Acute care handbook for physical therapists (fourth edition) chapter 21 acute pain management

CHAPTER

21

Acute Pain Management
Jaime C. Paz
Danika Quinlan

CHAPTER OUTLINE

CHAPTER OBJECTIVES

Pain Evaluation
Physical Therapy Considerations
for Pain Evaluation
Pain Management
Physical Therapy Considerations
for Pain Management

The objectives of this chapter are to provide the following:
1.
2.
3.
4.

An overview of pain evaluation scales most applicable to the acute care setting
A description of physical therapy considerations when evaluating pain
An overview of commonly utilized management strategies for acute pain including pharmacologic agents
A brief description of physical therapy management strategies for acute pain

PREFERRED PRACTICE PATTERNS

Pain is multifactorial in nature and applies to many body systems. For this reason, specific
practice patterns are not delineated in this chapter. Please refer to Appendix A for a complete
list of the preferred practice patterns in order to best delineate the most applicable practice
pattern for a given diagnosis.

This chapter provides information on the evaluation and management of acute pain with the
goal of facilitating patient care. The characteristics of acute pain include less than 6 months
in duration, often associated with tissue damage such as surgery or traumatic injury, the cause
of pain is easily recognized, pain can be treated readily, and the duration of pain is predictable.1
Acute pain in the medical patient may result from nonsurgical abdominal pain, renal or biliary
stones, and phantom limb pain.2

Pain Evaluation
The subjective complaint of pain is often difficult to objectify in the inpatient setting. Patients
may be mechanically ventilated, pharmacologically sedated, or in too much pain to articulate
their discomfort.3 Furthermore, patients who may be cognitively impaired are at higher risk
for their pain to be undertreated with a resultant decreased quality of life.4-6 Despite these
difficulties, an effective pain treatment plan depends on an accurate evaluation of the patient’s
pain.7,8
Each evaluation requires a complete physical and diagnostic examination of the patient’s
pain. The criterion standard for pain assessment is through self-report by the patient because
it is the most accurate indicator of the existence or intensity of his or her pain, or both.4,5,9
The goal for evaluation should be directed toward individualization while maintaining consistency among patients. To assist with this process, various pain-rating tools have been
developed to address both verbal and nonverbal (conscious or unconscious) patients.
Verbal pain scales (Table 21-1) include:
• Numeric rating scale (NRS)
• Visual analog scale (VAS)
• Verbal descriptor scale (VDS)
• Wong-Baker Faces Scale
• Functional pain scale

Nonverbal pain scales include:
• Adult Nonverbal Pain Scale (Table 21-2)
• Behavioral Pain Scale (Table 21-3)

457


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CHAPTER 21    Acute Pain Management

TABLE 21-1  Verbal Pain Scales
Tool

Description

Verbal descriptor scales
Numeric Rating Scale (NRS)

The patient describes pain by choosing from a list of adjectives representing gradations of pain intensity.
The patient picks a number from 0 to 10 to rate his or her pain, with 0 indicating no pain, and 10
indicating the worst pain possible.

Visual Analog Scales (VAS)
  Line scale
  Wong-Baker Faces scale
Functional Pain Scale

The patient marks his or her pain intensity on a 10-cm line, with one end labeled “no pain,” and the
other end labeled “worst pain possible.”

The patient chooses one of six faces, portrayed on a scale that depicts graduated levels of distress, to
represent his or her pain level.
A zero (0) to five (5) scale with corresponding pain descriptions
0 = No pain
1 = Tolerable (and does not prevent any activity)
2 = Tolerable (but does prevent some activities)
3 = Intolerable (but can use telephone, watch TV, or read)
4 = Intolerable (cannot use telephone, watch TV, or read)
5 = Intolerable (and unable to verbally communicate because of pain)

Data from Kittelberger KP, LeBel AA, Borsook D: Assessment of pain. In Borsook D, LeBel AA, McPeek B, editors: The Massachusetts General Hospital handbook
of pain management, Boston, 1996, Little, Brown, p 27; Carey SJ, Turpin C, Smith J et al: Improving pain management in an acute care setting: the Crawford Long
Hospital of Emory University experience, Orthop Nurs 16(4):29, 1997; Wong DL, Hockenberry-Eaton M, Wilson D et al: Wong’s essentials of pediatric nursing, ed
6, St Louis, 2001, Mosby, p 1301; Puntillo K, Pasero C, Li D et al: Evaluation of pain in ICU patients, Chest 135:1069-1074, 2009; Gloth FM, Cheve AA, Stober
CV et al: The functional pain scale: reliability, validity, and responsiveness in an elderly population, J Am Med Dir Assoc 2:110-114, 2001; Chanques G, Viel E,
Constantin JM et al: The measurement of pain in intensive care unit: comparison of 5 self-report intensity scales, Pain 151:711-721, 2010.

