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    1. Pain Managment

    2. A 40-year-old male with chronic hepatitis C has osteoarthritis in his knees that is beginning to limit his activity. He asks you if he can take acetaminophen for the pain.Which of the following would be appropriate advice? (Mark all that are true.)Acetaminophen overdose is a leading cause of fulminant liver failure in adultsAcetaminophen is excreted through the biliary systemHe can safely take up to 3 grams of acetaminophen per dayNSAIDs are preferred over acetaminophen in patients with chronic liver disease

    3. Answer • Acetaminophen overdose is a leading cause of fulminant liver failure in adults

    4. Acute acetaminophen overdose is a very common problem in the United States, and when unrecognized can lead to fulminant hepatic failure. In healthy adult nondrinkers, acetaminophen is safe taken chronically in doses up to 4 g/day. Adults who drink excessively, those with chronic liver disease, and those with malnutrition are at increased risk for toxicity. Acetaminophen should be limited to 2 g/day in these persons (B level recommendation). It appears safe at this dosage, and is preferred over NSAIDs in patients with chronic liver disease. Acetaminophen is metabolized in the liver and excreted by the kidneys.

    5. A 40-year-old male has had low back pain for 2 years. He asks your advice concerning physical therapy.Which of the following would be appropriate advice? (Mark all that are true.)Prescribed exercise programs are the most efficacious physical modality for chronic back painTranscutaneous Electrical Nerve Stimulation (TENS) units produce modest benefits in pain reductionRegular massage therapy often produces lasting benefitsWhile expensive, multidisciplinary rehabilitation programs are clearly beneficialHydrotherapy is ineffective for chronic back pain

    6. Answer • Prescribed exercise programs are the most efficacious physical modality for chronic back painWhile expensive, multidisciplinary rehabilitation programs are clearly beneficialHydrotherapy is ineffective for chronic back pain

    7. It is difficult to analyze the evidence for the efficacy of physical therapy, because improvement is affected by a patient's effort and motivation, as well as the personal attention one gets from the physical therapist. Randomized, controlled trials are difficult to perform and compare. On this subject, systematic reviews and meta-analyses do not always agree.A review of physical modalities for chronic back pain published in 2004 looked not only at efficacy, but also at the clinical significance of the effect. Only exercise programs and multidisciplinary rehabilitation programs (which can cost thousands of dollars) were shown to be effective and clinically beneficial. Laser therapy, spinal manipulation, and massage were shown to be mildly effective with little lasting clinical benefit. Using the same criteria, TENS, magnets, ultrasound, hydrotherapy, and traction were ineffective. There was too little evidence to rank acupuncture, back schools, and lumbar supports.Physical therapists not only administer modalities but also provide functional assessments, patient evaluations, and patient education. Therapists can specialize in areas such as neurologic rehabilitation, wound management, or sports training.

    8. Two weeks ago, a 30-year-old female with a history of lymphoma underwent her sixth and last cycle of chemotherapy before radiologic reevaluation. She has had chronic lymphoma-related back pain for the past six months, adequately controlled by oxycodone/acetaminophen (Percocet), 5 mg/325 mg, one to two tablets orally every 4 hours as needed. During her last chemotherapy cycle she became neutropenic, and was treated with filgrastim (Neupogen).The patient comes to your office today for regular follow-up of prednisone-induced hyperglycemia, and complains of severe bilateral lower extremity pain. The pain started about 2 weeks ago and is mostly over her shins. She tells you it is a constant, sharp pain, and that the Percocet is not relieving her pain anymore. What is the most likely cause of her new pain?Pain secondary to increased cytokines from chemotherapy-related tumorlysisNeuropathic pain related to her prednisone-induced hyperglycemiaOsteoporosis-related pain from high-dose prednisoneBone pain from increased bone marrow activity resulting from treatment with filgrastimTolerance to Percocet secondary to chronic use

    9. Answer • Bone pain from increased bone marrow activity resulting from treatment with filgrastim

    10. Filgrastim is used to treat neutropenia from chemotherapy or bone marrow transplantation. It stimulates granulocyte and macrophage proliferation and differentiation. One of its most common side effects is bone pain (30% of patients) that usually starts in the first 3 days of treatment.Although tumor lysis can cause pain from increased circulating cytokines, this pain is usually diffuse. Long-lived hyperglycemia does cause neuropathic pain that is usually described as burning, shooting, "pins and needles," and "painful numbness." The onset is very rarely acute, however. Osteoporosis does not cause pain. Tolerance does not occur abruptly. Any pain escalation should be thoroughly investigated before a diagnosis of tolerance is made, especially when the pain has an acute onset.

