Добавил:
Sekretar
kiopkiopkiop18@yandex.ru
t.me/Prokururor I Вовсе не секретарь, но почту проверяю
Опубликованный материал нарушает ваши авторские права? Сообщите нам.
Вуз:
Предмет:
Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_2590_Библиотеки_им_академика_М_И_Перельмана
.pdf
https://t.me/med1917
C H A P T E R
https://t.me/med1917
PAIN MANAGEMENT GUIDELINES
Kathleen Siders
ACUTE PAIN
DEFINITION
A. The American Academy of Pain Medicine denes acute
pain as the “physiologic response and experience to noxious
stimuli that can become pathologic, is normally sudden in
onset, time limited, and motivates behaviors to avoid actual
or potential tissue injuries.” Acute pain can last up to 7 days
but, depending on its etiology, may last up to 30 days, which
can assist in differentiating acute pain from subacute and
chronic pain. Pain can be categorized as somatic (involving
skin, muscles, or joints), visceral, or neuropathic (involving
the nervous system).
INCIDENCE
A. Acute pain is the most common reason for self- medication
and presentation for treatment in the healthcare system. Acute
pain is very individual, and if not treated properly can have
devastating physiologic and psychologic effects. Because pain
is very subjective, the client care plan needs to be individualized to meet the client’s needs. Proper management of acute
pain could prevent transition to chronic pain.
PATHOGENESIS
A. Acute pain is usually the result of stimulation of the sympa-
thetic nervous system. Noxious stimuli activate the nociceptors
(pain-producing sensors) to the thalamus and into the somatosensory cortex. Serotonin, norepinephrine, and neuropeptides
are neurotransmitters utilized in pain transmission.
PREDISPOSING FACTORS
A. Recent trauma/injury.
B. Recent surgery.
C. Stress.
D. Illness.
E. Compromised immune system.
F. Chronic conditions that affect immune system (diabetes, etc.).
G. Age (children/elderly).
COMMON COMPLAINTS
A. Pain at a specic site.
B. Increased heart rate.
C. Increased respiratory rate.
D. Elevated blood pressure (BP).
E. Sweating.
F. Nausea.
OTHER SIGNS AND SYMPTOMS
A. Urinary retention.
B. Pallor.
SUBJECTIVE DATA
A. Onset: Determine cause or mechanism of injury or etiol-
ogy of pain.
B. Location/distribution/radiation of pain.
C. Duration and pattern/timing.
D. Characteristic of pain:quality.
E. Precipitating/aggravating factors.
F. Alleviating factors.
G. Severity by utilizing a pain scale (0–10, with 0 indicating
no pain and 10 being the worst pain imaginable) and by noting the effects of pain on activities of daily living.
H. Associated symptoms related to pain.
Adaptations need to be made when assessing special populations who
are not able to express pain adequately. These include the very young,
cognitively impaired, and potentially the elderly. There are other scales
and tools available to evaluate pain in these populations.
PHYSICAL EXAMINATION
A. In clients presenting with acute pain, the physical exami-
nation is based on the location and etiology of pain. A general guide can be altered based on the type/location/cause of
pain.
1. Check temperature, pulse, respiration, and BP.
2. Inspect:
a. Observe overall appearance.
b. Note affect and ability to express self and pain.
c. Note facial grimaces with movement.
d. Note gait, stance, and movements.
e. Inspect area at pain site.
3. Auscultate:
a. Auscultate heart and lungs.
b. Auscultate neck and abdomen.
4. Palpate:
a. Palpate affected area of pain.
When performing a musculoskeletal examination, identify the location of
pain, presence of trigger points, evidence of injury or trauma, edema, erythema, warmth, lesions, petechiae, tenderness, decreased range of motion,
pain with movement, crepitus, laxity of ligaments, spasms, or guarding.
5. Percuss (if applicable):
a. Percuss chest.
b. Percuss abdomen.
6. Perform abdominal examination (if applicable).
7. Perform musculoskeletal examination:
a. Perform a complete musculoskeletal examination,
concentrating on the area of pain.
b. Assess deep tendon reexes (DTRs).
The contributions of Moya Cook and Kala Christopherson to this chapter in prior editions are acknowledged here.
60
https://t.me/med1917
3: PAIN MANAGEMENT GUIDELINES
8. Perform neurologic examination:
a. Perform a complete neurologic examination.
b. Identify changes in gait, sensory function, skin ten-
derness, weakness, muscle atrophy, and/or loss of DTRs.
DIAGNOSTIC TESTS
A. No diagnostic testing is required unless clearly indicated
to rule out anorganic cause of pain. If organic disease is suspected, diagnostic testing may include:
1. CT imaging.
2. MRI.
3. Blood chemistries.
4. Radiographic x-ray.
5. Lumbar puncture.
6. Ultrasound.
7. EKG/echocardiogram.
DIFFERENTIAL DIAGNOSES
A. The common differential diagnoses are organized by loca-
tion of the acute pain.
1. Head:
a. Migraine.
b. Cluster headache/migraine headache.
c. Temporal arteritis.
d. Intracranial bleeding or stroke.
e. Sinusitis.
f. Dental abscess.
2. Neck:
a. Meningitis.
b. Muscle strain/sprain.
c. Whiplash injury.
d. Thyroiditis.
3. Chest:
a. Pulmonary emboli.
b. Myocardial infarction.
c. Pneumonia.
d. Costochondritis.
e. Angina.
f. Gastroesophageal reux disease/esophagitis.
4. Abdomen:
a. Peritonitis.
b. Appendicitis.
c. Ectopic pregnancy/uterine pregnancy.
d. Endometriosis.
e. Pelvic inammatory disease.
f. Peptic ulcer.
g. Cholelithiasis.
h. Colitis/diverticulitis.
i. Constipation.
j. Gastroenteritis.
k. Irritable bowel syndrome.
l. Urinary tract infection, kidney stone, pyelonephritis.
m. Prostatitis.
n. Malignancies.
