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PAIN MANAGEMENT
A COMPREHENSIVE REVIEW
PART I
Jassin M. Jouria, MD
Dr. Jassin M. Jouria is a medical doctor, professor of academic medicine, and medical author. He graduated from Ross University School of Medicine and has completed his clinical clerkship training in various teaching hospitals throughout New York, including King’s County Hospital Center and Brookdale Medical Center, among others. Dr. Jouria has passed all USMLE medical board exams, and has served as a test prep tutor and instructor for Kaplan. He has developed several medical courses and curricula for a variety of educational institutions. Dr. Jouria has also served on multiple levels in the academic field including faculty member and Department Chair. Dr. Jouria continues to serves as a Subject Matter Expert for several continuing education organizations covering multiple basic medical sciences. He has also developed several continuing medical education courses covering various topics in clinical medicine. Recently, Dr. Jouria has been contracted by the University of Miami/Jackson Memorial Hospital’s Department of Surgery to develop an e-module training series for trauma patient management. Dr. Jouria is currently authoring an academic textbook on Human Anatomy & Physiology.
Abstract
There are a number of approaches in the management of pain, each with respective advantages and disadvantages. Ultimately, there should be proper pain management measures in place in order to reduce the root cause of pain, the length of pain, and the effectiveness of pain management. This course aims to offer a comprehensive review of pain management that is currently available, as well as offer some new insight into the modern and innovative measures of pain management.
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Continuing Nursing Education Course Director & Planners
William A. Cook, PhD, Director, Douglas Lawrence, MS, Webmaster,
Susan DePasquale, CGRN, MSN, FPMHNP-BC, Lead Nurse Planner
Accreditation Statement
This activity has been planned and implemented in accordance with the policies of NurseCe4Less.com and the continuing nursing education requirements of the American Nurses Credentialing Center's Commission on Accreditation for registered nurses.
Credit Designation
This educational activity is credited for 4 hours. Nurses may only claim credit commensurate with the credit awarded for completion of this course activity.
Course Author & Planner Disclosure Policy Statements
It is the policy of NurseCe4Less.com to ensure objectivity, transparency, and best practice in clinical education for all continuing nursing education (CNE) activities. All authors and course planners participating in the planning or implementation of a CNE activity are expected to disclose to course participants any relevant conflict of interest that may arise.
Statement of Need
Individuals experience pain in unique ways. Health professionals need to be informed of the various pain theories and tools to help identify individual perceptions of pain and methods of treatment.
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Course Purpose
To provide nursing professionals with knowledge of types of pain, methods to identify pain and options for treatment.
Learning Objectives
1. Define pain 2. Describe the magnitude of pain 3. Enumerate the characteristics of pain 4. Explain the types of pain 5. Describe the negative consequences of pain 6. Describe the pathophysiology of pain 7. Elaborate the theories of pain 8. Identify the factors affecting the pain
Target Audience Advanced Practice Registered Nurses, Registered Nurses and Licensed Practical Nurses, and Associates
Course Author & Director Disclosures
Jassin M. Jouria, MD, William S. Cook, PhD, Douglas Lawrence, MS,
Susan DePasquale, CGRN, MSN, FPMHNP-BC – all have no disclosures
Acknowledgement of Commercial Support:
There is no commercial support for this course.
Activity Review Information:
Reviewed by Susan DePasquale, CGRN, MSN, FPMHNP-BC
Release Date: 1/1/2015 Termination Date: 7/8/2016
Please take time to complete the self-assessment Knowledge Questions before reading the article. Opportunity to complete a self-assessment of knowledge learned will be provided at the end of the course
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1. At least 3 types of somatic discernable pain include:
a. surface pain b. sub-surface pain c. deep pain d. all of the above
2. True or False. The visual analog scale is ideal for use with individuals who possess a strong ability to define their pain.
a. True b. False
3. Chronic pain is pain that:
a. persists for 1 to 3 months b. can be affected by physical impairments and lack of energy c. can be associated with depression, anxiety, anger and fear d. answers b and c above
4. Melzack and Casey offered a theory of pain focused on:
a. cognitive-evaluative, sensory-discriminative, affective- motivational dimensions b. cultural and superstitious beliefs c. age-specific factors d. none of the above
5. Education for patient and caregivers include a variety of tools, such as:
a. pain-specific brochures b. videos/audio material and web-based sites c. pain notebooks d. all of the above
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Introduction
Pain can be defined as a complex, multi-dimensional provocation. It is one of the major reasons that people seek health care. Pain is a response to noxious stimuli and can function as a protective mechanism of the body to prevent further injury. The sensation of pain as the warning of potential tissue damage may be absent in people with certain disorders, such as diabetic neuropathy, multiple sclerosis, and nerve or spinal cord injury. According to a recent medical report titled ‘Relieving the pain in America' published by A Blueprint for Transforming Prevention, Care, Education, and Research, pain is a significant public health problem that costs Americans at least $560-$635 billion annually, an amount equal to about $2,000.00 per person living in the U.S. Consequently, the total incremental cost of health care for controlling pain ranges between $261 and $300 billion, and $297-$336 billion is attributable to a loss in manpower productivity.
Pain is considered a “universal disorder”1 that comes in many forms. Regardless of the form it is seen in, everyone experiences pain, with the perception of pain occurring differently in each individual.
In the most benign form, pain serves to warn the individual that something is not quite right. Pain can, however, disrupt productivity, well- being, and indeed, the entire life of the individual experiencing the pain. At its core, pain is complex and differs greatly among individuals, including those who seem to have identical injuries or illnesses.
Pain has a long history. Ancient civilizations recorded accounts of pain and the various treatments and cures used on stone tablets. Early humans also related pain to magic, demons, and evil. In early times, the responsibility of pain relief fell on shamans, priests, and sorcerers, who utilized herbs, rites and ceremonies to treat pain. The Romans and Greeks were the first peoples to advance the idea that the brain and nervous system is key in producing pain sensations. However, evidence was not
nursece4less.com nursece4less.com nursece4less.com nursece4less.com 6 available to support this theory until well into the Renaissance in the 1400 and 1500s. It was not until the 19th century that real advancements in science led to advancements in pain treatment. Physicians discovered that such drugs as morphine, codeine, cocaine, and opium could be used to treat pain. These drugs then led to the development of aspirin as a pain treatment; even today this is the most commonly utilized pain reliever. Finally, anaesthesia advanced and became the standard for surgery. As we have moved into the 21st century, scientists and physicians are gaining an even greater understanding of pain and pain treatment.1
Pain: definition
The International Association for the Study of Pain defines pain as: “An unpleasant sensory and emotional experience associated with actual or potential tissue damage or described in terms of such damage”.5 Pain is an unpleasant sensation that ranges from mild, localized discomfort to extreme agony. There are physical as well as emotional components to pain. The physical component is the result of nerve stimulation.6 Emotions have the ability to affect the way a person perceives pain. While all human beings have the same anatomical structures that convey nociception to the central nervous system, there are quite a few factors that alter the intensity of the pain perception.7 It is important that practitioners consider both physical and emotional factors when treating patients, as these both influence a patient’s recovery.8
The word pain is derived from the Latin word poena, which means a fine, or penalty. Some people indicate that they tolerate pain well, whereas other individuals indicate that they are highly sensitive to pain. Pain is clinically as the 5th vital sign,9 an important landmark implementing the standard assessment of pain using a pain analogue as part of the routine patient assessment. The assessment of pain as the 5th vital sign has evolved, as a standard process to avoid undertreating pain, to become more integrally part of a comprehensive biopsychosocial evaluation where
nursece4less.com nursece4less.com nursece4less.com nursece4less.com 7 the patient’s belief system and culture are expected to be considered. Beyond the use of a pain analogue to quantify pain, the evaluation of pain must include “recognition of the intersubjective, a place where numbers and stories converge… patients should be encouraged to be active participants in their pain-related care”.9
Magnitude of pain
Magnitude of pain is a difficult thing to measure, primarily because different people experience pain in different ways.10 However, there are some instruments designed to measure pain that apply universal standards to pain sensation and can be used across the board for all individuals.