    11. You decide to use a pain rating scale to help guide the management of a 77-year-old female with peripheral neuropathy who has daily pain. True statements regarding these scales include which of the following? (Mark all that are true.)They are simple and easy to administerThey eliminate embellishment of painThe emotional state of the patient can influence the ratingThere are valid scales which are useful in children

    12. Answer • They are simple and easy to administer • The emotional state of the patient can influence the rating • There are valid scales which are useful in children

    13. Pain rating scales are used by many physicians to measure intensity of pain and monitor the effect of therapy. (C level recommendation, evidence level II) They can be administered in a matter of minutes and are easy to score. These scales can be adapted for any age group by substituting words and/or pictures. Most children understand that 10 is greater than 2 and can use the simple 1-10 scale.There are four scales in wide use: numeric rating scales, verbal rating scales, visual analog scales, and pain drawings. Some clinicians use pain diaries to further enhance the rating's accuracy and provide information on function. One drawback is that the scales allow for embellishment and can be skewed one direction or the other by someone with little pain experience (Evidence level III). A teenager who is naive to pain might rate the pain of a sore throat as a 10, or a patient seeking sympathy or additional treatment might overrate the amount of pain he or she is having. Emotions affect the pain experience and can also affect the rating. While there is some controversy about how accurate these scales are, most clinicians have learned to use them for assessment and management of pain.

    14. 40-year-old nurse presents with neck pain. He has no history of specific injury. His symptoms are intermittent and seem worse when turning his head to the left. The pain radiates into the left thumb and index finger. At times it can be severe.Which one of the following is true regarding this problem?The irritated nerve root is most likely C5Diagnostic imaging would be helpfulFlexion of the neck is likely to worsen the painThe most common cause is osteophytes

    15. Answer • Diagnostic imaging would be helpful

    16. Cervical radiculitis is quite common and results from irritation of the cervical nerve as it leaves the spinal cord. The location of the symptoms may help to identify the irritated nerve. A C5 root irritation will cause pain in the shoulder but without radiation into the arm. The pain is generally made worse by extension, a maneuver that decreases the space for the nerve root. Flexion may actually help the pain. The pain is generally also made worse by turning toward the side of the compression. Reflexes decrease as the duration of the compression lengthens.The most common cause of cervical nerve root compression is either an acute disc herniation or a degenerative disc. Osteophytes may cause no impingement. Diagnostic imaging is helpful and should start with plain films of the cervical spine with oblique views (C level recommendation). An MRI is the most definitive imaging test, but should be used to confirm the diagnosis since there is a fair amount of asymptomatic cervical pathology (Evidence level II).

    17. Cervical Radiculopathy • C5 impairment can send pain over the top of the shoulder in the first fourth of the arm which is also where numbness occurs, when present. When there is weakness, it involves the ability to elevate the arm sideways to the level of the shoulder or above. There are no good (rubber-hammer-type) reflexes the doctor can use to test this root.C6 impairment can send pain as far as the thumb which is also where numbness occurs, when present. When there is weakness, it involves the ability to bend the elbow. The doctor can additionally test for C6 impairment with the biceps-reflex which involves striking a tendon in the crook of the elbow.

    18. Cervical Radiculopathy • C7 impairment can send pain as far as the middle fingers which is also where numbness occurs, when present. When there is weakness, it involves the ability to straighten the elbow. The doctor can additionally test for C7 impairment with the triceps-reflex which involves striking a tendon on the back of the elbow.C8 impairment can send pain as far as the little finger which is also where numbness occurs, when present. When there is weakness, it involves certain hand-movements, including the ability to join the tips of the thumb and the little finger and also to spread the fingers sideways. There are no good reflexes the doctor can use to test this root.

