Bread & Butter of Family Medicine: Pain Management
Pain is one of the most common patient complaints in family medicine. It is very difficult to control effectively because it is highly subjective and multidimensional. The different types of pain are:
Nociceptive/somatic Pain: linked to tissue damage and the resulting inflammation.
Neuropathic Pain: results from a lesion or disease of the somatosensory system. It can persist even after healing, and is lancinating, shock-like, and burning.
Central Sensitization: alteration to the CNS processing of sensation, leading to amplification of pain signals (mechanisms poorly understood)
Psychogenic Pain: compounded by mental states of anxiety, depression, maladaptive coping mechanisms, excessive stress, and influence of social support systems.
Idiopathic Pain: no identifiable etiology.
Unfortunately, a patient’s complaint of pain is likely a combination of all of the above factors.
The history is the most valuable tool for evaluation because the patient’s self report has been proven to be the most reliable indicator of pain. Be sure to ask thorough questions regarding onset, provoking/palliating factors, quality, radiation, severity, timing, and associated symptoms. Severity can be difficult to gauge, as all patients handle and interpret pain differently. There are three common scales:
1. Visual Analog Scale 2. Numeric Rating Scale: Either ask to rate from 1-10, 10 being worst pain you can imagine, or if they would say their pain is mild, moderate, or severe. 3. Wong-Baker FACES Pain Rating Scale
An important clinical distinction to be made is if the pain is acute or chronic. Chronic pain is pain not associated with cancer or other medical conditions that persists more than 3-6 months, pain lasting 1 month longer than the acute illness or injury, or pain recurring in intervals of months to years . Acute pain could require more investigation to rule out injuries, while chronic pain often requires more consideration of compounding factors (especially psychiatric issues).
Observation: There are nonverbal cues for pain such as jaw clenching, pacing/restlessness, immobility, guarding, and wincing.
Vital Signs: Patients may be hypertensive, tachycardic, and tachypneic.
Examination: Evaluate for warmth, tenderness to palpation, range of motion restriction, and misalignment in the area of the pain. Pay close attention to changes in sensation, asymmetric reflexes, or poor motor function. Perform any special tests indicated [straight leg raise for low back pain, Anterior Drawer Test for ACL, McMurray’s for meniscus, Tinel’s/Phalen’s for carpal tunnel, etc.]
X-ray: Least expensive imaging study, can rule out fractures and evaluate joint space changes associated with arthritis.
MRI: Ordered with high suspicion of ligament/tendon tear, intervertebral disc damage, radiculopathy; or in the case of pain refractory to treatment attempts. (CT if MRI is contraindicated)
There are various non-pharmacologic ways of relieving pain. Patients should attempt these instead of or in conjunction with their medications.
Stretching/Exercise/Weight Loss **No complete bed rest with back pain!**
Physical Therapy 4. Massage 5. Psychiatric eval.
Thermo-therapies: Alternating hot and cold patches, warm baths, hot tubs.
Chiropractors, Osteopathic Manipulative Medicine Specialists
Caspaicin, Lidoderm, Salonpa, IcyHot
Caspaicin, Volteran gel, BenGay
Help preserve cartilage. Glucosamine Chondroitin, Osteo Bi-Flex
Pain medication is a slippery slope, and prescribers need to be extremely cautious with regard to max doses of harmful medications and their risk of dependence/addiction. A rule of thumb is to start with low initial doses and increase slowly, perpetually offering conservative options for pain relief.
The World Health Organization developed a ladder for the management of pain. Their steps are:
Start with non-opioid +/- adjuvant medication (anti-anxiety or muscle relaxers).
If pain persists or increases, use weak opioid (hydrocodone) +/- non-opioid, +/- adjuvant.
If pain still worsening, use stronger opioid (morphine), +/- non-opioid, +/- adjuvant.
Heart block, diabetics (especially on insulin), depression
Medical Marijuana: Uses- Chronic and severe pain, anti-nausea, appetite stimulant. Most often used for late stage cancer. THC binds to cannabinoid receptors to alter signaling with neurotransmitters. Physicians apply for licensure through their state’s program. In Michigan, it is the Medical Marijuana Program at [http://www.michigan.gov/lara/0,4601,7-154-35299_63294_63303_51869---,00.html]. Patients undergo full evaluation by licensed physician and then apply for their registration cards.
Bickley, L., & Szilagyi, P. (2013). Bates' guide to physical examination and history-taking (11th ed.). Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins.2. uptodate.com 3. http://www.who.int/cancer/palliative/painladder/en/,
Somerset Family Medicine Clinical Module
Bread & Butter of Family Medicine:
CONSTIPATION - Less than 3 bowel movements a week or hard, dry, or small, difficult to pass stool
Diet low in fiber, and not enough liquids
Lack of physical activity
Neurological (spinal cord injury, Parkinson’s etc) and metabolic disorders
GI tract (adhesions, tumors, celiac, diverticulosis, colon polyps)
Bulk laxatives bind to fecal content and pull water to the stool. Bulk forming holds water in the stool. (not useful when patients on opioids, avoid if patient has celiac disease or gluten intolerance due to wheat dextrin products). More bloating occurs. May take up to 3 days to work.
Osmotic laxatives: Miralax and Lactulose. (Second-line therapy)
Increased concentration of solutes creates osmotic pressure by drawing fluid from a less concentrated gradient to a more concentrated gradient, thus increases osmotic pressure to stimulate intestinal motility.
Research shows Miralax more effective than lactulose. Osmotic laxatives have less bloating
Increase peristalsis through direct effects on the smooth muscle and simultaneously promote fluid accumulation in the colon. Avoid for long-term use as they have short-term usefulness.
Surfactant laxatives: (stool softener) Colace, Philips, and mineral oil (Third-line therapy)
Reduces surface tension of the liquid contents of the bowel, therefore allowing water and fat to enter and soften. Only prevents constipation, but do not treat it.
Chloride channel activator: Amitiza
Derived from prostaglandin. Works by enhancing chloride-rich intestinal fluid without altering serum sodium and potassium concentration. The activation of chloride in the intestines pulls water into the lumen of intestine.
The drug is poorly absorbed systemically and appears to act locally on the intestines, improving stool consistency and motility. No studies to compare efficacy of Amitiza to other medications.
Diet and nutrition management
20-35 grams of fiber a day (no refined or processed foods)
Drinking plenty of liquids (water, vegetable juice, & fruit juice)
Examples of Foods That Have Fiber
Beans, cereals, and breads
½ cup of beans (navy, pinto, kidney, etc.), cooked
½ cup of greens (spinach, collards, turnip greens), cooked
“Physical activity appears to be unrelated to the risk of constipation in employed adults, but higher physical activity was associated with improved quality of life. Recommendations to increase physical activity may not alter symptoms of constipation but may improve overall well-being.” (American Journal of Gastroenterology, 2005)
1. Which describes constipation?
Less than one stool per day
Less than three bowel movements per week or difficult and painful defecation with incomplete evacuation
Blood in stool
2. Which lifestyle causes of constipation?
A. Lack of fiber in diet
B. Lack of exercise
C. Lack of fluids in diet
D. All of the above
3. Which disease has constipation as its clinical feature?