©2011, Shelene Giles. All rights reserved. No part of this publication may be reproduced, stored in a retrieval system, or transmitted, in any form or by any means, electronic, mechanical, photocopying, recording, or otherwise, without prior written permission from the publisher.
Section 6
Chronic Pain
WORKBOOK
Nurse Life Care Planning - Through the Ages
©2011, Shelene Giles. All rights reserved. No part of this publication may be reproduced, stored in a retrieval system, or transmitted, in any form or by any means, electronic, mechanical, photocopying, recording, or otherwise, without prior written permission from the publisher.
Nurse Life Care Planning - Through the Ages Section 6 - Chronic Pain
OBJECTIVE 1: Explain the classifications of chronic pain. Identify levels of impairment based on severity of chronic
pain.
OBJECTIVE 2: Describe complications related to chronic pain. Identify long term treatment and outcomes of chronic
pain.
OBJECTIVE 3: Apply and demonstrate the nursing process as a life care planning foundation for a chronic pain client.
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Agenda
Overview
Nurse Life Care Planning
Case Study
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Overview
Incidence
3rd
largest health problem in US
80% of patients seek medical care due to pain
Pain is #1 reason for unscheduled hospital admissions
40 million visits per year to physicians for “new” pain
86 million Americans affected by chronic pain to some degree
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65 million Americans suffer from painful disabilities each year
40% of acute care patients reported poor pain control
50% of dying patients reported moderate to severe pain
Pain is an unpleasant sensory and emotional experience associated with actual or potential tissue damage or described in
terms of such damage - as defined by International Association for the Study of Pain
Pain is difficult to study because of its subjectivity with variability among individuals – even within individuals across
time and situations
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Gender
Pain affects men and women differently
Estrogen and testosterone play a role in how men and women receive pain signals
Women recover more quickly, seek help more quickly, and are less likely to allow pain to control their lives
Women more likely use a variety of resource coping skills, support, and distraction when dealing with pain
Pain medications react differently in men and women
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Age
41% of adults with back pain are between 18 - 44 years old
Pain is number one complaint of older Americans
American Geriatrics Society issued guidelines for pain management in older people - Journal of American Geriatrics
Society (Vol. 46, 1998, pg 635-651)
Children unable to describe degree of pain
Special tools for measuring pain in children
Non-steroidal agents most often prescribed for pain management in younger children
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Etiology (HANDOUT - Ethics, Law, and Pain Management as a Patient Right)
Unclear etiology for chronic pain
During injury/illness, certain nerves send pain signals to brain
Pain signals continue for weeks/months/years after recovery of injury/illness
Dysfunction of certain brain chemicals that usually suppress pain
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Pathophysiology
Origin of stimulus
Nociceptors – naked nerve endings found at ends of small unmyelinated and light myelinated afferent neurons
Unimodal nociceptors are mechanosensitive only – found in skin/mucous membranes/some wall linings of body
cavities
Polymodal nociceptors are mechanosensitive, thermosensitive, and chemosensitive – more common in skin and
deep tissue
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Stimulus transmission
Stimulation of nociceptors produces impulses transmitted through Ad-fibers and C-fibers to spinal cord where
they form synapses with neurons
Myelinated Ad-fibers transmit rapidly and are responsible for initial pain response
Unmyelinated C-fibers produce slower response and felt several seconds after injury
Acute pain noted in neospinothalamic tract
Dull/burning pain noted in paleospinothalamic tract
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Termination of stimulus
Neospinothalamic tract transmits info to midbrain/postcentral gyrus/cortex
Paleospinothalamic tract transmits info to reticular formation/pons/limbic system/midbrain
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Classification
Neurogenic/neuropathic pain - peripheral nerves or central nervous system damaged - nerves themselves cause pain
and does not respond well to treatment, numbness/tingling/electrical shock
Nociceptive pain – caused by activation of nociceptors, specific to body part and function
Somatic pain - well localized, sharp/aching/throbbing, occurs in muscle/bone/deep tissue
