Pain Management in Long Term Care

Pain Management in Long Term Care
Todd Olson, OTR/L
August 16, 2019

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This text-based course is an edited transcript from the live course titled Pain Management in Long Term Care by Todd Olson, OTR/L.  It is highly recommended to follow along with the course handout
 
 

Learning Outcomes

 

  • Participants will be able to identify at least four different classifications of pain
  • Participants will be able to identify at least two benefits to pain management as an essential component of assessment and care planning in the Long Term Care setting
  • Participants will be able to identify at least five pain assessment rating scales that are effective with the Long Term Care population
  • Participants will be able to list at least six common pain behaviors in cognitively impaired elderly persons
  • Participants will be able to identify at least five skilled interventions to treat pain in the Long Term Care population
Today we will discuss pain management for the long term care population with an interdisciplinary team perspective and with a very strong focus on therapy, of course. Pain is a common experience among all people, and how pain is perceived, internalized, and handled is different for every individual. Effective pain management is essential to one's quality of life, their wellbeing, and it's a key element in all aspects of successful rehabilitation. With that, our residents of skilled nursing facilities, have the right to an effective pain management program and to effective pain management just like everybody else. In today's webinar we're gonna be discussing how to establish a pain management program for residents specifically in long term care, but also realizing that much of what we discuss today is applicable to those short-stay patients, and really those patients in every setting of healthcare.

Why Pain Management?

The purpose of establishing a pain management program is first to minimize or eliminate pain so that the resident is able to perform his or her daily activities at their highest level of independence. The second purpose is to educate residents and caregivers alike to compensatory strategies and/or adaptive strategies, that can help minimize, if not totally eliminate pain. Further, we need to implement pain management because it is mandated by CMS, and it is also stated in the State Operations Manual. It's in section F309. It states that "effective pain recognition and management requires an ongoing facility-wide commitment to resident comfort, to identifying and addressing barriers to managing pain, and to addressing any misconceptions that residents, families, and staff may have about managing pain". Nursing home residents, in particular, are at a high risk for pain that many effect function, impair their mobility, impair mood, disturb sleep, and overall diminish their quality of life.  The onset of acute pain may indicate a new injury, or potentially life-threatening condition or illness. It's important, therefore, that a resident's report of pain or non-verbal signs of pain, be evaluated.
 

Pain Myth Busters

Before we get into pain management let's review so common myths about pain, in particular regarding pain management and treatment in an elderly population.

Before we get into pain management programming, let’s review some common myths about pain – particularly regarding pain management and treatment in the elderly population.

MYTH: Aches and pains are a normal part of aging – FACT: Chronic pain is common after age 65 as the prevalence of diseases like osteoarthritis increase with age. Although pain is common in this population it is not is not inevitable. More important is it does not have to be tolerated because effective treatments are available.

MYTH: Patients with dementia are unable to report their pain – FACT: Studies have demonstrated that many people with dementia, even those with moderate to severe dementia, can reliably report pain. Therefore, providers should not assume a person can’t report pain based on a diagnosis or score on a dementia staging tool.

MYTH: Pain for the most part is an emotional or psychological issue – FACT: Pain isn’t all in somebody’s head. There are physical reasons for pain.  Pain can, however, cause negative emotions that can worsen pain perception.  Thus it is important to be aware of the physical and psychological effects that impact a resident’s pain experience.

MYTH: Doctors, nurses & therapists are the experts about pain. – FACT: No, the patient is the expert. In fact, studies have shown that nurses often under-report pain. Pain is a complex, subjective experience that can only be measured and described by the person who feels it. 

MYTH: It’s important to be stoic about pain – FACT: Being stoic about pain is often valued in our society, and the tendency may be more common among older adults. Unfortunately, stoicism can prevent health care providers from identifying and treating pain.  Therefore, we need to educate patients who don’t want to complain that reporting pain is not complaining; it’s the only way to identify the problem and treat it.

MYTH: A similar injury suffered by two people will cause the same amount and type of pain in both people – FACT: Pain perception is influenced by many factors, like previous injury, mood, and fatigue.  Depending on the person and the situation, two people can respond very differently to the same pain stimulus.