5. Musculoskeletal:
a. Muscle sprain/strain/tear.
b. Tendonitis.
c. Skeletal fracture.
d. Viral infection.
e. Gout.
f. Vitamin D deciency.
PLAN
A. General interventions:
1. Acute pain is a symptom, not a diagnosis.
2. Analgesic treatment should be provided as soon as
possible and not be delayed by diagnostics.
3. Identify the cause or source of the acute pain depend-
ing on the location. If the pain is organic in nature, make
the appropriate referral.
4. The overall goal is to treat the acute pain appropriately.
B. Client teaching:
1. The pain management plan must include client and
family education regarding preventing and controlling
pain, potential medication side effects, and preventing
side effects.
2. Nonsteroidal anti-inammatory drugs (NSAIDs) are
often equally or more effective than opioids in pain management of some acute pain etiologies.
3. The newest (2016) recommendation from the Centers
for Disease Control and Prevention (CDC) is the lowest possible dose of narcotics for pain no longer than 3 to
5 days before reevaluation.
4. Opioid addiction education should be discussed.
Explain that therisk of addiction is low when medication
is used as directed for a short duration. Explain that complete pain relief may not be achievable initially, but the
overall goal is to decrease the pain, thus allowing some
daily activities at home to begin recovery.
C. Pharmaceutical therapy:
1. Non-low back musculoskeletal injuries: First-line treat-
ment of choice is topical NSAIDs with or without menthol gel. Oral NSAIDs or acetaminophen may also be used.
Opioids are not recommended except for severe injuries
and intolerance of rst-line therapy. Specic acupressure
or transcutaneous electrical nerve stimulation may be
used to reduce pain.
2. Acute low back pain: Educate the client, advise about
returning to normal activity andavoiding bedrest, and recommend use of NSAIDs.
3. Visceral pain: Treat the cause.
4. Neuropathic pain: Tricyclic antidepressants (TCAs) are
the rst-line treatment for neuropathic pain. Gabapentin
can be effective and is the rst oral treatment approved
by the Food and Drug Administration (FDA) for postherpetic neuralgia (PHN). Pregabalin is approved by the FDA
for neuropathic pain from diabetic peripheral neuropathy,
PHN, bromyalgia, and neuropathic pain associated with
spinal cord injury. Other treatments include local anesthetics and glucocorticoids.
D. Nonpharmaceutical treatment:
1. Nonpharmacologic treatment can be used in conjunc-
tion with analgesics during acute pain. Treatment should
be chosen based on etiology and severity.
a. Application of heat or ice.
b. Immobilization or exercise, which can include phys-
ical therapy treatment.
c. Massage, compression, spinal manipulation, tactile
stimulation, transcutaneous electrical nerve stimulation, acupressure, or acupuncture.
Know each medication’s mechanism of action, potential adverse side
effects, half-life, and drug–drug interaction potential. Always document that you have advised on the potential for sedation, suggested
no driving/ machinery use, and indicated no alcohol should be consumed while taking medication with these potential adverse side
effects. The FDA advises extreme caution when using NSAIDs in clients with cardiovascular disease due to the increased risk of heart
attack and stroke.
CHRONIC PAIN
https://t.me/med1917
61
FOLLOW-UP
A. Once an organic cause of pain has been ruled out, initial
follow-up is 48 to 72 hours after onset.
B. Ensure that the client has consistent access to care.
CONSULTATION/REFERRAL
A. If the acute pain is organic, make the appropriate referral
to a specialist.
INDIVIDUAL CONSIDERATIONS
A. Geriatrics:
1. Physiologic changes that occur in older adults, such as
decreased body mass, hepatic dysfunction, and renal dysfunction, may cause increased serum drug concentrations
of pain medication. Use caution when prescribing pain
medication to this population.
2. Anti-inammatories are not recommended for older
adults as a general rule due to the effects of the medication
on the kidneys and cardiovascular system.
BIBLIOGRAPHY
American Academy of Family Physicians. (2020). Family medicine
updates. Annals of Family Medicine, 18(6), 565–566. https://doi.org/
10.1370/afm.2618
Centers for Disease Control and Prevention. (2016a, March 15). CDC
guidelines for prescribing opioids for chronic pain—United States, 2016.
Morbidity and Mortality Weekly Reports. https://www.cdc.gov/mmwr/
volumes/65/rr/rr6501e1.htm
Centers for Disease Control and Prevention. (2016b, March 22). Checklist
for prescribing opioids for chronic pain. https://www.cdc.gov/drugover
dose/pdf/PDO_Checklist-a.pdf
Kent, M. L., Tighe, P. J., Belfer, I., Brennan, T., Bruehl, S., Brummett, C.,
Buckenmaier, III., C, C., Buvanendran, A., Cohen, R. I., Desjardins,
P., Edwards, D., Fillingim, R., Gewandter, J., Gordon, D. P., Hurley,
R. W., Kehlet, H., Loeser, J. D., Mackey, S. … Terman, G. (2017). The
ACTION-APS-AAPM Pain Taxonomy (AAAPT) multidimensional
approach to classifying acute pain conditions. Journal of Pain, 18(5),
479–489. https://doi.org/10.1016/j.jpain.2017.02.421
Oliveira, C. B., Maher, C. G., Pinto, R. Z., Traeger, A. C., Lin, C.-W. C.,
Chenot, J.-F., Tuld, er M., & Koes, B. W. (2019). Clinical practice guidelines for the management of non-specic low back pain in primary
care: An updated overview. European Spine Journal, 27, 2791–2803.
https://doi.org/10.1007/s00586-018-5673-2
Tighe, P., 3rd, Buckenmaier., C, C., Boezaart, A. P., Carr, D. B., Clark, L.
L., Herring, A. A., Kent, M., Mackey, S., Mariano, E. R., Polomano, R.
