Palliative Care and Pain Management Quiz

Pain & Sensory Perception

• Pain is whatever the experiencing person says it is, Existing whenever they say it does (International Pain Society, 2018).
• Pain is shaped by many different factors.
• It's vital to listen to a patient's description of pain and how it affects their life.
• Consider psychological distress as a potential factor in ineffective pain management and over-reliance on medication.
• Assess the patient as a whole.

Main Types of Pain

• Nociceptive Somatic: Pain related to skin nociceptive activity, localized pain (sharp, aching, throbbing).
• Nociceptive Visceral: Pain related to organs/body cavities, gnawing, cramping, dull pain.
• Neuropathic: Pain resulting from nerve damage, burning, prickling, tingling, numbness.

Pain Pathways

• Pain starts in one or more body parts.
• Pain signals travel through nerves to the spinal cord.
• The brain interprets the signals as pain.
• Endorphins released by the brain may reduce pain perception.

Pain Assessment

• Onset: When did the pain start?
• Provocative/Palliative: Does pain increase with movement? Are symptoms relieved with rest?
• Quality: Describe the pain (e.g., sharp, dull, throbbing).
• Region: Where is the pain located?
• Severity: Rate the pain on a scale (e.g., 0-10).
• Treatment/Timing: What treatments have worked in the past? Is the pain dull, constant, or intermittent?
• Understanding: Patient history and past experiences
• Values: Acceptable levels of pain, patient goals of care

Nonverbal Signs of Pain

• Facial expressions (grimacing, furrowed brows, pursed lips)
• Clenched jaw/teeth
• Grasping blankets
• Rigid body
• Unusual breathing patterns
• Agitation/irritability
• Moaning/calling out
• Not responding to voice
• Flinching to touch
• Guarding painful areas
• Kicking or restless legs
• Rocking

Fibromyalgia

• Fibromyalgia (FM) is a chronic condition characterized by widespread, non-articular musculoskeletal pain and fatigue.
• Patients often experience nonrestorative sleep, morning stiffness, irritable bowel syndrome, anxiety, and more.

Fibromyalgia Diagnosing

• Women are nine times more likely to be diagnosed than men.
• Age range: 30-50 years old
• Past medical history (rheumatic conditions, chronic fatigue, Lyme disease, trauma, deep sleep deprivation).
• Family history of fibromyalgia.

Fibromyalgia - Understanding

• There isn't a full understanding of how fibromyalgia works yet.
• It is believed to involve central processing problems of nociceptive pain input.
• Patients often report a lower pain threshold.
• Neuroimaging studies show possible neurotransmitter level imbalances affecting sensory transmission.
• There appear to be potential physiological abnormalities, such as increased Substance P in the spinal cord, and lower levels of blood flow to the thalamus and lower levels of serotonin.

Most Common Signs of Fibromyalgia

• Widespread pain: worsens and improves throughout the day
• Difficulty determining the pain's origin (muscle, joint, or soft tissue)
• Head/face pain, often stiffness/pain in neck and shoulder muscles, and TMJ dysfunction (in about 1/3 of cases).
• Point tenderness at specific sites across the body.

Additional Fibromyalgia Symptoms

• Fatigue, sleep issues, cognitive issues, memory problems, headaches, dizziness, pain in muscles and joints, and skin problems, with urinary issues (Dysmenorrhea) and restless leg syndrome also being common.

When Is It Fibromyalgia?

• Widespread pain, lasting at least three months
• Tender points (previously considered necessary, though now less emphasized)
• Ruling out other possible causes for the pain.

Nerve Root Compression

• Normal Disc: A healthy spinal disc has a nucleus pulposus enclosed by an annulus fibrosus..
• Degenerative Changes: When the disc loses hydration, it becomes degenerated. Bulging, and herniated discs occur as the nucleus pusposus bulges or herniates through the annulus.
• Symptoms: Nerve root compression results in radiculopathy. Symptoms can include pain, numbness, and weakness.
• Risk Factors: Older age (30-50), male, family history, obesity, spine overuse

Radiculopathy Symptoms

• Pain (type and location dependent on the injured area)
• Numbness (especially along the skin area near the affected nerve)
• Weakness (loss of sensation, impaired reflexes, changes in soft tissues)

Radiculopathy Diagnosing

• Physical exam (muscle strength, reflexes, pain in response to movement).
• Imaging (X-ray, CT, MRI)
• Nerve conduction studies to pinpoint nerve dysfunction.