Visceral pain - poorly localized, cramping/pressure, occurs in internal organs, deferred pain
Psychogenic pain - caused by emotional or mental health issue, not caused by disease/injury/damage to nervous
system, psychogenic pain not common - but stress/depression/mental health factors worsen pain
Unidentifiable pain - cause of pain unknown, diagnostic studies do not reveal injury/illness/damage
Central pain - pain associated with disease of central nervous system (brain and spinal cord)
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Types of pain
Acute pain
Results from disease, inflammation, or injury to tissues
Sudden onset
Accompanied by anxiety or emotional distress
Usually diagnosed and treated - short term
Pain is self limiting - confined to given period of time and severity
Often associated with autonomic symptoms – tachycardia, sweating, hypertension, vasoconstriction
Can become chronic pain
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Chronic pain
Widely believed to represent disease itself
Worsened by environmental and psychological factors
Persists over longer period of time
Resistant to most medical treatment
Usually not associated with autonomic symptoms
Can cause severe problems
Pain management is integral part of treating chronic pain
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Chronic Pain Syndrome
Likelihood of developing Chronic Pain Syndrome (CPS) is unrelated to pain intensity
Psychological variables (depression & somatic focus) and self-perceived disability consistently found to be most
accurate predictors of subsequent pain syndrome development
Defined by psychosocial dysfunction
Symptoms usually develop slowly over course of months/years
More symptoms present - more severe CPS
(HANDOUT - Kinesiophobia Among Patients with Musculoskeletal Pain in Primary Healthcare)
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Pain Cycle
Pain
Disability
Distress
Experience of pain includes emotional reaction and is influenced by many factors - prior experiences with pain, meaning
given to pain, emotional stresses, and family/cultural influences
Pain is subjective phenomenon and clinicians cannot reliably detect its existence or quantify its severity without asking
patient directly
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Symptoms
Pain that does not go away as expected
Described as shooting, burning, aching, pounding, or electrical
Associated discomfort, soreness, tightness, stiffness, or weakness
Fatigue, impatience, loss of motivation, sleeplessness
Weakened immune system - leading to frequent infection/illness
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Mood changes - hopelessness, fear, irritability, anxiety, stress
Depression - worsens pain, vicious cycle
Disability from school, work, or activities of daily living
Pain behaviors vary from individual to individual
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10 indicators of pain – developed by University of Alabama (UAB) to assist healthcare professionals when observing
pain
1. Verbal vocal complaints
2. Nonverbal vocal complaints
3. Down time – time spent lying down each day between 8am and 8pm because of pain
4. Facial grimaces
5. Standing posture – stooped, favoring one side of body
6. Mobility – limping, slow pace
7. Body language – clutching or rubbing site of pain
8. Use of visible supportive equipment – braces, crutches, cane
9. Stationary movement – squirming, restlessness
10. Use of medication
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Care
Assessment (HANDOUT - Chronic Pain Assessment and Validation) (HANDOUT – Assessment Tools)
Detailed medical history
Comprehensive assessment - medical, psychological, psychosocial
Pain diary
Physical exam - musculoskeletal system, nervous system, cognitive
Mental health assessment - rule out psychological diagnosis which can contribute to chronic pain
Diagnostic studies - x-rays, MRI, CT scan, ultrasound, myelogram, discogram, EMG/NCV studies, angiogram,
vascular studies, bone scan
Lab work
Diagnostic procedures - nerve blocks/injection, identify nerve causing pain
Referral to specialist (pain management, physiatrist, neurologist, anesthesiologist)
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Co-morbidities
Pre-existing health problems
Overall general health condition
Lifestyle choices
Smoking
Addictions
Psychiatric illness/psychological diagnosis
Psychological stress
Aging
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Diagnoses
Arachnoiditis
1 of 3 membranes covering brain/spinal cord (arachnoid membrane) becomes inflamed
Produce disabling, chronic, progressive pain
Arthritis
Osteoarthritis
Rheumatoid arthritis
Ankylosing spondylitis
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Sciatica
Pressure on sciatic nerve
Pain in buttocks
Common cause is herniated disc
Spondylolisthesis
Vertebra extends over another vertebra
Causes pressure on nerves
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Spinal stenosis
Narrowing of canal surrounding spinal cord
