Pain School for Caregivers
Course 3- Chronic Pain
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Pain School for Caregivers
Course 3- Chronic Pain
Author: Mark Parkinson RPh: President AFC CE
Credit Hours 2.5 - Approximate time required: 150 min.
Educational Goal:
To provide Adult Foster Care providers with information that will help them understand and manage chronic pain.
Educational Objectives:
1. Instruct about Chronic Pain and how to manage it.
2. Explain about chronic pain management tools
Procedure:
1. Read the course materials. 2. Click on exam portal [Take Exam]. 3. If you have not done so yet fill in Register form (username must be the name you want on your CE certificate). 4. Log in 5. Take exam. 6. Click on [Show Results] when done and follow the instructions that appear. 7. A score of 70% or better is considered passing and a Certificate of Completion will be generated for your records.
Disclaimer
The information presented in this activity is not meant to serve as a guideline for patient management. All procedures, medications, or other courses of diagnosis or treatment discussed or suggested in this article should not be used by care providers without evaluation of their patients’ Doctor. Some conditions and possible contraindications may be of concern. All applicable manufacturers’ product information should be reviewed before use. The author and publisher of this continuing education program have made all reasonable efforts to ensure that all information contained herein is accurate in accordance with the latest available scientific knowledge at the time of acceptance for publication. Nutritional products discussed are not intended for the diagnosis, treatment, cure, or prevention of any disease.
Pain School for Caregivers
Course 3- Chronic Pain
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The definition of chronic pain is pain lasting over 3-6 months. But chronic pain is more than just the mere passage of time. Prolong pain presents other challenges to cope with. Patients and their care givers must learn to deal with the biological, emotional and social stresses that come from the prolonged exposure to pain. To successfully cope with these new concerns caregivers and patients must have a change of mindset.
Change of care giving goals
The care giving goal in acute pain is to eliminate it. After six months of suffering it’s time to realize that’s probably not going to happen. Caregivers have to help their patients to start looking at the problem from a different angle. Instead of striving to eliminate pain it’s time to start working toward the more obtainable goal of managing pain to reach tolerable levels. The goal of care giving should be switched from being pain free to living a normal life despite the pain that won’t completely go away.
Chronic Pain Management tools
In order to successfully switch to a new pain management mindset you’re going to need a few new care giving tools in your medical tool chest. As you will see, I’m mostly talking about the mental medical tool chest in the caregiver’s and patient’s head.
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Clean out the tool box
Whether they intended to or not those who suffer from chronic aches have started to adjust to a life with pain. Maladaptive behaviors are common, especially in pseudo-addiction cases.
Usually driven by the fear of pain and the lack of knowledge patients will start to;
Living with long term, sometimes severe pain is very hard. It is easy to understand why the resolve of pain victims gets worn down and over time maladaptive behaviors arise. Most patients aren’t trained in chronic pain management and are simply doing the best they can to just survive. It is up to the caregiver to help them see what they are doing and help them clean out all these dull and broken pain management tools. To accomplish the task it is critical that a proper patient assessment be done and that a relationship of trust is developed between the caregiver and their patient.
Getting new tools that work
Filling up the medical pain management tool box is going to be a process. Some things will have to be un-learned; some things will have to be learned. Not all tools will be needed every time and you’ll develop your favorites. And don’t forget, “practice makes perfect”. So let’s talk about the tools now.
Involvement tool
Modern society has trained patients to just show up at the doctor’s office and passively do whatever they are told to do, almost completely ignoring personal responsibility for their own health. In chronic cases where pain can’t be eliminated that approach leads to a lot of problems. The doctor can’t be with the patient all the time but the pain can be. If the patient is only relying on the doctor to eliminate the pain whenever it pops up, they will become frustrated when the pain continues despite following the doctor’s instruction. In other words the person in pain is looking for a magic bullet to permanently kill the pain monster and gets mad and depressed when the doctor doesn’t give them one.
Patients must learn to go from a completely passive role to a more active participation role, forming a partnership with the doctor. Caregivers can place themselves right in the middle to make things happen. On the one hand are the doctor and the care team, with all their knowledge and prescriptive power. On the other is the patient, taking on more personal responsibility for their own pain management.
Caregivers roll
The caregiver’s role is to facilitate both efforts to reach the goal of a normal lifestyle for the chronic pain patient. How? Communication and follow through.
The doctor’s side- The caregiver can help the doctor by making sure all of their instructions are followed. More importantly they can give feed back to the doctor about what is working and to what degree it is working, what is not working and what other problems and concerns are popping up. The doctor can’t be with the patient all the time but their influence can be; through the caregiver’s efforts.
The patient’s side- The ability of patients to take care of themselves varies a lot. They have hired the caregiver to help them do what they can’t do. It will be up to the caregiver to help the patient take a more active role in their pain management. To help them understand the doctor’s instructions and what the requirements are in managing their own pain. To help them establish realistic expectations about eliminating their aches. To help them communicate the important details about the outcomes of their pain therapy back to the care team. They can succeed at living a normal life because you are there all the time to help them through every event, expected and unexpected, that effects their pain levels.
Patience tool
Being in the middle is sometimes not fun. It helps to remember some basic realities in pain management and compensate for them with copious amounts of patience.
Measurement tools
Chronic pain is treated differently than other chronic conditions. Therapy decisions are driven by how a patient feels more than what the doctor thinks is the next logical medical step concerning the progression of the underline disease state. The course of therapy is determined by feedback from the patient more than what can be measured with other medical instruments. But quantifying how much pain is felt is very difficult. Pain is a biological and emotional experience therefore literally each case is different from all others. How do you measure how much pain there is so the doctor can decide what to do next? Answer, pain scales and symptom journals.
Pain Scales
Pain scales are assessment systems where the patient is asked to rate their pain on a set scale. For example a numerical pain scale would be 1 through ten with ten being the worse pain ever experienced. Other pain scales add cartoon figures or colors to help patients better describe their pain.
It is important for the caregiver to use the pain scale properly.
Example- The pain today is a 7, predominately a dull ache.
Symptom Journals
Because pain is subjective and is emotionally influenced, what is going on in the rest of the client’s life is also important factors to consider when treating pain. It is entirely possible for a patient to experience pain at level 8 and cope with it because they are feeling happy that day, whereas on down days a pain level 0f 5 might be hard to cope with. Other factors can affect pain like uncontrolled blood sugars or blood pressure.
Some doctors have their patients keep a symptoms diary to help the doctor understand the bigger picture. Symptom diaries give the doctor more information about the condition of the patient. Consider the different answers to the question, “How have you felt over the past week?” 1. I feel fine, sometime painful. 2. Here is a record of the symptoms I felt last week. If you were a doctor which answer would you want?
Here again the caregiver must know how to properly complete a symptoms journal.
Giving the doctor more information is always good. In addition you will find that once a journal is kept that self-management of pain will become easier to accomplish. It forces the client to evaluate what is going on and what they are doing that effect the pain levels they experience. It also helps keep track of what works and how much improvement happens over time. Success breeds optimism and more success.
Communicating how a patient feels is a critical piece of information that the doctor needs in order to achieve effect pain therapy. Knowing how to collect that information is a critical role that a well-informed caregiver can fulfill. It is a “must do” function in order to have happy (therefore easier to take care of) residents.
Sleep tool
Pain disturbs sleep and not getting enough sleep causes you to feel pain more. It also reduces your ability to handle stress. It’s a downward spiral that around 2/3 of pain patients experience. But the cycle can be broken. It takes a bit of work but it’s worth the effort. A good night of restorative sleep is an excellent pain killing technique.
Sleep has a natural pattern that we don’t even have to think about. But when that pattern is disrupted we do have to make a concerted effort to maintain our regular sleep cycle. We have to pay attention to our sleep hygiene which is a fancy way of saying what we do that affects our sleep.
