Simple approach to PAIN

Pain is ubiquitous in medicine and often overlooked. Despite a thorough definition, 'an unpleasant, sensory and emotional experience associated with actual or potential tissue damage', it is impossible to really understand someones pain unless you have felt it yourself. It is a highly diffuse symptom with a massive impact on patient well being and quality of life (it may even be much more diffuse than believed). It is an all encompassing entity which if you take Dame Cicely Saunders concept of 'total pain' concerns not only physical aspects but also social, spiritual and emotional aspects. 

If you take cancer pain, it is the most frequent presenting symptom and present overall in the majority of cancer patients. Shockingly pain is reported in a minority of cancer medical records, it would seem that many oncologists dont assess pain, probably fixating on battling the cancer itself (one of the toughest battles in medicine to add). Pain should be considered a disease entity itself and if it is properly assessed, addressed and treated, it could go a long way to enhance patient quality of life.

Here is a simple approach to pain you should consider whenever a patient says they are in pain:

First ASSESSMENT:

ABCDE 

A is for Ask: Ask about the pain: use the OPQRST approach:

• Onset
• Provoking factors 
• Quality of pain
• Region and Radiation of pain
• Severity 
• Timing and history 

When assessing severity use the NRS or VAS technique; "on a scale of zero to ten, where ten is the worst pain imaginable and zero is no pain, how would you describe your pain severity" (this is NRS, VAS is the application of a mark on a 10cm line to indicate pain severity in the same way).

score of 1-3 is mild  (VAS would be 1-3cm)

score of 4-6 is moderate pain (4-6cm mark)

score of 7-10 is severe pain (7-10cm mark)

One really important thing to think about after you have taken a thorough history is "what is causing the pain?"

B is for Believe the patient, don't dismiss them.

C is for Control: choose and appropriate pain control method, best way to apparoch pain treatment is with the WHO pain treatment ladder, which can be applied to all pain and not just cancer pain. move up the steps if pain is not well managed or still present.

• 1st step: PARACETOMOL (to treat mild pain)
• 2nd step: WEAK OPIOIDS (for example tramadol or codiene, these are opioids with a ceiling effect where inceasing drug dosgae will not improve effect from a certain point)
• 3rd step: STRONG OPIOIDS (consider for mod-severe pain). (for all opioids "start low and go slow"
• at any point you can add adjuvants to the ladder: NSAIDS, corticosteriods, antidepressants, anticonvulsants, benzodiazepines.

D is for Deliver pain control in a timely manner

E is for Empower the patient in pain control, patient education is so important. 

Second MANAGEMENT:

The four A's:

• Optimize ANALGESIA
• Optimize ACTIVITIES of daily living
• Minimize ADVERSE EFFECTS due to treatment
• AVOID unnecessary  drug taking

Third REASSESSMENT:

Simply, reassess often!

Summary: ABCDE OPGRST AAAA Reassess!

Rheumatology: Fibromyalgia

Fibromyalgia AKA fibromyalgic syndrome (FMS) is one of the most common causes of chronic pain. It is characterised by allodynia, hyperalgesia and a wide range of other symptoms.
On average a FMS patient will have seen three or four different doctors before being diagnosed (taking an average of 2-3 years)!

Epidemiology
Prevalence 2-4%
Female (9:1)
35-60yrs (working age)
increased incidence in patients with autoimmune disorders

Symptoms/Signs
Widespread pain with tender points (pain elicited with palpation of these specific points)
Fatigue (doesn't improve with rest, number one complaint after pain)
Morning stiffness
Sleep disturbances (pt sleeps well but wakes up more tired)
variety of other disturbances; Headaches (tension-type and migraine), paresthesias, trouble concentrating, variable bowel habits, depression, mood and affective disorders, temporomandibular joint syndrome,  idiopathic back pain, non cardiac chest pain, vestibular complaints, ENT symptoms...

Diagnosis
Diagnosis is entirely clinical, by exclusion generally.
Rule out differentials, be vigilant of common co-existing conditions like irritable bowel syndrome
ACR 2010 diagnostic criteria
Reasonable diagnosis:
>Chronic widespread pain for greater than 3 months
>pain at 10 or more tender points (see image linked for specific locations, there are 18 defined areas)
(> also aiding in diagnosis; presence of Fatigue/stiffness and sleep disturbances)

Treatment
Centred towards the pain, but be aware that many FMS patients have concomitant psychiatric problems, so psychiatry referral suggested. Reassure patient its a physical diagnosis and warn them in some cases the symptoms will never resolve completely.

>Non pharmacological treatment
Exercise, CBT, homeopathy, physiotherapy, acupuncture, diet changes, relaxation techniques
all safe in the long term and may have potential benefits (small % of acupuncture pts had increased pain though)
Graded exercise showed benefits in many patients

>Pharmacological treatment
simple analgesics, tramadol,
tricyclic antidepressants
serotonin noradrenaline reuptake inhibitors (SNRIs)
alpha2 agonists (gabapentin, pregabalin)

Differential dx
Chronic fatigue syndrome (fatigue much more prevalent and severe, more an issue than pain)
Multiple bursitis/tendonitis (good response to local inection treatment, tender points absent)
Rheamatoid arthritis/Osteoarthritis (joint swelling, hands affected)
SLE (rash, systemic sx, ANA)
Ankylosing spondylitis (young male, lower back pain)
Polymyalgia rheumatica (older pt, acute onset, steroid responsive)
Hypothyroidism (weight gain, goitre)
Myositis (weakness more than pain)

Random pearls

• Although the etiology is unknown it is believed to be a central sensitization disorder, fitting in with the considerable overlap of IBS and dysmenorrhea with FM. A kind of abnormal response of the nervous system.
• RA and SLE often present as well. 
• FMS is increased in patients that have suffered a physical of psychiatric trauma (perhaps a starting point of the disease)
• increase in metabolic syndrome in FMS patients
• There are three subgroups to further classify FMS patients based on pain control, tenderness and associated symptoms
• In USMLE exam 'steroids' or 'NSAIDS' will not be the correct answer answer to treatment options
• 12th May is Fibromyalgia awareness day
• One third of FMS patients experience major depression or significant anxiety. 

Resources and Sources:
Medscape Fibromyalgia
Paul Bolin CRASH USMLE video on Fibromyalgia
ArthritisUK Great site for patients
More detailed look at diagnostic criteria

 #MEDed #FOAMed #Fibromyalgia #Rheumatology #Chronicpain #widespreadpain