East Meets West From The Bottom Up: When Podiatry and Fibromyalgia Collide

East Meets West From The Bottom Up: When Podiatry and Fibromyalgia Collide

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The Skills System Instructor's Guide: An Emotion-Regulation Skills Curri.. Suffer the ChildOn the bestseller list for Walden Books and required reading for psychology classes,.. As pain duration increases, more of the above factors begin to influence the experience of pain. Successful chronic pain treatment often involves multiple specialties delivering a range of interventions for a variety of related problems. CRPS usually develops following trauma and is thought to involve both central and peripheral components. Continuous pain is the most devastating symptom and has been reported to spread and worsen over time, and it is usually disproportionate to the severity and duration of the inciting event Alexander et al, Complex regional pain syndrome, types I and II, is the current accepted nomenclature for related neuropathic pain syndromes that typically develop following injury or surgery to an extremity.

Type I designation originally referred to conditions that were not believed to have been associated with nerve injury; this condition was previously called reflex sympathetic dystrophy RSD Inchiosa, In view of evidence that small nociceptive fibers may be damaged in CRPS I, the validity of a distinction between type I and type II syndromes—in terms of etiology, symptomatology, and therapeutic approaches—is controversial Inchiosa, The pain in complex regional pain syndrome is regional, not in a specific nerve territory or dermatome, and it usually affects the hands or feet with pain that is disproportionate in severity to any known trauma or underlying injury.

Complex regional pain syndrome has an estimated incidence rate of While acute CRPS sometimes improves with early and aggressive physical therapy, CRPS present for a period of one year or more seldom spontaneously resolves. The syndrome encompasses a disparate collection of signs and symptoms involving the sensory, motor, and autonomic nervous systems, cognitive deficits, bone demineralization, skin growth changes, and vascular dysfunction Gallagher et al.

The acute phase of the condition is often characterized by edema and warmth, and is thought to be supported by neurogenic inflammation. Alterations in central nervous system structure and function may be more important to the sustained pain and neurocognitive features of the chronic phase of the CRPS Gallagher et al.

Although the pathophysiology of complex regional pain syndrome is not completely understood, two mechanisms based largely on experimental animal models have wide support in the literature as contributors to its initiation and maintenance. One mechanism is centered on neuronal sensitization and the other on neuroimmune interactions. Pain perception has been classically viewed as being mediated solely by neurons and most early studies of exaggerated pain conditions centered on peripheral and central neuronal sensitization as the driving mechanism.

However, over the last decade a vast number of studies support the notion of both glia and immune system involvement in chronic pain disorders including complex regional pain syndrome Alexander et al. Following an injury, several immune mediated mechanisms can affect pain signaling systems. Mast cells, neutrophils, and macrophages are activated and recruited to the site of injury. Disruption of the blood-nerve barrier allows for the invasion of the nerve by fibroblasts, macrophages, and Schwann cells.

These cells release pro-inflammatory cytokines and chemokines that have been implicated in the generation of neuropathic pain either via direct sensitization of nociceptors or indirectly by stimulating the release of agents that act on neurons and glia. Microglia and astrocytes are the immunocompetent cells in the central nervous system and are activated following tissue injury or inflammation. Once activated, microglia and astrocytes release a number of substances known to excite pain transmission in neurons. Activated microglia and astrocytes have been shown to be both necessary and sufficient for enhanced nociception.

A number of studies have shown an altered cytokine profile in blood, cerebrospinal fluid, and blister fluid in patients with complex regional pain syndrome. In addition, activation of both microglia and astrocytes has been reported in spinal cord autopsy tissue from a subject afflicted with complex regional pain syndrome. Although numerous drugs and interventions have been tried in attempts to treat CRPS, relieve pain, and restore function, a cure remains elusive. Two analyses have attempted to develop evidence-based guidelines for the treatment of CRPS.

One covers trials in the period between and June ; the second covers the period from June to February The earlier review identified the following treatments that had varying degrees of positive therapeutic effect:. Despite the difficulty in classifying and understanding different mechanisms of pain, certain pain syndromes are pervasive.

Low back pain, headache pain, postoperative pain, cancer pain, and pain associated with arthritis are some of the most common reasons patients seek medical care for pain. To understand the prevalence of certain types of pain, a National Health Interview Survey of adults during — found that during the three months prior to an interview, participants reported that:.

Low back pain LBP is one of the most common types of disability affecting individuals in Western countries, and the assessment of LBP-related disabilities represents a significant challenge. It is the fifth most common reason for all physician visits. Approximately one-quarter of U. Nevertheless, the location of pain, frequency of symptoms, and duration of pain, as well as any history of previous symptoms, treatment, and response to treatment should be considered.

The possibility of low back pain due to problems outside the back such as pancreatitis, nephrolithiasis, or aortic aneurysm, or systemic illnesses such as endocarditis or viral syndromes, should also be considered.

