The Nature of Pain What is pain? A sensory and emotional experience of discomfort. Single most common medical complaint.

Qualities of Pain Organic vs. psychogenic Acute vs. chronic (daily for > 6 months) Malignant (indicating injury) or benign (harmless) Continuous or episodic What Initiates Most Pain? Algogenic (pain-causing) substances chemicals released at the site of the tissue injury (bradykinin, histamine, serotonin, prostaglandins) Nociceptors afferent neurons whose dendrites or free nerve endings are sensitive to algogenics Peripheral Nerve Fibers Involved in Pain Perception A-delta fibers neurons with myelinated axons that quickly transmit sharp localized pain messages to cortex C-fibers neurons with small unmyelinated nerve axons that transmit diffuse, dull burning or aching pain to brainstem and limbic system Pain Without Detectable Tissue Injury Can occur with no obvious damage Can persist long after healing of damage May spread and increase in intensity May become stronger than the initial acute pain from the injury Examples: Neuralgia an extremely painful condition consisting of recurrent episodes of intense shooting or stabbing pain along the course of the nerve. Causalgia recurrent episodes of severe burning pain often triggered by a gentle sensation Phantom limb pain feelings of pain in a limb that is no longer there and has no functioning nerves. Some other chronic pains Another Puzzle: Decreased pain experience despite tissue injury

Steps The

in Pain Perception

http://www.youtube.com/watch?v=0Ck9ji9aS8M

Pain Message http://www.youtube.com/watch?v=n8y04SrkEZU&feature=related Gate-Control Theory Ronald Melzack (1960s) Neural gate can open or close, thereby modulating amount of pain input that reaches the brain Gate is located in the spinal cord. Three Factors Involved in Opening and Closing the Gate The amount of activity in the pain fibers. The amount of activity in other peripheral fibers Messages that descend from the brain. Conditions That Close the Gate Physical conditions Medications (narcotic analgesics) Counter stimulation (e.g., heat, massage) Acupuncture, TENS SPA (stimulation produced analgesia) Emotional conditions Positive emotions Relaxation Mental conditions Intense concentration or distraction Involvement and interest in life activities Conditions that Open the Gate Physical conditions Extent of injury Inappropriate activity level Emotional conditions Anxiety or worry Tension Depression Mental Conditions Focusing on pain Boredom

Acute

vs Chronic Pain

http://www.youtube.com/watch?v=kmdYt0OAJbs http://www.youtube.com/watch?v=hmo-UuCNW74

Four Types of Pain Behaviours Facial/audible expression of distress Distorted ambulation or posture Negative affect Avoidance of activity Pain behaviors Use of Medication Altered Activity Rest Verbalization Guarding Crying Relaxation Withdrawal Aggression Alcohol/drugs Hot/cold packs Three conclusions from the MMPI studies of pain sufferers Chronic pain is associated with very high scores on the 3scales of the neurotic triad (hypochondriasis, depression, hysteria), although scores on the other scales are within the normal range. This pattern holds regardless of whether there is a known cause for the pain. Pattern may disappear if pain goes away. Individuals with acute pain may show moderate elevations of the neurotic triad scales, although scores on the other scales are normal. Assessing Pain Detailed interviews History of pain problem Patients emotional adjustment Lifestyle, interests before pain Impact of pain on lifestyle, relations, work Factors that seem to trigger or worsen pain Social context of pain attacks

How patient tries to cope

Uni-dimensional Scales Verbal Rating Scale (VRS) None, mild, moderate, severe Numeric Rating Scale (NRS) Visual Analog Scale (VAS) Pictorial Scale Multi-dimensional Questionnaires McGill Pain Questionnaire (MPQ)(Melzack) The Brief Pain Inventory (BPI) The Memorial Pain Assessment Card

MPQ Extensively validated in clinical setting Three domains of descriptors Sensory, affective, and evaluative Takes up to 15 min Relies on strong English vocabulary Individuals with similar pain syndromes choose similar words Those with different pains (e.g. arthritis, cancer, phantom limb) choose different words

Multi-dimensional: BPI Quicker and relatively easier than MPQ Well established reliability in cancer, arthritis, and AIDs. Sensory, affective and functional status Useful for treatment response Good choice for patients with progressive disease Multi-dimensional: Memorial Pain Assessment Card Rapid Sensory and affective PLUS (pain relief) Reliable in Cancer patients Validated and correlates well with longer scales And fits in your pocket Pain Behavior Ratings

May May

observe individual for level of pain behaviors ask patient to do various things (walk, pick up something, remove shoes while sitting, perform exercise actions) May use video and trained assessors May train family members to make observations at home Pain Rating Scales The FLACC scale should be used with patients who are nonverbal or noncommunicative Psychophysiological Measures EMG muscle tension HR and skin conductance autonomic nervous system indicators EEG evoked potentials Qualities of Pain Organic vs. psychogenic Acute vs. chronic (daily for > 6 months) Malignant (indicating injury) or benign (harmless) Continuous or episodic
http://www.youtube.com/watch?v=kmdYt0OAJbs