Proper Sleep Hygiene
One final note on the subject of sleep; many patients forget to talk about their sleep problems with their doctor. You as an informed caregiver should not. There are many sleep inducing options to choose from, including those medications that have a side effect of drowsiness. But watch the daytime napping that may occur as well.
Emotional tools
It is an established medical fact that people with positive mental attitudes can handle pain better. Conversely it is also known that stress, worry, depression or those thing that affect us negatively emotionally makes us feel pain more. In other words a positive, warm, caring and stress free environment is a good pain killer. If the patient can’t manage it by themselves the caregiver can greatly influence the client’s environment to create a positive attitude.
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Here are a few helpful hints for you.
Exercise/Mobility tool
Uncontrolled chronic pain creates an intense fear of pain. The fear of pain creates a down ward cycle of pain avoidance; avoidance leads to inactivity, inactivity lead to a sedentary life style, a sedentary life style leads to poorer health which increases the pain that is felt. Exercise and staying mobile breaks this harmful cycle.
Exercise benefits the chronic pain patient by;
Releasing endorphins, the body’s natural pain killer and mood enhancer.Two major hurdles to overcome in establishing an exercise routine are the fear of pain and overexertion caused pain. Both can be overcome by the principle of low and slow. Start with the easy stuff and gradually increase. I’m a huge fan of daily walks. Other easy exercises are shopping trips, stationary bikes, tread mills and steppers. Exercise articles always suggest water aerobics but that’s very problematic for care homes.
Mobility
Set exercise routines are not the only way to go. Any movement is exercise. Just keeping mobile will have its benefits. Keeping mobile also makes regular exercising easier.
Some mobility exercise ideas for you to try are;
I think you get the idea. These types of activities also give back to the client a sense of control in their life that they might feel they have lost. Mobility aides help tremendously. You could buy them and rent them to the patient, (another income source for you).
Alternative/complementary therapy tools
Drugs are not the only way to handle chronic pain. There are a number of different therapies that could be utilized. Frankly though that is not an area that caregivers have much to do with. You could make suggestions to the doctor or the family of the client could make the suggestions. You could also plant the idea in the head of the doctor or family by asking the right questions. But for the most part these therapies are for the doctor to worry about.
It would be nice though for you to have a list of therapies and a short description to consider.
Massage
Massage is probably the oldest pain relieving therapy that has ever existed. Numerous studies have proven its therapeutic benefits over and over again and yet modern medical science still haven't figured out exactly why it works. Current thinking is massages are beneficial for several different reasons.
Therapeutic massage should be done be a licensed professional. The care provider can perform everyday duties that can have massaging benefits such as apply lotion on the legs and back or just a simple back rub.
Posture
There are neutral positions for our bodies that present the least amount of stress on our systems. In the classic pain management theory "good posture relieves chronic pain" the goal of therapy was to relieve pain by trying to keep the body in those neutral positions for as long as possible. There are pain experts who question that assumption but it is undeniable that bad posture can add to pain if the area still has damage. So good posture takes stress off of areas where it's not supposed to be, resulting in less pain. Once the body is healed good posture may still have a role to play in convincing the mind that there is no need for pain. New studies show correct posture has a great positive effect on mental attitudes. Patients with positive attitudes can bear chronic pain better. So sit up straight, be proud and smile. There are devices such as “Back Joy” and various kinds of back and leg braces that the doctor could choose from. The care provider must know that holding a body in any one position for too long is actually bad for chronic pain. The body is built to move around not to stay in one place.
TENS Units-
Transcutaneous electrical nerve stimulation unit. It is a device that sends mild electrical current to the skin with the goal of disrupting nerve signals. It sounds modern and high tech but the use of electricity in pain control has been around for some time. There are even pictures of ancient Egyptians using electric eels to cure pain. Science has yet to figure out how it actually works. The current theory is that the electrical signal shuts the “pain nerve gate” so the pain signals never reach the brain. It has also been discovered that lower electrical signals stimulate the release of the body natural pain killing chemicals called endorphins.
Trigger Point Massage
Trigger Points are hyperirritable spots in muscle tissue. They are associated with nodules of taut muscle fibers thought to be a defensive mechanism to protect injury sites. They can contribution to chronic pain flairs, referred pain and unexplained pain in larger areas. Trigger points develop when muscle structures become weakened or damaged resulting in tiny tears appearing in muscle tissue. As these tears heal they contract or shorten the muscle tissue causing twisted and knotted fibers. These knots restrict blood flow and muscle movement. The nerve senses something is different and sends signals to the brain. The brain then produces pain as a warning and protection against the abnormality. Due to nervous system "wiring" the body may feel the pain in a larger area or even at distant areas of the body. Deep tissue massage by the use of a “Thera Cane” or similar device can resolve the trigger point.
Chiropractic Manipulation
Chiropractic medicine is a controversial area of therapy because of its many unscientifically proven tenets of practice. In regards to pain, its basis of practice is to manipulate the spine and joints thus effecting nervous system signals to the brain in order to alleviate the pain.
Acupuncture
Acupuncture is another controversial area of medicine because of its unscientifically proven tenets of practice. In regards to pain its technique is to inset pins into the specific points on the body for a set amount of time.
Range of Motion.
There are multiple therapies that effect pain through the movement and exercise of the body. It is thought to affect pain by, increasing blood flow, strengthening of muscle and joints, reducing stress, increasing relaxation. They also might combat the “fear of pain” by proving to the body and the mind that activity can be done without significant damage to the body. Therapy should always be done by skilled experts so harm can be avoided. Therapies include; water aerobics, physical therapy, yoga, tae chi, Feldenkrais method and others
Nerve block
Nerve block is as the name suggests, is a therapy that blocks the nerve from functioning. It can be temporary or permanent. Temporary nerve block is achieved by the injection of anesthetic drugs to a specific region where the pain originating nerves are. Usually the injections are a combination of numbing agents and anti-inflammatory medication. Permanent nerve block is killing the nerve through the use of chemicals, freezing (cryoanagesia) or heating the nerves (radiofrequency radioabaltion)
Cognitive and Biofeedback
Cognitive and Biofeedback are psychological therapies practiced by mental health professionals design to help the pain patient develop greater mental coping skills. Many pain patients get confused and worried when their doctor refers them to a mental health professional. You the care provider can help them understand that they are there to help the client cope with the pain and not any mental health issues.
Pain Pumps
Pain Pumps are medication delivery devices that inject pain medicines directly into the spine. To lower the risk of infection they are usually surgically placed under the skin. Since the medicine is injected directly into the spine the quantities needed are greatly reduced. Medicines are replenished by injecting the drug into a reservoir in the pump. Dosages can be altered through the use of a remote control device.
Care plan tool
As with any chronic condition, chronic pain is best managed by establishing a plan of action. In medical terms that’s called a care plan. As a medical professional and as part of the care team it is perfectly normal (and in most states legally required) for you the caregiver to ask the doctor to give you a pain management care plan. Pain specialists will have one all set up. They may not be used to working with residential care providers. It will be wise to educate them about what you are and what you can do. Doctors who don’t have pain training might stonewall you. Be patient they probably don’t know what to put into a pain care plan and don’t want to look like they don’t know what to do.
Elements of a basic pain care plan
Each care plan is unique to the patient and their condition but there are elements common to most care plans. If the doctor isn’t forthcoming with a plan of action you can use the following form that might get the process kick started.
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Dr _________.
Your patient _________________ is in (care home name) and under my care. It is required by the state that I get detailed instruction from you in regards to the management of (patient’s name) chronic pain condition.
I understand that most likely we will not be able to totally eliminate all the pain. I also understand that patient feedback is critical in the management of pain. I feel confident that by working closely with you we can manage the pain so that the patient can live a normal life.
Please provide me with your pain management care plan for (patient’s name). I would like to have your instructions about the following.
What pain measurements/evaluations would you like to see and how often?
Would you like a pain/symptom journal kept?
What pain medication and instructions am I to use for base line pain control?
What PRN pain medication and instructions do you have for breakthrough pain?
