- 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
Why Pain Management?
Pain Myth Busters
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.
Definition of Pain
Classification of Pain
How the Body Feels Pain
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
Biological Mechanisms of Chronic Pain
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.
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.