TABLE 21-2  Adult Nonverbal Pain Scale
Categories
Face
Activity (movement)
Guarding

0

1

No particular expression or
smile
Lying quietly, normal position

Occasional grimace, tearing, frowning,
wrinkled forehead
Seeking attention through movement
or slow, cautious movement
Splinting areas of the body, tense

Frequent grimace, tearing, frowning,
wrinkled forehead
Restless, excessive activity and/or
withdrawal reflexes
Rigid, stiff

Change over past 4 hours in any of the
following: SBP > 20 mm Hg, HR
> 20/min, RR > 10/min
Dilated pupils, perspiring, flushing

Change over past 4 hours in any of the
following: SBP > 30 mm Hg, HR
> 25/min, RR > 20/min
Diaphoretic, pallor

Physiologic I (vital
signs)

Lying quietly, no positioning
of hands over areas of body
Stable vital signs (no change
in past 4 hours)

Physiologic II

Warm, dry skin

2

From Odhner M, Wegman D, Freeland N et al: Assessing pain control in nonverbal critically ill adults, Dimens Crit Care Nurs 22:260-267, 2003.
HR, Heart rate; RR, respiratory rate; SBP, systolic blood pressure.

Pain scales used for both verbal and nonverbal patients
include:
• Face, Legs, Activity, Cry, Consolability (FLACC) scale
(Table 21-4)
• Critical Care Pain Observational Tool (CPOT) (Table 21-5)
The validity of these scales may be improved by asking
the patient about his or her current level of pain, rather than
asking the patient to speculate about “usual” or “previous”
levels of pain.10

  CLINICAL TIP
The therapist should be sensitive to, and respectful of, how different cultures perceive pain, as pain expression may vary
among cultures.5,11

The therapist should be aware that some physiologic indicators exist normally in critically ill patients. One needs to analyze
the behavioral trend and differentiate pain from physiologic
changes.12 The Adult Nonverbal Pain Scale is targeted toward
adult patients who are intubated and sedated and is adapted
from the FLACC Pain Assessment Tool.12 The Behavioral Pain
Scale (BPS) is used for mechanically ventilated, sedated patients

in the intensive care unit (ICU).4 Validity measured by BPS
scores increase with painful stimuli.13 Good construct validity
(p < 0.001) has been reported for the FLACC as evidenced by
decreased pain scores after administration of analgesics and from
painful to nonpainful situations. The FLACC has also demonstrated good interrater reliability when assessing pain in critically ill patients.14 This was consistent when compared among
use with adults, children, and patients who are mechanically
ventilated. However, there is some disagreement concerning
the use of this scale with adults because of their inability to


CHAPTER 21    Acute Pain Management



demonstrate some behaviors associated with the pediatric population. Those who disagree suggest utilizing the NVPS, as it
has good interrater reliability and validity with critically ill,
sedated, mechanically ventilated, and/or cognitively impaired
adults.12,14,15
The CPOT was developed to assess pain in critically ill ICU
patients and was mainly used with those recovering from cardiac
surgery. It is reliable and valid in this population and further
research is required for its use in other populations.16 The CPOT
can be used with both verbal and nonverbal patients.4,16

Physical Therapy Considerations for Pain Evaluation
• Observe pain-related behaviors to appropriately select an
assessment tool. Use nonverbal assessment tools when selfreport is unattainable.5
• Select the appropriate tool based on the clinical environment
and relevance to the specific patient population.5

TABLE 21-3  Behavioral Pain Scale
Item

Description

Facial expressions

Relaxed
Partially tightened (e.g.,
brow lowering)
Fully tightened (e.g., eyelid
closing)
Grimacing
No movement
Partially bent
Fully bent with finger flexion
Permanently retracted
Tolerating movement
Coughing but tolerating
ventilation for most of
the time
Fighting ventilator
Unable to control ventilation

