Pain Management PDF Print E-mail

According to the International Association for the Study of Pain, pain is an unpleasant sensory and emotional experience arising from actual or potential tissue damage. Clinically, pain is whatever the person says he or she is experiencing whenever he or she says it occurs. Pain is commonly categorized along a continuum of duration. Acute pain usually lasts hours, days, or weeks and is associated with tissue damage, inflammation, a surgical procedure, or a brief disease process. Acute pain serves as a warning that something is wrong. Chronic pain, in contrast, worsens and intensifies over time and persists for months, years, or a lifetime. It accompanies disease processes such as cancer, HIV/AIDS, arthritis, fibromyalgia, and diabetes. Chronic pain can also accompany an injury that has not resolved over time, such as reflex sympathetic dystrophy, low back pain, or phantom limb pain.



In general, there are three types of pain, based on where in the body the pain is felt: somatic, visceral, and neuropathic. Pain of all three types can be either acute or chronic. Acute pain is short lasting and usually manifests in ways that can be easily described and observed. Chronic pain is defined as pain lasting more than three months. It is much more subjective and not easily described as acute pain. The three pain types can be felt at the same time or singly and at different times. The different types of pain respond differently to the various pain medications. Somatic and visceral pains are easier to treat than neuropathic pain.


Somatic Pain
Somatic pain is caused by the activation of pain receptors in either the body surface or musculoskeletal tissues. A common cause of somatic pain is postsurgical pain from the surgical incision. It is usually described as dull or aching. Somatic pain occurs with increased frequency in the shoulder, hip, and hand, although it also occurs in the lower back and buttocks. Somatic pain is probably caused by a combination of factors, such as abnormalities that may have always been there, inflammation, repetitive trauma, excessive activity, vigorous stretching, and contractions due to paralysis, spasticity, flabbiness, disuse and misuse. Generally speaking, somatic pain is usually aggravated by activity and relieved by rest.


Features of Somatic Pain

  • Aching, often constant                                     
  • May be dull or sharp
  • Often worse with movement
  • Well localized


  • Bone & soft tissue
  • chest wall


Visceral Pain
Visceral pain is the pain we feel when our internal organs are damaged or injured and is by far the most common form of pain. Viscera refer to the internal areas of the body that are enclosed in a cavity. Visceral pain is caused by the activation of pain receptors in the chest, abdomen or pelvic areas. Visceral pain is vague and not well localized and is usually described as pressure-like, deep squeezing, dull or diffuse. Visceral pain is caused by problems with internal organs, such as the stomach, kidney, gallbladder, urinary bladder, and intestines. These problems include distension, perforation, inflammation, and impaction or constipation, which can cause associated symptoms, such as nausea, fever, and malaise, and pain. Visceral pain is also caused by problems with abdominal muscles and the abdominal wall, such as spasm.


Features of Visceral Pain

  • Constant or crampy
  • Aching
  • Poorly localized
  • Referred


  • CA pancreas
  • Liver capsule distension
  • Bowel obstruction


Neuropathic Pain

Neuropathic pain is caused by injury or malfunction to the spinal cord and peripheral nerves. Neuropathic pain is typically a burning, tingling, shooting, stinging, or "pins and needles" sensation. Some people also complain of a stabbing, piercing, cutting, and drilling pain. This type of pain usually occurs within days, weeks, or months of the injury and tends to occur in waves of frequency and intensity. Neuropathic pain is diffuse and occurs at the level or below the level of injury, most often in the legs, back, feet, thighs, and toes, although it can also occur in the buttocks, hips, upper back, arms, fingers, abdomen, and neck.


