions and not indicated in the initial management of acute cervical or lumbar spine pain. Overall, research is limited in regard to the isolated use of TENS in the treatment of patients with acute cervical and lumbar spine disorders, though it has been used in combination with ROM exercises, spray and stretch, and myofascial release.
  44. 44. Superficial Heat Superficial heat can produce heating effects at a depth limited to between 1 cm and 2 cm. Deeper tissues are generally not heated owing to the thermal insulation of subcutaneous fat and the increased cutaneous blood flow that dissipates heat. It has been found to be helpful in diminishing pain and decreasing local muscle spasm. Superficial heat, such as the hydrocollator pack, should be used as an adjunct to facilitate an active exercise program. It is most often used during the acute phases of treatment when the reduction of pain and inflammation are the primary goals.
  45. 45. Cryotherapy Cryotherapy can be achieved through the use of ice, ice packs, or continuously via adjustable cuffs attached to cold water dispensers. Intramuscular temperatures can be reduced by between 3 °C and 7 °C, which functions to reduce local metabolism, inflammation, and pain. Cryotherapy works by decreasing nerve conduction velocity, termed cold-induced neuropraxia, along pain fibers with a reduction of the muscle spindle activity responsible for mediating local muscle tone. It is usually most effective in the acute phase of treatment, though it can be used by patients after their physical therapy sessions or their home exercise program to reduce pain and the inflammatory response.
  46. 46. Exercise Correction of posture may be the simplest technique to relieve symptoms in patients with nonspecific neck or low back pain, though it is extremely difficult to change habits. The physician should instruct patients to assume their worst postural “slump position” with forward protrusion of the head, flexion of the neck, rounding of the shoulders, and increased thoracic kyphosis and reversed lumbar lordosis while sitting. Next, the physician should instruct patients to correct these postural abnormalities through retraction and extension of the head, retraction of the shoulders, extension of the thoracic spine, and return of the lumbar lordosis.
  47. 47. Electrical Stimulation High-voltage pulsed galvanic stimulation has been used in acute neck pain to reduce muscle spasm and soft tissue edema. It is commonly used despite the lack of hard scientific evidence for its efficacy. Its effect on muscle spasm and pain is thought to occur by its counterirritant effect on nerve conduction and a reduction in muscle contractility. Use of electrical stimulation should be limited to the initial stages of treatment, such as the first week after injury, so that patients may quickly progress to more active treatment that includes restoration of ROM and strengthening. Electrical stimulation often may be combined with ice or heat to enhance its analgesic effects.