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  1. We have all experienced the discomfort of muscle pain. As nurses, we often overuse our musculoskeletal system during the workday and experience the consequences later. Intense pain can occur from simply sitting, standing or sleeping in the wrong position. Fortunately, most muscle aches and pains are usually relieved after a few days of rest and good self-care. But, some are not as lucky. Muscle pain can become chronic (myofascial pain syndrome) and significantly impact a person’s function and quality of life. In these cases, trigger point injections (TPIs) may be used to help ease pain in muscles and surrounding tissue. What Are Trigger Points? Trigger points are focused areas of spasm and inflammation in skeletal muscle. You can often feel a knot in the muscle where the trigger point is located. The primary site and surrounding area is usually tender with pain that radiates when pushed. The upper back and behind the shoulder areas are common sites and can cause headaches and neck and shoulder pain. However, trigger points can be found throughout the musculoskeletal system. What Are Trigger Point Injections? TPIs are injections of medication given directly in the painful trigger point for pain management. The medication makes the trigger point inactive and relieves the spasming muscle. It is an outpatient procedure and performed by a doctor, usually in their office or clinic. Medications Used for TPIs Include Local anesthetics Used alone, mixed with other anesthetics or with corticosteroids Xylocaine (Lidocaine), bupivacaine (Marcaine) Corticosteroids- dexamethasone Used alone or mixed with an anesthetic Botox (botulinum toxin A) Interferes with nerve signals and prevents muscle contraction What Conditions Are Typically Treated With TPIs? TPIs are used to help relieve pain in conditions that affect our musculoskeletal and nervous systems. Myofascial pain syndrome TPIs may help relieve symptoms of myofascial pain syndrome, a chronic pain syndrome affecting muscles and their surrounding tissue (referred pain). Myofascial pain syndrome may be caused by: Muscle trauma or injury Repetitive motions Poor Posture Psychological stress Fibromyalgia Fibromyalgia is a chronic condition that has some of the same symptoms as arthritis, but affects our soft tissue instead of our joints. Headaches Trigger points in the shoulder, neck and head can contribute to tension headaches and migraines. Endometriosis A small study, published in PM&R, found TPIs may help with pelvic floor pain that is common with endometriosis. However, the authors recommend further research before firm conclusions can be drawn. A Word About Dry Needling Dry needling for easing muscle pain is gaining in popularity. The procedure uses filiform needles and is referred to as “dry” because it does not inject any medications into the body. The needles are inserted into the knot, or affected area, to relieve muscle pains or spasms. What Are The Side Effects? Some people experience pain and/or tenderness at the injection site that typically resolves after a few hours. Other side effects include: Lightheadedness, dizziness Discoloration or dimpling of skin around the injection site Bleeding at the injection site (rare) What Are The Risks? TPIs rarely cause serious complications, however, in rare cases they may lead to: Infection at the injection site Bruising Muscle or nerve damage Pneumothorax Needle breakage Who Should Not Have TPIs? TPIs should not be administered in the following circumstances: Presence of systemic or local infection In pregnant patients Person who feels or appears ill Precautions should be taken when administering TPIs in people with: Bleeding disorders or anticoagulation therapies Debility Diabetes Current steroid medications Do They Work? In people with chronic muscle pain, TPIs may provide immediate pain relief and improved range of motion. However, everyone does not respond to the injections the same way. Researchers have found that some people do not benefit at all. What do you think? Do TPIs have a place in pain management? Additional Resources A New Look at Trigger Point Injections Trigger Point Injections Everything You Need to Know About Trigger Point Injections