C., & Reiseld, G. (2015). Acute pain medicine in the United States: A
status report. Pain Medicine [APM Shared Interest Group of the American
Academy of Pain Medicine], 16(9), 1806–1826. https://doi.org/10.1111/
pme.12760
CHRONIC PAIN
DEFINITION
A. The International Association for the Study of Pain denes
pain as “[a]n unpleasant sensory and emotional experience
associated with, or resembling that associated with, actual or
potential tissue damage.” The group goes on to add six key
statements for context:
1. “Pain is always a personal experience that is inuenced
to varying degrees by biological, psychological, and social
factors.
2. Pain and nociception are different phenomena. Pain
cannot be inferred solely from activity on sensory neurons.
3. Through their life experiences, individuals learn the
concept of pain.
4. A person’s report of an experience as pain should be
respected.
5. Although pain usually serves an adoptive role, it may
have adverse effects on function and social and psychological well-being.
6. Verbal description is only one of several behaviors to
express pain; inability to communicate does not negate the
possibility that a human or a nonhuman animal experiences pain.”
B. The World Health Organization and the International
Association for the Study of Pain dene chronic pain as
“persistent or recurrent pain lasting longer than 3 months.”
Chronic pain may be continuous or recurrent and of sufcient
duration and intensity to interfere with a person’s ability to
function with normal daily activities, as well as decrease a
person’s quality of life.
C. The Centers for Disease Control and Prevention (CDC) dis-
tinguishes high-impact chronic pain as that which “frequently
limits life or work activities.” Approximately 4.8% of the
adult population in the United States experience high-impact
chronic pain.
INCIDENCE
A. Pain syndromes are commonly seen in clinical practice.
Chronic pain costs the American people about $635 billion
yearly in healthcare expenses, disability costs, and lost productivity. The CDC estimates 20.4% of U.S. adults (50.0 million) experience chronic pain and 8.0% of U.S. adults (19.6
million) experience high-impact chronic pain. The prevalence
increases with advancing age. As the U.S. population continues to age, primary care providers will care for increasing
numbers of clients with chronic diseases, including chronic
pain. Pain prevalence is higher in females than in males. Onset
can begin at any age, but usually occurs in the fourth, fth, or
sixth decades and is often associated with marked functional
disability.
PATHOGENESIS
A. Skeletal muscle pain occurs in the soft tissue involving
the neck, shoulders, trunk, arms, low back, hips, and lower
extremities. Myofascial pain syndrome relates to the fascia sur-
rounding the muscle tissue.
B. Inammatory pain arises from complex relationships
between the immune system and injured tissue, leading to the
stimulation of pain receptors (nociceptors). Multiple chemical
mediators are involved in the expression of pain. Examples
include arthritis, infection, tissue injury, skeletal muscle pain,
and postoperative pain.
C. Neuropathic pain is caused by a lesion or disease of the
central or peripheral somatosensory system. The most common types include diabetic neuropathy, sciatica from nerve
root compression, trigeminal neuralgia, and postherpetic
neuralgia.
D. The nociceptive system involves neurons that detect nox-
ious stimuli, including mechanical, thermal, and chemical.
Nociceptors are found in all tissues, except the central nervous
system, and generally produce pain sensation proportionate to the injury. Somatic pain is generally described as dull
and aching, whereas visceral pain is additionally described as
pressure-like and vague. They both respond well to opioids,
with the exception of arthritis.
PREDISPOSING FACTORS
A. Older age overall, but younger age for postsurgical chronic
pain.
B. Female sex.
62
https://t.me/med1917
3: PAIN MANAGEMENT GUIDELINES
C. History of seeking multiple healthcare providers for the pur-
pose of obtaining multiple prescriptions for pain management.
D. Occupational exposures.
E. Depression and anxiety.
F. Behavior health disorders, including moods, fears, expec-
tations, and dysfunctional coping efforts.
G. History of traumatic adverse childhood experiences.
H. Pre- and postsurgery.
I. Job dissatisfaction and low work status.
J. Effects of a developing chronic disease.
K. Smoking.
L. Body mass index >30.
M. Genetics.
N. Passive coping strategies (rest and taking medications).
O. Lack of social support.
COMMON COMPLAINTS
A. Specic to site of pain.
B. Emotional distress related to fear, maladaptive or inade-
quate support systems, and other coping resources.
C. Treatment-induced complications.
D. Overuse of drugs.
E. Inability to work.
F. Financial complications.
G. Disruption of usual activities.
H. Sleep disturbances.
I. Pain becomes primary life focus.
OTHER SIGNS AND SYMPTOMS
A. Pain lasts longer than 3 months.
B. There may be anger and loss of faith or trust in the health-
care system. This type of client frequently takes too many
medications, spends a great deal of time in bed, sees many
physicians, and experiences little joy in either work or play.
SUBJECTIVE DATA
A. Elicit a clear description of the onset, location, quality,
intensity, and time course of pain, and any aggravating or
relieving factors.
1. Use the acronym OLD CARTS-U: O = onset, L = loca-
tion, D = duration, C = characteristics, A = aggravating
triggers, R = relieving triggers, T = timing, S = severity,
U = YOU. What do YOU think is going on? What have
YOU done to relieve it?
2. Or use the acronym PQRST: P = provokes, palliate;
Q = quality, quantity; R = radiation; S = severity; T = timing, temporal.
3. For clients on opioid analgesics, askabout:
a. Analgesia: effectiveness of medications.
b. Activity: can they do more?
c. Adverse reactions: constipation and other side
effects.
d. Aberrant behaviors: other drug use including ethyl
alcohol and self-escalating doses.
e. Affect: changes in mood?
B. Self-reporting pain assessment tools should be used early in
the process of client evaluation. Use the tool at each ofce visit
to see progression or regression. Lack of pain assessment is
a barrier to good pain control. Consider the age of the client;
their physical, emotional, and cognitive status; and theirpreference when choosing the self-reporting pain assessment tool.
1. The Numeric Rating Scale (NRS) rates pain inten-
sity from 0 to 10. The scale is client-friendly and quick to
complete.
2. The Verbal Rating Scale rates pain as mild (1–3 NRS),
moderate (4–6 NRS), or severe (7–10 NRS).
3. The Faces Scale is useful for pediatric and cognitively
impaired clients. Multicultural translations may be downloaded at www.wongbakerfaces.org.
