Sex an Gender Differences and Pain Management in Physical Therapy

Lecture No 2

Pain
An unpleasant sensation occurring in varying degrees of severity as a consequence of injury, disease, or emotional disorder.

Clinical Terms For The Sensory Disturbances Associated With Pain

Dysesthesia An unpleasant abnormal sensation, whether spontaneous or evoked. Allodynia Pain due to a stimulus which does not normally provoke pain, such as pain caused by light touch to the skin Hyperalgesia An increased response to a stimulus which is normally painful Hyperesthesia - Increased sensitivity to stimulation, excluding the special senses. Hyperesthesia includes both allodynia and hyperalgesia, but the more specific terms should be used wherever they are applicable.

 Physical suffering associated with a bodily disorder (such as a disease or injury) and accompanied by mental or emotional distress. Pain, in its simplest form, is a warning mechanism that helps protect an organism by influencing it to withdraw from harmful stimuli (such as a pinprick). In its more complex form, such as in the case of a chronic condition accompanied by depression or anxiety, it can be difficult to isolate and treat. Pain receptors, found in the skin and other tissues, are nerve fibres that react to mechanical, thermal, and chemical stimuli. Pain impulses enter the spinal cord and are transmitted to the brain stem and thalamus. The perception of pain is highly variable among individuals; it is influenced by previous experiences, cultural attitudes (including gender stereotypes), and genetic makeup. Medication, rest, and emotional support are the standard treatments

Structure sensitive to noxious stimuli

Periosteum Joint capsule

moderate sensitive structures to noxious stimuli

Subchondral bone Tendons ligaments

Less sensitive structure to noxious stimuli

Muscles Cortical bone

Insensitive structure to noxious stimuli

Synovium Articular cartilage Fibro cartilage

Acute Pain
Acute pain often results from tissue damage, such as a skin burn or broken bone. Acute pain can also be associated with headaches or muscle cramps. This type of pain usually goes away as the injury heals or the cause of the pain (stimulus) is removed. To understand acute pain, it is necessary to understand the nerves that support it. Nerve cells, or neurons, perform many functions in the body. Although their general purpose, providing an interface between the brain and the body, remains constant, their capabilities vary widely. Certain types of neurons are capable of transmitting a pain signal to the brain. As a group, these pain-sensing neurons are called nociceptors, and virtually every surface and organ of the body is wired with them.

 The central part of these cells is located in the spine, and they send threadlike projections to every part of the body. Nociceptors are classified according to the stimulus that prompts them to transmit a pain signal.
Thermoreceptive nociceptors are stimulated by temperatures that are potentially tissue damaging. Mechanoreceptive nociceptors respond to a pressure stimulus that may cause injury. Polymodal nociceptors are the most sensitive and can respond to temperature and pressure. Polymodal nociceptors also respond to chemicals released by the cells in the area from which the pain originates

 Nerve cell endings, or receptors, are responsible for pain sensation. A stimulus at this part of the nociceptor unleashes a cascade of neurotransmitters (chemicals that transmit information within the nervous system) in the spine. Each neurotransmitter has a purpose. For example, substance P relays the pain message to nerves leading to the spinal cord and brain. These neurotransmitters may also stimulate nerves leading back to the site of the injury. This response prompts cells in the injured area to release chemicals that not only trigger an immune response but also influence the intensity and duration of the pain.

Chronic and Abnormal Pain

Chronic pain refers to pain that persists after an injury heals, cancer pain, pain related to a persistent or degenerative disease, and long-term pain from an unidentifiable cause. It is estimated that one in three people in the United States experiences chronic pain at some point in their lives. Of these people, approximately 50 million are either partially or completely disabled. Chronic pain may be caused by the body's response to acute pain. In the presence of continued stimulation of nociceptors, changes occur within the nervous system. Changes at the molecular level are dramatic and may include alterations in genetic transcription of neurotransmitters and receptors

 These changes may also occur in the absence of an identifiable cause; one of the frustrating aspects of chronic pain is that the stimulus may be unknown. For example, the stimulus cannot be medically identified in as many as 85 percent of individuals suffering from lower back pain. Other types of abnormal pain include allodynia, hyperalgesia, and phantom limb pain. These types of pain often arise from some damage to the nervous system (neuropathic). Allodynia refers to a feeling of pain in response to a normally harmless stimulus. For example, some individuals who have suffered nerve damage as a result of viral infection experience unbearable pain from just the light weight of their clothing.

 Hyperalgesia is somewhat related to allodynia in that the response to a painful stimulus is extreme. In this case, a mild pain stimulus, such as a pinprick, causes a maximum pain response. Phantom limb pain occurs after a limb is amputated; although an individual may be missing the limb, the nervous system continues to perceive pain originating from the area.

Types of Pain
There are three types of pain, based on where in the body the pain is felt: somatic, visceral, neuropathic. Pain of all three types can be either acute or chronic. Somatic, visceral, and neuropathic pain can all be felt at the same time or singly and at different times.

