Pain Management for Primary

Care
Daniel Alves, MD, MPH

About Me
Practice at Universal Pain Management
Offices at:
Victorville, CA
Palmdale, CA
Santa Clarita, CA

Medical School at LLU

Board certified specialist in Physical Medicine &
Rehabilitation (Medical College of Wisconsin)
Specialty trained in Pain ManagementUCLA/WLA VA hospital- PM&R program

Goals of Todays Lecture

Why should we learn about
Pain?
How is it measured
What are the different types of
pain
Treatments
Strategies

Pain patients often need specialized

care.
Pain accounts for 80% of all physician visits.
Less than half (48%) of pain patients felt they
were getting enough information on the most
effective ways to manage chronic pain.
86% of chronic pain sufferers report an inability
to sleep well.
60% of pain patients experience breakthrough
pain one or more times daily.

What is Pain
An unpleasant sensory and
emotional experience
associated with actual or
potential tissue damage, or
described in terms of such
damage. -IASP
Subjective nature sensation
and emotional component to
it.

Famous Descartes Image: "Fast moving particles of fire ..the

disturbance passes along the nerve filament until it reaches the
brain..." Descartes (1664)

Components of Pain
Biological Injury or disease processremoving
tissue makes the pain go away.
Psychological -- Personality disorder, depression
Social Family dynamics, financial
Cultural Effects of pain on behavior
BIO-PSYCHO-SOCIAL model

Nurses working with clients in pain need to recognize and

avoid common misconceptions and myths about pain. In
regard to the pain experience, which of the following is
correct

1. The client is the best authority on the pain

experience.2. Chronic pain is mostly
psychological in nature.3. Regular use of
analgesics leads to drug addiction.4. The amount
of tissue damage is accurately reflected in the
degree of pain perceived.

Pain Physiology Truisms

There are no pain fibers and no pain pathways in
the nervous system
Pain is a complex perception that has profound
effective and cognitive features.
Pain is not a stimulus; whether or not a stimulus
is perceived as painful depends on the nature
existing this, the situation in which it is
experience, memories, emotions, etc.
Modulation can occur at multiple levels.

Measuring Pain
How do you measure subjective phenomenon
Good History and Physical Exam
Pain location, frequency, severity, exacerbating or alleviating
factors, response to therapy, previous treatments surgical
or medical.

Visual Analog Scale

Verbal or visual analog scale:
0-10
Appropriateness for chronic
pain??
Chronic pain patients tend to
report higher number for
their baseline level.

Scale is therefore skewed to

the right.

 Assessment of acute pain includes determining

the location of the pain, a description of the type
of pain (in the patient's own words), and an
evaluation of the pain intensity and duration.
What are some of the tools used to establish the
intensity of the pain?
Numeric Pain Intensity Scale and Visual
Analog Scale
McGill Pain Questionnaire
Pain Outcomes Questionnaire

Brief Pain Inventory

Activity Level and Pain

May be more useful than VAS
Documenting treatment efficacy what are you
able to do now since pain management? Work,
yard work, increased ability to walk or sit?
Can be more useful in assessing the efficacy of
treatment.

Waddells Signs 5 elements

Pain/ Tenderness that is superficial or
nonanatomic.
Back pain with axial loading/ pelvis shoulder
Sitting vs Supine SLR test discrepancy
Nondermatomal sensory disturbance or motor
weakness not fitting neurological basis
Overreaction during examination

Factitious vs. Malingering

Factious Disorder Intentionally
feign psychological or physical
symptoms, to assume sick role,
voluntary purposeful deliberate act,
underlying psychopathology
Malingering Intentional, but
motivated by external factors
(disability paycheck, lawsuit), fully
conscious of this behavior
NOT a psychiatric disorder

Somatoform Disorder Question

Somatoform disorders include which of the
following:

a)
Conversion disorder

b)
Somatization disorder

c)
Hypochondriasis

d)
All of the above

Somatoform Answer
All of the above
Somatization Disorder: A pattern of
recurring, multiple, clinically-significant
somatic symptoms that require medical
treatment, and which cause significant
impairment in social, occupational and
other areas of functioning

Question:
A 25-year-old janitor has severe back pain and is
unable to stand up straight after he fell at work.
On physical examination, he has positive pain
behavior but no neurologic deficits. A
surveillance video from the insurance company
shows he continues to play baseball with friends.
Which of the following is the most likely
diagnosis?