One such instrument is the visual analog scale. This scale is utilized to measure pain characteristics in a way that ranges across a scale of numerical values, with the number 1 being no pain and the number 10 being the worst pain imaginable. This pain scale is ideal for use with those individuals who possess a strong ability to define their pain.
Retrieved online June 29, 2013 @ http://www.cpmc.org/learning/documents/pain.pdf
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Another scale that is commonly utilized is the faces pain scale. This scale is frequently utilized with children or with those who are better able to provide a description of what their pain feels like according to the expression depicted on a face. This scale ranges from a smiley face that represents no pain to a face with a frown and tears on it to describe the worst pain imaginable.
There are special descriptive scales to measure pain in infants. Since infants are unable to talk to describe their pain as well as being not cognitively developed enough to identify a face representative of their pain, practitioners rely on descriptions of the infant’s behaviour to determine the magnitude of pain.
The use of these scales has its advantages as well as disadvantages. An advantage of utilizing scales such as these is that there is a universal standard by which practitioners may assess pain and in turn determine an initial idea of the severity of injury. However, since these pain scales are universal, people who are more or less sensitive to pain don’t necessarily fit into the pain “norm”, which can make an initial determination of how severe a condition or injury is difficult to make. This can mean that some patients are not receiving adequate care for their pain.
One scale that may help correct a pain discrepancy is the magnitude matching scale. Applying this scale to pain, for instance, would be particularly useful in hospital settings; for example, it can be argued that a woman undergoing childbirth is in more pain than any pain a man could experience. Therefore, even if a pregnant woman rates her pain as a 4 on a scale of 10, it is probable that they are in more pain than a man who provides the same rating.
Characteristics
Pain is a particular feeling that protects the body from noxious stimuli. Pain alerts the brain that a particular stimulus is unsafe, prompting the
nursece4less.com nursece4less.com nursece4less.com nursece4less.com 9 brain and the body to respond. However, pain is not just one feeling. It is instead a grouping of distinct feelings, all of which differ in clinical characteristics. What this means, for example, is that pain in the skin is a different type of feeling than is pain in the muscles.
In order for practitioners to effectively treat injuries and pain conditions, it is essential that practitioners listen to the patient describe his or her pain in order to correctly determine all pertinent information – such as pain location, pain sensation, pain modality, and pain radiation – and to in turn present a treatment plan that will address all aspects of the pain.11 It is also particularly important to determine the site of injury, although often the patient is not sure where their pain is originating. In order to determine effective treatment, it is therefore essential that practitioners understand the clinical nature of pain.
Pain Severity
Many things influence the level of severity of pain. Things such as the patient’s personality, surrounding influences, and general sensitivity to pain make a difference. It is important to note that the severity of pain does not predict enough about the injury to allow a practitioner to draw reliable conclusions for diagnosis or prescribing. A more useful predictor is the relative sensitivity of the tissues involved. For example, the cornea, when injured, may only be injured slightly; however, the pain effect may be very serious. This is because the cornea is more sensitive than are certain other tissues in the body.
It would pose a very large inconvenience if all of the tissues in the body were equally sensitive. Sometimes injury occurs in body tissue that is relatively minor and does not reach the consciousness; other times injury can be extensive and prompt extreme reaction. Further, if a particular stimulus – even a mild one – continues for too long a time period or if the affected tissue is still weakened following a previous injury, further damage to the tissues may be dangerous and the threshold for pain in
nursece4less.com nursece4less.com nursece4less.com nursece4less.com 10 that tissue is lowered. What this means is that sensitivity of tissues is not constant, but rather variable; sensitivity changes in response to circumstances surrounding previous injury.
Pain Site
The ability to locate the injury site simply by analyzing the pain that is perceived often depends on the tissue that has been injured.
Pain Quality
Quality refers to the distinctive character of a pain sensation. It can best be described by comparing it to a pain or sensation that is familiar. For instance, comparison is utilized with familiar pain that is related to areas in the body; one example of this is describing pain in the area of the stomach as feeling like a tummyache. Pain may also be compared to function; one example of this is when an individual describes their pain as throbbing. Further, pain can also be described in comparison with another pain that is prompted by a stimulus that is familiar; one example of this is describing pain as burning because this sort of pain is prompted by the physical experience of sustaining a burn.
Somatic Pain
There are at least 3 types of discernable pain:
Surface pain: this comes from the cutaneous surface as well as the mucosal surface.
Sub-surface pain: this type of pain is also called intermediate pain, which comes from subcutaneous tissues as well as from the submucosae. This type of pain also comes from adjacent tissue structures when subcutaneous tissue is thinner.
Deep pain: this comes from the muscles as well as other deep tissue that is generally considered more sensitive.
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Surface Pain
Surface pain can feel different depending on the duration of the stimulus affecting it. For example, if the duration of the experience is very short, generally the resulting sensation is a pricking. However, if the duration of the experience is prolonged, the resulting sensation is generally a burning. This highlights differences only in pain duration, not in pain quality. While burning is a sensation that is commonly associated with excessive heat, it is not the response of the organ systems of the body to heat; rather, it is the response of the surface to the prolonged painful stimuli. Burning can be produced by extreme cold as well as by heat. The two sensations of pricking and burning on the surface are only present if cutaneous pain organs are not functional as a result of destruction or extreme damage.
Itching
Sometimes injury to the skin also prompts an itchy sensation; however, for itching to be present the pain stimulus must be acting on skin that is hyperalgesic. There will be no itching on skin that has remained normal. An example of this is seen in skin that has been injured by a condition such as dermatitis. This skin is not in a normal state and there is a risk of provocation even if the added injury to the skin is very slight, such as scratching, applying ointments to the affected area, and temperature changes. Itching is a variety of surface pain that is entirely free of other sensations and occurs only in skin that is hyperalgesic from previous injury.
Other notable characteristics of surface pain
The main function of surface pain is to provide information about the painful stimulus so that the individual may make effective defensive reactions. Surface pain is very accurate: the pain is located in a precise spot and localized. The protective reflexes that the injury provokes are
nursece4less.com nursece4less.com nursece4less.com nursece4less.com 12 entirely directed with extreme precision toward eliminating the painful stimulus or toward withdrawing the injured part of the body from danger.
Pain from Mucosae
Not all mucosae are sensitive. For example, those mucosae that are distant from the site of injury are not sensitive at all. However, when a mucosa is sensitive the pain sensation felt is either pricking or burning. Itching may also be present. Regardless of the stimulus, the quality of the pain is always the same. For example, burning in the mouth may occur as a result of eating overly heated food or as a result of another irritant, such as chemicals, ulcers, or catarrhal inflammation.
The mucosa in the esophagus is not normally sensitive to thing such as gastric juice, which is frequently regurgitated even in normal digestion. However, when the mucosa is injured from another cause, it becomes sensitive to another injury and exhibits burning pain. Therefore, if the mucosa is injured by overly heated food, it will react more sensitively to gastric juice.