    19. Which one of the following agents provides the greatest analgesic effect when compared milligram to milligram?Oxycodon(OxyContin)Morphine(MSContin)CodeineHydromorphone(Dilaudid)Hydrocodone

    20. Answer • Hydromorphone (Dilaudid)

    21. True statements regarding the management of vertebral compression fractures in the elderly include which of the following? (Mark all that are true.)These fractures are normally unstable, making surgical treatment idealIf conservative treatment is selected, a minimum of 4 weeks of bed rest is requiredIn the elderly, NSAIDs are safer than opioidsCalcitonin-salmon (Miacalcin) nasal spray can be used for treatment of painPercutaneous vertebroplasty can be helpful in managing the pain when conservative treatment failsAfter the fracture heals, returning to a normal exercise program may still be dangerous

    22. Answer • Calcitonin-salmon (Miacalcin) nasal spray can be used for treatment of painPercutaneous vertebroplasty can be helpful in managing the pain when conservative treatment fails

    23. Compression fractures of the vertebral body are common, especially in older adults. Vertebral compression fractures usually are caused by osteoporosis, and range from mild to severe. More severe fractures can cause significant pain, leading to the inability to perform activities of daily living, and life-threatening decline in the elderly patient who already has decreased reserves. While the diagnosis can be suspected from the history and physical examination, plain radiographs are often helpful for determining the diagnosis and prognosis. Occasionally, it may also be helpful to obtain CT or MRI.The physician must first determine if the fracture is stable or unstable. A stable fracture will not be displaced by physiologic forces or movement. Fortunately, compression fractures are normally stable as a result of their impacted nature. Traditional treatment is non-operative and conservative. Patients are treated with a short period (no more than a few days) of bed rest. Prolonged inactivity should be avoided, especially in elderly patients. Oral or parenteral analgesics may be administered for pain control, with careful observation of bowel motility. If bowel sounds and flatus are not present, the patient may require evaluation and treatment for ileus. Calcitonin-salmon nasal spray can be used for treatment of pain. Muscle relaxants, external back braces, and physical therapy modalities also may help (Evidence level B). NSAIDs have been shown to significantly increase gastrointestinal bleeding in the elderly and must be used with caution (Evidence level A, randomized controlled trial).Patients who do not respond to conservative treatment or who continue to have severe pain may be candidates for percutaneous vertebroplasty. This involves injecting acrylic cement into the collapsed vertebra to stabilize and strengthen the fracture and vertebral body. This procedure does not, however, restore the shape or height of the compressed vertebra. Kyphoplasty, where cement is injected into a cavity created by a high-pressure balloon, is being evaluated for use and may be successful in restoring height to the collapsed vertebra.Most patients can make a full recovery or at least significant improvements within 6-12 weeks, and can return to a normal exercise program after the fracture has fully healed. A well-balanced diet, regular exercise program, calcium and vitamin D supplements, smoking cessation, and medications to treat osteoporosis (such as bisphosphonates) may help prevent additional compression fractures. Age should never preclude treatment.There is now good evidence that diagnosing and treating osteoporosis does indeed reduce the incidence of compression fractures of the spine (Evidence level A). Regular activity and muscle strengthening exercises have been shown to decrease vertebral fractures and back pain. Measures to prevent falls must be initiated by patients and their caregivers.Family physicians can help patients prevent compression fractures by diagnosing and treating predisposing factors, identifying high-risk patients, and educating patients and the public about measures to prevent falls.

