Acute care handbook for physical therapists (fourth edition) chapter 21 acute pain management

Acute care handbook for physical therapists (fourth edition) chapter 21 acute pain management Acute care handbook for physical therapists (fourth edition) chapter 21 acute pain management Acute care handbook for physical therapists (fourth edition) chapter 21 acute pain management Acute care handbook for physical therapists (fourth edition) chapter 21 acute pain management Acute care handbook for physical therapists (fourth edition) chapter 21 acute pain management Acute care handbook for physical therapists (fourth edition) chapter 21 acute pain management Acute care handbook for physical therapists (fourth edition) chapter 21 acute pain management

Acute Pain Management

21

Jaime C Paz Danika Quinlan

CHAPTER OBJECTIVES

The objectives of this chapter are to provide the following:

1 An overview of pain evaluation scales most applicable to the acute care setting

2 A description of physical therapy considerations when evaluating pain

3 An overview of commonly utilized management strategies for acute pain including pharmacologic agents

4 A brief description of physical therapy management strategies for acute pain

PREFERRED PRACTICE PATTERNS

Pain is multifactorial in nature and applies to many body systems For this reason, specific practice patterns are not delineated in this chapter Please refer to Appendix A for a complete list of the preferred practice patterns in order to best delineate the most applicable practice pattern for a given diagnosis.

This chapter provides information on the evaluation and management of acute pain with the goal of facilitating patient care The characteristics of acute pain include less than 6 months

in duration, often associated with tissue damage such as surgery or traumatic injury, the cause

of pain is easily recognized, pain can be treated readily, and the duration of pain is predictable.1

Acute pain in the medical patient may result from nonsurgical abdominal pain, renal or biliary stones, and phantom limb pain.2

Pain Evaluation

The subjective complaint of pain is often difficult to objectify in the inpatient setting Patients may be mechanically ventilated, pharmacologically sedated, or in too much pain to articulate their discomfort.3 Furthermore, patients who may be cognitively impaired are at higher risk for their pain to be undertreated with a resultant decreased quality of life.4-6 Despite these difficulties, an effective pain treatment plan depends on an accurate evaluation of the patient’s pain.7,8

Each evaluation requires a complete physical and diagnostic examination of the patient’s pain The criterion standard for pain assessment is through self-report by the patient because

it is the most accurate indicator of the existence or intensity of his or her pain, or both.4,5,9

The goal for evaluation should be directed toward individualization while maintaining con-sistency among patients To assist with this process, various pain-rating tools have been developed to address both verbal and nonverbal (conscious or unconscious) patients.

Verbal pain scales ( Table 21-1 ) include:

• Numeric rating scale (NRS)

• Visual analog scale (VAS)

• Verbal descriptor scale (VDS)

• Wong-Baker Faces Scale

• Functional pain scale Nonverbal pain scales include:

• Adult Nonverbal Pain Scale ( Table 21-2 )

• Behavioral Pain Scale ( Table 21-3 )

CHAPTER OUTLINE

Pain Evaluation

Physical Therapy Considerations

for Pain Evaluation

Pain Management

Physical Therapy Considerations

for Pain Management

TABLE 21-1 Verbal Pain Scales

Verbal descriptor scales The patient describes pain by choosing from a list of adjectives representing gradations of pain intensity Numeric Rating Scale (NRS) The patient picks a number from 0 to 10 to rate his or her pain, with 0 indicating no pain, and 10

indicating the worst pain possible

Visual Analog Scales (VAS)

Line scale The patient marks his or her pain intensity on a 10-cm line, with one end labeled “no pain,” and the

other end labeled “worst pain possible.”