  2. We Are In So Much Pain According to the CDC, the prevalence of chronic pain in the U.S. ranges from 11%-40%.1 In 2016, an estimated 20.4% (50 million) adults had chronic pain and 8% (19.6 million) had high-impact chronic pain. Chronic pain is defined as pain on most days or every day in the past 6 months. High-impact chronic pain is persistent pain with substantial restriction of life activities lasting 6 months or more.2 These are sobering statistics, but even more disturbing is that both types of pain are more prevalent among adults living in poverty, adults with less than a high school education, adults with public health insurance, women and rural residents.1 We are taught in nursing school to set aside prejudice and bias and meet the patient where they are. When it comes to pain management, however, it appears we aren’t following this directive. Chronic pain is one of the most common reasons adults seek medical care. It is linked to restrictions in mobility and daily activities, dependence on opioids, anxiety, depression, poor perceived health, and reduced quality of life. One of the many goals of Healthy People 2020 is to decrease the prevalence of adults having high-impact chronic pain. Chronic pain contributes to an estimated $560 billion each year in direct medical costs, lost productivity and disability programs.1 Pain is a problem that just won’t go away. A History of Pain Pain has been our teacher from the beginning, directing us to avoid harm; fire, poison, sharp objects. It is a signal for body injury and disease. It is a constant for humanity. The question for healthcare workers is, how much is too much? Pain is the oldest medical problem, but it isn’t well understood. Pain was treated by opium in the 1600s, Chloroform and ether were used in the 1800s for anesthesia. Up until the 1900s, when morphine and heroin were used as pain medication, pain was an acute care issue – related to injury, surgery or death from cancer. When patients complained of pain they were told “it’s all in your head” and were referred to psychiatrists and neurosurgeons.3 In the 1980s, there was an increased push to use opioids for long-term, non-cancer pain. Drug companies began a 20-year campaign to convince physicians to prescribe opioids more freely. According to Marcia Meldrum, a researcher at the University of California, “We are in this culture now where too many people see drugs as the answer not only to pain, but to improving their lives.”3 In 2001 the Joint Commission published new pain management standards, billing pain as the fifth vital sign. They added pain to HCAHPS patient satisfaction surveys, tying pain management to reimbursement. I came up as a nurse during this time, and it’s hard for me to wrap my brain around it now, the idea that some amount of pain is okay. We were taught to ask every patient about their pain. It was drilled into me as a student that any amount of pain was considered abnormal; outside of normal limits. We pursued the pain target on our patient’s walls, the center being the elusive “0”. It never occurred to me that I was giving my patients the idea that their pain score should be zero, all the time. The goal of better pain management is a great idea; however, the end result for the JC's pain initiative was not. Some experts believe that focusing patient attention on pain has led to an increased perception that pain is undertreated.4 Physicians for Responsible Opioid Prescribing (PROP) have lobbied the JC to stop calling pain a vital sign and to remove it from patient satisfaction surveys. They believe that pain is not a vital sign, since it can’t be measured objectively. PROP states, “aggressive management of pain should not be equated with quality healthcare as it can result in unhelpful and unsafe treatment.” The JC has responded that the requirements to assess patients for pain do not require the use of drugs to manage the patient’s pain.4 Dry Needling – A Drug Alternative I had chronic pain for over 10 years. It was in my right hip. On a daily basis, I had a deep, cramping pain where my sciatic nerve passed through my hip on its way from my spine to my leg. I leaned on desk corners and tennis balls, I stretched, I exercised, I took handfuls of ibuprofen, but it only let up briefly. At times it interfered with my sleep. It was always in the back of my mind, ceaselessly throbbing. It never occurred to me to seek help for this pain. It was just part of my story, part of who I was. I assumed the pain was my fault – I ran too far, played too hard, did too much. My refusal to stop was causing my pain. Now, that pain is a distant memory thanks to physical therapy. I married a PT who ended up becoming certified in dry needling. It took me a while to trust him enough to let him stick a 5-inch needle into my gluteus maximus, but I’m very glad I did. I hope you’ll join me for part 2 to learn more about dry needling and how it can be used to treat chronic pain (…and you don’t have to marry a PT). REFERENCES Centers for Disease Control and Prevention - Prevalence of Chronic Pain and High-Impact Chronic Pain Among Adults-United States, 2016 American Pain Society - United States National Pain Strategy for Population Research: Concepts, Definitions, and Pilot Data National Center for Biotechnology Information, U.S. National Library of Medicine - A Short History of Pain Management MedPage Today - Opioid Crisis: Scrap Pain as the 5thVital Sign?