    24. You are seeing a colleague's patient for a follow-up visit. The patient has been taking opioids for 12 months for chronic low back pain. After reviewing his chart you notice numerous phone messages from the patient asking for early refills, as he has been using his opioids more frequently than prescribed. During the encounter, the patient admits to borrowing pain medications from his wife.In the absence of other aberrant behavior, this is highly indicative ofdependenceaddictionpseudoaddictiondrug trafficking

    25. Answer • pseudoaddiction

    26. The suspicion of opioid addiction in chronic pain sufferers is often triggered by the occurrence of what have been called aberrant drug-related behaviors. Ambiguities inherent in this approach affect patient care adversely. Rather than consistently signifying abuse or addiction, these behaviors are often motivated by undertreated pain.The term pseudoaddiction was coined in 1989 to describe chronic pain victims mistakenly diagnosed as suffering from opioid addiction when undertreated pain led to certain drug-related behaviors. Simply stated, pseudoaddiction is a misdiagnosis that results from undertreatment of chronic pain. Patients are frequently harmed by the misdiagnosis of addiction and these behaviors should prompt an aggressive search for undertreatment of pain. Unfortunately, this usually does not happen. Instead, when a patient displays certain behaviors, he or she is typically threatened with termination of treatment, rather than questioned about its effectiveness.Undertreatment of chronic pain should be considered first on the list of differential diagnoses when considering the cause of worrisome drug-related behaviors. Some of these behaviors includeborrowing another patient's drugsobtaining prescription drugs from nonmedical sourcesunsanctioned dosage escalationsaggressive complaining about the need for higher dosesdrug hoarding during periods of reduced symptomsrequesting specific drugsacquisition of similar drugs from medical resources(Evidence level III)The diagnosis of opioid addiction should be based on observation of deteriorating function, which can be directly attributed to opioid abuse, rather than inferred from an anecdotal set of behavioral criteria derived from medical folklore. Behaviors suggestive of opioid addiction include injection of substances prescribed for oral use, concurrent use of related illegal drugs, and selling prescription drugs (Evidence level III).When patients are obtaining opioids from more than one medical source, the primary physician must reevaluate the pain syndrome. Factors to consider include whether the patient is undermedicated, whether the syndrome is misdiagnosed, and whether the patient is abusing or diverting drugs.Physicians must work with chronic pain patients to adequately evaluate and treat their pain. In turn, physicians must expect patients to use only one source to obtain opioid prescriptions. A written opioid use agreement is recommended.

    27. Mind-body therapy (MBT), such as relaxation, (cognitive) behavioral therapies, meditation, imagery, biofeedback, and hypnosis, is used for several common clinical conditions. There is good evidence to support which of the following statements about MBT? (Mark all that are true.)MBT is more effective for decreasing pain intensity than for improving functional status associated with low back pain MBT has NO significant effect in the symptomatic treatment of arthritisStress management training can be as effective as tricyclic antidepressants in the management of chronic tension-type headacheThe combination of relaxation training and thermal biofeedback is the preferred behavioral treatment for recurrent migraine disorder

    28. Answer • MBT is more effective for decreasing pain intensity than for improving functional status associated with low back pain Stress management training can be as effective as tricyclic antidepressants in the management of chronic tension-type headacheThe combination of relaxation training and thermal biofeedback is the preferred behavioral treatment for recurrent migraine disorder

    29. Multimodal mind-body therapy (MBT) treatments typically include some combination of relaxation, biofeedback therapy, cognitive strategies (e.g., for coping with pain), and education. Narrative reviews suggest that the Arthritis Self-Management Program (ASMP) might be a particularly effective adjunct in the management of arthritis (Evidence level III). This community-based program consists of education, cognitive restructuring, relaxation, and physical activity to reduce pain and distress and facilitate problem solving. Using this program, reductions in pain were maintained 4 years after the intervention, and physician visits were reduced by 40% (Evidence level II).A review of the efficacy of MBTs in chronic low back pain concluded that there was strong evidence (defined as generally consistent findings in multiple high-quality randomized, controlled trials) that MBTs, when compared with wait-list controls or usual medical care, have a moderate positive effect on pain intensity and only small effects on functional status and behavioral outcomes (Evidence level I, Cochrane review).A review of the efficacy of relaxation and biofeedback in recurrent migraine headache showed a 43% reduction in headache activity in the average patient compared with a 14% reduction with placebo medication and no reduction in unmedicated subjects (Evidence level II). A more recent narrative review concluded that a combination of relaxation training and thermal biofeedback is the preferred behavioral treatment for recurrent migraine disorder (C level recommendation). Recent evidence indicates that stress management training is as effective as tricyclic antidepressants in the management of chronic tension-type headache, suggesting that combining these two therapeutic approaches might be more effective than using either one alone (Evidence level I).

