THE INTERDISCIPLINARY NATURE OF MANAGING PAIN

The most important member of the interdisciplinary team is the person with pain—the patient. Other team members can include:

  • Significant others (family, friends, etc.)
  • Physicians, physician assistants, and nurse practitioners
  • Nurses
  • Psychologists
  • Physical therapists
  • Occupational therapists
  • Recreational therapists
  • Vocational counselors
  • Pharmacists
  • Nutritionists/dietitians
  • Social workers
  • Support staff
  • Volunteers

Role of the Nurse

Many disciplines are involved in managing a patient’s pain, and nurses play a pivotal role in the assessment, monitoring, interpretation, and evaluation of pain. Effective pain management by nurses is fundamental to quality of care and is the first responsibility of the nurse.

NURSING STANDARDS OF CARE

Standards of care for nurses in the management of pain include, but are not limited to:

  • Acknowledging and accepting the patient’s pain
  • Identifying the most likely source of the pain
  • Assessing pain at regular intervals, including each new complaint of pain, utilizing a pain assessment tool
  • Assessing barriers to effective pain management
  • Reporting the patient’s level of pain and developing a plan of care that includes interdisciplinary input
  • Aggressively treating side effects such as nausea, vomiting, constipation, etc.
  • Educating patient, family, and significant others on:
    • Their role in the pain management plan and expected outcomes
    • Detrimental effects of unrelieved pain
    • Overcoming barriers to effective pain management
  • Evaluating effectiveness of strategies and nursing interventions
  • Documenting and reporting the interventions, patient responses, outcomes
  • Advocating for the patient and family for effective pain management
    (MD BON, n.d.)

PATIENT EDUCATION AND OPIOID MEDICATIONS

Nurses have an important role to play in educating patients about the proper use of opioid medications. The following information should be included in the education provided to patients who are receiving opioids as well as to their caregivers:

  • Take opioids as prescribed.
  • In case of a missed dose or if the pain is not managed by the recommended doses:
    • If pain is not managed, talk with the healthcare team and do not take extra doses.
    • If a dose is missed, take it as soon as possible; however, if it is almost time for the next dose, skip the missed dose and go back on schedule.
    • Do not double doses.
    • For slow-release medication, if more than four hours late, do not take it.
  • Oral capsules may be opened and mixed with cool foods, but extended-release medication should not be opened, crushed, broken, or chewed.
  • It can be dangerous to use CNS depressants, including sedatives, alcohol, or illicit drugs, when taking opioid medications.
  • Due to the addictive nature of opioids, discontinuation should be accomplished by tapering the drug’s dose with the assistance of one’s primary care provider.
  • Opioids slow peristalsis and can lead to constipation; adequate fluid and fiber intake will facilitate the passage of stool.
  • Opioids can impact one’s ability to drive or operate machinery and affect one’s balance, increasing the risk for falls.
  • Death due to respiratory depression is a potential side effect.
  • Drugs should never be shared.
  • To avoid diversion, opioids should be locked in a secure location.
  • Unused opioids should be disposed of safely (see table below).
    (Jackson, 2020)
FDA’s “FLUSH LIST” OF MEDICATIONS FOR DISPOSAL BY FLUSHING
Drug Name Examples
(U.S. FDA, 2020)
Drugs That Contain Opioids
Any drug that contains the word buprenorphine Belbuca, Buavail, Butrans, Suboxone, Subutex, Zubsolv
Any drug that contains the word fentanyl Abstral, Actiq, Duragesic, Fentora, Onsolis
Any drug that contains the words hydrocodone or benzhydrocodone Apadaz, Hysingla ER, Norco, Reprexain, Vicodin, Vicodin ES, Vicodin HP, Vicoprofen, Zohydro ER
Any drug that contains the word hydromorphone Exalgo
Any drug that contains the word meperidine Demerol
Any drug that contains the word methadone Dolophine, Methadose
Any drug that contains the word morphine Arymo Er, Avinza, Embeda, Kadian, Morphabond ER, MS Contin, Oramorph SR
Any drug that contains the word oxycodone Codoxy, Combunox, Oxadydo (formerly Oxecta), Oxycet, Oxycontin, Percocet, Percodan, Roxicet, Roxicodone, Roxilox, Roxybond, Targiniq ER, Troxyca ER, Tylox, Xartemis XR, Xtampza ER
Any drug that contains the word oxymorphone Opana, Opana ER
Any drug that contains the word tapentadol Nucynta, Nucynta ER
Drugs That Do Not Contain Opioids
Any drug that contains the terms sodium oxybate or sodium oxybates Xyrem, Xywav
Diazepam rectal gel Diastat, Diastat Acudial
Methylphenidate transdermal system Daytrana