C. Determine the extent to which the client is suffering, dis-
abled, and unable to enjoy usual activity. Inquire about activities of daily living and level of function.
D. Obtain a complete review of systems, including nausea,
numbness, weakness, insomnia, loss of appetite, dysphoria,
malaise, fatigue, or depression signs and symptoms.
E. Obtain a complete family and social history. Address spiri-
tual and cultural issues. History of chemical dependency is of
interest in this client population.
F. Inquire about childhood trauma or abuse, including sex-
ual abuse. Have a ready referral system established for use
with traumatized individuals.
G. Obtain the client’s medical history relevant to the pain,
including diagnosis, testing, treatments, and outcomes.
H. Obtain pain history to identify the client’s attitudes, beliefs,
level of knowledge, and previous experiences with pain. Are
previously used methods for pain control helpful? What is the
client’s attitude toward the use of certain pain medications?
Often, the client discusses certain adverse side effects or allergies from undesired pain medication.
PHYSICAL EXAMINATION
A. Check temperature, pulse, respirations, and blood pressure.
B. Inspect:
1. Observe overall appearance.
2. Note affect and ability to express self and pain.
3. Note facial grimaces with movement.
4. Note gait, stance, and movements.
5. Inspect area at pain site.
C. Auscultate:
1. Heart and lungs.
2. Neck and abdomen.
D. Palpate:
1. Affected area of pain.
E. Percuss:
1. Chest.
2. Abdomen.
F. Perform musculoskeletal examination:
1. Perform a complete musculoskeletal examination, con-
centrating on the area of pain.
2. Note limitations in range of motion.
When performing the musculoskeletal examination, identify the location of pain, presence of trigger points, evidence of injury or trauma,
edema, erythema, warmth, heat, lesions, petechiae, tenderness,
decreased range of motion, pain with movement, crepitus, laxity of ligaments, spasms, or guarding.
G. Perform neurologic examination:
1. Perform a complete neurologic examination.
2. Note the client’s affect and mood. Is the client coopera-
tive during examination?
3. Identify abnormal sensory function such as allodynia
(painful sensation to nonnoxious stimuli), hyperpathia (pain
sensation that lingers after nonnoxious stimuli are extinguished), and dermatomal areas of numbness or tingling.
4. Measure muscle strength, noting any weakness and/or
muscle atrophy.
CHRONIC PAIN
https://t.me/med1917
63
5. Grade deep tendon reexes and presence of clonus or
other signs of spasticity.
H. Perform functional assessment:
1. A baseline functional assessment provides objective
measurable data on a client’s physical abilities and limitations. This assessment can be useful in evaluating the validity and reliability of the client’s efforts and complaints.
2. The information may be used to identify areas of
impairment, establish specic functional goals, and measure the effectiveness of treatment interventions.
3. These objective data may be used in worker compensa-
tion cases, returning-to-work status, federal disability, and
motor vehicle accident lawsuits.
4. Know the resources in your area prepared to perform
functional assessments.
DIAGNOSTIC TESTS
A. None required unless clearly indicated to establish an
organic cause of pain.
1. Remember that pain previously diagnosed as chronic
pain syndrome can be organic and vice versa. Organic
causes must always be evaluated and excluded.
2. Plain radiography should be ordered rst for muscle,
inammatory, or skeletal pain. Plain radiography will
diagnose a fracture or calcic tendonitis. Additional studies may be recommended by the radiologist if a lesion/
abnormality is seen on plain radiography.
3. MRI and CT are ordered if the plain radiograph is neg-
ative and the client continues to complain of pain.
4. Electromyography and nerve conduction studies are
used to evaluate neuropathic pain generators. Numerous
serum and urine studies should also be considered if the
neuropathic pain is undiagnosed.
B. Screen for depression: Consider using the Beck Depression
Inventory or Patient Health Questionnaire 9. These tools can
be administered at subsequent appointments to follow the client’s symptoms.
DIFFERENTIAL DIAGNOSES
A. Pain disorder.
B. Pain related to a disease with no cure/malignancy.
C. Somatic symptom disorder.
D. Conversion disorder.
E. Depressive disorder.
F. Chemical dependency.
PLAN
A. General interventions:
1. Treatment is multidimensional and should not focus
on pharmacologic treatment alone.
2. Offer hope and potential for improvement of pain con-
trol, but not a cure.
3. Identify realistic functional physical goals for the cli-
ent and reassess at each visit. The client discussion needs
to include the idea that the goal may be decreasing pain
intensity, not eliminating pain.
4. The pain is real to the client, and acceptance of the
problem must occur before a mutually agreed-on treatment plan can be initiated.
5. Depression and anxiety are common emotional distur-
bances in clients with chronic pain and are treatable.
6. Identify specic and realistic functional goals for ther-
apy, such as having a good night’s sleep, going shopping,
yard work, cooking, or returning to work.
7. Carefully assess the level of pain using available tools,
such as a daily pain diary or other pain assessment scales.
8. Avoid pain reinforcement such as sympathy and atten-
tion to pain. Provide a positive response to productive
activities. Improving activity tolerance assists in desensitizing the client to pain.
9. Shift the focus from the pain to accomplishing daily
assigned self-help tasks. The accomplishment of these
tasks functions as positive reinforcement.
B. Client teaching: See Client Teaching Guide for this chapter,
“Chronic Pain.”
C. Pharmaceutical therapy:
1. Skeletal muscle pain: Treatment should focus on physi-
cal rehabilitation and behavioral management. Tricyclic
antidepressants (TCAs) and muscle relaxants may be used.
Research is lacking regarding the effectiveness of opioids.
All muscle relaxers are on the Beers list and should be
carefully prescribed in the elderly population. In children
and adults, some muscle relaxers can cause a dangerous
withdrawal syndrome if suddenly discontinued.
2. Inammatory pain: Nonsteroidal anti-inammatory
drugs (NSAIDs) and corticosteroids are rst-line pharmaceutical interventions. Topical creams and solutions have
been used in treating arthritis and other somatic sources of
pain.
