The document discusses pain, including definitions of pain, types of pain (such as acute vs. chronic), consequences of pain, pain assessment scales, and approaches to pain management. It notes that pain management may involve pharmacological approaches like opioids, non-pharmacological approaches like physical therapy, and interventional procedures like spinal cord stimulators. The WHO analgesic ladder is also summarized, which recommends treating mild pain with non-opioids, moderate pain with mild opioids, and severe pain with strong opioids by the clock and by mouth until the patient is pain-free.

1. PAIN
Dr Sushma saroa

2. IASP DEFINITION
An unpleasant sensory and emotional experience
associated with actual or potential tissue damage, or
described in terms of such damage.

3.  Margo Mc caffery (1968) first defined pain as whatever the person
experiencing.

4. Consequences Of Pain
 Disturbed sleep
 Withdrawal from talking or social activities
 Sadness, anxiety, or depression
 Poor appetite and weight loss
 Physical and verbal aggression, wandering,
acting-out behavior, resists care
 Difficulty walking or transferring and may
become bed bound

5. Consequences of Pain
Skin ulcers
Incontinence
Increased risk for use of chemical and
physical restraints
Decreased ability to perform
movements
Impaired immune function

6. TYPE OF PAIN
 Nociceptive vs. Neuropathic pain
Acute vs. Chronic pain
Pain at rest vs. Pain on movement
Malignant vs. Non-malignant pain

7. Acute pain
 Acute pain is a complex multidimensional
experience
 occurs in response to tissue trauma.
 Responses may be adaptive,
 They can have adverse physiologic and
psychological consequences (e.g., reduced tidal
volume, excessive stress response)
 Treatment of acute pain is imperative.
 It may progress to chronic pain .

8. Chronic Pain
Chronic pain is a complex
phenomenon where the intensity/
impact of the pain is not always
directly related to pathology.

9. Evaluation of pain
Assessment and documentation of pain
 Cause,
 Severity
 Activity and sleep disturbance
 Mood eg. anxiety, depression
 social impact

10. PAIN ASSESMENT SCALE
A variety of pain scales are available but none has
been shown to be superior to others
 To evaluate,
 To measure
 To monitor pain

11. PAIN ASSESMENT SCALE

12. PAIN ASSESMENT SCALE
Wong baker’s face pain scale

13. PAIN MANAGEMENT
PHARMACOLOGICAL
NON-PHARMACOLOGICAL
INTERVENTIONAL
PROCEDURES
SURGICAL

14. PHARMCOLOGICAL
 Non-opioids,
 Opioids,
 Antidepressants,
Antiepileptic drugs,
Stimulants,
 Antihistamines

15. NON-PHARMACOLOGICAL
 Explanation, Beliefs.
 Education.
 Relaxation therapy.
 Hypnosis.
 Physical therapy eg heat and cold therapy
,vibrations,exercise.
 Peripheral stimulation therapy eg. transdermal
electronic nerve stimulation (TENS), acupuncture.
 Psychological therapy eg.cognitive behavioural
therapy, mindfulness meditation.
 Supportive therapy eg.occupational therapy,
employment etc.

16. INTERVENTIONAL PROCEDURES
 Neurolytic blocks, eg. diagnostic, somatic,
sympathetic, visceral, trigger point
 Intraspinal and Epidural analgesia with opioids,
clonidine, baclofen, local anesthetics
 Spinal cord stimulators
 Intrathecal drug delivery system implants.
 Pulsed radiofrequency, neuromodulation, direct
introduction of medication and nerve ablation
 Cordotomy

17. Patient education
Counseling about the pain
 Pain aggravating and alleviating
factors,
 management strategies,
 lifestyle
factors that may influence the pain
e.g., use of nicotine,alcohol etc.