The mucosa of the cervix does not burn in response to pain; however when underlying tissues are affected it prompts pain in this mucosa. This lends to the idea that this particular mucosa is insensitive, as it does not respond to such painful stimuli as a sharp needle. Likewise, pain in the nasal mucosa is due mostly to the periostium underlying the mucosa. Nasal sinuses as well as the middle ear are generally described as possessing sensitive mucosa, but it is a likely conclusion that the mucosa itself is not sensitive and the perceived pain is periosteal.
Sub-surface/Intermediate pain
Pain in the subcutaneous surface has some differing qualities from deep pain, particularly if subcutaneous tissues are thinner, as is the case in the tissue over the forearm, tibia or knuckles. However, if the subcutaneous tissue is thicker – as is the case in the mammary region on females – pain
nursece4less.com nursece4less.com nursece4less.com nursece4less.com 13 in the inner strata is not described as being much different in quality from deep pain.
Pain of the subcutaneous surface is somewhat diffuse, but the diffusion is limited to a small zone surrounding the injury.
Deep Pain
Pain in the deep tissues possesses an aching quality. This type of pain is commonly found in the muscles or in other deep tissues that generally are more highly sensitive. Deep pain is non-discriminative and does not have the ability to offer information about the stimulus or the source of the pain perception. This type of pain starts well after the injury and is generally persistent. Additionally, this type of pain is very diffuse. Pain in deep tissues is impossible to be felt only at the injury site. This is a type of radiating pain, and the radiation is frequently quite extensive.
However, there are several factors that determine whether pain remains local or exhibits extensive radiation. For example, the severity of the injury sustained is very important, as is the depth of injured tissues. The deeper the tissue the more likely it is that pain will radiate out extensively. Additionally, if the injured tissues are close to areas of the body that are vitally important, there is a greater likelihood of radiation.
Reflexes accompany deep pain. However, these reflexes do not provoke brisk and defensive movements, as is the case with surface pain. They are more focused on resting the part of the body that is injured and serve to protect that part of the body from further injury. They are not as focused on removing the injurious stimuli. The pain may then be felt as a spasm that radiates outward. Additionally, the way an individual reacts when experiencing deep pain tends to inhibit further activity in order to protect the injured area.
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Visceral Pain
The viscera is generally lying so deeply that it is well protected and does not respond to stimuli that normally provokes pain in somatic tissue. In fact, many viscera are entirely insensitive and the pain that may be associated with them is prompted by the extension of the lesion to adjacent tissues. However, some other viscera are sensitive.
TYPES OF PAIN
Duration-acute, chronic and malignant pain
Acute pain is a type of pain that begins suddenly and is generally sharp in quality; it warns the body of a threat of some kind, either as an injury or a disease.12 However, acute pain can be caused by a number of events, which include:
Surgery
Dental work
Labor and childbirth
Broken bones
Burns or cuts
Acute pain may present as mild and momentary, but it can also be severe pain that lasts for weeks or months. Generally however, acute pain does not last beyond six months. Additionally, acute pain disappears when whatever is causing the pain is healed or treated. When acute pain is not relieved it can lead to chronic pain.
Chronic pain is pain that persists even after an injury has been healed or treated. This type of pain is a result of pain signals remaining active in the nervous system over an extended period of time and can last for years. It can also be affected by physical impairments, such as tense muscles or limited mobility, or a lack of energy. Emotions such as depression, anxiety, anger, and fear of aggravating an existing injury can also affect
nursece4less.com nursece4less.com nursece4less.com nursece4less.com 15 the sensation of chronic pain. Emotions in particular can hinder an individual’s ability to return to normal activity at work or play.
Some of the common complaints associated with chronic pain are:
Headache
Cancer pain
Neurogenic pain
Low back pain
Arthritis pain
Psychogenic pain
Chronic pain frequently originates with some initial trauma or injury. However, it is possible that there could be an ongoing cause of chronic pain. It is important to note though that there are those individuals who suffer from chronic pain without the presence of a past injury or trauma. It is important to understand that the pain these individuals feel is no less real than that pain caused by an ongoing disease or injury.
In an effort to better understand chronic pain, some studies13,14 have indicated that chronic pain ranges from 10.1% to 55.2% of the population. One theory of chronic pain is that prolonged exposure to acute pain may prompt long-standing changes to the central nervous system, which creates chronic pain.15,16 Under normal conditions, the painful stimuli diminishes as the healing process moves forward, leading to lessened pain sensations until there is minimal to no pain detectable.17 However, persistent pain may activate secondary mechanisms in the central nervous system that cause hyperalgesia, hyperpathis, and allodynia, which can diminish normal function.
One way to better understand pain comes from the idea of neuroplasticity. Neuroplasticity occurs a short while after acute pain sets in. The remodelling of the neuronal cytoarchitecture that occurs leads to a transition from acute pain to chronic pain.18,19
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To best understand chronic pain, practitioners must understand that even small amounts of residual pain may affect physical and social function in a negative way. Practitioners must understand that chronic pain is a common and serious problem that can greatly alter the lives of individuals who suffer it.20,23
Location
Pelvic
Pelvic pain is defined as being pain that exists in the lower portion of the abdomen and pelvic.24 Generally, pelvic pain is utilized in reference to symptoms that women suffer that arise from the reproductive or urinary system. Pelvic pain can range from dull to sharp sensations, be either constant or intermittent, and may be anywhere from mild to very severe. Pelvic pain is frequently felt in the lower back as well, as pain from the pelvis can radiate up into the lower back. Chronic pelvic pain indicates any pain in the pelvic region that has been present for more than a few months. The pain can be either constant or intermittent; what makes pelvic pain chronic is time duration.
Pelvic pain may only be noticeable at certain times. Examples of this would be pain during urination, menstruation, or sexual activity. Additionally, conditions and diseases of various body systems can contribute to pelvic pain. For example, pelvic pain may originate in the intestinal tract, reproductive system, or urinary system. Pain in this area may also originate in the muscle tissues of the pelvic floor. Less frequently, pelvic pain can be caused by nerve irritation in the pelvis.
Reproductive pain is the most common in the pelvic region. This kind of pain can arise from a variety of causes, including: adenomyosis, ectopic pregnancy, endometriosis, cramping during the menstrual cycle, miscarriage, ovarian cysts or cancer, or pelvic inflammatory disease.
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Other causes of pelvic pain that exist in both men and women include: Adhesions, appendicitis, colon cancer, constipation, Crohn’s disease, Fibromyalgia, a herniated disk, interstitial cystitis, irritable bowel syndrome, kidney stones, a urinary tract infection, physical or sexual abuse, muscle spasms of the pelvic floor, or sciatica. If an individual suddenly develops pelvic pain that is severe, this can indicate a medical emergency, and prompt medical attention is necessary. Pelvic pain should be examined by a practitioner in particular if it is a new sensation, is disrupting the patient’s daily life, or if it has been getting worse as time passes.
Headache
Headache may take a variety of form where pain is concerned. Headache pain can feel like a vise is being tightened around the top of the head, throbbing pain at the base of the skull or in the temples, or occur in combination with nausea and an increased sensitivity to such stimuli as light and sound, to offer a few examples. Headache can occur on its own or along with another disease or condition. Headache is nearly universally experienced across age groups. Both children and adults experience headache, and nearly two-third of children experience headache by the time they turn 15 years of age.25 Therefore, headache is considered the most common form of pain and often leads to missed days at school or work. Some individuals experience headache only once or twice a year; others experience headache for more than 15 days per month. Headache episodes may ease and disappear for some time and then re-emerge later in life, recur, or last for weeks at a stretch. Additionally, it is also possible to have more than one type of headache at one time. Headache can range from mild to severe to the point it interferes with daily activities. This makes it essential that headache is treated promptly and effectively.
