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Ann Quinlan‐Colwell
PhD, RNBC, DAAPM
Author Conflict of Interest;
A. Quinlan‐Colwell,
A consultant and presenter of
non‐branded education for Mallinckrodt
1) Describe the challenges and barriers to providing good management of chronic pain during pregnancy
2) Explain the importance of using multi‐modal analgesia (MMA) when treating chronic pain during pregnancy
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AQC_January_2012
AQC_12/14
Myths ‐Misinformation – Misconceptions ‐ Beliefs
Communication
Underreporting
Culture differences
Pain Behaviors
Coping styles
FearAQC_12/14
AQC_January_2012
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Effective
Stoic
Whining
Complaining
Over reliance on medications
Substance misuse ‐ abuse
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Reluctant to seek treatment for pain
Unable to afford medications or procedure to manage pain
Insurance determines treatment
Depletion of reserve money
Lack of money for complementary therapies
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Educational Limitations
Legal concerns
Concerns regarding fetal well being
Competing priorities
Concern regarding “drug seeking”
Complicated comorbidities
Time
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AQC_January_2012
Epidemiology
Prevalence ~ 25 – 56% lumbopelvic or peripartum pelvic pain ~ 8% become severely incapacitated
Challenges Terminology and definitions Formal mechanism for tracking
Studies NY hospital 200 women w/ 56% w/ LBP by Fast, et al, 1987 Yale study 950 surveys w/68.5% w/LBP by Wang et al, 2004
(IASP, 2007; Wang, et al, 2004)
Back Low back Pelvic girdle pain Neck
Pelvis
Pubic area
Hip
Knee
Thorax(Licciardone, et al, 2010; Vleeming, et al, 2013)
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Headache
Nerve entrapment Meralgia paresthetica
Degenerating fibroid
Carpal tunnel syndrome
DeQuervain’s tenosynovitis
Post herpetic neuralgia
(ACOG, 2013; IASP, 2007; Licciardone, et al, 2010)
Pain Control Safety
Maternal Concerns Neonate Concerns
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Physiological Impact of poorly controlled pain Immobility
Premature delivery
Psychological Impact of poorly controlled pain Antenatal and postnatal depression
Stress cascade resulting from unrelieved pain
Withdrawal from opioids
“the fetus is a passive recipient of any medication that may be administered” (IASP, 2007)
Rx that are harmful to developing fetus
Neonatal Abstinence Syndrome
Intrauterine withdrawal
Neural Tube Defects (Yazdy, et al, 2013)
All opioids are Pregnancy Class C
Prevalence 2001 Wilbourne et al reported opioid use in 7.5% of
pregnancies 2011 Kellogg et al reported steady increase from 1998‐2009
Indications for using opioids during pregnancy Chronic pain Genitourinary pain w/ pathologic evidence Headaches Orthopedic w/ pathologic evidence Other (CA; varicosities; neurofibromatosis)
(APS, 2009; Kellogg et al, 2011)
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Increased risk of miscarriage
1st and 2nd trimesters (up to 30 weeks) probably ok
3rd trimester – NSAIDS are contraindicated NSAIDS inhibit cyclo‐oxygenase
Cyclo‐oxygenase dilates the ductus arteriosus & pulmonary resistance vessels
Inhibition could cause premature closure
(Kennedy, 2011)
Platelet inhibition
Possible maternal and fetal bleeding
Associate with increase risk of miscarriage
Associated with increased risk of vascular disruption;gastroschisis
BUT, may be Rx’d to reduce other adverse outcomes
(Babb, 2010; Kennedy, 2011)
“Women receiving opioid‐assisted therapy who are undergoing labor should receive pain relief as if they were not taking opioids because the maintenance dosage does not provide adequate analgesia.” (ACOG, 2012)
