Chronic Pain: Stopping a Downward Spiral -- The complete article!!

From: Helen Dynda (
Mon Aug 27 14:57:05 2001

You may have found my previous posts on this article confusing; so I decided to post the entire article. If you were confused, I apologize. I believe the information in this article is very important; and I hope that you will take the time to read it.

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[]] Chronic Pain: Stopping a Downward Spiral

Acute and chronic pain may begin in the same way, usually due to an injury. Acute pain has its purpose: It alerts the body that there is a problem. But chronic pain serves no similar protective function. When pain persists for more than six months, it is said to be chronic or intractable pain. This type of pain no longer assists the body, and normal living becomes severely restricted or even impossible. Chronic pain syndrome Chronic pain syndrome involves a persistent pattern of pain that starts with an organic cause and becomes compounded by psychological and social problems, creating a downward spiral. The major clinical indicators of chronic pain syndrome are persistent pain, functional impairment, and emotional distress. The primary problem for people with chronic pain syndrome is the presence of pain over time despite treatment. People who still have pain six months after an injury represent a group that presents unique challenges to healthcare practitioners and the healthcare system. Currently, it’s impossible to predict which patients will have their acute pain develop into chronic pain syndrome.

The economic consequences of inadequately treated chronic pain include medical expenses, lost income and productivity, compensation payments, and legal fees. Unmanaged pain results in high costs, including multiple emergency room visits and expensive diagnostic procedures, hospitalizations with multiple surgeries, rehabilitation and drugs, and the continuing loss of the patient’s potential for economic productivity. And in addition to the economic costs, patients with chronic pain syndrome experience disruption in nearly all aspects of their lives, including family and work life.

The most common nursing diagnoses for patients with chronic pain syndrome are ineffective coping related to chronic pain, activity intolerance related to decreased muscle tone and strength from inactivity, and sleep pattern disturbance related to pain and anxiety.

Nociceptive and neuropathic pain Chronic pain may be either nociceptive or neuropathic in origin. Nervous system structures called nociceptors are located in cutaneous and deep tissues and the viscera. Nociceptive pain results from direct stimulation of peripheral nerve endings that are sensitive to noxious mechanical, thermal, or chemical stimuli. Patients often describe nociceptive pain as aching or throbbing. Bone or muscle pain or injury, cancer pain, and post-laminectomy back pain are examples of nociceptive pain. Opiate drugs usually help relieve nociceptive pain.

Neuropathic pain is caused by damage to nerves or altered nervous system function. Patients often describe neuropathic pain as burning or shooting. Examples of neuropathic pain include complex regional pain syndrome (formerly known as reflex sympathetic dystrophy or RSD), which is characterized by severe upper extremity pain; phantom limb pain; and post-herpetic neuralgia or shingles. Neuropathic pain responds poorly to opiates.

Treatment continuum Pain produces anxiety and muscle tension. The tense, contracted muscles eventually produce spasms, which causes more pain. In response to pain, the muscles continue to contract, creating a pain-spasm-pain cycle. In order to reduce pain, this cycle must first be broken. There are three strategies for controlling chronic pain: early intervention, an interdisciplinary approach, and an individualized, goal-directed care plan that considers multiple treatment options.

It is essential that patients and families understand and accept that cure from pain is not a realistic goal of a pain treatment program. Health professionals should reinforce achievable and realistic goals: controlling pain, decreasing suffering, decreasing the use of healthcare services, and restoring function. The first step in the treatment continuum is an evaluation of the problem, diagnosis, and establishment of treatment goals that are realistic for the patient and provide some predictability for the payer.

Patient and family involvement and education are at the core of a pain management program. Education helps patients manage their lives and regain the sense of control that has been lost due to pain. Patients and families benefit from learning about the physiology of the affected body systems, the pain cycle, body mechanics, the purpose and side effects of medications, assertiveness techniques, problem-solving skills, communication techniques, nutrition, and effective sleep habits. Pain behaviors are modified by reinforcing healthy behaviors that facilitate self-management of pain and by de-emphasizing behaviors that remind patients and those close to them of their pain.

