Coursework

Pain Management

In this essay we would discuss the physiology and mechanism of pain and highlight the differences of chronic and acute pain as well as the underlying neurological pathways responsible for producing a sensation of pain. In this context we differentiate Nociception or general physiological bodily pain and the wider definition of general pain that can involve emotional and psychological dimensions.

From an analysis of pain, we move on to pain management and discuss in some detail the Chronic Pain Rehabilitation program identified by the NSF and Department of Health. Pain management techniques recommended by the Department of Health (DH) as well the services provided are discussed along with the emphasis shown on cognitive behavioral therapy (CBT) and related techniques. We finally give research evidence to show the efficacy of various pain management techniques through art, cognitive behavioral and group therapeutic approaches highlighting the increased importance of creative therapies in mainstream pain management.

Introduction to Pain

Pain is usually considered as a subjective experience that can accompany nociception although pain can arise without a stimulus and may include an emotional reaction. Nociception is neurophysiologic term denoting activity in nerve pathways which transmit unpleasant signals and pain is usually associated with tissue damage and inflammation. Pain is an important aspect of the defense system of the body and pain signals instruct motor neurons of the central nervous system to minimize harm or injury to the body. Pain is explained by the gate control theory which concerns cognitive and emotional factors influencing painful sensations and is determined by different pain states at the brain rather than pain at a particular injured area of the body.

Nociception is the perception of physiological pain although the term pain itself is a broader term and involve psychological pain as well. When nociceptors are stimulated, signals are transmitted through sensory neurons in the spinal cord and are ultimately relayed to the thalamus in the brain and perception of pain takes place. As the brain is itself devoid of nociceptors it cannot experience pain by itself and pain is usually referred to as tissue damage by some harmful stimulus. Pain can thus be both physiologic and emotional or either one of them, nociception describes physiologic pain or pain related to physical injury to body tissues and pain picked up and transmitted as signals via receptors. Pain in general can however also be emotional or psychological and may be associated with neural factors not entirely known.

The main characteristic of pain is its unpleasantness and usually an organism uses all means to separate itself from any unpleasant stimuli that may be the cause of the pain. Pain can be due to an injury or may even indicate that an injury is imminent but it can also serve as a protective and defensive physiologic function as organisms tend to protect injured regions in the body from further damage due to the unpleasantness of pain sensations (Notcutt, 1996). Thus pain is an important part of human existence and is a strong defense of the body helping in organism’s survival. It is because we perceive pain as unpleasant that we tend to avoid harm and injury to the body. The study, treatment and management of pain include pharmacology, psychology and neurobiology and the subjective psychological aspects of pain is an important part of study for the search for neural correlates of consciousness.

Pain receptors are usually free nerve endings and are receptors to chemical, mechanical and thermal pain sensation usually found in the skin, internal and joint surfaces. Tissue damage in deeper part of the skin produces an aching dull pain spread across wider areas as pain receptors are fewer and spread around in deeper levels of the skin, so pain can also not be localized in these cases (Walsh, 1957). In certain cases with prolong pain stimulation, excitation of pain fibers increases leading to a condition known as hyperalgesia.

Pain can be classified into several types including Acute pain which is a short term pain from an identifiable cause and is related to tissue damage or a disease. It is sharp sensation followed by aching and is usually centralized to one area usually following an injury, wound or fall (Gleberzon, 2005). This sort of pain is usually treated with medications. Medically a chronic pain lasts six months or longer and this sort of pain does not help the body to prevent any further injury by being constantly present and is even more difficult to treat than acute pain. Medical advice is however sought for these cases and drug tolerance, chemical dependency and psychological addiction to drugs may also occur especially in case of opioids. The experience of physiological pain can be cutaneous, somatic, visceral or neuropathic. Cutaneous pain is referred to pain that happens due to injury to the skin or the superficial tissues of the body as cutaneous nociceptors terminate just below the skin and produce localized defined pain for short duration and include pain due to cuts and burns. Somatic pain is pain of ligaments, muscles, bones, tendons and blood vessels and may be dull and continue for longer duration than cutaneous pain. Sprained ankles, fractures and torn ligaments are examples of this sort of pain. Visceral pain involve pain originating in body organs and this sort of pain is located in internal cavities and organs producing an aching , poorly localized sensation that may be of much longer duration than somatic pain and the dull pain can spread to many areas. Neuropathic pain or neuralgia refers to pain in the nerve tissue due to injury or disease and can disrupt the ability of the nerves to transmit correct signals to the thalamus, so the brain may interpret pain although there may be no obvious physiologic causes of pain (Beckman, 1982).