(A) Conversion disorder

(B) Factitious disorder
(C) Hypochondriasis
(D) Malingering
(E) Somatization disorder with psychological
factors

 In order to assume the sick role, Intentionally

produced Physical or psychological symptoms
are known as?

a)
factitious disorder

b)
conversion disorder

c)
somatization disorder

d)
hypochondriasis

Somatoform Disorder
Expression of unconscious conflicts as physical
complaints
Pain Predominant symptom, often no known
medical explanation, or symptom and complains
of impairment are excessive to normal
Pain Disorder:
No intention to deceive

Types of Pain
Nociceptive versus
Neuropathic
Acute versus Chronic
Complex Regional Pain
Syndrome

Cross Section of Spinal Cord

Neurophysiologic Classification of Pain

Nociceptive Activation of nociceptors (Adelta
and C fibers) by (tissue injury) noxious stimuli,
mechanical, thermal, chemical which is
mediated by various substances
Substance P, Bradykinin, Prostaglandins,
Histamine

Somatic - Superficial
Visceral Deep pain from the internal organs.
Often times referred and difficult to locate.

Neuropsychological/physiological
Classification of Pain
Nociceptive
Osteoarthritis, RA
Cuts, Fractures, Burns
Cancer

Neuropathic
Diabetic neuropathy
Post-herpetic neuralgia
Radiculopathy

Mixed
Cancer low back pain
Cancer

Visceral

IBS
Pancreatitis
Bladder pain
Noncardiac chest pain
Abdominal pain syndrome

Psychogenic
Cannot be explained by any
other cause.

Acute vs Chronic
Acute Pain Serves a clear role as indicator for
injury, postoperative pain and flare ups.
Chronic Pain Pain of > 3-6 months, often
without a clear purpose, after initial injury is
long over, often due to an inadequately treated
acute pain

Hyperalgisia
Primary: Tissue damage caused by injury that
produces a similar type of sensitization at the
site of injury.
Secondary: after primary, a much larger area of
the hyperalgesia and allodynia develops
surrounding the site of injury. The CNS
develops a memory.

Somatic vs Visceral Pain

Dull, Achy pain, incident pain, localized
Post-op, metatasis bone pain, musculoskeletal
pain arthritis

Visceral Deep, squeezing, crampy, autonomic

sensations, cutaneous referral sites
Pancreatitis, bowel obstruction

Visceral nociception is accurately

characterized by which of the following
statements?
It responds to cutting, burning, or crushing
stimuli
It typically has a signifcant autonomic
component
It involves more nociceptors than cutaneous
nociception
It is often diffuse and poorly localized.

Neuropathic Pain
NeuropathicNeural injury or
irritation of nerve is the cause,
may persist long after initial
cause, abnormal centralization
may occur
Deafferentation pain:
phantom limb pain, thalamic
pain (stroke patients)
RSD (Reflex sympathetic
dystrophy) or CRPS
Type I
Type II
Injury to a large nerve
No migration of pain

Symptoms

Burning
Numbness
Tingling
Lancinating
Pins and needles
Electrical

Psychogenic Pain
When no nociceptive or neuropathic mechanism
is identifiable and sufficient psychological
symptoms exist to meet the criteria for somatic
pain disorder, depression, etc

Pain Terms
Allodynia: Pain due to a stimulus which does not
normally provoke pain
Dysesthesia: An unpleasant abnormal sensation,
whether spontaneous or evoked.
Paresthesia: An abnormal sensation, whether
spontaneous or evoked.
Central Pain: Pain initiated or caused by a primary
lesion or dysfunction in the central nervous system.
Hyperalgesia: An increased response to a stimulus
which is normally painful.
Causalgia: A syndrome of sustained burning pain,
allodynia, and hyperpathia after a traumatic nerve lesion,
often combined with vasomotor and sudomotor
dysfunction and later trophic changes.

Complex Regional Pain Syndrome

Type I RSD (post fracture)
Can occur with minor trauma
Postsurgery

Type II Causalgia-Actual nerve damage

In either case may not be sympathetically
mediated (reason for the name change)
Aberrant somatosensory processing in the PNS
or CNS

Really cold or really hot, swelling,

shiny, hair loss, nail changes, allodynia

Wind-up Phenonemon
When a tissue is stimulated repetitively, there is
more injury (ie more pain) with the same
stimulus (e.g. skin rubbing becomes irritating
over time.
Why? Because the dorsal horn has been
sensitized to the stimulus so it remembers the
stimulus the next and next and next time
(substance P mediated)

 A 55-year-old woman comes to the pain clinic for a follow-up

examination two months after sustaining a fracture of the left wrist.
Initial treatment consisted of cast immobilization for six weeks.
Since removal of the cast, there has been swelling, sensitivity to
touch, erythema, and burning pain. Physical therapy exacerbates the
symptoms. A trial of nortriptyline therapy has provided no relief of
the pain. Which of the following is the most appropriate next step in
management?