Generally require increase opioid dosing
Avoid opioid agonist‐antagonists
Do not use buprenorphine in a pt taking methadone(ACOG, 2012)
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Epidural or spinal anesthesia
Local anesthetic
Injectable NSAID or acetaminophen
Breathing and Relaxation Techniques
40 Post Caesarean Section patients
Group 1 – IT bupivacaine + morphine + incisional bup
and ibuprophen + acetaminophen to d/c
and prn codeine
Group 2 ‐ IT bupivacaine + IV morphine PCA weaned to
acetaminophen + codeine
Pain at Rest 0.6 vs. 2.1 (p < 0.0001)
Pain with Activity 1.9 vs. 4.1 (p < 0.0001)
(Rosaeg, et al, 1997)
533 breast feeding mothers
CNS depression rate in neonates Oxycodone 20.1% (28/139)
Codeine 16.7% (35/210)
Acetaminophen 0.5% (1/184)
Group characteristics Mothers taking codeine more likely first time mothers
Infants exposed to oxycodone were younger
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May be safe in small doses (< 30 mg/ day)
Hydrocodone metabolizes to hydromorphone
Sauberan, et al: Little to no hydromorphone excreted into breast milk
Concern is Only one study Neonate metabolism
Awareness, Education, Assessment still needed
(Sauberan, 2011)
CYP2D6 gene Codeine – metabolizes to morphine metabolite Oxycodone – metabolizes to oxymorphone (14 x potent)
Know: Potential Underlying mechanisms r/o in lethargic infants
Educate breast feeding mothers taking opioids be alert for signs of lethargy and sedation seek prompt medical assistance
(Kennedy, 2011; Koren et al, 2006; Timm, 2013; vandenAnker, 2012)
Non‐pharmacologic interventions
Acetaminophen
NSAIDs during pregnancy
do not seem to increase risk of adverse birth outcome
But should be avoided after 30 weeks
and are associated with increased risk of miscarriage
Opioids in pregnancy do not cause fetal malformations
but can result in neonatal abstinence syndrome(Kennedy, 2011)
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Identify and address the cause of pain
Individualized plan of care
Patient education:
‐ indications for different interventions
‐ potential side effects
Start at low dose and
gradually titrate dose
Is the Key to Pain
Management
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Determine Etiology Obstetric
Ectopic pregnancy Preterm labor Placental abruption Uterine rupture
Gynecologic Adnexal torsion
GI Appendicitis Intestinal obstruction
Hepatobiliar Acute fatty liver of pregnancy
GU Hydronephrosis of pregnancy Renal calculi
Vascular Gonadal vein thrombosis or syndrome Messenteric vein thrombosis Aneurysm rupture
Intervene accordingly (Woodfield, et al, 2010)
Avoid ergots and sodium valproate
Non‐pharm
Hydration
Diet
Acetaminophen
Propranolol generally considered safe
Combo metoclopramide & diphenhydramine (MAD) metoclopramide ‐ used to tx heartburn 2/2 reflux Diphenhydramine ‐ antihistamine OTC allergy/sleep aids considered safe in pregnancy & reasonably priced
(ACOG, 2013; Mehta, 2011)
What is 32%
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LBP is the ____________ cause for HCP visits in US.
At least __ % of people will have LBP at some time.
Most women first experienced LBP _____ _____.
In pregnancy LBP interferes w/ ability to _____ and ___________ _______ ______.
Women who have had LBP during pregnancy are at greater risk of experiencing LBP _____ ______.
_______% of women who avoid subsequent pregnancies 2/2 fear of recurrence of LBP.
George, et al, 2013; Wang, et al, 2004
LBP is the ____________ cause for HCP visits in US.
At least __ % of people will have LBP at some time.
Most women first experienced LBP __________ _____.
In pregnancy LBP interferes w/ ability to ______ and _____________.
Women who have had LBP during pregnancy are at greater risk of experiencing LBP ______________.
