Chapter 10 Chronic Pain Management and Arthritis

Transcription

1 Chapter 10 Chrnic Pain Management and Arthritis Juvenile rheumatid arthritis a frm f arthritis that affects children befre the age f 16 Sectin I: Chrnic Pain Management - Individuals generally experience pain when an illness r injury causes inflammatin r changes t the nervus system the changes are relayed t the brain, resulting in a physical sensatin that a change has ccurred - Chrnic pain episdic r cntinued sensatins f pain Measuring Pain - Chrnic illnesses lng term (3-6 mnths r lnger) and cmplex illnesses that can be cntrlled but nt cured - Chrnic pain pain that can be cntrlled but nt cured - Factrs that cntribute t the general perceptin f pain: Pain intensity r duratin Type f pain Tempral pattern Treatment effect Pain quality Lcatin Interference Affect Pain histry Beliefs abut pain (attitude, cping, beliefs abut the causes and cnsequences f pain) - It is nt pssible t measurable quantify pain difficult t gauge because it is very subjective Changing Characteristics f Pain - Sensatin f pain may differ ver time - A persn s pain experiences ver weeks r mnths can appear different each day The surce f pain may be the same but the perceptin f pain can change based n a persn s subjective assessment f the sensatin at the time - Factrs that influence perceptin: Psychlgical state Md General affect - Reprts f chrnic pain lasting ver a year is cmmn in lder individuals - Pain and disability cause by injuries can last even after the injury has healed Injury-related pain and disability shw rapid imprvement fr the first 3 mnths After that, prgress slws Individuals may never be fully free f pain due t injury r return t full and nrmal functining ability - Chrnic pain can affect a persn s perceived quality f life and verall well-being One f the gal f palliative care is pain relief t imprve quality f life as best as pssible

2 Pain Management vs. Pain Eliminatin - There is n prven, effective treatment that ffers ttal and cmplete relief frm chrnic pain - Research n injury-related pain als fcuses n management because ften pain due t injury lingers well beynd the pain f treatment i.e. rtatr cuff injuries in athletes surgery and therapy can nly smetimes restre full functining - Individuals must learn t deal with the decreased functining r chrnic pain as the result f injury - Healing prcess always requires bth physical and psychlgical adjustments Differences in Pain Perceptin - Wmen ften reprt mre pain than men - Wmen are mre likely t receive prescriptins fr sedatives t suppress the sensatin f pain than analgesics t relieve the pain - Perceptins f pain may differ amng ethnic grups - There are differences in the epidemilgy f pain, access t pain care, and assessment and treatment f pain, as well as pain utcmes - Studies shw that African Americans have a lwer threshld fr heat pain than nn- Hispanic whites results were the same fr acute and chrnic pain tlerance - Faucet/Grdn/Levine: study n pst-perative pain African Americans and Latins reprted greater pain than Caucasians - Studies examining chrnic pain related t chrnic health cnditins African Americans were mst likely t reprt persistent pain related t AIDS, arthritis, and severe lw back pain - Sme studies have reprted bilgical causes that can explain the ethnic differences in perceptin f pain Speculatin that ethnic factrs play a rle in triggering activity in the nervus centers f the bdy that mdulate pain - Greater supprt fr causatin due t scial factrs i.e. limited access t health care due t SES, lack f knwledge, cping styles - Minrity patients are mre likely t be undertreated fr pain and are less likely t receive a cmprehensive diagnsis and treatment fr their cmplaints f pain i.e. Latins and African American are significantly LESS likely t receive pain medicatin fr a bne fracture - Pssible reasn fr high ratings n pain perceptin by ethnicities is due t inadequate treatment f pain - Other studies suggest that attitudes r biases that prviders hld abut their patients may interfere with effective treatment - Ethnicity affects cping strategies fr pain management African Americans are mre likely t rely n supprt systems and religius cping t manage thrugh the pain Caucasians are mre likely t implement techniques such as ignring the pain r t believe in a greater ability t cntrl the pain themselves Differences in strategies may be learned within ethnic grups r cultures that such differences may affect an individual s awareness f and a level f cmfrt with the pain Caregivers, Pain Management, and Psychlgical Stress

