Muscle/Skeletal - Lecture 2 - Dr. Klucken

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VASUpharm14
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Muscle/Skeletal - Lecture 2 - Dr. Klucken
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2013-04-08 18:19:11
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M/S Pain Describe the various types of pain  Understand the pathophysiology of pain  Recommend various non-pharmacologic and pharmacologic options for pain management  Understand the pros and cons of the various treatment options
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  1. diminished pain in response to normally painful stimulus
    HYPO algesia
  2. increased response to painful stimulus
    HYPER algesia
  3. pain caused by a stimulus that does NOT normally cause pain
    Allodynia
  4. pain definition
    unpleasant sensory and emotional experience associated with actual or potential tissue damage or described in terms of such damage
  5. t/f pain is clearly objective
    false. subjective - pain is what patient says
  6. functions of pain
    • protect body
    • maintain homeostasis
  7. types of pain: duration
    2 types
    • acute
    • chronic
  8. acute duration of pain
    • nociceptive
    • limited duration
    • decreases over time
  9. objective features of acute pain
    • increased BP/HR
    • anxiety
    • sweating
    • local muscle contraction
  10. chronic duration of pain
    • nociceptive, neuropathic, or mixed
    • long-term
    • cancer/no cancer pain
    • changes to receptors and nerve fibers
  11. Pain treatment goals: acute vs chronic
    • acute = cure
    • chronic = functionality
  12. pain dependence/tolerance to meds: acute vs chronic
    • acute = unusual
    • chronic = common
  13. organic cause : acute vs chronic
    • acute = common
    • chronic = may not be present
  14. psychological component : acute vs chronic
    • acute = usually not present
    • chronic = often a problem
  15. types of pain: pathophysiology 2 types
    • nociceptive 
    • neuropathic
  16. pathophysiology: noxious stimuli
    pressure, temperature, chemical, stimuli 
    dull, aching, throbbing, sharp
    Nociceptive
  17. pathophysiology: nervous system dysfunction
    burning, tingling, electric shock-like
    neuropathic
  18. 2 locations of pain
    • visceral
    • somatic
  19. locations of pain: internal organs, not well localized, "pressure"
    visceral
  20. locations of pain: surface/deep tissue like skin, bone, joint, muscle, connective tissue
    specifically located, sharp/piercing (surface), dull/aching (deep tissue)
    somatic
  21. 4 steps in pathophysiology of pain
    • 1. stimulation
    • 2. transmission
    • 3. perception
    • 4. modulation
  22. pathophysiology step 1
    • stimulation (transduction)
    • -mechanical, thermal, chemical stimulus to electrical
  23. pathophysiology step 2
    • transmission
    • nerve fibers to dorsal horn in spine
  24. pathophysiology step 3
    • perception
    • conscious experience higher cortical structures
    • process a limited number of signals
  25. pathophysiology step 4
    • modulation
    • body modulates pain with endogenous opiate system
    • NMDA receptor (dorsal horn)
    •    - stimulation = decrease mu receptor responsiveness to opiates
    •    - antagonists = increase mu receptor responsiveness to opiates
  26. placebo effect
    • expectation of tx working
    • activation of endogenous opioid system
  27. nocebo effect
    pain worsens, expect pain
  28. lower threshold variables
    anxiety, depression, fatigue, anger, fear
  29. higher threshold variables
    rest, mood elevation, sympathy, diversion, understanding
  30. referred pain
    • neurons converge same area in the spine so there is cross transmission of signals 
    • ex. mi and feel in shoulder, etc.
  31. Goal of therapy for pain (3)
    • 1. relieve suffering - reduce not eliminate
    • 2. restore functionality 
    • 3. limit ADRs of therapy
  32. special populations
    • infants and elderly
    • -can't communicate
    • -cognitive impairment
  33. non-opioid analgesics (5)
    • 1. APAP
    • 2. ASA
    • 3. NSAIDs
    • 4. TCAs
    • 5. SMRs
  34. acetaminophen - pros
    • CENTRAL PG inhibition
    • 1. few adrs
    • 2. few ddis
    • 3. synergistic with opioids
  35. acetaminophen - cons
    • mild-moderate pain only
    • no anti-inflammatory
    • -cause liver failure - avoid hepatic dysfunction
    • -avoid alcoholics
  36. NSAIDs - pros
    • PERIPHERAL PG inhibition = anti-inflammatory
    • CENTRAL PG inhibition = analgesic
    • 1. minimal CNS adrs
    • 2. non-constipating
    • 3. synergistic with opioids
  37. NSAIDs - cons
    • ceiling analgesic effect
    • short duration
    • GI BLEED 
    • ASA - irreversible cox1
    • DEC PG = decreased GFR
  38. NSAIDs GI Risk vs CV risk
    • low both = ibuprofen
    • low cv/mod GI = celecoxib, etc
    • high cv/low GI = Naproxen
    • high cv/mod GI = naproxen + ppi/misopristol/h2 blocker
    • high = avoid
  39. opioid analgesics ADRs and tolerance
    • develop tolerance: n/v, sedation/confusion, urinary retention, pruritis, respiratory depression 
    • no tolerance: constipation, HYPO tension

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