    30. True statements regarding dysmenorrhea include which of the following? (Mark all that are true.)Leiomyomata can cause secondary dysmenorrheaOral contraceptives will not help primary dysmenorrheaNSAIDs can be used on an intermittent basis to help with dysmenorrheaProstaglandins play a principal role in dysmenorrhea

    31. Answer • Leiomyomata can cause secondary dysmenorrheaNSAIDs can be used on an intermittent basis to help with dysmenorrheaProstaglandins play a principal role in dysmenorrhea

    32. Dysmenorrhea is pain that occurs during the menses and is crampy in nature. It is commonly classified as either primary or secondary. Primary dysmenorrhea is a condition unto itself that is not a symptom of another disorder. Secondary dysmenorrhea can be caused by leiomyomata or by other pelvic pathology. Prostaglandin release is the understood pathophysiology for primary dysmenorrhea. Oral contraceptives provide relief for primary dysmenorrhea by suppressing ovulation and thereby reducing the release of prostaglandins (Evidence level II). NSAIDs that inhibit prostaglandin synthetase provide relief in most patients and are usually initiated for 2-5 days, just before and during the menses (Evidence level I). In some recalcitrant cases the NSAIDs could be used continuously, with proper attention to the risks of chronic NSAID use.

    33. A 34-year-old female presents with intermittent facial pain. The pain occurs in brief episodes and always on the left side of her face. She reports that the pain is like an electric shock. The episodes may be evoked by smoking, talking, or washing her face. There are times, however, where there is no inciting stimulus. Between episodes she is pain free and there are no sensation deficits on her face.True statements regarding this problem include which of the following? (Mark all that are true.)Facial sensory loss associated with facial pain should prompt cerebral imagingThis may be the first manifestation of multiple sclerosisA large proportion of cases are caused by compression of the nerve by a blood vesselCarbamazepine (Tegretol) is first-line medical managementPatients not responding promptly to pharmacotherapy should be offered referral for interventional therapy

    34. Answer • Facial sensory loss associated with facial pain should prompt cerebral imagingThis may be the first manifestation of multiple sclerosisA large proportion of cases are caused by compression of the nerve by a blood vesselCarbamazepine (Tegretol) is first-line medical managementPatients not responding promptly to pharmacotherapy should be offered referral for interventional therapy

    35. Trigeminal neuralgia (TGN) is a painful condition which affects one side of the face. It is characterized by brief shock-like pain limited to the distribution of one or more divisions of the trigeminal nerve. The pain may be stimulated by such actions as washing, shaving, smoking, talking, or brushing the teeth, but may also occur spontaneously. It begins and ends abruptly, and may remit for varying periods.Loss of facial sensation or any suspected involvement of a cranial nerve should prompt appropriate cerebral imaging (C level recommendation). In the last three decades, evidence has been mounting that in a large proportion of cases, compression of the trigeminal nerve root at or near the dorsal root entry zone by a blood vessel is a major causative or contributing factor (Evidence level III). Of the known etiologic factors, the association of multiple sclerosis (MS) with TGN is well established. MS is seen in 2%-3% of patients with TGN. Conversely, TGN is diagnosed in 1%-5% of patients with MS. In a small proportion of patients with MS, TGN is the first manifestation of the disease.Pharmacotherapy remains the mainstay of treatment of TGN. Unfortunately, only a few randomized, controlled trials have been conducted. Carbamazepine (Evidence level I), oxcarbazepine (Evidence level II), phenytoin (Evidence level III), lamotrigine (Evidence level II), and baclofen are commonly used to treat TGN. Patients with TGN are often willing to consider surgery as a first-line treatment in anticipation of a permanent cure. Numerous interventional procedures (e.g., cryotherapy, alcohol blocks, radiofrequency lesions) and operations (e.g., microvascular decompression) are available to treat TGN. Each is associated with complications and recurrences. Patients should be provided a realistic view and balanced information regarding treatment choices.

