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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
CHAPTER 21 Acute Pain Management Jaime C Paz Danika Quinlan CHAPTER OUTLINE CHAPTER OBJECTIVES Pain Evaluation Physical Therapy Considerations for Pain Evaluation Pain Management Physical Therapy Considerations for Pain Management The objectives of this chapter are to provide the following: An overview of pain evaluation scales most applicable to the acute care setting A description of physical therapy considerations when evaluating pain An overview of commonly utilized management strategies for acute pain including pharmacologic agents 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 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 consistency 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) 457 458 CHAPTER 21 Acute Pain Management TABLE 21-1 Verbal Pain Scales Tool Description Verbal descriptor scales Numeric Rating Scale (NRS) The patient describes pain by choosing from a list of adjectives representing gradations of pain intensity The patient picks a number from to 10 to rate his or her pain, with indicating no pain, and 10 indicating the worst pain possible Visual Analog Scales (VAS) Line scale Wong-Baker Faces scale Functional Pain 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.” The patient chooses one of six faces, portrayed on a scale that depicts graduated levels of distress, to represent his or her pain level A zero (0) to five (5) scale with corresponding pain descriptions = No pain = Tolerable (and does not prevent any activity) = Tolerable (but does prevent some activities) = Intolerable (but can use telephone, watch TV, or read) = Intolerable (cannot use telephone, watch TV, or read) = 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 self-report intensity scales, Pain 151:711-721, 2010 TABLE 21-2 Adult Nonverbal Pain Scale Categories Face Activity (movement) Guarding No particular expression or smile Lying quietly, normal position Occasional grimace, tearing, frowning, wrinkled forehead Seeking attention through movement or slow, cautious movement Splinting areas of the body, tense Frequent grimace, tearing, frowning, wrinkled forehead Restless, excessive activity and/or withdrawal reflexes Rigid, stiff Change over past hours in any of the following: SBP > 20 mm Hg, HR > 20/min, RR > 10/min Dilated pupils, perspiring, flushing Change over past hours in any of the following: SBP > 30 mm Hg, HR > 25/min, RR > 20/min Diaphoretic, pallor Physiologic I (vital signs) Lying quietly, no positioning of hands over areas of body Stable vital signs (no change in past hours) Physiologic II Warm, dry skin 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 HR, Heart rate; RR, respiratory rate; SBP, systolic blood pressure 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 CLINICAL TIP The therapist should be sensitive to, and respectful of, how different cultures perceive pain, as pain expression may vary among cultures.5,11 The therapist should be aware that some physiologic indicators 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 demonstrated good interrater reliability when assessing pain in critically 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 CHAPTER 21 Acute Pain Management demonstrate some behaviors associated with the pediatric population 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 selfreport is unattainable.5 • Select the appropriate tool based on the clinical environment and relevance to the specific patient population.5 TABLE 21-3 Behavioral Pain Scale Item Description Facial expressions Relaxed Partially tightened (e.g., brow lowering) Fully tightened (e.g., eyelid closing) Grimacing No movement Partially bent Fully bent with finger flexion Permanently retracted Tolerating movement Coughing but tolerating ventilation for most of the time Fighting ventilator Unable to control ventilation Movements of upper limbs Compliance with ventilation Score 4 459 • 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, description, and most importantly, an “intervention,” 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 complain 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 medicalsurgical 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 management is insufficient to allow the patient to accomplish functional tasks Pain Management 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 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 combination.19,20 This section focuses on pharmacologic management while the next section will describe physical therapy management considerations TABLE 21-4 FLACC Pain Assessment Tool Categories Score = Score = Score = Face No particular expression or smile Legs Activity Frequent to constant frown, clenched jaw, quivering chin Kicking, or legs drawn up Arched, rigid, or jerking Cry Normal position or relaxed Lying quietly, normal position, moves easily No cry (awake or asleep) Consolability Content, relaxed Occasional grimace or frown, withdrawn, disinterested Uneasy, restless, tense Squirming, shifting back/forth, tense Moans or whimpers, occasional complaint Reassured by occasional touching, hugging, or “talking to,” distractible Crying steadily, screams or sobs, frequent complaints 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 460 CHAPTER 21 Acute Pain Management TABLE 21-5 Critical-Care Pain Observation Tool (CPOT) Indicator Descriptor Score Facial expression No muscular tension observed Presence of frowning, brow lowering, orbit tightening and levator contraction All of the above facial movements plus eyelid tightening Does not move at all (does not necessarily mean absence of pain) Slow cautious movements, touching or rubbing the pain site, seeking attention through movements Pulling tube, attempting to sit up, moving limbs/ thrashing, not following commands, striking at staff, trying to climb out of bed No resistance to passive