MYTH: There’s not much that can be done to relieve chronic pain – FACT: There is a lot that can be done.  Effective chronic pain management often requires more than one approach and even periods of trial and error to come up with the best plan. A pain management plan often includes both medication and non-pharmacological strategies.

Pain

Definition of Pain

According to the International Association for the Study of Pain, pain can be defined as an "unpleasant sensory and emotional experience associated with actual or potential damage". Pain may be a symptom of an underlying disease or disorder or a disorder in its own right. Many nursing home residents suffer from untreated pain, and it's thought that as many as 50 to 80% of nursing home residents have pain that leads to significant functional impairment, and decreased quality of life. Pain can decrease a residents ability to concentrate, to socialize, to perform daily tasks, and overall decrease their quality of life. This can all lead to a downhill slide, or what I call a downhill spiral towards depression, isolation, and loss of self-esteem. Pain is also positively correlated with aggression scores as well, so we need to be aware of that. Further evidence suggests that around 60 to 80% of people with dementia in care homes, regularly experience pain. This pain is most commonly related to musculoskeletal, gastro-intestinal, cardiac conditions, genito-urinary infections, and pressure ulcers.

Classification of Pain 

Pain can generally be classified as either acute or chronic.   We all know this. Understanding the difference between these two types of pain will assist in determining the most appropriate treatment approach to control the pain.
 
Acute pain alerts the body to change behavior, avoid further injury, cease the activity or rest an injured limb, or seek aid. Depending on the injured or inflamed structure, acute pain can be described as sharp, intense, and throbbing.  It's typically well localized, meaning the patient is able to pinpoint it. It usually only lasts as long as the duration of the stimulus. Treatment of acute pain is generally aimed at resolving the underlying cause of the pain.
 
Chronic pain, on the other hand, persists for an extended period of time. It is usually defined as equal to or greater than three months, and it accompanies a disease or an injury that is not resolved with the expected period of time or has not responded to routine methods of pain control. Chronic pain is thought to affect about 25 to 30% of Americans. It causes numerous impairments and can affect all aspects of a person's life. Persons with chronic pain often experience depression, decreased socialization, sleep disturbances, and inactivity.  Chronic pain is typically described as a burning or an aching. It's usually poorly localized, as opposed to our acute pain.  It outlasts the duration of the stimulus, meaning that it's hard to pinpoint to a specific structure or location, and it lasts much longer than expected. Treatment for chronic pain is typically focused on controlling the pain, and teaching the individual how to cope with it, how to live with the pain, and manage it, but not necessarily cure it.
 
Pain that is caused by organic disease and disorders like injuries or inflammation are diseases known as somatogenic pain.
 
Psychogenic pain is influenced by psychological factors. The patient is generally experiencing the pain, that is, he or she is not malingering, but the pain has either no organic explanation or else a weak one. The psychological factors that cause the pain may be more intense or debilitating than would normally be expected. Common psychogenic pain syndromes include things chronic headache, or low back pain, atypical facial pain or pelvic pain of an unknown origin.
 
It's important to recognize that some pain syndromes may involve more than one type of pain. For example, a cancer patient may suffer from neuropathic pain as a side effect of cancer treatment as well as nociceptive or mechanical pain associated with pressure from the tumor itself. In addition, to the somatogenic pain, the patient may experience this psychogenic pain related to loss of physical functioning, or attractiveness, coupled with the anxiety about the progression or the recurrence of their cancer diagnosis.

How the Body Feels Pain

A person begins to feel pain when the nociceptors in the skin, or muscles, or internal organs detect a pressure, an inflammation, a toxic substance, or some other harmful stimulus. The pain message travels along the peripheral nerve fibers in the form of an electrical impulse until it reaches the spinal cord. At this point, the pain message is filtered by specialized nerve cells and they act as gatekeepers. Depending on the cause and the severity of the pain, the nerve cells in the spinal cord may either activate motor nerves which govern the ability to move away from the painful stimulus, maybe block the painful message, or release chemicals that increase or lower the strength of the original pain message on its way to the brain. The part of the spinal cord that receives and "processes" the pain message from those peripheral nerves is known as the dorsal horn. 
 
