Pain Medicine at a Glance

Beth B. Hogans

• Publisher: Wiley-Blackwell
• Year: 2021
• ISBN:
  9781118837641
• Edition: 1
• Topic: Médecine
• Subtopic: Anesthésiologie et gestion de la douleur

Pain Medicine at a Glance

The market-leading at a Glance series is popular among healthcare students and newly qualified practitioners for its concise, simple approach and excellent illustrations.

Each bite-sized chapter is covered in a double-page spread with clear, easy-to-follow diagrams, supported by succinct explanatory text.

Covering a wide range of topics, books in the at a Glance series are ideal as introductory texts for teaching, learning and revision, and are useful throughout university and beyond. Everything you need to know about Pain Medicine... at a Glance!

Pain Medicine at a Glance is a user-friendly, visual introduction to the impact of pain in various clinical care settings, focusing on primary care needs. Aligned with learning objectives developed by the Johns Hopkins School of Medicine, this authoritative guide covers the basic forms and pathophysiology of pain, the clinical skills necessary for delivering excellent care, pharmacological and non-pharmacological treatments, and a variety of special cases such as healthcare ethics, integrative care, and treatment planning for chronic pain self-management therapy and the management of pain in children and older adults.

A new addition to the market-leading at a Glance series, the text offers concise and accessible chapters, full-color illustrations, self-assessment questions, and easy-to-follow diagrams. Topics include pain assessment, cognitive factors that influence pain, applying behavioral perspectives on pain, managing opioids and other pharmacological therapies, treating acute pain in patients with substance abuse issues, and more. Perfect for learning, revision, and teaching, this book:

• Provides a foundation of clinical and basic science knowledge about pain and its mechanisms
• Describes major forms of pain, including surgical, orofacial, musculoskeletal, and obstetric pain
• Offers advice on fostering empathy and compassionate practices in pain medicine
• Covers non-pharmacological treatments such as physical therapy, hydrotherapy, meditation, acupuncture, massage, and various focal treatments
• Includes discussion of recent advances and new discoveries in pain science

Pain Medicine at a Glance is the ideal companion for medical and healthcare students, junior doctors, advanced practice providers, nurse practitioners, and others involved in diagnosing and treating pain-associated illness.

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1
What is pain and how do we assess it?

Formally defined as an “unpleasant sensory and emotional experience associated with, or resembling that associated with, actual or potential tissue damage” (Raja et al. 2020), pain has an enormous impact on clinical outcomes. This formal definition captures several important aspects of pain: first, it is unpleasant, meaning that most people strongly prefer pain relief to continued pain. Second, pain is a sensory AND emotional experience, which means that pain has both sensory‐discriminative qualities, i.e. descriptive features such as burning or stabbing; as well as unpleasantness, i.e. aspects that pertain to suffering (Figure 1.1). The unpleasantness of pain profoundly motivates most people to seek relief. The suffering associated with pain motivated Epicurean philosophers (300 BCE) to observe in that the height of pleasure is reached with the absence of pain.

Figure 1.1 Pain has sensory‐discriminative and emotional‐motivational components.

Essential to survival, pain normally functions as a warning sign of damage to the body. High mortality rates are associated with painless myocardial ischemia; patients who cannot perceive a heart attack won't seek medical care until it is too late. At the extreme end of this spectrum are patients born with genetic mutations that eliminate pain sensing, e.g. SCN9A sodium channel defects, these patients are at increased risk for mutilation and death (Cox et al. 2006).

Perhaps the most important aspect of pain the tremendous variability from one person to another, interindividual variability, Figure 1.2. Due to diverse biology, genetic, and environmental factors, it is truly not possible to “know another's pain.” We must ask people about their pain in order to understand it. In a clinical setting, we call this “pain assessment.”

Figure 1.2 Interindividual variability in pain showing tremendous variability in healthy individuals exposed to pain stimulus.

Standard basic pain assessment includes assessment of: (i) Quality (burning, sharp, etc.), (ii) Region involved (arm, leg, etc.), (iii) Severity (also pain intensity), (iv) Timing (sudden, slow, waxing/waning), (v) Usually associated symptoms (rashes, vomiting, etc.), (vi) the things which make the pain Very much better (medicines, rest), and (vii) the things which make the pain Worse, Figure 1.3. This information, taken together, enables the clinician to formulate a preliminary differential diagnosis. Caring for patients with pain relies on strong basic clinical skills. It is essential to establish a problem list and a working differential diagnosis.

Functional pain assessment includes appraisal of how pain impacts a patient's functioning in daily life. Are they able to: Carry out tasks at home? Work to full capacity? Engage in self‐care? Interact with family and friends? Contribute to society normally? Enjoy life? And What is their quality of sleep? How is pain impacting their mood?

Figure 1.3 Standard pain assessment: the pain ‘Alphabet’.