Clinicians should also be aware that back pain can be caused by cancer. History of cancer, unexplained weight loss, failure to improve after 1 month, and age older than 50 years have been associated with a higher likelihood for cancer.

Back pain can also be due to vertebral compression fractures, especially in older and frail adults, anyone with a history of osteoporosis, and those who use steroids. A focused examination that includes straight-leg-raise testing and a neurologic examination that includes evaluation of knee strength and reflexes L4 nerve root , great toe and foot dorsiflexion strength L5 nerve root , foot plantar flexion and ankle reflexes S1 nerve root , and distribution of sensory symptoms should be done to assess the presence and severity of nerve root dysfunction.

Low back pain can vary in different situations and positions. Some patients have pain in motion, but no pain when standing, and some have pain after standing for long time, but no pain in motion. This classification system uses three subtypes:. In adolescents with nonspecific low back pain, sitting is a common aggravating factor and accounts for significant disability. Conversely, older patients may have low back pain while in motion and standing, but less pain when sitting Aoki et al.

Low back pain is generally a steady, aching, or sharp pain and is felt near the spinal injury. Referred pain is felt in the structures or viscera within the territory of a dermatome, an area of skin supplied by a single nerve. Radicular pain , by contrast, is associated with irritation of the nerve root, and pain can be evoked by any motion that stretches the root of the nerve, for example, a straight-leg raise.

Radicular pain can occur in patients with serious or progressive neurologic deficits or underlying conditions requiring prompt evaluation, as well as patients with other conditions that may respond to specific treatments. Clinically, the natural course of low back pain is usually favorable; acute low back pain frequently disappears within 1 to 2 weeks. In some cases acute low back pain becomes chronic and difficult to treat. Any of the spinal structures, including intervertebral discs, facet joints, vertebral bodies, ligaments, or muscles could be an origin of back pain, which is, unfortunately, difficult to determine.

In those cases in which the origin of back pain cannot be determined, the diagnosis given is nonspecific low back pain Aoki et al. A migraine is a very painful headache thought to result from vasodilation of blood vessels in the brain. It usually manifests as an intense, pulsing or throbbing pain on one or possibly both sides of the head.

People with migraine headaches often describe pain in the temples or behind one eye or ear. Migraine sufferers may also have symptoms of nausea, vomiting, and sensitivity to light and sound. Some people see spots or flashing lights or have a temporary loss of vision that forewarn of an impending headache.

If a migraine occurs more than 15 days each month for 3 months, it is considered chronic. Migraines often start in the morning, and the pain can last from a few hours up to 2 days. These headaches can occur as often as several times per week for some patients or as infrequently as once or twice a year.

For many with migraines, the quality of life and activity is greatly diminished during attacks, and their frequency can interfere with the ability to work or to perform activities of daily living. Migraine headaches are still under-diagnosed and under-treated because they can have features in common with other types of headache. Over time, episodes of migraine headache afflict patients with increased frequency, longer duration, and more intense pain.

Numerous imaging studies of migraine patients have described multiple changes in brain functions as a result of migraine attacks: Migraine headaches also cause an annual loss of million workdays. Migraine has no cure. Drug therapies are broadly divided into two groups: Many people with migraine use both forms of treatment. The goal is to treat migraine symptoms as soon as possible and to minimize the number of migraine occurrences by avoiding triggers. Four major medications are used for abortive therapy:. Most drugs for acute migraine work best when taken right away, when symptoms first appear, followed by rest or sleep in a darkened room.

Patients should always have their migraine medicine nearby in case of an attack. For people with extreme migraine pain, a powerful rescue drug containing opiates might be prescribed. Because not everyone responds the same way to migraine drugs, patients must work with their healthcare provider to find the treatment that is most effective. For relatively mild migraine symptoms, over-the-counter OTC pain medications such as aspirin, acetaminophen Tylenol , or nonsteroidal anti-inflammatory drugs NSAIDs like ibuprofen Advil, Motrin , may be sufficient.

Some combination medicines are sold specifically for migraines eg, Excedrin Migraine, which contains aspirin, acetaminophen, and caffeine but these are usually not strong enough for severe migraines. The patient needs to understand that taking migraine medications more than 3 days a week may lead to rebound headaches—headaches that keep coming back, in part because of the medications. Many migraine medicines work by narrowing blood vessels to counteract vasodilation in the vessels of the brain.

Caution is advised if the patient has risk for heart attacks or has heart disease. Ergots should not be given if the patient is pregnant or planning to become pregnant. Pain is one of the major concerns in the postoperative care, not only because of the suffering it causes, but also because of its potential association with the process of recovery. The severity of postoperative pain is influenced by multiple factors aside from the extent of the surgical trauma.

For identical surgical procedures there is, postoperatively, a large variation in the pain experience and analgesic requirement Ene et al.