After the pain message reaches the brain it is relayed to an egg-shaped central structure called the thalamus which transmits the information to three specialized areas of the brain: the somatosensory cortex which interprets physical sensations, the limbic system which forms a border anatomically around the brain stem and it governs emotional responses to physical stimuli, and then finally the frontal cortex which handles our thinking and consciousness. The activation of these three regions explains why human perception of pain is a complex combination of sensation, emotional arousal, and conscious thought.
 
In addition to receiving and interpreting the pain signals, the brain responds to pain by activating parts of the nervous system that send additional blood to the injured part of the body or that release natural pain-relieving chemicals. These include serotonin, endorphins, and enkephalins.

Nociceptive Pain

Nociceptive pain involves the normal activation of the nociceptive system by noxious stimuli. Nociception consists of four processes: transduction, transmission, perception, and modulation. Transduction is the depolarization at the peripheral nociceptors in response to noxious stimuli. Transmission is the stimulus; it proceeds along the primary afferent nociceptive nerves to the spinal cord and then on to the brain. Perception is how the brain recognizes the nociceptive impulses as pain itself.  Modulation is the concept of dampening of the pain impulses during the transmission and/or the perception via the release of endorphins, or other neurotransmitters, as well as via the gate control at the spinal cord by the peripheral or central nervous system.
 
Nociceptive pain can be acute, which would be short-lived, or it can persistent (long-lived or chronic), and may primarily involve injury to somatic or visceral tissues. Nociceptive pain of any type can be referred to some other structure or it could have a referral pattern. These are clinically relevant. For example, you may have experienced a patient with an injury to the hip joint, and with pain that might be referred to the knee. Another that maybe isn't quite so obvious is a bile duct blockage that can produce pain near the right shoulder blade.

Somatic Pain

Pain due to activation of these somatic primary afferents is termed somatic pain and it's typically localized. It's described as aching, squeezing, stabbing, throbbing. This is typically like your arthritis ad maybe your metastatic bone pain.  

Visceral Pain

Viscera refers to the internal areas of the body that are enclosed within a cavity. Visceral pain is caused by activation of pain receptors resulting from infiltration, compression, extension, or stretching of the thoracic, abdominal or the pelvic viscera. This visceral pain is the most common form of pain produced by disease, and one of the most frequent reasons for patients to seek medical attention.
 

The five characteristics of visceral pain are

  • visceral pain is not evoked by the viscera itself
  • is not linked to a visceral injury
  • is referred to another location
  • is diffuse and poorly localized
  • is accompanied by a motor autonomic reflex.

Pain can be described such as a dull, achy, crampy, and it's poorly localized. It also has a longer duration. Patients are usually restless and they can't get comfortable.  Autonomic symptoms like nausea, sweating, and pallor are frequently seen. Pain arising from stimulation of these afferent receptors in the viscera is referred to as visceral pain.  It's usually caused by an obstruction of a hollow viscous that is poorly localized and is often described as cramping and gnawing. It usually has a daily pattern that can vary in intensity. When organ capsules are involved, the pain may be described as a sharp, stabbing or throbbing and it might be more similar in those situations to more of a somatic pain.

Neuropathic pain mechanisms 

With neuropathic pain, otherwise known as nerve pain, it's a type of chronic pain that occurs when nerves in the central nervous system become injured or damaged. Neuropathic pain is the label applied to pain syndromes inferred to result from a direct injury or dysfunction of the sensory axons in the peripheral or central nervous system. These changes may be caused by an injury to either neural or non-neural tissue. Although neuropathic pain is influenced by ongoing tissue injury, there is an assumption that the functional mechanisms sustaining the pain have become independent of the injury or the damage itself. Neuropathic pain has varied characteristics but is frequently described as continuous burning pain, shock-like, or paresthetic.  The pain may or may not be lancinating(piercing or stabbing). Neuropathic pain syndromes may be associated also with referred pain, allodynia (pain induced by a non-noxious stimulus, e.g. light touch); or hyperalgesia (increased response to generally noxious stimuli), or hyperpathia (exaggerated responses to painful stimuli, with a continuing sensation of pain after the stimulation has ceased).
 