Types of headaches can include the following:
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Primary headaches
This type of headache occurs independent of any other medical condition.26 Researchers currently do not know exactly what mechanism sets a primary headache into motion. However, events that affects the blood vessels and nerves inside and outside the head cascade to cause pain signals that are then sent to the brain. The brain’s neurotransmitters as well as changes in the activity of nerve cells – an occurrence called cortical spreading depression – create the head pain. Primary headaches are divided into four main groupings: migraines, tension headaches, trigeminal autonomic cephalgias, and miscellaneous. Primary headache types include:
Migraine
Approximately 12% of people in the United States experience migraine, which is a form of vascular headache.27 Vascular headache is characterized by pulsating, throbbing pain that is the result of the activation of nerve fibers and reside in the brain blood vessels. The blood vessels temporarily narrow, which serves to decrease the flow of blood – and therefore oxygen – to the brain. This narrowing makes other blood vessels open wider in an attempt to increase the blood flow to the brain.
Migraines often strike one side of the head. Symptoms include a throbbing, pulsing pain, sensitivity to light or sound as well as odors, and nausea or vomiting. If left untreated, migraine generally lasts between 4 and 72 hours. Even the most routine movements – such as sneezing of coughing – can worsen the pain of a migraine. The most common occurrence of migraine is in the morning hours, particularly upon waking. However, migraine can occur at any time in the day. Some individuals experience migraines at predictable times – for example, before menstruation or on the weekend after a stressful work week. Most people who experience migraine are symptom-free following a migraine.
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There are two main types of migraine.27 These are presented below as:
Migraine with aura:
This is commonly considered the classic migraine. This type of migraine often includes neurologic symptoms that present from 10 to 60 minutes before onset of headache. These neurologic symptoms generally do not last more than one hour. Visual disturbances are a hallmark of the migraine with aura. Individuals may experience partial or complete vision loss while having this kind of migraine. This can occur even without the presence of a headache. Individuals also frequently have trouble speaking, experience numbing or muscle weakness, and tingling in the face or hands.
Migraine without aura:
This type of migraine is commonly considered a common migraine, as it occurs more frequently than does classic migraine. Individuals frequently have sudden headache pain occurring on one side of the head that comes on with no warning. Additional symptoms include nausea, blurry vision, mood changes and confusion, and increased sensitivity to light, noise or sound.
Migraines consist of four phases. Each phase or some combination of the four may be present. These phases are:
Prodromal phase: this can occur up to 24 hours prior to migraine development. Premonitory symptoms include unexplained food cravings and mood changes, fluid retention, uncontrollable yawning, and increased urination. Aura phase: in this phase some people see bright or flashing lights or an “aura” of light. This occurs immediately prior to onset of a migraine or during a migraine.
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Headache phase: this is the phase in which the migraine starts. The migraine may build in intensity in the headache phase. Some people experience migraine with no headache. Postdromal phase: this is the phase following the migraine attack. Individuals are frequently very tired or confused post migraine. This phase can last up to one day.
There are a number of factors that increase the risk of migraine. These factors vary from individual to individual; however, these factors include sudden changes to environment or weather, too much or not enough sleep, exposure to strong fumes or odors, strong emotions, such as stress reactions, sudden noises, low blood sugar, and bright or flashing lights. In addition, medication that is overused or missed may cause sudden migraine headache. Also, certain foods or food ingredients can trigger migraine in up to 50% of those who suffer from migraine.25 These foods include aspartame, wine, chocolate, certain cheeses, MSG, yeast, and caffeine (or withdrawal from caffeine). Individuals can help determine which foods trigger their own migraines by keeping a detailed food journal that includes indicating the onset of migraine.
Tension headache:
This type of headache, also commonly known as a muscle contraction headache, is the most common of the headache types. Stress, as well as mental and emotional conflicts triggers pain that originates from muscle contractions that take place in the scalp, neck, jaw, or face. The clenching of the jaw, depression or anxiety, intense and stressful work, or lack of sleep may in addition cause this type of headache. Sleep apnea is also a known cause of tension headaches particularly upon awakening.
Tension headache pain is frequently felt on both sides of the head and the pain often resembles the feel of a vise around the head. Tension headaches often disappear once the period of stress that caused the
nursece4less.com nursece4less.com nursece4less.com nursece4less.com 21 headache has ended. Further, depression can bring on a tension headache, as can certain postures that strain the muscles of the head and neck.
There are two types of tension headaches, as outlined below:
Episodic headaches, which present between 10 to 15 days a month, with each episode lasting from 30 minutes to several days in length. Chronic headaches generally occur more than 15 days a month over 3 months. The pain from chronic tension headache can be constant over this time and cause soreness in the scalp.
Trigeminal Autonomic Cephalgia:
This type of headache presents as severe pain that resides in or around the eye socket, generally on one side of the face and involuntary reaction of the same side of the face, for example, red or teary eyes, droopy eyelids, or runny nose. This type of headache is considered a pain disorder that comes in both episodic and chronic forms.28 Episodic cephalgia may occur on a daily basis for weeks or even months per year with remissions that are pain free. Chronic cephalgia may occur on a daily basis for a year or even longer with brief or no remission period.
Cluster Headache:
A cluster headache is considered the most severe form of primary headache. This type of headache consists of sudden and extreme headaches that occur in “clusters”, generally around the same time of day or night for weeks at a time. Cluster headaches affect one side of the head and present either around or behind one eye. This type of headache may start with a migraine-type aura and nausea. The nose and the eye on the side of the face that is affected may become red, teary, or swollen.
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Cluster headache frequently wakes people from sleep. Cluster headache generally is of shorter duration and frequency than is migraine headache.
This type of headache most frequently begins between ages 20 and 50, but they can present at any age. Cluster headache is more frequent in men than in women. Alcohol and smoking in particular may prompt the onset of cluster headache.
Paroxysmal Hemicrania:
This type of primary headache is rare and generally begins in adulthood. Pain and other symptoms are similar to those that present in cluster headache, but the pain and symptoms are usually shorter in duration. Pain from paroxysmal hemicrania can occur between 5 and 40 times per day, with each headache attack between 2 and 45 minutes in duration.
Pain is felt as a severe throbbing or piercing pain on one side of the face, with pain located in, around, or behind the eye and sometimes extending to the back of the neck. Additional symptoms may include watery or red eyes, swollen or drooping eyelid, or nasal congestion. Some individuals also experience pain and soreness between headache attacks and may be sensitive to light.
There are two forms of paroxysmal hemicranias:29
Chronic paroxysmal hemicranias - patients experience headache attacks on a daily basis, lasting a year or longer. Episodic paroxysmal hemicranias - patients experience headache attacks intermittently and may go months or years before experiencing a recurrence of headache pain. Paroxysmal hemicrania occurs more frequently in women than it does in men.
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SUNCT (Short lasting, Unilateral Neuralgiform headache with Conjunctival injection and Tearing):
This type of primary headache is very rare and presents with small bursts of moderate or severe piercing or throbbing pain felt in the forehead, temple, or eye. Location is usually confined to one side of the head. Other symptoms include bloodshot or reddened eyes, watering of the eyes, nasal congestion, sweating on the face, puffiness in the eyes, and increased blood pressure. Pain may peak within a few seconds of headache onset and generally follows a pattern of increasing and decreasing intensity. Headache attacks usually occur during the day and can last between 5 seconds and 4 minutes.30 Those who experience these attacks generally experience five or six attacks per hour and do not usually have pain between attacks.