____% of women who avoid subsequent pregnancies 2/2 fear ofrecurrence of LBP.
George, et al, 2013; Wang, et al, 2004
Age
h/o LBP
h/o LBP during menstruation
h/o LBP during prior pregnancies
(Wang, et al, 2004)
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Use of birth control pills
Hormonal therapy 2/2 infertility
Caffeine
Cigarette smoking
Physical exercise
Previous epidural or spinal procedures
Repetitive daily activities
Body weight pre‐pregnancy (others disagree)
Number of pregnancies(Wang, et al, 2004)
Stretching Exercise Frequent rest Cold or hot compresses Supportive belt Acetaminophen Complementary therapies
Acupuncture Massage Chiropractic Osteopathy Aromatherapy Relaxation Herbs Yoga Energy work (Reiki, Therapeutic Touch)
(Wang, et al, 2002, 2004)
Patient Education from 1st trimester Posture Body mechanics
Mechanical supporter information
Physical Therapy
(Wang, et al, 2004)
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STOB = Standard of Obstetric Care
MOM = Multimodal musculoskeletal & obstetric management with weekly chiropractic specialist based on biopsychosocial model
Education
Reassurance
Manual therapy
Stabilization exercises
(George, et al, 2013)
STOB group at 33 weeks Significant increase in pain in 5 indices
MOM group at 33 weeks Statistically significantly less pain in 7 indices Significantly less sleep difficulty Improved ROM Stability Less lumbar and pelvic joint irritation NO ADE
Conclusion
MMA is beneficialGeorge, et al, 2013
Prevention Shoes with good arch support Firm mattress Good body mechanics Chairs w/ good back support Small pillow to support lower back Lumbar supports Side sleeping w/ pillow/s between legs or under abdomen
Treatment Regular exercises to strengthen & stretch muscles Good posture Heat and/or cold
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OMT – a form of manual therapy by DO
Licciardone, et al study 144 subjects
3 groups UOBC increase in NRS most disability rise
UOBC + SUT no change in NRS mod disability rise
UOBC + OMT decrease in NRS minimal disability rise
Goal: achieve functional physical restoration
Role: prescribe, facilitate, pace therapeutic interventions
PT influence pain by:
Resolving inflammation
Assisting with tissue repair
Stimulating temporary pain relief
Moving nerve conduction’
Providing counterirritant
Modifying muscle tone
Reducing chance of maladaptive neuropathic changes
(Allen, et al, 2006)
Systematic Review 1992‐2013
22 RCT studies Dx – lumbopelvic pain Interventions
Combination (education, relaxation) “helpful” Exercise therapy moderate evidence
Manual therapy limited evidence
Material support limited evidence
Conclusion Evidence based recommendation for use of exercise therapy during pregnancy to treat lumbopelvic pain
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Ee, et al Systematic Review (2008) Limited evidence supports Ac
for pregnancy related pelvic/back pain Additional study needed
Elden et al study (2008) 351 women w/ pelvic girdle pain 3 groups
standard of care 22% good or very good help SOC + stabilising exercises 81% good or very good help SOC + acupuncture 83% good or very good help
minor ADE reports
but no severe ADE effect on pregnancy, deliver, fetus
Wang et al Study (2010) 152 Pregnant women w/ posterior pelvic/LBP
Control, sham acupuncture, acupuncture
Decrease in pain Control group 18%
Sham acupuncture group 32%
Acupuncture group 68%
Significance between groups
Significant improvement in functional status
ADEs No adverse pregnancy outcomes
One in each group bed rest post study
Ear tenderness 1/54 Ac group and 3/50 Sham Ac group
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AQC 12/14
Environmental Modification
Education
Cognitive Behavioral Interventions
Healing Arts
Physical
Energy Based Interventions
Exercise
Spirituality & Prayer
Devices
Other Complementary Interventions
AQC_
Lighting
Sounds
Temperature
Odors
Position
Patient PositionHead
Neck
Limbs
Pillows
Side rails
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AQC_11_11
Include family and caregivers
Focus on: Etiology
Interventions to alleviate pain
Pharmacological preparations
Side effect management
Comfort measures
Nonpharmacological interventions
Muscle relaxation
Dietary needs and measures
Rest and relaxation
Usual bio‐rhythms
Patient priorities
Pre‐medicate
Pace activities
Educate re: benefits
Schedule activities rest
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Cognitive Behavioral Therapies
Rationale for using CBT“altering patterns of negative thoughts and dysfunctional
attitudes leads to more positive thoughts, emotions, and
behavior changes, including improved self‐
management.”