movements Resistance to passive movements Strong resistance to passive movements, inability to complete them Alarms not activated, easy ventilation Alarms stop spontaneously Asynchrony: blocking ventilation, alarms frequently activated Talking in normal tone or no sound Sighing, moaning Crying out, sobbing = Relaxed, neutral = Tense Body movements Muscle tension (evaluation by passive flexion and extension of UEs) Compliance with mechanical ventilator (intubated patient) Vocalization (extubated patient) = Grimacing = Absence of movement = Protection = Restlessness = Relaxed = Tense, rigid = Very tense, rigid = Tolerating ventilator or movement = Coughing but tolerating machine = Fighting ventilator = Talking in normal tone or no sound = Sighing, moaning = Crying out, sobbing 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 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 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 is for patients with mild pain in whom the use of nonopioid analgesia is recommended, step is for moderate pain and advocates the use of weak opioids with or without nonopioids, and step is for patients with severe pain in whom strong opioids with or without nonopioids are recommended.20 Table 21-7 provides an overview of commonly utilized opioid agents in the management of acute pain Nonopioid drugs typically comprise nonsteroidal antiinflammatory drugs (NSAIDs) (Table 21-8) and acetaminophen (paracetamol), which is a centrally acting analgesic that interacts 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 inhibitors 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 Prostaglandins have a protective role for the mucosal lining of the gastrointestinal 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 Unfortunately, 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 selection 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 vascular 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) 461 CHAPTER 21 Acute Pain Management TABLE 21-6 Comparison of Pain Assessment Scales Tool Targeted Population Benefits Reliability Validity Numeric Rating Scale (NRS) Adults Easy to use Interrater reliability coefficient = 0.54 Visual Analog Scale (VAS) Adults Visual face and number scale to rate pain Reliability coefficient range = 0.95-0.98 Functional Pain Scale (FPS) Verbal Descriptor Scale (VDS) Geriatric Relates pain to function Adults, geriatrics Descriptions aid patient to rate pain Face, Legs, Activity, Cry, Consolability (FLACC) Pediatrics mostly Clinically useful and efficient in the ICU Reliability coefficient range = 0.95-0.98 Interrater reliability coefficient range = 0.77-0.89 Interrater reliability coefficient = 0.84 Critical-Care Pain Observation Tool (CPOT) Verbal and nonverbal Mechanically ventilated patients Interrater reliability coefficient = 0.74 Nonverbal Pain Scale (NVPS) Sedated ICU patients Conscious adults Good reliability and validity when applied to cardiac surgical patients Assessment of burn and trauma patients Behavioral Pain Scale (BPS) Unconscious critically ill, mechanically ventilated, sedated ICU patients Widely used for sedated patients Interrater reliability Intraclass correlation coefficient = 0.95 p < 0.001 Compared to VDS and VAS p < 0.001 Compared to NRS and VDS p < 0.0054 Compared to VAS p ≤ 0.002 Compared to NRS and VAS Criterion validity p < 0.01 Compared to Checklist of Nonverbal Pain Indicators (adults) and COMFORT scale for children Criterion validity p < 0.001 Compared to NVPS and BPS Criterion validity p < 0.005 Compared to FLACC Construct validity p < 0.0.001 when used for measuring pain in nonverbal ICU patients Interrater reliability coefficient = 0.78 Verbal or Nonverbal Verbal Verbal Verbal Verbal Both Both Nonverbal Nonverbal Data from Chanques G, Viel E, Constantin JM et al: The measurement of pain in intensive care unit: comparison of 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 2:110114, 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 462 CHAPTER 21 Acute Pain Management TABLE 21-7 Systemic Opioids Indication Mechanism of action General side effects Medications: Generic name (trade name) Moderate to severe postoperative pain; can also be used preoperatively Blocks transmission of pain from the periphery to the cerebrum by interacting with opioid receptors Can be administered orally, intravenously, intramuscularly, subcutaneously, and intrathecally 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 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) 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 *Opioid antagonist TABLE 21-8 Nonsteroidal Antiinflammatory Drugs (NSAIDs) Indications Mechanism of action General side effects Commonly prescribed medications: Generic name (trade name) 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 months of age Contraindicated in patients undergoing anticoagulation therapy, with peptic ulcer disease, or with gastritis, renal dysfunction, and NSAID-induced asthma 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 Platelet dysfunction and gastritis, nausea, abdominal pain, anorexia, dizziness, and drowsiness Severe reactions that include nephrotoxicity (dysuria, hematuria) and cholestatic hepatitis 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 CHAPTER 21 Acute Pain Management 463 TABLE 21-9A Local Anesthetics Type Indication Description Topical administration Minor injuries; surgical procedures; hypertonicity Pain relief in subcutaneous structures such as tendons and bursae Direct application to skin, mucous membrane, cornea, or other areas requiring anesthesia Direct application to skin or other surfaces in concentrations to allow penetration to deeper tissues Injection directly into selected tissue in order to diffuse to sensory nerve endings Injection close to nerve trunk to interrupt signal transmission Injection within the epidural or intrathecal spaces Transdermal administration Infiltration anesthesia