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Pain management leon
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- 3. Introduction DR-RIFATUZZAMAN & DR-SAYEDA SULTANABITHI Intern Doctor Surgery Department TMMC & H
- 4. The word painis derived from latin word peone & greek word poine meaning penalty or punishment. Pain is an unpleasant sensory and emotional experience associated with actual and potential tissue damage. Medical Definition of “PAIN”
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- 10. ACCORDING TO 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)
- 19. INTENSIT Y Classified using astandard 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.
- 20. ETIOLOGY Physiological pain- experiencedwhen 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.
- 21. Neuropathic pain- experiencedby people with damaged or malfunctioning nerves. Peripheral neuropathic pain- follows damage and/or sensitization of peripheral nerves.
- 22. NOCICEPTIO NNociceptive pain occurswhen nociceptors in the body detect noxious stimuli that have the potential to cause harm to the body. Neuropathic pain is caused by damage to the neurons that are involved in the pain signaling pathways in the nervous system.
- 23. TRANSDUCTION Transduction is theconversion of a noxious stimulus (mechanical, chemical or thermal) into electrical energy by a peripheral nociceptor (free afferent nerve ending)
- 24. TRANSMISSION Includes 3 segments. Firstsegment- 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.
- 25. Pain control cantake 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.
- 26. 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.
- 27. PERCEPTION Is when theclient becomes conscious of the pain.
- 29. NURSING MANAGEMENT ASSESSING- painhistory, 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.
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- 41. Chronic Pain Management Nociceptivepain: It may result from musculoskeletal disorders or cancer activating cutaneous nociceptors.
- 42. Neuropathic or neurogenicPain: It is classically of a ‘burning’, ‘shooting’ or ‘stabbing’ type & may be associated with allodynia,numbness & diminished thermal sensation. It is poorly response to opoids. Monoaminergic, tricyclic inhibitors & anticonvulsant drugs are the mainstay of treatment.
- 43. Psychogenic Pain: It isassociated with depressive illness, chronic pain & illness may exacerbate each other.
- 44. Chronic Pain controlin Benign Disease: * Bring pain under control before amputation to avoid phantom pain. * Local anesthetic & steroid Injection around a nerve may reduce muscle spasm. * Transcutaneous nerve stimulators (TNS) modify pain by increasing endorphin production. * Trigeminal neuralgia responds to decompression of the nerve.
- 45. Drugs In ChronicNon Malignant Pain:
- 46. Pain Control inMalignant Disease * First step: Simple analgesics: -aspirin -paracetamol -non steroidal anti inflammatory drugs -Tricyclic drugs or anticonvulsant drugs
- 47. *Second Step: Intermediate Strengthopoids: -codeine -tramadol or dextropropoxyphene *Third Step: Strong opoids: -morphin (pethidine has now been withdrawn)
- 48. Infusion of subcutaneous, intravenous,intrathecal or epidural opiate Drugs: as possible of developing infection with catastrophic effect.The infusion of opiates is necessary if a patient is unable to take oral drugs. Subcutaneous infusion of diamorphine is simple & effective to administer. Epidural infusions of diamorphine with an external pump can be used on mobile patients. Intrathecal infusions with pumps programmed by external computer are used.
- 49. Neurolytic Techniques inCancer pain: * Subcostal phenol injection for a rib metastasis * Coeliac plexus neurolytic block with alcohol for pain of pancreatic,gastric or hepatic cancer * Intrathecal neurolytic injection of hyperbaric phenol * Percutaneous anterolateral cordotomy divides the spino- thalamic ascending pathway
- 50. Alternative strategies Include: *The development of anti-pituitary hormone drugs, such as tamoxifen & cyproterone, enables effective pharmacological therapy for the pain of widespread metastasis instead of pituitary ablation surgery * Palliative radioptherapy can be most beneficial for the relief of pain in metastatic disease * Adjuvant drugs, such as corticosteroids to reduce cerebral oedema or inflammation around a tumor, may be useful in symptom control
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- 54. NON - PHARMACOLOGIC Non-pharmacologicalpain management is the management of pain without medications. Methods of non-pharmacological pain include:
- 55. Bed Rest The useof 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.
- 56. Manipulation and MobilizationManipulative treatmentis 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.
- 57. TractionCervical traction isa 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-of-motion (ROM) exercises, appropriate strengthening, and correction of postural issues.
- 58. Therapeutic Modalities Therapeutic modalities shouldbe 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.
- 59. Transcutaneous Electrical Nerve Stimulation Transcutaneouselectrical 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.
- 60. Superficial Heat Superficial heatcan 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.
- 61. Cryotherapy Cryotherapy can beachieved 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.
- 62. Exercise Correction of posturemay 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.
- 63. Electrical Stimulation High-voltage pulsedgalvanic 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.
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