Occurs naturally with aging
Causes weakness and pain in legs
Relieved by sitting down
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Radiculopathy (HANDOUT - Evaluation and Management of Low Back Pain)
Damage to spinal nerve roots
Causes pressure on nerves
Headaches
Migraines
Cluster headaches
Tension headaches
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Head and facial pain
Temporomandibular joint syndrome - TMJ
Cranial neuralgia
Trigeminal neuralgia
Myofascial pain syndrome - injury/trauma or overuse of muscles
Trigger points
Fibromyalgia
Polymyositis/dermatomyositis
Spasticity
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Neuropathic pain
Injury to nerves - peripheral or central nervous system
Can occur in any part of body
Described as hot, burning, pins/needles, numbness, electricity
Common diagnoses
Diabetic neuropathy
Phantom limb pain
Post-herpetic neuralgia
Complex regional pain syndrome (CRPS) - injury or noxious stimuli to nerve fibers in extremity - mainly
median/sciatic/ tibial/ulnar, develops after injury/surgery (onset immediately or delayed for months), symptoms -
burning pain, allodynia (pain due to stimulus that does not normally provoke pain), edema, changes in blood
flow/skin temperature - colder/color - shiny, hair loss, muscle atrophy, excessive perspiration, hyperalgesia
(increased response to pain), hypersensitive to temperature/touch; guarding, pain not proportional to injury/surgery;
symptoms can travel to other extremities
CRPS I - formerly reflex sympathetic dystrophy, not limited to single peripheral nerve, nerve study would rule
out CRPS I
CRPS II - formerly causalgia, damaged peripheral nerve, nerve study would confirm CRPS II
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(HANDOUT - Evidence Based Guidelines for Complex Regional Pain Syndrome Type I)
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Other
Vascular - inflammation of blood vessels, interruption between blood vessels and nerves
Ischemia - lack of blood supply to organs/tissues/limbs
Circulatory problems
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CPS Cycle
more PAIN
INACTIVITY
WEAKNESS
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Treatment (HANDOUT - Assessment and Management of Chronic Pain) (HANDOUT - MAMC Chronic Pain
Outpatient Management Guideline)
Studies show the presence of CPS strongly suggests that medical interventions (including surgery) will not be effective -
accurately distinguishing between chronic pain and CPS is critical for effective treatment
Pain management is complex biological, psychological, social, spiritual, and cultural process
Most successful treatment plans incorporate psychological, physical, and pharmacological (non-invasive and invasive)
components provided by interdisciplinary team
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Combination therapy is more effective than single therapy for long term pain management
Early treatment of pain syndromes improve outcomes
Primary goals are to reduce/remove pain to greatest extent possible
Improve functioning to greatest extent possible
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(HANDOUT – Diagnosis and Treatment of Depressive Illness in Chronic Pain Patients: Effects on Functional
Restoration)
Psychological Examples of traditional psychological approaches
Education
Psychotherapy - cognitive behavioral therapy
Relaxation training
Biofeedback
Support group
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Physical
Examples of traditional physical approaches
Facility
Physical therapy
Occupational therapy - ultrasound, iontophoresis, conditioning, strengthening, flexibility, mobility
Home modalities
Transcutaneous electrical nerve stimulation (TENS) unit - lead attached to skin patch, brief pulses of electricity to nerve
endings in skin to relieve pain, alters pain signals that travel to brain
Ultrasound
Heat/cold
Home exercise program
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Alternative - compliments traditional treatment for psychological and physical approaches
Biofeedback - method of consciously controlling a body function that is normally regulated automatically by body
(example - skin temperature)
Relaxation therapy/guided imagery - series of thoughts/suggestions that directs person's imagination toward
relaxed/focused state
Exercise - walking, yoga
Chiropractic therapy
Acupuncture
Acupressure/reflexology
Healing touch - influences person's physical or emotional health without physically touching person
Meditation/distraction
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Homeopathic medicine - belief that body has ability to heal itself
Aromatherapy - essential oils
Hydrotherapy/aquatic therapy
Hypnosis
Humor therapy
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Music therapy
Magnet field therapy
Massage therapy
Naturopathy - organize foods, exercise, healthy/balanced lifestyle to prevent disease and treat illness