 (A) Initiate massage therapy

(B) Initiate opioid therapy
(C) Perform peripheral nerve block
(D) Perform stellate ganglion block
(E) No further management is necessary

Areas of Pain

Cervical Disks
Annulus Fibrosis and Nucleus Pulposus:
Less elastic than lumbar.
Disk is more likely to herniate in the
posterolateral portion in which the annulus is
the most concave.
Degenerative changes can result in fissures and
weakening of the outer annular fibers.

Cervical HNP
HNP may be observed with MRI in 10% of
asymptomatic individuals aged younger than 40
years and 5% of those older than 40 years.
Degenerative disc disease (DDD) may be
observed with MRI in 25% of asymptomatic
individuals aged less than 40 years and 60% of
those aged more than 40 years.
Emedicine (Cervical Disc Disease), Dr. Furman

Brachial Plexus Injuries

Forced lateral flexion of the head and neck away
from the injured side combined with shoulder
depression can result in a traction injury to the
brachial plexus.
C5-C6 roots are at the greatest risk for this type
of injury.
Brachial plexus passes between the Anterior and
medial scalene muscles.
Thoracic outlet syndrome: affects C8-T1.

Cervical Strain
Generalized term that can include muscular starin or
ligamentous sprain as a result of an overload injury to
the muscle-tendon unit.
A forward positioned head with increased cervical
lordosis and increased thoracic kyphosis results in
increased capital extension.
Abnormal strain is created to levator scapulae, upper
trapezius, SCM, scalenes, and subocciptal muscles.

Location of Disk Injuries

Most common at C5-C6 followed by C6-C7 and
C4-C5.
Pain from a disk protrusion or annular tear
without radiculopathy can result in neck or
referred pain to the interscapular area.
Archives Phys Med Rehabil. Vol
83 suppl 1, March 2002

Key Diagnostic Exams

Central compression Test
Cervical distratction Test
Spurling maneuver

Diagnostic imaging: in Severe Trauma of

Spine
Radiographs: C-spine and lateral
To rule out fracture, disclocation or ligamentous
instability.
Open-mouth odontoid views to r/o fracture.

Lateral films: allow for assessment of the

atlantodens interval.

CT versus MRI in Cervical Spine

CT:
Useful in detecting central or formanial stenosis.

MRI
Disk herniation but can also help r/o myelopathy
(demyelinating or metastatic disease and
intradural or extradural spinal tumors.

Acute Management of an Injury

Ice, rest and medications
Muscle relaxants have no direct effect on muscle
and exert their effect on central pathways.
Narcotics can be used for severe acute pain
Corticosteroids: oral (tapering dose) or
injections done under fluoroscopy.

Acute Management of Cervical Injuries

Rest: can vary to a few days to 2 to 3 weeks
Cervical Collar: wear for 24 hours/day for 2-3
weeks, then wean. Goal is to prevent significant
extension.

Exercises for the C-spine

Exercises help to restore normal muscle length
to the scalene muscles.
Begin with minimal pain and proceed to point of
pain.
Do Range of Motion in the nonpainful range
Can begin isometric exercises and progress to
progressive resisted neck motion while utilizing
rubber tubing.

Low Back Pain

An Introduction to Assessment and
Treatment

History
Critical
Weakness
Spinal stenosis or radiculopathy
Myopathy, peripheral neuropathy, motor neuron
disease
Neuromusclar junction disease

Dysuria or hematuria
Suggestive of renal cause of pain

 A 75-year-old man comes to your clinic with a 3-year history of low

back pain radiating down both legs to his ankles. The pain is achy
and sometimes stabbing. Over time, he has noticed numbness in his
right leg. He also has gradually developed weakness in his right leg
and has been using a cane for the past year. Walking as few as 3
blocks aggravates the pain and weakness. When leaning forward, his
pain is decreased; when lying supine, the pain is relieved. He suffers
from osteoarthritis of both knees and does not report any prior
infection or trauma to his lower back. There is no bowel and bladder
dysfunction. Which of the following most likely explains his
symptoms?