Limited pain assessment, at a minimum, focuses on pain severity. Through the use of pain intensity scales, it is possible to rapidly and reproducibly ask patients about pain. Clearly subjective, but highly reproducible, the numerical rating scale (NRS) is the preferred pain intensity scale (Figure 1.4). Widely used, it is easy to understand, rapidly explained and scored, does not require literacy, translates well to other languages, and shows robust response properties in clinical practice. Intubated patients can use an NRS presented visually. The NRS is properly referred to as an “11‐point scale” as 0 and 10 are both included. Changes of less than 2 points on the NRS are generally below the “minimal clinically significant change” threshold and not meaningful. Limited pain assessment, focusing on pain severity alone is only appropriate for ultra‐rapid re‐assessment of patients with an established diagnosis. Initial appraisal of a patient with pain should always include the elements of the standard basic assessment, and the functional pain assessment, pain frequently impacts function (Figure 1.5).

Figure 1.4 The numerical rating scale of pain severity (intensity).

Over the years, a number of other pain scales have been used for verbal adults including the ‘verbal descriptor scale’ (mild/moderate/severe), the visual analog scale (a bar with no tick marks), a 100‐point scale, and a pain thermometer. The NRS is currently the most widely preferred scale.

For children, it is important to conduct an age‐appropriate pain assessment. Infants and pre‐verbal children require behavioral pain scales, Chapter 50. For those with communication barriers, cognitive impairments, or dementia, situationally appropriate pain scales are necessary, Chapters 10 and 51.

There are several scales used in research that were designed to assess various aspects of pain. The McGill Pain Questionnaire includes a list of 77 pain descriptors organized into 20 categories that are grouped in major domains of sensory, affective and evaluative in nature, and ranging in intensity (Melzack 1975). For example, pain that is pulsatile, ranges from flickering to pounding. Reviewing this instrument can build awareness of the diverse qualities of pain descriptors. The Brief Pain Inventory (BPI) is another informative and widely validated pain assessment instrume...

Table of contents

• Cover
• Table of Contents
• Title Page
• Copyright Page
• Dedication Page
• Preface
• Foreword
• Acknowledgment
• 1 What is pain and how do we assess it?
• 2 Nociceptive processing
• 3 What are the major types of pain?
• 4 How prevalent is pain and what are the common forms?
• 5 Pain and ethical practice
• 6 Advanced skillfulness in clinical practice
• 7 Cognitive factors that influence pain
• 8 Approach to the patient with pain
• 9 The pain‐focused clinical history
• 10 Assessing pain in those with communication barriers
• 11 Examination skills I
• 12 Examination skills II
• 13 Integrating knowledge, skills, and compassionate practices
• 14 Motivational interviewing and shared decision‐making
• 15 Communication and interprofessional teams caring for patients with pain
• 16 Planning therapy
• 17 Basic considerations for pharmacological therapy – balancing mechanisms of drugs and disease
• 18 Over‐the‐counter analgesia
• 19 Neuromodulating agents
• 20 Opioids – the basics and use in perioperative pain care
• 21 Opioids – the details
• 22 Opioids – advanced practice – alternative delivery routes
• 23 Focal treatments for pain in primary practice
• 24 Interventional treatments and surgery for pain
• 25 Activating therapies
• 26 Mind‐based therapies
• 27 Manual therapies: massage; trigger points, acupressure, chiropractic, stretching, inversion
• 28 Therapies that utilize descending pain pathways: meditation, vocation, games, music, and others
• 29 Acute and chronic pain: the basics
• 30 Surgical and procedural pain
• 31 Musculoskeletal pain
• 32 Orofacial pain
• 33 Neck pain, cervical, and thoracic spine pain
• 34 Arm and hand pain
• 35 Low back pain
• 36 Back pain emergencies
• 37 Radiating leg, buttock, and groin pain
• 38 Knee pain
• 39 Foot and ankle pain
• 40 Headache emergencies
• 41 Headaches
• 42 Headache – chronic pain and the acute flare
• 43 Visceral pain
• 44 Pelvic pain
• 45 Exceptional causes of severe, chronic pain
• 46 Management of pain in those with substance abuse
• 47 Pain at the end of life, opioid rotation
• 48 Opioids for chronic pain: preventing iatrogenic opioid use disorders
• 49 Tapering opioids in patients with pain
• 50 Pain in infants, children, and adolescents
• 51 Pain in older adults
• 52 Tailoring pharmacotherapy in aging, renal, liver, and other metabolic dysfunctions
• 53 Pain in pregnancy and the puerperium
• References
• Appendix I: Sample exam sheet
• Appendix II: Sample pain diary worksheet
• Appendix III: Glossary
• Appendix IV: Daily stretching guide – essential for pain prevention
• Appendix V: Patient packet – your power over pain
• Multiple choice questions
• Answers
• Index
• End User License Agreement