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Pharmacological/Non-invasive (HANDOUT – Pharmacological and Nonpharmacological Pain Management)
(HANDOUT - Palliative Care & Pain Management, Table 5-3 & Table 5-4)
Over-the-counter medication
Analgesic - Acetaminophen
Non steroidal anti-inflammatory (NSAID) - Aspirin, Ibuprofen, Naproxen, , used for cold/sinus/allergies
Topical and transdermal - Capsaicin, Biofreeze, creams/gels
Prescription medications (HANDOUT – Chronic Pain Medications: Current Trends for Life Care Planners)
Four major classes of prescription medications to treat chronic pain - 1) non-opioid, 2) opioid, 3) adjuvant analgesics -
medications originally used to treat other conditions and have cross-over relief from chronic pain (example - anti-
depressant, anti-convulsants), and 4) other - medications with no direct pain-relieving properties, but prescribed in pain
management regimen (example - insomnia, anxiety, depression, and muscle spasms)
Non-opioids
Analgesic - Acetaminophen, Aspirin
Non steroidal anti-inflammatory (NSAID)/COX-2 inhibitor - Relafen, Toradol, Voltaren, Indocin, Feldene,
Daypro
(HANDOUT – The Marginalization of Chronic Pain Patients on Chronic Opioid Therapy) (HANDOUT - Use of
Chronic Opioid Therapy in Chronic Noncancer Pain)
Opioids
Long-acting/sustained or extended release – Morphine, Oxycodone, Fentanyl
Sedative/tranquilizer - Ambien, Lunesta, Rozerem
Topical and transdermal - EMLA cream, Lidocaine patch, Duragesic patch, creams/gels with compound
medications
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Adjuvants/Other - does not directly provide analgesia, used more extensively in chronic pain than acute pain
Anti-depressants
Tricyclic anti-depressants – Elavil, Sinequan, Remeron, Pamelor
Selective Serotonin Re-uptake Inhibitors - Prozac, Zoloft, Paxil, Celexa, Lexapro
Selective Serotonin and Norepinephrine Re-uptake Inhibitors - Cymbalta, Effexor, Wellbutrin
Corticosteroids - Prednisone
Anti-convulsants/anti-eleptics - Neurontin, Lyrica, Dilantin, Keppra, Topamax, Tegretol, Klonopin
Muscle relaxants - Soma, Flexeril, Robaxin, Skelaxin, Valium, Parafon Forte
Benzodiazepines
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Pharmacological/Invasive (HANDOUT - Botulinum Toxins for Analgesia) (Consensus Guidelines for the Selection
and Implantation of Patients with Noncancer Pain for Intrathecal Drug Delivery)
Intramuscular medications
Trigger point injections
Botox injections
Intravenous medications
Epidural steroid injections - cervical, thoracic, lumbar, caudal
Nerve block therapy
Spinal joint blocks - facet neurotomy, facet injections
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Radiofrequency ablation/lesioning
Intra-disk Electrothermal Therapy (IDET)
Vertebroplasty/kyphoplasty
Dorsal column stimulation/neurostimulation therapy - treats chronic intractable pain (neuropathic)
Intrathecal drug infusion system - treats pain or spasticity
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Health Care Expenses
Billions of $$ spent each year for unrelieved pain
Direct costs for care related to migraine headaches exceeded $2.4 billion/year in U.S.
Average cost for 1st year of pain management related to failed back surgery was $34,716 in U.S.
Annual total of direct and indirect costs for chronic pain estimated $295 billion/year
Annual total of direct and indirect costs for chronic back pain estimated $100 billion/year
Pain medication - 2nd most frequently prescribed drug during MD and ER visits
Surgery - 2nd most common treatment for chronic pain
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Implantable devices - initial costs for screening/hospital/professional charges range $27,577 - $55,135
Multidisciplinary pain rehabilitation centers - only 6% of patients treated by pain specialists participate, average cost is
$15,339
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Nurse Life Care Planning Process
Assessment
Location/onset/duration/intensity
Character
Associated symptoms
Aggravating and alleviating factors
Previous treatment outcomes
Psychological intervention
Family history of chronic pain, substance abuse, physical/sexual abuse
Assess for secondary gain
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Assess for impact of pain on social, physical, occupational, and sexual function and overall quality of life
Observe all cues
Neurologic
Musculoskeletal
Psychosocial
FIM-FAM
Bathing/showering/hygiene
Grooming
Dressing
Feeding
Mobility
Transportation
Living arrangements
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Nursing Diagnosis
Chronic pain
Risk for injury
Social isolation
Spiritual distress
Ineffective individual coping
Activity intolerance
Anxiety and fear
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Outcomes
Collaboration
Pain management
Physiatrist
Physicians
Therapists (OT, PT, psych)
Home health providers
Equipment vendors
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Medical Research (HANDOUT - Practice Guidelines for Chronic Pain Management)