Patients with chronic pain may attempt to avoid it by limiting their activities. Over time, lack of exercise and movement causes physical deconditioning. To improve conditioning, patients may benefit from an individualized exercise program designed by a physical therapist. The exercise program emphasizes increased functioning, strength, flexibility, and endurance. As the patient’s activity level increases, he or she should also learn pacing techniques that assist with well-being and avoidance of injury.

Stress management skills are an important part of chronic pain management. It’s helpful to teach behaviors that can become part of daily routines as adaptive coping strategies to manage the anxiety and depression that often accompany chronic pain. Cognitive-behavioral strategies include progressive muscle relaxation, biofeedback, guided imagery, distraction, meditation, and humor.

Range of treatments Therapeutic modalities for pain can range from simple and noninvasive to surgical and irreversible. At peripheral pain sites, nonopioid analgesics, heat and cold application, and local anesthetics can alter the release of nociceptive substances and reduce muscle spasms. In the spinal cord, epidural analgesics, tricyclic antidepressants, neurosurgical procedures, and stimulation of large nerve fibers by direct electrical stimulation, massage, heat and cold application, and therapeutic touch can interfere with nerve impulse transmissions. In the brain stem, electrical stimulation, tricyclic antidepressants, opioid analgesics, and neurosurgical procedures can reduce or eliminate the transmission of pain impulses. In the cerebral cortex, cognitive techniques such as hypnosis, imagery, music therapy, relaxation, behavioral training, and opioid analgesics provide additional ways to control pain.

Pharmacological managementof chronic pain includes non-narcotic analgesics, narcotic analgesics, and psychotropic drugs. Oral medications start with nonsteroidal anti-inflammatory drugs (NSAIDs) and may progress to include muscle relaxants, antidepressants, and anticonvulsant drugs. NSAIDs such as aspirin, acetaminophen, ibuprofen, and indomethacin are widely available, have few serious side effects, and are effective in relieving pain associated with inflammation, such as musculoskeletal disorders. Narcotic analgesics range from weak to strong opioid drugs. Effective oral doses of oral narcotics range from 15 to 30 mg a day of morphine or its equivalent. Patients may develop tolerance and require increasing dosages. Systemically absorbed opiates can produce many undesirable gastrointestinal side effects such as constipation, nausea, and vomiting and also produce sedation that results in memory impairment, drowsiness, and impaired concentration. Other common side effects of opioid analgesics are fatigue, weakness, and central nervous system depression.

Older patients may have increased sensitivity to the analgesic effects of medications and may have more central nervous system side effects, such as confusion, dizziness, and drowsiness. Aging affects the absorption, detoxification, and excretion of medications, increasing toxicity risks and adverse reactions. Since the average older patient takes four to five medications daily, the adverse risks are increased. These problems underscore the need to consider nonpharmacological means of pain management in this age group.

Nerve blocks may be used to stop the transmission of pain impulses. For patients not responsive to any other form of treatment, a neuroablative procedure—which destroys nervous system tissues—may be considered to relieve intractable pain. Two examples of a neuroablative procedure are a rhizotomy—destruction of the sensory root of a spinal nerve—and a cordotomy—destruction of part of the spinal cord’s major sensory tract. Because their effects are irreversible, they are a last resort.

Advanced pain therapies Two new methods to manage chronic pain take advantage of the fact that pain only seems to be felt at the point of injury. Actually, pain messages are sent up the spinal cord to the brain, where the pain sensation is experienced. So blocking pain impulses from reaching the brain can prevent pain from being perceived, and that’s the idea behind spinal cord stimulation therapy and intrathecal pain therapy. Both can be used when less invasive therapies have failed to provide pain relief.

Spinal cord stimulation therapy delivers low-voltage stimulation to the spinal cord to inhibit or block the sensation of pain. The patient often feels a tingling or vibration that is not unpleasant - the patient, in effect, trades one sensation for another. With spinal cord stimulation, leads are placed near the spinal cord and connected to an implantable or an external power source. Spinal cord stimulation therapy differs from transcutaneous electrical nerve stimulation in that TENS has no implantable components and acts only in the periphery.