Features of Neuropathic Pain

Steady, Dysesthetic
  • Burning, Tingling
  • Constant, Aching
  • Squeezing, Itching
  • Allodynia
  • Hypersthesia   
  • Diabetic neuropathy
  • Post-herpetic neuropathy
Paroxysmal, Neuralgic
  • Stabbing
  • Shock-like, electric
  • Shooting
  • Lancinating  
  • trigeminal neuralgia
  • may be a component of any neuropathic pain


Pain Assessment
“Describing pain only in terms of its intensity is like describing music only in terms of its loudness”.
Assessment of the patient experiencing pain is the cornerstone to optimal pain management. However, the quality and utility of any assessment tool is only as good as the clinician's ability to thoroughly focus on the patient. This means listening empathically, believing and legitimizing the patient's pain, and understanding, to the best of his or her capability, what the patient may be experiencing. A health care professional's empathic understanding of the patient's pain experience and accompanying symptoms confirms that there is genuine interest in the patient as a person. This can influence a positive pain management outcome. After the assessment, quality pain management depends on clinicians' earnest efforts to ensure that patients have access to the best level of pain relief that can be safely provided. Clinicians most successful at this task are those who are knowledgeable, experienced, empathic, and available to respond to patient needs quickly.
Pain assessment usually begins with an open-ended inquiry: “Tell me about your pain.” This allows the patient to tell his or her story, including the aspects of the pain experience that are most problematic. The clinician must listen closely to these first words. Patients in pain want to tell their stories, and clinicians need to take time to listen. Stories are narratives that provide meaning in our lives. They can teach, heal, validate, offer reflection, and shape how patients are cared for. Storytelling provides a different lens through which an experience can be viewed.


A patient's statement, “I have pain,” is not descriptive enough to inform a health care professional about pain type. Asking patients to describe their pain using words will guide clinicians to the appropriate interventions for specific pain types. Patients may have more than 1 type of pain. The following questions should be asked of patients:

  • What does your pain feel like?
  • Because various pain types are described using different words, what words would you use to describe the pain you are having?


Breakthrough pain refers to a transitory exacerbation or flare of pain occurring in an individual who is on a regimen of analgesics for continuous stable pain. Patients need to be asked, “Is your pain always there, or does it come and go?” or “Do you have both chronic and breakthrough pain?” Pain descriptors, intensity, and location are important to obtain not only on breakthrough pain but on stable (continuous) pain as well.


The ability to quantify the intensity of pain is essential when caring for persons with acute and chronic pain. Though no scale is suitable for all patients, Dalton and McNaull advocate a universal adoption of a 0 to 10 scale for clinical assessment of pain intensity in adult patients. Standardization may promote collaboration and consistency among caregivers in multiple settings—inpatient, outpatient, and home care environments. Using a pain scale with 0 being no pain and 10 being the worst pain imaginable, a numerical value can be assigned to the patient's perceived intensity of pain. Asking patients to rate their present pain, their pain after an intervention, and their pain over the past 24 hours will enable health care providers to see if the pain is worsening or improving. Also, inquiring about the pain level acceptable to the patient will help clinicians understand the patient's goal of therapy. The Wong/Baker faces rating scale is a visual representation of the numerical scale. Although the faces scale was developed for use in pediatric patients, it has also proven useful with elderly patients and patients with language barriers.


Most patients have 2 or more sites of pain. Thus, it is important to ask patients, “Where is your pain?” or “Do you have pain in more than one area?” The pain that the patient may be referring to may be different than the one the nurse or physician is talking about. Having the patient point to the painful area can be more specific and help to determine interventions.


Aggravating/alleviating factors
Asking the patient to describe the factors that aggravate or alleviate the pain will help plan interventions. A typical question might be, “What makes the pain better or worse?” Analgesics, non-pharmacologic approaches (massage, relaxation, music or visualization therapy, biofeedback, heat or cold), and nerve blocks are some interventions that may relieve the pain. Other factors (movement, physical therapy, activity, intravenous sticks or blood draws, mental anguish, depression, sadness, bad news) may intensify the pain.
Other things to include in the pain assessment are the presence of contributing symptoms or side effects associated with pain and its treatment. These include nausea, vomiting, constipation, sleepiness, confusion, urinary retention, and weakness. Some patients may tolerate these symptoms without aggressive treatment; others may choose to stop taking analgesics or adjuvant medications because of side effect intolerance. Adjustments, alterations, or titration may be all that is necessary.
Inquiring about the presence or absence of changes in appetite, activity, relationships, sexual functioning, irritability, sleep, anxiety, anger, and ability to concentrate will help the clinician understand the pain experience in each individual. Additionally, the clinician should discern how pain is perceived by the patient and his or her family or significant other and what works and doesn't work to help the pain.
Acute and chronic pain not properly assessed can result in inadequate pain management outcomes and can negatively affect the physical, emotional, and psychosocial well-being of patients. Pain assessment is the cornerstone to optimal pain management.


