CLINICAL PAIN
The term clinical pain refers to any pain that receives or requires professional care. The pain may be either acute or chronic and may result from known or unknown causes. Relieving pain is important for humanitarian reasons and doing so also produces medical and psychosocial benefits for the patient.
ACUTE CLINICAL PAIN
Acute pain promotes survival when it serves as a warning of injury, but much of the acute pain people experience in today’s world has little survival value.
Inadequately reduced pain after surgery can cause physiological reactions that can lead to medical complications and even death. For instance, high pain and related stress after surgery impairs immune and endocrine function, slows wound healing, and increases the likelihood of infection or of the pain becoming chronic. As a result, the American Pain Society recommends that practitioners assess patients’ pain intensity and satisfaction with pain relief after surgery.
CHRONIC CLINICAL PAIN
When pain persists and becomes chronic. Patients begin to perceive its nature differently. Although the acute phase of pain was very aversive, they expected it to end and did not see it as a permanent part of their lives. As pain persists, they tend to become discouraged and angry. When regular medical care doesn’t help, increasing hopelessness and despair may lead them to try methods that lack good evidence for safety and effectiveness.
The transition from acute to chronic pain is a critical time when many of these people become increasingly disabled, especially if they experience a loss of self efficacy for performing activities and a fear that certain behaviors will cause painful episodes or worsen their condition. As this happens, these people may develop feelings of helplessness and psychological disorders, such as depression. The neurotic triad – hypochondriasis, depression, and hysteria – often becomes a dominant aspect of their personalities. Chronic pain often creates an array of long-term psychosocial problems and impaired interrelationships. Chronic patients often use drugs excessively and experience frequent sleep disturbance. Because of the differences between acute pain and chronic pain, these conditions require different treatment methods.
MEDICAL TREATMENTS FOR PAIN
SURGICAL METHODS FOR TREATING PAIN
Treating clinical pain with surgical methods is a relatively radical approach and is likely to be more effective for acute pain than chronic pain.
- Neuroablation: the surgery removes or disconnects part of the peripheral nervous system or the spinal cord, thereby preventing pain signals from reaching the brain. It seldom provides long-term relief and often has side effects, such as producing numbness in the affected region of the body.
- Spinal fusion (treating back pain), joining two or more adjacent vertebrae.
- Laminectomy (treating back pain), removing part of a vertebra to reduce pressure on spinal nerves.
Surgery for chronic skeletal pain conditions is most appropriate when the person is severely disabled and nonsurgical treatment methods have failed.
CHEMICAL METHODS FOR TREATING PAIN
Using chemical for acute pain
Many pharmaceuticals are very effective for relieving acute pain. Physicians choose the specific drug and dosage by considering many factors, such as how intense the pain is and its location and cause. Their effective use of these chemicals depends on characteristics of the drug, the patient, and sociocultural factors.
Many hospital patients in pain are undermedicated, and those who receive too little pain relief tend to be children and minority group members. The reasons for these age and sociocultural differences are unclear. In the case of children, it may be that practitioners believe children feel less pain than adults or are more likely to become addicted to drugs. Or children may simply request less medication, perhaps because they dislike injections or taking pills more than adults do.
The conventional ways for administering pain-killing chemicals involve giving injections or pills, and are given under one of two arrangements: a precripes schedule or “as needed” by the patient. But two other methods are available today:
- Epidural block: practitioners inject narcotics or local anesthetics epidurally, these chemicals then prevent pain signals from being transmitted to the brain.
- Patient-controlled analgesia: this procedure allows the patient to determine how much painkillers, such as morphine, they need, and get it without delay.
Using chemicals for chronic pain
Using opioids for managing moderate to severe cancer pain is widely accepted today. Some cancer patients may still receive inadequate analgesic drugs or underuse them, perhaps because they fear they will become addicted if the drug is a narcotic and believe that “good” patients don’t complain.
The results of many studies shows that narcotics provide substantial pain relief for patients with several non-cancer chronic pain conditions, such as arthritis, neuralgia and phantom limb pain.
But increases in using narcotics for chronic pain are occurring cautiously for at least four reasons:
- Some patients do become addicted to narcotics used to treat chronic pain and those with depressive or anxiety disorders are at higher risk for addiction than others are.
- Studies need to determine specifically how taking daily doses of narcotics alters patients’ lives and functioning.
- Researchers need to find out why tolerance and addiction to narcotics is often less likely when taken to relieve pain, at least for some condition.
- Some evidence indicates that marijuana may be an effective alternative chemical for relieving chronic pain for certain medical conditions.