Postoperative pain can be caused by tissue damage, the presence of drains and tubes, postoperative complications, or a combination of these. It is often under-estimated and under-treated, leading to increased morbidity and mortality, mostly due to respiratory and thromboembolic complications, increased hospital stay, and impaired quality of life EAU, In the United States, nearly million surgeries take place annually—about 46 million inpatient and about 53 million outpatient procedures.

Failure to control postoperative pain adequately drives up the cost of care and is thought to be a factor in the development of chronic pain Chapman et al. Good pain management during recovery from surgery requires good pain measurement in each patient. Unfortunately, current pain measurement methods suffer from low precision due to unreliability in scores within individuals.

The common practice of characterizing postoperative pain day by day as a static entity fails to take this into account and loses information that can help define the unique pain management requirements of the individual Chapman et al. Effective post surgical pain management is associated with patient satisfaction, earlier mobilization, shortened hospital stays, and reduced costs. Post surgical pain management should be multimodal and designed for the particular patient, operation, and circumstances. Assessment should occur at scheduled intervals, in response to new pain, and prior to discharge.

Good post surgical management aims to:. This may be because there is not enough time to assess post surgical pain prior to discharge or to establish a pain management program at home. Psychological factors such as anxiety and depression have been considered important predictors of postoperative pain.

Age has also been found as a predictor, with younger individuals being at higher risk for moderate to intense pain. It is a good practice to identify patients at high risk for severe postoperative pain and provide those patients with special attention. Patients with good analgesia are more cooperative, recover more rapidly, and leave the hospital sooner. They also have a lower risk for prolonged pain after surgery Ene et al. Preoperative and perioperative pain management may influence postoperative pain ASA, The American Society of Anesthesiologists ASA Task Force on Acute Pain Management recommends that perioperative anesthesiologists be involved in both pre and post operative pain management, including ongoing education and training to hospital personnel.

Be aware of persistent pain following surgery in the following instances:. Most, if not all, patients in intensive care units ICUs will experience pain at some point during their ICU stay related to their injury, surgery, burns, or comorbidities, such as cancer, or from the myriad procedures performed for diagnostic or treatment purposes.

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Some patients may even experience substantial pain at rest. Unrelieved pain in adult ICU patients is far from benign. Medical and surgical ICU patients who recalled pain and other traumatic situations while in the ICU had a higher incidence of chronic pain and posttraumatic stress disorder symptoms than did a comparative group of ICU patients. Pain is one of the most severe and common symptoms of a variety of cancers and is a primary determinant of the poor quality of life in cancer patients.

In a large number of clinical cases, cancer-associated pain—particularly neuropathic pain—has been shown to be resistant to conventional therapeutics. In addition, their application may be severely limited due to widespread side effects Bali et al. The prevalence of pain in cancer patients was investigated in a meta-analysis involving 52 studies.

Research from Europe, Asia, Australia, and the United States has confirmed that cancer patients are repeatedly found to be in pain, both as inpatients and outpatients, with under-treatment of their pain—sometimes with no analgesia at all. As pain prevalence is noted to vary amongst different cancer types, it is necessary to determine the prevalence of pain in specific cancer types, to raise awareness amongst clinicians, and to improve patient management Kuo et al. Accurate assessment and treatment of cancer pain is quite rightly becoming more important, because cancers are being diagnosed at an earlier stage and patients are living with cancer for a longer period of time Kuo et al.

Pain from cancer tends to increase in severity as the cancer advances, and patients often experience pain at multiple sites concurrently. The highest prevalence of severe pain occurs in adult patients with advanced cancer National Cancer Institute, There may be multiple mechanisms with distinct patterns, such as continuous pain, movement-related pain, and spontaneous breakthrough pain. There is no universally accepted pain classification measure that assists with predicting the complexity of pain management, particularly for cancer pain patients.

Clinicians and researchers lack a common language to discuss and compare outcomes of cancer pain assessment and management. Most oncologists use the tumor, nodes, metastases TNM system as a universal language to describe a variety of cancers National Cancer Institute, The need for a similar classification system for cancer pain has resulted in the development of the Edmonton Staging System. This system has been refined in two reports that have gathered construct validity evidence using an international panel of content experts and a multicenter study to determine inter-rater reliability and predictive value.

The development of an internationally recognized classification system for cancer pain could play a significant role in improving the assessment of cancer pain, allow a more meaningful assessment of clinical prognosis and treatment, and better enable researchers to compare results with regard to cancer pain management National Cancer Institute, Despite difficulties with classification of pain, identifying its etiology is important to its management. Clinicians treating patients with cancer should recognize the common cancer pain syndromes see table below.

Prompt diagnosis and treatment of these syndromes can reduce morbidity associated with unrelieved pain. Distinct cultural components may need to be incorporated into a multi-dimensional assessment of pain National Cancer Institute, For example, one study evaluated the association between psychological distress and pain in patients with advanced cancer.

