Pain and its management
Significance of Pain <ul><li>Pain </li></ul><ul><ul><li>A clear example of the mind–body (BPS) model  (and most common pro...
The Physiology of Pain <ul><li>“ How you know that you stubbed your toe” handout </li></ul><ul><ul><li>1.  Nociceptor  —  ...
The Physiology of Pain <ul><li>“ How you know that you stubbed your toe” handout </li></ul><ul><ul><li>3.  Dorsal Horn  — ...
Pain Pathways    PAG area of midbrain (next slide)
Pain Pathways <ul><li>Periaqueductal Gray (PAG)  </li></ul><ul><ul><li>midbrain region-- activates a  descending neural pa...
Gate Control Theory  <ul><li>Proposed by Melzack & Wall (1965) </li></ul><ul><ul><li>A neural “gate” in the spinal cord re...
The Gate Control Theory  of Pain
The Biochemistry of Pain <ul><li>Substance P  (pain NT)   </li></ul><ul><li>NTs (e.g., serotonin) that alter “gate”  </li>...
Psychosocial Factors in the Experience of Pain <ul><li>Stress </li></ul><ul><ul><li>pain perception is influenced by stres...
Psychosocial Factors in the Experience of Pain <ul><li>Learning </li></ul><ul><ul><li>modeling  </li></ul></ul><ul><ul><li...
Psychosocial Factors in the Experience of Pain <ul><li>Cognition </li></ul><ul><ul><li>anticipation of pain is often worse...
Pain Management <ul><li>Overview: </li></ul><ul><ul><li>The Fifth Vital sign </li></ul></ul><ul><ul><ul><li>Body Temp, Pul...
Measuring Pain <ul><li>Psychophysiological Measures </li></ul><ul><ul><li>Electromyography (EMG)  —muscle tension and pain...
Measuring Pain <ul><li>Behavioral Measures </li></ul><ul><ul><li>Pain Behavior Scale </li></ul></ul><ul><ul><ul><li>e.g., ...
Measuring Pain <ul><li>Self-Report Measures </li></ul><ul><ul><li>Structured interviews  (When did the pain start? How has...
Chronic Pain Management <ul><li>Acute vs. Chronic pain </li></ul><ul><li>Who becomes a chronic pain patient? </li></ul><ul...
The toll of chronic pain <ul><li>Dysfunction </li></ul><ul><ul><li>report high levels of pain, feel they have little contr...
Treating Pain <ul><li>Pharmacological Treatments </li></ul><ul><ul><li>Analgesic  (pain-relieving) drugs are the mainstay ...
Opioid Analgesics <ul><li>Formerly called  narcotics </li></ul><ul><li>Agonists  (excitatory chemicals – e.g., morphine) a...
Nonopioid Analgesics <ul><li>Nonsteroidal Anti-Inflammatory Drugs (NSAIDs) </li></ul><ul><ul><li>Aspirin, ibuprofen -- rel...
Other Medical Interventions <ul><li>Counterirritation </li></ul><ul><ul><li>Analgesia in which one pain is relieved by cre...
Cognitive-Behavioral Therapy <ul><li>Cognitive-Behavioral Therapy (CBT)   </li></ul><ul><ul><li>A multidisciplinary pain-m...
Cognitive-Behavioral Therapy <ul><li>Components  </li></ul><ul><ul><li>Education and goal-setting  component is used to cl...
Cognitive-Behavioral Interventions <ul><li>Biofeedback / muscle relaxation </li></ul><ul><li>Cognitive distraction </li></...
Cognitive Errors in the Thinking of Pain Patients <ul><li>Catastrophizing  — overestimating distress and discomfort </li><...
Reshaping Pain Behavior <ul><li>Identify the events (stimuli) that precede pain behaviors (responses) as well as the conse...
Which Approach to Pain Control Works Best? <ul><li>It depends on which type and aspect of pain </li></ul><ul><li>Overall, ...
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Pain

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Pain

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

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