What preventative, complementary or alternative pain therapy and instruction do you have?
Do you have any instructions about the chronic pain issues of?
Sleeplessness
Pain caused anxiety and fear,
Depression
Exercise (endurance, range of motion, etc…)
Pain medication induced constipation
Pain medication tolerance
Bed rest
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This form works on a couple of different levels.
Common sense Helpful hints.
A lot of good care giving practices are just a good helping of old fashioned common sense. Here’s a few that have been found to help in reducing pain.
Overall Focus
I have talked to you about a lot of things and it’s easy to get lost in all the details so let us get back to the overall focus. Chronic pain management is more than just eliminating pain. It’s dealing with all the contributing factors that affect the pain levels of your client. As you have been shown it is much more than trying to find that “magic bullet’ pill. It goes beyond the “Just fix me Doc” attitude of patients. It’s realizing that doctors do not have a crystal ball and they need your observations and feedback. It’s realizing that many things affects pain levels and it up to you to help find them and help control those events with the goal of making your client feel better. It’s realizing that your pain management efforts will mostly likely never be done. It’s realizing that the most important member of the pain management team is the patient and you as their advocate will have to help them in all their efforts. It’s realizing that good pain management is good care giving and will ultimately make your job easier in the long run.
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Conclusion
Pain is the most prevalent aspect of practicing medicine today. Our focus on pain has become more sharpened. Ongoing research has given us a clearer understanding about what it is and where it comes from. With that new understanding, new and better methods of dealing with pain are being developed.
Care givers must realize that because pain is felt so subjectively, the most effective pain management techniques are patient driven. Because care givers have so much interaction with patients and are their advocates, care givers are the engines that drive the patient’s efforts.
So, after reading these courses about the different aspects of pain, how does your current pain management tool box look? Are there any dull, broken or just plain wrong tools cluttering up your tool box? What efforts are you going to do to get the tools you need and sharpen the dull ones in your pain management tool box?
Good luck in your efforts, I hope you become a pain management expert. Many of your clients certainly need you to be one.
Speaking of pain..... it's time to take the test now.
PS congratulations on finishing pain school.
Other resources
Here are places you can go more information and training. They are designed with the patient in mind. You will get the most out of them by placing yourself in the role of the patient.
References:
1. Thomas E.Quinn. Pain Topics, What is Pseudoaddiction?. PainRreliefCconnection Vol 2 #1.Jan 2004.
http://www2.massgeneral.org/painrelief/pain%20topics/what%20is%20pseudoaddiction.pdf
2. Stephan F. Grinstead. Addiction Versus Pseudoaddiction. Addiction-Free Pain Management blog. Jan 2008 .http://www.addiction-free.com/blog/addiction-versus-pseudoaddiction/
3. Back Pain treatment. Back Pain Center. eHealth.com http://ehealthforum.com/healthcenter/back-pain/back_pain_treatment-e82.html
4. AAPM Facts and Figures on Pain. American Academy of Pain Medicine. http://www.painmed.org/patientcenter/facts_on_pain.aspx
5. Partners Against Pain. http://www.partnersagainstpain.com/
6. American Chronic Pain Association. http://www.theacpa.org/
7.WebMD Back Pain Health Center. http://www.webmd.com/back-pain/default.htm
8. Suzanne Levy. 6 Mistakes Pain Patients Make. Health.com http://www.health.com/health/gallery/0,,20387697_7,00.html
9. John P Revord. Pain Management for Chronic Back Pain. Spine-Health.com.10/12/2012
http://www.spine-health.com/treatment/pain-management/invasive-pain-management-techniques
10. Pain Treatment Topics. Glossary of Terms. Pain Topics.org. http://pain-topics.org/glossary/
11. Massage Therapy: An Introduction. National Center for Complementary and Alternative Medicine 8/2010.
http://nccam.nih.gov/health/massage/massageintroduction.htm#safety
12. Pain Action. http://www.painaction.com/
13. Pain Medications. Drugs.com http://www.drugs.com/condition/pain-generic.html
14. Massage. Wikipedia The Free Encyclopedia http://en.wikipedia.org/wiki/Massage
15. Anesthetic. Wikipedia The Free Encyclopedia http://en.wikipedia.org/wiki/Anesthetic
16. Nora Volkow, The Essence of Drug Addiction. The Brain-Understanding Neurobiology, Teachers Guide. National Institute of Drug Abuse, National Institutes of Health
http://science.education.nih.gov/supplements/nih2/addiction/guide/essence.htm
17. NINDS Chronic Pain Information Page. National Institute of Neurological Disorders and Strokes. 5/22/13
http://www.ninds.nih.gov/disorders/chronic_pain/chronic_pain.htm
18. Sleep Hygiene: Helpful Hints To Help You Sleep. Sleep Disorder Center. University of Maryland Medical Center 8/3/2010
http://www.umm.edu/sleep/sleep_hyg.htm
19. R. Morgan Griffin, When Aches and Pain Disrupt Sleep. Osteoarthritis Health Center. WebMD 2/1/07
http://www.webmd.com/osteoarthritis/features/when-pain-disrupts-sleep
20. Exercise to Help Manage Chronic Pain And/Or Fatigue. War Related Illness and Injury Center, Office of Public Health, Department of Veterans Affairs.
http://www.warrelatedillness.va.gov/education/factsheets/exercise-to-manage-pain.pdf
21. Using the Pain Scale: How to Talk About Pain. Living With Chronic Pain, WebMD.3/9/11
http://www.webmd.com/pain-management/chronic-pain-11/pain-scale?page=2
22. Chiropractic. Wikipedia The free Encyclopedia http://en.wikipedia.org/wiki/Chiropractic
Pain School for Caregivers
Course 3- Chronic Pain
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Pain School for Caregivers
Course 2 Acute Pain
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Pain School for Caregivers
Course 2- Acute Pain
Test Questions
Instructions: Select answer by clicking on circle to the left of selection. (the circle will turn a color when clicked) When done click on [show results] and follow further directions.
You need to be registered and logged in to take this quiz. Log in or Register
Pain School for Caregivers
Course 2- Acute Pain
Author: Mark Parkinson RPh: President AFC CE
Credit Hours 2 - Approximate time required: 120 min.
Educational Goal:
To provide Adult Foster Care providers with information that will help them understand and manage acute pain.
Educational Objectives:
Procedure:
1. Read the course materials. 2. Click on exam portal [Take Exam]. 3. If you have not done so yet fill in Register form (username must be the name you want on your CE certificate). 4. Log in 5. Take exam. 6. Click on [Show Results] when done and follow the instructions that appear. 7. A score of 70% or better is considered passing and a Certificate of Completion will be generated for your records.
Disclaimer
The information presented in this activity is not meant to serve as a guideline for patient management. All procedures, medications, or other courses of diagnosis or treatment discussed or suggested in this article should not be used by care providers without evaluation of their patients’ Doctor. Some conditions and possible contraindications may be of concern. All applicable manufacturers’ product information should be reviewed before use. The author and publisher of this continuing education program have made all reasonable efforts to ensure that all information contained herein is accurate in accordance with the latest available scientific knowledge at the time of acceptance for publication. Nutritional products discussed are not intended for the diagnosis, treatment, cure, or prevention of any disease.
Pain School for Caregivers
Course 2- Acute Pain
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All pain starts off as acute pain. These are the aches that resolve quickly, or at least that is what everyone hopes for. At this point pain is just a symptom of a larger issue. So how do care providers manage acute pain correctly? It’s time to apply some of your new found knowledge from pain school-course 1.
It is human nature to try to resolve the pain as quickly as possible. But as a care giver you have to see things from a broader point of view. If you remember, pain is a warning signal that something is wrong. So the first step in effective care giving would be to understand what is going wrong? What is the patient’s body trying to tell you? Is that head ache, toe pain, or whatever, the tip of a much bigger iceberg of trouble? As you take care of your client’s complaints are you looking for unusual signs and symptoms when the resident is in pain? Or are you just mindlessly signing your initials on the pain med prn medication log? I hope you are getting the point of how to use this knowledge for more effective care giving and not just clicking off another CE hour for re-licensure.