Pain Management
Many different treatments can ease pain. Medicines are the most common treatment. But to feel better, you also can try other things, such as reducing your stress level or changing how you think.
You also can try physical therapy, relaxation, acupuncture, and other ways to feel better. Talk with your doctor about what mix of treatments might work best for you.
Your treatment depends on several things, including:

  • How bad your pain is (based on what you tell your doctor).
  • How long you've had pain.
  • The type of pain you have. For example, you might take different medicine for joint pain than you would for nerve pain.
  • Other health problems you may have.

If you have pain for a long time, your treatment may change over time.
Medicines to treat pain
Several types of medicines can be used to treat pain. Most of these medicines can treat more than one kind of pain. So you may need to try a couple of medicines to see which works best for you. Your doctor will work with you to find the right types and dosage of medicine. You may take more than one kind of medicine at the same time.


Medicines for different types of pain


Examples Types of pain
Acetaminophen :
 Example: Panadol
   Relieves mild to moderate pain but doesn't reduce inflammation
   Often used for short-term (acute) pain 
Muscle, joint, and bone pain
Organ pain
Corticosteroids :
   Examples: prednisolone and dexamethasone
   Relieves inflammation that can cause pain
   May be given as a pill or shot
Muscle, joint, and bone pain
Nonsteroidal anti-inflammatory drugs (NSAIDS) :
   Examples: acetylsalicylic acid, ibuprofen (such as Aspro and Sapofen), and naproxen (Naproxen).
   Relieves pain and inflammation
   May be used for short- or long-term (chronic) pain
Muscle, joint, and bone pain
Organ pain
Anticonvulsants :
Examples: gabapentin carbamazepine, and topiramate
 May be used for long-term pain
Nerve pain
Narcotics (also called opioids) :
 Examples: acetaminophen and hydrocodone and morphine
   Used to treat cancer pain
   Used for severe short-term pain (such as from injury or after surgery)
   May be used for long-term pain
Organ pain
Serotonin and norepinephrine reuptake inhibitor (SNRI) antidepressants :
   Examples: duloxetine and venlafaxine.
   Often used to treat fibromyalgia
Nerve pain
Organ pain
Selective serotonin reuptake inhibitor (SSRI) antidepressants:
   Examples: fluoxetine, sertraline and citalopram
Can be used for any type of pain
Tricyclic and tetracyclic antidepressants :
   Examples: amitriptyline, desipramine and nortriptyline
   May be used for long-term pain
Can be used for any type of pain


Chronic Pain Management
The treatments for chronic pain are as diverse as the causes. From over-the-counter and prescription drugs to mind/body techniques to acupuncture, if one approach doesn't work, another one might. But when it comes to treating chronic pain, no single technique is guaranteed to produce complete pain relief. Relief may be found by using a combination of treatment options.


Drug Therapy: Nonprescription and Prescription
Milder forms of pain may be relieved by over-the-counter medications such as Tylenol (acetaminophen) or Non-Steroidal Anti-Inflammatory Drugs (NSAIDs) such as acetylsalicylic acid. Both acetaminophen and NSAIDs relieve pain caused by muscle aches and stiffness, but only NSAIDs can also reduce inflammation (swelling and irritation). Topical pain relievers are also available, such as creams, lotions, or sprays that are applied to the skin in order to relieve pain from sore muscles and arthritis.