Movements of
upper limbs

Compliance with
ventilation

Score
1
2
3
4
1
2
3
4
1
2

459

• Table 21-6 provides a comparison of the various pain scales
to aid in selecting an appropriate tool. The VAS and NRS
tend to be used commonly in the clinical setting.5,17
• Patients report a preference for the NRS because of its ease
of use and accuracy.
• In consideration of Joint Commission requirements, each
patient interaction needs a pain rating, even if the patient
reports 0/10 on the NRS.
• A pain grade is generally accompanied by location, description, and most importantly, an “intervention,” especially if
pain is graded greater than 4/10 on the NRS.
• The physical therapist should recognize when the patient is
weaning from pain medication (e.g., transitioning from
intravenous to oral administration), as the patient may complain of increased pain with a concurrent reduced activity
tolerance during this time period.
• To optimize consistency in the health care team, the physical
therapist should use the same pain rating tool as the medicalsurgical team to determine adequacy of pain management.

• Often the best way to communicate the adequacy of a
patient’s pain management to the nurses or physicians is in
terms of the patient’s ability to complete a given task or
activity (e.g., the patient is effectively coughing and clearing
secretions). Therapists should communicate both verbally
and in written form to the medical team if the pain management is insufficient to allow the patient to accomplish functional tasks.

Pain Management

3
4

From Payen JF, Bru O, Bosson JL et al: Assessing pain in critically ill sedated
patients by using a behavioral pain scale, Crit Care Med 29(12):2258-2263,
2001.

The primary goal in acute pain management is to promote the
resolution of the underlying causes of pain while providing
effective analgesia.18 Acute pain can be managed using both
pharmacologic and nonpharmacologic techniques (including
physical therapy) either in isolation or more often in combination.19,20 This section focuses on pharmacologic management
while the next section will describe physical therapy management considerations.

TABLE 21-4  FLACC Pain Assessment Tool
Categories

Score = 0

Score = 1

Score = 2

Face

No particular expression or smile

Legs
Activity

Frequent to constant frown,
clenched jaw, quivering chin
Kicking, or legs drawn up
Arched, rigid, or jerking

Cry

Normal position or relaxed
Lying quietly, normal position,
moves easily
No cry (awake or asleep)

Consolability

Content, relaxed

Occasional grimace or frown,
withdrawn, disinterested
Uneasy, restless, tense
Squirming, shifting back/forth,
tense

Moans or whimpers, occasional
complaint
Reassured by occasional touching,
hugging, or “talking to,”
distractible

Crying steadily, screams or sobs,
frequent complaints
Difficult to console or comfort

Indication: For nonverbal patients, particularly the pediatric population.
From Merkel SI, Voepel-Lewis T, Shayevitz JR et al: The FLACC: a behavioral scale for scoring postoperative pain in young children, Pediatr Nurs 23(3):293-297,
1997.


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CHAPTER 21    Acute Pain Management

TABLE 21-5  Critical-Care Pain Observation Tool (CPOT)
Indicator

Descriptor

Score

Facial expression

No muscular tension observed
Presence of frowning, brow lowering, orbit tightening

and levator contraction
All of the above facial movements plus eyelid tightening
Does not move at all (does not necessarily mean absence
of pain)
Slow cautious movements, touching or rubbing the pain
site, seeking attention through movements
Pulling tube, attempting to sit up, moving limbs/
thrashing, not following commands, striking at staff,
trying to climb out of bed
No resistance to passive movements
Resistance to passive movements
Strong resistance to passive movements, inability to
complete them
Alarms not activated, easy ventilation
Alarms stop spontaneously
Asynchrony: blocking ventilation, alarms frequently
activated
Talking in normal tone or no sound
Sighing, moaning
Crying out, sobbing

0 = Relaxed, neutral
1 = Tense

Body movements

Muscle tension (evaluation
by passive flexion and
extension of UEs)
Compliance with

mechanical ventilator
(intubated patient)
Vocalization (extubated
patient)

2 = Grimacing
0 = Absence of movement
1 = Protection
2 = Restlessness
0 = Relaxed
1 = Tense, rigid
2 = Very tense, rigid
0 = Tolerating ventilator or movement
1 = Coughing but tolerating machine
2 = Fighting ventilator
0 = Talking in normal tone or no sound
1 = Sighing, moaning
2 = Crying out, sobbing

Modified from Gélinas C: Nurses’ evaluations of the feasibility and the clinical utility of the Critical-Care Pain Observation Tool, Pain Manag Nurs 11(2):115-125,
2010.