SUNCT is more common in men than it is in women. Onset is usually after 50 years of age. SUNCT also has chronic and episodic forms.
Primary headaches can be further classified. These may be defined as:
Chronic episodes that occur daily for at least 15 days per month over a 3 month period, characterized by constant yet moderate pain throughout the day that is confined to the top or sides of the head. Stabbing, in which individuals feel intense and piercing pain that comes on without warning and lasts between 1 and 10 seconds. Stabbing headache is usually a spontaneous attack, but moving suddenly or looking into bright light can prompt stabbing headache. Exertional, in which physical exertion such as coughing or sneezing or exercise prompts headache, characterized by pain that lasts between a few minutes and 2 days, and may include nausea or vomiting. Hypnic, which is a type of headache that wakes people primarily during the night. This type of headache typically presents after 50
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years of age, and can occur 15 or more times each month and last between 15 minutes and 3 hours after the individual has woken up. Pain is dispersed to both sides of the head. There is no known trigger of hypnic headache; however, researchers believe that these attacks may be a disorder that occurs during REM sleep. “Ice cream headache”, which is a type of headache that occurs when the individual has inhaled or eaten something cold very fast. These attacks last for approximately 5 minutes and stop when the body adapts to the abrupt temperature change. “Ice cream headaches” are more common in those individuals who experience migraine.
Secondary Headaches
Secondary headaches occur as a symptom of some other medical condition.31 They may occur as a result of conditions such as infection, high blood pressure, fever, medication overuse, stress or conflict, tumors, stroke, head trauma, or mental disorders. Some of these causes are more serious than others.
Serious causes of a secondary headache include:
Brain tumors in the brain that can press against the nerves and blood vessel walls, which in turn disrupts communication and limits the supply of blood to the brain. Headache is intermittent and can develop or worsen, come or go, and become more frequent or infrequent at irregular periods. Headache pain generally worsens when performing certain exertional activities, such as coughing, or when changing physical position very suddenly. Brain tumors are rare among those who experience headache. Stroke headache can cause a stroke or be the result of a stroke, where blood vessel activity is altered. There are two types of stroke:
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Hemorrhagic stroke which is a form of stroke that occurs when an artery bursts in the brain. Hemorrhagic stroke is generally associated with brain function that is disturbed and a sudden and extremely painful headache that worsens with such events as coughing or physical activity. Ischemic stroke, in which an artery in the brain becomes blocked, which decreases or stops the flow of blood to the brain, leading to cell death. Headache commonly occurs in those individuals who have clotting in the brain’s veins, with pain occurring on the side of the head where the clot is blocking blood flow. Pain frequently radiates out to the eyes or on the side of the head.
Exposure to or withdrawal from certain substances
Headache can occur as a response to a toxic state, for example, drinking alcohol, being exposed to large doses of carbon monoxide, or from exposure to toxic chemicals found in cleaning products or pesticide. Headache response to a toxic state typically includes a pulsing and throbbing pain that increases with intensity the longer the individual is exposed to the substance. If left untreated, toxic exposure can cause permanent neurological damage as well as damage to organ systems within the body. Additionally, experiencing withdrawal from certain medications or from caffeine after heavy use can prompt headache.
Head Injury
Headache frequently occurs post-trauma and can be a symptom of concussion or other types of head injury. Pain is generally felt close to the site of injury, with pain radiating out through the head. The cause of headache that results from a trauma is frequently unknown; however, causes may include hematoma.
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An increase in intracranial pressure
Pressure changes in the brain may be caused by infections, hydrocephalus, or brain tumors that are increasing in size. These pressure changes frequently lead to headache with pain that is felt at the site of blood vessel compression or displacement, and radiates throughout the head.
Inflammation occurring as a result of meningitis or encephalitis
Inflammation from these types of infections may harm and destroy nerve cells. The result is headache pain that can range from dull to very severe. Other results include brain damage or stroke. These conditions require immediate medical attention. Additionally, headache can occur as a result of other infections, such as the flu or a bacterial infection. Inflammation of the sinuses in conditions such as the flu results in facial pain that becomes worse if the individual strains or makes certain movements of the head.
Seizure
Pain that is comparable to migraine can occur during or after seizure. The pain presents as moderate to severe, and lasts for a few hours. Pain can become worse if the individual moves their head suddenly or during physical exertion such as coughing. Symptoms also include nausea or vomiting, fatigue, and vision problems that can include sensitivity to light.
Leaking of the spinal fluid
Individuals who undergo lumbar puncture may experience headache that results from leakage if the cerebrospinal fluid post-procedure. Headache pain only occurs when the individual is standing; therefore, it is necessary for the individual to lie down and let the headache run its course. Headache resulting from a spinal fluid leak and can last from a few hours to a few days.
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Abnormalities to the structure of the head, neck, or spine
Abnormalities of structure to the head, neck, or spine can cause headache. This frequently results from such abnormalities as a restriction of blood flow through the neck or irritation of nerves along the spinal pathway. This type of headache can also be the result of holding the head in a stressful or awkward position. Additionally, this headache can be the result of conditions such as chiari malformation or syringomyelia.
Trigeminal neuralgia
Headache pain is caused in this condition by pressure placed on the trigeminal nerve, which sends sensations to the brain from certain portions of the face and mouth.32 This type of headache presents as shocking or stabbing pain that occurs suddenly and is typically only present on one side of the jaw. Muscle spasms of the face may also occur. Headache may occur spontaneously or be triggered when the cheek is touched through routine activities, such as washing the face. Additionally, pain can be triggered through activity of the mouth, such as that activity that occurs with eating, talking, or brushing the teeth.
Individuals should see a medical provider for headache under certain circumstances, as some types of headache can indicate the existence of serious medical conditions. Individuals should see a doctor immediately if they experience any of the following symptoms:
Headache with sudden and severe onset that is accompanied by stiffness in the neck. Headache that includes nausea or vomiting or fever that cannot be contributed to another illness. First occurrence of headache that is accompanied by weakness or confusion, or lack of consciousness. Headache that continually worsens as days or weeks passed, or headache that changes in pattern.
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Headache that recurs in children. Headache that occurs following injury to the head. Headache that is accompanied by weakness or loss of sensation in the body. This can indicate stroke. Headache that includes convulsions. Headache that includes shortness of breath. Headache that occurs two or more times per week. Sudden and persistent headache in an individual who was previously without headaches, particularly if the individual is more than 50 years of age. New headache in those individuals who have a history of HIV/AIDS or cancer.
BURN PAIN AND POSTHERPETIC NEURALGIA
Burn pain
Burn injuries can be extremely painful and disfiguring since they affect the largest organ in the body, the skin. These injuries, when major, can be disabling.33 Approximately 45% of burn injury affects children and requires hospital admission.34 Early pain management can significantly influence how the individual experiences pain resulting from burn injury later on.
Pain in burn injury is affected by how large and deep the injury goes. Additionally, pain may be exacerbated by conditions resulting from the injury, such as infections. Burn pain is frequently difficult to manage, and as a result may be undertreated.
When an individual feels the immediate pain following a burn injury, it is the result of stimulation of skin nociceptors whose job it is to respond to heat as well as both exogenous and endogenous stimuli. If the nerve endings are entirely destroyed by the injury they will not transmit pain
nursece4less.com nursece4less.com nursece4less.com nursece4less.com 29 signals, but undamaged nerve endings or others exposed to the injury will transmit pain over the course of treatment for the injury.