    36. A 52-year-old male is admitted to the hospital with abdominal pain and dehydration, and is diagnosed with inoperable pancreatic cancer. He chooses to return home with hospice care. While in the hospital, he has been using patient-controlled analgesia (PCA). His PCA is set to deliver 1 mg of intravenous morphine on demand, with a 10-minute lockout. There is no basal rate. He reports his pain is well controlled. Over the past 3 days, his morphine use has been 28 mg/day, 32 mg/day, and 29 mg/day.You wish to send the patient home on sustained-action opioids to help control his pain. Based on his PCA usage, which one of the following would be an appropriate starting dosage of a sustained-action morphine (MS Contin)?15 mg orally twice daily30 mg orally twice daily45 mg orally twice daily60 mg orally twice daily

    37. Answer • 45 mg orally twice daily

    38. While there is some variability, 10 mg of parenterally administered morphine is approximately equivalent to 30 mg orally (Evidence level I). On average, this patient has used 29.7 mg of intravenous morphine per day. This would be approximately equivalent to 90 mg of oral morphine per day. An appropriate dosage of sustained-action oral morphine would be 45 mg twice daily, or 30 mg three times daily. Milligram-to-milligram, oxycodone is about 50% more powerful than morphine.

    39. Important concepts for assessing pain in older adults with cognitive impairment include which of the following? (Mark all that are true.)Observing for changes in normal functioningAsking about pain using synonyms, such as discomfort, aching, and sorenessFraming questions in the present tense (e.g., "Are you hurting now?")Understanding that elderly patients are less sensitive to painRecognizing that persistent pain is likely to affect physical and psychosocial functioningUsing the 0-10 pain scale, as it works well for nearly all older adultsAllowing extra time for the patient to assimilate the questions

    40. Answer • Observing for changes in normal functioningAsking about pain using synonyms, such as discomfort, aching, and soreness • Framing questions in the present tense (e.g., "Are you hurting now?")Recognizing that persistent pain is likely to affect physical and psychosocial functioningAllowing extra time for the patient to assimilate the questions

    41. Persistent pain is common in older adults, particularly among the frail elderly, in whom cognitive impairment is more common. Age-related changes in pain perception are probably not clinically significant. Functional changes, both psychosocial and physical, are common sequelae to chronic pain and may be the first indicators of pain in cognitively impaired patients. A substantial portion of older adults (with and without cognitive impairment) have difficulty using the 0-10 pain scale. Many other scales have demonstrated their validity in this population (Evidence level II). Many cognitively impaired older adults deny pain, but may be able to report distress when synonyms such as "aching" and "soreness" are used. Focusing on assessment of current symptoms (e.g., asking "Are you hurting right now?") may also help those with short-term memory deficits.Validated pain rating systems for the cognitively impaired focus on facial expressions, posture, vocalizations, appetite, and interactivity (Evidence level II). Clinicians should choose one tool and use it consistently to ensure uniformity among health care providers (C level recommendation).

    42. A 40-year-old female with three children has chronic low back pain and frequent tension headaches. In addition, she was recently treated for shoulder pain. Her neighbor has suggested that she look into acupuncture and she asks you if acupuncture is safe and effective.Which of the following would be accurate advice? (Mark all that are true.)In a randomized study of chronic headache, those treated with acupuncture in addition to usual therapy had fewer headaches than controlsThe addition of acupuncture to diclofenac (Voltaren) in patients with shoulder pain improves function more than diclofenac aloneStudies that looked at more than 60,000 acupuncture treatments showed no serious adverse events

    43. Answer • In a randomized study of chronic headache, those treated with acupuncture in addition to usual therapy had fewer headaches than controlsStudies that looked at more than 60,000 acupuncture treatments showed no serious adverse events