Wong-Baker Faces scale The patient chooses one of six faces, portrayed on a scale that depicts graduated levels of distress, to

represent his or her pain level

Functional Pain Scale A zero (0) to five (5) scale with corresponding pain descriptions

0 = No pain

1 = Tolerable (and does not prevent any activity)

2 = Tolerable (but does prevent some activities)

3 = Intolerable (but can use telephone, watch TV, or read)

4 = Intolerable (cannot use telephone, watch TV, or read)

5 = Intolerable (and unable to verbally communicate because of pain)

Data from Kittelberger KP, LeBel AA, Borsook D: Assessment of pain In Borsook D, LeBel AA, McPeek B, editors: The Massachusetts General Hospital handbook

of pain management, Boston, 1996, Little, Brown, p 27; Carey SJ, Turpin C, Smith J et al: Improving pain management in an acute care setting: the Crawford Long Hospital of Emory University experience, Orthop Nurs 16(4):29, 1997; Wong DL, Hockenberry-Eaton M, Wilson D et al: Wong’s essentials of pediatric nursing, ed

6, St Louis, 2001, Mosby, p 1301; Puntillo K, Pasero C, Li D et al: Evaluation of pain in ICU patients, Chest 135:1069-1074, 2009; Gloth FM, Cheve AA, Stober

CV et al: The functional pain scale: reliability, validity, and responsiveness in an elderly population, J Am Med Dir Assoc 2:110-114, 2001; Chanques G, Viel E, Constantin JM et al: The measurement of pain in intensive care unit: comparison of 5 self-report intensity scales, Pain 151:711-721, 2010

TABLE 21-2 Adult Nonverbal Pain Scale

Face No particular expression or

smile Occasional grimace, tearing, frowning, wrinkled forehead Frequent grimace, tearing, frowning, wrinkled forehead Activity (movement) Lying quietly, normal position Seeking attention through movement

or slow, cautious movement Restless, excessive activity and/or withdrawal reflexes Guarding Lying quietly, no positioning

of hands over areas of body Splinting areas of the body, tense Rigid, stiff Physiologic I (vital

signs) Stable vital signs (no change in past 4 hours) Change over past 4 hours in any of the following: SBP > 20 mm Hg, HR

> 20/min, RR > 10/min

Change over past 4 hours in any of the following: SBP > 30 mm Hg, HR

> 25/min, RR > 20/min Physiologic II Warm, dry skin Dilated pupils, perspiring, flushing Diaphoretic, pallor

HR, Heart rate; RR, respiratory rate; SBP, systolic blood pressure.

From Odhner M, Wegman D, Freeland N et al: Assessing pain control in nonverbal critically ill adults, Dimens Crit Care Nurs 22:260-267, 2003

Pain scales used for both verbal and nonverbal patients

include:

• Face, Legs, Activity, Cry, Consolability (FLACC) scale

( Table 21-4 )

• Critical Care Pain Observational Tool (CPOT) ( Table 21-5 )

The validity of these scales may be improved by asking

the patient about his or her current level of pain, rather than

asking the patient to speculate about “usual” or “previous”

levels of pain.10

The therapist should be aware that some physiologic indica-tors exist normally in critically ill patients One needs to analyze the behavioral trend and differentiate pain from physiologic changes.12 The Adult Nonverbal Pain Scale is targeted toward adult patients who are intubated and sedated and is adapted from the FLACC Pain Assessment Tool.12 The Behavioral Pain Scale (BPS) is used for mechanically ventilated, sedated patients

in the intensive care unit (ICU).4 Validity measured by BPS scores increase with painful stimuli.13 Good construct validity (p < 0.001) has been reported for the FLACC as evidenced by decreased pain scores after administration of analgesics and from painful to nonpainful situations The FLACC has also demon-strated good interrater reliability when assessing pain in criti-cally ill patients.14 This was consistent when compared among use with adults, children, and patients who are mechanically ventilated However, there is some disagreement concerning the use of this scale with adults because of their inability to