3 - Chrnic pain can have lng-term psychlgical effects n the sufferer i.e. Arthritis can impair a persn s ability t be self-sufficient and t accmplish basic tasks such as preparing a meal, eating, r getting dressed - A persn with chrnic pain carried it with the psychlgical disadvantage f being dependent n thers fr basic necessities - An increase in functinal disability and dependency n thers, tgether with chrnic pain, is dispiriting t many individuals - Depressin, wrry, avidance behaviur, and a sense f helplessness are cmmn psychlgical reactins - Peple wh suffer frm chrnic pain d nt suffer alne affects family and caregivers Caregiver distress is a cmmn ccurrence Caregivers reprt mre medical visits than nn-caregivers - Caregivers are als at a higher risk fr anxiety, depressin and reprted increases in weight lss females mre affected than males - The task f prviding nging assistance and aid t smene with a chrnic illness (incl. chrnic pain) can cause emtinal, psychlgical, and physical harm t the caregiver Interventins fr Caregivers - Caregivers wh are able t set and accmplish small gal-specific tasks each day were mre likely t reprt better verall psychlgical health in the shrt term, and in the lng term nce their respnsibilities ended - Caregivers als reprt less lng-term psychlgical distress when they emply psychtherapy r psycheducatinal interventins Sectin II: Arthritis Defined Arthritis: - 1. A physilgical based disease cause either by degeneratin (gradual ersin f bnes near the jints) r by inflammatin (swelling f tissue surrunding the bnes and jints) - 2. Arthritis is a prgressive disease degeneratin r inflammatin wrsens ver time - 3. Arthritis is a chrnic disease - Describe a class f disease that refer t any jint cnditins r disease causing inflammatin, pain, and stiffness in the jin r in cnnective tissues Rheumatid Arthritis - Classified as a chrnic, inflammatry autimmune disease fr which the exact cause is unknwn - Swelling f the jints and f the synvium (thin layer f tissue that cvers the jints) - Triggered by the immune system inflammatin is nrmally the bdy s respnse t injury - In RA, the immune system triggers inflammatin in the absence f infectin r injury unnecessary inflammatin can damage tissue, bld vessels, and rgans, and cause pain, stiffness and swelling f inflamed jints - RA is a prgressive disease inflammatin, tissue damage and functinal limitatins becme wrse ver time - In advanced stages, the jints and surrunding areas may becme defrmed - RA affects psychlgical health b/c f physical disabilities Limit an individual s ability t be independent and capable Depressin, excessive wrry, avidance behaviur, and helplessness

4 Functinal limitatins affected ability t perfrm daily tasks independently - Often affects many jints simultaneusly Ankylsing Spndylitis (AS) - Specific type f RA that affects the spinal jints - Ankyls = bent - Spndylitis = inflammatin f the spinal clumn - Diagnsis suggests a rigid r stiff spine - The disease causes the spinal clumn t fuse - Limits individual s ability t turn neck r back - May cause a stped appearance - Largely genetic in rigin; AS gene HLA-B27 - Generally first appears in adlescence and mre cmmnly in men (unlike RA) - Studies mainly fcus n men (as with CV studies) - Essentially a genetic versin f RA Ostearthritis - Cmmnly assciated with wear and tear n the bdy - Cartilage is wrn away new bnes may frm bne spurs that rub against each ther pain and further deteriratin f jints - Ersin prcess degenerative jint disease - Unsure f what the cause is - Factrs: genetic abnrmality, develpmental defects, trauma that alters r disrupts the bdy s bimechanics, besity - Mst cmmn in hands, knees, hips and feet - Often nly affects ne r tw majr jints - Surgery fr jint replacements is a quite effective treatment Gut - Cause by crystal depsits in the jints - Cmmnly assciated with the elderly - Other factrs: envirnment, behaviur, genetics, gender i.e. vereating, excessive cnsumptins f red meat, excessive alchl cnsumptin - Main factr: fds cnsumed Buildup f uric acid by prduct f fds eliminated frm ur bdies as waste prducts - Acid becmes ldged in jints and causes inflammatin, redness, and sreness - Sme types f gut are preventable with changed in health behaviurs r lifestyles - Genetic disrders can cause an verprductin f uric acid Pain Measures - Pain is hard t measure because it is influenced by an individual s subjective perceptin f discmfrt and by a prvider s assessment f the physilgical symptms and f the persn s accurate recall - Pain is a private and internal sensatin that cannt be bserved directly - Pain is best understd as the cmbined influence f a painful stimulus experience by the bdy, the characteristics f the individual experiencing the pain and the scial and envirnmental circumstances that be prscribe an individual s perceptin f r respnse t pain - 3 types f measures used tday:

