pain theories and management 085153.pptx

Pain

1. Amity University Rajasthan Kant Kalwar, NH11-C, RIICO Industrial Area, Jaipur, Rajasthan (303002) Amity Institute of Clinical Psychology (AICP) Seminar Presentation Presented by: Supervised by: Sweta Mohanty Ms. Abhilasha Agarwal M.Phil. Clinical Psychology Trainee (Part II) Assistant Professor AICP, AUR AICP, AUR

2. Pain

3. Overview Introduction Classification of Pain Models of Pain Biological Process involved in pain Psychological Process involved in Pain Management

4. Introduction The International Association for the Study of Pain (IASP) defines pain as “an unpleasant sensory and emotional experience associated with actual or potential tissue damage, or described in terms of such damage”. The IASP’s definition highlights the multidimensional and subjective nature of pain, a complex experience that is unique to each individual. Pain involves the total experience of some noxious stimulus which is influenced by current context of the pain, previous experience, learning history and cognitive process. (Feuerstein et al.,1987).

5. These mechanisms are an integral part of the body’s defences , providing early warning of impending damage and triggering physiological (via nociception) and behavioural (via subjective pain) responses toavoid or minimize that damage.

6. CLASSIFICATION OF PAIN

7. 1. Acute or Chronic Pain both may differ in terms of duration, a more helpful distinction is to regard acute pain as that which serves to protect after injury and promote healing, and chronic pain as a disease of pain which does not serve this function. In some cases, however, ‘acute pain’ fails to resolve after the expected period, so that the pain itself becomes a disease state (that is, chronic).

8. Organic or Psychogenic Pain Psychogenic pain, also called psychalgia , is that is caused, increased, or prolonged by mental, emotional, or behavioural factors.Headache , back pain, or stomach pain are some of the most common types of psychogenic pain. The Causes may be linked to stress, unexpressed emotional conflicts, psychosocial problems, or various mental disorders. Organic pain It refers to any pain resulting from a disorder, abnormality or chemical imbalance in an organ system, namely the human body. Consequently, organic pain is an extremely broad term, covering pain causes that range in diversity from heartburn to multiple sclerosis.

9. Nociceptive or Neuropathic pain There are two types of Nociceptive pain: somatic and visceral pain. 1. Somatic pain is caused by the activation of pain receptors on the surface of the body, such as the skin (cutaneous tissues) or tissues that are deeper, such as muscle (musculoskeletal tissues). When pain occurs in the musculoskeletal tissues, it is called deep somatic pain. Deep somatic pain is usually described as “dull” or “aching” but localized

10. 2. Visceral pain It is caused by activation of pain receptors resulting from infiltration, compression, extension, or stretching of the chest, abdominal, or pelvic viscera. Visceral pain is not well localized and is usually described as “pressure-like, deep squeezing.” Examples of visceral pain include pain related to cancer, bone fracture, or bone cancer.

11. Neuropathic Pain Neuropathic pain is a neurological disorder resulting from damage to nerves that carry information about pain. Neuropathic pain is reported to feel different from somatic or visceral pain and is often described using words such as “shooting,” “electric,” “stabbing,” or “burning.” This may be felt travelling along a nerve path from the spine into the arms and hands or into the buttocks or legs. Examples of neuropathic pain conditions include phantom limb pain, post-herpetic neuralgias, and other painful neuropathies (e.g., diabetes or alcohol related).

12. MODELS OF PAIN

13. 1-The Gate Control Theory ( Melzack & Wall, 1965) According to the theory, modulation of the signal occurs at a site in the dorsal horn of the spinal cord, where a type of “gate mechanism” exists. The gate opens and closes depending on feedback from other nerve fibers in the body, including descending neural impulses from the brain such as those related to an individual’s thoughts or mood (e.g., anxiety or depression). Thus, the theory had a significant impact on the study of pain because it recognized that psychological factors can have important roles in the experience of pain

14. 2-Biopsychosocial Model the biopsychosocial model emphasizes the dynamic and reciprocal relationships between the social, biological, and psychological domains of physical health problems (Engel, 1977). Consistent with more general systems theory (von Bertanlanffy , 1968), the model notes that a change in one domain (e.g., the biological domain in the case of a chronic painful condition) necessarily results in changes in the other domains (e.g., psychological and social domains). Biopsychosocial models suggest that pain is not just a biological process involving the transmission of sensory information about tissue damage to the brain, but is the product of the interactions among biological, psychological, and social factors.

15. 3. Cognitive-Behavioral Transactional Model (Kerns, Otis, and Wise (2002). The cognitive-behavioral transactional model emphasizes the importance of social support and the family in the development and maintenance of chronic pain. The model suggests that interactions related to pain all take place within a social and family learning environment that selectively reinforces coping attempts and outcomes in terms of optimal pain management, continued constructive activity, and emotional wellbeing. It hypothesizes that the family plays an active role in seeking out and evaluating information about the painful condition itself and the specific challenges it poses, as well as in making judgments about the family’s and its members’ capacities and vulnerabilities in meeting the challenges. It is on the basis of these appraisals that the family and its members make active decisions about alternative responses, act upon their decisions, and evaluate the adequacy of the responses.