If over-the-counter drugs do not provide relief, your doctor may prescribe stronger medications, such as muscle relaxants, anti-anxiety drugs (such as Diazepam), antidepressants, prescription NSAIDs such as Celecoxib, or a short course of stronger painkillers (such as Codeine, Fentanyl, etc. A limited number of steroid injections at the site of a joint problem can reduce swelling and inflammation.

In April 2005, the FDA asked that  Celecoxib carry new warnings about the potential risk of heart attacks and strokes as well as potential stomach ulcer bleeding risks. At the same time the FDA asked that over-the-counter anti-inflammatory drugs -- acetylsalicylic acid - revise their labels to include information about potential heart and stomach ulcer bleeding risks.

Patient-controlled analgesia (PCA) is another method of pain control. By pushing a button on a computerized pump, the patient is able to self administer a premeasured dose of pain medicine. The pump is connected to a small tube that allows medicine to be injected intravenously (into a vein), subcutaneously (just under the skin), or into the spinal area. This is often used in the hospital to treat pain.

Sometimes, a group of nerves that causes pain to a specific organ or body region can be blocked with local medication. The injection of this nerve-numbing substance is called a nerve block. Although many kinds of nerve blocks exist, this treatment cannot always be used. Often blocks are not possible, are too dangerous, or are not the best treatment for the problem. You doctor can advise you as to whether this treatment is appropriate for you.


Trigger Point Injections
Trigger point injection is a procedure used to treat painful areas of muscle that contain trigger points, or knots of muscle that form when muscles do not relax. During this procedure, a health care professional, using a small needle, injects a local anesthetic that sometimes includes a steroid into a trigger point. With the injection, the trigger point is made inactive and the pain is alleviated. Usually, a brief course of treatment will result in sustained relief.

Trigger point injection is used to treat muscle pain in the arms, legs, lower back, and neck. In addition, this approach has been used to treat fibromyalgia, tension headaches, and myofascial pain syndrome (chronic pain involving tissue that surrounds muscle) that does not respond to other treatment.


Surgical Implants
When standard medicines and physical therapy fail to offer adequate pain relief, you may be a candidate for a surgical implant to help you control pain. There are two main types of implants to control pain:
•    Intrathecal Drug Delivery. Also called infusion pain pumps or spinal drug delivery systems. The surgeon makes a pocket under the skin that's large enough to hold a medicine pump. The pump is usually about one inch thick and three inches wide. The surgeon also inserts a catheter, which carries pain medicine from the pump to the intrathecal space around the spinal cord. The implants deliver medicines directly to the spinal cord, where pain signals travel. For this reason, intrathecal drug delivery can provide significant pain control with a fraction of the dose that would be required with pills. In addition, the system can cause fewer side effects than oral medications because less medicine is required to control pain.
•   Spinal Cord Stimulation Implants. In spinal cord stimulation, low-level electrical signals are transmitted to the spinal cord or to specific nerves to block pain signals from reaching the brain. In this procedure, a device that delivers the electrical signals is surgically implanted in the body. A remote control is used by the patient to turn the current off and on or to adjust the intensity of the signals. Most people describe the feelings from the simulator as being pleasant and tingling.

Two kinds of spinal cord stimulation systems are available. The unit that is more commonly used is fully implanted and has a pulse generator and a non-rechargeable battery. The other system includes an antenna, transmitter, and a receiver that relies upon radio frequency. The latter system's antenna and transmitter are carried outside the body, while the receiver is implanted inside the body.


Transcutaneous electrical nerve stimulation therapy, more commonly referred to as TENS, uses electrical stimulation to diminish pain. During the procedure, low-voltage electrical current is delivered through electrodes that are placed on the skin near the source of pain. The electricity from the electrodes stimulates the nerves in an affected area and sends signals to the brain that "scramble" normal pain signals.TENS is not painful and may be effective therapy to mask pain such as diabetic neuropathy. However, TENS for chronic low back pain is not effective and cannot be recommended, the American Academy of Neurology (AAN) now says.