Additionally, complications arise through the emergence of primary hyperalgesia and secondary hyperalgesia:35
Primary hyperalgesia – A burn initiates a very powerful inflammatory response, and inflammatory mediators are released, which sensitizes the nociceptors at the injury site. This makes the area of injury as well as the skin immediately adjacent to the injury become sensitive to certain mechanical stimuli, including touching or rubbing as well as to certain chemical stimuli, including the application of antiseptics or topical ointments.
Secondary hyperalgesia - Continuous peripheral stimulation of nociceptors causes greater sensitivity to areas surrounding the area of injury. This sensitivity is exacerbated by certain mechanical stimulation, such as that which occurs from changing wound dressing frequently.
Burns differ in size and degree, which results in differing pain dependent on these factors. Conventionally, burns are classified by the total area of the body surface that was burned as well as depth of the burn. Simple observation may indicate that the larger or deeper the burn is, the more pain the person will feel. Realistically however, even deep burns consist of a combination of depth where the nerve endings were damaged as well as more shallow areas where some of the nerve endings are undamaged. Therefore, all burns elicit a pain response, and it is important that each instance be treated well and thoroughly. Additionally, psychological factors – such as anxiety over the new appearance of the area that was burned – also play an important role in how much pain the individual experiences.
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There is also more than one type of pain seen in the burn recovery process:
Initial acute pain - Energy from the source of the burn leads to cell damage and the release of mediators. Individuals also experience reflex activity as a result of a burn, in which they attempt to remove the area that has been affected from the source to avoid further injury. However, this action is not always a possibility, and the individual ends up with a more severe injury. Additionally, sometimes the patient experiences stress-induced analgesia, in which the release of endorphins in the spinal cord results in there being either little or no pain immediately following the injury.
Pain following hospitalization - A patient may experience various pain classifications following a burn injury. One is procedural pain that is of short to medium duration. This pain can feel highly intense during or immediately following the cleaning of the affected area or when procedures such as skin grafting take place. A patient may also have resting pain, which presents as a dull pain that is of long duration. This type of pain frequently exists when the patient is between procedures. Finally, the patient may experience breakthrough pain. This type of pain is usually of short duration and is linked with resting pain.
Further, there is risk that the changes in damaged nerve fibers and surrounding tissues may lead to the development of chronic pain. In chronic pain syndromes, the sensation of pain continues for much longer than its expected duration. Chronic pain following burn injury can lead to other problems, such as difficulty sleeping, depression, and impairment of rehabilitation. The individual may experience hyperalgesia or allodynia. These issues may start very early in the post-injury course of recovery and can persist for a number of years following the initial injury. Chronic burn pain is extremely difficult to treat utilizing most analgesics unless
nursece4less.com nursece4less.com nursece4less.com nursece4less.com 31 there is inflammation or damage to tissues that is ongoing. Therefore, treatment of chronic burn pain frequently involves antidepressants, anticonvulsants, nerve blocks, or cognitive behavioural therapy.
Postherpetic neuralgia
Postherpetic neuralgia occurs as a complication of shingles, which is caused by the same virus that causes chicken pox. Once an individual has had chicken pox, the virus that caused the disease remains inside the body for the rest of the individual’s life.36 However, as the individual ages, the virus may reactivate. A number of things can cause this reactivation, including physical stress, such as that which occurs when the body is battling an infection or if the individual is taking medication that suppresses the immune system. The resulting infection is shingles.
The shingles rash occurs in the areas of skin that contain the nerve where the virus was reactivated. Shingles generally clears up within several weeks. However, if pain is lasting long after shingles has disappeared, it is then termed postherpetic neuralgia.
Postherpetic neuralgia affects the skin and the nerve fibers, and occurs if nerve fibers are damaged during a shingles outbreak. The damaged fibers are unable to send messages from the skin to the brain in a normal way, and instead sends confusing or exaggerated messages, which causes chronic – and frequently excruciating – pain that can last for months or years.
Pain presents as a burning sensation and can be so severe that it interferes with functions such as sleep and appetite. Those who are 60 years of age and older have the greatest risk of developing postherpetic neuralgia. Those who have shingles on the face are also at greater risk of developing postherpetic neuralgia as opposed to those who experience shingles on other parts of the body. There is currently no cure for the
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NEGATIVE CONSEQUENCE OF PAIN
Effect of acute pain
Acute pain is one of the leading health conditions that today’s society experiences.37 One source indicates that of Americans, pain is the most common ailment over hypertension, diabetes and cancer combined. Acute pain experience comes on quickly and can range from mild to severe pain; however, acute pain usually lasts shorter periods of time, for example, a few weeks, or until the injury has healed. This is in comparison with chronic pain, which lasts for a much longer duration, usually anywhere from weeks to over the course of an individual’s entire lifetime.
Acute pain is generally the result of such events as muscle strains, headaches, broken bones, cramps, dental work, or childbirth. Acute pain events are generally not life threatening; however, if acute pain is left untreated, the patient may experience a decrease in function and an increase in healthcare bills as a result. Not only are there physiological effects that come with acute pain, there is also a psychological component. Individuals who are unable to deal with their pain event or receive effective treatment may exhibit anger and irritability. Additionally, acute pain generally transitions to chronic pain if the acute pain has been prolonged, altering the individual’s way of life.
Effect of chronic pain
Chronic pain is a pain condition commonly thought to occur after prolonged exposure to acute pain. Chronic pain conditions can last for years. The biggest effect chronic pain has on individuals is an alteration of lifestyle; many individuals who experience chronic pain are unable to complete daily tasks in the same way they had previously been able to
nursece4less.com nursece4less.com nursece4less.com nursece4less.com 33 complete them. Chronic pain can also lead to a syndrome known as disuse, which means that people in chronic pain sometimes limit their activities in an effort to avoid pain. This in turn leads to weakness, which prompts the patient to limit activity even further, creating a vicious cycle. Additionally, there may be psychological complications that arise as a result of chronic pain.
Individuals who are in chronic pain frequently experience depression, with some patients experiencing depression so bad that they express suicidal thoughts or behaviors. However, the individual’s psychological state at the time they experience the pain plays a huge role as well. If an individual was already depressed, pain may be perceived as a worse sensation. Additional to diseases such as depression, those living with chronic pain may become easily angered or irritated, or have trouble concentrating. All of these things can lead to further problems in the individual’s daily life. Since the effects of chronic pain can be so life altering, it is important to address the individual’s ongoing need to cope with pain effectively through medication, alternative treatment, and appropriate activity to offer the individual the best quality of life possible.
PATHOLOGY OF PAIN
Past views on pain indicated that sensory input such as pricking one’s finger with a pin would then in turn cause a pain signal to make its way to the brain via one nerve. While pain isn’t entirely understood today, science has revealed that pain is much more complex; therefore, theories on pain continue to evolve.
There are four concepts that are essential to understanding the physiology of pain.38 These concepts are listed as:
Transduction - a process in which afferent nerve endings take part in translating the noxious stimuli into nociceptive impulses.
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Transmission - the process in which impulses progress to the dorsal horn and then travel along sensory tracts and make their way to the brain. Modulation - this process includes the dampening or amplifying of neural signals related to pain. This process occurs primarily in the dorsal horn, but it can also occur elsewhere, with inputs from both ascending and descending paths. Perception - this last concept refers to how pain is experienced by the individual. Pain is highly subjective and perception is a result of the interaction of the previous three concepts as well as certain psychological and environmental aspects.