Pain intensity and pain that interfered with walking ability, normal work, and relations with other people were found to be significant predictors of anxiety and pain that interfered with enjoyment of life and were a predictor of depression. A number of factors may influence analgesic response and result in persistent pain, including changing nociception due to disease progression, intractable side effects, tolerance, neuropathic pain, and opioid metabolites National Cancer Institute, Although cancer pain or associated symptoms often cannot be entirely eliminated, appropriate use of available therapies can effectively relieve pain in most patients.

Patients with advanced cancer may experience multiple concurrent symptoms with pain; therefore, optimal pain management necessitates a systematic symptom assessment and appropriate management for optimal quality of life National Cancer Institute, Although slight improvements in the treatment of pain in cancer patients have been noted in recent years—particularly in industrialized countries—nearly 1 in 2 patients with cancer still receives inadequate treatment for pain Deandrea et al.

Several trends in the treatment of cancer pain have been noted:. Arthritis and other rheumatic conditions are the leading cause of disability in adults in the United States. The negative consequences of arthritis and other rheumatic conditions, including pain, reduced physical ability, depression, and reduced quality of life can impact the physical functioning and psychological well-being of those living with the conditions.

A number of variables have been shown to be associated with arthritis and other rheumatic conditions such as older age, lower physical activity levels, female gender, and being overweight or obese Schoffman et al. Treatment of arthritis and other rheumatic conditions is very costly for insurers and patients alike, and given the growing number of people in the United States over the age of 65, arthritis and other rheumatic conditions are set to be an even larger burden on the healthcare system in the coming years.

Without effective prevention and treatment strategies, arthritis and other rheumatic conditions will cause significant increases in the already high health care costs weighing on Americans Schoffman et al. Osteoarthritis OA is a joint disorder, characterized by degeneration of joint cartilage, which creates joint pain and stiffness that worsens over time, most often affecting the hips and knees. OA is the most common form of arthritis and affects close to 27 million Americans. Best practice guidelines for chronic osteoarthritis focus on self-management: Although low-grade inflammation underlies chronic osteoarthritis, it has not been a focus of best practice guidelines, particularly of its non-pharmacologic management.

Obesity is an independent risk factor for osteoarthritis and there is an interactive relationship among osteoarthritis, obesity, and physical inactivity see figure below. Relationships among osteoarthritis, obesity, and physical inactivity and association with the etiology of chronic low-grade systemic inflammation. Pain associated with osteoarthritis leads to increasingly less physical activity, which is an independent risk factor for inflammation, likely due to the reduced expression of anti-inflammatory mediators.

Physiologic cyclic loading of cartilage tissue reduces the expression of pro-inflammatory mediators and decreases cytokine-induced extracellular matrix degradation.

Increased self-efficacy for physical activity is associated with increased participation in exercise for people with arthritis. Having high levels of self-efficacy is associated with higher quality of life, decreased pain, and increased activity for all people including those with OA Van Liew et al. Physical exercise has become widely recommended for individuals with OA because it has been related to longevity. A meta-analysis on treatments for OA found that exercise programs reduced pain, improved physical functioning, and enhanced quality of life among individuals with OA Van Liew et al.

The health professions that can have the most impact on the successful treatment of OA include physicians, nurses, and physical and occupational therapists. Traditionally, physicians are highly trained in administration of invasive interventions while nurses have assumed a role in patient education, including psychosocial considerations of patient care.

Physical therapists are moving toward a model of care based on health International Classification of Functioning, Disability and Health , which includes initiating and supporting behavior change such as optimal nutrition, weight reduction, reduced sedentary activity, and increased physical activity.

Psychological distress is another factor that is associated with exercise and quality of life among people with OA. Evidence suggests that anxiety and depression are related to reduced functioning and to lower levels of physical activity among the OA populations. Although depression may pose barriers to activity engagement, physical activity has been shown to improve its symptoms and is a common focus of behavioral therapies.

Conversely, improvements in depression are also likely to lead to increases in activity levels and quality of life Van Liew et al. Rheumatoid arthritis RA is among the most disabling forms of arthritis. Rheumatoid arthritis tends to affect the small joints of the hands and feet in a symmetric pattern, but other joint patterns are often seen. Females are nearly three times more likely than males to develop rheumatoid arthritis and RA can start at any age, although the mean age at the onset is 40 to 60 years. The precise cause of rheumatoid arthritis is unknown; like other autoimmune diseases it arises from a variable combination of genetic susceptibility, environmental factors, and the inappropriate activation of the immune responses that eventually result in the clinical signs of arthritis.

RA can damage virtually any extra-articular tissue due to a systemic pro-inflammatory state. Cardiovascular disease is considered an extra-articular manifestation and a major predictor of poor prognosis. Several studies have documented a high prevalence of cardiovascular disease in many autoimmune diseases. Several traditional risk factors such as obesity, dyslipidemia, type 2 diabetes mellitus, metabolic syndrome, hypertension, physical inactivity, advanced age, male gender, family history of cardiovascular disease, hyperhomocysteinemia, and tobacco use have been associated with cardiovascular disease in RA patients.