Psychological - Physical - Pharmacological approach yields best outcome for pain management
Agency for Healthcare Research and Quality (ahrq.gov) - National Guideline Clearinghouse
Journal of American Society of Interventional Pain Physicians (painphysicianjournal.com)
Department of Veterans Affairs (healthquality.va.gov/) (HANDOUT - VA CGP Management of Opioid Therapy for
Chronic Pain)
American Pain Society - Clinical Practice Guidelines (HANDOUT - Clinical Guidelines for the Use of Chronic Opioid
Therapy in Chronic Noncancer Pain)
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Chronic Complications
Opioid side effects
Central nervous system - sense of emotional well being/euphoria, drowsiness/sedation, sleep disturbance,
hallucinations, potential for diminished psychomotor performance, dysphoria, agitation, dizziness, seizure, hyperalgesia
Respiratory - respiratory depression due to toxicity or medication combining
Ocular - constriction of pupil
Gastrointestinal - constipation, nausea, vomiting, delayed gastric emptying
Genitourinary - urinary retention
Endocrine - hormonal and sexual dysfunction
Cardiovascular - decreased blood pressure, slowed heart rate, peripheral edema
Musculoskeletal - muscle rigidity/contractions, osteoporosis
Integumentary - itching (not allergic reaction)
Immune - suppression, at risk for infection/illness
Pregnancy and breast feeding - all opioids cross placenta, neonatal depression if opioids used during labor, use with
caution during breast feeding
Analgesic tolerance - decreased duration of analgesia, then decreased effectiveness
Withdrawal syndrome - may occur with abrupt opioid cessation
(HANDOUT - SCI Related Pain: Diagnosis, Treatment and Life Care Considerations) (HANDOUT - LCP for
Pediatric Chronic Pain Patients) (HANDOUT - LCP for the Amputee with Chronic Pain)
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Planning
Treatment Recommendations in Nurse Life Care Plan
Medical
Physician appointments/evaluations
Pain management
Neurological
Musculoskeletal
Genitourinary
Gastrointestinal
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Surgeries/Procedures (invasive vs. non-invasive)
Injections
Blocks
Spinal cord stimulator (HANDOUT - Neurostimulation Therapy - Commonly Billed Codes) (HANDOUT -
Neuromodulation Products) screening - psychological evaluation
trial
implantation
reprogramming
revision
Intrathecal infusion pump (HANDOUT - Intrathecal Drug Delivery - Commonly Billed Codes) (HANDOUT - External
Pump Trailing System) screening - psychological evaluation
trial
implantation
refill
revision
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Hospitalizations
Inpatient pain program
Exacerbations
Detoxification program
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Therapeutic Evaluations
OT
PT
Psychological
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Therapeutic Modalities
OT
PT
Psychological (individual & family)
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Diagnostic Studies
Neuropsychological
Musculoskeletal - x-rays, MRI, CT scan, bone scan
Neurological - EMG/NCV studies
Lab Work
Comprehensive metabolic panel - includes BUN & creatinine (liver & kidney function - should establish baseline &
then periodic follow-up
Therapeutic drug assay
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Medications
Non-opioid
Opioid
Adjuvant
Other
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Medical Supplies
TENS unit - leads/electrodes, wired, pads, unit, battery
Muscle stimulator - leads/electrodes, wired, pads, unit, battery
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Durable Medical Equipment/Aids for Independent Function
Hospital bed vs. electric bed & mattress/overlay
Transfer bench
Shower chair
Elevated toilet seat with rails
Recliner chair
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Mobility
Cane
Walker
Manual wheelchair
Power wheelchair
Motorized scooter
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Non-medical
Home care/living arrangements
Home
Home health care vs. respite care
Unskilled
Skilled
Assisted living
Skilled nursing facility
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Architectural renovations
Barrier free
Wheelchair accessible design
Assistive technology
OT home evaluation
Contractor home evaluation
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Transportation
Wheelchair accessible transportation
Personal vehicle
Handicap driver evaluation
Handicap driver training
Handicap parking permit
Vehicle modifications
Public transportation
Private transportation
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Educational/Vocational
Vocational evaluation
Vocational case management
Vocational retraining
Vocational modifications
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Other
Case management
Support group - pain associations/conferences
Fitness - gym vs. home
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