JURNAL READING

Pain Management
INTRODUCTION
assessment, diagnosis, and treatment of pain in various clinical
settings. Injury and surgery can cause acute pain. Some
orthopaedic conditions may be associated with persistent or chronic
pain that can significantly limit the patients functional status if not
adequately managed. Collaboration between orthopaedic surgeons
and other caregivers is required to providestate-of-the-art pain
management in patients requiring both acute and chronic care.

The lack of availability of analgesic drugs is also a significant

problem in many areas of the world.
 Pain associated with noncancerous chronic conditionsis highly
prevalent. An estimated 75 million Americans suffer from chronic
pain.

Other common conditions include inflammatory and degenerative

musculoskeletal conditions (a complex condition involving
generalized body pain and other symptoms).
 Chronic painful conditions in underdeveloped countries are more
likely to be related to malnutrition; infectious diseases and trauma,
including limb amputation. Millions of the worlds inhabitants are
affected by these conditions.
GENERAL CONSIDERATIONS
Basic Physiology of Pain

Pain is defined as a complex psychophysiologic phenomenon. It is

the perceptual product of a complex integration of multiple brain
circuits. Pain is a necessary and physiologic function of the nervous
system. Pathologic pain results from abnormal nervous system
functioning (neuropathic pain). A great deal of information has been
learned in recent decades about the peripheral and central
neurophysiologic mechanisms of human pain, including how acute
pain states can become chronic conditions.
 Analgesic mechanisms (antianalgesia) that facilitate healing and
recovery.

Many chemical mediators and neurotransmitters involved in pain

transduction, transmission, modulation, and perception have been
identified to the inhibition of pain signaling also is known.
PATHOPHYSIOLOGY AND PAIN
DIAGNOSIS

Advances in neuroscience research in learning, memory, and neural

plasticity have helped to elucidate the pathophysiology of chronic
pain states.

Pain is a dynamic perceptual product of higher cortical processing. It

is important to note that the central nervous system responds to
nociceptive signals acutely with activity at the spinal cord, the
brainstem, and the thalamus, and with immediate alterations in
cortical somatosensory synaptic patterns.
 A working classification of pain states, based on the two broad
categories of pain (nociceptive and nonnociceptive)
ACUTE PAIN

In the setting of injury, adequate control of acute pain is a necessary

part of stabilizing the injured patient for further diagnostic
evaluation and treatment. When surgery is planned, pain should be
anticipated and a pain management plan should be developed before
surgery whenever possible. Patients may be most cooperative
 Medical evidence has accumulated indicating that applying
nonpharmacologic and pharmacologic interventions in both
preoperative (preemptive or preventive) and postoperative phases
produces the best outcomes.3-6 These outcomes include pain
prevention, faster recovery, shorter hospitalization time, and
improved patient satisfaction
 Current standards of pain management include the formal
assessment of pain, the diagnosis of different physiologic
mechanisms of pain, and the development of individualized
treatment with nonpharmacologic and pharmacologic strategies. The
synthesis of knowledge of how to minimize acute pain and improve
postoperative recovery continues to advance, permitting some major
orthopaedic procedures to be done in the outpatient or day-surgery
setting
 The orthopaedic surgeon is in a pivotal position to prevent chronic
pain by identifying unrelieved pain in the acute setting and by
collaborating with other clinicians providing pain management
PERSISTENT PAIN IN ORTHOPAEDIC
PATIENTS

Steps in the management of persistent (chronic) pain are

(1) evaluating the patient and establishing the pain diagnoses,
(2) identifying any curative treatments,
(3) maximizing nonpharmacologic analgesic interventions,
(4) tailoring analgesic medications to the individual, and
(5) monitoring the patient for response to treatment and modifying
the treatment plan accordingly.
PATIENT EVALUATION

The gold standard of pain assessment remains the patients

self-report. Clinicians can use the PQRST mnemonic to elicit a
complete pain history
 Pain intensity rating scales are used in clinical practice to establish a
baseline against which the efficacy of analgesic interventions can be
assessed. Many patients must be encouraged to verbalize their pain,
and most need to learn how to report pain intensity. In circumstances
in which patients are unable to communicate, behavioral
observations may substitute for the patients report of pain intensity.
 Standardized tools are available to assess preverbal children and
impaired adults. The Behavioral Pain Scale (BPS) and the FLACC
Behavioral Pain Assessment Scale (acronym FLACC: face, legs,
activity, cry, and consolability) have been validated in adult and
pediatric populations.
 When formulating a medical treatment plan that includes the
prescription of controlled substances, it is especially important to
identify prior or current psychological dependency on licit or illicit
drugs, including alcohol.

Prior pain treatments, including prescription and nonprescription

medications, and their relative efficacies should be recorded.

