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Chapter Objectives

Upon completing this chapter, the learner will be able to:

  1. Define, compare, and contrast acute pain and chronic pain.

  2. Identify medical diagnoses in neurology that often produce chronic pain.

  3. Describe the pathophysiology of chronic pain, including central sensitization.

  4. Describe challenges to the optimal management of chronic pain.

  5. Describe the assessment of chronic pain and related areas and give examples of specific instruments that are used.

  6. Describe the functional restoration approach.

  7. Describe the roles of the psychologist and the therapist in the functional restoration approach.

  8. State examples of disease-specific considerations in the management of chronic pain.

  9. Describe how shoulder-hand syndrome is best managed.

  10. Describe Moseley’s work in complex regional pain syndrome type 1.

  11. Identify other medical diagnoses to which Moseley’s work is applicable, and describe the implications for therapist management of chronic pain.

Introduction

You have seen this before in your outpatient neurology clinic: Your 72 yearold patient, Mr. Simons, had a cerebrovascular accident 1 month ago and had been exhibiting some motor recovery in his affected arm. Now he has developed intense pain throughout the arm, down to the hand, and the arm is extremely sensitive to touch. He also has developed edema. His wife tells you that he has quit trying to move the arm. What will you do? This chapter will equip you to develop a plan for intervention for this and other pain syndromes.

Pain, particularly chronic pain, is commonly observed in occupational and physical therapy practice in those with neurologic conditions. It creates a challenging clinical problem requiring interdisciplinary (i.e., collaborative) treatment for optimal outcomes. We will see that the experience of pain includes not only the sensation but also the subjective awareness/perception and response to the unpleasant sensory experience, with profoundly detrimental effects on the individual’s functional activity and participation.

Foundational Concepts

What Is Chronic Pain?

Chronic pain is a complicated phenomenon. Consider two definitions of “pain”:

  • A disturbed sensation that causes suffering or distress (American Physical Therapy Association [APTA], 2015).

  • An unpleasant sensory and emotional experience associated with actual or potential tissue damage or described in terms of such damage (International Association for the Study of Pain [IASP], 1994).

Inherent in these definitions is the concept that pain involves both physical (sensory) and psychological (affective) components. As such, pain is always subjective—a symptom rather than a sign (IASP, 1994). However, pain behavior can be an accompanying sign—and chronic pain itself can be considered a disease (World Health Organization [WHO], 2006). Pain behavior is defined as “[v]erbal or nonverbal actions understood by observers to indicate a person may be experiencing pain and suffering. These actions may include audible complaints, facial expressions, abnormal postures or gait, use of prosthetic devices, avoidance of activities, overt expressions, and verbal or nonverbal complaints of pain, distress, and suffering” (Turk, 2001b, ...

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