Clinical Correlation: Pain

Front 1

What type of nerve is most important in pain generation?

Back 1

bare nerve endings

Front 2

What are the classifications of pain?

Back 2

anatomic, etiologic, qualitative, and temporal (acute or chronic)

Front 3

What is chronic pain?

Back 3

pain that persists longer than it is supposed to or is recurrent; often without precisely defined etiology, time course, or treatment processes

Front 4

What are the two clinically relevant types of pain?

Back 4

acute and chronic

Front 5

What are the two types of chronic pain classification?

Back 5

nociceptive and neuropathic (pain can be a mixture of the two)

Front 6

What is nociceptive pain?

Back 6

pain due to ongoing tissue damage/inflammation

Front 7

What is neuropathic pain?

Back 7

pain due to a nervous system injury, in past or ongoing

Front 8

What pharmocology does nociceptive pain respond to?

Back 8

traditional analgesics like narcotics and anti-inflammatories

Front 9

What type of pharmacology does neuropathic pain respond to?

Back 9

"adjuvant" analgesics such as anti-depressants, anti-convulsants

Front 10

What type of fibers carry pain information to CNS?

Back 10

C fibers and poorly myelinated A-delta fibers

Front 11

T/F: In degenerative joint disease, radiographs that show the joint distruction do not correlate with the amount of pain

Back 11

True

Front 12

What are the 4 signs/symptoms of tissue damage/inflammation?

Back 12

Redness
Swelling
Pain
Warmth

Front 13

What type of pain signal does the inflammatory process generate?

Back 13

nociceptive

Front 14

What are the effects of inflammation/tissue damage?

Back 14

nociceptive pain
inc. catecholamines
inc. heart rate
improper stress response (inc. cortisol and other stress hormones)
respiratory effects
autonomic effects (sweating)
psychological effects (aversion and distress)

Front 15

Is neuropathic pain immediate or delayed?

Back 15

can be either

Front 16

What type of pain results when a nerve is cut during surgery?

Back 16

neuropathic

Front 17

What are the effects of neuropathic pain?

Back 17

may have inc. catecholamines
may have dec. cortisol
unreliable respiratory effects
unpredictable autonomic effects
reliable psychological effects

Front 18

What are the cardinal signs/symptoms of neuropathic pain?

Back 18

Allodynia and Hyperalgesia

Front 19

What is allodynia?

Back 19

pain from stimuli that are not normally painful

Front 20

What is hyperalgesia?

Back 20

an exaggerated response to a normally painful stimulus

Front 21

What are some possible clinical manifestations of neuropathic pain?

Back 21

-allodynia/hyperalgesia
-autonomic dysfxn
-trophic changes
-motor impairment
-signs of neural dysfxn

Front 22

What are the types of neuropathic pain?

Back 22

1. compressive
2. inflammatory
3. deafferentation
4. Central injury
5. SNS related

Front 23

What is compressive pain? Is pain immediate or delayed?

Back 23

active compression on a neural structure; immediate source of pain

Front 24

What is inflammatory pain?

Back 24

neuritis can occur when nerves themselves are attacked

Front 25

What is deafferentation pain?

Back 25

part of signal is removed, such as with phantom limb pain (i.e. following amputation of a limb)

Front 26

What causes central injury pain?

Back 26

a stroke or spinal cord injury

Front 27

What is SNS related pain?

Back 27

complex regional pain syndrome; shows up in certain parts of the body every time the SNS fires

Front 28

T/F: Most neuropathic pain is constant

Back 28

F: most neuropathic pain is episodic

Front 29

What are some possible reasons for neuropathic pain?

Back 29

diabetes, heavy metal exposure, alcohol, vitamin deficiencies, trauma/structural lesions

Front 30

What do you look at in neurologic examination?

Back 30

-pain in peripheral nerve distribution
-sensory loss
-motor deficit
-autonomic changes

Front 31

What are six diagnostic tools to use in a neurologic exam?

Back 31

-X-rays
-MRI
-Nerve conduction velocities
-EMG
-Quantitative sensory testing
-epidermal skin biopsy

Front 32

What are the limitations of EMG/NCV as diagnostic for neuropathic pain?

Back 32

-insensitive in acute injury
-normal result does not rule out neuropathic pain
-cannot assess fxn of small fiber nerves involved in most neuropathic pain (C fiber)

Front 33

What are the ABC's of nerve damage?

Back 33

Angry Backfiring C-fibers are diseased and causing the pain

Front 34

How do you treat acute pain?

Back 34

-assume nociceptive
-traditional analgesics
-treat injury (i.e. broken leg)

Front 35

What is the pharmacology for nociceptive pain?

Back 35

-traditional analgesics
-opiods
-NSAIDS/Cox2 inhibitors
-Corticosteroids
-maybe adjuvants

Front 36

How do you treat chronic pain?

Back 36

Start with least invasive (which might not be most efficacious)
psychological physical approaches --> topical meds --> oral meds --> injections --> interventional techniques

Front 37

What are opiates?

Back 37

derived from opium related natural compounds

Front 38

What are the routes of administration of opioids?

Back 38

-oral
-IV
-subcutaneous
-oral transmucosal
-transdermal
-rectal
-neuraxial

Front 39

What are the opiod sites of action?

Back 39

-supraspinal
-spinal (via neuraxial rte)
-peripheral

Front 40

What is the benefit of central delivery of opiods?

Back 40

same efficacy with less side effects (on bowels, bladder, less nausea)

Front 41

What are important considerations for opiod dosing in chronic pain pts?

Back 41

-pt will always have pain
-use time-contingent dosing
-goal is improved function
-narcotics can be addictive
-long lasting formulations
-used with metastatic cancer pts
-neuraxial pumps for continuous dosage (only if trouble with oral routes)

Front 42

Types of anti-inflammatories?

Back 42

corticosteroids
non-specific cyclooxygenase inhibitors
cox-2 inhibitors

Front 43

Benefits of anti-inflammatories?

Back 43

less likely to be addictive
oral, parenteral, and injection routes

Front 44

Limitations of anti-inflammatories?

Back 44

not as efficacious as narcotics
have toxicities

Front 45

What are some adjuvant analgesics used in neuropathic pain?

Back 45

antidepressants, anticonvulsants, anti-arrhythmics, antispastics, alpha-adrenergic agents, topicals
*most were discovered by chance

Front 46

Neuropathic pain treatments?

Back 46

-analgesics
-adjuvant analgesics
-injection therapies
-counter-stimulus therapy (i.e. TENS)
-psychological and physical therapy
-spinal cord stimulation
-blocks

Front 47

Limitations of using traditional analgesics for neuropathic pain?

Back 47

rapid development of tolerance
not as efficacious for long term pain

Front 48

Limitations for using antidepressants for neuropathic pain?

Back 48

not all are effective for pain (classic such as amitryptyline more effective than newer like prozac)

Front 49

Limitations for using anti-spastic agents?

Back 49

side effects (BP, dizziness/balance)