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Pain
Pain
Pain
Pain
Pain
Pain
Pain
Pain
Pain
Pain
Pain
Pain
Pain
Pain
Pain
Pain
Pain
Pain
Pain
Pain
Pain
Pain
Pain
Pain
Pain
Pain
Pain
Pain
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Pain

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  • 1. Pain and its management
  • 2. Significance of Pain
    • Pain
      • A clear example of the mind–body (BPS) model (and most common problem associated with going to HCP)
      • Adaptive as a biological warning signal (e.g., congenital insensitivity to pain)
  • 3. The Physiology of Pain
    • “ How you know that you stubbed your toe” handout
      • 1. Nociceptor — a specialized neuron that perceives and responds to painful stimuli
      • 2. Special pain nerve fibers
        • A-Delta Fibers -- Large, myelinated (fast) nerve fibers that transmit sharp, stinging pain
        • C-Fibers -- Small, unmyelinated nerve fibers that carry dull, aching pain
  • 4. The Physiology of Pain
    • “ How you know that you stubbed your toe” handout
      • 3. Dorsal Horn — pain’s “arrival” to the CNS
      • 4. Brain – perception of pain. Heavily influenced by emotion, context, expectations, etc. (illustration next slide)
  • 5. Pain Pathways  PAG area of midbrain (next slide)
  • 6. Pain Pathways
    • Periaqueductal Gray (PAG)
      • midbrain region-- activates a descending neural pathway that uses serotonin to close the “pain gate”
  • 7. Gate Control Theory
    • Proposed by Melzack & Wall (1965)
      • A neural “gate” in the spinal cord regulates the experience of pain
      • Pain is not the result of a straight-through sensory channel
  • 8. The Gate Control Theory of Pain
  • 9. The Biochemistry of Pain
    • Substance P (pain NT)
    • NTs (e.g., serotonin) that alter “gate”
    • Enkephalins, endorphins, dynorphins (endogenous opioids)
  • 10. Psychosocial Factors in the Experience of Pain
    • Stress
      • pain perception is influenced by stress (emotionality and pain experience)
      • stress leads people to engage in behaviors (i.e., grinding teeth, tensing muscles), which in turn lead to pain
      • Good news: Stress-Induced Analgesia (SIA) — a stress-related increase in tolerance to pain, mediated by the body’s endogenous opioids
  • 11. Psychosocial Factors in the Experience of Pain
    • Learning
      • modeling
      • secondary gain / reinforcement
      • culturally learned -- groups establish norms for the degree to which suffering should be openly expressed and the form that pain behaviors should take
  • 12. Psychosocial Factors in the Experience of Pain
    • Cognition
      • anticipation of pain is often worse than pain itself
      • placebo and pain (e.g., child who gets ear examined feels better)
      • expectations of ability to cope (e.g., control and pain – PCA morphine )
  • 13. Pain Management
    • Overview:
      • The Fifth Vital sign
        • Body Temp, Pulse, BP, Resp Rate, Pain
      • Measuring pain
      • Chronic pain issues
      • Treatment
  • 14. Measuring Pain
    • Psychophysiological Measures
      • Electromyography (EMG) —muscle tension and pain
      • Indicators of autonomic arousal — HR, etc.
  • 15. Measuring Pain
    • Behavioral Measures
      • Pain Behavior Scale
        • e.g., vocal complaints, grimaces, awkward postures, mobility
  • 16. Measuring Pain
    • Self-Report Measures
      • Structured interviews (When did the pain start? How has it progressed?)
      • Pain rating scales (numerical ratings or a pain diary)
      • Standardized pain inventories
        • McGill Pain Questionnaire (MPQ): sensory quality, affective quality, evaluative quality of pain
  • 17. Chronic Pain Management
    • Acute vs. Chronic pain
    • Who becomes a chronic pain patient?
      • Not necessarily related to pain intensity
      • More important are reactions:
        • Physical (postural changes)
        • Functional disability (pain interferes with life activities)
        • Reactions to pain episodes and to stress
    • The toll of chronic pain (video clips from “Psychology of Pain”)
  • 18. The toll of chronic pain
    • Dysfunction
      • report high levels of pain, feel they have little control over their lives, and are extremely inactive
    • Interpersonal distress
      • perceive little social support and feel other people in their lives don’t take their pain seriously
      • often poor communication
      • sexual relationships deteriorate
    • Cost
      • Huge medical bills
      • Undergone many treatments (e.g., multiple surgeries) and rely on painkillers
      • Job loss/disability
  • 19. Treating Pain
    • Pharmacological Treatments
      • Analgesic (pain-relieving) drugs are the mainstay of pain control
      • Include “central acting” opioid drugs and “peripherally acting” nonopioid drugs
  • 20. Opioid Analgesics
    • Formerly called narcotics
    • Agonists (excitatory chemicals – e.g., morphine) act on receptors in the brain and spinal cord
    • Patient controlled analgesia — addresses control and undermedication
  • 21. Nonopioid Analgesics
    • Nonsteroidal Anti-Inflammatory Drugs (NSAIDs)
      • Aspirin, ibuprofen -- relieve pain and reduce inflammation at the site of injured tissue
  • 22. Other Medical Interventions
    • Counterirritation
      • Analgesia in which one pain is relieved by creating another, counteracting stimulus
    • Transcutaneous Electrical Nerve Stimulation (TENS)
      • A counterirritation form of analgesia involving electrically stimulating spinal nerves near a painful area
  • 23. Cognitive-Behavioral Therapy
    • Cognitive-Behavioral Therapy (CBT)
      • A multidisciplinary pain-management program that combines cognitive, physical, and emotional interventions
        • used by 73% of clinicians who treat chronic pain
  • 24. Cognitive-Behavioral Therapy
    • Components
      • Education and goal-setting component is used to clarify client’s expectations
      • Cognitive interventions to enhance patients’ self-efficacy and sense of control over pain
      • Teaching new skills for responding to pain triggers
      • Promote increased exercise and activity levels
  • 25. Cognitive-Behavioral Interventions
    • Biofeedback / muscle relaxation
    • Cognitive distraction
      • Imagery / virtual reality therapy (see Sci American Aug 2004)
      • Hypnosis
    • Cognitive restructuring — to challenge illogical beliefs and maladaptive thoughts (next slide)
  • 26. Cognitive Errors in the Thinking of Pain Patients
    • Catastrophizing — overestimating distress and discomfort
    • Overgeneralizing — global and stable attributions that pain will never end and will ruin one’s life
    • Victimization — Why me?
    • Self-blame
    • Dwelling on the pain
  • 27. Reshaping Pain Behavior
    • Identify the events (stimuli) that precede pain behaviors (responses) as well as the consequences that follow (reinforcers)
  • 28. Which Approach to Pain Control Works Best?
    • It depends on which type and aspect of pain
    • Overall, the most effective programs are multidisciplinary in nature, combining the cognitive, physical, and emotional interventions of CBT with the judicious use of analgesic drugs
    • Effective programs also encourage patients to develop (and rehearse) a specific pain-management program
    • Group settings are probably most effective

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