In fact, seropositive RA may, like diabetes, act as an independent risk factor for cardiovascular disease Sarmiento-Monroy et al. Psoriatic arthritis is an inflammatory joint disease characterized by stiffness, pain, swelling, and tenderness of the joints as well as the surrounding ligaments and tendons. The presentation is variable and can range from a mild, nondestructive arthritis to a severe, debilitating, erosive joint disease Lloyd et al. Psoriatic arthritis affects fewer people in the United States than rheumatoid arthritis about 1 million people.

It has a highly variable presentation, which generally involves pain and inflammation in joints and progressive joint involvement and damage. There are multiple clinical subsets of psoriatic arthritis:. Left untreated, a proportion of patients may develop persistent inflammation with deforming progressive joint damage which leads to severe physical limitation and disability.

In many patients articular patterns change or overlap in time. Enthesitis an inflammation of the area where tendons, ligaments, joint capsules, or fascia attach to bone may occur at any site, but more commonly at the insertion sites of the plantar fascia, the Achilles tendons, and ligamentous attachments to the ribs, spine, and pelvis Lloyd et al. Dactylitis , an important feature of psoriatic arthritis, is a combination of enthesitis of the tendons and ligaments and synovitis involving all joints in the digit. The severity of the skin and joint disease frequently do not correlate with each other.

Other manifestations of psoriatic arthritis include conjunctivitis, iritis, and urethritis Lloyd et al. Nonsteroidal anti-inflammatory drugs help with symptomatic relief, but they do not alter the disease course or prevent disease progression. Intra-articular steroid injections can be used for symptomatic relief. Physical or occupational therapy may also be helpful in symptomatic relief. Disease modifying anti-rheumatic drugs are the mainstay of treatment for patients suffering from psoriatic arthritis. Assessment and documentation of pain, systematically and consistently, guides the identification of unrelieved pain and the evaluation of treatment-related change.

Since the goal of therapy is to alleviate pain and improve function, assessment should focus on pain and functional status. Healthcare professionals are encouraged, within their scope of practice, to:. The most critical aspect of pain assessment is that it be done on a regular basis using a standard format. Pain should be re-assessed after each intervention to evaluate the effect and determine whether the intervention should be modified.

The time frame for re-assessment should be directed by the needs of the patient and the hospital or unit policies and procedures. The mainstay of pain assessment has traditionally been the patient self-report. Family caregivers can be used as proxies for patient reports, especially in situations in which communication barriers exist, such as cognitive impairment or language difficulties. Family members who act as proxies typically, as a group, report higher levels of pain than patient self-reports, but there is individual variation JNCI, Both physiologic and behavioral responses can indicate the presence of pain and should be noted as part of a comprehensive assessment, particularly following surgery.

Physiologic responses include tachycardia, increased respiratory rate, and hypertension. Behavioral responses include splinting, grimacing, moaning or grunting, distorted posture, and reluctance to move. A lack of physiologic responses or an absence of behaviors indicating pain may not mean there is an absence of pain. The Joint Commission requires documentation of pain assessment and the consideration of pain as the fifth vital sign as a means of prompting clinicians to re-assess and document pain whenever vital signs are obtained.

Documentation is also used as a means of monitoring the quality of pain management within the institution. The initial evaluation of pain should include a description of the pain. How long does it last? How often does it occur? Selecting a pain assessment tool should be a collaborative decision between patient and healthcare provider to ensure that the patient is familiar with the scale. Patients who are alert but unable to talk may be able to point to a number or a face to report their pain.

The pain tool selected should be used on a regular basis to assess pain and the effect of interventions; it should not, however, be used as the sole measure of pain AHRQ, Many pain intensity measures have been developed and validated. Most measure only one aspect of pain ie, pain intensity and most use a numeric rating. Some tools, such as the Pain Scale for Professionals, measure both pain intensity and pain unpleasantness and use a sliding scale that allows the patient to identify small differences in intensity.

The following illustrations show some commonly used pain scales. The Visual Analog Scale. The Numeric Rating Scale. The Pain Scale for Professionals. The patient slides the middle part of the device to the right and left and views the amount of red as a measure of pain sensation. The Risk Communication Institute. Simpler tools such as the verbal rating scale VRS classify pain as mild, moderate, or severe. Some studies indicate that older adults prefer to characterize their pain using the VRS. The description can be translated to a number for charting see following table and works particularly well if everyone on the unit uses the same scale.

Patients with advanced dementia may require behavioral observation to determine the presence of pain; tools such as the PAIN-AD are available for this patient population. Pain questionnaires typically contain a variety of verbal descriptors that help patients distinguish different kinds of pain.

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The McGill Pain Questionnaire, for example, asks patients to describe subjective psychological feelings of pain. Typically, patients describe deep-tissue pain as dull, aching, and cramping, while nerve-related pain tends to be more sporadic, shooting, or burning. It is an assessment tool that combines a list of questions about the nature and frequency of pain with a body-map diagram to pinpoint its location.

