Transcript Slide 1

1
Pain Management in
Geriatrics
Min H. Huang, PT, PhD, NCS
Learning Objectives
• Discuss the challenges and consideration for
pain management in geriatric clients.
• Apply physical therapy interventions to
address pain in geriatric clients.
Reading Assignments
• Guccione 2012, Chapter 21
Definition of Pain
• Pain (IASP Task Force, 1994)
―Unpleasant sensory and emotional
experience
―Subjective
• Pain signals are sent to many areas in the
brain that process the perception,
memory/cognitive, affective/emotional, and
behavioral perspectives of pain.
Pop Quiz
• Identify and compare the following terms
―Transient pain
―Acute pain
―Breakthrough pain
―Chronic pain due to cancer
―Chronic pain due to non-malignant
―Persistent pain
Pain management in geriatrics
• Prevalence of pain in community dwelling
older adults: 25% to 49%
• Older adults have longer pain duration and
more pain sites than working-age adults.
• Challenges of pain management in geriatrics
―Underreported and undertreated
―Medication adherence and adverse effects
―Impact of pain on function and mobility
―Comorbidity: physical, mental, cognitive
―Associated with socioeconomic factors
6
Consideration in the examination of
pain in geriatrics
• Standard exam procedures may have to be
modified, e.g. patients with congestive heart
failure and COPD cannot lie flat in supine or
prone during exam
• May require more time to evaluate
• May fatigue in long sessions
• May have difficulty answering abstract
questions or questions that are designed for
working adults
7
Persistent pain in older adults
• The American Geriatrics Society (AGS) Panel
defined persistent pain as “prolonged period of
time that may or may not be associated with a
recognizable disease process.’’
• Etzioni 2007: “Pain of a duration or intensity that
adversely affects the function or well-being of
the patient, attributable to ANY etiology.”
• Chronic pain defined by the American Society of
Anesthesiologists Task Force on Pain
Management does NOT include cancer pain.
Screening for persistent pain in
vulnerable elders (Etzioni 2007. JAGS. 55. S403-S408)
• Vulnerable Elders defined in RAND’s
ACOVE project
― Persons 65 + years who are at high risk for
death or functional decline
― Self-rated functional status as the predictor
of death and functional decline
• IF a vulnerable elder presents for an initial
evaluation, THEN a quantitative and
qualitative assessment for persistent pain
should be documented
Screening for persistent pain in
vulnerable elders (Etzioni 2007. JAGS. 55. S403-S408
• The prevalence of inadequately treated
persistent pain is high
• In community living older adults experiencing
daily pain, ~ 25% received analgesia.
• Risk factors for failing to receive analgesia in
patients with cancer (Centers for Medicare and Medicaid
Services data, n=13,625)
―Aged 85 and older
―Cognitive dysfunction
―Minority ethnicity
―Receiving 11 or more medications
Screening for persistent pain in
vulnerable elders (Etzioni 2007. JAGS. 55. S403-S408
• If cognitively impaired, a standardized pain
scale, behavioral assessment or proxy report
of pain should be used.
• ALL vulnerable elderly should be screened
for persistent pain annually.
• BECAUSE pain is common and
underdiagnosed in older patients, and routine
assessment will result in better detection and
treatment and less pain.
Pop Quiz: Screening for persistent
pain in vulnerable elders
• ALL adults aged 65+ years and older are
considered as “vulnerable elders”
True/False
• What is the frequency of screening for
persistent pain in vulnerable elders?
a. Twice an year
b. Once an year
• It is impossible to assess persistent pain in
vulnerable elders with cognitive impairments
True/False: use FACES to rate pain
Pop Quiz: pain intensity scale
• Compare the clinical utility of the following
pain intensity scales
―Visual analog scale (VAS)
―Verbal description scale
―Numerical Verbal rating scale: BEST
―Faces pain scale revised
―Iowa pain thermometer
Standardized assessment tool:
Geriatric Pain Measure
• 24-item multidimensional questionnaire that
measure pain among older adults with
multiple medical problems (see form and
article on Blackboard)
• Based on the relationship of pain to function
in older adults.
• Identifies dimensions of pain including
intensity, affect, and functional limitations
• Good Validity with comparison to McGill Pain
Questionnaire
(Ferrell 2000. JAGS. 48(12): 1169-73)
Pop Quiz: Consideration in plan of
care
• Passive treatment modalities focused
solely on temporarily decreasing pain
symptoms, such as heat, cryotherapy,
TENS, should be used sparingly and as a
means to allow patients to participate in
subsequent active treatment aimed at
positively affecting functional abilities.
True/False
Ultrasound
• Evidence of use in shoulder tendinitis
• OA in knee (Cochrane Review 2010 (Rutjes, 2010)
―Pulsed or continuous
―Improvement in pain measured by VAS by 1.2cm
on 10 cm scale (95% CI)
―Improvement in function by WOMAC disability
scale
―No adverse events
―Problems in studies’ methodology (low quality)
• Lack of evidence for pain in neck, hip, knee
Pop Quiz: Thermal agents
• When physical agents were applied prior to
exercise, older women with knee OA generated
greater force during isokinetic exercise.
