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Transcript of Pain Management
Bethan Taylor, Amalia Thornicroft, Elyse Santy
Pain and pain management
The IASP defines pain as ‘an unpleasant sensory and emotional experience associated with actual or potential tissue damage or described in-terms of such damage’ (IASP, 1979 cited Godfrey 2005 ).
Aims of our presentation
To identify some pre and post - operative pain management techiniques.
To relate this back to Mr Jameson's pain experience
Pain is a subjective experience for each individual involving sensory, emotional and physical factors.
Walls and Melzack (1965) Gate Control Theory of Pain
Proposed a gating mechanism within the dorsal horn of the grey matter of the spinal cord, sensory information has to pass before it is relayed and perceived in the pain centres of the brain.
Osteoarthritis (OA) Pain
Osteoarthritis causes the cartilage between the femur head and the socket to wear away.
When cartilidge is damaged the bone becomes exposed and damage occurs resulting in pain and stiffness.
Pain is categorised as nociceptive.
Factors effecting chronic pain management
Lack of understanding about the condition
Amount of attention paid to the pain
Observation of others reaction to the pain
Past experiences of pain – these are socially learnt responses. Therefore has meaning to the patient and affects the judgement of pain.
Their perceived ability to cope
Firstly, what do we mean by pain?
What do we mean by pain management?
Pain management is a complex and challenging area.
if a patients physical pain isn't management appropriately clients are at risk of:
Emotional disorders (anxiety and depression)
Maladaptive thinking (catastophising and worrying)
Physical conditioning (Goodacre and McArthur, 2013)
Cognitive Behavioural Therapy Model
Cognitive behaviour therapy (CBT) – is a psychological treatment and can help a patient approach the emotional side of pain. By targeting maladaptive cognitions and behavioural contribution to pain.
Reduce anxiety and fear
Except new roles within the family and society
Relaxation- The aim is to reduce muscle tension and help clients cope with the stress of live with pain.
Challenge thoughts and beliefs
Improve physical fitness
Balance of occupations
Assess the situation
Physiotherapist's pre-operative pain management
Occupational Therapist's pre-operative
Pre-op pain management
It is important for patients to be as prepared as they can be in terms of pain management both pre and post operation
'Single inteventions that only tackle the biomedical source of pain, without addressing the psychological and social stresses, are unlikely to be effective in the long term'
(Ashburn and Staats, 1999 cited in Goodacre and McArthur 2013)
Post-op pain management
Pain after surgery isn't predictable and quite variable
Immediately post-op, a patient will receive pain medication through an IV tube
After a day or two, injections or pills will replace the IV tube
Besiders the pain medication, antibiotics and blood-thinners are prescribed to hep prevent blood clots from forming in the leg veins
Pain management is best achieved through a combination medical/psychological/physical therapies
How quickly you get back to normal depends on many factors, including: age, general health, strength of muscles, condition of your other joints
It is easier to prevent pain than to control it
Evidence base supports physical therapy improving ambulatory function and rate of recovery after hip replacement
(arthritisresearchuk.org; Wang, Gilbey & Ackland 2002; Jan et al., 2004)
Role of an Occupational Therapist
in helping to manage pain
after a hip-replacement:
What adjustments can be made to the home environment?
• Not bend to get to the bottom of cupboards, fridge, freezer or oven
• Temporarily put everyday items in easy to reach places
• Use a ‘helping hand’ to pick up light objects from low areas
• Use assistive devices: e.g. a long-handled shoehorn or a grabbing tool, avoid bending too far over
• Sleep on back with legs slightly apart or on one side with an abduction pillow
• Dress sitting on a suitable chair or on the edge of the bed
• Not bend forward beyond a 90 degree angle to reach the foot
• Use a raised toilet seat
• Use a grab bar in the shower
• Use a bath board over the bath, always showering while sitting on the board, keeping the operated leg as straight as possible and without twisting or rotating it when manoeuvring on and off the bath board
• Use a long handled bath brush to wash lower legs and feet
General advice for household activities:
• Not bend to use low electrical sockets
• Not put the washing basket on the floor
• Be careful when picking up the post
• Be careful when feeding household pets
• Use a ‘helping hand’ where possible
• Sit only in chairs that have arms
• Not sit on low chairs or reclining chairs
• Not cross their legs
• Not kneel
• Keep a healthy diet to avoid weight gain, as this will put stress on the hip joint
• Rearrange furniture so the patient can get about on a walker or crutches
• When using stairs: unaffected leg should step up first, then bring the affected leg up to the same step, then bring your crutches up – reverse on the way down
• Not bring knee up higher than your hip
• Use ice to reduce pain and swelling
• Apply heat before exercising to assist with range of motion
Role of a Physiotherapist in helping to manage pain after a hip-replacement
It is important to start some activities immediately after a hip-replacement operation, to offset the effects of the aesthetic, help healing, and keep blood clots from forming in the leg veins.