CLINICAL TIP

The therapist should be sensitive to, and respectful of, how dif-ferent cultures perceive pain, as pain expression may vary

among cultures.5,11

TABLE 21-3 Behavioral Pain Scale

Partially tightened (e.g.,

Fully tightened (e.g., eyelid

Movements of

upper limbs No movementPartially bent 12

Fully bent with finger flexion 3 Permanently retracted 4 Compliance with

ventilation Tolerating movementCoughing but tolerating 1

ventilation for most of the time

2

Fighting ventilator 3 Unable to control ventilation 4

From Payen JF, Bru O, Bosson JL et al: Assessing pain in critically ill sedated

patients by using a behavioral pain scale, Crit Care Med 29(12):2258-2263,

2001

TABLE 21-4 FLACC Pain Assessment Tool

Face No particular expression or smile Occasional grimace or frown,

withdrawn, disinterested Frequent to constant frown, clenched jaw, quivering chin Legs Normal position or relaxed Uneasy, restless, tense Kicking, or legs drawn up Activity Lying quietly, normal position,

moves easily Squirming, shifting back/forth, tense Arched, rigid, or jerking Cry No cry (awake or asleep) Moans or whimpers, occasional

complaint Crying steadily, screams or sobs, frequent complaints Consolability Content, relaxed Reassured by occasional touching,

hugging, or “talking to,”

distractible

Difficult to console or comfort

Indication: For nonverbal patients, particularly the pediatric population

From Merkel SI, Voepel-Lewis T, Shayevitz JR et al: The FLACC: a behavioral scale for scoring postoperative pain in young children, Pediatr Nurs 23(3):293-297, 1997

demonstrate some behaviors associated with the pediatric

popu-lation Those who disagree suggest utilizing the NVPS, as it

has good interrater reliability and validity with critically ill,

sedated, mechanically ventilated, and/or cognitively impaired

adults.12,14,15

The CPOT was developed to assess pain in critically ill ICU

patients and was mainly used with those recovering from cardiac

surgery It is reliable and valid in this population and further

research is required for its use in other populations.16 The CPOT

can be used with both verbal and nonverbal patients.4,16

Physical Therapy Considerations for Pain Evaluation

• Observe pain-related behaviors to appropriately select an

assessment tool Use nonverbal assessment tools when

self-report is unattainable.5

• Select the appropriate tool based on the clinical environment

and relevance to the specific patient population.5

• Table 21-6 provides a comparison of the various pain scales

to aid in selecting an appropriate tool The VAS and NRS tend to be used commonly in the clinical setting.5,17

• Patients report a preference for the NRS because of its ease

of use and accuracy.

• In consideration of Joint Commission requirements, each patient interaction needs a pain rating, even if the patient reports 0/10 on the NRS.

• A pain grade is generally accompanied by location, descrip-tion, and most importantly, an “intervendescrip-tion,” especially if pain is graded greater than 4/10 on the NRS.

• The physical therapist should recognize when the patient is weaning from pain medication (e.g., transitioning from intravenous to oral administration), as the patient may com-plain of increased pain with a concurrent reduced activity tolerance during this time period.

• To optimize consistency in the health care team, the physical therapist should use the same pain rating tool as the medical-surgical team to determine adequacy of pain management.

• Often the best way to communicate the adequacy of a patient’s pain management to the nurses or physicians is in terms of the patient’s ability to complete a given task or activity (e.g., the patient is effectively coughing and clearing secretions) Therapists should communicate both verbally and in written form to the medical team if the pain manage-ment is insufficient to allow the patient to accomplish func-tional tasks.

Pain Management

The primary goal in acute pain management is to promote the resolution of the underlying causes of pain while providing effective analgesia.18 Acute pain can be managed using both pharmacologic and nonpharmacologic techniques (including physical therapy) either in isolation or more often in combina-tion.19,20 This section focuses on pharmacologic management while the next section will describe physical therapy manage-ment considerations.

CLINICAL TIP

Communication among therapists, nurses, physicians, and

patients on the effectiveness of pain management is essential

to maximize the patient’s comfort This includes a thorough

review of the patient’s medical history and the doctor’s orders

by the physical therapist before prescribing any modalities or

therapeutic exercises.