Back to the original question, so how does modern medicine manage acute pain? You find out what’s going wrong and fix it, of course. Then the warning light will turn off by itself, (the pain will resolve itself). That is why the doctor sometimes won’t prescribe pain medication. They are fairly sure that they can take care of the underlining problem and the pain will go away without the use of medication.
Realistically though most often the patient is going to need something extra to help manage the pain. And by managing pain what we’re really talking about is interrupting the pain signal pathway to the brain somewhere. Either you use chemicals (pain meds) or use some other means to mask, replace or stop the nerve pain signal from getting thru to the brain. You’ll be glad to know that I am not going to go into a lot of detail on how each pain remedy affects the pain pathway. That is way too much information and frankly sometimes we don’t even know exactly why a medication or treatment works. But I think some broad category understanding would be useful to you.
How to shut off the pain signal
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There are a lot of different pain killing options to choose from. The choice depends on a lot of different factors. What’s causing the pain? What pain signal pathway is being activated? What are the side effects? What is the doctor’s knowledge of a particular treatment? What is the expectation of the patient? What is the skill level of the care giver? How trustworthy is the patient?
Prevention strategies
The best pain killer is to not have pain in the first place. What can you do as a care provider to prevent pain from happing in the first place? Provide a safe living environment, ensure a healthy lifestyle, maintain a proper diet, get enough exercise (my first suggestion is regular walks), pay attention to the small complaints so they don’t become big ones, maintain proper blood flow and always, see the doctor regularly, always, always fight against a sedentary lifestyle. Having the patient just sit and watch TV may be easy care giving but your just asking for bigger problems down the road. Ever had to deal with a bedsore? It’s worth the effort to; establish a schedule of activities, regularly reposition the patient, massage the legs and back, encourage outings. Good care giving techniques will really pay off in the end. Healthier patients are easier, more “pain free” patients.
NON-DRUG therapies
There are some techniques that can either turn off or interrupt the pain signal without the use of drugs. Some of these are among the oldest known pain therapies and are considered just good care giving practice, which brings up a good question.
When do good care giving techniques turn into therapies and thus need to be approved by a doctor? The rule of thumb is when you have to make a medical decision. For example- you can massage a client’s legs when you apply skin lotion without the doctor’s permission. But if you want to apply a numbing lotion to cure pain then you have made a medical decision and you would have to get prior approval from a doctor. The bottom line is you do have some latitude as caregivers but the more involved therapies should be initiated and approved by the doctor. When in doubt, ask. It will keep you out of trouble.
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Massage is more than just rubbing an area of the body it is the purposeful manipulation of superficial and deeper layers of the muscles, joints and skin using various techniques. You might be surprised to know that there are over 40 different kinds of massages.
How does it work?
Massage is probably the oldest pain relieving therapy that has ever existed. Numerous studies have proven its therapeutic benefits over and over again and yet modern medical science still haven't figured out exactly why it works. Current thinking is massages are beneficial for several different reasons.
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Hot and Cold packs-
Reducing pain by applying Hot or Cold packs or compresses has been around for hundreds of years.
How does it work?
Hot packs are beneficial in the management of pain by increasing blood flow to the area. This brings more nutrients and oxygen to the damaged area and removes metabolic waste. It also relaxes tense muscles and stiff joints, increasing the range of motion in an area which is an important quality of life issue.
Cold packs on the other hand reduce blood flow, reducing inflammation and swelling. Reduced swelling also has a positive effect on range of motion. Additionally cold packs create area numbness, reducing the body’s ability to feel pain.
Alternating hot and cold packs is thought to be of greater benefit than either alone because it relieves a greater combination of factors. In addition constantly changing the areas temperature tends to compete with the pain signal for the brain attention, effectively "drowning out” some of the pain. Something similar happens when we relieve a painfully bumped elbow by rubbing it. Alternating packs is generally reserved for more chronic pain issues.
Other therapies
There are other non-drug therapies that are more complex. They are usually reserved for chronic pain issues so we will cover them in class number three.
Special note- There are those who would include herbs and homeopathic medicines in the non-drug section. Make no mistake, herbs and homeopathic remedies are a chemical therapy thus by definition a drug. The only exception is those herbs eaten for the purpose of food. Caregivers who give their residents an herb as a medical treatment have crossed the line into medical practice and need a doctor’s permission to do so. Even if it’s part of the menu.
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Drug Therapies
Over the years medical science has learn how to chemically alter and interrupt points all along the pain pathway. Caregivers should know how the drug works so that they can know what is going on and monitor the drug for effect. I will explain all the different pain meds as a group or category, based on their chemical structure and mechanism of action.
Pain Drug Categories
Topicals
Topical counterirritants are creams, ointment and oils that stimulate (irritate) the skin. They provide pain relief by diverting some of the mind’s attention away from the original pain signal. The chemicals themselves and the required massaging application techniques also have the added benefit of stimulating blood flow to the area. This increases the body’s own healing and pain resolution ability. An exception to this group is capsaicin (a pepper plant derivative). It has the added benefit of depleting a nerve transmission chemical called substance P. Without enough substance P around the nerves can’t transmit nerve pain signals very well.
APAP
Acetaminophen (Tylenol) is an analgesic that that blocks the pain signal and disrupts some of the chemical pathways in the central nervous system. It is considered a first-line therapy because its use is relatively safe, though it is possible to take too much and cause liver damage. It is not recommended to take more than 4 grams per day or 1.5 grams per day in continuous use from all sources. Many other medications contain acetaminophen and must be included in the daily limits. Unfortunately, acetaminophen does not reduce inflammation.
NSAID
Non-Steroidal Anti-Inflammatory Agents (NSAID) are drugs that reduce pain by modulating the inflammatory process that triggers the pain signal. They also help reduce the redness and swelling associated with such events. There are many side effects associated with this class of medication, which can include upset stomach, ulcers, tinnitus (ringing in the ears), heart and kidney problems, and blood thinning. Celecoxib (Celebrex) is a newer NSAID that has fewer side effect problems. Diclofenac (Voltarin) is available as a gel that is applied to the skin, which helps bypasses many of the NSAIDs troublesome side effects.
Other Agents
Other common anti-Inflammatory agents include Aspirin, and Magnesium Salicylate (Doans pills). They have a similar side effect and efficacy profiles as the NSAIDs.
Opiates
Opiate, narcotic and synthetic narcotics are pain killers that directly block the central nervous system pain receptors. As such they are very powerful pain killers. They are designed to mimic the body’s own pain killing endorphins. Unfortunately, this also leads to euphoria which means opiates can be diverted (stolen) and abused. Addictions are also possible but not always, more about this subject later. They are usually reserved for when other therapies produce difficulties or fail to relieve pain.
Steroid Injections
Intra-Articular Glucorticoids (Steroid Joint Injections) are a synthetic version of our bodies’ own anti-inflammatory chemicals. They are very powerful drugs, but are limited in their use due to their side effects and difficult route of administration.
OTC
Herbal Remedies and OTC supplements have been used for pain relief for a long time. Unfortunately, not much scientific research has been done on these cures and they are not officially FDA approved. They are medicines and must be reviewed by the patient’s doctor before they are used. Commonly used remedies for arthritis pain are Glucosamine, Chondrotin, S-adenosylmethionine (SAMe) and Methylsulfonylmethane (MSM). These medicines take a long time to be effective. It has been recommended that the patient take the supplements for at least a month before determining their continued use. They have limited use in Rheumatoid Arthritis. Willow bark extract contains aspirin. Clove oil and Tea tree oil can have numbing effect on the skin.