Researchers believe that pain can manifest and affect men and women in different ways.1 Sex hormones such as estrogen and testosterone play a part in this; however other factors such as age, psychology and culture may also play a part in the difference between how men and women respond to pain. For instance, young children may learn ways of responding to pain that are based on how they are treated when pain occurs. Therefore, if a child is encouraged to tough out the pain, or their pain is dismissed, the child learns not to highlight their discomfort.
Many researchers believe that women tend to recover more quickly than do men from pain, partly because estrogen helps women recognize pain more easily. Women also seek help more readily and quickly for pain. Women are also not as likely to let pain define or control their lives. This is likely because women keep more resources at the ready for when they experience discomfort; additionally, women are more likely to speak readily about their pain, seek support, or utilize coping skills such as taking medication or using alternative therapies to deal with pain. However, women have a lower tolerance for pain than do men, which may be part of the reason why women have more coping skills at the ready than do men.
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Pain is also different in younger and older people. For older people, pain is the number one issue and complaint. One in five older Americans take painkillers regularly. The American Geriatrics Society39 has issued guidelines to help with managing pain in older adults. These guidelines include incorporating non-drug approaches into the treatment regimen, such as exercise. They also recommend that older adults avoid utilizing NSAIDs (non-steroidal anti-inflammatory drug) because these drugs come with undesirable side effects that can manifest more prominently in older adults, such as gastrointestinal bleeding.
Pain in younger individuals also mandates special attention. This is particularly the case since younger individuals cannot always describe the magnitude of the pain they are in. Treating children poses a challenge to both practitioners and parents; however, there should be care taken to ensure that the pain of a child is never inadvertently undertreated. Utilizing scales that rate such clues such as crying or responsiveness are important tools to help accurately diagnose pain in children.
THEORIES OF PAIN
Theories of pain have changed throughout history, particularly as scientists have gained more insight into how the body operates. Before neurons were discovered and their part in pain was determined, there were various theories attributing the phenomenon of pain to different body parts. Greek theory is perhaps the earliest, and there were a number of competing theories to explain pain. For example, Aristotle thought that pain was the result of evil spirits entering the body. Hippocrates thought that pain was the result of an imbalance of the body’s vital fluids.40
As time progressed, so did theories of pain. For example, Avicenna posited in the 11th century that there were different feeling senses, which included titillation, touch and pain.41 However, all of these theories were a bit misguided, as before the scientific Renaissance that took place in
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Europe many had a poor understanding of pain. The predominant thought was that pain started outside the body, perhaps being a punishment from God.42
Descartes posited a more plausible explanation of pain by stating that pain was a kind of disturbance that travelled down along the nerve fibers, with the disturbance eventually reaching the brain, and therefore awareness.40,43 Descartes’ theory changed the perception of pain from being that of mystery or spirit into a physical sensation. Descartes theory was an early indication of specificity, which was developed in the 19th century.44 Another theory that was popular in the 19th century was intensive theory, the theory that thought of pain as an emotional state that was the result of unusually strong stimulus, including temperature, intense light, or pressure.45
In the 20th century, Sinclair and Weddell developed the peripheral pattern theory; this theory posited that the endings of skin fibers were all identical and that pain is the result of intensely stimulating these fibers.44 Another theory that was popular in the 20th century was the theory of gate control, which indicated that both thin and large nerve fibers carried information from the injury site to a couple destinations located in the dorsal horn.43 Both of these theories have since been replaced with more modern pain theories.
In the mid-20th century, Melzack and Casey offered a theory of pain that focused on three dimensions: cognitive-evaluative, sensory-discriminative and affective-motivational.46 The idea behind this theory was that the intensity and unpleasantness of pain sensation are not just determined by pain magnitude, but that cognitive activity can affect perceptions of certain aspects of pain. This theory led to new treatment recommendations: “Pain can be treated not only by trying to cut down the sensory input by anesthetic block, surgical intervention and the like, but
nursece4less.com nursece4less.com nursece4less.com nursece4less.com 37 also by influencing the motivational-affective and cognitive factors as well”.47,48 This theory is still influential today.
Today’s theories focus on how and which sensory fibers differentiate between mild and extreme stimuli. It has been determined that some sensory fibers do not differentiate, while others, such as nociceptors, only respond to highly intense stimuli.
Craig and Denton believe that pain is in a certain class of feelings, known as homeostatic emotions, which are feelings that are reflexive feelings. These feelings also include thirst or hunger, or fatigue. These feeling stem from the internal state of the body and are communicated by interoceptors to the central nervous system. Behavior is then prompted in an attempt to maintain the internal balance of the body. These emotions are different from classic emotions in that classic emotions are prompted by environmental stimuli, whereas homeostatic emotions are prompted by physical stimuli.49,50
FACTORS AFFECTING PAIN
Different factors may affect pain perception. There are in fact a number of factors that affect the perception of pain.2
Location and severity
Pain varies in intensity and quality. It may be mild, moderate, or severe. In terms of quality, it may vary from a dull ache to sharp, piercing, burning, pulsating, tingling, or throbbing sensations; for example, the pain from jabbing one's finger on a needle feels different from the pain of touching a hot iron, even though both injuries involve the same part of the body. If the pain is severe, the nerve cells in the dorsal horn transmit the pain message rapidly; if the pain is relatively mild, the pain signals are transmitted along a different set of nerve fibers at a slower rate.
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The location of the pain often affects a person's emotional and cognitive response, in that pain related to the head or other vital organs is usually more disturbing than pain of equal severity in a toe or finger.
Gender
Recent research has shown that sex hormones in mammals affect the level of tolerance for pain. The male sex hormone, testosterone, appears to raise the pain threshold in experimental animals, while the female hormone, estrogen, appears to increase the animal's recognition of pain. Humans, however, are influenced by their personal histories and cultures as well as by body chemistry. Studies of adult volunteers indicate that women tend to recover from pain more quickly than men, cope more effectively with it, and are less likely to allow pain to control their lives.
One explanation of this difference comes from research with a group of analgesics known as kappa-opioids, which work better in women than in men. Some researchers think that female sex hormones may increase the effectiveness of some analgesic medications, while male sex hormones may make them less effective. In addition, women appear to be less sensitive to pain when their estrogen and progesterone levels are high, as happens during pregnancy and certain phases of the menstrual cycle. It has been noted, for example, that women with irritable bowel syndrome (IBS) often experience greater pain from the disorder during their periods.
Family
Another factor that influences pain perception in humans is family upbringing. Some parents comfort children who are hurting, while others ignore or even punish them for crying or expressing pain. Some families allow female members to express pain but expect males to "keep a stiff upper lip." Additionally, birth order can play a part in how the individual is treated when in pain; and, sometimes, oldest children are expected to
nursece4less.com nursece4less.com nursece4less.com nursece4less.com 39 take charge and keep their pain responses to themselves, while the “baby” of the family is allowed to freely express his or her pain responses. People that suffer from chronic pain, as adults, may be helped by recalling their family's spoken and unspoken messages about pain, and working to consciously change those messages.
Culture and ethnicity
In addition to the nuclear family, a person's cultural or ethnic background can shape his or her perception of pain. People who have been exposed through their education to Western explanations of and treatments for pain may seek mainstream medical treatment more readily than those who have been taught to regard hospitals as places to die. On the other hand, Western medicine has been slower than Eastern and Native American systems of healing to recognize the importance of emotions and spirituality in treating pain.