TABLE 21-5 Critical-Care Pain Observation Tool (CPOT)

Facial expression No muscular tension observed 0 = Relaxed, neutral

Presence of frowning, brow lowering, orbit tightening

All of the above facial movements plus eyelid tightening 2 = Grimacing Body movements Does not move at all (does not necessarily mean absence

Slow cautious movements, touching or rubbing the pain site, seeking attention through movements 1 = Protection Pulling tube, attempting to sit up, moving limbs/

thrashing, not following commands, striking at staff, trying to climb out of bed

2 = Restlessness

Muscle tension (evaluation

by passive flexion and

extension of UEs)

No resistance to passive movements 0 = Relaxed Resistance to passive movements 1 = Tense, rigid Strong resistance to passive movements, inability to

Compliance with

mechanical ventilator

(intubated patient)

Alarms not activated, easy ventilation 0 = Tolerating ventilator or movement Alarms stop spontaneously 1 = Coughing but tolerating machine Asynchrony: blocking ventilation, alarms frequently

Vocalization (extubated

patient) Talking in normal tone or no sound 0 = Talking in normal tone or no sound

Modified from Gélinas C: Nurses’ evaluations of the feasibility and the clinical utility of the Critical-Care Pain Observation Tool, Pain Manag Nurs 11(2):115-125, 2010

Pharmacologic management of acute pain is based on the

World Health Organizations (WHO) Analgesic Ladder21,22

originally designed to promote ongoing assessment of pain

management during the palliative care of patients with cancer.20

The WHO ladder is a stepwise process in which step 1 is for

patients with mild pain in whom the use of nonopioid analgesia

is recommended, step 2 is for moderate pain and advocates the

use of weak opioids with or without nonopioids, and step 3 is

for patients with severe pain in whom strong opioids with or

without nonopioids are recommended.20Table 21-7 provides an

overview of commonly utilized opioid agents in the

manage-ment of acute pain.

Nonopioid drugs typically comprise nonsteroidal

antiin-flammatory drugs (NSAIDs) ( Table 21-8 ) and acetaminophen

(paracetamol), which is a centrally acting analgesic that

inter-acts with the cyclooxygenase system.18,19 Acetaminophen also

has antipyretic effects and is an effective analgesic when used

alone or as an adjunct to opioid analgesia.18

As a group, NSAIDs are nonselective cyclooxygenase inhibi-tors Cyclooxygenase (COX) is an enzyme that exists in two forms (COX-1 and COX-2).23 The homeostatic pathways, which include production of prostaglandins and thromboxane, primarily involve the COX-1 enzyme, while COX-2 is involved with pathways that produce pain and inflammation Prostaglan-dins have a protective role for the mucosal lining of the gastro-intestinal tract; therefore nonselective inhibition of these substances can result in gastrointestinal (GI) dysfunction (see Chapter 8) Selective inhibition of COX-2 was found to decrease injury to the mucosal lining of the stomach, leading to the development of COX-2 selective agents, which were aimed at reducing inflammation without adverse GI effects Unfortu-nately, these agents were also correlated with an increased risk

of cardiovascular events in susceptible individuals, resulting in agents such as rofecoxib (Vioxx) and valdecoxib (Bextra) being taken off the market Currently celecoxib (Celebrex) is the only COX-2 selective agent still available.23,24 Careful patient selec-tion regarding all NSAIDs and overall cardiovascular risk need

to be considered.23 Acetylsalicylic acid (aspirin) is the oldest form of NSAID prescribed for patients to help manage pain and inflammation, as well as providing antiplatelet effects for vas-cular conditions.23

Opioid agents and NSAIDs can be administered by oral, intravenous, or intramuscular routes Alternative routes of administration for pain medications include local anesthetics ( Tables 21-9A and 21-9B ) and patient-controlled analgesia (PCA) ( Table 21-10 ).

