Glossary of Clinical Correlation: Pain
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- What type of nerve is most important in pain generation?
- bare nerve endings
- What are the classifications of pain?
- anatomic, etiologic, qualitative, and temporal (acute or chronic)
- What is chronic pain?
- pain that persists longer than it is supposed to or is recurrent; often without precisely defined etiology, time course, or treatment processes
- What are the two clinically relevant types of pain?
- acute and chronic
- What are the two types of chronic pain classification?
- nociceptive and neuropathic (pain can be a mixture of the two)
- What is nociceptive pain?
- pain due to ongoing tissue damage/inflammation
- What is neuropathic pain?
- pain due to a nervous system injury, in past or ongoing
- What pharmocology does nociceptive pain respond to?
- traditional analgesics like narcotics and anti-inflammatories
- What type of pharmacology does neuropathic pain respond to?
- "adjuvant" analgesics such as anti-depressants, anti-convulsants
- What type of fibers carry pain information to CNS?
- C fibers and poorly myelinated A-delta fibers
- T/F: In degenerative joint disease, radiographs that show the joint distruction do not correlate with the amount of pain
- What are the 4 signs/symptoms of tissue damage/inflammation?
- What type of pain signal does the inflammatory process generate?
- What are the effects of inflammation/tissue damage?
- nociceptive pain
inc. heart rate
improper stress response (inc. cortisol and other stress hormones)
autonomic effects (sweating)
psychological effects (aversion and distress)
- Is neuropathic pain immediate or delayed?
- can be either
- What type of pain results when a nerve is cut during surgery?
- What are the effects of neuropathic pain?
- may have inc. catecholamines
may have dec. cortisol
unreliable respiratory effects
unpredictable autonomic effects
reliable psychological effects
- What are the cardinal signs/symptoms of neuropathic pain?
- Allodynia and Hyperalgesia
- What is allodynia?
- pain from stimuli that are not normally painful
- What is hyperalgesia?
- an exaggerated response to a normally painful stimulus
- What are some possible clinical manifestations of neuropathic pain?
-signs of neural dysfxn
- What are the types of neuropathic pain?
- 1. compressive
4. Central injury
5. SNS related
- What is compressive pain? Is pain immediate or delayed?
- active compression on a neural structure; immediate source of pain
- What is inflammatory pain?
- neuritis can occur when nerves themselves are attacked
- What is deafferentation pain?
- part of signal is removed, such as with phantom limb pain (i.e. following amputation of a limb)
- What causes central injury pain?
- a stroke or spinal cord injury
- What is SNS related pain?
- complex regional pain syndrome; shows up in certain parts of the body every time the SNS fires
- T/F: Most neuropathic pain is constant
- F: most neuropathic pain is episodic
- What are some possible reasons for neuropathic pain?
- diabetes, heavy metal exposure, alcohol, vitamin deficiencies, trauma/structural lesions
- What do you look at in neurologic examination?
- -pain in peripheral nerve distribution
- What are six diagnostic tools to use in a neurologic exam?
-Nerve conduction velocities
-Quantitative sensory testing
-epidermal skin biopsy
- What are the limitations of EMG/NCV as diagnostic for neuropathic pain?
- -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)
- What are the ABC's of nerve damage?
- Angry Backfiring C-fibers are diseased and causing the pain
- How do you treat acute pain?
- -assume nociceptive
-treat injury (i.e. broken leg)
- What is the pharmacology for nociceptive pain?
- -traditional analgesics
- How do you treat chronic pain?
- Start with least invasive (which might not be most efficacious)
psychological physical approaches --> topical meds --> oral meds --> injections --> interventional techniques
- What are opiates?
- derived from opium related natural compounds
- What are the routes of administration of opioids?
- What are the opiod sites of action?
-spinal (via neuraxial rte)
- What is the benefit of central delivery of opiods?
- same efficacy with less side effects (on bowels, bladder, less nausea)
- What are important considerations for opiod dosing in chronic pain pts?
- -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)
- Types of anti-inflammatories?
non-specific cyclooxygenase inhibitors
- Benefits of anti-inflammatories?
- less likely to be addictive
oral, parenteral, and injection routes
- Limitations of anti-inflammatories?
- not as efficacious as narcotics
- What are some adjuvant analgesics used in neuropathic pain?
- antidepressants, anticonvulsants, anti-arrhythmics, antispastics, alpha-adrenergic agents, topicals
*most were discovered by chance
- Neuropathic pain treatments?
-counter-stimulus therapy (i.e. TENS)
-psychological and physical therapy
-spinal cord stimulation
- Limitations of using traditional analgesics for neuropathic pain?
- rapid development of tolerance
not as efficacious for long term pain
- Limitations for using antidepressants for neuropathic pain?
- not all are effective for pain (classic such as amitryptyline more effective than newer like prozac)
- Limitations for using anti-spastic agents?
- side effects (BP, dizziness/balance)
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