  3. Elvish

    A letter to K.

    Dear K, I will not lie. When the powers that be told me you, a patient taking methadone for heroin addiction, were being assigned to me postpartum, I wasn't happy. "Oh, great," I thought. "A druggie." I was wrong, and I'm sorry. You shattered every perception I had, and I'm grateful for that. I thought I was going to be getting a whiny, self-absorbed, annoying, demanding patient. What I got was a sweet young lady who'd had a hard life. I saw someone who would make different choices if she had things to do over again. I saw someone who maybe didn't have all the tools in her proverbial tool box that I have. I saw someone who realized her mistakes and was trying to right them. I saw someone who didn't want to be separated from her baby, which is more than I can say for a lot of my patients. I saw someone who was really trying to do the right thing and realizing that sometimes the right thing is very hard. You and I had an eventful night. For starters, you fell. When you later asked for pain medication for your back, I gave you two Percocets. That didn't work; no surprise for either one of us. I called your doc and she was not willing to give you anything else because "she's already had enough." Forget that your opiate receptors were just a little occupied already. Maybe if she had seen the tears in your eyes she would have sung a different tune. Maybe if she'd tried to massage your pain away, or made you a heating pad, or just sat with you for a few minutes holding your hand, she'd have been moved to practice better pain control. But to her, you were "a heroin addict." And I'm so sorry. I believed you, and I wish she had too. You and your family were a complete joy to meet and care for. I am glad that you felt comfortable enough with me to ask honest questions about your baby. I'm glad that we were able to talk openly about circumcision, vaccines, the baby's methadone withdrawal process, and your own past. Thank you for trusting me with such precious information, and thank you for trusting me to tell you the truth. No, when I looked at you I did not see a heroin addict. I saw the human being that you are. Thank you for being willing to let me see her. You changed me. I became a nurse to help others; but you helped me and cared for me. Thank you, from the bottom of my heart.
  4. Approximately 1 in 4 persons have used some form of complementary and alternative medicine / therapy. Hospitals, physicians and nurses are finding ways to incorporate alternative options in health care to their patients. In keeping with current trends and a holistic approach in healthcare, there is a need for nurses to keep up with these modalities, one being massage and bodywork. Bringing massage back into the profession of nursing not only can benefit the patient but the hospital, physician and the nurse as well. Massage Therapists in general provide the application of various techniques to the muscular structure and soft tissues of the human body. They consist of massage, joint mobilizations and stretching. With so many modalities to choose from in massage, all have a place in patient care. For relaxation and stress reduction a good choice would be to utilize a form of Swedish massage. Pain reduction in musculature after or before physical therapy may need some deep tissue or a sports massage. As an example, patients who are unable to obtain a massage due to their diagnosis may be relaxed with a simple hand massage and some active listening while getting their chemotherapy. A registered nurse with a background in massage therapy can be a valuable resource person to provide comfort in a very overwhelming, scary environment of monitors, I.V.'s and medical procedures. Nurse Massage Therapists can offer more in the way of education in addition to massage and bodywork. With their background in the disease process, psychosocial issues, nutrition, medications and anatomy, nurse massage therapists can assess, develop, implement and evaluate a treatment plan for each patient. Teaching comes with the job of being a nurse and discussing prevention, nutrition and lifestyle changes for better health remains within our scope of practice while doing massage and bodywork. According to the National Association for Nurse Massage Therapists, the requirement is to be a licensed registered nurse (R.N.) who has completed 500 hours of post graduate education and training in massage therapy and bodywork. Most states recognize massage as within the scope of practice of physicians, physical therapists and nurses therefore leaving them exempt from the massage licensing act providing they have the 500 hour required education in massage therapy. The working environment for a nurse massage therapist can be numerous with new opportunities opening everyday. Listed below are just a few examples of areas a nurse may work with massage