Pain management a comprehensive review



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PAIN MANAGEMENT

A COMPREHENSIVE REVIEW

ABSTRACT

Pain can be defined as a complex, multi-dimensional provocation. It is one of the major reasons that people seek health care. Pain is a response to noxious stimuli and can function as a protective mechanism of the body to prevent further injury. The sensation of pain as the warning of potential tissue damage may be absent in people with certain disorders, such as diabetic neuropathy, multiple sclerosis, and nerve/spinal cord injury. There are a number of approaches in the management of pain, each with respective advantages and disadvantages. According to a recent medical report titled ‘Relieving the pain in America' published by A Blueprint for Transforming Prevention, Care, Education, and Research, pain is a significant public health problem that costs Americans at least $560-$635 billion annually, an amount equal to about $2,000.00 per person living in the U.S. Consequently, the total incremental cost of health care for controlling pain ranges between $261 and $300 billion, and $297-$336 billion is attributable to a loss in manpower productivity. Ultimately, there should be proper pain management measures in place in order to reduce the root cause of pain, the length of pain, and the effectiveness of pain management. This course aims to offer a comprehensive review of the pain management methods that are currently available, as well as offer some new insight into the modern and innovative measures of pain management.



LEARNING OBJECTIVES

1. Define pain

2. Describe the magnitude of pain

3. Enumerate the characteristics of pain

4. Explain the types of pain

5. Describe the negative consequences of pain

6. Describe the pathophysiology of pain

7. Elaborate the theories of pain

8. Identify the factors affecting the pain

9. Demonstrate appropriate use of pain measurement instruments

10. Explain the pharmacological management of pain

11. Describe the non-pharmacological management of pain

12. Explain alternative therapies for the relief of pain

13. Discuss the patient self care method to relieve pain



OUTLINE

  1. Introduction

Pain is considered a “universal disorder” [1] that comes in many forms. Regardless of the form it is seen in, everyone experiences pain, with the perception of pain occurring differently in each individual.

In the most benign form, pain serves to warn the individual that something is not quite right. Pain can, however, disrupt productivity, well-being, and indeed, the entire life of the individual experiencing the pain. At its core, pain is complex and differs greatly among individuals, including those who seem to have identical injuries or illnesses.

Pain has a long history. Ancient civilizations recorded accounts of pain and the various treatments and cures used on stone tablets. Early humans also related pain to magic, demons, and evil. In early times, the responsibility of pain relief fell on shamans, priests, and sorcerers, who utilized herbs, rites and ceremonies to treat pain. The Romans and Greeks were the first peoples to advance the idea that the brain and nervous systems are key in producing pain sensations. However, evidence was not available to support this theory until well into the Renaissance in the 1400 and 1500s. It was not until the 19th century that real advancements in science led to advancements in pain treatment. Physicians discovered that such drugs as morphine, codeine, cocaine, and opium could be used to treat pain. These drugs then led to the development of aspirin as a pain treatment; even today this is the most commonly utilized pain reliever. Finally, anaesthesia advanced and became the standard for surgery. As we have moved into the 21st century, scientists and physicians are gaining an ever greater understanding of pain and pain treatment [1].

Pain today is a costly and very serious public health issue [2]. It is also a challenge for friends and family as well as health care practitioners there to offer support to the individual suffering from the pain. Pain related issues currently account for approximately 80% of doctor’s visits [3].

There are many things that affect how pain is felt. One is the type and extent of the injury itself. Another big thing that affects how pain is felt is the emotions the individual feels during the injury and recovery periods. Emotions strongly affect the perception of pain. Pain is not something that has any unit of measure. While practitioners can measure the extent of severity of an injury, there is no way for them to measure how or why some people feel more or less pain than others with the same injury [4]. However, there are a number of ways to address pain conditions, from pharmacological to nonpharmacological options as well as alternative therapies.

