All about pain

Don’t let it control your life!

What you will learn

This slide show looks at pain:• Physiology of pain• Treatment: medical• Treatment: self• Common questions about pain

Physiology of pain

Simplest description:• Pain stimulates pain receptors (responding

to a touch to a hot surface)• Stimulus transferred via specialized nerves

to spinal column• Stimulus travels through spinal column to

brain• Stimulus processed in brain

• Brain sends impulse down spinal column via nerves

• Impulse causes body to react (withdraw hand from hot surface)

Physiology of Pain

http://www.mayoclinic.com/print/pain/PN00017/METHOD=print

From MayoClinic.com

Physiology of pain (continued)

Pain receptors• AKA “nociceptors”• Found in all tissues except brain• When they detect potentially harmful stimulus,

relay pain messages as electrical impulses along peripheral nerve to spinal cord and brain.

• Three types of pain receptors: – Mechanical (high pressure/stretch)– Thermal (extreme heat or cold)– Chemical (acids, or even products within

body released by trauma, such as lactic acid or serotonin)

Physiology of pain (continued)

Spinal cordNerve fibers that are transmitting

pain messages from pain receptors enter spinal cord at dorsal horn. They then release neurotransmitters that activate other nerve cells in spinal cord, processes information, and travels to brain.

Physiology of pain (continued)

BrainNews from spinal cord arrives at thalamus, which forwards

message to 3 specialized regions of the brain:• Somatosensory cortex (Identifies and localizes pain)• Limbic system (emotional feeling region that experiences

suffering)• Frontal cortex (thinking region that assigns meaning to pain)

Physiology of pain (continued)

Pain stimulus transmitted through nerves to spinal cord and brain

2 sensations of pain stimulus• Fast pain• Slow pain

Physiology of pain (continued)

Fast pain: • Warning pain, produces fight or flight

response (increased heart rate, sweating, dilation of pupils, restlessness)

• Immediate, sharp, lasts for a few seconds• Thick fibers mean fast transmission,

allowing body to withdraw from painful stimulus and prevent further damage

• Well localized• Pain doesn’t radiate• Little relief from opioids• Mainly skin, mouth, anus

Physiology of pain (continued)

Slow pain• Transmitted by thin nerve fibers• Instead of quick withdrawal, body wishes

instead to be immobile• Poorly localized• Pain often radiates or is referred• Good relief from opioids• Affects all internal organs (except brain)• Fight or flight response does NOT occur

with slow pain

Physiology of pain (continued)

Transmission of pain stimulus• Fast pain and slow pain travel

through different pathways to brain• Fast pain goes to specific and

limited part of brain (cortex)• Slow pain impulse distributed

throughout brain. Different areas of brain create different responses (suffering, insomnia, nausea, depression)

Physiology of pain (continued)

Brain sends signal back to spinal column via nerves

• Brain releases opioids which bind to receptors to block transmission and perception of pain.

• Medical opioids (morphine) bind to same receptors in brain to block pain perception.

• Antidepressants medications can decrease chronic pain, by blocking pain impulses

Assessing Pain

• Often underrated• Can be inaccurate if patient is medicated or

unconscious• Must rely on sensory, physiological, and

behavioral parameters to assess. • Examples: heart rate, blood pressure, anxiety,

difficulty breathing• Pain Scales: numeric rating scale and FACES scale• Sedated or cognitively impaired patients use The

Behavioral Pain Scale, which evaluates behaviors such as facial expression, upper limb movement, and ventilation compliance.

Assessing Pain (continued)

Pain perception : Level at which a person starts to find stimulus painful. Pain perception levels are similar among people.

Pain tolerance : Much more subjective. Varies from person to person as well as within the individual from time to time.

Treatment: Medical

Pharmacological and nonpharmacological

Pain killers (analgesics)•Paracetamol (Tylenol)•NSAIDs (Ibuprofen)•Opioids (morphine)Local anaethetics (lignocaine)Nerve blocksEpidurals

Comfort-producing measures:•Endotracheal tube suctioning•Repositioning in bed•Massage•Oral care•Reassurance•Heat/cold therapy•Therapeutic touch•Guided imagery•Relaxation

Treatment: Self

BODY: Exercise!• Releases endorphins (body’s natural pain

relievers)• Builds strength (redistribute force & load)• Increase flexibility (results in less aches)• Improve sleep (lowers stress hormones)• Boosts energy level• Help to maintain healthy weight• Enhances mood• Protects heart and blood vessels

Treatment: Mind

MIND: The mind as medicine• Guided imagery (language of autonomic

nervous system, regulates involuntary body functions)– Develop rapport with guide– Relax and come up with image (or can be

given an image) and a place in the mind to go

– Engage the senses (ask what you see, hear, smell, feel and taste).