skills added to her scope of practice: Hospice Massage Nurse Physicians Office Prenatal/ Postpartum Care Infant/ Pediatric Massage Therapy Hospital Based Massage Practice Labor Doula Chiropractors Office Medical Spa Solo Practitioner The list provides a diverse inter-relationship with other medical fields and can provide physicians with an opportunity for a more "hands on" practice for their patients. In a hospital based setting the nurse massage therapist can implement massage into his/her care of the patient's treatment in any setting from the physical therapy department to oncology and to it can be formatted to any age group. By employing qualities of active listening, experience as a nurse, wider knowledge base and the comforts of therapeutic touch it benefits the hospital by providing continuity of care and making their patients feel special or pampered. It takes away some of the clinical feeling of the hospital setting and makes it more spa-like, warm and welcoming. This makes our patients a satisfied customer and they return for their wellness needs. Salary varies with place of employment but a hospital based nurse massage therapist would expect to get a minimum of $60,000/ year. Benefits that may be options to the therapists are dental, health insurance, paid vacation, sick time and retirement benefits. Some hospitals even have tuition reimbursement benefits providing it may be used at their place of employment and you may have to guarantee working there a minimum of one year after you have graduated or received your certificate. The benefits obtained from a patient whose heart you have touched with a massage outweigh any benefit that can be written. It truly is an act of kindness and fulfills the basic need of touch in everyone. To know you can change someone's outlook on their life or help change their prognosis with something as simple as touch from a hand massage or back massage is very rewarding. The benefits to the patient are phenomenal. Enhanced immune system, relaxation to decrease muscle tension and their perception of pain being decreased are just a small example of things massage can help with. Did you know a 20 minute hand and foot massage decreases a patients pain by 20 % after surgery? This decreases the need for high doses of pain meds because the massage increases the output of endorphins in our body which are neurotransmitters that act like morphine, reducing the pain and producing a euphoric feeling. The drawbacks are very few in this profession. It is a good exercise for the person giving the massage, provides a time for meditation and is almost like doing a dance or comparable to tai chi exercises. The hours can be hard as nurses work eight hour shifts and also are required to work the holidays. You must be in good physical health which enables you not only to provide good massage techniques but makes you a good role model to your patients as well. The different areas of nursing provide many opportunities for use of several different massage modalities so continuing education is a must and this can be costly. Some of the continuing education seminars require out of town travel and can run upwards of $500.00 for a 4 day seminar not including airfare and hotel stay. The requirement is 48 continuing education hours every 4 years. To bring massage back into the nursing profession provides benefits to everyone involved. As a Nurse Massage Therapist it expands our career choices, complements our profession by following trends in therapy and allows us to become closer to our patients. It benefits the hospital by expanding their therapies and offering the community complimentary and alternative medicine. It benefits the patients with an alternative choice in medical treatment and makes them feel special by nurturing their need for touch. Physicians are less likely to prescribe costly medications with many side effects to a patient if alternative therapy were available. Best of all it benefits the nurse with the reward of knowing you made someone's life better because you decreased their pain and stress with just what nurses are known for a little "TLC", Tender, Loving , Care. Author : Denise , R.N., B.S., C.C.E., NCBTMB massageRN Copyright 2007 Bibliography Goley R.N., B.S.N., April, "APN's Need to Learn More about Complementary and Alternative Medicine," Advanced Practice Nursing eJournal, 2004, accessed 9/4/05. Huebscher Roxana, PhD. and Pamela Schuler. Natural, Alternative and Complementary Health Care Practices, Mosby, Inc., St Louis, Missouri, 2004. McIntyre R.N., MAS, NCTMB, Elizabeth, "State Regulations Vary For Massage Therapists", Nursing Spectrum, Dec., 2003. Massage Licensing Act of Illinois and Rules of Practice, printed by American Massage Therapy Association, Illinois Chapter. March 2005. National Association of Nurse Massage Therapists, Http//: www.nanmt.org. Accessed 9/4/05.