16. 4 Cognitive-Behavioral Fear-Avoidance Model Vlaeyen and Linton (2000) have proposed a cognitive- behavioural , fear-avoidance model of chronic pain to explain the role of fear and avoidance behaviours in the development and maintenance of chronic pain and related functional limitations. According to this model, there are two opposing responses an individual may have when experiencing pain. One response is that an individual may consider pain to be nonthreatening and consequently engage in adaptive behaviours that promote the restoration of function. In contrast, pain may be interpreted threatening, a process called catastrophizing. Vlaeyen and Linton proposed that catastrophizing contributes to a fear of pain and may lead to avoidance of activities that may elicit pain, guarding behaviours (i.e., behaviours performed with the goal of protecting a site of pain such as bracing while walking), and hypervigilance to bodily sensations.

17. Biological processes involved in pain Physiological Neurotransmitters Nociception (pain perception) Opioids Thermal damage Serotonin and Norepiphrine polymodal nociception, GABA, thyrotropin-releasing hormone somatostatin acetylcholine

18. Psychological processed involved in pain

19. Assessment of Pain

20. 1. Self Reports Visual Analog Scale (VAS), which is simply a line anchored on the left by a phrase such as “no pain” and on the right by a phrase such as “worst pain imaginable.”. Visual analog scales have been criticized as sometimes being confusing to patients not accustomed to quantifying their experience (Burckhardt & Jones, 2003b) and difficult for those who cannot comprehend the instructions, such as older people with dementia or young children (Feldt, 2007)

21. The McGill Pain Questionnaire (MPQ) An inventory that provides a subjective report of pain and categorizes it in three dimensions: sensory, affective, and evaluative. Sensory qualities of pain are its temporal, spatial, pressure, and thermal properties; affective qualities are the fear, tension, and autonomic properties that are part of the pain experience; evaluative qualities are the words that describences the subjective overall intensity of the pain experiences.

22. The Multidimensional Pain Inventory (MPI), It is also known as the West Haven–Yale Multidimensional Pain Inventory (WHYMPI), is another assessment tool specifically designed for pain patients. (Kerns, Turk, & Rudy, 1985). The 52-item MPI is divided into three sections. The first rates characteristics of the pain, interference with patients’ lives and functioning, and patients’ moods. The second section rates patients’ perceptions of the responses of significant others, and the third measures how often patients engage in each of the 30 different daily activities

23. 2. Psychological assessment in pain MMPI-2 The most frequently used of these tests is the MMPI-2 ( Arbisi & Seime , 2006) . Recent research ( Arbisi & Seime , 2006) confirms the use of the MMPI for such assessment. One of the major advantages of using the MMPI-2 for pain assessment is its ability to detect patients who are being dishonest about their experience of pain ( Bianchini , Etherton , Greve , Heinly , & Meyers, 2008).

24. Researchers also use the Beck Depression Inventory and the Symptom Checklist–90 to measure pain. (Beck, Ward, Mendelson, Mock, & Erbaugh , 1961) The Beck Depression Inventory is a short self-report questionnaire that assesses depression; the Symptom Checklist–90 measures symptoms related to various types of behavioral problems. People with chronic pain often experience negative moods, so the relationship between scores on psychological tests and pain is not surprising. The factor analyses of the Beck Depression Inventory with pain patients indicate that pain patients present a different profile than depressed people with no chronic pain. (Poole, Branwell , & Murphy, 2006)

25. MANAGEMENT OF THE PAIN

26. Pharmacological control of Pain: The traditional and most common method of controlling pain is through the administration of drugs. In particular, Morphin (named after Morpheus, the Greek god of sleep) has been the most popular painkiller for decades.( Melzack & Wall,1982). Some drugs ,such as local anesthetics ,can influence transmission of pain impulse from the peripheral receptors to the spinal cord. The injection of drugs such as spinal blocking agents that block the transmission of pain impulse up the spinal cord is another method.

27. Paracetamol (acetaminophen), or a non steroidal anti-inflammatory drug (NSAID) such as ibuprofen are preferable in mild pain. Pentazocine, dextromoramide and dipipanone are not recommended in new patients except for acute pain where other analgesics are not tolerated or are inappropriate, for pharmacological and misuse-related reasons. Amitriptyline is prescribed for chronic muscular pain in the arms, legs, neck and lower back. While opiates are often used in the management of chronic pain, high doses are associated with an increased risk of opioid overdose.

28. Surgical control of Pain: It involves cutting or creating lesion in the so called pain fibers at various points in the body so that pain sensation can no longer be conducted. Some surgical techniques attempt to disrupt the conduct of pain from the periphery to the spinal cord whereas others are designed to interrupt the flow of pain sensation from the spinal cord upward to the brain. But sometimes the effects are short lived and can ultimately worsen the problem it damages the nervous system. Sensory control of Pain: One of the oldest known techniques of pain control is counter irritation, a sensory method. It involves inhibiting pain in one part of the body by stimulating or mildly irritating another area.