The physiologic signs of acute painelevated blood pressure,

respiratory rates, and pulse ratesare not reliable in patients with
subacute and chronic pain.
 The pain specialist will perform a complete physical examination
including a detailed neurologic examination, especially if
neuropathic pain is suspected. Pain in an area of reduced sensation,
allodynia (pain elicited by normally nonpainful stimuli), and
hyperpathia (summation of painful stimuli) indicate neural
dysfunction.
 A careful mechanical and soft-tissue evaluation is part of the
comprehensive pain evaluation. Soft-tissue conditions may
contribute to ongoing pain. Muscle spasms, tender
musculotendinous points of fibromyalgia, or discrete muscle trigger
points may be palpated; when stimulated, pain may be referred to
another site in a predictable pattern (criteria for myofascial pain
syndrome)
PAIN TREATMENT
Nonpharmacologic Interventions

Nonpharmacologic strategies using neurostimulation or

neuroaugmentation techniques are being refined and may produce
pain relief that lessens the requirement for systemic medications.
 Physical Treatment and Psychological and Behavioral
Interventions

Specific treatments (such as soft-tissue manipulation) for myofascial

pain and musculoskeletal disorders may be performed in the clinic

Patients with pain should be referred to physical medicine and

rehabilitation physicians to determine the need for rehabilitation and
occupational and physical therapy programs.
 psychoeducational support groups are useful as adjunctive outpatient
pain treatments. Spiritual support is a part of maintaining overall
wellness especially in the setting of life-threatening illness and end-
of-life care. Many patients with chronic noncancerous pain use a
variety of complementary and alternative medicine techniques for
pain relief.

Clinicians should inquire about their patients use of these methods.

PHARMACOLOGIC TREATMENT

Analgesic medications are considered to have broad effects,

including reducing transduction of painful peripheral stimuli,
altering pain transmission within the central nervous system, or
altering pain perception at the higher cortical level. Nonsteroidal
anti-inflammatory drugs (NSAIDs) and acetaminophen, the opioids,
and an assorted group of medications referred to as adjuvant
analgesics or coanalgesics are the three main classes of drugs used to
treat pain.
 Many patients with chronic noncancerous pain are prescribed
medications from more than one drug class

Patients requiring long-term treatment should be monitored for

cumulative renal and hepatic toxicity
 Opioid Analgesics
Oral administration of opioid analgesics is preferred because of
convenience and costs.

Modified release or long-acting preparations are recommended to

produce more uniform serum drug levels and to enhance patient
compliance with dosing.
 Adjuvant Analgesics
Adjuvant analgesics are a heterogeneous class of medications, which
are administered to provide additive analgesic effects, to counteract
the adverse side effects of more traditional analgesics such as
NSAIDs and opioids, and/or to treat a concurrent symptom
EVIDENCE-BASED GUIDELINES
Numerous professional societies and government agencies have
developed guidelines and policies for the treatment of chronic
noncancerous pain.

It is recognized that societal concerns related to drug abuse and

diversion should not outweigh a patients rights to compassionate,
effective pain treatment
OUTCOMES OF PAIN MANAGEMENT

Clinicians working with patients on a long-term basis to manage

pain follow several outcome variables to judge the efficacy of the
pain management plan. These include the patients self-report of
pain intensity, pain relief, side effects of treatment, adverse events,
quality of life, and functional status.

Communication between care providers is important, especially

when patients are treated with complex pharmacotherapy, including
controlled substances.
SPECIAL CONSIDERATIONS
The Pediatric Population
Although much progress has been made in identifying pain in
children, pain management in the pediatric population remains
challenging

Elderly patients
has been a focus for guideline development. In 2009, the American
Geriatric Society updated its guideline for the pharmacologic
management of chronic pain in older persons, specifying risks and
benefits of different analgesics and outlining the role of opioid
analgesics in the treatment of pain
 Opioid Therapy
The management of chronic pain with long-term opioid therapy
remains controversial, although some patients clearly benefit from
this treatment approach

Long-term opioid therapy should be prescribed only by clinicians

with adequate knowledge, skill, and the necessary clinical
infrastructure with interdisciplinary support.
 Methadone Therapy
Methadone is an effective, inexpensive analgesic that is generally
available
Methadone has high oral bioavailability, three times that of
morphine. Methadone is metabolized extensively by the cytochrome
P450 system
 There is emerging concern that patients prescribed methadone by
inexperienced practitioners may be at increased risk of death from
inadvertent drug accumulation and its resultant respiratory
depression

Clinicians prescribing methadone for the first time are strongly

encouraged to consult with a qualified pain specialist regarding
dosesand titration schedules
THE ROLE OF THE ORTHOPAEDIC SURGEON
IN PALLIATIVE AND END-OF-LIFE CARE

There are three elements which define palliative care:

(1) medical symptom management,
(2) psychosocial and spiritual support of the patient and family, and
(3) advanced care planning
ETHICAL CONSIDERATIONS

Ethical considerations may arise in relation to declining to intervene

and withdrawing specific medical interventions.
Advance care planning is essential for the prevention of unwanted
interventions and, more importantly, for supporting families when
they act as surrogate decision makers in choosing to accept, decline,
or stop specific interventions.
Health care professionals have an obligation to provide treatments
that carry a favorable balance of benefits to burdens or risks
SUMMARY

With continued basic and clinical research, improvements are

anticipated in diagnostic imaging, which will better define clinical
pain states; new pharmacologic and nonpharmacologic treatments of
pain; and in the development of standardized measures of clinical
outcomes in pain management. To best serve their patients in all
clinical settings, orthopaedic surgeons should have a basic
understanding of pain physiology and familiarity with state-of-the-
art pain management techniques.