5 Verbal r written questinnaires Measure an individual s self-assessment f his r her pain Allw respndents t characterize their pain, describe its duratin, rate its intensity and explain any functinal limitatins resulting frm the pain i.e. Brief Pain Inventry, McGill Pain Questinnaire An individual s perceptin f pain will influence his r her participatin in daily activities r dependence n thers fr assistance Sme pain questinnaires als assess an individual s psychlgical state Behaviural bservatins During a health care visit with a health care prfessinal r during the executin f daily activities as bserved by relatives, friends, r caregivers Observe the individual ding assigned tasks t test the flexibility r maneuverability f the affected jints The functinal assessment identifies any diminished capacity n tasks f daily living Lazarus and Flkman: diminished functinal capacity created the type f daily hassles that may lead t depressin Visual analgue pain ratings Typical scale includes a straight, vertical line capped at each end with the wrds that describe pain severity Individuals are instructed t place a mark alng the vertical cntinuum t indicate the pain level experiences as a result f a specific injury r illness All these measures are used t evaluate an individual s pain tlerance - Studies suggest that pain tlerance and perceptin f pain severity vary due t demgraphic and cultural factrs such as gender r ethnicity - Females tend t reprt mre pain and a greater number f affected areas than men Sectin III: Medical and Psychtherapeutic Treatments Medical Therapies fr Arthritis - Nnsteridal Anti-inflammatry Drugs (NSAIDs) Drugs that reduce pain and inflammatin assciated with arthritis - Opiid analgesics Narctic substances used t treat nncancer pain - Antitumr necrsis factr (TNF) drugs Nnsteridal Anti-Inflammatry Drugs - Aspirin Can be used t treat mild arthritic pain Relatively safe medicatin when taken in lw dses But t relive inflammatin and stiffness, must be taken in HIGH dses frequently High dsing can lead t disruptive effects n the urinary and digestive tract stmach ulceratin is a cmmn effect - Ibuprfen Can cause stmach distress in high dses - Naprxen and Ketprfen

6 Believed t be mre effective because they blck prductin f COX-1 and COX-2 inhibitrs COX-1 prtects the stmach lining COX-1 prduces inflammatin - NSAIDs are cnsidered inadequate pain relievers because they cannt adequately relieve pain and stiffness - NSAIDs d nt slw r reverse the prgressin f the disease - Are mderate pain relievers that manage symptms and minimize pain Opiid Analgesics - Aka pium mst ptent pain reliever knwn t medicine Rarely used because it is highly addictive - Believed t be mre effective than NSAIDs Anti-Tumr Necrsis Factr (anti-tnf) Drugs - Significantly reduce pain and stp the prgressin f the disease - Mre effective than NSAIDs and are nt highly addictive like piids - Infliximab and etanercept - Prblems: Anti-TNFs fight the bdy s natural inflammatin prcess leaving individuals prne t infectins Drugs must be given by injectin either as a blus r by IV Expensive Exercise Therapy - Exercise will, in the lng term, minimize pain and imprve functinality - Best dne with the aid f a physical therapist mre effective if there is a plan and gals set in place - The gal f exercise therapy prgrams is t increase an individual s range f mvement while decreasing their pain levels - Impediments: Shrt term pain fr lng term benefit Studies wh individuals actually reprt decrease in pain after shrt-term exercise regimens Participatin nrmal mvement is painful, exercise wuld be even mre challenging - By matching an individual t his r her preferred physical activity, therapist and psychlgists may be mre likely t imprve retentin rates in prgrams and btain gd immediate and lng term utcmes Psychtherapeutic Interventins Psychlgical Interventins - Effects f arthritis n the daily activities f individuals, in additin t the cntinual pain and discmfrt, ften lead t feelings f frustratin, helplessness, and depressin feelings f helplessness and lss f cntrl - Frequently use treatments: Cgnitive behaviural therapy fr pain management/pain cping skill training Mst frequently use and mst successful technique Bifeedback