3. Mechanical/compressive pain: Opioids may be used to
manage these symptoms while other measures are being
taken.
4. Neuropathic pain:
a. Gabapentin (Neurontin) and pregabalin (Lyrica) have
become rst-choice treatments in recent years for diabetic neuropathy, bromyalgia, neuropathic pain associated with spinal cord injury, and postherpetic neuralgia.
b. TCAs are extremely useful. Clients who are not
depressed obtain excellent pain relief with TCAs such
as amitriptyline and doxepin.
c. Selective serotonin reuptake inhibitors (SSRIs) are
also effective for chronic pain control. Duloxetine
(Cymbalta) has been approved for chronic pain as
monotherapy or in conjunction with TCAs.
d. Anticonvulsants are useful in controlling some neu-
ropathic pain: carbamazepine (Tegretol), phenytoin
(Dilantin), and valproic acid (Depakene). Clients need
to be monitored monthly for hepatic dysfunction and
hematopoietic suppression.
e. Topical agents: Capsaicin applied three to four times
per day can reduce pain without signicant systemic
effects. Topical lidocaine 5% patches are approved for
postherpetic neuralgia and are used off-label for other
topical pain.
f. Carbamazepine is used as rst-line treatment for tri-
geminal neuralgia.
g. Opioids: Tramadol is considered a good choice if an
opioid is indicated. In addition to pain control, tramadol
causes serotonin reuptake inhibition similar to that seen
with the TCAs. Peak plasma levels occur approximately
1.5 hours after ingestion and elimination; the half-life
of tramadol is approximately 5 to 6 hours. Risk for seizures and serotonin syndrome increases even at recommended doses with coadministration of other SSRIs,
alcohol, TCAs, and antipsychotics. Know the Drug
Enforcement Administration’s and the state’s rules and
regulations within the prescription drug monitoring program (PDMP) database systems for opioid prescribing.
64
https://t.me/med1917
3: PAIN MANAGEMENT GUIDELINES
5. All therapies need a 2- to 3-week trial period to ade-
quately evaluate therapy. Evaluation of some medications
takes longer.
6. NSAIDs should be used for are-ups of mild to moder-
ate inammatory or nonneuropathic pain.
7. Opioids require careful client selection, titration, and
monitoring. Explain to the client starting on an opioid
that this will be a trial to see if the opioid is effective. The
goal is to improve function and quality of life more than to
reduce the pain scale. Have an exit plan when starting an
opioid if the opioid is ineffective or is not well-tolerated.
Avoid long-term, daily treatment with short-acting opioids (Vicodin, Norco, and Percocet). For as-needed use,
prescribe small quantities.
8. Benzodiazepines and barbiturates are not advised for
treatment of chronic pain due to the high risk of substance
abuse.
9. Mitigate risks when considering opioids.
a. Check your state’s PDMPs before prescribing con-
trolled substances. PDMPs are state-run electronic
databases that track dispensing of controlled substances. PDMPs provide clinicians with critical information about client narcotic prescription history and
identify drug-seeking behavior patterns. For more
details regarding PDMPs and your state’s information,
visit www.cdc.gov/drugoverdose/pdmp/states.html.
b. Contact the client’s pharmacy for a list of current
medications. Currently, the PDMP access time is less
than 5 minutes real time, and all active client prescriptions are available from the pharmacy.
c. Perform urine drug tests before prescribing con-
trolled substances initially, as needed, and annually.
National guidelines recommend the enzyme immunoassay and gas chromatography/mass spectroscopy
urine drug test. Depending on the results of urine drug
test, the provider may seek additional consultation,
change medication therapy, refer for substance abuse,
or discharge the client.
d. A written controlled substance treatment agree-
ment among the client, provider, and clinic is recommended. Include the expectations of the client. No
other controlled substances will be prescribed by any
other provider. Only one pharmacy should be used.
Medications must be taken as prescribed. Prescriptions
of controlled substances will not be lled early. The client must agree to random drug tests and may be called
to report to the clinic for random drug screening and/
or pill counts. Both analgesic goals and functional
goals should be dened and realistic expectations
established. Potential risks including common opioid
side effects, abuse/addiction risks, respiratory depression, overdose, sleep disordered breathing, and death
should be discussed with the client. The client should
be informed of alternative treatment plans that do not
include opioids. All of these risks should be addressed
in follow-up appointments as well.
e. Utilize tools such as the Screener and Opioid
Assessment for Patients with Pain and/or the Opioid
Risk Tool (ORT).
f. Red ags for misuse, abuse, addiction, and diver-
sion with opioids include:
i. Psychiatric illness.
ii. Personal history of alcohol or drug abuse.
iii. Family history of alcohol or drug abuse.
iv. Younger age.
v. Male sex.
vi. Preadolescent.
vii. Psychiatric comorbidities.
viii. Psychotropic medication use.
D. Alternative interventions:
1. Psychological interventions: Cognitive behavioral ther-
apy is most commonly used and is an effective method of
treatment to reduce pain and improve function. Examples
include problem-solving, guided imagery, controlled
breathing exercises, attention diversion, meditation, and
yoga exercises; progressive muscle relaxation (PMR) to
help relax major muscle groups; acceptance commitment
therapy; biofeedback; and mindfulness.
2. Exercise: Examples of exercises include yoga exer-
cises and PMR. Research indicates that yoga reduces a
large degree of bothersome pain after 12 weeks of regular
exercise. The benets of yoga exercise include improved
strength, balance, coordination, range of motion, and
reduced anxiety. Yoga instruction by a qualied teacher is a
low-cost intervention. Yoga is an effective form of self-care
and is an affordable way to alleviate pain. Always advise
clients to start slowly and be prepared for an approach to
pain management that may take several weeks of therapy.
3. Alternative therapies: Randomized controlled tri-
als showed signicant reduction in pain with alternative
interventions such as music, relaxation, distraction, acupuncture, myofascial release treatments, and massage use.