Clinical Pain Any pain that receives or requires clinical care May be acute or chronic Requires treatment in and of itself Makes procedures go more smoothly, decrease stress and distress, speeds recovery But many people receive inadequate pain treatment. The resulting increase in stress impairs immune function, slows healingand increases the risk of infection Types of Pain Medications Peripherally active analgesics work at the periphery (e.g. acetominophen(Tylenol) and NSAIDS(aspirin, ibuprofen, naproxen). Centrally active analgesics narcotics that bind to the opiate receptors in the brain (e.g., codeine, morphine, Darvon, Demerol, Percodan, oxycodone). Local anesthetics can be locally injected or applied topically (e.g., novocaine, lidocaine). Indirectly acting drugs affect non-pain conditions such as emotions that can exacerbate pain experience (tranquilizers, antidepressants)

Pharmacologic Control of Pain About half of hospitalized patients who have acute pain are under-medicated Children are at particular risk of poor pain control methods. Medications are given as: On a prescribed schedule PRN as needed PCA patient controlled analgesia Situation even worse for chronic pain Benign pain/chronic pain may not respond the same

Under-prescribing of Medical Narcotic Analgesics Other Medical/Physical Treatments Surgical procedures to block the transmission of pain from the peripheral nervous system to the brain. Synovectomy Removing membranes that become inflamed in arthritic joints. Spinal fusion joins two or more adjacent vertebrae to treat chronic back pain. Physical therapy may be used to increase mobility Massage Stimulation of nerves under the skin (acupuncture, TENS, brain or spinal cord stimulation, etc.)

Psychological Pain Control Methods Placebo pain relief Biofeedback provides biophysiological feedback to patient about some bodily process the patient is unaware of (e.g., forehead muscle tension) to allow some learned control over body Relaxation & meditation Hypnosis & self-hypnosis relaxation + suggestion + distraction + altering the meaning of pain. May combine methods Pain management strategies Slow, deep (diaphragmatic) regular breathing Progressive relaxation Meditation Peaceful or pleasant imagery

Self-hypnosis Brief

(cue) relaxation induction External focusing (stimuli outside body, engage in activity) % Relief of Tension Headache Placebo biofeedback 17% reduction Relaxation training 37% Biofeedback 43% Biofeedback+relaxation 56% Alternative Routes to Relaxation Mindfulness meditation http://www.npr.org/templates/story/story.php?storyId=7654964 Yoga http://www.youtube.com/watch?v=ccBWVAIc3qk
A

Chronic Pain Sufferer

http://www.npr.org/templates/story/story.php?storyId=1139836

Hypnosis An Acute Pain Example http://www.youtube.com/watch?v=zsKsRnTX8I0 Go to 7:00

A

Chronic Pain Example (New Medicine Video) Complementary and Alternative Medicines (CAM) (30% of Americans Use) PBS The Alternative Fix A Shocking Statistic http://www.pbs.org/wgbh/pages/frontline/shows/altmed/view/2_hi.html (1st 4 min) Where is the Evidence (acupuncture) http://www.pbs.org/wgbh/pages/frontline/shows/altmed/view/3_hi.html CAM Resources http://www.healthandhealingny.org/complement/index.asp http://nccam.nih.gov/ http://takingcharge.csh.umn.edu/therapies/mind-body/what http://www.ahc.umn.edu/cahcim/members/home.html (training & jobs too)

Pain Behaviors May Be Reinforced Secondary Gains Get attention, care, sympathy May decrease work responsibilities Disability payments Likewise we can use Operant behavior approach to reduce pain behavior Cognitive strategies Training for self-efficacy in pain control Redefinition or reappraisal (transforming your view of pain and ability to cope with it) Positive self-talk (e.g. de-catastrophizing) Persistence or non-avoidance of activity Mental distraction (thoughts, visualization, memories, music, mathematics . . .) Emotion defusing/problem solving strategies

Interesting Bandura Study 72 students given self-efficacy for pain control training in preparation for a cold pressor test Cognitive coping group resisted pain 60% longer than control group or placebo pill group. What if these groups are pre-treated with either saline or naloxone injections before the pain test?
No

significant difference in pain tolerance of saline or naloxone groups for the control or placebo pill conditions. BUT naloxone eliminated the pain tolerance of the cogntive coping group! Ramachandrans Mirror Box http://www.youtube.com/watch?v=2vibK_NjOVc Psychological Pain Methods Acupuncture not sure how it works. Could include: Counter-irritation may close the spinal gating mechanism in pain perception. Expectancy Reduced anxiety from belief that it will work. Distraction Trigger release of endorphins Integrative model of pain care; Pain Clinics Stepped care approach to pain management

Level one: Primary responsibility rests with primary care providers Level two: Living with Pain Class Patient education and rehabilitation model Review of common pain conditions Personal review of medications Discussion of self-management model Personalized exercise plan Practice of self-regulatory pain strategies, e.g., breathing, relaxation, activity pacing Level three: Comprehensive Pain Management Center

Pain management strategies Increasing movement walking, swimming, physio exercises Direct statement of needs/assertiveness Coaching significant others to reinforce positive pain behaviour and ignore negative Increasing either mastery or pleasure activities to at least one per day