18. Psychological approaches
 Relaxation training
 Hypnosis,
 Biofeedback,
 Copings skills,
 Behavior modification,
 Psychotherapy

19. Hypnosis
 Pain reduction may be due to patient expectation
(the "placebo effect").
 The effects of self hypnosis on chronic pain are
roughly comparable to those of progressive muscle
relaxation.

20. Psychological approach
Cognitive behavioral therapy
Cognitive behavioral therapy (CBT) is cognitive
restructuring between one's physiology (e.g., pain and
muscle tension), thoughts, emotions, and behaviors. By
targeting behavioral activation of healthy activities such
as
1. Regular exercise and pacing.
2. Lifestyle changes are also trained to improve sleep
patterns and to develop better coping skills for pain and
3. Reduce stressors using various techniques (e.g.,
relaxation, diaphragmatic breathing, and even
biofeedback).

21. Physical therapy
 Physical rehabilitative approaches
walking, stretching,
 Exercises to improve strength and endurance,
oscillatory movements
 Application of heat or cold,
 TENS, massage, acupuncture

22. TENS
 Electrical current is applied by the electrodes at the
site .

23.  This three step approach is inexpensive and 80-90%
effective when optimally utilized.
 Drug selection should be appropriate to the severity of the pain
 With severe pain begin at the top of the ladder with a strong opioid;
 When pain is controlled, the patient should be maintained on the
dose that effective e.g. post-operatively or in remission from cancer.
 Along with step in the ladder, additional drugs – “adjuvants”- may
be used. Adjuvants include: antidepressants
 (e.g. amitriptyline), anticonvulsants (e.g. gabapentin),
corticosteroids (e. g. dexamethasone), and anxiolytics
 (e.g. diazepam).
 Surgical intervention on appropriate nerves may provide further
pain relief if drugs are not wholly effective. More
 invasive routes of administration (e.g. epidural) may be necessary
for a small subset of patients.

24. ACUPUNCTURE
Acupuncture involves the insertion and
manipulation of needles into specific
points to stimulates energy channels
called the meridians to reduces pain
signals through production of
endorphins

25. Light Therapy
 Light therapy such as low level laser
therapy is an effective therapy for
relieving low back pain.

26. SUPPORTIVE THERPY
Occupational therapy
 Attention to proper body mechanics
 Resumption of normal levels of
activities of daily living

27. Mindfulness meditation
 Findings suggest that MBIs decrease the intensity of
pain for chronic pain patients

28. Treatment strategy
 The underlying cause of pain should be treated
whenever possible
 Therapeutic regimes need to be individualised
 Oral medicines are among the key components of
pain management
 Some medicines should be given regularly
 There is necessity to monitor and evaluate
therapeutic and unwanted effects.

29. Medicine
 Efficacy
 Safety
 Cost-effectiveness
 Limitations
 Benefits
 Side effects

30. WHO guidelines
 To achieve rapid, effective and safe pain control
 Ensuring proper use of analgesics and other
modalities
 Facilitating legal access

31.  Treatment goals and strategies for acute pain can
be summarized as:
 Early intervention.
 Reduction of pain to acceptable levels
 Facilitation of recovery from underlying disease or
injury.

32. WHO STEP LADDER FOR PAIN
MEDICATIONS

33. Principles of the WHO analgesic ladder
By the clock
 Around the clock regularly on scheduled basis
 Should not only on demand

34. Principles of the WHO analgesic ladder
 By the mouth:
 The oral route is usually the preferred route for ease
of use
 However, it may not be possible e.g. end-of-life,
unconscious, swallowing issues
 When the oral route is not feasible considered e.g.
sub-lingual or sub-cutaneous before intra-venous
 The intra-muscular route should never be used.

35.  By the ladder:Drug selection should be
appropriate to the severity of the pain
 If pain occurs there should be prompt administration
in the following order:
 For mild pain -- non-opiods e. g. acetaminophen
 For moderate pain-- mild opiods e. g. codeine
 For sever pain-- strong opiods (e. g. morphine or
hydromorphone until the patient is free of pain.

36. THANK YOU