PAIN

• Costochondritis - inflammation where your ribs join the bones in the middle of your chest
• Pain


  An unpleasant sensory and emotional experience, which we primarily associate with tissue damage or describe in terms of such damage
• Pain


  Whatever the experiencing person says it is, existing whenever he/she says it does
• Pain is a combination of physiologic phenomena but with psychosocial aspects that influence its perception
• Opioid crisis


  The Joint Commission designated "Pain" as the "fifth vital sign"
• Primary care strategies for preventing opioid misuse and opioid use disorders

  1. Screening for illicit drug use and misuse of prescription drugs

  2. Intervention to prevent drug use in adolescents and young adults
• Pathophysiology of pain


  • Associated with the central and peripheral nervous system
  • Source of pain stimulates peripheral nerve endings (nociceptors), which transmit the sensation to the central nervous system (CNS)
• Types of nociceptors


  • Mechanosensitive (sensitive to intense mechanical stimulation)
  • Thermosensitive (temperature sensitive, sensitive to heat and cold)
  • Polymodal nociceptor (sensitive to noxious stimuli of mechanical, thermal or chemical nature)
• Some nociceptors may respond to more than one type of stimulus
• Physiologic process involved in pain perception

  1. Transduction of pain begins when a mechanical, thermal, or chemical stimulus results in tissue injury or damage stimulating nociceptors

  2. Transmission process is initiated by this inflammatory process, resulting in the conduction & an impulse in the primary afferent neurons to the dorsal horn of the spinal cord
• Modulation of pain is difficult to explain as emotional status affects directly the level of pain perceived and thus reported by clients
• Physiologic response to pain

  • Elicits a stress response in the human body that triggers the sympathetic nervous system
  • Includes anxiety, fear, thoughts of suicide, focus on pain, cries and moans, decrease in cognitive function, increase in heart rate, increase in respiratory rate
• Classification of pain


  • Physical
  • Psychological/emotional/mental
  • Psychosomatic
  • Neuropathic (damage to nervous system)
  • Inflammatory
  • Somatic
  • Radicular
  • Referred
  • Phantom
  • Cancer
• Dimensions of pain


  • Physical dimension
  • Sensory dimension
  • Behavioral dimension
  • Socio-cultural dimension
  • Cognitive dimension
  • Affective dimension
  • Spiritual dimension
• Other classification categories for pain

  • Duration (acute, chronic)
  • Location (central, peripheral)
• Pain assessment tools


  • Visual Analog Scale (VAS)
  • Numeric Rating Scale (NRS)
  • Behavioral Pain Scale (BPS)
  • Pain Assessment in Advanced Dementia (PAINAD)
  • Wong-Baker FACES Pain Rating Scale
  • McCaffrey Initial Pain Assessment tool
  • Indiana Polyclinic Combined Pain Scale
  • Clinically Aligned Pain Assessment (CAPA)
• Types of pain


  • Acute pain (associated with recent injury)
  • Chronic non-malignant pain (specific cause or injury, constant pain more than 4 months)
  • Cancer pain
  • Intractable pain (high resistance to pain relief)
• Pain location classification


  • Cutaneous pain (skin or subcutaneous tissue)
  • Visceral pain (abdominal cavity, thorax, cranium)
  • Deep somatic pain (ligaments, tendons, bones, blood vessels, muscles)
• Pain is subjective by nature
• Pain is the most common reason patients seek health care
• If left untreated, pain can have serious physical, psychological, and financial consequences that affect the patient's quality of life
• Nociception


  The process by which a painful stimulus is transmitted to the Central Nervous System (CNS)
• The role of the CNS is to provide an auto response to nociception
• Neuropathic pain


  • Burning, tingling, pins and needles, shooting pain, painful numbness
  • Allodynia (stimulus does not cause pain, but patient experiences pain)
  • Hyperalgesia (increased sensation of pain)
• Neuropathic pain is a disease of the somatosensory nervous system
• Aggressive management is needed to avoid developing another chronic pain condition
• Arthritis


  Inflammation of the joints
• Opioid crisis


  PCA (Patient Controlled Analgesia)
• Types of pain


  • Acute pain (short duration, identifiable cause, physiologic response, effect if left unattended - e.g. pain from surgery, trauma, injury)
  • Chronic pain (lasts beyond normal healing period of 3-6 months, no identifiable cause, causes depression, no changes in vital signs)
  • Cancer or malignant pain (acute or chronic, due to disease progression, tumor growth, metastasis)
• Neuropathic pain does not need tissue damage to exist
• Complex Regional Pain Syndrome (CRPS)

  • Debilitating pain, vasomotor dysfunction, swelling
  • CRPS Type 1 (Reflex Sympathetic Dystrophy, no nerve injury)
  • CRPS Type 2 (Causalgia, nerve injury)
• Stages of CRPS


  • Acute (may last up to 3 months, severe burning/aching pain, sensitivity to touch)
  • Dystrophic (constant swelling, less than normal temperature)
  • Atrophic (affected area becomes pale, dry, stiff and tightly muscular and tendon atrophy)
• The prognosis of CRPS depends on the ability of the patient to manage the condition aggressively
• Gate Control Theory of Pain

  Proposed by Ronald Melzack and Patrick Wall in 1965, states that the transmission of pain signals can be modulated at the spinal cord by non-painful inputs as well as descending signals from the brain
• Non-painful inputs


  • Typically "close the gate" to painful inputs, reducing pain
  • Beta nerve fibers help close the gate in the spinal cord, thus reducing pain
• Pain signal transmission

  1. Pain receptors (nociceptors) detect pain

  2. First-order neurons transmit signals via spinal nerves to the spinal cord

  3. Second-order and third-order neurons carry pain signals to the brain
• Perception of pain is not simply due to stimulation of nociceptors
• Nerve gate


  • Located in the dorsal horn, controls the passage of pain signals to the brain
  • Consists of inhibitory interneurons that inhibit second-order neurons, stopping or reducing signal transmission
• Pain signal modulation


  1. Nociceptors activate second-order neurons and inhibit inhibitory interneurons, opening the gate and allowing pain signal transmission

  2. Non-noxious stimuli (touch, pressure, temperature) activate large diameter A-beta fibers, reactivating inhibitory neurons and closing the gate
• Pleasurable activities, excitement, meditation, laughter, vigorous exercise

  Endorphins action underlies the pain-relieving effect