7 Stress management Emtinal disclsure Psychdynamic therapy - Cgnitive Behaviural Therapy Invlves 4 key cmpnents: Educatin Skills acquisitin Skills cnslidatin Generalizatin and maintenance Aim is t help individuals remve self-impsed inhibitins t independent functining based n their fear f pain and feelings f helplessness Encurages individuals t realize that they can manage their pain independently by mastering their pain, their fear f pain, and their feelings f frustratin and hpelessness Self-efficacy is central t this apprach - Bifeedback Self-regulatry technique in which individuals learn t vluntarily cntrl their respnses t pain t minimize its sensatins The gal is t teach peple t cntrl the physilgical prcess and t reregulate the ANS Uses stress management techniques t manage pain Assumptin is that management f pain will lead t imprved cntrl f arthritic pain - Emtinal Disclsure Therapy based n the assumptin that current and past unreslved issues create stressrs that are prly managed Supprts the ntin that stress cntributes t arthritic pain Includes stress management as a critical cmpnent in minimizing the pain f arthritis Individuals talk r write abut traumatic experiences and assciated emtins belief that by releasing suppressed feelings abut traumatic events, peple with arthritis als btain relief frm the stress and ther related pain that aggravates arthritis Seeks t address unreslved cnflicts that cntribute t pain - Psychdynamic Therapy Assume that the underlying emtins cntributing t the arthritic discmfrt are unknwn Seeks t address unreslved cnflicts that cntribute t pain - Frms f therapy are ften used in cmbinatin Cping Strategies - Meant t help an individual manage the cnsequences f the prblem - Significant gender differences - Wmen use less effective cping strategies perceptins f greater and less-cntrlled pain - 2 principal cping styles: prblem/emtin fcused and engagement/disengagement - Prblem/emtin fcused cping

8 Prblem fcused invlves seeking infrmatin t generate slutins t address the issue r prblem (MOST EFFECTIVE) Emtin fcused seeks slace r emtinal supprt frm ther fr emtinal reasns - Engagement/disengagement Engagement includes bth prblem slving and emtinal supprt Disengagement characterized as withdrawal r denial abut a prblem (LEAST EFFECTIVE) - Cping techniques individuals use t cpe with everyday life are the same nes adpted t deal with specific illnesses - Wmen are mre likely t use emtin-fcused strategies t cpe with pain lwer pain tlerance and higher verall perceptin f pain Scial Supprt - Individuals are able t achieve better verall utcmes when they receive supprt frm thers - Tangible assistance materials r help with issues that directly address the prblem Mst beneficial i.e. help with daily tasks when needed - Wmen wh receive strng scial supprt are less likely t experience depressive symptms Wmen are mre likely t feel guilt if unable t perfrm husehld and family respnsibilities due t restricted mvements due t arthritis - Scial supprt has als been linked t imprvements in an individual s cping prcess and daily functining and perceptin f pain - Patients wh reprt passive cping strategies t deal with pain reprted greater functinal disability ver time as did thse wh did nt receive scial supprt