Neuropathic pain syndromes can be subclassified according to a broad set of inferred mechanisms. Some neuropathic pain syndromes are presumed to involved predominating peripheral generators (e.g. compressive or entrapment syndromes, neuropathies, plexopathies, radiculopathies). Then other syndromes appear to depend on processes that reside in the spinal cord, or the brain, or both. The pain may be due to a spinal cord injury, or post-stroke pain. Injury to peripheral neural axons can result in abnormal nerve regeneration, and this usually happens in the weeks or months following the injury, The damaged axons, they could grow multiple nerve sprouts, and these can form neuromas. These nerve sprouts, including those forming neuromas, can generate spontaneous activity which peaks in intensity several weeks after the injury. Unlike normal axons, these structures are more sensitive to physical distension, which is clinically associated with tenderness, and the appearance of a Tinel's sign (i.e. sensation of pins and needles, tingling when the area is tapped or manipulated). After a period of time, atypical connections may develop between nerve sprouts or demyelinated axons in the region of the nerve damage, that can start to permit a "cross-talk" between the somatic and sympathetic efferent nerves and nociceptors. The dorsal root fibers of these may also sprout following an injury to the peripheral nerves. The specific changes associated with centrally generated pain syndromes are not known.

Biological Mechanisms of Chronic Pain 

It's important to determine which of these mechanisms are at work in the chronic pain patient because the treatments really do depend on the type of pain. Two decades ago, the type of pain was not so important as all pain was generally treated in a similar way with a very narrow scope of drugs and therapies. We basically used non-steroidal anti-inflammatory drugs (NSAIDs), Tylenol, and then some opioids in terms of a medication regimen. There are now available mechanism specific treatments for neuropathic pain, inflammatory pain, mechanical pain, and muscle dysfunction. We have to remember that patients often will present with pain that has more than one mechanism and we might be dealing with more than one way that this pain has presented itself. The clinician should determine the relative contribution of each mechanism to the total pain picture, to the total pain condition, and devise treatment methods and strategies to address the relative and relevant mechanisms.
 

Inflammatory. With inflammatory pain such as arthritis, infection, tissue injury, post-operative pain, this is also known as nociceptive pain because the inflammatory chemicals directly stimulate those primary sensory nerves that carry pain information to the spinal cord. The clinical features include heat, redness, swelling at the pain site, and a history of the injury or the known inflammation.

Mechanical/compressive pain. Mechanical compressive pain is aggravated by activity and temporarily relieved by rest. Neck and back pain are commonly related to muscle and ligament strains, degeneration of discs or facets, or osteoporosis with compression fractures. Mechanical and compressive pain is also a type of nociceptive pain because mechanical pressure or stretching directly stimulates the pain-sensitive neurons. In this setting, the history and the radiological findings can usually tell the story here. Examples include fractures, obstructions, dislocations, compression of tissue by tumors or cysts or bony structures. The treatment usually requires some sort of decompression or stabilization.

Neuropathic pain. Neuropathic pain is produced by damage or dysfunction of the nervous system. Examples of this include sciatica from nerve root compression, diabetic peripheral neuropathy, trigeminal pain, and postherpetic neuralgia (pain after shingles) The clinical features are: the setting, the distribution, the character of the pain, and the physical examination findings.  The clinical setting is usually the first clue to the neuropathic pain. A diabetic who complains of persistent pain is likely to have neuropathic pain since about 50% of people with diabetes develop neuropathy related pain. A patient who develops pain after a stroke in the same territory is most likely to have post-stroke neuropathic pain. The character of the neuropathic pain is usually described as burning or shooting/stabbing. If the pain follows a nerve distribution such as the median nerve, we can suspect carpal tunnel. Neuropathic pain should always be considered with any of these types of syndromes. Other examples of this could be a stocking-glove distribution for peripheral neuropathy, or trigeminal distribution for trigeminal neuralgia,  and also dermatomal distributions for postherpetic neuralgia. The physical findings to look for with neuropathic pain are numbness in the pain territory, sensitivity to a non-noxious stimulus like light touch or rubbing (allodynia), or coolness of the skin in the pain territory.