  CLINICAL TIP
Communication among therapists, nurses, physicians, and
patients on the effectiveness of pain management is essential
to maximize the patient’s comfort. This includes a thorough
review of the patient’s medical history and the doctor’s orders
by the physical therapist before prescribing any modalities or
therapeutic exercises.
Pharmacologic management of acute pain is based on the

World Health Organizations (WHO) Analgesic Ladder21,22
originally designed to promote ongoing assessment of pain
management during the palliative care of patients with cancer.20
The WHO ladder is a stepwise process in which step 1 is for
patients with mild pain in whom the use of nonopioid analgesia
is recommended, step 2 is for moderate pain and advocates the
use of weak opioids with or without nonopioids, and step 3 is
for patients with severe pain in whom strong opioids with or
without nonopioids are recommended.20 Table 21-7 provides an
overview of commonly utilized opioid agents in the management of acute pain.
Nonopioid drugs typically comprise nonsteroidal antiinflammatory drugs (NSAIDs) (Table 21-8) and acetaminophen
(paracetamol), which is a centrally acting analgesic that interacts with the cyclooxygenase system.18,19 Acetaminophen also
has antipyretic effects and is an effective analgesic when used
alone or as an adjunct to opioid analgesia.18

As a group, NSAIDs are nonselective cyclooxygenase inhibitors. Cyclooxygenase (COX) is an enzyme that exists in two
forms (COX-1 and COX-2).23 The homeostatic pathways,
which include production of prostaglandins and thromboxane,
primarily involve the COX-1 enzyme, while COX-2 is involved
with pathways that produce pain and inflammation. Prostaglandins have a protective role for the mucosal lining of the gastrointestinal tract; therefore nonselective inhibition of these
substances can result in gastrointestinal (GI) dysfunction (see
Chapter 8). Selective inhibition of COX-2 was found to decrease
injury to the mucosal lining of the stomach, leading to the
development of COX-2 selective agents, which were aimed at
reducing inflammation without adverse GI effects. Unfortunately, these agents were also correlated with an increased risk
of cardiovascular events in susceptible individuals, resulting in
agents such as rofecoxib (Vioxx) and valdecoxib (Bextra) being
taken off the market. Currently celecoxib (Celebrex) is the only
COX-2 selective agent still available.23,24 Careful patient selection regarding all NSAIDs and overall cardiovascular risk need
to be considered.23 Acetylsalicylic acid (aspirin) is the oldest

form of NSAID prescribed for patients to help manage pain and
inflammation, as well as providing antiplatelet effects for vascular conditions.23
Opioid agents and NSAIDs can be administered by oral,
intravenous, or intramuscular routes. Alternative routes of
administration for pain medications include local anesthetics
(Tables 21-9A and 21-9B) and patient-controlled analgesia
(PCA) (Table 21-10).


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CHAPTER 21    Acute Pain Management



TABLE 21-6  Comparison of Pain Assessment Scales
Tool

Targeted Population

Benefits

Reliability

Validity

Numeric Rating
Scale (NRS)

Adults

Easy to use

Interrater reliability
coefficient = 0.54

Visual Analog
Scale (VAS)

Adults

Visual face and number
scale to rate pain

Reliability coefficient
range = 0.95-0.98

Functional Pain
Scale (FPS)
Verbal Descriptor
Scale (VDS)

Geriatric

Relates pain to function

Adults, geriatrics

Descriptions aid patient
to rate pain

Face, Legs,
Activity, Cry,
Consolability
(FLACC)

Pediatrics mostly

Clinically useful and
efficient in the ICU

Reliability coefficient
range = 0.95-0.98
Interrater reliability
coefficient range
= 0.77-0.89
Interrater reliability
coefficient = 0.84

Critical-Care Pain
Observation
Tool (CPOT)

Verbal and nonverbal
Mechanically
ventilated patients

Interrater reliability
coefficient = 0.74

Nonverbal Pain
Scale (NVPS)

Sedated ICU patients
Conscious adults

Good reliability and
validity when
applied to cardiac
surgical patients
Assessment of burn and
trauma patients

Behavioral Pain
Scale (BPS)

