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Treatment Options for Clinical Pain

Tammy Hanby

HCA250

March 20, 2011

Dr. Kadrie
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With the ever changing medical field there are many options for patients to consider

when it comes to pain management. Many patients are burdened with the decision to choose

between surgical, pharmaceutical, behavioral, and cognitive treatment methods to manage their

pain. In this essay we will review the different measures pertaining to three different case

scenarios involving pain and what treatments would or would not be considered appropriate. The

scenarios are considered for those patients dealing with chronic pain in a traditional hospital

environment.

The first case being reviewed are various types of pain from a below-the-knee amputation

(BKA) resulting from diabetic neuropathy. Nearly 40% of patients who undergo below the knee

amputation do so as a result of diabetes. In the instance of BKA the leg below the knee is being

amputated because of lack of blood flow to the affected area and avoiding amputation could lead

to necrotic (dead) tissue and possibly death (Papaloi,2009). For many patients after surgery they

experience emotional changes like depression due to a process of bereavement for the loss of the

limb. Along with the emotional side of dealing with the amputation patients sometimes

experience what’s called “Phantom Limb Pain” (PLP) in the area where the limb no longer

exists. According to Heidi Schultz (January 2005) author of "Phantom Input” 50 to 80% of the

amputees experience this phenomena. The pain has been described as fairly mild and self

limiting, but it may be an ongoing nuisance resulting in a chronic pain condition. The condition

resulting from BKA can be fairly difficult to treat (Taylor SM, Kalbaugh CA, Blackhurst DW et

al, 2005).With phantom limb pain the patient may still feel as though the toes and foot are still

present. Though the original pain has subsided the PLP can be a lasting effect of the surgery but

may fade over time.

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The aspects of emotional and physical pain vary in intensity from patient to patient. Some

scientists believe that PLP is the result of the brain sending messages to the brain in reference to

the limb whether the limb exists or not. It is easy to see that treatment for PLP can be difficult to

accomplish successfully.

Phantom limb pain can be treated from a surgical aspect which would encompass a

secondary surgery to remove the entangled nerve tissue that is sending impulses. Patient and

doctor may decide to go the pharmaceutical route to manage the pain by prescribing medications

like pain-relievers, neuroleptics, anticonvulsants, antidepressants, beta-blockers, and sodium

channel blockers. Another option for relief of PLP is behavioral methods of managing pain by

using relaxation techniques, coping techniques, and other methods (WebMD, 2010).Cognitive

methods of teaching patients to understand their pain can change the thoughts, emotions, and

behaviors related to pain, improve coping strategies, and put the discomfort in a better context

(WebMD,2010).Methods like Heat application, Biofeedback to reduce muscle tension, Massage

of the amputation area, physical therapy, Neurostimulation techniques such as spinal cord

stimulation or deep brain stimulation, and transcutaneous electrical nerve stimulation (TENS) of

the stump area are all effective treatment methods (WebMD,2010).

In this instance Physical Therapy combined with teaching the patient relaxation

techniques and coping skills would be highly effective. The short term use of pharmaceuticals

like pain relievers and antidepressants would be helpful to the patient who may be overwhelmed

with the physical change as well as the physical pain of the body. Involvement in a support group

or with psychologists to assist the patient with the emotional, psychological and physical effects

of amputation would be necessary for a good recovery and may shorten treatment and healing
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time. Education and nutritional support with a dietician for the control of diabetes would

definitely be a necessity.

In case two we are looking at acute pain from an abdominal hysterectomy. In this

instance pain management is also dependent of the tolerance level of the patient. Once again

each patient is different. According to WebMD, a hysterectomy is is an operation that removes

the uterus of a female patient. Treatment for pain after a hysterectomy depends on which surgical

procedure was used. The hysterectomy technique will partly determine healing time and scarring

afterwards (WebMd, 2010). There are two approaches to surgery – a traditional or open surgery

and surgery using a minimally invasive procedure or MIP.WebMD says that 70% if

hysterectomies are performed as open surgery where the abdomen is actually cut either up-and-

down or side-to-side, across the belly then the uterus is removed through the incision. According

to WebMD the MIP procedures allow for faster recovery, shorter hospital stays, less pain and

scarring, and a lower chance of infection than does an abdominal hysterectomy. Treatment is

assimilated to the kind of hysterectomy performed as well is the hospital stay.

