heterotopic pain

Several factors influence the experience of pain. Among these are the nature of the injury or illness causing the symptom, the physical and emotional health of the patient, the acuity or chronicity of the symptom, the social milieu and/or cultural upbringing of the patient, neurochemistry, memory, personality, and other features. See: table

Symptoms

Many clinicians use the mnemonic “COLDER” to aid the diagnosis of painful diseases. They will ask the patient to describe the Character, Onset, Location, and Duration of their painful symptoms, as well as the features that Exacerbate or Relieve it. For example: The pain of pleurisy typically is sharp in character, acute in onset, located along the chest wall, and long-lasting; it is worsened by deep breathing or coughing and relieved by analgesics or holding still. By contrast, the pain of myocardial ischemia usually is dull or heavy, gradual in onset, and located substernally. It may be worsened by activity (but not by taking a breath or coughing) and relieved by nitroglycerin.

In 2000, the Joint Commission on Accreditation of Healthcare Organizations (JCAHO) issued pain-management standards, in 2001 began surveying for compliance, and in 2004 added patient-safety goals, thus most U.S. health care facilities have devised policies and procedures that require pain-intensity rating as a routine part of care (the fifth vital sign). Pain intensity usually is assessed on a numerical scale, in which 0 = no pain, 1 to 3 = mild pain, 4 to 6 = moderate pain, and 7 to 10 = severe pain. However, obtaining a numerical rating of pain intensity is possible only if the patient is able to provide this report of the pain being experienced, which infants, children, the critically ill, and cognitively impaired usually are unable to do. The Wong’ Baker FACES scale, developed for pediatric use, has been used successfully in other patient populations. It uses visual representations of smiles or grimaces to depict the level of pain a patient feels.

Patient care

Health care professionals must be aware that pain in non-verbal patient can easily be overlooked and must make a conscious effort to ensure that pain in these patients is assessed and treated. Observing subtle behaviors and being sensitive to contextual clues are two pain methods used by health care professionals to try to determine when nonverbal patients are in pain. When this judgment is made, a trial of pain-relieving medication may be used. The responses of the patient and any complications of treatment should be carefully observed and appropriate changes made in dosing or the type of analgesic drug as indicated.

Because pain is a subjective and intensely personal problem, sympathetic care is an important part of its relief. In addition to administering analgesic drugs, health care professionals should use a wide range of techniques to help alleviate pain, including local application of cold and heat, tactile stimulation, relaxation techniques, diversion, and active listening, among others.

Etiology

Common causes of back pain include pain caused by muscular or tendon strain, herniated intervertebral disk, lumbar spinal stenosis, or spondylolisthesis. Patients with a history of cancer may have back pain caused by metastatic tumors to the vertebrae and should be evaluated to be certain that damage to the spinal cord is not imminent. Patients with back pain and fever (esp. those with a history of injection drug use, tuberculosis, or recent back surgery) should be evaluated for epidural abscess or osteomyelitis.

Treatment

Depending on the underlying cause of the back pain, treatment may include drugs, rest, massage, physical therapy, chiropractic, stretching exercises, injection therapy, and surgery, among others. Most nonmalignant causes of back pain improve with a few days of rest, analgesics, and antiinflammatory drugs, followed by 2 to 4 weeks of anti-inflammatory treatment, appropriate muscle strengthening, and patience. Pain caused by an osteoporotic fracture may prove more debilitating and longer-lasting. Back pain produced by a spinal metastasis can improve with corticosteroids, radiation therapy, intravenous bisphosphonates, and/or surgical decompression. Patients with a spinal epidural abscess will need surgical drainage of the infection and antibiotics.

Patient care

Prolonged bedrest is inadvisable in most patients with back pain. The treatment regimen is explained, implemented, and reinforced. Factors that precipitate symptoms are identified and preventive actions are discussed.

Treatment

The pain associated with CIPP should be treated symptomatically and sympathetically. The participation of pain management specialists, complementary medical providers, and the primary health care provider should be integrated. Realistic goals (e.g., the reduction of pain rather than its elimination) should be set. Medroxyprogesterone acetate, oral contraceptives, presacral neurectomy, hypnosis, and hysterectomy have been tried with varying degrees of success.

Treatment

The child should be reassured and given acetaminophen or ibuprofen; heat and massage can be applied locally. Children with growing pains benefit from concern and reassurance from their parents and health care providers.

Treatment

Drugs like gabapentin or pregabalin provide effective relief of neuropathic pain for some patients. Other treatments include (but are not limited to) regional nerve blocks, selective serotonin and norepinephrine reuptake inhibitors, psychological counseling, acupuncture, transcutaneous electrical nerve stimulation, and physical therapy.

Patient care

Phantom limb pain or nonpainful sensations are reported by most amputees. A multimodal or combination approach to management is appropriate. Drugs used to treat neuropathic pain may be helpful, including some anticonvulsant drugs, tricyclic antidepressants, selective serotonin inhibitors, and muscle relaxants. Nerve blockade and/or transcutaneous electrical stimulation may also be helpful. Health care professionals should encourage amputees to move the affected extremity, seek counseling or group therapy, engage in physical and occupational therapy, and use distraction techniques.

1. In order to increase the clinician's responsiveness to complaints of pain, it is now considered by some health care professionals to be the fifth vital sign.2. Acute pain and cancer pain are recognized and effectively treated. Essential to this process is the development of a clinically useful and easy-to-use scale for rating pain and its relief. Patients will be evaluated according to the scales and the results recorded as frequently as needed.3. Information about analgesics is readily available. This includes data concerning the effectiveness of various agents in controlling pain and the availability of equianalgesic charts wherever drugs are used for pain.4. Patients are informed on admission of the availability of methods of relieving pain, and that they must communicate the presence and persistence of pain to the health care staff.5. Explicit policies for use of advanced analgesic technologies are defined. These advances include patient-controlled analgesia, epidural analgesia, and regional analgesia. Specific instructions concerning use of these techniques must be available for the health care staff.6. Adherence to standards is monitored by an interdisciplinary committee. The committee is responsible for overseeing the activities related to implementing and evaluating the effectiveness of these pain standards.