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 ³Phantom 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-anddown 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 headaches²stress, 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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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

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