In the case of open surgery most patients receive pharmaceutical support through the

means of On-Q. (A pain management system where local anesthesia is administered to the area

of the surgery through a tiny tube that is inserted through the incision), a morphine pump, or a

Post-op epidural .This form of pain relief is usually administered for up to two days following

surgery (Hysterectomy911, 2010). After this patients are usually given oral pain medications

every four to six hours followed by an anti-inflammatory medication every eight hours. Women

often experience depression following a hysterectomy which usually fades during the recovery

process. Those who have a prolonged depression after surgery would need to receive oral

medication to treat depression as well as possible psychological support through counseling or

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support group. Hormone replacement may also be offered to those patients whose ovaries have

been removed. Limited physical activity and lifting (10 lbs for 6 weeks) are immediate orders to

avoid complications. Loose fitting clothing will help to avoid applying too much pressure on the

incision (Hysterectomy911, 2010).Applications of heat to the site of the incision can be helpful

in relieving pain. Patients should refrain from sexual activity until otherwise advised by the

doctor that it is ok. Avoiding bending and moving slowly would also be prescribed by the doctor.

Unless complications arose there would be no necessity to use surgery treatment options

(WebMD, 2010).Case two is a good explanation of treatment to manage pain for acute pain. In

reviewing case three we can see how diverse pain management is.

Pain management in case number three is for the patient with chronic headaches. The

definition of chronic pain is pain that is ongoing and appears to be permanent

(treatmentsolutionsnetwork).These headaches are categorized as non-migraine. This list includes

headaches from tension, cluster headaches, and sinus headaches. The most common of these

types of headaches is the tension headache. They are said to affect 90% of all Americans,

occurring more frequently in women than men .They are describes as a band steadily tightening

around the head. There also may be pain in the back of the neck or base of the skull. Tension

headaches can last 30 minutes to a week (Lehigh Valley Hospital, 2004). They rarely cause

dysfunction in a person’s life but if occurring more than 15 times in one month they are

considered chronic. They can be brought on by headaches—stress, poor posture and depression.

It is also believed that the very pain relievers you’re taking to ward off the headache can actually

cause it. Tension headaches occur most often when face, neck, scalp and jaw tighten up. (Lehigh

Valley Hospital, 2004). Treatment for chronic headaches is similar in the pain relief essence.
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Both sinus headaches and tension headaches can be relieved by using analgesics like

Aspirin, acetaminophen or ibuprofen for pain with Rest, ice packs, warm compresses or a hot

Shower can relieve an occasional tension and sinus headache. Severe headaches can be treated

with aspirin, acetaminophen and muscle relaxants. Sinus headaches may need the added help of

decongestants .According to Lehigh Valley Hospital (2004) cluster headaches are usually treated

with medications (such as triptans) similar. The majority of chronic headaches need an analgesic

for pain. Methods like Heat application, Biofeedback to reduce muscle tension, Massage,

methods of managing pain by using relaxation techniques, coping techniques would be beneficial

(WebMD, 2010).

In all three cases pain management is an accomplishable task. However, learning better

coping skills and forms of relaxation techniques would benefit patients in all aspects. Whether it

be chronic pain or acute changing a Person’s perception of pain is helpful in the healing process.

.
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References

Ertl Janos P, MD, William, Ertl, MD & Pritchett, James W, MD. Nov 4, 2010 Amputations of

the Lower Extremity: Treatment Retrieved from

http://emedicine.medscape.com/article/1232102-treatment

Hysterectomy 911, 2010.Hysterectomy Pain, Retrieved from

http://www.hysterectomy911.com/blog/hysterectomy-pain/

Lehigh Valley Hospital, 2004.Sept/Oct,2004.Better Health for Life A

Guide to Non-Migraine Headaches. Retrieved from

http://www.lvhn.org/downloads/hy_septoct_04/headaches.pdf

Papaloi, Vassilios.2009.Amputation below the Knee.Retreived from

www.netdoctor.co.uk/surgical-procedure/amputation-below-knee.html

Schultz, Heidi. January 2005. "Phantom Input. Retrieved from National Geographic Magazine.

http://magma.nationalgeographic.com/ngm/0501/resources_who.html

Taylor SM, Kalbaugh CA, Blackhurst DW et al, 2055. Amputation and Amputation

Surgery, Retrieved from vascular.co.nz>amputation surgery