Bioelectric Therapy
Bioelectric therapy relieves pain by blocking pain messages to the brain. Bioelectric therapy also prompts the body to produce chemicals called endorphins that decrease or eliminate painful sensations by blocking the message of pain from being delivered to the brain.
Bioelectric therapy can be used to treat many chronic and acute conditions causing pain, such as back pain, muscle pain, headaches and migraines, arthritis, TMJ disorder, diabetic neuropathy, and scleroderma.
Bioelectric therapy is effective in providing temporary pain control, but it should be used as part of a total pain management program. When used along with conventional pain-relieving medications, bioelectric treatment may allow pain sufferers to reduce their dose of some pain relievers by up to 50%.


Physical Therapy
Physical therapy helps to relieve pain by using special techniques that improve movement and function impaired by an injury or disability. Along with employing stretching and pain-relieving techniques, a physical therapist may use, among other things, TENS to aid treatment.


Although resting for short periods can alleviate pain, too much rest may actually increase pain and put you at greater risk of injury when you again attempt movement. Research has shown that regular exercise can diminish pain in the long term by improving muscle tone, strength, and flexibility. Exercise may also cause a release of endorphins, the body's natural painkillers. Some exercises are easier for certain chronic pain sufferers to perform than others; try swimming, biking, walking, rowing, and yoga.
Psychological Treatment
When you are in pain, you may have feelings of anger, sadness, hopelessness, and/or despair. Pain can alter your personality, disrupt your sleep, and interfere with your work and relationships. In turn, depression and anxiety, lack of sleep, and feelings of stress can all make pain worse. Psychological treatment provides safe, nondrug methods that can treat your pain directly by reducing high levels of physiological stress that often aggravate pain. Psychological treatment also helps improve the indirect consequences of pain by helping you learn how to cope with the many problems associated with pain.
A large part of psychological treatment for pain is education, helping patients acquire skills to manage a very difficult problem.


Alternative Therapies
In the past decade, strong evidence has accumulated regarding the benefits of mind-body therapies, acupuncture, and some nutritional supplements for treating pain. Other alternative therapies such as massage, chiropractic therapies, therapeutic touch, certain herbal therapies, and dietary approaches have the potential to alleviate pain in some people. However, the evidence supporting these therapies is less concrete.


Mind-Body Therapies
Mind-body therapies are treatments that are meant to help the mind's ability to affect the functions and symptoms of the body. Mind-body therapies use various approaches including relaxation techniques, meditation, guided imagery, biofeedback, and hypnosis. Relaxation techniques can help alleviate discomfort related to chronic pain.
Visualization may be another worthwhile pain-controlling technique. Try the following exercise: Close your eyes and try to call up a visual image of the pain, giving it shape, color, size, motion. Now try slowly altering this image, replacing it with a more harmonious, pleasing -- and smaller -- image.
Another approach is to keep a diary of your pain episodes and the causative and corrective factors surrounding them. Review your diary regularly to explore avenues of possible change. Strive to view pain as part of life, not all of it.
Electromyographic (EMG) biofeedback may alert you to the ways in which muscle tension is contributing to your pain and help you learn to control it. Hypnotherapy and self-hypnosis may help you block or transform pain through refocusing techniques. One self-hypnosis strategy, known as glove anesthesia, involves putting yourself in a trance, placing a hand over the painful area, imagining that the hand is relaxed, heavy, and numb, and envisioning these sensations as replacing other, painful feelings in the affected area.
Relaxation techniques such as meditation or yoga have been shown to reduce stress-related pain when they are practiced regularly. The gentle stretching of yoga is particularly good for strengthening muscles without putting additional strain on the body.