Numbing Anesthetics
One way to eliminate pain is to reduce or completely block all feeling in the nerves which is called anesthesia. There are two classes of drugs; general anesthesia that cause a loss of consciousness (used in surgery) and local anesthesia used for a limited area of the body. The medications are topical (on the surface) or injections. The anesthetic agents most seen and used by care givers are mild numbing cream and ointments that help with skin irritations, cold sores and teeth numbing agents.
Nerve pain
Nerve pain originates from the nerve fibers themselves. These types of pain are generally harder to manage. The damage to the nerve fibers make the nerve fire easier. This results in random and uncontrolled nerve signals to the brain. Traditional pain killers just don’t work very well in controlling this type of pain. Fortunately it was discovered that anti-seizure medications that was used to slow down or block the nerve function itself could be utilized to relieve some nerve pain.
Add ons
There are many drugs that are used as add on therapy that you would not normally be considered pain killers. They help relieve pain by helping to control contributing factors that make us feel pain more intensely. Anxiety, depression and stress are symptoms that are major contributors to how we feel pain. Usually reserved for chronic pain conditions, nevertheless care givers should not be surprised if they see drugs like antidepressants, muscle relaxers, and sedatives used in conjunction with pain meds. The care provider can help the patient understand why they are being used if they have questions. For example it can confuse and worry a client if the doctor all of a sudden prescribes an anti-depressant medication to a patient who feels they are not depressed.
Care givers and medications
It is not by accident that another name for practicing health care is practicing medicine. Medication use involves a major portion of how we treat patients. We have done some amazing things through the use of drugs. Unfortunately these chemicals can interfere with other portions of our bodies as well. Professional care giving requires that you understand what the medicine is for (what is the purpose of taking the chemical). What are the goals of therapy (what is the doctor trying to do). What effects do you have to monitor the patient for (is it having the desired effect). Are there significant side effects (unintended drug effects that are interfering with the patient’s welfare)?
You may think (like most patients) that you don’t have to worry about all the details because doctor and pharmacist will take care of them. You as a professional care giver are part of the medical team, in my opinion the most important part. You live with the patient. You have more opportunity to monitor the patient than all other members of the health care team combined. With your full involvement patients can reach therapeutic goals faster and problems can be resolved much quicker. All it requires is you read the drug information that comes with the medication, know what the doctor is trying to treat (diagnosis) and communicate effectively with the doctor.
Here is a general overview of pain medication that will help monitor for effect. For more details contact your pharmacist.
|
Drug Class |
On set of action |
How they work |
Major side effects |
|
Topical counterirritants |
Very quick |
Creates hot and cold sensations that competes with pain signal for the brain attention |
Skin irritation |
|
APAP |
½ - 1 hour |
Acts on the central nervous system. |
High dose liver toxicity |
|
NSAID |
¼ - 1 hour |
Interrupts the chemical cascade that leads to inflammation |
Some sedation, Stomach problems with long term use, interacts with blood thinners, nausea |
|
Opiates |
¼-1/2 hour |
Binds to opioid receptors in the central nervous system that produces pain relief and euphoria |
Euphoria, sedation, breathing problems, dizziness , dependency hallucinations, nausea, allergies |
|
Steroids |
Very slow, days |
Interrupts the chemical cascade that leads to inflammation |
Nausea, injection site reaction |
|
Numbing agents |
Very quickly |
Stops nerves from feeling |
Skin reactions, allergies |
|
Nerve pain agents |
Slow- hours to days |
Changes the way nerves send signals to the brain |
sedation |
|
Antidepressants |
Very slow- days to weeks |
Alters the chemical balance in nerves and brain |
Sedation, alters mood, nausea hallucinations, dizziness |
|
Muscle Relaxers |
½-1 hour |
Alters nervous system |
Dependency, euphoria, sedation, dizziness |
|
Anti-anxiety |
Slow- hours to days |
Alters the chemical balance in the nerves and brain |
Dependency, sedation, dizziness |
Pain and the PRN medication orders
Most pain prescriptions end with PRN or take as needed. Sometimes I think that the doctor should give better instruction than that. PRN forces the caregiver to make a decision, “when does the patient need it? So to help the care provider make good decisions about “take as needed” med orders, consider the following.
I always tell people that they will use less medication if they keep the pain under control. Don’t wait until you have a five alarm fire pain before getting help. It takes more water (drugs) to put it out.
A Major issue with pain meds- Abuse
Pain killer drug abuse is a serious problem in health care today. It is an unavoidable problem that needs to be address in every health care setting where they are used. Home owners and care givers must understand the problem, monitoring drug use vigilantly, and aggressively solve issues before they become problems.
Understanding
Drug abuse and addiction have become part of our pop culture. There are so many myths surrounding it that it’s hard to understand what really is happening. We are constantly being bombarded with information that makes a good story line but is just plain wrong. You need to take some time to become familiar with some proper definitions to key terms concerning drug abuse.
Addiction
Our understanding of term addiction has become clearer after much research. It is a complex reaction with physical, emotional and genetic factors. Simply put, addiction is a brain disease process that is characterized by compulsive drug cravings, where the individual has impaired self-control. Impairment is so advanced that drug use will persist despite potentially devastating consequences. Due to multiple factors the drug use has grown beyond voluntary control. Some of those factors are genetics, social pressures, mental health, and impairment of brain development. It is important to remember that addiction is both a psychological and biological occurrence. True addiction is occurring when the patient cannot physically and emotionally resist the urge to take the medication.
Dependency
Drug dependence means that a person needs a drug to function normally. It usually takes a prolong period of use for dependency to develop. Abruptly stopping the drug leads to withdrawal. Dependency itself is not always a bad thing. It all depends on why the medication is being used and what the consequences are for continued use verses stopping the drug. Example- an advanced arthritic patient with no joint cartilage will be dependent on pain killers to function normally. Being dependent on a drug is not the same thing as being addicted.
Withdrawal
Withdrawals are the symptoms an individual experiences after reducing or stopping a drug that is beyond what was caused by the original condition for which the medication was taken. The symptoms are frequently the opposite of what the meds are taken for. For example pain med withdrawal creates more sensitivity to pain, anti-anxiety withdrawal creates more anxiety. For drugs that create euphoria, withdrawal often generates depression, anxiety and craving. When the cravings become so strong that it overcomes the user’s voluntary control, addictive behaviors start to occur.
Abuse
Abuse is any use of a drug beyond what is prescribed by the doctor or manufacturer instructions. It may seem like an overly harsh definition but that is really what abuse is. You do not have to be addicted to abuse a drug, and most people who abuse drugs don’t become addicted. Yes, you can abuse OTC medication.
Diversion
Diversion is the use of a medication by any person other than whom it was originally intended. It is theft and a felony. Caregivers who “borrow” medication are putting themselves at a very high risk, even if they are giving it to a family member or another resident. They would also be guilty of practicing medicine without a license and patient abuse.
Tolerance
Often a patient’s body will become use to a medication and more drugs will be required to achieve the same results. Tolerance almost always develops with opiate pain killers though at different rates with different people. Tolerance for a drug creates a real need for higher doses and is often confused with addiction. The main outward difference is what the patient is willing to do in order to get the desired drug effect. Developing tolerance is not the same as becoming addicted.
Pseudo addiction
Addiction is a very complex drug outcome. There is always a risk of becoming addicted to any pain medication that creates euphoria but the risk may not be as high as people might think. Some experts think that real addiction occurrence can be as low as 3-20% with long term use.
No one wants themselves or a patient to become addicted to a drug. Such thinking often creates fear, which leads patients and practitioners to misinterpret pain symptoms. The natural effects of tolerance and dependence are often mistakenly labeled as addictive behaviors.
