Approach to Patient with Pain PDF

Understanding, Assessment, and Management of Pain Walid Abu Arab Professor of Cardiothoracic Surgery University of Alexandria Learning Objectives 1. Describe...

Understanding, Assessment, and Management of Pain Walid Abu Arab Professor of Cardiothoracic Surgery University of Alexandria Learning Objectives 1. Describe the definition of pain. 2. Describe the different types of pain 3. Differentiate between psychogenic and somatic pain 4. Follow a systematic method for evaluating patients with pain 5. How to manage a patient with pain  Understanding, Assessment, and Management of Pain ❑ Introduction: Pain is a complicated sensation influenced by physical, psychological, and social factors. It is not just a symptom but often an indicator of an underlying pathology, making it crucial for clinicians to understand, analyze, and manage effectively. ❑ Definition and Nature of Pain Pain is a complex sensory and emotional experience often associated with actual or potential tissue damage. It is subjective feeling and can vary significantly between individuals based on physiological, psychological, and contextual factors. Tenderness is pain induced by a stimulus, such as pressure from the doctor’s hand or forced movement. It is possible for a patient to be lying still without pain and yet have an area of tenderness. Patients may complain of tenderness if they happen to have pressed their fingers on a painful area or have discovered a tender spot by accident. Thus, tenderness can be both a symptom and a physical sign. ❑ Classification of Pain: 1) Acute Pain: Usually sudden in onset and related to a specific injury or illness. It acts as a protective mechanism and resolves as the underlying cause is treated. 2) Chronic Pain: Persistent pain that lasts beyond the normal healing period (typically 3-6 months). It can be related to ongoing tissue damage or may exist without a clear cause, often resulting in significant psychological and social impact. ❑ Types of Pain: 1) Nociceptive Pain: a- Somatic: Originating from the skin, muscles, or joints. It’s typically well localized, sharp, or aching. b- Visceral: From internal organs. This type of pain is often diffuse, poorly localized, and can be associated with other symptoms like nausea or sweating.  2) Neuropathic Pain: Results from damage to the nervous system. Patients often describe it as burning, tingling, or electric-shock-like. It may be due to conditions like diabetes (diabetic neuropathy) or nerve compression (e.g., sciatica). 3) Psychogenic Pain: Though the pain has no obvious physical cause, psychological factors such as anxiety, depression, or past trauma play a significant role. It does not make the pain any less real to the patient. Beware of patients whose mental attitude to their pain symptoms seems out of proportion – either over responding to them or ignoring them. Munchausen's syndrome is a psychological disorder where someone pretends to be ill or deliberately produces symptoms of illness in themselves. Their main intention is to assume the "sick role" so that people care for them and they are the center of attention. A diagnosis of Munchausen’s syndrome or psychogenic cause should only be made when all possible organic causes for the patient’s symptoms have been excluded. In this situation, your clinical experience is your greatest help. Malingering is an act, not a psychological condition. It involves pretending to have a physical or psychological condition in order to gain a reward or avoid something. For example, people might do it to avoid military service or jury duty. Others might do it to avoid being convicted of a crime. ❑ Pain Analysis and Assessment Pain assessment is essential for understanding the nature, severity, and cause. It's a dynamic process that involves both subjective and objective components. ▪ COMMON ITEMS FOR ANALYSIS OF PAIN: (SOCRATES) S: Site. O: Onset. C: Character. R: Radiation. A: Associations. T: Timing. E: Exacerbating/relieving factors. S: Severity. ❑ Dimensions of Pain: 1) Site: The most valuable indicator of the source of pain is its site. Although patients do not describe the site of their pain in anatomical terms, they can normally point to the site of maximum intensity, which you should convert into an exact anatomical description. It is also worthwhile asking about the depth of the pain. Patients can often tell you whether the pain is near to the skin or deep inside. Splanchnic pain from an internal organ, which is experienced through the autonomic system, is poorly localized to the midline, while Somatic pain from the body’s surface layers is well localized. Physician should ask the following questions: Where exactly is the pain? Does it radiate or stay localized? Radiating pain might suggest nerve involvement, while localized pain may suggest musculoskeletal issues. 2) Onset (Timing), Progress & Offset: Physician should ask about the timing of a pain, include its onset, progress and offset. The onset may be sudden or gradual. Sudden onset is typical of pain associated with an injury or with the blockage or rupture of an artery (as in myocardial infarction or a ruptured abdominal aorta) or the rupture of a viscus (such as a spontaneous pneumothorax or a perforated peptic ulcer). Most patients are be able to describe the precise time of onset in these examples. With a Gradual Onset, the timing may vary greatly. Acute inflammatory lesions may progress during a day or overnight, while claudication from degenerative arterial disease or the pain of an osteo-arthritic knee may build up over many years before the patient realizes that a vague ache is a specific problem and seeks medical advice. ‘Gradual’ in these examples implies a gradual awareness of the pain; it also indicates a gradual increase in the severity of the pain. The progress of the current attack. Pain may gradually increase or decrease or become continuous or persistent. It may also fluctuate. There may be total relief from the pain between bouts.  Enquire carefully about previous bouts of pain or anything similar in the past. Record the patterns of previous attacks, their frequency, how many there have been in all and their duration. Note whether they are changing in character. The offset of pain may be gradual or sudden, and this may be characteristic of the condition. Physician should ask the following questions: When did the pain start? Is it constant or intermittent? Acute, sudden onset pain usually indicates injury or inflammation, whereas chronic pain might point to long-standing issues. 