It is also important to address the education of both practitioners as well as the individual, friends and family to ensure that pain is managed effectively. The better practitioners communicate with and educate their patients, the more likely that pain will be effectively addressed and managed. Additionally, there is a treatment gap that exists in pain management, which cannot be ignored. Women, children and older adults are at greater risk of being negatively affected by chronic pain and frequently end up receiving treatment that falls short. Understanding why this happens as well as what to do about it is essential for practitioners who are seeking to adequately and fully treat a variety of pain conditions that are experienced differently from individual to individual.



  1. Definition.

The word pain is derived from the Latin word poena, which means a fine, or penalty. The International Association for the Study of Pain defines pain as: “An unpleasant sensory and emotional experience associated with actual or potential tissue damage or described in terms of such damage”. [5]. Pain is an unpleasant sensation that ranges from mild, localized discomfort to extreme agony. There are physical as well as emotional components to pain. The physical component is the result of nerve stimulation [6]. Emotions have the ability to affect the way a person perceives pain. While all human beings have the same anatomical structures that convey nociception to the central nervous system, there are quite a few factors that alter the intensity of the pain perception [7]. It is important that practitioners consider both physical and emotional factors when treating patients, as these both influence a patient’s recovery [8]. Some people indicate that they tolerate pain well, whereas other individuals indicate that they are highly sensitive to pain [9].

  1. Magnitude of pain.

Magnitude of pain is a difficult thing to measure, primarily because different people experience pain in different ways [10]. However, there are some instruments designed to measure pain that apply universal standards to pain sensation and can be used across the board for all individuals.

One such instrument is the visual analog scale. This scale is utilized to measure pain characteristics in a way that ranges across a scale of numerical values, with the number 1 being no pain and the number 10 being the worst pain imaginable. This pain scale is ideal for use with those individuals who possess a strong ability to define their pain.

Another scale that is commonly utilized is the faces pain scale. This scale is frequently utilized with children or with those who are better able to provide a description of what their pain feels like according to the expression depicted on a face. This scale ranges from a smiley face that represents no pain to a face with a frown and tears on it to describe the worst pain imaginable.

There are special descriptive scales to measure pain in infants. Since infants are unable to talk to describe their pain as well as being not cognitively developed enough to identify a face representative of their pain, practitioners rely on descriptions of the infant’s behaviour to determine the magnitude of pain.

The use of these scales has its advantages as well as disadvantages. An advantage of utilizing scales such as these is that there is a universal standard by which practitioners may assess pain and in turn determine an initial idea of the severity of injury. However, since these pain scales are universal, people who are more or less sensitive to pain don’t necessarily fit into the pain “norm”, which can make an initial determination of how severe a condition or injury is difficult to make. This can mean that some patients are not receiving adequate care for their pain.

One scale that may help correct pain discrepancies is the magnitude matching scale. Applying this scale to pain, for instance, would be particularly useful in hospital settings; for example, it can be argued that a woman undergoing childbirth is in more pain than any pain a man could experience. Therefore, even if a pregnant woman rates her pain as a 4 on a scale of 10, it is probable that they are in more pain than a man who provides the same rating.



  1. Characteristics

Pain is a particular feeling that protects the body from noxious stimuli. Pain alerts the brain that a particular stimuli is unsafe, prompting the brain and the body to respond. However, pain is not just one feeling. It is instead a grouping of distinct feelings, all of which differ in clinical characteristics. What this means, for example, is that pain in the skin is a different type of feeling than is pain in the muscles.

In order for practitioners to effectively treat injuries and pain conditions, it is essential that practitioners listen to the patient describe his or her pain in order to correctly determine all pertinent information – such as pain location, pain sensation, pain modality, and pain radiation – and to in turn present a treatment plan that will address all aspects of the pain [11]. It is also particularly important to determine the site of injury, although often the patient is not sure where their pain is originating. In order to determine effective treatment, it is therefore essential that practitioners understand the clinical nature of pain.