    44. Acupuncture has been practiced for thousands of years and has been used for hundreds of different ailments. Studies of the method use sham treatments or minimal treatments as controls. Studies often show conflicting results or small clinical effects. Acupuncture is quite safe, with no serious adverse effects reported in two studies including more than 60,000 treatments. Infection is minimized by using disposable needles and aseptic technique. Serious bleeding is very rare.In a meta-analysis of chronic back pain studies, acupuncture proved to be more effective than sham acupuncture or no treatment. For short-term pain relief in these patients it does not appear to be superior to other active therapies. It was not particularly effective in acute back pain (Evidence level I). As an adjunct to usual therapies, acupuncture has proven effective in randomized studies of chronic headache and osteoarthritis of the knee (Evidence level I). It is used as an adjunct in cancer pain management. One randomized, controlled trial of auricular acupuncture showed a positive effect in decreasing cancer pain when used with routine analgesics.

    45. A new patient comes to your office for evaluation of pain. The patient history should include which of the following? (Mark all that are true.)Identification of possible pain generatorsA worker's compensation and litigation historyA history of the onset and progression of the painA complete medication historyA substance abuse history

    46. Answer • Identification of possible pain generatorsA worker's compensation and litigation historyA history of the onset and progression of the painA complete medication historyA substance abuse history

    47. In the evaluation of pain, the history may be more valuable than the physical examination. An important goal of the encounter is to identify the pain generator when possible, and the history may be the most illuminating part of the evaluation in this regard (C level recommendation). Often the specific pain generator cannot be identified. History taking requires very active listening, with interplay between what the patient is saying and the physician's interpretation and clarification.Obtaining a history of the onset and progression of the pain is of great importance. It can tell the physician whether this is an acute process and if immediate action is needed (C level recommendation). It also provides clues as to the amount of additional history that will be needed to sort out previous treatment successes and failures. A history of legal action related to pain, for example, is associated with a worse prognosis.The medication history is a very important part of the initial evaluation. Rather than just a list of medications the patient is taking, it should include a discussion of efficacy, tolerability, and economics (C level recommendation). It might also provide some idea of the patient's attitudes toward medicines and expectations for efficacy. A history of substance abuse must be elicited because it has important implications in the treatment plan and the need for safeguards.

    48. A 30-year-old brick mason presents to your office with mid-back pain. On examination you note that his rhomboid muscles are in spasm, and he jumps when you touch three discrete points in the muscles.He is concerned that he may be developing fibromyalgia like his mother. True statements regarding the differentiation between myofascial pain syndrome and fibromyalgia include which of the following? (Mark all that are true.)The tender points of fibromyalgia are different from the trigger points seen with myofascial pain syndromeMuscle spasm is most often associated with fibromyalgiaA jump/twitch response is most often associated with myofascial pain syndromeThe tender points in fibromyalgia patients tend to be distributed asymmetricallyMyofascial pain tends to be regional

    49. Answer • The tender points of fibromyalgia are different from the trigger points seen with myofascial pain syndromeA jump/twitch response is most often associated with myofascial pain syndromeMyofascial pain tends to be regional

    50. The trigger points seen with myofascial pain syndrome are different from the tender points seen with fibromyalgia. Trigger points are discrete, focal, hyperirritable spots located in a taut band of skeletal muscle. Compression of these points is painful and can produce referred pain, referred tenderness, motor dysfunction, and autonomic phenomena. Trigger points may be single or multiple, and are usually asymmetric. Pressing them may elicit a twitch in the muscle or a jump response from the patient. Trigger points are associated with regional pain syndromes. Patients with fibromyalgia exhibit multiple tender points symmetrically distributed along the axial skeleton, and have constitutional symptoms such as fatigue, sleep disturbance, and depressed mood.No single modality stands out as the best for long-term treatment of trigger points and myofascial pain. However, trigger point injections are widely accepted and recommended for providing short-term relief (C level recommendation).Dry-needle techniques usually result in more soreness the next day than injection of local anesthetic. The addition of corticosteroids and other medications to local anesthetics is unnecessary for efficacy and may cause muscle damage. The technique for trigger point injection is well described in the reference article.