True/False. Why? –Studies show an increase in
muscle performance –either due to pain relief or
comforting
• Use of thermal agents (heat or cool) is a
commonly used home remedy for older adults,
even among minority.
True/False
Manual therapy
• Spinal manipulation for low back pain
―2011 National Guideline Clearinghouse (NGC9259) indicate NO or INSUFFICIENT evidence
―2007 American Pain Society's clinical practice
guidelines indicate GOOD evidence
―2004 Cochran review supports the use for
headache
• Manipulative therapy + exercises
―Level B (fair) evidence for knee osteoarthritis
―Level C (limited) evidence for hip osteoarthritis
―Cochran review supports the use for neck pain
TENS
• 2009 Cochrane review
― Compared TENS with sham treatment for knee
OA
― 11 Used TENS, 4 Interferential, 1 TENS and
IFC, and 2 pulsed electrostimulation
― Change of 0.2 cm on 10 cm VAS (SMD was -.07
cm)
― Could NOT determine if TENS helped with
function or pain relief
Pop Quiz: TENS parameters
• Describe the key parameters of TENS for
management of postoperative pain
―Review Table 21-1 on page 407 in your
textbook
―Frequency: 100hz
―Intensity: highest to tolerance
―Duration/; 30min to 24hrs
―What were the conditions of patients listed in
this table? CABG, postthoracotomy, cardiac
suergery, TKA, abdominal surgery
Guided imagery
• An alternative medicine technique
• A powerful psychological strategy
• Focus on relaxation, mind and body harmony
• Aid clients to use mental imagery to help with
health problems, e.g. imagining the busy,
focused buzz of thousands of loyal immune
cells
www.med.umich.edu/cancer/support/guided_im
agery.shtml
Guided imagery in patients with
fibromyalgia (Verkaik, 2013. RCT, n=65)
• Daily imagery for 4 weeks
―Example of the instruction “now imagine that you
leave all the pain you experience at the beach post.”
• Visual Analogue Scale for pain
• Fibromyalgia Impact Questionnaire for
functional status
• Chronic Pain Self-Efficacy Scale for selfefficacy
• NO effects could be established
Guided imagery for managing OA
symptoms (Baird 2012, n=30, age=55+ years, mean=70 years)
Patients with self-reported OA and moderate to severe
pain participated in 4 months Guided imagery vs. sham
Using real-time functional MRI as
biofeedback to control pain
• Real-time fMRI feedback is a potential tool for
pain modulation that directly targets the brain
to restore pain regulatory function
• After training, patients with chronic pain
improved their ability to control anterior
cingulate cortex activation and consequently,
ability to modulate the pain
• Stanford’s lab: Human Body - Pushing The
Limits http://paincenter.stanford.edu/press/
video_discovery.html
Cognitive behavioral therapy (CBT)
• Standard treatment for chronic pain patients
who have to deal with psychological distress
and disabilities
Cognitive behavioral therapy (CBT)
• Teach patients specific cognitive and
behavioral skills to better manage pain
• Inform patients regarding the effects that
specific cognitions (thoughts, beliefs,
attitudes), emotions (fear of pain), and
behaviors (activity avoidance due to fear of
pain) can have on pain
• Emphasize the primary role that patients can
play in controlling their own pain as well as
adaptations to pain
Use of cognitive behavioral therapy by
PTs nationwide (Beissner 2009. PTJ. 89(5): 456–469)
• CBT techniques: pacing (81%), pleasurable
activity scheduling (30%)
• Non-CBT interventions: exercises focusing
on joint stability (94%) and mobility (94%),
strengthening and stretching (91%).
• Barriers to use of CBT: lack of knowledge of
and skill in the techniques, reimbursement
concerns, and time constraints.
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2716379/
Acceptance and commitment therapy
(ACT)
• Attempts to change certain aversive internal
experiences (e.g. chronic pain) are likely to
be futile and may result in increased distress
• Awareness and non-judgmental acceptance
of all experiences, both negative and positive
• Identify valued life directions and appropriate
action toward goals that support those values
• The objective is to improve function and
decrease interference of pain
RCT comparing CBT and ACT (Wetherell
2011. PAIN 152 (2011) 2098–2107)
• Individuals with chronic, non-malignant pain
for at least 6 months (N = 114) received 8
weeks of CBT or ACT
• All participants improved on pain
interference, depression, pain-related anxiety
• NO significant group differences in
improvement on any outcome variables
• ACT participants reported significantly higher
satisfaction than did CBT participants
Change in pain
interference during
treatment and at 6month follow-up for
114 patients
receiving groupadministered
acceptance and
commitment
therapy
(ACT) or cognitivebehavioral therapy
(CBT) for chronic
pain.
Wetherell 2011. PAIN 152 (2011) 2098–2107