Suturing of skin lacerations Peripheral nerve block Minor surgical procedures; management for chronic pain; specific nerve pain Obstetric procedures; alternative anesthesia for orthopedic procedures such as lumbar surgery; acute or chronic pain management Complex regional pain syndrome Central nerve blockade Sympathetic block Intravenous regional anesthesia (Bier block) Short surgical procedures Selective interruption of sympathetic efferent pathways 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 General side effects Medications: Generic (trade name) Blocks action potential propagation, thereby preventing transmission of sensation from the periphery to the central nervous system Somnolence, confusion, agitation, restlessness Hypotension, bradycardia, fatigue, dizziness 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: Pharmacology 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 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 sessions, 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, particularly when they are on an “as needed” (PRN) pain medication 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 occurrence 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 mobilization (PIEM), which can be perceived by patients as a decreased quality of life and result in fears about participation in physical therapy and refusal of care Enhanced communication among care providers and with the patient about expected pain responses during therapy may lessen the adverse results of PIEM.27 CLINICAL TIP Patients, particularly those who are postsurgical, are often prescribed 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 464 CHAPTER 21 Acute Pain Management TABLE 21-10 Patient-Controlled Analgesia Indications Side effects Medications For patients with moderate to severe acute pain who are not cognitively impaired and are capable of properly using the pump 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 Similar to those of opioids (see Table 21-7) Morphine, meperidine, fentanyl, and hydromorphone Types Description Intravenous patient-controlled analgesia (IV PCA) Patient-controlled epidural analgesia (PCEA) An intravenous line to a peripheral vein is connected to a microprocessor pump, and a patient is provided a button to allow self-dosing 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 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 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 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 doses/hour Considerations Patient-controlled regional analgesia (PCRA) Patient-controlled intranasal analgesia (PCINA) Fentanyl iontophoretic transdermal system (ITS) Data from Ciccone CD: Pharmacology in rehabilitation, ed 4, Philadelphia, 2007, FA Davis, pp 237-249; Viscusi E: Patient-controlled drug delivery for acute postoperative pain management: a review of current and emerging technologies, Region Anesth Pain Med 33(2):146-158, 2008; Chumbley G, Mountford L: Patientcontrolled analgesia infusion pumps for adults, Nurs Stand 25(8):35-40, 2010 References Mackintosh C: Assessment and management of patients with post-operative pain, Nurs Stand 22(5):49-55, 2007 Helfand M, Freeman M: Assessment and management of acute pain in adult medical inpatients: a systematic review, Pain Med 10(7):1183-1199, 2009 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 Cade CH: Clinical tools for the assessment of pain in sedated critically ill adults, Nurs Crit Care 13:288-297, 2008 Puntillo K, Pasero C, Li D et al: Evaluation of pain in ICU patients, Chest 135:1069-1074, 2009 Shega JW, Rudy T, Keefe FJ et al: Validity of pain behaviors in persons with mild to moderate cognitive impairment, J Am Geriatr Soc 56:1631-1637, 2008 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 26 Cristoph SD: Pain assessment: the problem of pain in the critically ill patient, Crit Care Nurs Clin North Am 3(1):11-16, 1991 Acello B: Meeting JCAHO standards for pain control, Nursing 30(3):52-54, 2000 10 Turk DC, Okifuji A: Assessment of patients’ reporting of pain: an integrated perspective, Lancet 353(9166):1784, 1999 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 WongBaker 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 20 McMain L: Principles of acute pain management, Pain Manage 18(11):472-478, 2008 21 World Health Organization: WHO 1986 cancer pain relief, Geneva, World Health Organization 22 World Health Organization: WHO 1996 cancer pain relief: with a guide to opioid availability, ed 2, Geneva, World Health Organization 23 Ciccone CD: Pharmacology in rehabilitation, ed 4, Philadelphia, 2007, FA Davis, pp 183-249 24 Chakraborti AK, Garg SK, Kumar R et al: Progress in COX-2 inhibitors: a journey so far, Curr Med Chem 17:1563-1593, 2010 CHAPTER 21 Acute Pain Management 465 25 Chumbley G, Mountford L: Patient controlled analgesia infusion pumps for adults, Nurs Stand 25(8):35-40, 2010 26 Cahalin L, Lapier T, Shaw D: Sternal precautions: is it time for change? Precautions versus restrictions—a review of literature and recommendations for revision, Cardiopulm Phys Ther J 22(1):5-15, 2011 27 Alami S, Desjeux D, Lefèvre-Colau MM et al: Management of pain induced by exercise and mobilization during physical therapy programs: views of patients and care providers, BMC Musculoskelet Disord 12:172, 2011 ... administration for pain medications include local anesthetics (Tables 2 1- 9A and 2 1- 9B) and patient-controlled analgesia (PCA) (Table 2 1- 10) 461 CHAPTER 21 Acute Pain Management TABLE 2 1- 6 Comparison... behavioral tool in assessing acute pain in critically ill patients, Am J Crit Care 19:5 5-6 1, 2010 ICU, Intensive care unit 462 CHAPTER 21 Acute Pain Management TABLE 2 1- 7 Systemic Opioids Indication... postoperative pain in young children, Pediatr Nurs 23(3):29 3-2 97, 1997 460 CHAPTER 21 Acute Pain Management TABLE 2 1- 5 Critical -Care Pain Observation Tool (CPOT) Indicator Descriptor Score Facial