Acupuncture is thought to decrease pain by increasing the release of endorphins, chemicals that block pain. Many acu-points are near nerves. When stimulated, these nerves cause a dull ache or feeling of fullness in the muscle. The stimulated muscle sends a message to the central nervous system (the brain and spinal cord), causing the release of endorphins that block the message of pain from being delivered to the brain.
Acupuncture may be useful as an accompanying treatment for many pain-related conditions, including headache, low back pain, menstrual cramps, carpal tunnel syndrome, tennis elbow, fibromyalgia, osteoarthritis (especially of the knee), and myofascial pain. Acupuncture also may be an acceptable alternative to or may be included as part of a comprehensive pain management program.


Chiropractic Treatment and Massage
Chiropractic treatment is the most common nonsurgical treatment for back pain. Improvements of people undergoing chiropractic manipulations were noted in some trials. However, the treatment's effectiveness in treating chronic back and neck pain has not been supported by compelling evidence from the majority of clinical trials. Further studies are currently assessing the effectiveness of chiropractic care for pain management.
Massage is being increasingly used by people suffering from pain, mostly to manage chronic back and neck problems. Massage can reduce stress and relieve tension by enhancing blood flow. This treatment also can reduce the presence of substances that may generate and sustain pain. Available data suggest that massage therapy, like chiropractic manipulations, holds considerable promise for managing back pain. However, it is not possible to draw final conclusions regarding the effectiveness of massage to treat pain because of the shortcomings of available studies.


Therapeutic Touch and Reiki Healing
Therapeutic touch and reiki healing are thought to help activate the self-healing processes of an individual and therefore reduce pain. Although these so called "energy-based" techniques do not require actual physical contact, they do involve close physical proximity between practitioner and patient.
In the past few years, several reviews evaluated published studies on the efficacy of these healing approaches to ease pain and anxiety and improve health. Although beneficial effects with no significant adverse side effects were reported in several studies, the limitations of some of these studies make it difficult to draw definitive conclusions. Further studies are needed before the evidence-based recommendation for using these approaches for pain treatment can be made.


Nutritional Supplements
There is solid evidence indicating that glucosamine sulfate and chondroitin sulfate relieve pain due to knee osteoarthritis. These natural compounds were found to decrease pain and increase mobility of the knee and were well tolerated and safe.
Other dietary supplements, such as fish oils, also show some evidence of benefit, although more research is needed.


Herbal Remedies
It has been difficult to draw conclusions about the effectiveness of herbs. If you decide to use herbal preparations to better manage your pain, it is of critical importance to share this information with your doctor. Some herbs may interact with drugs you are receiving for pain or other conditions and may harm your health.
Dietary Approaches to Treating Pain
Some people believe that changing dietary fat intake and/or eating plant foods that contain anti-inflammatory agents can help ease pain by limiting inflammation.
A mostly raw vegetarian diet was found helpful for some people with fibromyalgia, but this study was not methodologically strong. One study of women with premenstrual symptoms suggested that a low-fat vegetarian diet was associated with decreased pain intensity and duration. Weight loss achieved by a combination of dietary changes and increased physical activity has been shown to be helpful for people suffering from osteoarthritis.
Still, further research is needed to determine the effectiveness of dietary modifications as a pain treatment.


Things to Consider
Alternative therapies are not always benign. As mentioned, some herbal therapies can interact with other medications you may be taking. Always talk to your doctor before trying an alternative approach and be sure to tell all your doctors what alternative treatments you are using.


Other Options: Pain Clinics
Many people suffering from chronic pain are able to gain some measure of control over it by trying many of the above treatments on their own. But for some, no matter what treatment approach they try, they still suffer from debilitating pain. For them, pain clinics -- special care centers devoted exclusively to dealing with intractable pain -- may be the answer. Some pain clinics are associated with hospitals and others are private; in either case, both inpatient and outpatient treatment are usually available.

Pain clinics generally employ a multidisciplinary approach, involving physicians, psychologists, and physical therapists. The patient as well should take an active role in his or her own treatment. The aim in many cases is not only to alleviate pain but also to teach the chronic sufferer how to come to terms with pain and function in spite of it.

Various studies have shown as much as 50% improvement in pain reduction for chronic pain sufferers after visiting a pain clinic, and most people learn to cope better and can resume normal activities.


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