In addition sometimes the fear of addiction and lack of knowledge about pain will lead prescribers and caregivers to under treat a painful condition. Not enough drugs are given to eliminate the pain and the patient suffers terribly. Understandably after suffering for so long the patient becomes more aggressive about obtaining pain relief. Such aggressiveness mistakenly leads the practitioners to believe the patient is becoming addicted and they limit the pain killers even more. Tragically this leads to more suffering and more aggressive addictive behaviors. This maladaptive behavior is known as pseudo-addiction and is actually caused by the medical prescriber and or caregiver. The main way to tell addiction and pseudo-addiction apart is in pseudo-addiction aggressive drug seeking behaviors will subside once pain is adequately controlled.
Monitoring Vigilance
There are many ways that pain medication therapy can get sidetracked. Too much drugs given, too little drugs given, side effects problem, abuse and diversion are all pitfalls of managing pain medication. The main way that care givers can avoid the pitfalls of pain therapy is to diligently paying attention to the medication administration record (MARS) and follows the doctor’s orders. The following are some of my thoughts on how to be diligent.
Aggressive intervention
Because drug abusers hide their activities, irregularities such as the ones listed above are red flags that must be followed up on. You are not doing anyone any favors by ignoring the problem. The main characteristic of addiction is that abusers have lost the ability to control themselves and need outside help. The first step to getting that help is by blowing the whistle on them. The cycle of abuse most often has to be broken from someone else. By not doing anything you’re actually saying, “Go ahead and ruin your life. I don’t care about you or the others around you that are being harmed.” For care home owners not catching and getting rid of drug abuse is a business killer. Your reputation and thus your income is on the line.
Conclusion
End of Course 2
Acute pain is managed as a symptom of larger issues. Treatment emphasizes taking care of the underlining problem and the temporary relief of pain through various therapies. Caregivers must remember that pain is a warning signal of the body that something is going wrong. More effective caregiving entails a more investigative approach to the management of acute pain. Find out what is going wrong first then treat the pain.
Caregivers must also remember that acute pain management goes beyond the simplistic “a pill for every ill” approach. Non pill therapy can be just as effective as oral pain killers. If a medication is chosen for acute pain relief, skill and understanding must be practiced by caregivers and their supervisors. These efforts are necessary for safe, effective therapy and to avoid the pitfalls of abuse.
It’s time to test your knowledge again with another exam-Good Luck. 
After you take the exam- class is dismissed.
References:
1. Thomas E.Quinn. Pain Topics, What is Pseudoaddiction?. PainRreliefCconnection Vol 2 #1.Jan 2004.
http://www2.massgeneral.org/painrelief/pain%20topics/what%20is%20pseudoaddiction.pdf
2. Stephan F. Grinstead. Addiction Versus Pseudoaddiction. Addiction-Free Pain Management blog. Jan 2008 .http://www.addiction-free.com/blog/addiction-versus-pseudoaddiction/
3. Back Pain treatment. Back Pain Center. eHealth.com
http://ehealthforum.com/healthcenter/back-pain/back_pain_treatment-e82.html
4. AAPM Facts and Figures on Pain. American Academy of Pain Medicine.
http://www.painmed.org/patientcenter/facts_on_pain.aspx
5. Partners Against Pain.
http://www.partnersagainstpain.com/
6. American Chronic Pain Association.
7.WebMD Back Pain Health Center.
http://www.webmd.com/back-pain/default.htm
http://www.health.com/health/gallery/0,,20387697_7,00.html
http://www.spine-health.com/treatment/pain-management/invasive-pain-management-techniques
10. Pain Treatment Topics. Glossary of Terms. Pain Topics.org.
http://pain-topics.org/glossary/
11. Massage Therapy: An Introduction. National Center for Complementary and Alternative Medicine 8/2010.
http://nccam.nih.gov/health/massage/massageintroduction.htm#safety
12. Pain Action.
13. Pain Medications. Drugs.com
http://www.drugs.com/condition/pain-generic.html
14. Massage. Wikipedia The Free Encyclopedia
http://en.wikipedia.org/wiki/Massage
15. Anesthetic. Wikipedia The Free Encyclopedia
http://en.wikipedia.org/wiki/Anesthetic
16. Nora Volkow, The Essence of Drug Addiction. The Brain-Understanding Neurobiology, Teachers Guide. National Institute of Drug Abuse, National Institutes of Health
http://science.education.nih.gov/supplements/nih2/addiction/guide/essence.htm
17. NINDS Chronic Pain Information Page. National Institute of Neurological Disorders and Strokes. 5/22/13
http://www.ninds.nih.gov/disorders/chronic_pain/chronic_pain.htm
18. Sleep Hygiene: Helpful Hints To Help You Sleep. Sleep Disorder Center. University of Maryland Medical Center 8/3/2010
http://www.umm.edu/sleep/sleep_hyg.htm
19. R. Morgan Griffin, When Aches and Pain Disrupt Sleep. Osteoarthritis Health Center. WebMD 2/1/07
http://www.webmd.com/osteoarthritis/features/when-pain-disrupts-sleep
20. Exercise to Help Manage Chronic Pain And/Or Fatigue. War Related Illness and Injury Center, Office of Public Health, Department of Veterans Affairs.
http://www.warrelatedillness.va.gov/education/factsheets/exercise-to-manage-pain.pdf
21. Using the Pain Scale: How to Talk About Pain. Living With Chronic Pain, WebMD.3/9/11
http://www.webmd.com/pain-management/chronic-pain-11/pain-scale?page=2
22. Chiropractic. Wikipedia The free Encyclopedia
http://en.wikipedia.org/wiki/Chiropractic
Pain School for Caregivers
Course 2- Acute Pain
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Pain School for Caregivers
Course 1 What is Pain?
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Exam
Pain School for Caregivers
Course 1- What is Pain?
Test Questions
Instructions: Select answer by clicking on circle to the left of selection. (the circle will turn a color when clicked) When done click on [show results] and follow further directions.
You need to be registered and logged in to take this quiz. Log in or Register
Pain School for Caregivers
Course 1- What is Pain?
Author: Mark Parkinson RPh: President AFC CE
Credit Hours 1.5- Approximate time required: 90 min.
Educational Goal:
To provide Adult Foster Care providers with information that will help them understand and manage pain.
Educational Objectives:
1. Give a better understanding of what pain really is.
2. Provide the definitions of pain terminology
Procedure:
1. Read the course materials. 2. Click on exam portal [Take Exam]. 3. If you have not done so yet fill in Register form (username must be the name you want on your CE certificate). 4. Log in 5. Take exam. 6. Click on [Show Results] when done and follow the instructions that appear. 7. A score of 70% or better is considered passing and a Certificate of Completion will be generated for your records.
Disclaimer
The information presented in this activity is not meant to serve as a guideline for patient management. All procedures, medications, or other courses of diagnosis or treatment discussed or suggested in this article should not be used by care providers without evaluation of their patients’ Doctor. Some conditions and possible contraindications may be of concern. All applicable manufacturers’ product information should be reviewed before use. The author and publisher of this continuing education program have made all reasonable efforts to ensure that all information contained herein is accurate in accordance with the latest available scientific knowledge at the time of acceptance for publication. Nutritional products discussed are not intended for the diagnosis, treatment, cure, or prevention of any disease.
Pain School for Caregivers
Course 1- What is Pain?
When considering medical topics care givers usually don’t think of pain as a separate subject. We usually consider it as part of other topics such as cancer or back injury. Did you know that in the US, pain is the number one medical concern of all patients? It is THE reason why patients see doctors. It is by far the most common complaint, more than all other complaints combined. Think about it, isn’t the first words out of your mouth at a doctor’s office is “Doc, I have a pain right here”. I bet that if you did a study that a major part of your own care giving efforts would be involved in taking care of pain. If pain is such a big concern why don’t we in the medical community make a bigger deal about it? Why don’t we focus more attention on the problem? Why don’t you think about pain as a separate subject?