Patients being evaluated for spinal cord stimulation therapy participate in a screening trial using local anesthesia to evaluate their response to electrical stimulation. A stimulating electrode is placed in the appropriate position in the epidural space over the nerves corresponding to the painful area. The lead is connected to an external power source during the trial screening period of several days. If the patient experiences adequate pain relief, the leads are placed in the epidural space by percutaneous placement or laminectomy. A subcutaneous tunnel is created to connect the lead to the generator and receiver pocket site. A subcutaneous pocket is created for implantation of the neurostimulator. Complications of spinal cord stimulation therapy include lead migration, hardware malfunction, or undesirable sensations described by patients as a jolt or shock. Batteries for a spinal cord stimulation system last about five years, and follow-up involves periodic assessments and adjustment of the effectiveness of treatment.

Intrathecal pain therapy delivers morphine directly into the intrathecal space of the patient’s spinal cord, where the drug binds to pain receptors, inhibiting the release of substance P, a neurotransmitter involved in the transmission of pain signals. Because morphine is delivered directly into the spinal cord, a fraction of the dose needed for oral or intravenous administration is given. For example, an intrathecal dose of morphine sulfate is approximately one-three hundredths of an oral equivalent dose. During trial screening, small doses of morphine are given through a bolus dose or continuous infusion into the epidural or intrathecal space. If the trial produces adequate pain relief, the catheter is placed intrathecally and connected to a surgically implanted programmable pump that releases prescribed amounts of morphine. The pump is refilled by inserting a needle through the skin into a filling port at the center of the pump. For most patients, refills are needed between one and three months, depending on dosage requirements. The programmable pump allows dosage adjustments to be made noninvasively using an external programmer. Batteries for the infusion system last three to four years. Complications and side effects of intrathecal pain therapy may be surgical, mechanical, or pharmacological. The surgical procedure to implant the device can cause bleeding, infection, and leakage of cerebrospinal fluid, although such complications are rare. Mechanical complications may involve the catheter and the pump. The most common complications are kinking, occlusion, or dislodgment of the catheter. Side effects of morphine include: constipation, pruritis, urinary retention, nausea, vomiting, and decreased libido.

In general, spinal cord stimulation therapy is indicated for neuropathic pain and unilateral or bilateral extremity pain. Intrathecal pain therapy is most often indicated for patients whose pain is nociceptive, in multiple or axial sites (located on the body’s head-to-toe axis), or changeable in pattern and for patients with neuropathic pain who have failed to respond to a trial with stimulation therapy.

Careful selection Implantable therapies are not for everyone. For some patients, an implantable therapy is the last alternative before considering permanent ablative neurodestructive procedures. The ideal candidate for an implantable device is a patient who did not respond effectively with more conservative therapies and who achieves a significant amount of pain relief from a trial screening period with spinal cord stimulation or intraspinal opioids. Advanced pain treatment therapies are more likely to succeed in patients who don’t have serious drug dependence and have a strong desire to participate in treatment. A psychological evaluation, including both psychological testing and clinical interview, is essential for determining the patient’s chance for success with implantable therapy. Patients with drug abuse histories, those who obtain important secondary gains from their pain, and those with significant psychological problems are not good candidates for implantable therapies.

The intended outcomes of implantable therapy are improvement in the person’s ability to participate in activities of daily living, pain reduction, decreased use of oral medications, return to work, and improved quality of life. The advantages of implantable therapies are that they are cost-effective, nondestructive, and reversible. In general, the implantation procedure costs approximately what alternative therapy costs per year and produces better long-term results in appropriately selected patients. In one study, 50 percent of suitable patients receiving spinal cord stimulation experienced pain relief; 24 percent returned to work. The results for intrathecal morphine are even more impressive—80 percent of patients reported pain relief and 40 percent resumed work. Patient age, length of disability, occupational mobility, and activity levels are among the factors that predict the likelihood that a patient with chronic pain will return to work.

To stop the downward spiral of chronic pain, a partnership is needed between nurses, other healthcare professionals, and the patient and family. Nurses have many roles to play in managing chronic pain: educator, clinician, case manager, and consultant. Nurses are also often in a position to suggest a referral to a chronic pain treatment clinic for the patient whose pain has become a disabling problem. Chronic pain is a complex, multidimensional health problem. As part of an interdisciplinary management team in a variety of healthcare settings, nurses can use their knowledge of pain management to help patients improve their health status and enhance their quality of life.

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