Pain Severity:

Many things influence the level of severity of pain. Things such as the patient’s personality, surrounding influences, and general sensitivity to pain make a difference. It is important to note that the severity of pain does not predict enough about the injury to allow a practitioner to draw reliable conclusions for diagnosis or prescribing. A more useful predictor is the relative sensitivity of the tissues involved. For example, the cornea, when injured, may only be injured slightly; however, the pain effect may be very serious. This is because the cornea is more sensitive than are certain other tissues in the body.

It would pose a very large inconvenience if all of the tissues in the body were equally sensitive. Sometimes injury occurs in body tissue that is relatively minor and does not reach the consciousness; other times injury can be extensive and prompt extreme reaction. Further, if a particular stimulus – even a mild one – continues for too long a time period or if the affected tissue is still weakened following a previous injury, further damage to the tissues may be dangerous and the threshold for pain in that tissue is lowered. What this means is that sensitivity of tissues is not constant, but rather variable; sensitivity changes in response to circumstances surrounding previous injury.

Pain site:

The ability to locate the injury site simply by analyzing the pain that is perceived often depends on the tissue that has been injured.



Pain Quality:

Quality refers to the distinctive character of a pain sensation. It can best be described by comparing it to a pain or sensation that is familiar. For instance, comparison is utilized with familiar pain that is related to areas in the body; one example of this is describing pain in the area of the stomach as feeling like a tummyache. Pain may also be compared to function; one example of this is when an individual describes their pain as throbbing. Further, pain can also be described in comparison with another pain that is prompted by a stimulus that is familiar; one example of this is describing pain as burning because this sort of pain is prompted by the physical experience of sustaining a burn.



Somatic Pain:

There are at least 3 types of discernable pain:



  • Surface pain, which comes from the cutaneous surface as well as the mucosal surface.

  • Sub-surface pain; this type of pain is also called intermediate pain, which comes from subcutaneous tissues as well as from the submucosae. This type of pain also comes from adjacent tissue structures when subcutaneous tissue is thinner.

  • Deep pain, which comes from the muscles as well as other deep tissue that is generally considered more sensitive.

Surface Pain:

Surface pain can feel different depending on the duration of the stimulus affecting it. For example, if the duration of the experience is very short, generally the resulting sensation is a pricking. However, if the duration of the experience is prolonged, the resulting sensation is generally a burning. This highlights differences only in pain duration, not in pain quality. While burning is a sensation that is commonly associated with excessive heat, it is not the response of the organ systems of the body to heat; rather, it is the response of the surface to the prolonged painful stimuli. Burning can be produced by extreme cold as well as by heat. The two sensations of pricking and burning on the surface are only present if cutaneous pain organs are not functional as a result of destruction or extreme damage.



Itching:

Sometimes injury to the skin also prompts an itchy sensation; however for itching to be present the pain stimulus must be acting on skin that is hyperalgesic. There will be no itching on skin that has remained normal. An example of this is seen in skin that has been injured by a condition such as dermatitis. This skin is not in a normal state and there is a risk of provocation even if the added injury to the skin is very slight, such as scratching, applying ointments to the affected area, and temperature changes. Itching is a variety of surface pain that is entirely free of other sensations and occurs only in skin that is hyperalgesic from previous injury.



Other notable characteristics of surface pain:

The main function of surface pain is to provide information about the painful stimulus so that the individual may make effective defensive reactions. Surface pain is very accurate: the pain is located in a precise spot and localized. The protective reflexes that the injury provokes are entirely directed with extreme precision toward eliminating the painful stimulus or toward withdrawing the injured part of the body from danger.



Pain from Mucosae:

Not all mucosae are sensitive. For example those mucosae that are distant from the site of injury are not sensitive at all. However, when a mucosa is sensitive the pain sensation felt is either pricking or burning. Itching may also be present. Regardless of the stimulus, the quality of the pain is always the same. For example, burning in the mouth may occur as a result of eating overly heated food or as a result of another irritant, such as chemicals, ulcers, or catarrhal inflammation.

The mucosa in the esophagus is not normally sensitive to thing such as gastric juice, which is frequently regurgitated even in normal digestion. However, when the mucosa is injured from another cause, it becomes sensitive to another injury and exhibits burning pain. Therefore, if the mucosa is injured by overly heated food, it will react more sensitively to gastric juice.

