skin, surfaces of the joints, periosteum , walls of the arteries, and certain structures in the skull. Other organs, such as the gut and muscles, have fewer pain receptors. It is interesting to note that the brain itself does not have any pain receptors and is therefore insensitive to pain! but also by certain products present in the body and released as a result of trauma, inflammation or other painful stimuli. Examples of these substances are bradykinins, serotonin, potassium ions and acids (such as lactic acid, which causes muscle pain after heavy exercise
Huge difference in copingAny threat to health or new illness acts as new problem, patient has to solve problemThe way people go about it is to problem solve... Forming an internal representation which determines what you do (how you think affects how you feel and react)IdentityCauseTimelineConsequencesCure / Control
Presentation pain management
“Pain is whatever the experiencing
person says it is, existing where
he/she says it does”
Physiology of pain
In its simplest form, the pain circuit in the body
can be described as follows
• pain stimulates pain receptors, and this stimulus
is transferred via specialised nerves to the spinal
cord and from there to the brain.
• The pain stimulus is processed in the brain,
which then sends an impulse down the spinal
cord and via appropriate nerves which command
the body to react, for instance by withdrawing
the hand from a very hot object.
• Pain receptors are present everywhere in the
Pain receptors are free nerve endings.
There are three types of pain receptor stimuli:
mechanical, thermal and chemical.
A mechanical stimulus e.g. high pressure or
stretching; thermal pain stimulus would be
extreme heat or cold.
Chemical pain receptors can be stimulated by
chemicals from within and outside the body.
Pain nerve fibres
• Pain stimulus is transmitted from the receptors
through peripheral nerves to the spinal cord and
from there to the brain.
This happens via two different types of nerve
fibre: “fast pain” and “slow pain” fibres
Fast pain is well localised, sharp and “cutting”
and do not radiate.
Fast Pain Nerve Fibres
• They are thick nerve fibres called A-delta fibres.
Because of their relative thickness.
Pain stimulus are transferred very fast at a
speed of 2-5s/m
This allows the body to withdraw immediately
from the painful and harmful stimulus in order to
avoid further damage
Slow Pain Nerve Fibre
• They are thin nerve fibres called c nerve
• Pain impulse are transmitted slowly to the
brain, at a speed of less than 2 m/s.
• The body responds by holding the
affected part immobile (guarding, spasm
or rigidity), so that healing can take place.
Pain transmission in the spinal cord and
• The peripheral nerves carry the pain impulse to
the spinal cord.
In the spinal cord, fast pain and slow pain are
carried up to the brain via different pathways
The impulse of the fast pain goes to the cortex,
allowing for the relatively precise localisation of
the pain stimulus.
The impulse from slow pain is distributed
diffusely in the brain, with each area eliciting a
Characteristics of fast pain and slow
• Transmitted by very thin nerve
• Poorly localised
• All internal organs (except the
• Body wants to be immobile to
allow healing (guarding,
• Pain often radiates, or is
• Transmitted by relatively
thicker (and therefore faster
conducting) nerve fibres
• Well localised
• Mainly skin, mouth, anus
• Immediate withdrawal of
stimulation to avoid further
• Pain does not radiate
• Little relief from opioids
Reviewed by Prof CL Odendal, senior specialist at the
department of anaesthesiology at the University of the
Free State, April 2010.
Pain in the Elderly
• Effects of aging on pain sensation, perception, and
behaviour are not well established
Compared with younger adults, elderly persons rely more on
slow/second pain (C fibre) than on fast/ first pain (A fibre).
• Another well-documented finding in the elderly is a slower
response time to pain
• No evidence exists that pain intensity lessens with age
• Altered reactions to painful events may be due to loss of
communications skills, cognitive abilities, or the failure of
basic reflexes due to aging
• Additionally, pain in the elderly may be manifested as
something other than pain, such as delirium
Pain in Children
• Children and young people have a right to appropriate
prevention, assessment and control of their pain
Historically, pain has been underestimated and under
treated in children and particularly babies.
