1. Nancy Wiedemer,CRNP Pain Management Coordinator Philadelphia VA Medical Center nancy.wiedemer@med.va.gov Not all pain is the same: implications Not all pain is the same: implications for assessment and treatment for assessment and treatment

2. Assessment and Treatment of Pain:Issues and Challenges Underassessment and undertreatment Interpatient variability Patient not believed OPIOIDS Complex pathophysiology

3. Defining Pain Arthritis Spinal Stenosis Failed Back Neuropathy DM,PHN,HIV,post CVA Cancer Pain Mechanisms Acute Chronic < episodic < persistent End of life

4. Defining Pain By definition…… a disease process alters the way a system or organ system responds to different types of homeostatic processes within the body.  Hypertension  Diabetes  Chronic Pain Chronic Disease

5. Biopsychosocial Model of Pain

8. Suffering People suffer from what they have lost of themselves….. it continues until the threat of disintegration has passed or until the integrity of the person can be restored in some other manner. Eric J Cassel, NEJM, 1982

10. Cascade of negative emotions experienced by health care providers Inadequacy Helplessness Frustration Anger Gallagher,2004

11. PAIN is a sensory processing system with a known anatomy and physiology WHAT IS PAIN?

12. Overview of Pain Perception

13. Transient pain in response to a noxious stimuli Key early warning – Alarm system Announces the presence of a potentially damaging stimulus Nociceptive Pain Woolf,CJ Ann Internal Med 2004;140:441-451

14.  Tissue damage  edema  activation of mechanoreceptors Release of chemicals from mast cells and injured nociceptors Woolf,CJ Ann Internal Med 2004;140:441-451 Glutamate Histamine Prostaglandin Substance P Serotonin Bradykinin

15. Nociceptive Pain SOMATIC Well-localized Aching,throbbing, gnawing  bone  joints  soft tissue  muscle  skin VISCERAL Poorly localized Deep aching, cramping,pressure, Referred  Bowel obstruction  Biliary colic  liver pain  appendix

16. NEUROPATHIC PAIN

17. Afferent fibers C fiber A beta fiber Nerve injury Phenotypical Changes Spinal cord Neuro- plasticity Central sensitization Alteration of modulatory systems Ectopic discharge Ectopic discharge Woolf & Mannion, Lancet 1999 Attal & Bouhassira, Acta Neurol Scand 1999

18. Central Sensitization

19. Overview of Pain Perception

20. Modulation of Pain Perception Antinociceptive system Endorphins Enkephalins Receptor sites GABA Opioids Serotonin Neurepinephrine Endorphins Enkephalins Opioids

21. Neuropathic Pain: injury to peripheral nerves and/or CNS Burning Stinging Shooting Lancinating Pins and needles Vicelike Electric Tingling

22. Focus of medical attention is often centered on nerve/disc/bony relationship Little to no attention is given to the soft tissue that supports and binds the spine The Myofascial System Guarded movements Pelvic tilt when standing Limited flexion and extension in the spine Paraspinal tenderness Trigger points – active or latent

25. Myofascial Pain Deep aching pain Burning or stinging sensation Restricted movement in involved areas Muscle spasms Trigger points- feel indurated to palpation Taut muscle bands

26. VA Clinician 

27. Pain Assessment What is the pain generator ? What is the pain mechanism ? Nociceptive Neuropathic Myofascial Mixed

28. Are there pain amplifiers ? Anxiety Depression PTSD Substance Abuse Disorder Pain Assessment

29. Tumors Fractures Infection Cauda Equina Syndrome Factors that may impede recovery: Emotional state Fear-avoidance beliefs Poor coping strategies Linton,SL & Boresma,K,2003 Are there RED FLAGS ?????

30. History and Physical Exam Events at pain onset Pain: site & radiation quality intensity (numeric score 0-10) temporal pattern provocations & sources of relief Activities and functional limitations Sleep disruption Previous therapies

31. Conclusions Chronic Pain ↔ Chronic Disease Chronic Disease Management Approach based on Biopsychosocial Model

32. Conclusions Not all patients with the same pain diagnosis have the same pain mechanisms Different mechanisms can coexist Treatment approaches that target each pain generator can improve outcomes

33. Conclusions Secondary prevention depends on early and aggressive assessment and management of pain