Underlying assumption is that:perceptions and evaluations influence emotional and
behavioral reactions to painful conditions
(Menzies, Taylor & Bourguignon, 2006, p.24)
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Involves increased mental focus and concentration with expanded awareness, diminishing perception and interest in peripheral sensations, thoughts, and feelings of the external environment.
Used since early 1800’s
Generally safe and effective
Caution with people with h/o mental illness
Effective for: Osteoarthritis Fibromyalgia Cancer Headaches Sickle cell disease
( Anselmo, 2009; Fass, 2008).
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With significant attention required for activity,
pain scores decreased
(Berman, Iris, Bode, & Drengenberg, 2009; Ersek, Turner, & Kemp, 2006; Veldhuijzen, Kenemans, De Bruin, Olivier, & Volkerts, 2006).
Specific Techniques Imagery
Focal point attention
Music
Counting
Pleasurable leisure activities
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Imagery is “a dynamic, psychophysiologic process in which a person imagines, and experiences, aninternal reality in the absence of external stimuli.”(Menzies, Taylor & Bourguignon, 2006, p.24)
Imagery is “the spontaneous flow of thoughts originating from the unconscious mind” (Seaward, 2004, p. 381)
Free flow of thoughts
May include: Day dreaming
Reminiscing/14
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A deliberate process of imagining
“A conscious choice with intentional instructions”
(Seaward, 2004, p. 381)
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A coach/guide is added to deliberate process of visualization
Generally begins with relaxation
Research
Studies small
Generally effective when used 2 – 3 times daily
Cautions:
Always have the person choose the location
Select a comfortable and SAFE location
Not indicated with psychotic disorders
Cognitive impairment
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“Person may experience an affective, behavioral or physiologic response without a real stimulus event.”
(Menzies, Taylor & Bourguignon, 2006, p.24)
Improved: function, self‐efficacy and reduced pain;reduced emotional distress
Beneficial with: Fibromyalgia (improvement in tender point measures)
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Behavioral Interventions
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Combine psychological and physical responses
Involve parasympathetic system, visceral and somatic organs
Cerebral, physical and
tensions are released
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Diaphragmatic
Square
Conscious
Lamaze
Yoga
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Also called “soft belly breathing”
Process:
Slowly inhale
Focus bringing inhaled air down into abdomen
Watching abdomen fill with air
Exhale
Focus on watching air leave abdomen
Analogous to watching an imaginary balloon
Benefits:
Easy to learn
Helps relaxation process
No known negative consequences
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Developed to help people relax muscles that become tense because of anxiety, stress, or pain
Benefits
Reduced muscle tension
Reduced stress
Alters patterns of muscle activities that cause increased pain
Alters the emotional response to pain
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No tensing
Images
Color
Guided PMR
Mindfulness PMR
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the use of “music to address physical,
emotional, cognitive, and social needs of
individuals of all ages” (AMTA, 2004).
Used to promote wellness and improve health including managing stress and pain during activities,at rest, and while preparing for sleep (Herr et al., 2006).
Suggested that beneficial effects of music therapy are related to arousal of emotional responses anddistract from the pain experience, thus interrupting
pain perception (Kinney & Faunce, 2004).
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Pet Visitation
Animal Assisted Therapy
Pet ownership
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Superficial heat Heating pads, hot water bottles, poultices, hot compresses, heat wraps, infrared heat lamps
Soothe musculoskeletal pain &/or muscle spasms Some evidence of relief of short term relief of low back pain
Cryotherapy Ice, cold cloths, cold gel packs, ice massage No research to support effectiveness or guidetreatment
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Limit time
Limit temperature extremes
NEVER use heat over transdermal fentanyl patches
AVOID using heat with capsaicin cream
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“The practice of skilled touch for the purposes of reducing pain brought about by injury disease or prolonged stress”(Calenda & Weinstein, 2008, p. 144).