The answers to those questions are more complicated than you think. For being such a prevalent subject, it’s surprising what misconceptions and lack of knowledge surrounds the concept of pain. What you think you know turns out to be inaccurate, incomplete and sometimes just plain wrong. There have been a lot of advances in the study of pain and caregivers must bring themselves up to speed. What you need is to start fresh from the beginning. What you need is to go back to school, pain school. The following course is the first of a three part series of CE courses, designed to help you think of pain as a separate component of care giving. They will help you know what it is and why we have pain. They will give you the knowledge and care giver tools that you need to manage the aches and pains of your clients more effectively.
So let’s get started, School is now open.
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Understanding the Basics of Pain
Is Pain Bad?
Pain is a tricky subject for caregivers. We and our residents are genetically and socially hard wired to avoid it. We eliminate pain as quickly as possible. When we can’t get rid of the pain our whole life is affected. We usually don’t even want to think about the subject of pain. There is just no good that comes from it, right? Don’t be so fast to judge, pain is good. That’s right; pain is a blessing, a necessary and important part of your residents lives. It helps them avoid trouble and keeps them from damaging themselves. Where would you be without pain? You’d probably be dead that’s where, or at least always in danger of being hurt. Those who can’t feel pain have to spend most of their time and efforts being very, very careful. Without the aches and pains of your patients your care giving job would be much more difficult. As caregivers your real job is not to eliminate pain but to manage it. The first step of effective pain management is to understanding what pain really is?
What is pain?
It may sound like a silly question. Everyone has experienced it, so we all know what pain is, right? Let me ask the question in a different way. We all know what pain feels like but do we know what pain actually is? Understanding the answer to this most basic question is critical in attempting to managing pain.
Pain as defined by the experts
"An unpleasant sensory and emotional experience associated with actual or potential tissue damage, or described in terms of such damage." International Association for the Study of Pain (IASP)
"Huh" What a mouthful, let me try to put that into everyday language. Pain is a reactionary defensive mechanism whereby the mind interprets signals from the nerves as unpleasant for the purpose of stimulating action to prevent injury, even if there is just the potential for injury and no actual damage.
That's still is a pretty complicated definition. Let us break it down a bit further and explain some details that will help you later on.
First: Let's start with nerve signals to the brain.
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The nerves are a system of specialized tissues built to send electro-chemical signals, mainly to and from the brain. Individual nerve cells are set in a series, like wiring all through the body. Eventually the "wiring" connects to the spinal column and then to the brain. Surrounding and in the nerves (especially at the ends) are chemical ions that carry tiny electrical charges. Normally these charges are balanced and nothing happens. But alter the chemicals even a little bit and the balance tips, resulting in an electric signal build up. Once the electricity reaches a certain charge the nerves "fires" and sends the charge all the way to the end where it upsets the ion balance of the next nerve. Thus the next nerve fires and so on, sending the signal eventually to the brain. Once the signal is gone, nerves quickly bring all the chemical ions back into balance again and the nerve is "reset" for the next stimulus.
The brain interprets the nerve signal
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When a nerve signal reaches the brain, it is just an "on" signal. There is no such thing as a pain signal, or a hunger signal, etc… The brain has to receive input signals from other nerves and interpret what the combination of signals mean. Once the brain has enough signals it can figure out what is going. It's amazing to me that all the complex action, reaction, thoughts and emotions we have all comes down to is combination of on or off signals. Of course nerve function is much more complicated than that. There are millions of nerve cells. Each nerve is connected to each other at several points creating trillions of connections. Don't forget about the complex chemical "ion soup" that effects the on and stay off signal. All these trillions of connections all going on or staying off in infinite variety is what really creates the interpretation of nerve signals we call brain function.
Second: Let’s consider how nerve and brain function relates to what we call pain.
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Most of the nerve function of our body happens automatically without much active thought from us. Our heart beats, we breathe in and we breathe out, our senses constantly send signals etc…. It all occurs automatically as we move through our life. Then something happens that starts to damage our tissues. Let's say our hand gets too close to a fire. Lots of nerve signals flood toward the brain. Our brain receives the sudden rush of signals and automatic alarms systems (Pain) start going off. Those alarms (Pain) are reporting that our hand is getting damaged and you got to do something about that. Our body quickly pulls the hand away.
Unfortunately we weren't fast enough and some fingers got damaged. The nerves continue to send signals to the brain that something is still wrong. New alarms go off (Pain) and your brain thinks "I have to do something about that". Over the years our brain has learned that cold blocks out hot. So reacting to the alarms going off (Pain), we stick our hand in cold water to try to stop the heat damage signals. With no damage signal happening the alarms (Pain) are turned off. As a result the cold water cools down the damaged hand, preventing further harm. In the future when our hand starts to feel the heat we remember what happened before and the whole process happens even faster, preventing future tissue injury.
So pain is a reaction to nerve stimulus that is produced in the brain after the fact, not at the point of damage. Pain is a learned "output" of the brain that is supposed to stimulate a physical reaction, not the nerve signal input itself. After the brain has become sensitized to the process (learning), pain can happen even if there is no tissue to damage. All the brain needs is enough of the right combination of nerve signal inputs to set the alarm off.
A new way of thinking about pain.
For most of you this will be a brand new set of thoughts that is hard to swallow. But consider, knowing what you know now, can you explain phantom limb pain? Pain that is "felt" even when the limb is not there. Or can you understand why you feel the pain of a cut only after you see the blood dripping out of the wound.
This is pretty deep medical thinking and it goes against what is commonly thought. But as you go through your life consider what is going on around you in regards to pain and how you react to it. You'll find that some of those loose dots of your life start to get connected with understanding. You can now start to form a clearer picture of what actually is going on. A clearer picture gives you power over pain that you did not have before. With this new understanding your care giving efforts will become much more effective in helping your resident’s live normal lives.
The Language of Pain
Pain is a multifaceted medical concept. It seems so simple and yet is very complex because of the many variables involved. It can be felt in every part of the body, to varying degrees and for different length of time. Each person feels pain differently and many factors contribute to how pain is perceived and felt. In order to make sense of it all and communicate effectively special terms have been added to the medical language of our time.
But with new terminology come new challenges.
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I've seen it over and over again. Well-meaning medical professionals start to tell a patient or their caregiver what they are supposed to be doing. They start spouting phrases and words that seem to come from a different planet. When the patient's eyes start to glaze over and their mouth hang slack the medical professional will say something like "Do you understand what I just said?" How are you supposed to follow instructions when you don't even know what the words mean? How are you supposed to be a good caregiver when everyone is talking in a foreign language? -"Medicalesse".
Get the Book
When you're in a foreign country you bring along a translating book so you can understand and make communication easier. It's time for you to get a Medicalesse translation book. They are medical dictionaries, medical terminology workbooks and medical encyclopedias. You can get small inexpensive pocket versions where ever books are sold and on-line from your computer.
They are easy to use and small enough to carry with you. So do that- carry it with you. Bring it to doctor appointments, set it by the computer, and use it when you need to. When you understand the terminology better you will start to understand better what to manage and how better to care for your patients.
Knowing what to do will give you power over the pain.
Pain Terminology
Ache and pains can be experienced and described in a dizzying amount of ways. Literally each case can be different from all others. To make sense of all those cases, modern medicine has classified the different types of pain that a person can experience.
Descriptive terms
Duration:
It may not seem like it at times but pain is a temporary situation. A basic truth of pain is "Usually pain lasts only as long as the brain sees a need for it." There are two general categories that describe how long pain has lasted.
Sometimes you'll see Subacute which means pain that lasts 1 to 6 months
Intensity:
Everyone feels pain differently. There is no way to subjectively measure how intense pain is. Therefore pain is most often measured objectively by a pain scale. For example- "On a scale of 1 to 10, ten being the worst pain imaginable, what is your pain like today?" We'll cover pain scales later. Because pain is subjective- everyday descriptive terminology is most often used. Like dull, sharp, tingly, cold, hot, etc….
Location:
Even though pain is generated in the brain the stimulus for the pain comes from a different location. To help describe the location of the stimulus, terms are stuck on to the word pain, like the following;
Classification:
Another basic truth is- Pain comes from our nervous system, not from the damage being done. It is possible to have damage done to the body without feeling pain and it is possible to feel pain without any damage being done. To help recognize which part of the nervous system is being activated the following terms are used.