Somatic Pain
Aching, often constant May be dull or sharp Often worse with movement Well localized

Eg/ Bone & soft tissue chest wall

Visceral Pain
Constant or crampy Aching Poorly localized Referred

Eg/ CA pancreas Liver capsule distension Bowel obstruction

FEATURES OF NEUROPATHIC PAIN

COMPONENT
Steady, Dysesthetic

DESCRIPTORS
Burning, Tingling Constant, Aching Squeezing, Itching Allodynia Hypersthesia

EXAMPLES
Diabetic neuropathy Post-herpetic neuropathy

Paroxysmal, Neuralgic

Stabbing Shock-like, electric Shooting Lancinating

trigeminal neuralgia may be a component of any neuropathic pain

Neuropathic Pain
Neuropathic pain is caused by injury to the nervous system either as a result of a tumor compressing nerves or the spinal cord, or cancer actually infiltrating the nerves or spinal cord. It also results from chemical damage to the nervous system that may be caused by cancer treatment (chemotherapy, radiation, surgery). This type of pain is severe and usually described as burning or tingling. Tumors that lie close to neural structures are believed to cause the most severe pain that cancer patients feel.

Myofascial pain
By far the most common type of pain is myofascial painachy and tender muscles. Common examples include tension headaches and the majority of neck, shoulder, and low back pain. It can be triggered by injury, illness, depression, anxiety, fear, insomnia, and stress. There is no actually pathology associated with myofascial pain: your muscles are tense and sore but not injured. Sometimes pain and spasm create a mutually reinforcing vicious cycle. Most patients are surprised at how intense myofascial pain can be, and how long it can last (years, although usually it improves on its own).

 Most people don't realize how important stress can be in causing and maintaining myofascial pain. Moreover, learning relaxation can dramatically reduce the pain you're in, regardless of the underlying cause. Blocked anger is also a major contributor.

Quality of pain
Sharp, well localized pain suggests a superficial lesion Sharp lancination, shooting pain suggests a nerve lesion, affecting A-delta fibers

Tingling suggests stimulation of nerve tissue affecting A-alpha fibers

Dull aching pain is typical of pain of deep somatic origin Change in quality

Pain management and gender differences

Scientists investigating gender differences in pain fount that

1. Women report more pain throughout of their life time 2. Women experiences pain in more bodily areas 3. Women experiences pain for long durations

 Women tend to focus on the emotional aspects of pain they experiences Men tend to focus on the sensory aspects for example-concentrating on the physical sensation they experience

 The sensory-focused straightedges used to men helped increase their pain threshold and tolerance of pain,

It was unlikely to have any benefit for women

Women who concentrate on the emotional aspects of their pain may actually experience more pain as result ,possibly because the emotion associate with pain are negative

1. The female brain showed greater activity in limbic regions, which are emotion based centers 2. In men, the cognitive regions or analytical centers showed greater activity

 The reason for the two different responses may date back to primitive days, when the roles of men and women were more distinct

These gender differences in brain responses to pain may have evolved as part of a more general difference in stress responses between men and women

Pain Assessment

Describing pain only in terms of its intensity is like describing music only in terms of its loudness
von Baeyer CL; Pain Research and Management 11(3) 2006; p.157-162

PAIN HISTORY
Description: severity, quality, location, temporal features, frequency, aggravating & alleviating factors Previous history Context: social, cultural, emotional, spiritual factors

Meaning
Interventions: what has been tried?

Example Of A Numbered Scale

Medication(s) Taken
Dose Route Frequency Duration Efficacy Adverse effects

Physical Exam In Pain Assessment

Inspection / Observation
You can observe a lot just by watching Yogi Berra

Overall impression the gestalt?

Facial expression: Grimacing; furrowed brow; appears anxious; flat affect Body position and spontaneous movement: there may be positioning to protect painful areas, limited movement due to pain Diaphoresis can be caused by pain Areas of redness, swelling Atrophied muscles Gait Myoclonus possibly indicating opioid-induced neurotoxicity

Physical Exam In Pain Assessment

Palpation

Localized tenderness to pressure or percussion

Fullness / mass Induration / warmth

Physical Exam In Pain Assessment

Neurological Examination
Important in evaluating pain, due to the possibility of spinal cord compression, and nerve root or peripheral nerve lesions

Sensory examination Areas of numbness / decreased sensation Areas of increased sensitivity, such as allodynia or hyperalgesia
Motor (strength) exam - caution if bony metastases (may fracture)

Deep tendon reflexes intensity, symmetry Hyperreflexia and clonus: possible upper motor neuron lesion, such as spinal cord compression or cerebral metastases. Hyoporeflexia - possible lower motor neuron impairment, including lesions of the cauda equina of the spinal cord or leptomeningeal metastases.
Sacral reflexes diminished rectal tone and absent anal reflexes may indicate cauda equina involvement of by tumour

Physical Exam In Pain Assessment

Other Exam Considerations

Further areas of focus of the physical examination are determined by the clinical presentation. Eg: evaluation of pleuritic chest pain would involve a detailed respiratory and chest wall examination.