a. L5/S1 herniated disc

b. Lumbar spinal stenosis
c. Facet arthropathy
d. Arachnoiditis
e. Muscle spasms

Special Tests
SLR and Crossed SLR (Well Leg SLR) tests
Hoover Test (Malingering)-synergistic contraction
Kernig Test (indicates meningeal irritation, root
involvement or dural irritation)
With knee flexed, attempt to straighten the leg
Valsalva Maneuver (increases intradiscal pressure)
Femoral Stretch Test (L2, L3 or L4 radiculopathy) note HF tightness
Have the patient lay on stomach (prone position)
and flex knee and then stretch.

Special Tests
Sacroiliac Joint
Pelvic Rock Test (anterior
pressure on ASIS to evaluate SI
instability)
Gillet Test (Stork Test) - SI
mobility
Gaenslens Test - Ipsilateral SI
pathology
FABER (Patrick) Test - Ipsilateral
SI pathology
Direct Palpation of SI joint

Waddells Signs
(supratentorial signs)
STORD

Simulation (axial load and axial rotation)

Tenderness (non-anatomic or skin rolling)
Over-reaction
Regional disturbances (non-dermatomal
numbness or non-myotomal weakness)
Distraction - sitting and supine SLR

Differential Diagnosis of LBP

Non-radiating Low Back Pain

osteoarthritis (spondylosis)
back strain/sprain
cancer (mets or primary)
infection
fracture (compression or traumatic)

Differential Diagnosis of LBP

Radiating Low Back Pain

lumbosacral radiculopathy
spinal stenosis
facet disease
sacroiliac dysfunction
myofascial pain

EMERGENCY!

When to Urgently ask for Spine Surgical

Consultation
Unstable Spine Causing Impending Neurologic
Compromise
Dynamic Spondylolisthesis (movement over 5
mm with neurologic deficit)
Spinal Fractures
Cauda Equina Syndrome
Progressive Leg Weakness
Bowel/Bladder Incontinence, Urinary Retention
Intractable Pain

RED FLAGS!!

3% with acute LBP may have a potentially

life-threatening condition
Cancer

fever/chills
unexplained weight loss
persistent night pain
greater than 50 years old
previous history of cancer (may require early
imaging)

RED FLAGS!!
Spinal Infection
fever with or without chills
worsening back pain, especially at night
increased risk if:
IV drugs
immunocompromised
recent bacterial infection (UTI, wound, dental work)

RED FLAGS!!
Possible Epidural Abscess (MRI)
fever
progressive neurological deficits
localized tenderness over abscessed bone

RED FLAGS!!
AAA
sudden searing intensifying pain from back to
lower extremities
abdominal ultrasound
consider vascular consult

Lumbar Radiculopathy
Sciatica
1-2 % of LBP patients have a compressed or
inflamed lumbosacral nerve root
Most common levels are L4-5 and
L5-S1 (90% involve these two levels)
Mechanism
annular degeneration leads to fissuring or tearing
of the annulus which leads to disc rupture

Radicular Symptoms
Pain Drawing - side, distribution and quality of
pain
Dermatomal distribution of pain or
numbness/tingling
L3 or L4 - anterior thigh pain
L5 - top of foot and great toe
S1 - pain in posterior calf, sole and/or lateral foot

Lower extremity pain > back pain!

Radicular Symptoms
Increased pain with:
forward flexion
sitting, driving in car
cough, sneeze and bowel movement

Decreased pain with:

lying supine
knees flexed
standing

Radiculopathy - Treatment
50 % with sciatica recover within 1 month with
conservative therapy
dynamic exercise, gravity traction
NSAIDs/ muscle relaxants
consider narcotics for short term

70 % of the others within 4-6 weeks

90 % can be treated conservatively
usually LBP resolves before leg pain

Radiculopathy - Treatment
Back and leg pain resolve BEFORE neurological
deficits normalize, which occurs over 6-12 weeks
after treatment begins
5-10 % with disc herniation undergo surgery
(~280,000 per year in the US)

Radiculopathy - Treatment
Epidural steroid injections
interlaminar
caudal
transforaminal (SNRB)

Indications
relief of pain from nerve root irritation
diagnosis of root level involved (SNRB)

Medrol dose pack may be tried, if not

contraindicated (infection, diabetes)