The questionnaire uses word lists separated into four classes to assess the total pain experience. The ability to resume activity, maintain a positive affect or mood, and sleep are relevant functions for patients. The BPI uses a numeric rating scale to assess difficulties with:. For the cognitively intact adult, assessment of pain intensity in the clinical setting is most often done by using the 0 to 10 numeric rating scale or the 0 to 5 Wong-Baker faces scale, or the VRS.

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For example, a patient on morphine may report a pain level of zero but be unable to stay awake enough to talk with her family. The patient must decide how much discomfort she can tolerate and still do what is important to her AHRQ, The assessment of pain in communication-impaired patients, such as those with severe cognitive impairment, is a significant challenge.

Cognitively impaired patients tend to voice fewer pain complaints but may become agitated or manifest unusual or sudden changes in behavior when they are in pain. Caregivers may have difficulty knowing when these patients are in pain and when they are experiencing pain relief. This makes the patient vulnerable to both under-treatment and over-treatment.

Behavioral assessment tools are helpful in assessing pain and evaluating interventions in cognitively impaired adults. There are two types of tools: The number or intensity of behaviors is not a pain intensity score and no research as yet confirms that a pain behavior score correlates with pain intensity. It is unsafe to use pain behavior scores as pain intensity scores because a patient with only a few behaviors may have as much pain as a patient with many more behaviors AHRQ, It evaluates and scores three categories of behavior on a 1—4 scale:.

A cumulative score above 3 may indicate pain is present; the score can be used to evaluate intervention, but cannot be interpreted to mean pain intensity. The patient must be able to respond in all categories of behavior—for example, the BPS should not be used in a patient who is receiving a neuromuscular blocking agent AHRQ, Behavior checklists differ from pain behavior scales in that they do not evaluate the degree of an observed behavior and do not require a patient to demonstrate all of the behaviors specified, although the patient must be responsive enough to demonstrate some of the behaviors.

A checkmark is made next to any behavior the patient exhibits. The total number of behaviors may be scored but, again, this cannot be equated with a pain intensity score. It is unknown if a high score represents more pain than a low score. In other words, a patient who scores 10 out of 60 behaviors does not necessarily have less pain than a patient who scores However, in an individual patient, a change in the total pain score may suggest more or less pain AHRQ, This tool was developed by a team of clinicians at the E.

Rogers Memorial VA Hospital in Bedford, Massachusetts and involves the assessment of breathing, negative vocalization, facial expression, body language, and consolability. Accurate pain measurements in children are difficult to achieve. Both verbal and nonverbal reports require a certain level of cognitive and language development for the child to understand and give reliable responses. Although observed reports of pain and distress provide helpful information, particularly for younger children, they are reliant on the individuals completing the report Srouji et al.

Behavioral measures consist of assessment of crying, facial expressions, body postures, and movements. They are more frequently used with neonates, infants, and younger children where communication is difficult. Physiologic measures include assessment of heart rate, blood pressure, respiration, oxygen saturation, palmar sweating, and sometimes neuroendocrine responses. They are generally used in combination with behavioral and self-report measures, as they are usually valid for short-duration acute pain and differ with the general health and maturational age of the infant or child.

In addition, similar physiologic responses also occur during stress, which results in difficulty distinguishing stress versus pain responses Srouji et al. The most common pain measures used for infants are behavioral. These measures include crying, facial expressions, body posture, and movements. Preterm or acutely ill infants, for example, do not elicit similar responses to pain due to illness and lack of energy. In addition, interpretation of crying in infants is especially difficult, as it may indicate general distress rather than pain.

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Cry characteristics are also not good indicators in preterm or acutely ill infants, as it is difficult for them to produce a robust cry Srouji et al. Other scales used with infants are composite measurement scales, meaning they use a combination of behavioral and physiologic measures. Some scales also take into consideration gestational age and the general behavioral state of the infant. In toddlers, verbal skills remain limited and quite inconsistent. Pain-related behaviors are still the main indicator for assessments in this age group.

Nonverbal behaviors such as facial expression, limb movement, grasping, holding, and crying, are considered more reliable and objective measures of pain than self-reports. Most children of this age are capable of voluntarily producing displays of distress, with older children displaying fewer pain behaviors eg, they cry, moan, and groan less often Srouji et al. Most 2-year-old children can report the incidence and location of pain, but do not have the adequate cognitive skills to describe its severity. Common pain scales used in toddlers are:. By the age of four years, most children are usually able to use 4- to 5-item pain discrimination scales.

Their ability to recognize the influence of pain appears around the age of five years, when they are able to rate the intensity of pain. Facial expression scales are most commonly used with this age group to obtain self-reports of pain. These scales require children to point to the face that represents how they feel or the amount of pain they are experiencing.