4. Occupational therapy.
5. Vocational therapy.
6. Physical therapy, such as noninvasive techniques,
transcutaneous electrical nerve stimulation, hot or cold
therapy, hydrotherapy, traction, massage, bracing, and
exercise.
7. Individual and family therapy or counseling.
8. Aesthetic or neurosurgical procedures.
9. Clients may inquire about the use of herbal products to
treat chronic pain. Advise clients that these products are not
regulated by the Food and Drug Administration. Advise
them that these herbal products may interact with current medications and cause complications. Advise them to
research all herbal products on reputable medically based
websites, not blogs or chat rooms. Caution clients regarding devil’s claw, feverfew, willow bark, glucosamine, and
chondroitin. Discourage any use of dimethylsulfoxide.
10. Acupuncture and acupressure may be considered.
11. Neuromodulation with spinal cord stimulators and/or
intrathecal pumps can be explored with a board-certied
pain management physician.
FOLLOW-UP
A. See the client every 4 to 6 weeks for evaluation.
B. Ensure that the client has access to care on a regular
schedule.
C. These brief visits should be consistent so that care is not
perceived to be dependent on escalation of symptoms.
CONSULTATION/REFERRAL
A. Consider client referral to a pain management clinic if pain
control is not adequate. Interventions commonly performed
at the specialty clinic include facet joint injections, percutaneous radiofrequency neurotomy, epidural corticosteroid injections, transforaminal epidural injections, and sacroiliac joint
injections.
LOWER BACK PAIN
https://t.me/med1917
65
B. Consult with the full interdisciplinary team and/or an
addictionologist for suspected substance abuse and/or
addiction.
C. Refer to a certied pain specialist physician if the client is
taking high doses of opioids and detoxication is indicated.
Buprenorphine (Suboxone) is the most common medication
prescribed by a certied pain specialist physician.
D. Consider a rheumatology consult if indicated.
BIBLIOGRAPHY
AmericanPsychiatric Association. (2013). Diagnostic and statistical manual
of mental disorders (5th ed.). https://doi.org/10.1176/appi.books.9780
890425596
Centers for Disease Control and Prevention. (2016a, March 15). CDC
guidelines for prescribing opioids for chronic pain—United States, 2016.
Morbidity and Mortality Weekly Reports. https://www.cdc.gov/mmwr/
volumes/65/rr/rr6501e1.htm
Centers for Disease Control and Prevention. (2016b, March 22). Checklist
for prescribing opioids for chronic pain. https://www.cdc.gov/drugover
dose/pdf/PDO_Checklist-a.pdf
Centers for Disease and Prevention. (2019). What states need to know
about PDMPs. CDC: Opioid. State Information. https://www.cdc.gov/
drugoverdose/pdmp/states.html
Dahlhamer, J., Lucas, J., Zelaya, C., Nahin, R., DeBar, L., Kerns, R., Von
Korff, M., Porter, L., & Helmick, C. (2018). Prevalence of chronic pain
and high-impact chronic pain among adults—United States 2016.
Morbidity and Mortality Weekly Report, 67(36), 1001–1006. https://doi.
org/10.15585/mmwr.mm6736a2
Mills, S. E. E., Nicolson, K. P., & Smith, B. H. (2019). Chronic pain: A review
of its epidemiology and associated factors in population-based studies. British Journal of Anaesthesia, 123(2), e273–e283. https://doi.org/
10.1016/j.bja.2019.03.023
Pitcher, M. H., VonKorff, M., Bushnell, M. C., & Porter, L. (2019).
Prevalence and prole of high-impact chronic pain in the United
States. The Journal of Pain, 20(2), 146–160. https://doi.org/10.1016/j.
jpain.2018.07.006
Raja, S. N., Carr, D. B., Cohen, M., Finnerup, N. B., Flor, H., Gibson, S.,
Keefe, F. J., Mogil, J. S., Ringkamp, M., Sluka, K. A., Song, S. J., Stevens,
B., Sullivan, M. D., Tutelman, P. R., Ushida, T., & Vader, K. (2020). The
revised international association for the study of pain denition of
pain: Concepts, challenges, and compromises. Pain, 61(9), 1976–1982.
https://doi.org/10.1097/j.pain.0000000000001939
LOWER BACK PAIN
DEFINITION
A. Painful conditions of the lower back may be categorized as
follows:
1. Potentially serious disorders: acute fracture, tumor,
progressive neurologic decit, nerve root compression,
and cauda equina syndrome.
2. Degenerative disorders: aging or repetitive use, degen-
erative disease, and osteoarthritis.
3. Nonspecic disorders: benign and self-limiting with
unclear etiology.
INCIDENCE
A. Lower back pain (LBP) is commonly seen in clients of ages
20 to 40 years.
B. About 75% of adults will experience LBP in their lifetime.
PATHOGENESIS
A. Pain arises from fracture, tumor, nerve root compression,
degenerative disc, osteoarthritis, and strain of the ligaments
and musculature of the lumbosacral area.
PREDISPOSING FACTORS
A. Trauma causing ligament tearing; stretching of vertebra,
muscles, tendons, ligaments, or fascia.
B. Repetitive mechanical stress.
C. Tumor.
D. Exaggerated lumbar lordosis.
E. Abnormal, forward-tipped pelvis.
F. Uneven leg length.
G. Chronic poor posture due to inadequate conditioning of
muscle strength and exibility, improper lifting techniques
causing excessive strain, and poor body mechanics.
H. Inadequate rest.
I. Emotional depression.
COMMON COMPLAINTS
A. Pain in the lower back area may range from discomfort to
severe back pain, with or without radiation.
OTHER SIGNS AND SYMPTOMS
A. Ambulating with a limp.
B. Limited range of motion.
C. Posture normal to guarded.
SUBJECTIVE DATA
A. Ask the client to discuss the origin of pain. How has the
pain progressed or changed since the initial injury?
B. Ask the client to point to an area where pain is felt.
C. Have the client describe the pain. Is it radiating, with
sharp, shooting pain down to the lower leg and feet?