Pseudoclaudication
Neurogenic Claudication
Spinal Stenosis
Greater than 50 years of age (usually in 60s or
70s)
C/O LBP and leg pain with walking
Relieved with sitting

Can be unilateral or bilateral

Increased pain with down hill walking and better
with walking uphill
+ shopping cart sign

Spinal Stenosis
(Central or Foraminal)
May be caused by:

congenital narrowing
spondylolisthesis
trauma
degenerative changes due to aging

Treatment
medications and exercise
decompressive laminectomy (1/3, 1/3, 1/3)

Facet Disease
Pain may be localized to low back or radiate into
buttocks and posterior thigh
unusual for this pain to go below the knee
worse with extension and with prolonged standing
can be dull toothache pain or sharp stabbing pain

Facet Disease
Treatment

lumbar stabilization
program
facet mobilizations
intra-articular
injections under
fluoroscopy
medial branch
blocks/denervation
under fluoro (diagnosis
and treatment)

Sacroiliac Dysfunction
Pain is located in the low back
and radiates into the buttocks
and posterior thighs
special tests not very reliable
patient will point to SI as
source of pain
can have associated
piriformis spasm with
sciatica
common in pregnancy

 Which of the following is associated with pain

arising from the sacroiliac joint?
(A) Paresthesia of the lateral thigh
(B) Positive Patrick's (FABER) test
(C) Sexual dysfunction
(D) Weakness of plantar flexion of the great
toe

Sacroiliac Dysfunction
Treatment

NSAIDs
heat/ice
correct leg length discrepancy
SI mobilization
SI belt
intra-articular injection under fluoroscopy

Vertebral fracture:
Associated conditions
Postmenopausal
women over the
age of 55
Low bone mass
evaluations suggest
vertebral fracture
Diagnosis of
osteoporosis

1.

Ismail AA et al. Osteoporos Int. 1999;9:206213.

91

16000296-03

Prominent thoracic
kyphosis

Loss of 2 or more
inches in height

Glucocorticoid therapy
(7.5 mg prednisolone)

VERTEBRAL COMPRESSION FRACTURE

DIAGNOSIS
History and Physical

Back Pain with Minimal

Stresses (loads)
Pain and Tenderness Upon
Palpation
No Radicular or Neurologic
Findings
Dowagers Hump or
Kyphosis
Loss of height in patient
Rule out Neoplastic Process
700,000 spinal fractures
per year

Myofascial Pain
Trigger Points - palpable taut bands that radiate
pain/tingling into the buttocks or lower
extremity
treated with injections of local anesthetic (and
perhaps steroid)
spray & stretch with home program
deep cross tissue massage

Key Differences Between MFP and Fibromyalgia

Myofascial Pain

Fibromyalgia

M=F

F>>M

Localized/
Regional

Generalized

Fatigue
Poor Sleep
Depression

Less Common

Common

Prognosis

Generally Good

Generally
Chronic

Gender
Location of Pain

When to Order Radiological Evaluation

To rule out compression fracture or other
bony damage, especially if over 50 (plain
films or CT)
In patients with known osteoporosis or
history of cancer
If NO red flags, no need for imaging or lab for
first 4-6 weeks of conservative therapy for
LBP as 90% recover within one month!

When to Order Radiological Evaluation

Consider MRI if no improvement after 4-6
weeks conservative treatment
MRI for suspicion of Cauda Equina Syndrome

Conclusion
Be aware of serious conditions that may present
with low back and leg pain
Most patients recover within 4-6 weeks with
conservative therapy
Know the surgical indications and make referrals
as appropriate

 A 28-year-old man has had constant pain in a bandlike

pattern at the waistline since sustaining an incomplete
transection of the spinal cord at T12 five months ago.
Which of the following is the most likely explanation?
(A) Central neuropathic
(B) Mechanical instability
(C) Primary myofascial pain
(D) Psychosomatic pain
(E) Referred visceral pain

All of the following are potential red flags for

suspectingcaudalequine syndromein a patient with low
back pain except

A.
B.
C.
D.
E.

Urinary retention
Urinary Frequency
Night time pain
Neurologic Deficits
Urinary incontinence

 Which of the following is not a red flag for

suspecting a tumor or infection in a case of low
back pain is?

Pain that worsens with supine position

Motor weakness
Fever/Weight Loss
Age of 50 years

 Which of the following test is a clinical test used

for evaluation of sciatic tension?

SLR test
Crossover pain
Sitting knee extension
Dorsiflexion of the ankle
All of the above