Pain Management
Pain is one of the most common reasons for patients to seek medical attention and is one of the most prevalent medical complaints in the US. According to a 1999 Gallup survey, 9 out of 10 Americans aged 18 or older reported suffering pain at least once a month, and 42% of adults reported experiencing pain every day. Women, minority groups, elderly persons (especially nursing home residents), and individuals with cancer are at significant risk of suboptimal pain assessment and treatment.
Effective pain management presents a significant challenge for physicians, healthcare professionals, and their patients. Approximately 75 million Americans experience chronic pain, and at least 9% of the US adult population is estimated to suffer from moderate to severe noncancerous pain. Patients with chronic pain can be especially difficult to treat. In a survey conducted for the American Pain Society, 47% of those with moderate, severe, or very severe pain had changed physicians at least once since their initial visit for pain relief. Reasons for the change included continued suffering (42%), the physician’s lack of knowledge (31%), not taking the pain seriously enough (29%), and unwillingness to treat it aggressively (27%).
Physicians and other healthcare providers need current, state-of-the-art education to develop the necessary skills to evaluate and manage patients with pain. Addressing prevailing attitudes toward pain is also necessary, as physician and patient views can present barriers to optimal pain management.
Introduction: What is Pain?
The International Association for the Study of Pain (IASP) defines pain as “an unpleasant sensory and emotional experience which we primarily associate with tissue damage or describe in terms of such damage, or both.” This definition acknowledges that pain is a combined sensory, emotional, and cognitive phenomenon. Pain can be thought of as being composed of three hierarchical levels: a sensory-discriminatory component (e.g., location, intensity, quality), a motivational–affective component (e.g., depression, anxiety), and a cognitive-evaluative component (e.g., thoughts concerning the cause and significance of the pain).
Clinically, this concept serves to focus attention on the broad range of factors that may contribute to the pain experienced by the patient. Although pain is typically regarded as a primary indicator of tissue damage, it does not always correlate with an identifiable causative injury.
The perception of pain is supported by a system of sensory neurons (nociceptors) and neural afferent pathways that respond to potentially noxious, tissue-damaging stimuli. However, nociception can be influenced by non-nociceptive pathophysiologic (e.g., abnormal nervous system processing) or psychological factors.
Pain assessment is challenging for clinicians because, unlike blood pressure, there is no objective measure for pain. Pain is, however, objective to the patient, and experts agree that the best clinical approach is to assume that the patient is reporting a true experience, even in the absence of an obvious demonstrable origin. Accepting a patient’s complaint of pain as valid does not necessarily lead to the initiation of a specific treatment, but it is a useful beginning in developing an effective physician-patient dialogue.
Pathophysiology of Pain:
The pathophysiology of pain can be broadly divided into nociceptive, neuropathic, or idiopathic processes. Pain processes are complex and represent the interplay of several underlying mechanisms.
Nociceptive Pain Mechanisms:
Clinically, pain can be labeled “nociceptive” if it can be inferred that the pain is related to the degree of receptor stimulation by processes causing tissue injury. Nociceptive pain involves the normal activation of the nociceptive system by noxious stimuli. Pain can be thought of as composed of three hierarchical levels:
- Sensory-discriminatory component
- Motivational–affective component
- Cognitive-evaluative component
Normal processing of these stimuli requires interaction between primary afferent and pain modulating systems. The primary afferent system includes nociceptors (A-delta and C-fibers), signal processing in the dorsal horn of the spinal cord, ascending neural pathways, and thalamic and other specialized brain structures. Nociceptors with various response characteristics can be found in skin, muscle, joints, and visceral tissues.
Pain modulation is influenced by the endorphinergic system and other pain modulating systems. The principal mediators of modulation are endogenous opioid compounds (endorphins). Analgesia in the endorphinergic system is mediated by the binding of endogenous opioid compounds to receptors: mu, delta, and kappa. Other neurotransmitters, such as serotonin and norepinephrine, also play a role in the endogenous pain modulating system.
Nociceptive pain processes can be involved in both acute and chronic pain. Pain due to activation of somatic primary afferents is termed somatic pain and is localized and typically described as aching, squeezing, stabbing, or throbbing. Examples include arthritis and metastatic bone pain. Nociceptive pain that arises from the stimulation of afferent receptors located in the viscera is referred to as visceral pain, which is generalized and often described as cramping and gnawing.
Psychological and Idiopathic Pain Mechanisms:
The patient’s psychological state significantly contributes to complaints of pain and suffering and is fundamental to the subjective nature of pain. Symptoms and their associated distress are real to the patient, independent of the degree to which psychological factors are involved, and should be taken seriously. Healthcare personnel need to maintain a willingness to believe the patient’s self-report of pain and to investigate its cause. Concurrently, the presence of anxiety, depression, or other affective or psychological disorders should also be assessed so that appropriate supportive care and/or pharmacotherapy can be instituted.
Pain Characteristics:
- Temporal: Acute, recurrent, or chronic onset and duration; course and daily variation, including breakthrough pain.
- Intensity: Pain “on average,” “at its worst,” “at its least,” and “right now.”
- Topography: Focal or multifocal, focal or referred, superficial or deep.
- Quality: Any descriptor (e.g., aching, throbbing, stabbing, or burning), familiar or unfamiliar.
- Exacerbating/relieving factors: Volitional (“incident pain”) or non-volitional.
Acute vs Chronic Pain:
The distinction between acute and chronic or “persistent” pain is particularly relevant in the selection of effective analgesia. Acute pain is of recent onset with a relatively short duration, lasting no more than days or weeks. Pain is usually considered chronic if it persists for more than 3 to 6 months. Management strategies become significantly altered once pain becomes chronic, making timely pain management interventions essential.
Nearly all patients with progressive diseases, such as cancer and AIDS, experience repeated episodes of acute pain, which may be related to the disease, therapeutic interventions, or unrelated processes. In patients with persistent pain, intermittent episodes of acute pain may occur spontaneously or in association with a particular activity, referred to as breakthrough pain. Almost two-thirds of cancer patients with chronic pain report breakthrough pain.
Given their frequency, breakthrough pain and other acute pain should be specifically assessed during the evaluation of chronic pain. A daily pattern of varying pain intensity may exist, and diurnal variations are found in some painful conditions such as arthritis (e.g., pain worse in the morning).
Modern Pain Management with Microcurrent and TENS Devices:
TENS & Microcurrent devices are modern, non-pharmacological, and non-invasive tools for managing pain. They offer a way to treat various types of pain, including chronic pain, by using electrical currents to stimulate the body’s natural healing processes and modulate pain signals.
Microcurrent Therapy operates with electrical currents at lower frequencies, mimicking the body’s natural electrical currents. It promotes cellular healing and regeneration, indirectly contributing to pain relief through muscle relaxation, inflammation reduction, and improved circulation. Microcurrent therapy is used in sports medicine, wound healing, and conditions like tendonitis and inflammation.
TENS Devices deliver electrical stimulation at higher frequencies, targeting sensory nerves to modulate nerve signals and reduce pain perception. TENS is versatile, managing muscle and joint pain, arthritis, post-surgery pain, and more. Precise electrode placement enhances its effectiveness, especially when targeting trigger points.
These therapies provide valuable, versatile approaches to alleviating various types of pain, making them essential tools for individuals seeking pain relief and improved physical well-being. Consulting with a healthcare professional can provide guidance on electrode placement and therapy settings tailored to individual pain-related needs.
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