The mucosa of the cervix does not burn in response to pain; however when underlying tissues are affected it prompts pain in this mucosa. This lends to the idea that this particular mucosa is insensitive, as it does not respond to such painful stimuli as a pin prick. Likewise, pain in the nasal mucosa is due mostly to the periostium underlying the mucosa. Nasal sinuses as well as the middle ear are generally described as possessing sensitive mucosa, but it is a likely conclusion that the mucosa itself is not sensitive and the perceived pain is periosteal.



Sub-surface/Intermediate pain:

Pain in the subcutaneous surface has some differing qualities from deep pain, particularly if subcutaneous tissues are thinner, as is the case in the tissue over the forearm, tibia or knuckles. However, if the subcutaneous tissue is thicker – as is the case in the mammary region on females – pain in the inner strata is not described as being much different in quality from deep pain.

Pain of the subcutaneous surface is somewhat diffuse, but the diffusion is limited to a small zone surrounding the injury.

Deep Pain:

Pain in the deep tissues possesses an aching quality. This type of pain is commonly found in the muscles or in other deep tissues that generally are more highly sensitive. Deep pain is non-discriminative and does not have the ability to offer information about the stimulus or the source of the pain perception. This type of pain starts well after the injury and is generally persistent. Additionally, this type of pain is very diffuse. Pain in deep tissues is impossible to be felt only at the injury site. This is a type of radiating pain, and the radiation is frequently quite extensive.

However, there are several factors that determine whether pain remains local or exhibits extensive radiation. For example, the severity of the injury sustained is very important, as is the depth of injured tissues. The deeper the tissue the more likely it is that pain will radiate out extensively. Additionally, if the injured tissues are close to areas of the body that are vitally important, there is a greater likelihood of radiation. .

Deep pain is accompanied by reflexes. However, these reflexes do not provoke brisk and defensive movements, as is the case with surface pain. They are more focused on resting the part of the body that is injured and serve to protect that part of the body from further injury. They are not as focused on removing the injurious stimuli. The pain may then be felt as a spasm that radiates outward. Additionally, the way an individual reacts when experiencing deep pain tends to inhibit further activity in order to protect the injured area.



Visceral Pain:

The viscera is generally lying so deeply that it is well protected and does not respond to stimuli that normally provokes pain in somatic tissue. In fact, many viscera are entirely insensitive and the pain that may be associated with them is prompted by the extension of the lesion to adjacent tissues. However, some other viscera are sensitive.



  1. Types

  1. Duration-acute, chronic and malignant pain

Acute pain is a type of pain that begins suddenly and is generally sharp in quality. Acute pain warns that there is a threat of some kind to the body, either an injury or a disease [12]. However, acute pain can be caused by a number of events, which include:

  • Surgery

  • Dental work

  • Labor and childbirth

  • Broken bones

  • Burns or cuts

Acute pain may present as mild and momentary, but it can also be severe pain that lasts for weeks or months. Generally however, acute pain does not last beyond six months. Additionally, acute pain disappears when whatever is causing the pain is healed or treated. When acute pain is not relieved it can lead to chronic pain.

Chronic pain is pain that persists even after an injury has been healed or treated. This type of pain is a result of pain signals remaining active in the nervous system over an extended period of time and can last for years. It can also be affected by physical impairments, such as tense muscles or limited mobility, or a lack of energy. Emotions such as depression, anxiety, anger, and fear of aggravating an existing injury can also affect the sensation of chronic pain. Emotions in particular can hinder an individual’s ability to return to normal activity at work or play. Some of the common complaints associated with chronic pain are:



  • Headache

  • Cancer pain

  • Neurogenic pain

  • Low back pain

  • Arthritis pain

  • Psychogenic pain

Chronic pain frequently originates with some initial trauma or injury. However, it is possible that there could be an ongoing cause of chronic pain. It is important to note though that there are those individuals who suffer from chronic pain without the presence of a past injury or trauma. It is important to understand that the pain these individuals feel is no less real than that pain caused by an ongoing disease or injury.

