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Introduction to Pain Management

Wilton Remigio, DSc Clarkson University Physical Therapy

Epidemiology of Pain
1 out of 2 Americans experience pain at some given time 1 out of 4 live with chronic pain Increase in lifespan Associated pathologies 80% of people left with believe we must live with pain. Ignoring the Pain or the Patient?
Minority gap (geographic) Gender gap Disease gap (Cancer undertreatment, dementia) Physician Assisted suicide phobia Age Gap
Undertreatment in children
Attitudes toward children and pain (Pain builds character?)

Overtreatment in the Elderly


Family and nursing home issues,

Pain Publicity
Pain in the public psyche and media

Pain in end of life, pain and addiction Public demands we treat pain (social constraint) Most common reason to see MD 80% of PT orthopedic practice
Conflicting messages (legal, patients, risks) Little medical continuing education and management Concern with addiction Assistance in dying Damned if they treat , damned if you dont. Physician fear of stigma if addiction develops

Doctors and pain

Definition
An unpleasant sensory and emotional experience associated with actual or potential tissue damage, or described in terms of such damage. IASP Subjective nature Nociception vs suffering Pain is several diseases. Difficulty to quantify objectively

Legal Issues
Medical Responsibility to treat pain
Liabilities and Risks Risks of death Risk of Addiction No pharmacological treatment without risk. IS Doing nothing is no risk ? Risk/benefit is less when we do something than nothing

Addiction
Shift from illegal drugs to pharmaceutical drug addiction Oxycoton (websites of law officers suing doctors) Data shows problem is not with prescribers but with dispensers Drug addiction is the compulsive use of a substance that causes dysfunction and the continued use despite of the dysfunction When an addict gets the drug it will decrease function When a pseudo addict receives the drug he/shes begging for (undertreatment) it improves the function If pain is all you focus on pain becomes an addiction Good analgesics improve function Truth is in the middle

Function and Pain


Visual Analogue scales The lower the score the higher the dysfunction Function related to quality of life Suicides increase in unmanaged pain patients Physical therapies and function Pain relief is not an objective way of assessing good pain management

Classifying pain
Acute Pain: injury or stimulus is there. Goes away when stimulus go away Chronic Pain Nociceptive (perception based of the alarm) Neuropathic pain ( the alarm system is dysfunctional or injured) Idiopathic Pain ( MD is an ideot and patients is pathetic, suffering)
Fibromyalgia Fuzzy pathophysiology but concrete signs of dysfunction

Pain Issues in PT Practice

Measurement of Pain
Unidimentional
Visual or numerical analogue scales Scales for children

Multidimentional
McGill Pain Questionaire (MPQ) Pain Charts (plotting pain levels during the day) Pain Detect Pain Quality Assessment Scale Malingering Limitations of Self reporting scales

PT pain Patient
Typically chronic pain or recurrent acute pain of less severity Referred by physician
Pain Medication and Physical Therapy Confusion and mental caused by drugs Voluntary unemployment Unwilling to try PT

Multidisciplinary vs compartmentalizing patient

Non-pharmacological therapies
Acupuncture and herbs Heat/cold Topical use of Anti-inflammatories
NSAIDS and corticosteroids

Exercise Therapy/stretching Manipulation/mobilization Massage Electrotherapy Postural Therapies and Ergonomics Trigger point/tender point

Management of Pain in PT Practice


Fear Avoidance Chronic pain patient
Disconnect between severity and clinical picture Patient role

Locus of Control Depression Patient Education