There are various techniques forcontrolling pain• Pain relieving chemicals• Behavioural and cognitive methods for treating pain• Hypnosis• Inside oriented psychotherapy• Physical and stimulation therapies for pain
Pain relieving chemicals• Chemical - Aspirin -Acetylsalicylic acid - found in Willow trees, as discovered by a clergyman from Chipping Norton in 1763• it relieved his rheumatism and bouts of fever.
Chemicals• Aspirin, Ibuprofen, Paracetamol (acetaminophen) Against pain Against inflammation Against fever Opium used before then, as early as 1550 BC
Chemicals • From Opium is produced morphine, heroin and codeine - all produce analgesia, drowsiness, change of mood, mental clouding.
Chemicals • Inhibit pain messages (close the gate). Opiates work well because many nerves respond to opiates.
Chemicals • Peripherally active analgesics, for example aspirin which acts on the peripheral nervous system by inhibiting the synthesis of neurochemicals • Centrally acting analgesics, for example narcotics derived from the opium poppy, which acts on the central nervous system. There is a problem of tolerance and addiction though. • Local anaesthetics. These act directly on the site whether pain originates. The problem is that the drugs will paralyse muscles in the region as well.
Chemicals • Indirectly acting drugs. These drugs include sedatives, tranquillisers, antidepressants, and anticonvulsants. Sedatives, such as barbiturates and tranquillisers such as diazepam are depressants that depress bodily functions. The problem is the patient could become psychologically and physically dependent upon the drugs. Antidepressants, such as doxepin, helped patients by reducing the psychological depression that accompanies chronic pain. Anticonvulsants inhibit random nerve impulses, which will control some types of pain.
Chemicals• Patients in hospital tend to demand medication too often, which inconveniences the busy staff. Allowing the patient to self-administer their medication has led to the unexpected result that they receive less of the drug than others who receive injections on demand. It would seem that once the patient feels in control they can manage without the drug for longer.
Chemicals• Naturally the machine that allows the patients to self inject does restrict the amount and rate of injections in order to avoid an overdose, but this would not explain why self administering patients manage on less pain killer than other patients, who would be subject to a controlled dose as well.
Chemicals• In short, Keeri-Szanto (1979) - machine that dispenses tablets by the patients bed, with lock to prevent patient from over-dosing - patient self-administering in this way reduces their drug intake, compared with when issued with tablets from the medical staff.
Behavioural and cognitivemethods for treating pain• Operant - useful if patient has developed inappropriate response to the pain (e.g. too many tablets). • Use social reinforcement to gradually increase activity levels • Gradually decrease the use of medication • Training carers not to reinforce pain behaviours by being sympathetic
The operant approach• An example of the operant approach for a child with burns.• The child cries and complains of pain when ever she puts on her splints. The hospital staff has been giving attention to the crying behaviour. The remedy is as follows: • Ignore the pain behaviours • Provide rewards for compliant behaviour • Give praise if the child helps in putting on the splints etc..
The operant approach• A technique for reducing medication is as follows:• Use a fixed schedule, such as every four hours, rather than when ever the patient requests it. The drug therefore does not become a reward for the patient. In addition, the medication is mixed with flavoured syrup to mask its taste.
The operant approach• Over a period of several weeks the dosage is gradually reduced, but the patient, because of the syrup, does not detect this.
Problems with these studies• Studies often do not include control groups, so it is difficult to know whether the operant methods changed the behaviour or some other factor, such as being studied.• The technique is not suitable for chronic progressive pain, such as in cancer patients.
Problems with these studies• Patients who are unwilling to participate or who receive disability compensation are not likely to benefit from this technique.
Relaxation and biofeedback• Patients using the technique of progressive muscle relaxation focus their attention on specific muscle groups while alternately tightening and relaxing these muscles. Patients who received training in relaxation to control pain are urged to use this technique to reduce feelings of stress, particularly if they feel pain episodes coming on.
Relaxation and biofeedback• In biofeedback procedures, patients learned to exert voluntary control over a bodily function, such as heart rate, by monitoring its status with information, usually from electronic devices. Muscle contraction headaches can be treated by biofeedback procedures.
Relaxation and biofeedback• Patients learned to control the tension of specific muscle groups -such as those in the scalp and neck- by receiving biofeedback from an electromyograph (EMG.) device.