ANA POSITION STATEMENT ON PAIN MANAGEMENT

The American Nurses Association Position Statement (2018) on the nurse’s role and ethical responsibility in the management of pain states that:

  • Nurses have an ethical responsibility to provide clinically excellent care to relieve pain. Clinically excellent pain management considers clinical indications, mutual identification of goals for pain management, and ongoing reassessment with the patient of the effectiveness of pain control efforts.
  • Nurses use the nursing process to guide actions to improve pain management and should ensure that each patient experiencing pain has an individualized pain management plan with appropriate monitoring to avoid undertreatment, overtreatment, or addiction.
  • Nurses provide respectful, individualized nursing interventions to all patients experiencing pain regardless of the person’s personal characteristics, values, or beliefs.
  • Nurses consider that multimodal and interprofessional approaches are necessary to achieve effective pain relief.
  • Nurses use pain management modalities that are evidence-based. Lack of knowledge and understanding of best practices for assessing and optimally managing pain constrain the nurse’s ability to effectively minimize pain.
  • Nurses have an obligation to assess and address factors within themselves and their practice environments that constrain ability and willingness to relieve pain and the suffering it causes.
  • Nurses advocate for policies to assure access to all effective modalities. Nurses have a duty to advocate for improved parity in coverage for all effective pain relief modalities
PAIN MANAGEMENT GUIDELINES FOR NURSING FACILITIES

The Centers for Medicare and Medicaid Services guidance under F697, Interpretive Guidelines for Selected Specific Quality of Care Issues, states the following in §483.25:

Nursing facilities must assess and address pain in all residents, including the cognitively impaired, to help a resident attain or maintain his/her highest practicable level of well-being and to prevent or manage pain to the extent possible. Facilities must ensure that pain management is provided to residents who require such services, and in order to help a resident attain or maintain his or her highest practicable level of well-being and to prevent or manage pain, the facility, to the extent possible:

  • Recognizes when the resident is experiencing pain and identifies circumstances when pain can be anticipated
  • Evaluates the existing pain and the causes(s)
  • Manages or prevents pain consistent with the comprehensive assessment and plan of care, current professional standards of practice, and the resident’s goals and preferences
    (CMS, 2017)

Role of the Occupational Therapist

The role of the occupational therapist within an integrative pain management program focuses on function in daily living and takes a holistic and comprehensive approach to evaluate structural, physiologic, psychological, environmental, and personal factors that influence the experience of pain. The information obtained by patient evaluation is then used in the application of self-management strategies, functional activities, hands-on techniques, and specific exercises to improve function and participation.

OCCUPATIONAL THERAPY INTERVENTIONS

Depending on the area impacted by chronic pain, the occupational therapist provides the following interventions:

Physical mobility:

  • Adaptive equipment selection and training
  • Positioning equipment and strategies
  • Functional mobility training (e.g., static positioning, dynamic movement, transfers, lifting and bending techniques)

Activities of daily living/self-care:

  • Neuromuscular re-education
  • Nerve mobilization
  • Functional range of motion and strengthening exercises
  • Activity pacing and energy conservation strategies
  • Ergonomic and body mechanics training
  • Fall prevention and safety
  • Home evaluation

Instrumental activities of daily living:

  • Adaptive equipment selection and training
  • Transportation training, including comprehensive driver evaluations and driver rehabilitation

Health management:

  • Patient education and disease self-management training, including trigger identification, symptom tracking, and pain flare-up planning
  • Pain coping strategies, including physical modalities, complementary and alternative pain coping strategies, sensory strategies, self-regulation, and mobilization
  • Pain and assertive communication training
  • Medication management
  • Eating routine strategies to avoid dietary pain triggers and improve energy management
  • Establishing sustainable physical activities
  • Time management strategies

Rest and sleep:

  • Sleep hygiene and positioning strategies
  • Cognitive behavioral therapy for insomnia
  • Energy conservation and fatigue management

Education and work:

  • Academic and work accommodations
  • Ergonomic and body mechanics training
  • Sensory strategies to monitor environmental triggers or exacerbating factors
  • Advocacy and self-advocacy training
  • Assertive communication training
  • Community reintegration, including gradual re-entry plans
  • Activity pacing and energy
  • Environmental modifications
  • Community and online resources exploration
  • Compensatory cognitive strategies

Play, leisure, and social participation:

  • Strategies to prevent social isolation
  • Assertive communication strategies
  • Personal values and interests exploration

(Reeves et al., 2022)

PRINCIPLES FOR OCCUPATIONAL THERAPISTS

The International Association for the Study of Pain (IASP, 2021b) identifies the following principles that should guide occupational therapists in the management of pain. These principles include:

  1. Pain is an unpleasant sensory and emotional experience associated with actual or potential tissue damage, or described in terms of such damage.
  2. Pain is a complex phenomenon and a multidimensional experience.
  3. Pain is a public health problem with social, ethical, and economic considerations.
  4. People can experience pain at any stage of life.
  5. The impact of pain on daily life needs to be considered in terms not only of physical limitations but also emotional and social influences on health and patient-defined well-being.
  6. Activity analysis to explore the impact of pain on occupational performance (engagement in activities) needs to be considered from different perspectives, including factors (biological/psychological/spiritual/sociopolitical/environmental) that contribute to acute (or potential) challenges in the individual’s everyday life.
  7. Cultural aspects relevant to pain expression and the pain experience need to be considered with all patients.
  8. Self-management strategies need to focus on scheduling and adapting activities so that the person’s energy is maintained and pain is minimized.
  9. Assessment and intervention plans to manage pain need to be collaborative between patient and therapist to ensure that the patient’s goals for intervention are identified and the strengths of the patient are recognized.
  10. Occupational therapy assessment and management must be based on best available research evidence.
  11. Prevention and intervention need to be addressed at both micro (individual) and macro (sociopolitical) levels.

Role of the Physical Therapist

Physical therapy is one of the most important nonpharmacologic measures to be considered in the management of pain. The physical therapist evaluates the patient with pain in order to:

  • Determine the identity of the pain mechanism(s) to guide treatment
  • Identify physical and psychosocial factors impacting pain so they can be addressed
  • Assess the impact of pain on physical and psychosocial function
  • Select appropriate goals
  • Determine whether the patient requires referral to other healthcare providers

The goals of physical therapy include the reduction of pain, restoration of function, improved mobility, prevention or limitation of permanent physical disabilities, and encouragement of self-management through the use of physical, cognitive, and behavioral approaches to help reduce the impact of pain and disability (Sullivan et al., 2019).

PHYSICAL THERAPY INTERVENTIONS

When physical therapists work with patients who are experiencing pain, tests and measures are utilized to determine the causes of pain and to assess its intensity, quality, physical characteristics, and progression. Patients are also evaluated for risk factors for pain in order to prevent future pain issues. These factors may include disease history, cognitive and psychological factors, negative beliefs, and sedentary lifestyle.

Once contributors to the pain are identified, the therapist works with the patient to design an evidence-based management program with goals that are specific, measurable, achievable, relevant, and time-framed.

The physical therapist then implements the management program, which includes active approaches and passive approaches as indicated. These approaches include:

  • Education about pain and how to manage pain, working with the patient toward regaining the ability to perform normal activities of daily living.
  • Strengthening and flexibility exercises to improve movement with less pain. A graded exercise program may be instituted that gradually increases according to abilities. Exercises help to improve movement and coordination, reduce stress and strain on the body, and decrease pain.
  • Manual therapies using hands-on techniques to manipulate or mobilize tight joint structures and soft tissues. Manual therapy may help increase range of motion, improve tissue quality, and reduce pain. Such therapies may include peripheral joint mobilization, myofascial mobilization, spinal mobilization, soft tissue mobilization, and therapeutic massage.
  • Instruction in proper postural awareness and body mechanics, in order to help patients use their body more efficiently.
  • Physical agents, which may include electrotherapies.

The therapist educates and supports the patient to adopt active rather than solely passive pain-management strategies that are meaningful to the patient and achievable, using motivational strategies and adherence techniques to support compliance.

Physical therapists include cognitive and behavioral approaches that support improved functional movement and pain outcomes, along with self-management strategies, as a key component of the management plan (IASP, 2021c).

MODALITIES

Modalities physical therapists may employ in pain management include:

  • Thermotherapy
    • Dry heat
    • Hot packs
    • Paraffin baths
    • Tecar therapy
  • Cryotherapy
    • Ice packs
    • Ice spray
    • Immersion
    • Ice massage
    • Cryokinetics
  • Biofeedback
  • Manual therapies
    • Massage
      • Connective tissue massage
      • Therapeutic massage
    • Manipulation/mobilization
      • Dry needling
      • Soft tissue mobilization
      • Spinal and peripheral joint mobilization
      • Neural tissue mobilization
    • Passive range of motion
  • Electric stimulation
    • Electric stimulation for tissue repair (ESTR)
    • Functional electrical stimulation (FES)
    • High-voltage pulsed current (HVPC)
    • Neuromuscular electrical stimulation (NMES)
    • Transcutaneous electrical nerve stimulation (TENS)
  • Electrotherapeutic delivery of medications
    • Iontophoresis
  • Hydrotherapy
    • Contrast bath
    • Pools
    • Pulsatile lavage
    • Whirlpool tanks
  • Acoustic
    • Ultrasound
    • Phonophoresis
  • Traction devices
    • Intermittent
    • Positional
    • Sustained
  • Light therapy
    • Laser (low level and high power)
    • Ultraviolet
    • Infrared and near infrared
    • Cold laser therapy
    (Physiopedia, 2021)