Evidence shows that pain is inadequately dealt with for
children, requiring better prevention, assessment and
In order to treat children's pain effectively, a thorough
pain assessment is necessary; a number of guides are
available to do this
• British association for Emergency Medicine
Clinical Effectiveness committee: Guideline for the
management of pain in children
How do we assess pain?
• Self report
• Use pain rating tools
• Non-verbal signs
• Assess on movement
Severe Pain (3)
“Pain is whatever the patient says it is”
„Hurts as much
as I can imagine
Moderate Pain (2)
Mild Pain (1)
„Hurts just a little bit‟
No Pain (0)
„Happy because I
don‟t hurt at all‟
Always assess on movement
Other Pain tools
Intensity scores - VAS, Categorical
Pain relief scales
Quality of Life Questionnaire
Brief Pain Inventory
Pain Self Efficacy Questionnaire
What do we assess?
What needs to be considered when
Knowledge of pain
• Expectations of pain
Barriers to pain assessment in the older
• Failure to recognise
• Failure to assess
• Assume stoicism
• Patients & carers expectations of pain in
• May use different words e.g. discomfort,
• Time consuming
Inadequate pain management can
• physiological effects (increased HR, BP, delayed
gastric emptying, increased adrenaline
post-operative complications (respiratory
infection, VTE, PE)
restlessness, irritability, aggression
raised levels of anxiety
distress and suffering
(Sjostrom et al 2000, Macintyre & Ready 2002, Carr et al 2005)
Acute Vs Chronic Pain
– Short Term
– Less than 3 months
– Natural Healing Occurs
Longer than 3 months
Natural Healing occurs
but huge IMPACT
Pain as a result of
Central NS changeslocal, spinal cord,
Why do people react so differently to Pain?
Leventhal‟s Common Sense Model
Action Taken /
Chronic Pain and
How does psychological distress affect
pain experience and management?
Cognitive Behavioural Therapy shown to
– Has impact on biopsychosocial variables
However, psychological interventions for
chronic pain most effective when
incorporate other treatment components
– e.g. physiotherapy, education
– Pain Management Programmes
Impact of Chronic Pain
Reduction in activity
eg physio, med
Loss of Job,
Fear re Future
Loss of Independence
Boom and Bust
Pain Management Aims
NOT cure or pain reduction
Change the person‟s relationship with pain
– Reduce disability and distress
– Manage increases in pain (flare-ups)
– Develop confidence in ability to carry out activities
– Reduce unhelpful encounters with public and private
Aims of Pain Management
•Education re Pain
•Goal Setting &Practice
Increase confidence Distress
Reduce incidence of
Consultants, physios, psychologists,
Pain Management Programmes
– Good evidence base, improve functioning
NICE guidance 88, May 2009
– Outpatient Programmes
PMP @ Whittington, COPE @ UCH
– Inpatient Programmes
INPUT Pain Management Unit @ St Thomas‟
Bath Pain Management Unit
Sharp & Keefe (2006). Psychiatry in Chronic Pain: A review and Update.
Focus, American Psychiatric Association.
Turk & Okifuji (2002). Psychological factors in chronic pain: Evolution and
revolution. Journal of Consulting and Clinical Psychology.
Vlaeyen & Linton, (2006). Are we „fear avoidant‟. Pain.
Vlaeyen & Morley (2005). Cognitive-Behavioural Treatments for Chronic
Pain: What works for whom? Clinical Journal of Pain.
Morley, Eccleston & Williams (1999). Systematic review and meta-analysis
of randomized controlled trials of cognitive behaviour therapy and behaviour
therapy for chronic pain in adults, excluding headache. Pain.
Nicholas M, Molloy A, Tonkin I and Beeston L (2000) Manage your Pain
ABC Books, Sydney
Nice, Nice Guideline 88 (2009) – Early management of persistent nonspecific low back pain, http://www.nice.org.uk/CG88