The following section describes scales commonly used with this age group:.

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Healthcare professionals depend more comfortably on self-reports from school-aged children. Although children at this age understand pain, their use of language to report it is different from adults. At roughly 7 to 8 years of age children begin to understand the quality of pain. Self-report, visual analog, and numerical scales are effective in this age group. A few pain questionnaires have also proven effective for this age eg, pediatric pain questionnaire, adolescent pediatric pain tool.

A brief discussion of these tools is presented in this course:. Adolescents tend to minimize or deny pain, especially in front of friends, so it is important to provide them with privacy and choice. For example, they may or may not choose to have parents present. They expect developmentally appropriate information about procedures and accompanying sensations. Some adolescents regress in behavior under stress. They also need to feel able to accept or refuse strategies and medications to make procedures more tolerable.

To assess pain, specifically chronic pain, the adolescent pediatric pain tool APPT or the McGill pain questionnaire are helpful Srouji et al. Evidence suggests men and women experience and report pain differently Horn et al. Clinically, this is relevant because research has demonstrated that a greater percentage of chronic pain sufferers are women.

Women also generally report more areas of bodily pain and more pain-related disability compared to men. Given that pain is such a prevalent and debilitating condition with serious health and economic consequences, the Institute of Medicine has stressed the need to improve healthcare delivery of pain management, including individualized treatment approaches Horn et al. The etiology of sex differences in pain reports is still not clear.

Evidence suggests that differing biologic and psychosocial factors may account for these differences. Psychosocial factors influence the perception and evaluation of pain. One commonly studied psychosocial factor is pain-related fear. Pain-related fear includes fear of the sensation of pain, fear of movement or re-injury, and fear of physical activities that are assumed to cause pain.

Pain-related fear is believed to contribute to the shift from acute low back pain to chronic low back pain, and numerous studies have demonstrated the association of pain-related fear with disability in patients with chronic and acute low back pain, hip and knee osteoarthritis, and foot and ankle dysfunction Horn et al.

The differences in psychosocial factors, such as pain-related fear, across sexes may contribute to differences in the pain reports between men and women. Several lines of research using experimentally induced pain have begun to disentangle these sex differences. For example, an experimental pain study using electrical stimuli found the increased pain experienced by women during a movement task was accounted for by higher reports of fear among women compared to men.

In addition to pain-related fear, Robinson and colleagues found women to be more willing to report pain and consider themselves to be more sensitive to pain compared to males.

Conversely, some males believe that they have higher pain endurance than women and as compared to the typical male. Interestingly, after controlling for these gender role differences and anxiety, the previous sex differences in temporal summation, a proxy measure of central sensitization, were attenuated.

These findings indicate that sex differences in reported pain may be attributed to underlying differences in psychosocial factors Horn et al. Research has shown that gender of experimenters influences the results of pain assessment in laboratory studies. For example, males reported significantly less cold pressor-evoked pain in front of a female experimenter than a male experimenter, while female subjects tended to report higher pain to the male experimenter. A significant interaction of experimenter gender and subject gender on pain tolerance indicated that subjects tolerated pain longer when they were tested by an experimenter of the opposite sex.

Additionally, a significant main effect for experimenter gender showed higher pain intensities for subjects tested by female experimenters Belfer, A recent review of 11, electronic medical records containing at least one disease-associated pain score analyzed differences in disease-specific pain reported by men and women and found significant gender specificity. Apparently, women feel pain more intensely than men across almost all disorders.

These findings are in line with previous evidence that females are at greater risk for developing several chronic pain disorders such as fibromyalgia, temporomandibular dysfunction, migraine, rheumatoid arthritis, and irritable bowel syndrome, and women exhibit greater sensitivity to noxious stimuli in the laboratory compared with men, for all types of stimulation and tests.

In addition, clinical pain is often reported with higher severity and frequency, longer duration, and present in a greater number of body regions in women than in men. Gender also affects analgesic response, so that opioids produce greater analgesic responses in women than men Belfer, Finally, gender role influences sensitivity to pain in experimental settings.

Individual responses to pain vary widely—some people are unfazed by painful piercings and tattoos while others cannot stand even a flu shot. Inter-individual variability is one of the main characteristics of pain on every level including the processing of nociceptive impulses at the periphery, modification of pain signals in the central nervous system, perception of pain, and response to analgesic strategies.

As with many other complex behaviors, the sources of this variability have both environmental and genetic components Belfer, Pain perception—the conscious recognition and awareness of a painful stimulus—is modulated and modified by many psychological and personality-related factors. These can include previous pain experiences, emotions and cognition, somatization and catastrophizing, the presence of acute and chronic stressful life events, fatigue, anxiety, fear, boredom, and anticipation of more pain. Pain perception is also influenced by socioeconomic factors such as social support, acceptance, incentives, education, occupation, and quality of life.

