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Advanced Musculoskeletal > Persistent Pain Eval/Treatment > Flashcards

Persistent Pain Eval/Treatment Flashcards

1
Q

3 parts of the pain assessment

A
  • characteristics
  • meaning
  • effect on individual
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2
Q

5 goals of eval/pain assessment

A
  • create the therapeutic alliance/relationship
  • identify symptom behaviors
  • identify yellow flags
  • identify the pain dominance
  • identify asterisk signs
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3
Q

why do we need to create the therapeutic alliance/relationship?

A
  • association with outcomes
  • increases ability to challenge their beliefs
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4
Q

identify yellow flags

A
  • beliefs/expectations
  • psychological irritability
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5
Q

subjective information

A
  • symptom behavior and irritability
  • pain intensity - relies on patients memory
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6
Q

short term memory

A
  • relatively accurate average pain intensity
  • poor agreement for worst/least pain
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7
Q

long term memory

A
  • inaccurate recall of pain intensity
  • good recall of location and activities that decrease pain
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8
Q

persistent pain patients have …..

A
  • seen multiple providers
  • been given multiple diagnoses
  • received multiple treatments
  • had multiple failures
    ALL LEADING TO POOR EXPECTATIONS AND MALADAPTIVE BELIEFS
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9
Q

patient’s beliefs are significantly influences by…

A

providers
- we can have a strong effect over beliefs and expectations by modifying content
- identify/change maladaptive beliefs and negative expectations

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10
Q

yellow flags

A
  • psychosocial risk factors that may be barriers to progress
  • fear
  • anxiety
  • fear avoidance
  • maladaptive beliefs
  • low social support
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11
Q

Yellow flags - emotions

A
  • fear of increased pain
  • depression
  • irritability
  • anxiety
  • stress
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12
Q

yellow flags - behaviors

A
  • extended rest
  • poor compliance w/ exercise
  • excessive reliance on aids/devices
  • high intake of medication or alcohol
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13
Q

yellow flags - family

A
  • overprotective
  • punitive response (“I’ve got to do everything now”)
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14
Q

yellow flags - work

A
  • fear that returning to work with damage the spine
  • belief that work is harmful
  • unhappy at work
  • previous negative experiences with work/LBP
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15
Q

yellow flags - compensations

A
  • extended time off work
  • number of WC claims
  • previous history of LBP
  • lack of incentive to return to work
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16
Q

yellow flags - diagnosis and intervention

A
  • sanctioning disability
  • conflicting diagnoses
  • too many healthcare providers
  • passive treatments
  • lack of satisfaction
  • selling treatment in numbers
  • interactions with the provider
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17
Q

yellow flag screening tools

A
  • OMPSQ: self administered pain screening questionnaire
  • Central sensitization inventory
  • Tampa scale of kinesiophobia
  • pain catastrophizing scale
  • fear avoidance beliefs questionnaire
  • neurophysiology of pain questionnaire
  • patient specific functional scare
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18
Q

Orebro Musculoskeletal Pain Screening Questionnaire

A
  • drill down on the intake forms and questionnaires
  • why did they answer the way they did?
  • how the answers affect their lives?
  • what they feel like the barriers to changing these are?
  • use through episode of care
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19
Q

What is psychological irritability

A
  • how aggressively can you challenge beliefs before the patient goes on the defensive
  • How difficult will it be to get the patient to “return to baseline”
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20
Q

What is psychological irritability determined by?

A
  • strength of patient beliefs
  • strength of therapeutic alliance
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21
Q

is psychological irritability static or dynamic?

A
  • dynamic
  • constantly changing over the course of treatment
  • increased trust –> decreased psychological irritability
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22
Q

motivational interviewing

A

OARS
- open ended questions
- affirmations
- reflective listening
- summarizing

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23
Q

motivational interviewing

A
  • RISE
  • roll with resistance (avoid arguing)
  • identify discrepancies
  • support self-efficacy
  • engage with empathy
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24
Q

Nociceptive dominant pain pattern summary

A
  • pain initiated by activation of peripheral receptors of primary afferents in response to noxious chemical, mechanical, or thermal stimuli
25
Q

peripheral neuropathic pain dominance summary

A

pain initiated or caused by primary lesion or dysfunction the peripheral nervous system

26
Q

central sensitization pain dominance summary

A
  • pain initiated or cased by dysfunction in the CNS
27
Q

where is pain located with nociceptive pain dominance

A
  • pain localized to area of injury/dysfunction
28
Q

pain patters in nociceptive pain dominance

A
  • clear, proportionate mechanical/anatomical nature to aggravating and easing factors
  • usually intermittent and sharp with movement/anatomical provocation; may be dull or throb at rest
29
Q

nociceptive pain dominance has an absence of:

A
  • pain in association with other dysthesias
  • night pain/disturbed sleep
  • antalgic postures/movement patterns
  • pain variously described as burning, shooting, sharp, electric shock like
30
Q

Peripheral neuropathic pain dominance pain patterns

A
  • pain referred in a dermatomal cutaneous distribution
  • pain/symptoms provocation with mechanical/movement tests that move/load/compress neural tissue
31
Q

peripheral neuropathic pain dominance history

A

history of nerve injury, pathology, or mechanical compromise

32
Q

central sensitization pain dominance pain pattern

A
  • disproportionate, non-mechanical, unpredictable pattern of pain provocation in repose to multiple/non-specific aggravating/easing factors
  • pain disproportionate to the nature and extent of injury or pathology
  • diffuse/non-anatomical areas of pain/tenderness on palpation
33
Q

what does central sensitization pain dominance have a strong association with ?

A

maladaptive psychosocial factors

34
Q

how do we identify pain dominance?

A
  • we ID the dominant/driving feature of pain experience
  • patients will have aspects of all domains
35
Q

if a patient has neurological symptoms, radiating pain, weakness, what should you do?

A

perform full neuro screen/exam

36
Q

nociceptive pain dominance evaluation

A
  • standard PT eval
  • consider language (avoid nocebo, pathoanatomic, damage-specific language)
  • take opportunity to reinforce adaptive beliefs of the body’s resilience vs maladaptive beliefs of frailty
37
Q

peripheral neuropathic pain dominate evaluation

A
  • full neuro screen
  • nerve palpation
  • neurodynamic testing
  • PPT
38
Q

nerve palpation

A
  • perpendicular palpation
  • sustained pressure (up to 30 sec)
  • “twang” the nerve
  • Tinel’s Sign
39
Q

Positive nerve palpation findings

A
  • reproduction of symptoms
  • bilateral differences
  • retrograde firing - paresthesia
  • pressure threshold
40
Q

+ neurodynamic test findings

A
  • reproduction of symptoms
  • bilateral asymmetry
  • sensitizing maneuver- unload/load tension in system remotely
41
Q

key things when performing neurodynamic testing

A
  • active before passive
  • cue patient for sensitization maneuver before passive test
  • use your body/table to control all motions
  • order matters - changes sensitization of symptoms
42
Q

What s pain pressure threshold

A

minimum force applied with induced pain

43
Q

what is PPT commonly used for?

A

evaluating tenderness

44
Q

how to do PPT testing

A
  • slow application of force until the patient states that the sensation has changed from pressure to pain
  • 3 measurements with 30 sec between trials - use average
45
Q

what are the hallmark signs of central sensitization pain dominance

A
  • hyperalgesia
  • allodynia
46
Q

central sensitization pain dominance evaluation

A
  • hyperalgesia
  • allodynia
  • PPT
  • movement dysfunction
  • laterality testing
  • 2PD
47
Q

what does laterality testing assess

A

cortical smudging - structural and functional changes

48
Q

what is laterality testing

A
  • determining handedness of object
  • form of motor imagery
  • implicitly motor imagery
  • activates cortical network involved in limb representation and preparation for movement
  • does NOT activate S1 or S2
49
Q

laterality testing norms

A
  • > 80% accuracy
  • 1.6 +/- 0.5 sec/slide for neck/back
  • 2 +/- 0.5 sec/slide for hands/feet
50
Q

laterality testing - acute pain state

A

the initial presumption towards the acutely injured hand results

51
Q

laterality testing - chronic pain state

A
  • the initial presumption is towards the non-painful side/part
  • protective response
52
Q

persistent pain leads to

A

cortical reorganization

53
Q

increased 2PD correlated with

A
  • decreased body awareness
  • decreased proprioception
  • increased pain
54
Q

2PD norms

A
  • lumbar spine: 55.5m
  • posterior neck: 45.9-55.4 mm
  • lateral mandible: 10.4 mm
  • forehead: 14.9 mm
55
Q

goal setting

A
  • pt’s goals guide specific treatment choices
  • functional and specific to pt experience
  • pt-centered goals
  • check in on goals every session
  • develop with the patient
56
Q

things to consider when goal setting

A
  • asterisk sign
  • functional limitations
  • movement dysfunction
  • endurance
  • yellow flags
57
Q

patient specific functional scale

A
  • pt identifies 3 functional goals
  • rate on a scale of 0-10
  • 0: can’t do it now
  • 10: no problem at all
58
Q
A

Advanced Musculoskeletal (21 decks)

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