In an effort to better understand chronic pain, some studies [13, 14] have indicated that chronic pain ranges from 10.1% to 55.2% of the population. One theory of chronic pain is that prolonged exposure to acute pain may prompt long-standing changes to the central nervous system, which creates chronic pain [15, 16]. Under normal conditions, the painful stimuli diminishes as the healing process moves forward, leading to lessened pain sensations until there is minimal to no pain detectable [17]. However, persistent pain may activate secondary mechanisms in the central nervous system that cause hyperalgesia, hyperpathis, and allodynia, which can diminish normal function.

One way to better understand pain comes from the idea of neuroplasticity. Neuroplasticity occurs a short while after acute pain sets in. The remodelling of the neuronal cytoarchitecture that occurs leads to a transition from acute pain to chronic pain [18, 19].

To best understand chronic pain, practitioners must understand that even small amounts of residual pain may affect physical and social function in a negative way. Practitioners must understand that chronic pain is a common and serious problem that can greatly alter the lives of individuals who suffer it [20-23].



  1. Location-pelvic, head ache

Pelvic pain is defined as being pain that exists in the lower portion of the abdomen and pelvic [24]. Generally, pelvic pain is utilized in reference to symptoms that women suffer that arise from the reproductive or urinary system. Pelvic pain can range from dull to sharp sensations, be either constant or intermittent, and may be anywhere from mild to very severe. Pelvic pain is frequently felt in the lower back as well, as pain from the pelvis can radiate up into the lower back. Chronic pelvic pain indicates any pain in the pelvic region that has been present for more than a few months. The pain can be either constant or intermittent; what makes pelvic pain chronic is time duration.

Pelvic pain may only be noticeable at certain times. Examples of this would be pain during urination, menstruation, or sexual activity. Additionally, conditions and diseases of various body systems can contribute to pelvic pain. For example, pelvic pain may originate in the intestinal tract, reproductive system, or urinary system. Pain in this area may also originate in the muscle tissues of the pelvic floor. Less frequently, pelvic pain can be caused by nerve irritation in the pelvis.

Reproductive pain is the most common in the pelvic region. This kind of pain can arise from a variety of causes, including: adenomyosis, ectopic pregnancy, endometriosis, cramping during the menstrual cycle, miscarriage, ovarian cysts or cancer, or pelvic inflammatory disease.

Other causes of pelvic pain that exist in both men and women include: Adhesions, appendicitis, colon cancer, constipation, Crohn’s disease, Fibromyalgia, a herniated disk, interstitial cystitis, irritable bowel syndrome, kidney stones, a urinary tract infection, physical or sexual abuse, muscle spasms of the pelvic floor, or sciatica. If an individual suddenly develops pelvic pain that is severe, this can indicate a medical emergency, and prompt medical attention is necessary. Pelvic pain should be examined by a practitioner in particular if it is a new sensation, is disrupting the patient’s daily life, or if it has been getting worse as time passes.



Headache may take a variety of forms where pain is concerned. Headache pain can feel like a vise is being tightened around the top of the head, throbbing pain at the base of the skull or in the temples, or occur in combination with nausea and an increased sensitivity to such stimuli as light and sound, to offer a few examples. Headache can occur on its own or along with another disease or condition. Headache is nearly universally experienced across age groups. Both children and adults experience headache, and nearly 2/3 of children experience headache by the time they turn 15 years of age [25]. Therefore, headache is considered the most common form of pain and often leads to missed days at school or work. Some individuals experience headache only once or twice a year; others experience headache for more than 15 days per month. Headache episodes may ease and disappear for some time and then re-emerge later in life, recur, or last for weeks at a stretch. Additionally, it is also possible to have more than one type of headache at one time. Headache can range from mild to severe to the point it interferes with daily activities. This makes it essential that headache is treated promptly and effectively.
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