Radiculopathy Treatment

• Pharmacology (NSAIDs, opioids, muscle relaxants, corticosteroid injections).
• Heat therapy to decrease spasms and inflammation
• Massage therapy
• Ultrasound therapy
• TENS (Transcutaneous Electrical Nerve Stimulation)
• Physiotherapy (to limit extreme movement, brace, corset, belt, building muscles)
• Possible surgical treatments (laminectomy or discectomy).

Cauda Equina Syndrome

• A medical emergency.
• Damage to the cauda equina, the nerve roots below the spinal cord.
• Symptoms include bladder and bowel dysfunction, sexual dysfunction, saddle anesthesia, limb impairment, and weakness.
• Crucial to get an MRI immediately (within 48 hours) and surgical decompression if indicated to prevent permanent damage.

Palliative Pain Management

• Palliative care: aims to improve quality of life for those with life-threatening illnesses, and often works in conjunction with other treatments
• Palliative care is not meant to hasten or postpone death; it's about providing relief from pain/distress and support to live as actively as possible.
• Important goals include pain control, preventing prolonged suffering, achieving control, easing family burden, clear decision-making, and completing life tasks if possible..
• Phases and layers: involve symptom management, maximizing quality of life, end-of-life, and terminal care (including physical, psychological, social and spiritual support).

Palliative Pain Management - Potential Causes of Pain

• Disease related: Nerve alterations/invasions, pressure on organs/tissues.
• Indirect factors: Constipation or other issues caused by disease.
• Treatment related: Side effects from radiation, chemotherapy, surgery.

Barriers to Palliative Care

• Lack of resources, knowledge
• Misunderstanding
• Provider bias
• Reluctance
• Restrictive eligibility criteria

Palliative Assessment

• Full Patient History (absolutely crucial)
• Complete Examination (physical, psychological, social, spiritual)
• Investigations based on the reason for palliative involvement, if necessary.

Basic Principles of Pain Management

• Avoid Delay in treatment
• Utilize the "pain ladder"
• Oral medications preferred wherever possible
• Consistent pain management plan
• Manage breakthrough pain, as needed.
• Education is necessary so patients feel empowered to understand how to manage their pain.

WHO Pain Ladder

• A step-by-step approach for managing pain using different types of medications, depending on the severity.

Common Opioid Side Effects (Possible Complications)

• Respiratory depression
• Constipation
• Nausea
• Sedation
• Itching (pruritus)
• Urinary retention

Non-pharmacological Interventions

• Relaxation techniques. Includes relaxation, superficial heating/cooling (e.g., warmth, ice packs), and acupuncture.
• Reflection
• Activity pacing

Age-Related Considerations

• Treatment cautions, such as slower drug metabolism, increased risk of adverse effects from medications, and increased risk of GI bleeding if treating with NSAIDs.

Special Populations (clients with substance abuse issues)

• The right to effective pain management.
• Need a dual approach to manage pain and substance abuse issues.
• A multidisciplinary team approach is frequently needed.

Peripheral Neuropathy

• Mononeuropathy (one nerve), Polyneuropathy (multiple nerves).
• Symptoms vary based on which nerves are damaged.
• Can include motor, sensory, and autonomic problems.

Known Conditions that Cause Nerve Damage

• Autoimmune conditions (e.g., Guillain-Barré syndrome, SLE, Rheumatoid Arthritis)
• Diabetes
• Infections (e.g., Lyme disease, herpes, shingles, syphilis, HIV)
• Other medical conditions (e.g., kidney/liver disorders, metabolic disorders, vascular issues, tumors)
• Medications (e.g., antibiotics, chemotherapy, radiation)
• Injuries/surgery, Falls, car accidents (temporary or permanent damage)
• Vitamin deficiencies.