Unconscious critically
ill, mechanically
ventilated, sedated
ICU patients

Widely used for sedated
patients

Interrater reliability
Intraclass correlation
coefficient = 0.95

p < 0.001
Compared to VDS and

VAS
p < 0.001
Compared to NRS and
VDS
p < 0.0054
Compared to VAS
p ≤ 0.002
Compared to NRS and
VAS
Criterion validity
p < 0.01
Compared to Checklist
of Nonverbal Pain
Indicators (adults)
and COMFORT
scale for children
Criterion validity
p < 0.001
Compared to NVPS
and BPS
Criterion validity
p < 0.005
Compared to FLACC
Construct validity
p < 0.0.001 when
used for measuring
pain in nonverbal
ICU patients

Interrater reliability

coefficient = 0.78

Verbal or
Nonverbal
Verbal

Verbal

Verbal
Verbal

Both

Both

Nonverbal

Nonverbal

Data from Chanques G, Viel E, Constantin JM et al: The measurement of pain in intensive care unit: comparison of 5 self-report intensity scales, Pain 151:711-721,
2010; Gloth FM, Cheve AA, Stober CV et al: The functional pain scale: reliability, validity, and responsiveness in an elderly population, J Am Med Dir Assoc 2:110114, 2001; Odhner M, Wegman D Freeland N et al: Assessing pain control in nonverbal critically ill adults, Dimens Crit Care Nurs 22:260-267, 2003; Cade CH:
Clinical tools for the assessment of pain in sedated critically ill adults, Br Assoc Crit Care Nurse 13:288-297, 2008; Gelinas C, Fillion L, Puntillo K et al: Validation
of the critical-care pain observation tool in adult patients, Am J Crit Care 15:420-427, 2006; Aissaoui Y, Zeggwagh AA, Zekraoui A et al: Validation of a behavioral
pain scale in critically ill, sedated, and mechanically ventilated patients, Anesth Analg 101:1470-1476, 2005; Voepel-Lewis T, Zanotti J, Dammeyer JA et al:
Reliability and validity of the face, legs, activity, cry, consolability behavioral tool in assessing acute pain in critically ill patients, Am J Crit Care 19:55-61, 2010.
ICU, Intensive care unit.


462

CHAPTER 21    Acute Pain Management

TABLE 21-7  Systemic Opioids
Indication
Mechanism of
action
General side effects

Medications:
Generic name
(trade name)

Moderate to severe postoperative pain; can also be used preoperatively
Blocks transmission of pain from the periphery to the cerebrum by interacting with opioid receptors
Can be administered orally, intravenously, intramuscularly, subcutaneously, and intrathecally
Decreased gastrointestinal motility, nausea, vomiting, and cramps
Mood changes and sedation
Pruritus (itching)
Urinary retention
Bradycardia, hypotension
Respiratory and cough depression
Pupillary constriction, blurred vision
Buprenorphine (Buprenex, Subutex)
Butorphanol (Stadol)
Codeine (Paveral)
Fentanyl (Actiq, Sublimaze, Duragesic)
Hydromorphone (Dilaudid, Hydrostat)
Levorphanol (Levo-Dromoran)
Meperidine (Demerol, Pethidine)
Methadone (Dolophine, Methadose)

Morphine (MS Contin, Kadian, Morphine sulfate)
Nalbuphine (Nubain)
Naloxone (Narcan)*
Oxycodone (Oxycontin, Roxicodone, Percocet [oxycodone with acetaminophen], Percodan [oxycodone with aspirin])
Oxymorphone (Numorphan)
Pentazocine (Talwin)
Propoxyphene (Darvon, Dolene, Doloxene, Novopropoxyn)
Remifentanil (Ultiva)
Sufentanil (Sufenta)
Tramadol (Ultram)

Data from Ciccone CD: Pharmacology in rehabilitation, ed 4, Philadelphia, 2007, FA Davis, pp 183-198; Opioid analgesics and antagonists. In Panus PC, Katzung
B, Jobst EE et al: Pharmacology for the physical therapist, New York, 2009, McGraw-Hill, pp 278-279; Analgesics, sedatives and hypnotics. In Woodrow R, Colbert
BJ, Smith D: Essentials of pharmacology for health occupations, ed 6, Clifton Park, NY, 2011, Delmar, pp 327-333.
*Opioid antagonist.