D. Ask: What makes the pain worse or better? Does activ-
ity make the pain worse or better? Have the client list current medications or therapies used for pain, noting results of
treatment.
E. Investigate occurrence of systemic symptoms such as fever
and weight loss.
F. Explore the client’s medical history. Note previous trauma
or overuse, tuberculosis, arthritis, cancer, and osteoporosis.
G. Inquire about symptoms such as dysuria, bowel or bladder
incontinence, muscle weakness, paresthesia, and loss of sensation. Bowel or bladder dysfunction, bilateral sciatica, and saddle distribution of dysesthesias may be symptoms of severe
compression of the cauda equina that necessitate an urgent
workup and referral. Other red ags include fever, history
of cancer, history of intravenous (IV) drug use, immunosuppression, steroid use, history of osteoporosis, and worsening
symptoms.
H. Ask the client about precipitating factors such as athlet-
ics, heavy lifting, driving, yard work, occupation, sleep habits,
any new activity, or systemic disease.
I. Use a pain scale to describe the worst pain and the best
pain levels.
PHYSICAL EXAMINATION
A. Check temperature, pulse, blood pressure, and respiration.
B. Inspect:
1. Observe general appearance; note discomfort and gri-
macing on movement and/or examination.
2. Distraction may distinguish pain behavior from actual
pathology.
3. Note evidence of trauma with bruises, cuts, and
fractures.
4. Note posture and gait.
C. Palpate:
1. Palpate spine and paravertebral structures, noting
point tenderness and muscle spasm. Palpation elicits paravertebral tenderness and generalized tenderness over the
lower back to upper buttocks.
66
https://t.me/med1917
3: PAIN MANAGEMENT GUIDELINES
2. Examine the abdomen for masses and presence of aor-
tic aneurysm, which can present as back pain.
3. Palpate the peripheral pulses of the extremities.
D. Perform neurologic examination:
1. Identify sensation and pain distribution.
2. Determine motor strength and evaluate whether mus-
cle strength is symmetrical: Upper extremity resistance is
equal bilaterally.
3. Test deep tendon reexes, check for clonus, and assess
strength of dorsiexion of the big toes.
4. Check sensation of perineum to rule out cauda equina
syndrome.
E. Perform traction tests: straight leg raises, crossed leg raises,
Yeoman Guying, and Patrick test. Musculoskeletal ndings
include the following:
1. Straight leg raising and dorsiexion of thefoot on the
affected side may reduce lower back discomfort.
2. Elevate each leg passively with exion at the hip and
extension of the knee. Positive straight leg raise produces
radicular pain when the leg is raised to 30° to 60°.
3. Crossed leg raises: Test is positive when pain occurs in
the leg not being raised.
4. Yeoman Guying: Unilateral hyperextension in prone
position identies lumbosacral mechanical disorder.
5. Patrick test: Place heel on opposite knee and apply lat-
eral force; check for hip or sacroiliac disease.
6. Range of motion: Increased pain with extension often
indicates osteoarthritis. Increased pain with exion often
indicates strain or injured disc.
F. Perform pelvic examination:
1. Consider pelvic and rectal examination, if indicated. If
the client has fallen on the coccyx, a rectal examination is
needed to check for stability.
DIAGNOSTIC TESTS
A. Laboratory: complete blood count, erythrocyte sedimen-
tation rate, serum calcium, alkaline phosphatase, urinalysis,
and serum immunoelectrophoresis when inammatory, neoplastic, diffuse bone disease, or renal disease is suspected.
B. Radiography of spine:
1. In the absence of red ags, do not perform an x-ray
unless pain persists past 6 weeks. When possible, begin
with plain radiographs with at least two views.
2. If radiographs and/or persistent symptoms indicate,
consider MRI to rule out disc disease and tumors.
3. Consider a bone scan to rule out cancer.
DIFFERENTIAL DIAGNOSES
A. Back pain secondary to musculoskeletal pain.
B. Herniated intervertebral disease.
C. Sciatica.
D. Fracture (compression or pars).
E. Ankylosing spondylitis.
F. Malignancy/tumor.
G. Abdominal aneurysm.
H. Pyelonephritis.
I. Metabolic bone disease.
J. Gynecologic disease.
K. Peripheral neuropathy.
L. Depression.
M. Prostatitis.
N. Spinal stenosis.
O. Osteoarthritis.
P. Osteoporosis.
Q. Abdominal aortic aneurysm.
PLAN
A. General interventions:
1. American College of Physicians guidelines for LBP:
a. Given that most clients with acute or subacute low
back pain improve over time regardless of treatment,
clinicians and clients should select nonpharmacologic
treatment with supercial heat (moderate-quality evidence), massage, acupuncture, or spinal manipulation
(low-quality evidence). If pharmacologic treatment is
desired, clinicians and clients should select nonsteroidal anti-inammatory drugs (NSAIDs) or skeletal
muscle relaxants (moderate-quality evidence).
b. For clients with chronic low back pain, clinicians
and clients should initially select nonpharmacologic
treatment with exercise, multidisciplinary rehabilitation, acupuncture, mindfulness-based stress reduction
(moderate-quality evidence), tai chi, yoga, motor control
exercise, progressive relaxation, electromyography biofeedback, low-level laser therapy, operant therapy, cognitive behavioral therapy, or spinal manipulation.
c. In clients with chronic low back pain who have had
an inadequate response to nonpharmacologic therapy,
clinicians and clients should consider pharmacologic
treatment with NSAIDs as rst-line therapy, or tramadol
or duloxetine as second-line therapy. Clinicians should
only consider opioids as an option in clients who have
failed the aforementioned treatments and only if the
potential benets outweigh the risks for individual clients and after a discussion of known risks and realistic
benets with clients.
B. Client teaching:
1. Give accurate information on the prognosis for quick
recovery, such as continuing light physical activity, performing back-strengthening exercises, and avoiding overuse of medications. Counsel clients to avoid bedrest.
2. Improvement occurs in most cases in a few weeks,
although mild symptoms may persist.