The recent upsurge of interest in alternative medicine in the United States is one reflection of dissatisfaction with a one-dimensional conventional approach to pain. There are also differences among various ethnic groups within Western societies regarding ways of coping with pain. One study of African American, Irish, Italian, Jewish, and Puerto Rican patients being treated for chronic facial pain found differences among the groups in the intensity of emotional reactions to the pain and the extent to which the pain was allowed to interfere with daily functioning. However, much more work on larger patient samples is needed to understand the many ways in which culture and society affect people's perception of and responses to pain.
EDUCATING PATIENTS
The prevalence of pain is high, and as a result exacts quite a large toll on society. Unfortunately, both public and professional knowledge regarding pain falls short. In particular, although pain should be a public health
nursece4less.com nursece4less.com nursece4less.com nursece4less.com 40 issue, this knowledge deficit surrounding pain and its management stems from the fact that pain is remarkably under addressed. Brown states, “If pain was formally recognized, as part of our national public health policy, public awareness campaigns would highlight pain prevention and cover risk factors for the development of the disease”.142 However, since pain is not a public health priority, the burden remains on practitioners, patients, and caregivers to educate themselves and to advocate for better pain management techniques.
Education strategies and tools for patient and caregivers should be presented in a variety of mediums that enhance wider learning. These include pain-specific brochures being displayed in-office, newsletters, videos, audio content, posters, the use of pain notebooks to track pain progression, referrals to credible web sites, structured education, and web-based tools to educate and manage pain.
There are several key objectives that practitioners should keep in mind as they work to educate patients and caregivers. These objectives are listed below:
Increase understanding of pain; Address disparities and cultural differences with care; Discuss the goals of treatment; Address more than just the physical aspects of pain; psychosocial and spiritual aspects should be addressed as well; Empower individuals to advocate for themselves by providing tools, handouts, or other tips; Teach how to use pain treatment options appropriately; Create an environment in which people can discuss pain openly and ask questions; provider-patient communication is essential.
Educating patients is a central tool in improving the management of pain. Therefore, practitioners should be prepared to offer educational tools to
nursece4less.com nursece4less.com nursece4less.com nursece4less.com 41 patients that present pain in a way that the individual will understand. Additionally, it is essential that practitioners work to dispel myths and misperceptions about pain to provide a better educational experience. This can be done through dispelling the six most common myths about pain. These myths are outlined as:143
Pain is “all in your head”142 is true to an extent that pain resides in the head, as the individual’s brain is responsible for processing the pain perception. However, this does not indicate that pain is an imaginary occurrence, even if the source of the pain is not understood that well. The pain is real to the person experiencing it; therefore, it must be adequately addressed. Pain is an occurrence that one simply must live with. Traditionally views on pain state that pain is the inevitable consequence of a disease or condition. However, the fact is that most pain can be avoided or relieved through careful pain prevention or management. Pain is just a natural part of growing older. It is true that pain becomes more common as people age, mostly because the conditions that cause pain, such as arthritis, shingles, or osteoporosis, are more common in older adults. However, regardless of age, pain is not something that anyone should have to endure untreated. The practitioner is the best judge of pain. There is not much of a relationship between what the practitioner judges the pain to be and the actual patient experience. This means that the patient must have the final word on pain existence and severity. The most reliable pain indicator is self-report. Seeking medical care for pain means that the patient is weak. Seeking medical care for pain often has a stigma attached because patients don’t want practitioners to view them as whiners, or bad
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patients. For this reason, patients don’t always mention pain and how it affects their life. Using strong pain medications leads to addiction. It is important to remember that drugs such as opioids are not universally addictive. There are risks associated with their use, but risks may be managed through properly prescribing and monitoring the use of the medication (i.e., taking the medication as it is prescribed).
There are several things that patients who experience pain want to know about their pain. It is therefore important to keep these things in mind when educating the patient or caregiver. These would include:144
How to understand the pain, most specifically, how to understand the cause of the pain; What to expect in terms of when the pain may be experienced and what it will feel like; Treatment options, which include options involving medication, surgical treatments, and nonpharmacological approaches; The best way to cope with pain; How pain can negatively impact the individual’s life in a variety of ways, including physical, psychological, and social impacts; How to connect with other people experiencing the same kind of pain to gain understanding of their pain through peer experience; Where to find specialists to help manage pain, as well as who should be consulted; How to effectively describe pain.
Methods to enhance pain communication are important. These methods are listed below as:
1. Utilize pain questions that are kept handy for each appointment. These questions include: a. Where is the pain located?
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b. How is the pain characterized? c. When and how did the pain start? d. Is the pain intermittent or continuous? e. What makes the pain feel better or worse – factors would include medication, activity, rest, stress, or the application of hot or cold to the affected area. f. Has the patient experienced any sleep disturbances as a result of their pain? g. Does the patient have any ongoing medical concerns that could have caused or could be exacerbating pain? h. How is the individual functioning at school or work? i. Does the pain affect certain quality of life activities, such as sex or recreation? j. What does the patient expect from pain treatments? 2. Instruct the individual to keep a pain diary and to utilize pain intensity scales to measure pain. Pain diaries not only help patients keep track of and measure their pain experiences and the effects of the pain on a variety of functions; they also offer practitioners the opportunity to educate the patient about their pain. 3. Encourage the individual to reach out for support. Support groups, whether they are in person or online, offer patients the opportunity to connect with others who are suffering in the same way as well as provide an opportunity for education through peer information exchange.
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SUMMARY
Pain is considered a “universal disorder”1 that comes in many forms. Up to 80% of visits to physicians are for treatment of pain. Regardless of the form that pain is seen in, everyone experiences pain, with the perception of pain occurring differently in each individual.
At its simplest, pain serves to warn the individual that something is not quite right. Pain can, however, be so severe that it disrupts productivity, wellbeing, and indeed, the entire life of the individual experiencing the pain. At its core, pain is complex and differs greatly among individuals, including those who seem to have identical injuries or illnesses.
It is also important to address the education of the individual as well as their friends and family in order to ensure effective pain management. Pain that is not managed effectively can alter the physical and psychological state of the individual experiencing the pain. Understanding how to effectively manage pain is therefore essential. Additionally, it is important as well to be mindful of the treatment gap that exists in pain management. Women, children and older adults are at greater risk of being negatively affected by chronic pain and frequently end up receiving treatment that falls short. Through education, careful listening, and exploration of the variety of treatment methods available to practitioners, successful pain management may be attained.
Please take time to help the NURSECE4LESS.COM course planners evaluate nursing knowledge needs met following completion of this course by completing the self-assessment Knowledge Questions after reading the article. Correct Answers, page 46.
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1. At least 3 types of somatic discernable pain include:
a. surface pain b. sub-surface pain c. deep pain d. all of the above
2. True or False. The visual analog scale is ideal for use with individuals who possess a strong ability to define their pain.
a. True b. False
3. Chronic pain is pain that:
a. persists for 1 to 3 months b. can be affected by physical impairments and lack of energy c. can be associated with depression, anxiety, anger and fear d. answers b and c above
4. Melzack and Casey offered a theory of pain focused on:
a. cognitive-evaluative, sensory-discriminative, affective- motivational dimensions b. cultural and superstitious beliefs c. age-specific factors d. none of the above
5. Education for patient and caregivers include a variety of tools, such as:
a. pain-specific brochures b. videos/audio material and web-based sites c. pain notebooks d. all of the above
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Correct Answers: 1. d 2. a 3. d 4. d 5. d
Footnotes:
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