Intro to Pain Management

MCTF Pain Features

Type: nociceptive, neuropathic, nociplastic, mixed

Characteristics: mechanical [provokable] non mechanical [constant/at rest]

Sensitization: low-high

Biopsychosocial model factors

Bio: genes, physiology

Psyche: catastrophizing, self-efficacy, control, anxiety, anger

Social: SES, Social, skepticism

Goals of pain assessment

• Find dominant mechanism

• Contributing factors

• Impact on physical fxn - body structures/fxn, activity limitations, participation restrictions

• Impact on overall life

• Goals (create plan to reach goals)

  • Increase standing tolerance, work mods

• Prognosis

ICF Model for Pain

Condition contributes to

Body structures/fxns: tight mm, impingement, limited ROM

Activities: lift, bend, sit, stand, stairs, walk

Participation in work, return to sport

+Environmental +personal factors

PQRST

Provoking + easing factors

Quality: feel?

Region + radiation: spread? Along dermatome?

Severity/intensity: how much pain

Temporal factors: start, come and go? constant?

What does Provoking tell us?

Noxious stimuli or loading of 1 tissue?

Non-noxious stimuli → Sensitization

• Makes worse/better?: positions, movements, touch,

• how much to do before pain starts? how long does it take to settle?

• What have you tried to make it better? Did it help?

Pain only when 1 tissue loaded?

What does Quality tell us?

Describing words tell us what mechanism

Neuropathic: burning, electrical, pins, needles

Inflammatory: aching

• Does pain feel same everywhere or diff in diff places?

• Record words, offer many options if have to list

  • Achy, throbby, sharp, burning, shooting, electric, tingling. pins + needles, numb

What does Region tell us?

• Localized? = nociceptive

• Spread?

• Does it follow nerve or root or diffuse?

• Where is pain? Can you point to it? 1+ painful areas?

What does Severity tell us?

Proportional to tissue damage or inflammation?

Ask about:

1. Timing: now, @ rest, w/ activity?, on average?

2. Set recall period: past 24 hrs, past week?

3. Use anchors: 10 is worst imaginable

4. Document it: write the question asked, recall period, and #. ASK THE SAME WAY!

Must have same questions, recall period + anchors to compare!

• Measuring intensity which tells us severity

What does Timing tell us?

• Evoked?

• Resting pain or spontaneous?

• Worse in am or pm?

• Onset

• Frequency of pain

• Duration

• 24 hr pattern: am diff from pm, times of day when pain more present

• Pain @ rest

• Spontaneous pain

• Average pain thru week, worst pain when aggrevate, least pain, right now

Ways to measure intensity

NPRS 0-10, verbal/written. Give anchors

Visual analogue scale: Good for nonverbal - draw line thru scale

• Written or electronic

Faces pain Scale Revised: point to face scored 0-10. No read, write or speak.

Other ways to measure quality of pain

Short form McGill Pain Questionnaire

PROMIS Nociceptive + neuropathic pain quality

How to measure interference of pain

Brief pain inventory short form

• Body map, worst, least, average and current pain

• Relief from treatment

• Interference w/ daily life

Which measure to use?

Language, culture

Ability to read, speak, write

Setting

Age

Not every tool is valid and reliable

Pain quality measures

PROMIS scale for nociceptive pain

PROMIS scale for neuropathic pain

Which tool measures the multi-dimensional factors of pain

McGill Pain Scale Short Form V2

• Pain quality, intensity, affective, region, intensity, past treatment, pain interference

Components of building a hypothesis

History > PQRST > Physical exam > working hypothesis

Based on subjective and physical exam

Mechanical pain means what?

Provoked by physical stimulus - certain movements/posture

Response = stimulus

Non mechanical pain means?

Not related to physical stimulus

Constant or spontaneous pain

Response » stimulus

What is the pain mechanism if the pain only occurs when load injured tissues?

Normal nociceptive pain, NO sensitization

• If light touch, constant pain, or gentle movement hurts, it is not normal nociceptive pain

Sensitiziation

Pain triggered by post, movement, load, palpation

Sensory stimuli: light touch, pressure, temp

Stress and distress

Local or widespread pain?

Typical for history + stage? What does it mean for rx?

Is pain clear cut?

NO! Based on individual’s perspective

Can have mixed pain

Fear + anxiety, stress heighten pain

PQRST in physical exam

Provocation done LAST in assessment

Location/sensory changes

Avoid asking pain intensity too many times

What to do if normal nociceptive pain

Tissue-specific tests to rule in/out

Stage, irritability and severity guide how far to push

Neuropathic Pain next steps

Screen dermatomes, myotomes, reflexes, neurodynamic tests

Map sensory loss/gain to nerve or root

Inflammatory nociceptive pain next step

Look for swelling, warmth, redness

Map sensory gain to swollen area

Screen for red flags + systemic disease

Nociplastic pain next steps

Map tenderness + sensory changes that don’t follow tissue/nerve

Sleep, mood, beliefs and stress

MCTF Yellow flags

MCTF Yellow flags

Cognitive factors: self-efficacy, attitudes + beliefs

Affective factors: depression, anxiety, stress, fear, worry

Social factors: SES, edu, relationship, health literacy, culture, health care

Psychosocial screening

3P Approach to Treat Pain

Physical: Ice, rest, comfort positioning, PT, OT

Pharmacological: Ibuprofen, opioids, NSAIDS

Psychological: distraction, watch TV, counselling

How to treat normal nociceptive pain

Targeted tissue exercise, manual therapy

How to treat inflammatory pain

RICE

EPAs

How to treat neuropathic pain

Graded exercise, desensitization, graded motor imagery to alter nociception

How to treat nociplastic pain

Graded exercise (i.e. gradually increase step count) to alter nociception

Common treatments suitable for any pain mechanism:

Heat, ice, TENS

Fxn: gait, stairs, gait aids, return to sport

Contributing factors: pain edu, self-management, goal setting, build self-efficacy

What types of questions to ask about pain?

Open

Standardized

Non leading