Chemical methods alone are usually not sufficient for controlling pain. The need for other approaches in helping pain patients is suggested in research findings:
- Chronic headache patients tend to use maladaptive ways of coping with everyday stressors more than people without chronic headaches.
- Arthritis patients with high feelings of helplessness before starting drug treatment report poorer treatment success in reducing pain and disability than do comparable low helplessness patients
- Many patients who receive placebos in drug research with double-blind procedures report substantial pain relief
Advantages of Group Psychotherapy Over Individual Therapy in Treating Pain
- Efficiency. Although each patient has unique problems, chronic pain sufferers also face common difficulties, such as depression and addiction to medication. As a result, they often need similar types of advice and information. Group meetings use the therapist’s time more efficiently.
- Reduced isolation. Chronic pain sufferers are typically isolated from extended social contact. This situation can lead to a sense of alienation.
- Credible feedback for patients. Pain patients often resist feedback or advice from therapists, saying such things as, “You don’t know what it’s like to live with pain 24 hours a day!” In their eyes, the type of feedback other patients can give may be more believable.
- A new reference group for patients. Patients in a pain group develop new social networks of individuals who are comparable to themselves and who can provide social pressure to conform to the realities and constructive “rules” of living with pain and physical limitations.
- A different perspective for the therapist. Watching a patient relate to other individuals in a group provides the therapist with certain kinds of information that may aid in identifying specific problems therapy should address, such as maladaptive coping styles.
BEHAVIORAL AND COGNITIVE METHODS FOR TREATING PAIN
Gate-control theory changed the way many health care workers conceptualize pain by proposing that pain can be controlled not only by biochemical methods that alter sensory input directly, but by modifying motivational and cognitive processes, too.
THE OPERANT APPROACH
The operant treatment of pain is based on Fordyce’s operant conditioning model of pain and involves behavioral exercises to reduce pain behaviors and to increase healthy behaviors.
Operant approach programs typically have two main goals:
- Reduce the patients reliance on medication
- Reduce the disability that generally accompanies chronic pain conditions.
FEAR REDUCTION, RELAXATION AND BIOFEEDBACK
Many people experience chronic episodes of pain resulting from underlying physiological processes that can be exacerbated by fears and stress. If these patients could control their physiological processes that cause pain or their fears or stress, they should be able to decrease the frequency or intensity of discomfort they experience.
Fear reduction
An example of fear exacerbating a pain condition comes from people with low back pain: many of these patients come to fear moving “the wrong way” and bringing on an episode of pain. These fears lead them to avoid certain activities, and each time they avoid an activity they receive negative reinforcement—they don’t experience the pain they feared would occur. This negative reinforcement makes the fear persist and leads them to engage in less and less activity, weakening their back muscles and worsening their condition.
Methods used to reduce anxiety are systematic desensitization and in vivo exposure.
Relaxation and Biofeedback
Stress is one of many factors that can cause episodes of migraine and tension-type headache. Although the exact role of stress in these processes is not yet known, researchers have applied relaxation and biofeedback methods to reduce stress and physiological processes that lead to headache and other pain conditions. These treatments are usually conducted in weekly sessions that span about 2 or 3 months.
- Progressive muscle relaxation: the person focuses attention on specific muscle groups while alternately tightening and relaxing these muscles.
- Meditation
- Biofeedback: the person learns to exert voluntary control over a bodily function by monitoring its status with information electronic devices (EMG).
Do relaxation and biofeedback help relieve pain?
Relaxation and biofeedback methods relieve pain. But several points need to be made about this conclusion:
- Most studies testing these treatments have focused on headache and low back pain.
- Although progressive muscle relaxation and EMG biofeedback treatments are very effective in relieving headache pain, biofeedback is somewhat more effective.
- Combining biofeedback and progressive muscle relaxation seem to be effective, but these differences are not reliable because patients vary greatly in the amount of benefit they get from these treatments.
- Besides the specific skills the patients learn for controlling physiological processes, other psychological factors also seem to play a role, Consider for instance, three findings: placebo effect, massage therapy, tai chi and yoga.
COGNITIVE METHODS
Not all people in pain focus on the ordeal and discomfort; many use cognitive strategies to modify their experience.
- Passive coping e.g. taking to bed or curtailing social activities. A vicious circle can develop with chronic pain in which passive coping leads to feelings of helplessness and depression, which leads to more passive coping and so on.
- Active coping. People who use active coping methods try to keep functioning by ignoring the pain or keeping busy with an interesting activity.