TABLE 21-8  Nonsteroidal Antiinflammatory Drugs (NSAIDs)
Indications

Mechanism of action

General side effects
Commonly prescribed
medications: Generic
name (trade name)

To decrease inflammation
Sole therapy for mild to moderate pain
Used in combination with opioids for moderate postoperative pain, especially when weaning from stronger
medications

Useful in children younger than 6 months of age
Contraindicated in patients undergoing anticoagulation therapy, with peptic ulcer disease, or with gastritis,
renal dysfunction, and NSAID-induced asthma
Accomplishes analgesia by inhibiting the enzyme cyclo-oxygenase (COX), which in turn stops the production
of prostaglandins, resulting in antiinflammatory effects (prostaglandin is a potent pain-producing chemical)
A useful alternative or adjunct to opioid therapy
Platelet dysfunction and gastritis, nausea, abdominal pain, anorexia, dizziness, and drowsiness
Severe reactions that include nephrotoxicity (dysuria, hematuria) and cholestatic hepatitis
Aspirin/acetylsalicylic acid (Bayer)
Celecoxib (Celebrex)
Choline salicylate (Arthopan)
Diclofenac (Cataflam, Voltaren)
Etodolac (Lodine)
Flurbiprofen (Ansaid)
Ibuprofen (Motrin, Advil)
Indomethacin (Indocin, Indocin SR, Indomethacin, Novomethacin, Nu-Indo)
Ketoprofen (Orudis)
Ketorolac (Toradol)
Naproxen (Anaprox, Naprosyn, Aleve)
Oxaprozin (Daypro)
Sulindac (Clinoril)
Tolmetin (Tolectin)

Data from Ciccone CD: Pharmacology in rehabilitation, ed 4, Philadelphia, 2007, FA Davis, pp 199-216; Frampton C, Quinlan J: Evidence for the use of non-steroidal
anti-inflammatory drugs for the acute pain in the post anaesthesia care unit, J Perioper Pract 19(12):418-423, 2009; Cox F: Basic principles of pain management:
assessment and intervention, Nurs Stand 25(1):36-39, 2010; Musculoskeletal and anti-inflammatory drugs. In Woodrow R, Colbert BJ, Smith D: Essentials of
pharmacology for health occupations, ed 6, Clifton Park, NY, 2011, Delmar, p 389; Drugs affecting the musculoskeletal system. In Panus PC, Katzung B, Jobst EE
et al: Pharmacology for the physical therapist, New York, 2009, McGraw-Hill, pp 522-523.

CHAPTER 21    Acute Pain Management



463

TABLE 21-9A  Local Anesthetics
Type

Indication

Description

Topical administration

Minor injuries; surgical procedures;
hypertonicity
Pain relief in subcutaneous structures such as
tendons and bursae

Direct application to skin, mucous membrane,
cornea, or other areas requiring anesthesia
Direct application to skin or other surfaces in
concentrations to allow penetration to deeper
tissues
Injection directly into selected tissue in order to
diffuse to sensory nerve endings
Injection close to nerve trunk to interrupt signal
transmission
Injection within the epidural or intrathecal spaces

Transdermal administration

Infiltration anesthesia

Suturing of skin lacerations

Peripheral nerve block

Minor surgical procedures; management for
chronic pain; specific nerve pain
Obstetric procedures; alternative anesthesia for
orthopedic procedures such as lumbar
surgery; acute or chronic pain management
Complex regional pain syndrome

Central nerve blockade

Sympathetic block
Intravenous regional
anesthesia (Bier block)

Short surgical procedures

Selective interruption of sympathetic efferent
pathways
Injection into a peripheral distal limb vein with a
proximally placed tourniquet to isolate limb
circulation

Adapted from Local anesthetics. In Panus PC, Katzung B, Jobst EE et al: Pharmacology for the physical therapist, New York, 2009, McGraw-Hill, pp 218-225.

TABLE 21-9B  Local Anesthetics
Mechanism of
action
General side
effects
Medications:
Generic
(trade
name)

Blocks action potential propagation, thereby
preventing transmission of sensation from
the periphery to the central nervous system
Somnolence, confusion, agitation, restlessness
Hypotension, bradycardia, fatigue, dizziness
Articaine (Septocaine)
Benzocaine (Americaine)
Bupivacaine (Marcaine, Sensorcaine)
Butamben picrate (Butesin Picrate)
Chloroprocaine (Nesacaine)
Dibucaine (Nupercainal)
Dyclonine (Dyclone)
Levobupivacaine (Chirocaine)
Lidocaine (Xylocaine)
Mepivacaine (Carbocaine)
Pramoxine (Tronothane)
Prilocaine (Citanest)
Procaine (Novocain)

Proparacaine (Alcain)
Ropivacaine (Naropin)
Tetracaine (Pontocaine)

Data from Local anesthetics. In Panus PC, Katzung B, Jobst EE et al: Pharmacology for the physical therapist, New York, 2009, McGraw-Hill, pp 218-225;
Ciccone CD: Pharmacology in rehabilitation, ed 4, Philadelphia, 2007, FA
Davis, pp 149-160.

