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Pain and its management. Significance of Pain zPain yA clear example of the mind–body (BPS) model (and most common problem associated with going to HCP)

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Presentation on theme: "Pain and its management. Significance of Pain zPain yA clear example of the mind–body (BPS) model (and most common problem associated with going to HCP)"— Presentation transcript:

1 Pain and its management

2 Significance of Pain zPain yA clear example of the mind–body (BPS) model (and most common problem associated with going to HCP) yAdaptive as a biological warning signal (e.g., congenital insensitivity to pain)

3 The Physiology of Pain z“How you know that you stubbed your toe” handout y1. Nociceptor — a specialized neuron that perceives and responds to painful stimuli y2. Special pain nerve fibers x A-Delta Fibers -- Large, myelinated (fast) nerve fibers that transmit sharp, stinging pain x C-Fibers -- Small, unmyelinated nerve fibers that carry dull, aching pain

4 The Physiology of Pain z“How you know that you stubbed your toe” handout y3. Dorsal Horn — pain’s “arrival” to the CNS y4. 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 zPeriaqueductal Gray (PAG) y midbrain region-- activates a descending neural pathway that uses serotonin to close the “pain gate”

7 Gate Control Theory zProposed by Melzack & Wall (1965) yA neural “gate” in the spinal cord regulates the experience of pain yPain is not the result of a straight-through sensory channel

8 The Gate Control Theory of Pain

9 The Biochemistry of Pain z Substance P (pain NT) z NTs (e.g., serotonin) that alter “gate” zEnkephalins, endorphins, dynorphins (endogenous opioids)

10 Psychosocial Factors in the Experience of Pain zStress ypain perception is influenced by stress (emotionality and pain experience) ystress leads people to engage in behaviors (i.e., grinding teeth, tensing muscles), which in turn lead to pain yGood 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 zLearning ymodeling ysecondary gain / reinforcement yculturally 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 zCognition yanticipation of pain is often worse than pain itself yplacebo and pain (e.g., child who gets ear examined feels better) yexpectations of ability to cope (e.g., control and pain – PCA morphine )

13 Pain Management zOverview: yThe Fifth Vital sign xBody Temp, Pulse, BP, Resp Rate, Pain yMeasuring pain yChronic pain issues yTreatment

14 Measuring Pain zPsychophysiological Measures yElectromyography (EMG) —muscle tension and pain yIndicators of autonomic arousal — HR, etc.

15 Measuring Pain zBehavioral Measures yPain Behavior Scale xe.g., vocal complaints, grimaces, awkward postures, mobility

16 Measuring Pain zSelf-Report Measures yStructured interviews (When did the pain start? How has it progressed?) yPain rating scales (numerical ratings or a pain diary) yStandardized pain inventories xMcGill Pain Questionnaire (MPQ): sensory quality, affective quality, evaluative quality of pain

17 Chronic Pain Management zAcute vs. Chronic pain z Who becomes a chronic pain patient? yNot necessarily related to pain intensity yMore important are reactions: xPhysical (postural changes) xFunctional disability (pain interferes with life activities) xReactions to pain episodes and to stress zThe toll of chronic pain (video clips from “Psychology of Pain”)

18 The toll of chronic pain zDysfunction yreport high levels of pain, feel they have little control over their lives, and are extremely inactive zInterpersonal distress yperceive little social support and feel other people in their lives don’t take their pain seriously yoften poor communication ysexual relationships deteriorate zCost yHuge medical bills yUndergone many treatments (e.g., multiple surgeries) and rely on painkillers yJob loss/disability

19 Treating Pain zPharmacological Treatments yAnalgesic (pain-relieving) drugs are the mainstay of pain control yInclude “central acting” opioid drugs and “peripherally acting” nonopioid drugs

20 Opioid Analgesics zFormerly called narcotics zAgonists (excitatory chemicals – e.g., morphine) act on receptors in the brain and spinal cord zPatient controlled analgesia — addresses control and undermedication

21 Nonopioid Analgesics zNonsteroidal Anti-Inflammatory Drugs (NSAIDs) yAspirin, ibuprofen -- relieve pain and reduce inflammation at the site of injured tissue

22 Other Medical Interventions zCounterirritation yAnalgesia in which one pain is relieved by creating another, counteracting stimulus zTranscutaneous Electrical Nerve Stimulation (TENS) yA counterirritation form of analgesia involving electrically stimulating spinal nerves near a painful area

23 Cognitive-Behavioral Therapy zCognitive-Behavioral Therapy (CBT) yA multidisciplinary pain-management program that combines cognitive, physical, and emotional interventions xused by 73% of clinicians who treat chronic pain

24 Cognitive-Behavioral Therapy zComponents yEducation and goal-setting component is used to clarify client’s expectations yCognitive interventions to enhance patients’ self-efficacy and sense of control over pain yTeaching new skills for responding to pain triggers yPromote increased exercise and activity levels

25 Cognitive-Behavioral Interventions zBiofeedback / muscle relaxation zCognitive distraction yImagery / virtual reality therapy (see Sci American Aug 2004) yHypnosis zCognitive restructuring — to challenge illogical beliefs and maladaptive thoughts (next slide)

26 Cognitive Errors in the Thinking of Pain Patients zCatastrophizing — overestimating distress and discomfort zOvergeneralizing — global and stable attributions that pain will never end and will ruin one’s life zVictimization — Why me? zSelf-blame zDwelling on the pain

27 Reshaping Pain Behavior zIdentify the events (stimuli) that precede pain behaviors (responses) as well as the consequences that follow (reinforcers)

28 Which Approach to Pain Control Works Best? zIt depends on which type and aspect of pain zOverall, the most effective programs are multidisciplinary in nature, combining the cognitive, physical, and emotional interventions of CBT with the judicious use of analgesic drugs zEffective programs also encourage patients to develop (and rehearse) a specific pain- management program zGroup settings are probably most effective


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