There are two different and distinct pathways for transmission of pain in the CNS. These are transmitted either through the neospinothalamic tract for fast pain or paleospinothalamic tract for slow pain. For transmission for fast pain A-delta fibers terminate on lamina marginalis of the dorsal horns. Neospinothalalmic tract neurons branch off as long fibres and transmit signals upwards in the contralateral anterolateral columns. These fibres finally terminate on the ventrobasal complex of the thalamus. Fast pain is easily localized when A and delta fibres are stimulated with tactile receptors. Slow pain is however transmitted by the slower C fibres to lamina II and III or dorsal horns also known as substantia gelatinosa and neurons take off and join fast pain pathways and move upwards along the anterolateral pathway. These slow pain neurons terminate in the brain stem with a tenth of fibres stopping at the thalamus and also at the medulla, pons and mesencephalon although localization for slow pain is poor.

There are several clinical research studies conducted to help determine which pain management therapies are most effective in treating neck, back and body pain in general. There is no universally accepted definition, or classification of pain management techniques and pain management is usually grouped in terms of their effectiveness and invasiveness. Physical therapy methods are not invasive and do not involve the use of medications although pain medications may involve invasive techniques such as injections as medications are introduced in the body (Raj, 1986). Pain management can involve non-invasive non drug pain management, non-invasive pharmacologic pain management or invasive pain management.

Non invasive pain management may or may not involve drug administration and the non invasive non-drug treatments are widely available for back pain and neck pain and these can range from exercise, manual techniques such as massage, behavioral and cognitive behavioral therapy, cutaneous stimulation and electrotherapy. Exercise method can involve aerobics, flexions, water therapy or simple exercises necessary for musculoskeletal health. Manual techniques generally involve massage, osteopathy and are quite similar to cutaneous stimulation which uses hot and cold packs for heating and cooling of the skin. TENS or transcutaneous electrical nerve stimulation stimulates the nervous system by using low voltage electrical stimulation and is generally effective for back pain. Behavioral therapy, although not related to direct physiological manipulation helps in optimizing patient responses to painful stimuli by means of relaxation and coping techniques (Puder, 1988).

Noninvasive pharmacologic pain management includes administration of drugs such as analgesics, muscle relaxants to treat muscle spasms, non steroidal anti-inflammatory agents (NSAIDs) such as ibuprofen, antidepressants, anticonvulsants to treat nerve pain, and narcotic medications for acute and post operative pains.

The invasive pain management techniques involve using devices and instruments into the body such as injections. Some of the common methods of invasion on the body used as pain management techniques are using injections in which a steroid or anaesthetic is directly delivered to a nerve and provide temporary relief to pain. Certain surgically implanted devices such as spinal cord stimulators and peripheral nerve stimulators are used for pain management. In some cases a specialized device is used to produce heat to deaden the sensation of a painful nerve and this method is called Radiofrequency radioablation (Gupta, 2005).

However there are several alternative pain management techniques and pain is one of the most common reasons of using complementary and alternative medicine or CAM. In a recent survey by the NCCAM, 16.8% of adults used CAM to treat back pain, 6.6% for neck pain, 4.9% for arthritis, 4.9% for joint pain, 3.1% for headache and 2.4% used CAM to treat recurring pain of unknown cause. One of the alternative forms of pain management is traditional Chinese herbal medicine and according to this method pain is a blockage in electrical resistance or stagnation of blood and inhibits metabolism through dehydration. Acupuncture is considered more effective for non traumatic dull pain than for acute traumatic pain.

Modern method of pain treatment and management stresses on holistic methods that are multidisciplinary and involve the application of a variety of drugs as also physical and psychosocial interventions including exercise and behavioral therapy. Pain therapy is given to patients with both chronic and acute pain and usually a medicine or drug is applied followed by other forms of therapy. In this essay we would discuss pain management from various perspectives and include the importance of relaxation, exercise, cognitive behavioral therapy, client centered approach, art and group dynamics as effective pain management techniques.