Effective: Low back pain
Dementia (hand massage)
Generally considered safe
Cautions: Some discomfort
Reactions to oils
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a contemporary interpretation of ancient healingpractices developed in 1973 by Dolores Krieger, andDora Kunz
It is the conscious and intentional use of hands to direct human energies with the intent of helping or healing someone through modulation of their energy field (Krieger, 1979; Krieger, 2002)
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a technique using focused pressure on the hands or feet with the intent of stimulating certain reflex areas or zones that correspond to the various body organs.
It is believed that stimulation can facilitate animproved flow of energy, promoting healing or achieving homeostasis.
Rare and mild adverse effects include
fatigue, headache, nausea,
perspiration, and diarrhea.
(Bisson, 2008)
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Central to maintaining function
Reconditioning exercises
Stretching
Cardiovascular
Strengthening
Individualized programs
Various locations
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“ philosophy of living” “unites physical, mental, andspiritual health” involves breathing & stretchingexercises (Anselmo, 2009)
Not necessary to adopt philosophy of yoga
Postures & breathing exercises designed to quiet &“cleanse” mind & body (Cashwell, Bentley, & Yarborough, 2007)
Exercises can be started very gently
Good to recondition muscles and joints
It is reported to be effective in
reducing pain in older adults.
may be modified to meet particular needs (Morone & Greco, 2007
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Meditative practice in the Christian tradition
Focuses on words or sounds
Considered to be nondenominational & appropriate for people of all faiths.
Contemplative journey is the vehicle
in a process of letting go
(Keating, 1999)
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Type of meditation from the Buddhist tradition
Intent is to release negative emotion and embrace a sense of love
Begins with evolving positive feelings & love toward:loved ones
then toward self
then toward a person who did harm to person meditating
Relationship between pain & anger
Carson et al study
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Introduced by Jon Kabat‐Zinn as a clinical intervention for chronic pain
“moment to‐moment awareness” that “is cultivated by purposefully paying attention to things we ordinarily never give a thought to” (Kabat‐Zinn, 1990, p. 2)
Can be integrated with daily activities, such as breathing, sitting, walking, washing dishes, or driving
Incorporated with learning and practicing
mindfulness are patient, nonjudgmental,
accepting, and nonstriving attitudes.
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Pain is reduced through surface electrodes, whichemit high or low frequency pulsed electrical currents that selectively stimulate particular sensory or motor nerve fibers through a portable device (Dreeben, 2007; Somers &
Clemente, 2006)
Research shows inconsistent findings
A study using rats indicated that TENS
is effective for allodynia and complex
regional pain syndrome(Somers & Clemente, 2006).
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Use of volatile & essential oils of aromatic plants that have been extracted for therapeutic use when inhaled through the olfactory system
Long considered an established portion of health care in the UK, Japan, and Australia, where the majority of research has been done.
More research is needed in the area of aromatherapy with pain, but early work is promising (Barde, Reichow & Halm, 2009)
Certification for nurses interested in aromatherapy (Buckle Associates, 2010)
Cautions include: All essential oils can cause skin irritation & some are toxic.
Caution with pregnancy
Topical use of essential oils should be done only
by practitioners trained in their use (Cook & Burkhardt, 2004)
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Facilitates person, as active participant, to self‐regulate physiological processes gain control over the body
Trained biofeedback technicians use concepts ofoperant conditioning and specially designedequipment that mirrors the autonomic physiologicalprocesses to help control those processes to: reduce tension and stress retrain muscles when muscle tone needs to improve train brain waves to improve attention & concentration
(Goldenberg, Burckhardt, & Crofford, 2004; Jensen, Bergstrom,
Ljungquist, & Bodin, 2005; McGrady, 2008; Turner, Mancl, & Aaron, 2006)
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10/29/10 AQC 96
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