3. Provide educational handouts on back exercises; see
Client Teaching Guide for this chapter, “Back Stretches.”
4. After intense pain abates, the client may perform
low-back exercises for range of motion and strengthening,
and isometric tightening exercises of abdominal and gluteal muscles.
5. Research indicates that yoga and other active exercise
programs are benecial for many types of back pain.
6. Encourage the client to perform walking, swimming,
or pool exercise daily.
7. Teach relaxation techniques.
8. Encourage the client to modify work hours and job tasks.
9. Refer the client for therapeutic massage or physical
therapy as needed.
10. Obesity is often related to decreased exercise and poor
physical tness with reduced trunk muscle strength and
endurance. Obese clients may experience back pain with
normal activity.
11. Protective factors:
a. Moderate physical activity.
b. Control weight.
c. Avoid injuries.
d. Adequate preoperative and postoperative analgesia.
e. Resilience and positive affect.
C. Pharmaceutical therapy:
1. Analgesics: acetaminophen 350 to 650 mg every 4 to 6
hours, maximum dose is 4,000 mg/d. Inquire about use
LOWER BACK PAIN
https://t.me/med1917
67
of any other current medications and/or over-the-counter
preparations containing acetaminophen.
2. NSAIDs: unless contraindicated due to gastrointestinal
symptoms or cardiovascular disease:
a. Aspirin: 325 to 650 mg every 4 to 6 hours.
b. Ibuprofen: 200 to 800 mg every 6 to 8 hours; maxi-
mum dose is 3.2 g/d under the care of the provider,
otherwise 1.2 g/d.
c. Naproxen: 500 mg initially, followed by 250 mg
every 6 to 8 hours.
d. Piroxicam (Feldene): 20 mg every day.
e. Meloxicam (Mobic): 7.5 to 15 mg daily.
f. Celebrex: 100 to 200 mg BID.
3. Muscle relaxants:
a. Cyclobenzaprine HCl (Flexeril): 10 mg TID.
b. Avoid carisoprodol (Soma) due to risk of addiction.
c. Methocarbamol (Robaxin): 500 to 750 mg three to
four times a day.
d. Orphenadrine citrate (Norex): 100 mg BID.
e. Metaxalone (Skelaxin): 800 mg three to four times
a day.
f. Tizanidine (Zanaex): 2 to 6 mg TID.
FOLLOW-UP
A. If pain is severe or unimproved, follow up in 24 hours.
B. If pain is moderate, reevaluate the client in 7 to 10 days.
C. See the client in 2 to 4 weeks to reevaluate their condition
and behavioral changes.
D. Recurrences are common but do not indicate a chronic or
worsening case.
CONSULTATION/REFERRAL
A. Consult with a physician when considering red ag diag-
noses such as cauda equina syndrome, herniated disc, widespread neurologic involvement, carcinoma, or signicant
trauma.
B. Referral to a rheumatologist is needed for clients who note
signicant morning stiffness with a gradual onset prior to age
40 years, with continuing spinal movements in all directions,
and involving some peripheral joints, iritis, and skin rashes,
indicating inammatory disorders such as ankylosing spondylitis and related disorders.
INDIVIDUAL CONSIDERATIONS
A. Pregnancy:
1. Pregnancy is often associated with low back discom-
fort. This is due to the redistribution of body weight. As
weight increases in the abdominal area with the growing
fetus, clients tend to compensate by changing posture and
tilting the spine back.
B. Adults:
1. For clients older than 50 years presenting with no his-
tory of backache, consider a differential diagnosis of neoplasm. The most common metastasis seen is secondary to
the primary site of breast cancer, prostate cancer, or multiple myeloma. Pain most prominent in a recumbent position rarely radiates into the buttock or leg.
2. Individuals in early adulthood (ages 20–45 years) who
present with chronic back pain that improves with activity
should be further evaluated for ankylosing spondylitis.
BIBLIOGRAPHY
Centers for Disease Control and Prevention. (2016a, March 15). CDC
guidelines for prescribing opioids for chronic pain—United States, 2016.
Morbidity and Mortality Weekly Reports. https://www.cdc.gov/mmwr/
volumes/65/rr/rr6501e1.htm
Centers for Disease Control and Prevention. (2016b, March 22). Checklist
for prescribing opioids for chronic pain. https://www.cdc.gov/drugover
dose/pdf/PDO_Checklist-a.pdf
Donaldson, M. (2018). Resilient to pain: A model of how yoga may
decrease interference among people experiencing chronic pain.
Explore, 15, 230–238. https://doi.org/10.1016/j.explore.2018.11.002
Murphy, K. R., Han, J. L., Yang, S., Hussaini, S. M. Q., Elsamadicy, A. A.,
Parente, B., Xie, J., Pagadala, P., & Lad, S. P. (2017). Prevalence of spe-
cic types of pain diagnoses in a sample of United States adults. Pain
Physician, 20, E257–E268. https://www.painphysicianjournal.com/
current/pdf?article=NDExNQ%3D%3D&journal=102
Owen, P. J., Miller, C. T., Mundell, M. L., Verswijveren, S. J. J. M.,
Tagliaferri, S. C., Brisby, H., Bowe, S. J., & Belavy, D L. (2020). Which
specic modes of exercise training are most effective for treating low
back pain? Network metanalysis. British Journal of Sports Medicine, 54,
1279–1287. https://doi.org/10.1136/bjsports-2019-100886
Treede, R. D., Rief, W., Barke, A., Aziz, Q., Bennett, M. I., Benoliel, R.,
Cohen, M., Evers, S., Finnerup, N. B., First, M. B., Giamberardino, M.
A., Kaas, S., Kosek, E., Lavand’homme, P., Micholas, M., Perrot, S.,
Scholz, J., Schug, S., H, Smith. B. … Wang, S. J. (2015). A classication
of chronic pain for ICD-11. Pain, 156(6), 1003–1007. https://doi.org/
10.1097/j.pain.0000000000000160
Соседние файлы в папке Библиотека им академика М.И. Перельмана