Muscle dysfunction.  Muscle dysfunction and skeletal muscle pain is a common cause of chronic pain.  Fibromyalgia or myofascial pain syndrome are frequently diagnosed in pain clinics. Failure to properly diagnose muscle pain may result in poor treatment outcomes, delayed recovery, and in worst-case scenarios, people are sent to ineffective surgeries. Fibromyalgia and myofascial pain both result in usually sore, stiff, aching painful muscles and soft tissues. Both syndromes share other symptoms that usually include fatigue, poor sleep, depression, headaches, and irritable bowel syndrome. Occasional acute muscle pain is probably universal.  Chronic muscle pain is extremely common.  Most are able to function satisfactorily within their daily activities despite chronic pain. Some report pain-related disability and presents more of a challenge to the healthcare system. For example, fibromyalgia syndrome is usually characterized by widespread musculoskeletal aching, and stiffness and tenderness. It's one of the most common pain syndromes that we see in outpatient clinics. The American College of Rheumatology usually classifies fibromyalgia under the following characteristics: it's usually widespread pain in the trunk and upper and lower extremities and there's usually pain located in 11 out of 18 tender spots with the pain present for at least three months. Other symptoms are chronic, but maybe not diagnostic including insomnia, depression, stress, fatigue, and irritable bowel syndrome. With myofascial pain, this a regional muscle soft tissue pain. This syndrome commonly involves the neck, the arms, the low back, hips, and the lower extremities. Trigger points will refer pain. Myofascial pain is common in patients in pain clinics. Usually, the etiology, diagnosis, and management are controversial.

Categories of Pain by Diagnosis

How are they treated differently?  The key is to define the cause of the pain.

Nociceptive pain. For nociceptive pain, the treatment needs to affect tissues that are damaged. For instance, more manual therapies, exercise, and modalities. Some of these diagnoses include your arthropathies (e.g. rheumatoid arthritis, Osteoarthritis, gout, mechanical neck and back syndromes, posttraumatic arthropathies), Mylagias, skin and mucosal ulcerations, ischemic disorders, non-articular inflammatory disorders, and visceral pain.

Neuropathic pain. Neuropathic pain is more nerve oriented and includes post-herpetic neuralgia, trigeminal neuralgia, diabetic neuropathy, post-stroke pain, post-amputation pain, myelopathic or radiculopathic pain, and also complex regional pain syndromes (CRPS).

Mixed Pathophysiology. Mixed Pathophysiology includes conditions like chronic recurrent headaches, migraine headaches, and vasculopathic pain syndromes.

Psychologically-Based Pain Syndromes. Then we have other psychologically-based syndromes like somatization disorders and hysterical reactions. 

 

Origin of Pain

One key point is that pain is often not where the problem is located, especially in the acute pain process. For instance, we might have pain in our shoulder, like the glenohumeral region, but the problem may be more related to a weak inferior trap that is causing poor stabilization, which is then causing an impingement (that's where the area of the pain is located). Pain can be a symptom of diseases or disorders, and these include neurologic, orthopedic, pulmonary, cardiac, degenerative and/or metabolic conditions.  At its core, we must always search for that root cause of the pain, knowing with some chronic conditions this could be pretty difficult.

Complication of Pain

Pain can be a symptom of a variety of neurologic, orthopedic, pulmonary, cardiac, degenerative or metabolic diseases/disorders. Some of the complications from this include range of motion deficits, muscle weakness/atrophy, incontinence, altered sensation, decreased activity, behavior and/or emotional changes, altered sensation, impaired coordination, pain resulting from a substitution of movement or protective posturing, and proprioceptive and kinesthetic deficits. Basically, all of these complications should be addressed by therapy.

Pain Modulation

Gait Control Theory. Pain messages originate in the nerves associated with the damaged tissue and then flow along the peripheral nerves to the spinal cord on the way to the brain. In the gate control theory, before they can reach the brain these pain messages encounter what we call nerve gates in the spinal cord, and they open or close depending on a number of factors. This possibly includes instructions coming down from the brain (e.g. relaxation, deep breathing, guided imagery). When these gates are open, the pain messages "get through" more or less easily and the pain can be intense. When those gates close, the pain messages are prevented from reaching the brain and may not be experienced, or experienced less. Basically, the thought is that no nociceptive input reaches the level of consciousness because the pain-transmitting cells are inhibited.  The gate gets closed at the level of the dorsal horn of the spinal cord.