TABLE 21-6 Comparison of Pain Assessment Scales

Tool Targeted Population Benefits Reliability Validity Verbal or Nonverbal

Numeric Rating

Scale (NRS) Adults Easy to use Interrater reliability coefficient = 0.54 p < 0.001Compared to VDS and

VAS

Verbal

Visual Analog

Scale (VAS) Adults Visual face and number scale to rate pain Reliability coefficient range = 0.95-0.98 p < 0.001Compared to NRS and

VDS

Verbal

Functional Pain

Scale (FPS) Geriatric Relates pain to function Reliability coefficient range = 0.95-0.98 p < 0.0054Compared to VAS Verbal Verbal Descriptor

Scale (VDS) Adults, geriatrics Descriptions aid patient to rate pain Interrater reliability coefficient range

= 0.77-0.89

p ≤ 0.002 Compared to NRS and VAS

Verbal

Face, Legs,

Activity, Cry,

Consolability

(FLACC)

Pediatrics mostly Clinically useful and

efficient in the ICU Interrater reliability coefficient = 0.84 Criterion validity p < 0.01

Compared to Checklist

of Nonverbal Pain Indicators (adults) and COMFORT scale for children

Both

Critical-Care Pain

Observation

Tool (CPOT)

Verbal and nonverbal Mechanically ventilated patients

Good reliability and validity when applied to cardiac surgical patients

Interrater reliability coefficient = 0.74 Criterion validity p < 0.001

Compared to NVPS and BPS

Both

Nonverbal Pain

Scale (NVPS) Sedated ICU patientsConscious adults Assessment of burn and trauma patients Interrater reliability coefficient = 0.78 Criterion validity p < 0.005

Compared to FLACC

Nonverbal

Behavioral Pain

Scale (BPS) Unconscious critically ill, mechanically

ventilated, sedated ICU patients

Widely used for sedated patients Interrater reliabilityIntraclass correlation

coefficient = 0.95

Construct validity

p < 0.0.001 when used for measuring pain in nonverbal ICU patients

Nonverbal

Data from Chanques G, Viel E, Constantin JM et al: The measurement of pain in intensive care unit: comparison of 5 self-report intensity scales, Pain 151:711-721, 2010; Gloth FM, Cheve AA, Stober CV et al: The functional pain scale: reliability, validity, and responsiveness in an elderly population, J Am Med Dir Assoc

2:110-114, 2001; Odhner M, Wegman D Freeland N et al: Assessing pain control in nonverbal critically ill adults, Dimens Crit Care Nurs 22:260-267, 2003; Cade CH: Clinical tools for the assessment of pain in sedated critically ill adults, Br Assoc Crit Care Nurse 13:288-297, 2008; Gelinas C, Fillion L, Puntillo K et al: Validation

of the critical-care pain observation tool in adult patients, Am J Crit Care 15:420-427, 2006; Aissaoui Y, Zeggwagh AA, Zekraoui A et al: Validation of a behavioral pain scale in critically ill, sedated, and mechanically ventilated patients, Anesth Analg 101:1470-1476, 2005; Voepel-Lewis T, Zanotti J, Dammeyer JA et al: Reliability and validity of the face, legs, activity, cry, consolability behavioral tool in assessing acute pain in critically ill patients, Am J Crit Care 19:55-61, 2010

ICU, Intensive care unit.

TABLE 21-7 Systemic Opioids

Indication Moderate to severe postoperative pain; can also be used preoperatively

Mechanism of

action Blocks transmission of pain from the periphery to the cerebrum by interacting with opioid receptorsCan be administered orally, intravenously, intramuscularly, subcutaneously, and intrathecally

General side effects Decreased gastrointestinal motility, nausea, vomiting, and cramps

Mood changes and sedation Pruritus (itching)

Urinary retention Bradycardia, hypotension Respiratory and cough depression Pupillary constriction, blurred vision Medications:

Generic name

(trade name)

Buprenorphine (Buprenex, Subutex) Butorphanol (Stadol)

Codeine (Paveral) Fentanyl (Actiq, Sublimaze, Duragesic) Hydromorphone (Dilaudid, Hydrostat) Levorphanol (Levo-Dromoran) Meperidine (Demerol, Pethidine) Methadone (Dolophine, Methadose) Morphine (MS Contin, Kadian, Morphine sulfate) Nalbuphine (Nubain)