29. Behavior therapy The goal of behavior therapy is to mitigate excessive problematic pain-associated behaviors (e.g., excessive medication usage, limping) and increase those adaptive behaviors occurring infrequently or not at all (e.g., walking, exercise, self-care, work). Behavior therapy is found to be less well controlled in outpatient settings. The assistance of others is needed to ensure that environmental contingencies are systematically applied at home or in other relevant settings.

30. Cognitive-Behavioral Therapy CBT is focusing upon the correction of distorted thinking processes and the development of strategies (coping) with which to deal effectively with pain, its effects, and psychosocial stressors. CBT is effective in a number of different chronic pain problems, including low back pain, headache, fibromyalgia, osteoarthritis, rheumatoid arthritis, and temporomandibular joint disorders (Turner and Chapman, 1982). CBT focuses on internal appraisals of pain and disability by examining and addressing the cognitions, emotions, and behaviours associated with pain and painrelated activities and modification of maladaptive cognitions and beliefs (schemata) and the development of effective coping strategies.

31. Cognitive restructuring & coping skill training: Cognitive restructuring, an interactive process involving the Socratic method, is used to teach patients to identify and modify maladaptive, negatively distorted thoughts that may lead to negative feelings, such as depression, anxiety, and anger. Coping skills training is aimed at helping patients develop a repertoire of skills for managing pain and stress and providing patients with a general set of problem-solving or coping skills that can be used in a wide range of situations that induce pain. The therapist helps the patient develop a broader range of effective coping strategies by examining existing coping strategies, determining their effectiveness, and facilitating the development of a broader range of strategies.

32. Mindfulness Mindfulness, breathing, imagery and visualization are effective for stress, anxiety, depression and pain. The practice of mindfulness develops ability to control attention and regulate emotions. Being aware of the present moment is a powerful method of directing our focus on what truly exists around us as opposed to thinking about the past or future.

33. Supportive therapy In supportive therapy therapist undertake a warm, reflective, and empathic approach to reduce patient distress and reassure the patient that he or she is understood and that the magnitude of his or her plight is appreciated. The therapist emphasize that modification and improvement in functioning are essentially the patient’s responsibility. This emphasis can enhance the patient’s sense of personal control and self-efficacy, which is critical for overcoming the tendency of the patient to succumb to powerlessness and helplessness. These advices fosters the notion of the patient’s responsibility and autonomy by allowing the patient to select those aspects of treatment that are most appealing, thus possibly facilitating patient compliance. (Miller and Sanchez 1994).

34. Acupuncture It includes use of long thin needles are inserted into specially designated areas of the body that theoretically influences the areas in which a patient is experiencing the disorder. Although the main goal of acupuncture is to treat the illness, it is also used in pain management because it appears to have an analgesic effect. Researchers believe that Acupuncture works partly as a sensory method of controlling pain as well as it is associated with other psychologically based techniques for pain control.

35. Biofeedback It refers to a procedure in which physical parameters (e.g., muscle tension) are continuously monitored and fed back to the patient, who then attempts to alter the physical parameter. The electrical signals from these electrodes would be relayed to a monitor and presented in any of a number of formats (e.g., visual, auditory). The patient, attending to the signal, would then use the information presented to develop strategies to reduce muscle tension. Biofeedback from electromyography assists the patient in learning to reduce muscle tension; the levels of measured muscle tension are signaled back to the patient for modification. This technique is useful in tension headache, temporomandibular joint disorders, fibromyalgia, and other myofacial pain disorders

36. Relaxation and Imagery Training Relaxation and imagery (R&I) has been employed in both acute and chronic pain and has been successfully implemented in the treatment of tension headache, migraine headache, temporomandibular joint pain, chronic back pain, and myofascial pain syndrome. Progressive muscle relaxation (PMR) is the most common approach used. Imagery involves talking the patient through vivid images that are particularly comforting and relaxing. Just as imagining the taste and aroma of a craved meal or an erotic thought can induce a dramatic constellation of physiologic responses, so too, it is thought, can guided imagery modify physiologic reactions to pain.

37. Hypnosis It is a self-induced state brought on by the patient with the assistance of the hypnotist. The mechanism of pain relief brought on by hypnosis is unclear. Current conceptualizations view hypnosis as a form of focused attention that is useful in managing acute and chronic pain states, including headache, fibromyalgia, back pain, trigeminal neuralgia, arthritis, phantom limb pain, and cancer pain. Analgesia produced in response to hypnosis was thought to be brought on by modification of attention control systems (i.e., anterior frontal cortex) within the brain .

38. Vocational Rehabilitation Patients with pain can experience significant losses, including the loss of work. Vocational rehabilitation may serve an instructional role, helping the patient develop skills that will be suitable for other kinds of work. Vocational rehabilitation also may be helpful in fostering the patient’s independence, autonomy, and selfefficacy and may assist the patient particularly when there is financial need, ineligibility for disability or compensation, and the need for insurance and medical coverage.

39. THANKYOU

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