In addition, pain perception is different among genders and ethnicities, and varies with age Belfer, Continuous, unrelieved pain affects the psychological state of both patient and family members, leading to common psychological responses such as anxiety and depression. The inability to escape from pain can create a sense of helplessness and even hopelessness, which may predispose a person to chronic depression.

Patients who have experienced inadequate pain management may be reluctant to seek medical care for other health problems Reinhard, There is little doubt that pain often is co-morbid with psychological conditions. The association between depression and pain appears to be stronger with the severity of each condition Bromley Milton et al. Depressive patients frequently report somatic symptoms including painful physical symptoms accompanying their depression. Pain can be a symptom, a cause, or a consequence of depression.

Neurobiologic evidence suggests that mood and chronic pain are connected via the serotonin and noradrenalin neurotransmitter pathways. A malfunctioning of the descending serotonergic and noradrenergic pathways could allow routine sensory input to be interpreted as uncomfortable or even painful. Studies investigating the direction of the association between pain and depression suggest that it is the stress of living with chronic pain that causes depression, but there is also evidence that pain develops secondary to depression through increases in pain sensitivity, and that high depression scores result in a greater risk of developing chronic pain Schneider et al.

This can lead to a lack of awareness of depression, missed diagnosis, and inappropriate treatment. Conversely, failure to treat painful physical symptoms in depressed patients may adversely impact depression treatment outcomes. Recognizing and optimizing the management of pain that commonly coexists with depression may be important in enhancing depression response and remission rates.

The presence of severe pain at the start of depression treatment has been associated with non-response to antidepressants, and a lower overall pain severity score at baseline was associated with higher odds of achieving remission Schneider et al. In a systematic review of studies looking at the psychological factors associated with knee pain, researchers found strong evidence for a positive association between depression and knee pain in adults.

The emerging evidence on pathogenesis of depression suggests that it is associated with dysfunction in the inflammatory cytokine production as a response to stressors, dysregulation of the autonomic nervous system, and destabilizing effect on hypothalamic-pituitary-adrenal axis. Each of these mechanisms also contributes to the development of chronic pain syndrome.

These findings indicate that physiologic similarities exist between depression and chronic pain Phyomaung et al. Another explanation for the association between depression and knee pain may be reduced physical activity, which could be due to either fear of pain or as a consequence of depression. The resulting muscle wasting and reduced joint stability resulting from less activity may have a negative effect on function and the disease outcomes of osteoarthritis Phyomaung et al.

Extensive data support the efficacy of tricyclic antidepressants for the alleviation of pain in chronic pain patients, and the newer serotonin and noradrenaline reuptake inhibitors SNRIs duloxetine, venlafaxine, and milnacipran have shown efficacy in the treatment of pain and depression. Duloxetine is a SNRI with proven efficacy for painful physical symptoms of depression. Analyses from short-term trials demonstrated that a greater reduction in pain was associated with a higher probability of remission.

Furthermore, the efficacy of duloxetine has been proven for the treatment of painful diabetic neuropathy Schneider et al. To explain the co-morbidity between depression, anxiety, and pain, researchers have used different theories and different opinions about factors of causality.

The presence of both pain and psychological symptoms has negative effects on, for example, prognosis of sick leave. Some researchers have discussed whether depression in patients with chronic pain feeds treatment resistance. Clinical observations of pharmacologic treatments indicate that it is easier to treat patients with depression only than to treat patients with both chronic pain and depression Bromley Milton et al. There is evidence that psychiatric disorders may increase pain intensity through a central pain modulation system, where the physiological bases of depression and pain share some of the pathways in the central nervous system.

Anxious patients may also interpret pain as being more intense than non-anxious patients. The presence of chronic pain makes it difficult to recognize and treat potential psychiatric disorders, and this delay may worsen the prognosis of psychiatric disorders Mangerud et al. Because of the cognitive, emotional, and psychological effects that may be associated with pain, a biopsychosocial concept of pain has emerged over the past two to three decades along with considerable evidence supporting management approaches addressing the psychosocial aspects of a patient with chronic pain Sessle, In this cross-sectional study of Norwegian adolescents with psychiatric disorders, two-thirds reported chronic pain.

One in five experienced pain-related disability, and reports of pain increased with age. Girls reported a higher frequency of chronic pain and pain-related disability than boys did. Adolescents with mood or anxiety disorders had a significantly higher frequency of chronic pain and pain-related disability than those with hyperkinetic disorders; however, this association practically disappeared when adjusting for sex. Adolescents with hyperkinetic and mood or anxiety disorders had a two- to three-fold increased risk of pain-related disability compared to those with hyperkinetic disorders alone Mangerud et al.

Psychological factors often play a role in chronic low back pain but in cross-disciplinary treatment individual psychological intervention is rarely included. Epidemiologic research has shown a link between low back pain and psychological factors, particularly depression and anxiety. In relation to low back pain, depression is often described as being atypical and takes the form of a so-called masked depression, often following a traumatic event.

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