Naloxone (Narcan)*

Oxycodone (Oxycontin, Roxicodone, Percocet [oxycodone with acetaminophen], Percodan [oxycodone with aspirin]) Oxymorphone (Numorphan)

Pentazocine (Talwin) Propoxyphene (Darvon, Dolene, Doloxene, Novopropoxyn) Remifentanil (Ultiva)

Sufentanil (Sufenta) Tramadol (Ultram)

*Opioid antagonist

Data from Ciccone CD: Pharmacology in rehabilitation, ed 4, Philadelphia, 2007, FA Davis, pp 183-198; Opioid analgesics and antagonists In Panus PC, Katzung

B, Jobst EE et al: Pharmacology for the physical therapist, New York, 2009, McGraw-Hill, pp 278-279; Analgesics, sedatives and hypnotics In Woodrow R, Colbert

BJ, Smith D: Essentials of pharmacology for health occupations, ed 6, Clifton Park, NY, 2011, Delmar, pp 327-333

TABLE 21-8 Nonsteroidal Antiinflammatory Drugs (NSAIDs)

Indications To decrease inflammation

Sole therapy for mild to moderate pain Used in combination with opioids for moderate postoperative pain, especially when weaning from stronger medications

Useful in children younger than 6 months of age Contraindicated in patients undergoing anticoagulation therapy, with peptic ulcer disease, or with gastritis, renal dysfunction, and NSAID-induced asthma

Mechanism of action Accomplishes analgesia by inhibiting the enzyme cyclo-oxygenase (COX), which in turn stops the production

of prostaglandins, resulting in antiinflammatory effects (prostaglandin is a potent pain-producing chemical)

A useful alternative or adjunct to opioid therapy General side effects Platelet dysfunction and gastritis, nausea, abdominal pain, anorexia, dizziness, and drowsiness

Severe reactions that include nephrotoxicity (dysuria, hematuria) and cholestatic hepatitis Commonly prescribed

medications: Generic

name (trade name)

Aspirin/acetylsalicylic acid (Bayer) Celecoxib (Celebrex)

Choline salicylate (Arthopan) Diclofenac (Cataflam, Voltaren) Etodolac (Lodine)

Flurbiprofen (Ansaid) Ibuprofen (Motrin, Advil) Indomethacin (Indocin, Indocin SR, Indomethacin, Novomethacin, Nu-Indo) Ketoprofen (Orudis)

Ketorolac (Toradol) Naproxen (Anaprox, Naprosyn, Aleve) Oxaprozin (Daypro)

Sulindac (Clinoril) Tolmetin (Tolectin)

Data from Ciccone CD: Pharmacology in rehabilitation, ed 4, Philadelphia, 2007, FA Davis, pp 199-216; Frampton C, Quinlan J: Evidence for the use of non-steroidal anti-inflammatory drugs for the acute pain in the post anaesthesia care unit, J Perioper Pract 19(12):418-423, 2009; Cox F: Basic principles of pain management: assessment and intervention, Nurs Stand 25(1):36-39, 2010; Musculoskeletal and anti-inflammatory drugs In Woodrow R, Colbert BJ, Smith D: Essentials of pharmacology for health occupations, ed 6, Clifton Park, NY, 2011, Delmar, p 389; Drugs affecting the musculoskeletal system In Panus PC, Katzung B, Jobst EE

et al: Pharmacology for the physical therapist, New York, 2009, McGraw-Hill, pp 522-523