Endorphin Release Theory. Natural morphine-like substances are released by certain stimuli-electrical stimulation, exercise, and possibly acupuncture. They block the pain messages from reaching the brain in a similar fashion to conventional drug therapy, but without those dangers of dependence or other side effects. Endogenous opioids like beta-endorphin, dynorphin, enkephalins and leucine enkephalin are neurochemicals produced by the body that inhibit transmission of pain. Beta-Endorphin has a half-life of about four hours, and it can produce pretty long-lasting pain modulation. Dynorphin and enkephalins have a shorter half-life of about 20 minutes, and therefore their modulation is much shorter. Beta-endorphin creates general analgesia and anti-inflammatory effects. Dynorphin causes segmental analgesia and leucine enkephalin creates spinal and cerebral analgesia and some vascular control. The release of these neurochemicals also causes the release of serotonin, which activates inner neurons that block pain transmission.  These endorphins are released slowly, but they can last up to eight hours.

In addition to receiving and interpreting pain signals, the brain responds to pain by activating parts of the nervous system that send additional blood to the injured part of the body, or that release natural pain-relieving chemicals including serotonin, endorphins, and enkephalins.  

Establishing a Pain Management Program

Many residents of skilled nursing facilities experience pain and from a therapy perspective almost every patient we see in every venue of healthcare for therapy has pain, it's very common. The degree to which pain affects each individuals ability to function can vary. Establishing effective pain management programming is essential to ensure that residents of our skilled nursing facilities whose pain impacts their quality of life and function receive the treatment that they need and deserve.

When establishing a facility pain management program, success will depend on how closely the interdisciplinary team works together.  We need to establish systems to consistently identify and track residents who demonstrate a risk for muscle issues, or weakness, or atrophy, due to pain; those that have experienced a functional decline in ADLs or mobility; those that demonstrate a change in range of motion, posture, standing ability, weight-bearing, or muscle tone because of pain; those residents that have decreased participation in activities, maybe decreased socialization or exhibiting behaviors that are directly related to pain.

We also have to establish facility systems to notify the therapy department when functional changes happen in self-care, mobility, in safety due to pain. That would include:

  • Providing ongoing facility education to therapy's role in the pain management program including the use of modalities, adaptive equipment, compensatory and coping strategies, manual therapy and exercise. 
  • Training staff other than therapy to identify impairments that could be related to pain
  • Training on techniques and strategies to be carried over after discharge from therapy, including things like positioning, exercise programs, splinting, coping mechanisms, the use of adaptive equipment
  • Scheduling regular meetings or rounds is critical to help to identify these patients. 
  • Ensure that we have supportive documentation, not just from therapy, but from all disciplines that are involved especially nursing.

...

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todd olson

Todd Olson, OTR/L

Todd Olson, in his 22+ years of rehabilitation practice, has worked in acute care, inpatient rehabilitation, outpatient, and long-term care as a clinician, operator, researcher, legal expert witness, consultant, and educator.  In his current position as the Director of Clinical Education and Training for Brighton Rehabilitation, he provides continuing education, clinical, operational, and regulatory support to over 600 therapists throughout the western United States.  In this position, Todd has presented licensure approved clinical education programming on dementia management, falls and balance, pain management, activities of daily living, function-based intervention, documentation and coding, and regulatory/reimbursement compliance.  Todd also serves as Brighton’s electronic medical record (EMR) Clinical Applications Director. In this role, he provides EMR clinical, operational, financial, regulatory, and IT support to Brighton’s employees and customers. In addition, Todd is the Owner and President of Athena Therapy Consulting which provides quality assurance, auditing, and operational support to clinical and legal clients.  Outside of work, Todd enjoys spending time with his family and tempting fate on his snowboard and mountain bike in the Wasatch Mountains surrounding his home of Park City, Utah. 

 



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