PRINCIPLES FOR PHYSICAL THERAPISTS

The International Association for the Study of Pain (IASP, 2021c) identifies the following principles to guide physical therapists in the management of pain. These principles include:

  1. Pain is a dynamic and complex experience involving interaction of biological, physical, psychological, social, and environmental factors specific to each individual.
  2. Pain may be acute, acute on chronic, recurrent, chronic/persistent, and occur at any stage across the lifespan.
  3. Pain assessment, treatment, and management are influenced by cultural, institutional, social, and regulatory factors.
  4. Pain must be assessed in a comprehensive, safe, ethical, and consistent manner using valid and reliable assessment tools and outcome measures that help inform prognosis-making with consideration of risks, benefits, costs, and limitations of interventions.
  5. Physical therapists should demonstrate empathic and compassionate patient communication when establishing person-centered pain-related goals and supporting self-management strategies.
  6. Comprehensive pain management should be supported by sound theoretical models and empirical evidence and facilitate active patient involvement in developing lifelong healthy pain behaviors.
  7. The physical therapist is an essential member of the pain management team and advocates for an individualized pain management plan that integrates the perspectives of patients, social support systems, and team members.
PHYSICAL THERAPY AND THE OPIOID EPIDEMIC

The American Physical Therapy Association, along with others, developed the NQP Playbook: Opioid Stewardship to provide concrete strategies and implementation examples for effective pain management and opioid stewardship. Other programs include the APTA’s #ChoosePT opioid awareness campaign, which encourages consumers and prescribers to follow the CDC’s opioid-prescription guidelines (APTA, 2021).

CASE

CHANG

Chang is a 62-year-old male who up until the past few weeks has been very active with a local cycling club. His worsening right hip pain led him to make an appointment with his primary physician. When X-rays of the affected area showed evidence of the early stages of osteoarthritis, Chang was referred to Shaliqua Booth, a private-practice physical therapist specializing in orthopedics, for further evaluation and treatment.

On his initial visit, Chang complained of dull and achy pain in his right hip that sometimes radiated to his thigh and buttock area, as well as stiffness in the hip first thing in the morning or after prolonged sitting. Occasionally, he stated, his hip “sounds crunchy” when he rises from a sitting position or when he pedals his bicycle. He reported exacerbating factors that included getting up from bed or other low surfaces, extended walking or cycling more than 0.5 miles, and ascending/descending stairs. Chang also stated that lying on his side to sleep is most comfortable at this time.

Self-management strategies he has tried thus far have included using the hot tub at the local fitness center and taking Tylenol, both of which have provided only minimal relief. Chang expressed some frustration at not being able to participate in some of his preferred physical activities, particularly cycling, which he stated has been his primary source of social engagement since his wife passed away.

Shaliqua’s physical examination of Chang’s complaints yielded the following:

  • Lumbar spine and knee pathology ruled out with screening
  • Significantly decreased active and passive range of motion (ROM) in right hip joint (particularly in hip abductors, flexors, and external rotators)
  • Significantly decreased manual muscle strength in right hip abduction and extension
  • Increased pain with passive ROM testing
  • Slightly antalgic gait pattern, with decreased stance time and weight-bearing on right side
  • Slight crepitus of hip joint when moved passively from close-packed to loose-packed positioning
  • Static and dynamic standing balance grossly within age-typical limits

The physical therapist discussed the results of her evaluation with Chang using a moveable anatomical model of the hip joint to explain the biomechanics of his hip dysfunction. She then asked Chang what he would like to gain from physical therapy intervention. Chang stated that his ideal goal would be to bike 10 miles with his cycling group relatively pain-free and without needing to stop for a break. Available management options were discussed and a treatment plan developed.

In order to address Chang’s hip dysfunction and resultant pain, Shaliqua employed a combination of treatments, including ice and electrotherapy for pain management; a combination of manual therapy, muscle-energy techniques, and joint mobilizations to address range of motion and joint restrictions; and a progressive program of exercises designed to maximize flexibility and strength of hip musculature. Chang was also given a progressive home exercise program (HEP) to perform on a daily basis between clinic visits.

After attending physical therapy three times weekly for four weeks and adhering to his prescribed HEP, Chang experienced a significant reduction in his pain as well as measurable improvements in his active and passive hip ROM and muscle strength. With continued progression of his prescribed exercise and mobility routines, Chang eventually dropped down to once-a-week physical therapy appointments and finally was discharged to an independent, long-term HEP. Four months after his initial evaluation, Chang had regained the ability to bike moderate distances with his cycling club and stated that he was satisfied with the results of his physical therapy.