Complications of Peripheral Neuropathy

• Burns/skin injuries
• Falls
• Infections
• Heart and circulatory system problems
• Diabetic foot ulcers
• Gangrene

Guillain-Barré Syndrome (GBS)

• An acute, rapidly progressive, and potentially fatal inflammatory condition.
• Affects the peripheral nervous system.
• Results in loss of myelin (segmental demyelination).
• Manifests as a symmetrical ascending paralysis.

GBS Pathophysiology

• Demyelination occurrence
• Reduced/stopped transmission of nerve impulses
• Muscle denervation/atrophy
• Proximal-to-distal recovery.

GBS Clinical Manifestations

• Symmetrical muscle weakness (ascending pattern)
• Loss of deep tendon reflexes
• Paresthesias (first in the feet)
• Autonomic dysfunction (e.g., blood pressure fluctuations, GI stasis)
• Respiratory problems (as disease progresses)
• Neuropathic pain.

GBS Diagnosing

• History and physical exam.
• CSF analysis (often normal or with low protein initially, elevated protein subsequently)
• Electromyography (EMG)
• Nerve conduction studies.

GBS Assessment & Management

• Supportive care
• Constant monitoring of the respiratory system (acute phase management in a critical care unit)
• Assess for fever and treat ASAP
• Prevention of DVT and PE (prophylactic anticoagulation)
• Assess gag, corneal, and swallowing reflexes
• Assess blood pressure (orthostatic hypotension is common)

GBS Treatments

• Intravenous immunoglobulin (IVIG)
• Plasmapheresis

GBS - Further Considerations

• Emotional support for patient and family.
• Frequent assessment of skin and wounds.
• Assessment for and management of urinary retention.
• Passive range of motion exercises
• Eye care to prevent corneal damage.
• Nutritional support (NG tube or TPN as necessary)

Trigeminal Neuralgia (TN)

• A condition characterized by intense, sudden, electric-shock-like pain in the face.
• Usually one side of the face
• It's an uncommon cranial nerve disorder.

TN Clinical Manifestations

• Intense electrical or stabbing pain in the face.
• Commonly the jaw, lips, gums, cheek, forehead, or side of nose
• Brief attacks (seconds to minutes)
• Unpredictable, but can cluster

TN Diagnosing

• Complete neurologic exam
• MRI to rule out other conditions, especially stroke
• EMG (electromyography: checks nerve and muscle function)

TN Management

• Pharmacological: Carbamazepine (first line), Baclofen.
• Conservative: Biofeedback strategies
• Surgical: Glycerol rhizotomy, Percutaneous radiofrequency rhizotomy, Microvascular decompression.

Bell's Palsy

• Facial nerve disorder (cranial nerve VII).
• One-sided facial muscle weakness.
• Often sudden onset.
• Usually recovers in 3 weeks.

Bell's Palsy Clinical Manifestations

• Unilateral facial paralysis (one side of the face is affected).
• Inability to frown, smile, close eyelid.
• Decreased muscle movement.
• Facial drooping.
• Loss of taste.
• Distorted taste.
• Abnormal tearing
• Pain (neck, mastoid, or ear).

Bell's Palsy Diagnosis

• Based on the clinical presentation, physical and neurological exams.
• Rule out other conditions like strokes with CT/MRI imaging.

Bell's Palsy Management

• Eyes: Protection, lubrication, tape for eyelid closure
• Oral: Soft diet
• Heat: Hot, moist heat therapy to support the affected area
• Medications: Analgesics, corticosteroids to reduce inflammation, antivirals possibly.
• PT/OT: Physical or occupational therapy, facial sling, other support measures as necessary.

Test your knowledge on palliative care barriers, pain management techniques, and assessment components. This quiz covers various aspects including opioid side effects, treatment priorities, and the role of acupuncture. Perfect for those studying palliative care and pain management practices.