  5. squeakykitty

    The language of pain

    I felt shame over this for years because even my own family had the attitude of "Don't bother me with your pain", "Don't embarrass me by expressing it/what will people think" type of stoicism. Then I went through CNA training and the first half of LVN school, and read what the textbooks had to say about pain. The first thing I learned was that different people and cultures have different attitudes about pain and express it differently. Even within the same culture, people will express their pain differently. The second thing I learned was people should not be judged on how they express their pain, and that people with chronic pain can look and act normal, and have normal vital signs. The shame I had lifted, when I realized there was nothing wrong with expressing my pain, but I was angered and disgusted at the judgmental attitudes of the people I have known. A year before the CNA class, I woke up to abdominal pain that gradually grew worse as the day progressed. I went to the doctor to have it checked out, just in case it was appendicitis. It turned out to be a ruptured ovarian cyst. The pain was high, about an 8 on the 10 scale. No one at the doctor's office had me rate the pain on the pain scale, and the doctor told me to take ibuprofen for the pain, instead of writing a prescription for a painkiller. The ibuprofen didn't even touch the pain. I didn't call back and tell them that because, at the time I was uninformed and thought that ibuprofen was all that they would recommend and all I would get, and they wouldn't prescribe anything stronger. I did know about codeine, since my dentist prescribed it after I had impacted wisdom teeth removed. It really helped the pain. When I took pharmacology, I learned about other types of painkillers, and wondered why didn't the doctor try something else, even if it was Toradol? Why didn't I just call back and tell them the ibuprofen is not helping? Would they have told me "That's all we can suggest? Would they have thought of me as a drug seeker? It kind of makes me wonder what would happen if I had a bone fracture. (Maybe I need to read my chart) I took care of a resident with dementia when I was a CNA and this resident would swear during care. A few months before I got the job, I had clinicals in the same facility and had the same resident assigned to me, and this resident wasn't swearing then and I wondered why. I would hear other coworkers telling this resident "You shouldn't swear" and I think they were thinking it was a behavioral thing. One day I was giving this resident a shower and heard swear words when I touched a knee, so I asked "Is your knee hurting?". The resident said yes and I told the nurse. After that, the resident didn't swear so much because the pain was finally adequately treated. I don't know how long this person had to live with the pain, because the staff thought it was a behavioral issue. I have heard of doctors being reluctant to give narcotics for terminal cancer pain. I never understood that, since if someone has terminal cancer, is in a lot of pain, and is going to die anyway, then becoming addicted would be the least of their problems. Or people with chronic pain are under medicated for this reason and their quality of life deteriorates. Also, people with dementia are under medicated because their pain isn't recognized. I've even heard of a few nurses reluctant to give legitimately prescribed narcotics, either trying to avoid giving them altogether, or making people wait for their pain medication, and this is wrong because people needlessly suffer. In a sense, we are all drug seekers and clock watchers. After my impacted wisdom teeth were pulled, I was prescribed codeine with Tylenol, one tablet every 4 hours. During the night my jaw would hurt; and when I looked at the time, it would be 4 hours after the last dose. I didn't need to watch the clock, the 7/10 pain in my jaw did it for me. When we have a cold we go down to the store for OTC meds. We look at the directions for how often to take them and we look at the clock to see when the next dose can be taken. I do believe that pain should be managed adequately for everyone, and no one in legitimate pain should be judged for how they cope with it or how they express it. I have never been in chronic pain-----yet. It could happen though, to any one of us at any time.

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