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Monday, April 19, 2010

Acute Pain Management (4)

Pain Management
Von Korff (1999) demonstrated that people in pain want to: know what the problem is; be reassured that it is not serious; berelieved of their pain; and receive information. People in pain want advice regarding the management of their pain, including non-pharmacological and pharmacological interventions. They also want advice on how to return to normal activity.

Patients may lack current knowledge of interventions for pain management. For instance, they may believe that xrays
will determine the cause of their pain and that bed rest is indicated. It is important to satisfy the need for knowledge, alleviate fear and to focus on preventing disability due to pain (Main 2002). The use of a preventive approach to shape behaviour is best done at the initial visit. This is particularly important in acute musculoskeletal pain, which may recur.

The following is a suggested framework to manage acute musculoskeletal pain:
1. Elicit a pain history in a biopsychosocial context.
2. Assess for clinical features (‘red flags’) of serious conditions including serious systemic illness, fracture, tumour and infection. If such features are present, further investigation or referral is warranted.
3. Assess for the presence of psychosocial and occupational factors (‘yellow flags’) that may affect the presentation of acute pain, response to treatment and influence the risk of progression to chronic pain.
4. Provide information on the prognosis of acute musculoskeletal pain and discuss options for pain management (pharmacological, non-pharmacological and activity).
5. Develop a management plan in conjunction with the patient, fostering a cooperative environment and reinforcing the importance of self-management.



Pain Management Plan

The management plan should be tailored to meet the needs of each patient, taking their preferences and abilities into account. It is important to ensure that the patient understands what is involved to facilitate their participation.

Management plans are designed to assist progress through an episode of acute pain and the return to normal function. The plan should include actions that the consumer and clinician may take in the event of an exacerbation or recurrence of pain or slow progress to recovery. The plan should enable the individual to take responsibility for his or her own rehabilitation (bearing in mind that some people will require greater levels of support and assistance) or to seek help from a clinician if necessary.

There are three phases of the management plan:

A history and physical examination are conducted to assess whether clinical features of serious conditions (‘red flags’) are present and to identify psychosocial and occupational factors (‘yellow flags’) that may influence recovery.
Ancillary investigations are not generally indicated unless features of serious conditions are identified.
In cases where features of serious conditions are present, an alternative plan of management is required.

Provide information — consumers seek an explanation and information about the nature of their pain. The clinician
should use effective communication techniques and use appropriate terms to describe acute musculoskeletal pain.
Provide assurance — the natural history of acute musculoskeletal pain is generally favourable; thus, epidemiological data serves as the basis for assurance that recovery can be expected. Information on the prognosis and the provision of assurance is an integral part of the management plan.
Provide advice to remain active — activity should be encouraged; resumption of normal activity should occur as soon as possible. For each of the conditions covered by these guidelines, activation is a seminal intervention for restoring function and avoiding disability.
Discuss other options for pain management including the addition of non-pharmacological and pharmacological interventions to the management plan to assist return to normal activity. A combination of measures may be used.

The clinician should provide information on the options available, what they are designed to achieve and describe
potential risks and benefits. It is important not to overstate the power of interventions to avoid unrealistic xpectations.
It is also important to avoid the assumption that consumers expect medication each time they visit. On the contrary, any do not want their consultation ended prematurely by the writing of a prescription.

Prescription of a single, one-step intervention is unlikely to be successful. The plan may be iterative, requiring small
amendments or major changes. On subsequent visits, the clinician should enquire whether the plan has been satisfactory and explore questions, concerns and possible alternatives as required. Further explanation and assurance can be provided.
Ongoing review provides an important opportunity to assess for features of serious conditions and psychosocial
factors that may not have been evident on previous visits and to intervene as required.
Review also demonstrates concern that progress has been made. This is particularly important when there was intense pain and distress at the initial presentation. The need for further visits can be discussed at each consultation.

Acute Pain Management (3) <||> Acute Pain Management (5)

taken from:
Australian Acute Musculoskeletal Pain Guidelines Group;2003; Evidence-based Management of Acute Musculoskeletal Pain; Bowen Hills: Australian Academic Press Pty. Ltd.

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