Physical Therapy Considerations for Pain Management
• The physical therapist should be aware of the patient’s pain
medication schedule and the duration of the effectiveness of
different pain medications when scheduling treatment sessions, particularly if premedication is necessary to optimize
intervention.

• Patients should be educated on the need to request pain
medicine or push their PCA button when they need it, particularly when they are on an “as needed” (PRN) pain medication schedule.25
• Patients should be asked about the specific type of pain that
the medication is intended for, such as postsurgical incisional
pain. Pain medications, such as opioids, may mask the occurrence of a new type of pain, such as angina.25
• The physical therapist should also use a pillow, blanket, or
his or her hands to splint or support a painful area, such as
an abdominal or thoracic incision or rib fractures, when the
patient coughs or performs functional mobility tasks, such
as going from a sidelying position to sitting at the edge of
the bed.26
• The physical therapist can also use a corset, binder, or brace
to support a painful area during intervention sessions that
focus on functional mobility.
• Patients may experience pain induced by exercise or mobilization (PIEM), which can be perceived by patients as a
decreased quality of life and result in fears about participation in physical therapy and refusal of care. Enhanced communication among care providers and with the patient about

expected pain responses during therapy may lessen the
adverse results of PIEM.27

  CLINICAL TIP
Patients, particularly those who are postsurgical, are often prescribed more than one type of pain medication in order to
achieve “breakthrough” pain levels. In other words, they require
additional medicine to break their pain.


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CHAPTER 21    Acute Pain Management

TABLE 21-10  Patient-Controlled Analgesia
Indications

Side effects
Medications

For patients with moderate to severe acute pain who are not cognitively impaired and are capable of
properly using the pump
Preoperative education of the patient on the use of patient-controlled analgesia
Ensuring that only the patient doses himself or herself
Dosage, dosage intervals, maximum dosage per set time, and background (basal) infusion rate can be
programmed
Pump apparatus, tubing and power lines could limit mobility
Similar to those of opioids (see Table 21-7)
Morphine, meperidine, fentanyl, and hydromorphone

Types

Description

Intravenous patient-controlled
analgesia (IV PCA)
Patient-controlled epidural
analgesia (PCEA)

An intravenous line to a peripheral vein is connected to a microprocessor pump, and a patient is
provided a button to allow self-dosing.
The tip of a small catheter is placed in either the epidural or the subarachnoid space and connected to
a pump.
For short-term use, the catheter exits through the back to connect to a pump.
For long-term use, the catheter is tunneled through the subcutaneous tissue and exits through the
front for patient control.
The catheter tip is inserted directly into a specific anatomic site such as a wound (incisional PCRA),
near a peripheral nerve (perineural PCRA), or into a peripheral joint (intra-articular [IA] PCRA).
The other end of the catheter is attached to a pump with a button for patient control.
Ropivacaine and bupivacaine are also used in PCRA.
Intranasal opioids are delivered using a syringe, nasal spray or dropper, or nebulized inhaler either in
dry powder or water or saline solution. A pump mechanism is adapted to provide PCINA.
A needle-free, self-contained fentanyl delivery system that does not require venous access for
administration.
System adheres to outer arm or chest with an adhesive backing and, via iontophoresis, delivers fentanyl
across intact skin.
Patient has on-demand dosing up to 6 doses/hour.

Considerations

Patient-controlled regional

analgesia (PCRA)

Patient-controlled intranasal
analgesia (PCINA)
Fentanyl iontophoretic
transdermal system (ITS)

Data from Ciccone CD: Pharmacology in rehabilitation, ed 4, Philadelphia, 2007, FA Davis, pp 237-249; Viscusi E: Patient-controlled drug delivery for acute postoperative pain management: a review of current and emerging technologies, Region Anesth Pain Med 33(2):146-158, 2008; Chumbley G, Mountford L: Patientcontrolled analgesia infusion pumps for adults, Nurs Stand 25(8):35-40, 2010.

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CHAPTER 21    Acute Pain Management

465

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