Treatment: Mind

MIND: Endorphins create “placebo” effect

Study found that placebo that was believed to be agonistic agent was able to enhance release of brain opioids.

• Knowing that pain drug was coming resulted in increase to pain tolerance

Treatment: Mind

MIND: Pain is in the mindStudy found that people who saw

damaged limbs through magnification had a greater perception of pain. Those who viewed damaged limb through minimized lens perceived pain to be less.

Treatment: Mind

Mindful MeditationFocus on specific

object or on specific process (breathing patterns)

Biofeedback Training

Teaches to recognize physical reaction to stress & tension

Guided ImageryRelaxation followed by

visualization of mental image or peaceful scene

Behavioral Modification

Changing habits, behaviors & attitudes from constant pain.

Treatment: Mind

Stress ManagementPain can produce

anxiety and catastrophic thoughts. Manage this through structure, physical activity, positive “self talk”, and ability to live in the moment.

Hypnotheraphy/Hypnosis

Direct attention inward to achieve relaxation, lessening of pain and/or anxiety, gain control over pain. Research has shown it to reduce pain perception.

Common Questions about Pain

1. Isn’t pain normal in aging? NO. Pain can be managed. Guidelines established in 1998.

2. How do I tell my health care provider about my pain? Use a “pain diary” to help explain. Tell: where, how often, how much, as well as what the pain feels like, what makes it better or worse, and what medications you have taken.

Common questions (continued)

3. What over the counter medications are best? First, ask doctor if right for you. Acetaminophen (tylenol) might be best for mild to moderate from musculosketal conditions. NSAIDSs (aspirin, ibuprofen) may have side effects, interact with other drugs. Use carefully. COX-2 inhibitors need prescription. More selective in activity. Also has risks.

Common questions

4. Can I get addicted to pain killers? Acetaminophen and NSAIDs are not

habit forming, but opioids can be. However addiction to opioid pain medicines is rare in older adults; risk probably overstated.

Common questions

5. Why did my health care provider suggest that I take antidepressants? Research has shown that some antidepressant medications (such as Pamelor and Norpramin) can relieve some types of persistent pain. Also potentially helpful include anticonvulsant drugs and local anesthetics. Most effective against persistent pain associated with nerve injuries and nerve disease.

Common questions

6. Why should I treat the pain? Can’t I just let it go away? No because:

– Pain can alter brain (can mimic brain of persons with other neurological conditions associated with cognitive impairments)

– Seems to alter the way that information is processed

Common questions

7. What do we know from psychological assessment in pain treatment?

– Chronic pain sufferers with moderate stress, anxiety or depression feel more pain

– More than half of patients with chronic pain also suffer from depression and anxiety

– Without treatment, emotional components of pain increase, making control very difficult

– When depression and anxiety decrease pain tolerance, surgery is unlikely to help (does not change psychology).

Common questions

8. Is there any value in marijuana (cannabinoids) as pain relief? Yes.

– Two receptors for cannabinoids in body– Numerous studies established lessen

pain and affect range of symptoms and bodily functions. Also work with opioids to enhance effectiveness.

– Problems involve delivery root, standardization of product, and side effects.

Sources“Looking Beyond the Pain: The Role of Psychological Assessment in Medical

Treatment”, from National Pain Foundation, http://www.nationalpainfoundation.org/MyTreatment/News_PsychAssessment.asp

“Treatment Options: A Guide for People Living with Pain”, from American Pain Foundation, http://www.painfoundation.org/Publications/TreatmentOptions2006.pdf

“The Management of Persistent Pain in Older Persons”, from AGS Foundation for Health in Aging, American Geriatrics Society, http://www.americangeriatrics.org/products/positionpapers/JGS5071.pdf

“Physiology of Pain”, from website: www.health24.com/medical/Condition_centres

“Physiology and Treatment of Pain”, from Critical Care Nursing (28:6, December 2008, pp 38-47)

“What Does the Future Hold for Marijuana for Pain?”, from National Pain Foundation, http://www.nationalpainfoundation.org/MyTreatment/MyTreatment_Cannabinoids.asp