TABLE 21-9A Local Anesthetics

Topical administration Minor injuries; surgical procedures;

hypertonicity Direct application to skin, mucous membrane, cornea, or other areas requiring anesthesia Transdermal administration Pain relief in subcutaneous structures such as

tendons and bursae Direct application to skin or other surfaces in concentrations to allow penetration to deeper

tissues Infiltration anesthesia Suturing of skin lacerations Injection directly into selected tissue in order to

diffuse to sensory nerve endings Peripheral nerve block Minor surgical procedures; management for

chronic pain; specific nerve pain Injection close to nerve trunk to interrupt signal transmission Central nerve blockade Obstetric procedures; alternative anesthesia for

orthopedic procedures such as lumbar surgery; acute or chronic pain management

Injection within the epidural or intrathecal spaces

Sympathetic block Complex regional pain syndrome Selective interruption of sympathetic efferent

pathways Intravenous regional

anesthesia (Bier block) Short surgical procedures Injection into a peripheral distal limb vein with a proximally placed tourniquet to isolate limb

circulation

Adapted from Local anesthetics In Panus PC, Katzung B, Jobst EE et al: Pharmacology for the physical therapist, New York, 2009, McGraw-Hill, pp 218-225

TABLE 21-9B Local Anesthetics

Mechanism of

action Blocks action potential propagation, thereby preventing transmission of sensation from

the periphery to the central nervous system General side

effects Somnolence, confusion, agitation, restlessnessHypotension, bradycardia, fatigue, dizziness

Medications:

Generic

(trade

name)

Articaine (Septocaine) Benzocaine (Americaine) Bupivacaine (Marcaine, Sensorcaine) Butamben picrate (Butesin Picrate) Chloroprocaine (Nesacaine) Dibucaine (Nupercainal) Dyclonine (Dyclone) Levobupivacaine (Chirocaine) Lidocaine (Xylocaine) Mepivacaine (Carbocaine) Pramoxine (Tronothane) Prilocaine (Citanest) Procaine (Novocain) Proparacaine (Alcain) Ropivacaine (Naropin) Tetracaine (Pontocaine)

Data from Local anesthetics In Panus PC, Katzung B, Jobst EE et al:

Pharma-cology for the physical therapist, New York, 2009, McGraw-Hill, pp 218-225;

Ciccone CD: Pharmacology in rehabilitation, ed 4, Philadelphia, 2007, FA

Davis, pp 149-160

CLINICAL TIP

Patients, particularly those who are postsurgical, are often pre-scribed more than one type of pain medication in order to achieve “breakthrough” pain levels In other words, they require additional medicine to break their pain.

Physical Therapy Considerations for Pain Management

• The physical therapist should be aware of the patient’s pain

medication schedule and the duration of the effectiveness of

different pain medications when scheduling treatment

ses-sions, particularly if premedication is necessary to optimize

intervention.

• Patients should be educated on the need to request pain medicine or push their PCA button when they need it, par-ticularly when they are on an “as needed” (PRN) pain medi-cation schedule.25

• Patients should be asked about the specific type of pain that the medication is intended for, such as postsurgical incisional pain Pain medications, such as opioids, may mask the occur-rence of a new type of pain, such as angina.25

• The physical therapist should also use a pillow, blanket, or his or her hands to splint or support a painful area, such as

an abdominal or thoracic incision or rib fractures, when the patient coughs or performs functional mobility tasks, such

as going from a sidelying position to sitting at the edge of the bed.26

• The physical therapist can also use a corset, binder, or brace

to support a painful area during intervention sessions that focus on functional mobility.

• Patients may experience pain induced by exercise or mobi-lization (PIEM), which can be perceived by patients as a decreased quality of life and result in fears about participa-tion in physical therapy and refusal of care Enhanced com-munication among care providers and with the patient about expected pain responses during therapy may lessen the adverse results of PIEM.27

TABLE 21-10 Patient-Controlled Analgesia

Indications For patients with moderate to severe acute pain who are not cognitively impaired and are capable of

properly using the pump Considerations Preoperative education of the patient on the use of patient-controlled analgesia

Ensuring that only the patient doses himself or herself Dosage, dosage intervals, maximum dosage per set time, and background (basal) infusion rate can be programmed

Pump apparatus, tubing and power lines could limit mobility Side effects Similar to those of opioids (see Table 21-7)