Relaxation and biofeedback• Another method used for migraine headaches, focuses on the constriction and dilation of arteries -such as those in the head- which can be measured indirectly on the basis of the temperature of the skin in the region of the target blood vessels. Biofeedback techniques, such as these, can be used at home whenever a patient feels a pain episode is about to begin.
Relaxation and biofeedback• Biofeedback techniques have been shown to be successful in controlling headaches, but there has been little evidence of biofeedback procedures being effective in relieving other types of pain. Treatment with relaxation and biofeedback is about twice as effective in relieving pain as placebo conditions.
Relaxation and biofeedback• A combination of relaxation and biofeedback has been shown to be more successful than biofeedback on its own. Biofeedback has been shown to be more successful than relaxation techniques. (Holroyd & Penzien, 1985). There is much variability in the success of these techniques.
Relaxation and biofeedback• Middle-aged and elderly patients seem to gain relatively little relief with these treatments (Blanchard & Andrasik, 1985). Biofeedback treatment is relatively expensive to conduct, and the likelihood of improvement beyond just using relaxation for many pain conditions may not justify its expense (Turk, Meichenbaum & Berman, 1979).
Relaxation and biofeedback• There is some evidence that most children and people who show certain psychophysiological patterns, such as a high correlation between their pain and EMG. Levels, may be better candidates for biofeedback treatment than other people (Attanasio et al., 1985).
Cognitive techniques• Researchers asked children and adolescents what they think about when getting an injection at their dentists (Brown, OKeeffe, Sanders, & Baker, 1986). Over 80% of these subjects reported thoughts that focused on negative emotions and pain, such as, "this hurts, I hate injections," "Im scared," and "my heart is pounding and I feel shaky."
Cognitive techniques• One fourth of the subjects had thoughts of escaping or avoiding the situation, as in, "I want to run away." These types of thoughts focus the persons attention on the unpleasant aspects of the experience and make the pain worse (Turk, Meichenbaum, & Genest, 1983).
Cognitive techniques• Many people use cognitive strategies to modify their experience of pain. For instance, by 10 years of age, many children reports that they tried to cope with pain in a dental situation by thinking about something else or by saying to themselves such things as, "its not so bad," or, "be brave" (Brown, OKeeffe, Sanders, & Baker, 1986).
Cognitive techniques• People cope with chronic pain by using one of two strategies: – Active coping, in which they try to keep functioning by ignoring the pain or keeping busy with an interesting activity. – Passive coping, such as taking to bed or curtailing social activities.
Cognitive techniques• The problem with passive coping is that this leads to feelings of helplessness and depression, which leads to more passive coping, and so on (Smith & Wallston, 1992).
Cognitive techniques• Patients who feel that their pain will last a very long time and their doctors dont know what causes their pain tend to cope poorly. On the other hand, patients who believe that they understand the nature of their pain and that their conditions will improve tend to use active coping strategies.
Cognitive techniques• Coping techniques can be classified into three basic types: – Distraction, – Imagery, – Redefinition (Fernandez, 1986).
Distraction• Distraction is the technique of focusing on a non-painful stimulus in the immediate environment in order to divert our attention from discomfort. Research has shown that distraction is more effective if the pain is mild or moderate than if it is strong (McCaul & Malott, 1984).
Distraction• A laboratory experiment involving college students rated the subjects pain distress for holding their hand in cold water. Subjects given a distraction task involving numbers did not give lower pain ratings than controls, who just watched numbers being displayed (McCaul, Monson, & Maki, 1992).
Distraction• This result might be because subjects needed to believe that these distraction techniques would relieve pain.• Subjects believing that loud sound would relieve pain, listened to the sound and did not feel as much pain (using the cold- presser procedure, hand in cold water) as did controls who were listening for a non- existent hum (Melzack, Weisz, & Sprague, 1963).
Distraction• Distraction works best for acute pain, such as the pain experienced in a dental surgery.• Chronic sufferers might find it useful to engage in an extended activity, such as watching a film or reading a book.
Imagery• Non-pain imagery-sometimes called guided imagery-is a strategy whereby the person tries to alleviate discomfort by conjuring up a mental scene that is unrelated to or incompatible with the pain (Fernandez, 1986). Therapists encourage the patient to include aspects of a variety of senses: vision, hearing, taste, smell, and touch.