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Classifications of Pain |
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Nociceptive Somatic Visceral |
Non-Nociceptive Neuropathic Sympathetic |
Nociceptive- pain signals that start at the ends of the nerves where the feeling receptors are.
Non-Nociceptive- pain that starts where there is no feeling receptors present. You might think how is that possible? Remember, nerve signals are just an electrochemical charge flowing to the brain. The nerves can still "fire" without them being touched.
Neuropathic- (also known as nerve pain) Pain that is caused by a lesion or disease anywhere on a nerve. (example shingles or a stroke)
Sympathetic- Pain that is caused by injury or abnormality in the sympathetic nervous system. These are the nerves that control the automatic systems of the body and the flight or fight response. (example generalized post surgery pain)
*note- In non-Nociceptive pain something has damaged the nerves and they become unstable and fire chaotic signals. The brain interprets these random signals as a pain alarm.
Other important terms
Allodynia- pain due to a stimulus that does not normally provoke pain
Analgesia- absence of pain in response to stimulation which would normally be painful. (analgesic = pain killer)
Anesthesia- the absence of all senses
Angina- pain associated with cardiac conditions.
Breakthrough- short term pain that is not relieved by normal pain management
Intractable pain- intense chronic pain that cannot be relieved by medical intervention
NSAID- Non-steroidal Anti-Inflammatory Drug, medication that controls pain by reducing the inflammatory response.
Neuralgia- pain in the nerves
Neuritis- inflation of the nerves
Neuropathy- change in the function of a nerve due to damage or disease
Noxious Stimulus- nerve stimulus that is potentially or actually causing tissue damage
Opioid Analgesics- narcotic pain killing drugs
Pain Tolerance threshold- the level of pain that motivates pain relieving activity.
Palliative therapy- designed to make the patient comfortable without attempting to cure the illness.
Parenthesis- an abnormal sensation, whether spontaneous or evoked
Psychogenic- pain that is caused prolonged or intensified by emotional, mental and behavioral factors
Pseudo-addiction- development of addiction behaviors that are actually desperation attempts to get relief from uncontrolled pain.
Radiculopathy- disturbance of function or pathologic change in one or more nerve roots
Refractory pain- pain that is resistant to therapy
Sensitization- nerves become more sensitive to inputs. (feeling things easier)
Rebound headache- headache that occurs after the pain medication wears off
Salicylates - a class of pain killers that includes aspirin
Sciatic- pain radiating from the back into the buttock and leg along it’s the back or side
Trigger point- a hypersensitive area or site in muscle or connective tissue
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Practice
It may feel strange and confusing at first, but practice by actually using the terminology. Once you sound like you know what you are talking about, people will start to pay attention to you. The medical community will start to be more cooperative as well. Your knowledge may be small now but it will grow!
As more and more adult foster care providers start sounding like medical professionals the whole in-home care provider industry will benefit.
Why should I even care?
If you’re like me at this point your brain is starting to get tired of dealing with abstract ideas like anatomy and medical terminology. You might be thinking, “What does all this have to do with what I am doing in my home and my clients?” What I am attempting to do is give you a better understanding what is actually going on. With this view of the bigger picture you’ll understand what is actually going wrong in the lives of your clients and what the doctor is attempting to do about it. With this greater understanding you’ll be able to focus your efforts on more effective care giving. You’ll be able to ignore old wives fables and quack placebo remedies. You’ll be able to be more effective in patient monitoring and communicating that information back to the doctor for quicker problem resolution. Ultimately, your clients will be pain free quicker, therefore happier and easier to take care of.
Applying Your Knowledge About Pain
An underlining principle of care giving in pain management is that everyone experiences pain differently. There is no-one size fits all. What works for pain in one case may not work for another. What remedies works for the mom may not work for the daughter, etc …. Because of this variability most medical professionals treat pain in a systematic way. Starting low and climbing a ladder to more potent remedies. Sometimes that ladder is more an elevator zooming up to the more powerful remedies fast. But the basic idea is the same. Start with what you think they need then titrate up (give them more by degrees) until the patient is comfortable.
Conclusion
End of Course 1
Hopefully by now you are more up to speed with your understanding of what pain really is. With some practice you can now even speak the language of pain. With this better understanding you are now prepared to learn how to be more effective in managing it. In Courses two and three you will be taught about acute and chronic pain management. As with any school it’s now time to test your knowledge with a final exam-Good Luck.
After you take the exam- class is dismissed.
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References:
1. Thomas E.Quinn. Pain Topics, What is Pseudoaddiction?. PainRreliefCconnection Vol 2 #1.Jan 2004.
http://www2.massgeneral.org/painrelief/pain%20topics/what%20is%20pseudoaddiction.pdf
2. Stephan F. Grinstead. Addiction Versus Pseudoaddiction. Addiction-Free Pain Management blog. Jan 2008 .http://www.addiction-free.com/blog/addiction-versus-pseudoaddiction/
3. Back Pain treatment. Back Pain Center. eHealth.com
http://ehealthforum.com/healthcenter/back-pain/back_pain_treatment-e82.html
4. AAPM Facts and Figures on Pain. American Academy of Pain Medicine.
http://www.painmed.org/patientcenter/facts_on_pain.aspx
5. Partners Against Pain.
http://www.partnersagainstpain.com/
6. American Chronic Pain Association.
7.WebMD Back Pain Health Center.
http://www.webmd.com/back-pain/default.htm
http://www.health.com/health/gallery/0,,20387697_7,00.html
9. John P Revord. Pain Management for Chronic Back Pain. Spine-Health.com.10/12/2012
http://www.spine-health.com/treatment/pain-management/invasive-pain-management-techniques
10. Pain Treatment Topics. Glossary of Terms. Pain Topics.org.
http://pain-topics.org/glossary/
11. Massage Therapy: An Introduction. National Center for Complementary and Alternative Medicine 8/2010.
http://nccam.nih.gov/health/massage/massageintroduction.htm#safety
12. Pain Action.
13. Pain Medications. Drugs.com
http://www.drugs.com/condition/pain-generic.html
14. Massage. Wikipedia The Free Encyclopedia
http://en.wikipedia.org/wiki/Massage
15. Anesthetic. Wikipedia The Free Encyclopedia
http://en.wikipedia.org/wiki/Anesthetic
16. Nora Volkow, The Essence of Drug Addiction. The Brain-Understanding Neurobiology, Teachers Guide. National Institute of Drug Abuse, National Institutes of Health
http://science.education.nih.gov/supplements/nih2/addiction/guide/essence.htm
17. NINDS Chronic Pain Information Page. National Institute of Neurological Disorders and Strokes. 5/22/13
http://www.ninds.nih.gov/disorders/chronic_pain/chronic_pain.htm
18. Sleep Hygiene: Helpful Hints To Help You Sleep. Sleep Disorder Center. University of Maryland Medical Center 8/3/2010
http://www.umm.edu/sleep/sleep_hyg.htm
19. R. Morgan Griffin, When Aches and Pain Disrupt Sleep. Osteoarthritis Health Center. WebMD 2/1/07
http://www.webmd.com/osteoarthritis/features/when-pain-disrupts-sleep
20. Exercise to Help Manage Chronic Pain And/Or Fatigue. War Related Illness and Injury Center, Office of Public Health, Department of Veterans Affairs.
http://www.warrelatedillness.va.gov/education/factsheets/exercise-to-manage-pain.pdf
21. Using the Pain Scale: How to Talk About Pain. Living With Chronic Pain, WebMD.3/9/11
http://www.webmd.com/pain-management/chronic-pain-11/pain-scale?page=2
22. Chiropractic. Wikipedia The free Encyclopedia
http://en.wikipedia.org/wiki/Chiropractic
Pain School for Caregivers
Course 1- What is Pain?
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