Pain management
(also called pain medicine; algiatry) is a branch of medicine employing an interdisciplinary approach for easing the suffering and improving the quality of life of those living with pain. The typical pain management team includes medical practitioners, clinical psychologists, physiotherapists, occupational therapists, and nurse practitioners. Pain sometimes resolves promptly once the underlying trauma or pathology has healed, and is treated by one practitioner, with drugs such as analgesics and (occasionally) anxiolytics. Effective management of long term pain, however, frequently requires the coordinated efforts of the management team

 Medicine treats injury and pathology to support and speed healing; and treats distressing symptoms such as pain to relieve suffering during treatment and healing. When a painful injury or pathology is resistant to treatment and persists, when pain persists after the injury or pathology has healed, and when medical science cannot identify the cause of pain, the task of medicine is to relieve suffering. Treatment approaches to long term pain include pharmacologic measures, such as analgesics, tricyclic antidepressants and anticonvulsants, interventional procedures, physical therapy, physical exercise, application of ice and/or heat, and psychological measures, such as biofeedback and cognitive behavioral therapy.

Non-Pharmacological Pain Management

Acupuncture
Cognitive/behavioral therapy Meditation/relaxation

Guided imagery
TENS

Therapeutic massage
Others

Medications
Mild pain Paracetamol (acetaminophen), or a non steroidal anti-inflammatory drug such as ibuprofen. Mild to moderate pain Paracetamol, an NSAID and/or paracetamol in a combination product with a weak opioid such as hydrocodone used in combination, may provide greater relief than their separate use.

Moderate to severe pain

When treating moderate to severe pain, the type of the pain, acute or chronic, needs to be considered. The type of pain can result in different medications being prescribed. Certain medications may work better for acute pain, others for chronic pain, and some may work equally well on both. Acute pain medication is for rapid onset of pain such as from an inflicted trauma or to treat postoperative pain. Chronic pain medication is for alleviating long-lasting, ongoing pain.

Opioids
medications can provide a short, intermediate or long acting analgesia depending upon the specific properties of the medication and whether it is formulated as an extended release drug. Opioid medications may be administered orally, by injection, via nasal mucosa or oral mucosa, rectally, transdermally, intravenously, epidurally and intrathecally. In chronic pain conditions that are opioid responsive a combination of a longacting or extended release medication is often prescribed in conjunction with a shorter-acting medication for breakthrough pain, or exacerbations.

Non-steroidal anti-inflammatory drugs

The other major group of analgesics are nonsteroidal anti-inflammatory drugs (NSAID). Acetaminophen is not always included in this class of medications. However, acetaminophen may be administered as a single medication or in combination with other analgesics (both NSAIDs and opioids). The alternatively prescribed NSAIDs such as ketoprofen and piroxicam, have limited benefit in chronic pain disorders and with longterm use is associated with significant adverse effects. The use of selective NSAIDs designated as selective COX-2 inhibitors have significant cardiovascular and cerebrovascular risks which have limited their utilization.[

Antidepressants and antiepileptic drugs

Some antidepressant and antiepileptic drugs are used in chronic pain management and act primarily within the pain pathways of the central nervous system, though peripheral mechanisms have been attributed as well. These mechanisms vary and in general are more effective in neuropathic pain disorders as well as complex regional pain syndrome.[11] Drugs such as gabapentin have been widely prescribed for the off-label use of pain control. The list of side effects for these classes of drugs are typically much longer than opiate or NSAID treatments for chronic pain, and many antiepileptics cannot be suddenly stopped without the risk of seizure.

Other analgesics
Other drugs are often used to help analgesics combat various types of pain and parts of the overall pain experience. In addition to gabapentin, the vast majority of which is used off-label for this purpose, orphenadrine, cyclobenzaprine, trazodone and other drugs with anticholinergic properties are useful in conjunction with opioids for neuropathic pain. Orphenadrine and cyclobenzaprine are also muscle relaxants and are therefore particularly useful in painful musculoskeletal conditions. Clonidine has found use as an analgesic for this same purpose and all of the mentioned drugs potentiate the effects of opioids overall.

Acupuncture
involves the insertion and manipulation of needles into specific points on the body to relieve pain or for therapeutic purposes

LLLT
A 2007 review concluded low level laser therapy may be effective in reducing inflammation and pain,[28] while a 2008 Cochrane collaboration review concluded that there was insufficient evidence to support the use of LLLT in the management of low back pain.[29]

TENS

Psychological approach
Cognitive and behavioral therapy Biofeedback Hypnosis