3) Character (Quality/Nature): Different descriptions provide clues to the underlying cause (e.g., burning often suggests nerve involvement). Burning pain or sensations in the skin following contact with intense heat. Throbbing pain from an inflammatory process such as toothache or an abscess. Stabbing pain is sudden, severe, sharp and short-lived e.g. angina pectoris Colicky pain comes and goes like a sine wave e.g. intestinal colic or in labor. Physicians should ask the following questions: What does the pain feel like? Is it stabbing, dull, aching, or burning? 4) Radiation/Referral: Radiation is the extension of the pain to another site while the initial pain persists. For example, patients with a posterior penetrating duodenal ulcer usually have a persistent pain in the epigastrium, but the pain may also spread through to the back. The extended pain usually has the same character as the initial pain. In another words, referred pain is pain that is felt at a distance from its source. For example, inflammation of the diaphragm causes a pain experienced only at the tip of the shoulder. Referred pain is caused by the inability of the central nervous system to distinguish between visceral and somatic sensory impulses. 5) Associated Symptoms: The systemic effects of pain may be primary or secondary. Primary effects are specific events related primarily to the cause of pain. However, these symptoms can be seen as non-  specific effects secondary to the severity of pain originating outside the alimentary tract e.g. vomiting. It is of paramount importance to ascertain any weight loss due to its frequent correlation with malignancy. Attempts should be made to quantify this, either by a change in the patient’s weight on measuring scales or in terms of whether the patient has noticed their clothing getting looser. Physician should ask the following questions: Is there numbness, tingling, swelling, or redness? These clues help differentiate between inflammatory, neuropathic, or ischemic pain. 6) Exacerbating/Relieving Factors: Aggravating/exacerbating factors include eating spicy foods (for peptic ulcers) and fatty foods (with biliary disease), movement such as coughing (for pleuritic pain and pain due to peritonitis) or walking (with lower limb injuries or ischemia), and certain postures such as sitting and standing (with lumbar disc protrusions) and raising the leg (in sacral nerve root compression). Relieving factors include analgesics and specific medications such as antacids for heart burn. Eating may relieve the pain of duodenal ulcers and resting a limb may ease pain caused by an injury. The severe pain of lower limb ischemia may be helped by hanging the leg out of bed. Physician should ask the following questions: What makes it better or worse? Does movement, rest, cold, or heat influence it? 7) Severity/Intensity: How severe is the pain? Use tools such as the Visual Analog Scale (VAS) or Numeric Rating Scale (NRS), where the patient rates pain on a scale of 0 (no pain) to 10 (worst imaginable pain). The quantity of pain is generally related to the severity of the underlying disease. However, individuals vary extensively in their pain tolerance, and this is further influenced by anxiety and a fear of the possible implications of the pain. Sometimes there may be a desire to impress the doctor over the extent of the problem or conversely to play down the symptoms for some personal reason. A useful indicator is the influence of the pain on the patient’s lifestyle.  A rough quantitative measure can be obtained using a pain scale of 0 to 10. The patient is asked to grade their pain on this scale, with 0 being no pain at all and 10 being the worst possible pain imaginable. Although this is still very subjective and dependent on the individual’s response, it can be of value. ❑ Review: What to Ask the Patient? The key to good pain management is understanding the patient's experience thoroughly. A thoughtful and detailed history can provide invaluable insights. "Can you describe your pain in your own words?" This allows patients to communicate in a way that feels natural, helping you capture nuances. "When did the pain begin?" This helps differentiate between acute and chronic conditions. "Does the pain stay in one area or does it travel?" Radiation of pain can give insights into nerve involvement or referred pain from internal organs. "What aggravates or alleviates the pain?" Factors such as movement, position, or medications that affect the pain provide clues about the underlying cause. "Does the pain affect your daily activities or sleep?" Understanding the functional impact gives insight into how pain interferes with quality of life. "Have you had similar pain in the past?" Previous pain experiences and treatments can help guide current management. ❑ Interpretation of Pain: Understanding pain requires both clinical reasoning and careful listening. Here’s how to interpret pain reports: Localized pain with tenderness often suggests musculoskeletal injury, such as a sprain or strain. Burning or shooting pain indicates neuropathic origins, which could stem from nerve compression or systemic issues like diabetes. Pain that worsens with movement is typically related to musculoskeletal causes. Pain unaffected by position might hint at a more systemic issue like visceral pain. Pain accompanied by systemic symptoms (fever, weight loss) could indicate infection or malignancy. ❑ Pain Management: Effective pain management should be multifaceted, targeting both the source of pain and the experience itself. ▪ Non-Pharmacological Interventions o Physical Therapy: Helpful for musculoskeletal pain. Exercises, manual therapy, and modalities like heat or cold can reduce pain and improve function. o Psychological Interventions: Techniques like cognitive-behavioral therapy (CBT) or mindfulness can help patients cope, particularly for chronic pain where emotional distress is high. o Lifestyle Modifications: Addressing factors like sleep, posture, and activity levels can contribute significantly to pain relief. o Complementary Therapies: Acupuncture, massage, and relaxation techniques are increasingly recognized for their role in pain management. ▪ Pharmacological Interventions: o Non-Opioid Analgesics: Paracetamol and NSAIDs (e.g., ibuprofen) are first-line for mild to moderate pain, particularly nociceptive in origin. o Opioids: Used for more severe pain (e.g., post-surgical, cancer-related), but with caution due to the risk of dependence, tolerance, and side effects. o Neuropathic Pain Medications: Drugs like gabapentin, pregabalin, or certain antidepressants (e.g., amitriptyline) can be effective for nerve-related pain. o Topical Analgesics: These can be useful for localized pain, especially in musculoskeletal or neuropathic conditions. o Invasive Procedures: In certain cases, nerve blocks, epidural injections, or surgical interventions may be necessary.