In addition to exercises, the patient will most likely be required to wear elastic stockings to help keep blood flowing freely.
Initially it may be that the patient can only manage exercises from their bed, so a physiotherapist would encourage the patient to do exercises such as:
• pedalling their feet
• bending and straightening their ankles, keeping knees straight so that calf muscles stretch
• sliding their leg out sideways and bringing it back, keeping their trunk straight and toes pointing towards the ceiling
When the patient is able to more easily get out of bed, the physiotherapist may suggest further exercises to strengthen the leg muscles , these can include:
• When sitting in the chair, pulling the toes up to tighten the thigh muscles and then straighten the knee
• Holding onto a chair: taking the leg out sideways and then slowly returning it back to standing position, keeping posture fully upright
• Holding onto a chair, lifting the leg out backwards, keeping it straight, making sure they don’t lean forwards
After this stage, the Physiotherapist will then guide the patient on how to walk with a frame or stick.
• Jan, M.H. et al. (2004). Effects of a home program on strength, walking speed, and function after total hip replacement. Archives of Physical Medicine and Rehabilitation; 85, 1943–1951
• Wang, A.W., Gilbey, H.J, Ackland, T.R. (2002). Perioperative exercise programs improve early return of ambulatory function after total hip arthroplasty: A randomized, controlled trial. American Journal Physical Medicine Rehabilitation; 81:801–806
• www.arthritisresearchuk.org/arthritis-information/surgery/hip-replacement-surgery/what-will-my-recovery-involve.aspx#sthash.9Fb7LqZm.dpuf (accessed: 13 March 2014)
• www.nwlh.nhs.uk/services/Resources/20_HIP_-_FINAL_VERSION2.pdf (accessed: 13 March 2014)
www.orthoinfo.aaos.org/topic.cfm?topic=a00356 (accessed: 13 March 2014)
Henschke, N., Diong, J. (2013) Exercise reduces pain and improves physical function for people awaiting hip replacement surgery. British Journal of sports medicine, 2014, Vol.48(6), pp.477-8.
Lucas, B., (2007) Preparing patients for hip and knee replacement surgery. Nursing Standard, Sept 19, 2007, Vol.22(2), p.50(8)
Goodarce, L., and McArthur, M., (2013) Rheumatology practive in Occupational Therapy Promoting lifestyle management. Oxford; John Wiley & Sons, Ltd.
What happens after a hip operation?
Pain needs to be measured as not just the pain levels and the location of it, but rather as an exploration of an individual's whole experience of the pain
Strong et al (2002) state that 3 components of pain need to be considered:
Description of pain (location, severity, type of sensation)
Responses to the pain (changes in behaviour, attitudes, fears, beliefs and confidence)
Impact of pain on a person's life (functional status and levels of activity)
Occupational Therapists are primarily concerned with the impact of pain on everyday life and the psychological, social and environmental factors that contribute to pain. They believe that minimising the impact of pain will maximise an individuals participation in valued occupations.
Patients want their pain to be believed and their distress acknowledged. This highlights the importance of listening and conveying a genuine interest in a person's pain which creates a therapeutic relationship.
Patients who are more anxious or depressed before an operation tend to have poorer pain relief after surgery (Ayers et al, 2004)
This highlights the need for Occupational Therapists to build a patients confidence before the operation.
OTs and PTs can build a person's confidence by strengthening their self-efficacy. This relates to their own belief about their capability post-operation.
Patients need to know they can work with the multi-disciplinary team to achieve their expected outcome.
There have been several studies aimed at determining whether pre-operative pain management exercises reduce pain and decrease post-operative recovery time. (Henschke & Diong, 2013; Lucas, 2007)
'There is evidence that exercise helps to reduce pain and improve function in patients with OA'. (Lucas, 2007) However, the degree to which this helps remains uncertain, which is why there is only a small proportion of prescribed pre-operative exercise intervention.
A general theme throughout the literature seems that developing a patients quadriceps muscles pre-op can improve their rehabilitation process.
This also strengthens a patients self-efficacy as they are practicing the exercises expected of them post-operation.
Particularly with hip resurfacing, it is important for the patient to keep as active as possible; as meaningful leisure activities are more closely linked to a patient's well-being.