Imagery• Imagery is like distraction except that imagery is based on the persons imagination rather than on real objects. The advantage here is that the patients can develop one or more scenes that work reliably and carry them around in their heads. Imagery works best for people with mild or moderate pain than with strong pain. A disadvantage is that some patients are less adept in imagining scenes than others.
Redefinition• Pain redefinition is when the person substitutes constructive or realistic thoughts about the pain experience for ones that arouse feelings of threat or harm. Therapists can help by providing information about the sensations to expect in medical procedures.
Redefinition• There are basically two kinds of self- statements for controlling pain:• Coping statements emphasise the persons ability to tolerate the pain by saying to themselves, "it hurts, but youre in control," or, "be brave-you can take it."
Redefinition• Reinterpretative statements are designed to negate unpleasant aspects of the pain, as when people think, "it is not so bad," "its not the worst thing that could happen," or, "it hurts, but think of the benefits of this experience."
Evaluation of cognitivestrategies in controlling pain• Cognitive strategies are effective in reducing acute pain. Distraction and imagery seem to be particularly useful with mild or moderate pain, and redefinition appears to be more effective with strong pain.
Evaluation of cognitivestrategies in controlling pain• A combination of behavioural and cognitive methods is at least as effective as chemical methods in reducing chronic muscle-contraction headaches (Holroyd et al., 1991). Patients with a variety of medical problems including arthritis, amputation, and spinal cord injury reported that redefinition helped in reducing the experience of pain more than distraction did (Rybstein-Blinchik, 1979).
Evaluation of cognitivestrategies in controlling pain• Arthritis sufferers received a five-week pain control programme that included training in distraction, imagery, and redefinition. The programme gave special emphasis to having the patients use these techniques in specific painful activities, such as carrying groceries, climbing stairs, and mopping floors.
Evaluation of cognitivestrategies in controlling pain• A control group simply received a self-help book for arthritis sufferers. The control group showed little improvement but the treated group reported having less pain, greater self-efficacy, less depression, and improved Sleep patterns.
Hypnosis• Hypnosis produces a high degree of analgesia in only a minority of individuals. Those people who can be hypnotised very easily and deeply seem to gain more pain relief from hypnosis than those who are less hypnotically susceptible. Hypnosis could be seen as a form of relaxation. Hypnosis often produces states of heightened attention to internal images and inattention to environmental stimuli.
Cold Pressor Task (CPT)
Muscle Ischemia Task (is-KEme-ah)
Hypnosis• Laboratory research on acute pain, induced by cold-presser or muscle-ischemia procedures, has found that:• Hypnosis can reduce pain.• The people who gained the most pain relief are highly responsive to other suggestions, such as that their arm is becoming light.• Whether under hypnosis or not, people tend to use distraction and redefinition techniques.
Hypnosis• People usually show as much pain reduction using cognitive strategies as they do under hypnosis (Barber, 1986).• Hypnosis is mainly effective for relieving acute pain. There is little evidence to suggest that hypnosis would be effective for relieving chronic pain.
Insight-orientedpsychotherapies for pain• This technique involves chronic pain patients gaining insights into the way that the pain is affecting their behaviour and the way their interpersonal relationships are being affected. Pain behaviour is seen as part of "pain games" they play with other people (Szasz, cited in Bakal, 1979).
Insight-orientedpsychotherapies for pain• In these games, the patient takes on a role in which they continually seek to confirm their identity as suffering persons, maintain their dependent lifestyles, and receive various rewards, such as attention and sympathy. The patients are most likely unaware of the game they are playing; it is the purpose of this psychotherapeutic approach to make them aware.
Surgical attempts• Cutting nerve pathways - gives temporary relief. Only recommended for people who are terminally ill.
Physical therapies• Manual therapies e.g. massage• Mechanical therapies e.g. traction• Heat treatments e.g. microwave diathermy, ultrasound.• Cold treatments e.g. ice packs
Physical therapies• Transcutaneous electrical nerve stimulation.• Not known how heat works, but fits in with the gate theory (closes the gate) Mild pulses of electricity in painful areas probably works in the same way.