Medications Morphine, meperidine, fentanyl, and hydromorphone

Intravenous patient-controlled

analgesia (IV PCA) An intravenous line to a peripheral vein is connected to a microprocessor pump, and a patient is provided a button to allow self-dosing Patient-controlled epidural

analgesia (PCEA) The tip of a small catheter is placed in either the epidural or the subarachnoid space and connected to a pump

For short-term use, the catheter exits through the back to connect to a pump

For long-term use, the catheter is tunneled through the subcutaneous tissue and exits through the front for patient control

Patient-controlled regional

analgesia (PCRA) The catheter tip is inserted directly into a specific anatomic site such as a wound (incisional PCRA), near a peripheral nerve (perineural PCRA), or into a peripheral joint (intra-articular [IA] PCRA)

The other end of the catheter is attached to a pump with a button for patient control

Ropivacaine and bupivacaine are also used in PCRA

Patient-controlled intranasal

analgesia (PCINA) Intranasal opioids are delivered using a syringe, nasal spray or dropper, or nebulized inhaler either in dry powder or water or saline solution A pump mechanism is adapted to provide PCINA Fentanyl iontophoretic

transdermal system (ITS) A needle-free, self-contained fentanyl delivery system that does not require venous access for administration

System adheres to outer arm or chest with an adhesive backing and, via iontophoresis, delivers fentanyl across intact skin

Patient has on-demand dosing up to 6 doses/hour

Data from Ciccone CD: Pharmacology in rehabilitation, ed 4, Philadelphia, 2007, FA Davis, pp 237-249; Viscusi E: Patient-controlled drug delivery for acute post-operative pain management: a review of current and emerging technologies, Region Anesth Pain Med 33(2):146-158, 2008; Chumbley G, Mountford L: Patient-controlled analgesia infusion pumps for adults, Nurs Stand 25(8):35-40, 2010

References

11 American Physical Therapy Association: Cultural competence

http://www.apta.org/CulturalCompetence Accessed March 16, 2012

12 Odhner M, Wegman D, Freeland N et al: Assessing pain control

in nonverbal critically ill adults, Dimens Crit Care Nurs 22:260-267, 2003

13 Aissaoui Y, Zeggwagh AA, Zekraoui A et al: Validation of a behavioral pain scale in critically ill, sedated, and mechanically ventilated patients, Anesth Analg 101:1470-1476, 2005

14 Voepel-Lewis T, Zanotti J, Dammeyer JA et al: Reliability and validity of the face, legs, activity, cry, consolability behavioral tool in assessing acute pain in critically ill patients, Am J Crit Care 19:55-61, 2010

15 Kabes AM, Graves JK, Norris J: Further validation of the nonverbal pain scale in intensive care patients, Crit Care Nurse 29:59-66, 2009

16 Gelinas C, Harel F, Fillion L et al: Sensitivity and specificity of the critical-care pain observation tool for the detection of pain

in intubated adults after cardiac surgery, J Pain Symptom Manage 37:58-67, 2009

17 Garra G, Singer AJ, Taira BR et al: Validation of the Wong-Baker FACES Pain Rating Scale in pediatric emergency department patients, Acad Emerg Med 17(1):50-54, 2010

18 Keene DD, Rea WE, Aldington D: Acute pain management in trauma, Trauma 13(3):167-179, 2011

19 Cox F: Basic principles of pain management: assessment and intervention, Nurs Stand 25(1):36-39, 2010

1 Mackintosh C: Assessment and management of patients with

post-operative pain, Nurs Stand 22(5):49-55, 2007

2 Helfand M, Freeman M: Assessment and management of acute

pain in adult medical inpatients: a systematic review, Pain Med

10(7):1183-1199, 2009

3 Young J, Siffleet J, Nikoletti S et al: Use of a behavioral pain

scale to assess pain in ventilated, unconscious and/or sedated

patients, Intensive Crit Care Nurs 22:32-39, 2006

4 Cade CH: Clinical tools for the assessment of pain in

sedated critically ill adults, Nurs Crit Care 13:288-297,

2008

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