Active coping techniques
Active coping is quite effective in helping people cope with pain. These techniques can be classified into three basic types: distraction, imagery and redefinition.
Distraction is the technique of focusing on a non painful stimulus in the immediate environment to divert one’s attention from discomfort. Distraction is more effective if the pain is mild or moderate than if it is strong. Three aspects of the distraction task seem to affect how well it works:
- The amount of attention the task requires: the greater the attention required, the lower the pain ratings.
- The extent to which the task is interesting or engrossing.
- The task’s credibility to the person e.g. if you were asked to listen to a sound that isn’t there, the task would lose its credibility quickly and not relieve pain.
Nonpain imagery (guided imagery) is a strategy whereby the person tries to alleviate discomfort by conjuring up a mental scene that is unrelated to or incompatible with the pain. The most common type of imagery is thinking of something nice. The imagery technique is in many ways like distraction. The main difference is that imagery is based on the person’s imagination rather than on real objects or events in the environment.
Pain redefinition: the person substitutes constructive or realistic thoughts about the pain experience for ones that arouse feelings of threat or harm. Therapists can help people redefine their pain experiences in several ways. One approach involves teaching clients to engage in an internal dialogue, using positive self-statements that take basically two forms:
- Coping statements emphasize the person’s ability to tolerate the discomfort, as when people say to themselves, “It hurts, but you’re in control” or “Be brave–you can take it”
- Reinterpretative statements are designed to negate the unpleasant aspects of the discomfort. E.g. “It’s not so bad”, “It’s not the worst thing that could happen” “It hurts, but think of the benefits of this experience”
Promoting pain acceptance
Pain therapists can promote active coping and pain acceptance with a cognitive-behavioral approach called Acceptance and Commitment Therapy (ACT), which is designed to teach clients to experience their condition and emotions directly, without the negative implications that have usually accompanied them. ACT teaches pain patients coping skills and has them perform activities to see that they can enjoy activity even when some pain is present, helping them redefine these situations, increase their self-efficacy, and reduce their pain fears.
HYPNOSIS AND INTERPERSONAL THERAPY
HYPNOSIS AS A TREATMENT FOR PAIN
Hypnosis can reduce the intensity of acute pain, but it is not highly effective for all people. People vary in their ability to be hypnotized, and those who can be hypnotized very easily and deeply seem to gain more pain relief from hypnosis than those who are less hypnotically susceptible. Studies have shown that hypnosis and cognitive-behavioral methods produce similar relief for acute pain and that combining these methods does not enhance their effects.
Hypnosis can reduce chronic pain. Although most relevant studies have tested patients with recurrent headache, some have shown that hypnosis helps also with other pain conditions, such as low back pain and cancer pain.
INTERPERSONAL THERAPY FOR PAIN
Interpersonal therapy uses psychoanalytic and cognitive-behavioral perspectives to help people deal with emotional difficulties, by changing the way they interact with and perceive their social environments. The underlying theory is that people’s emotional difficulties arise from the way they relate to others, particularly family members.
STIMULATION AND PHYSICAL THERAPIES FOR PAIN
Reducing one pain by creating another is called counterirritation. People in ancient cultures developed a counterirritation procedure called cupping to relieve headaches, backaches and arthritic pain. The principle of counterirritation is the basis for present-day stimulation therapies for reducing pain.
STIMULATION THERAPIES
Gate-control view of how counterirritation works led to the development of a pain control technique called transcutaneous electrical nerve stimulation (TENS). This technique involves placing electrodes on the skin near where the patient feels pain and stimulating that area with mild electric current, which is supplied by a small portable device.
A more promising electrical stimulation therapy for chronic pain is called spinal cord stimulation, which sends mild electrical pulses to the spinal cord from a device that is implanted in the body.
Another stimulation therapy for reducing pain is acupuncture, evidence points to a few conclusions about its effects and its limitations. Gate-control theory provides two plausible reasons for any effects of acupuncture: stimulation from the needles may close the gate by activating the peripheral fibers or the release of opioids, such as endorphins.
PHYSICAL THERAPY
Physical therapy is an important rehabilitation component for many medical conditions–for instance, after injury or surgery, patients perform exercises to enhance muscular strength and tissue flexibility to restore their range of motion. The therapist and patient generally plan the program together, setting daily or weekly goals that promote very gradual but steady progress.The spinal manipulation treatment people get from chiropractic and osteopathic specialist for low back pain is not generally considered to be physical therapy, but it is effective for many patients–and the best candidates can be identified by features of their condition, such as symptom durations of less than 16 days and low scores on a test of fear and avoidance of pain.
Physical therapy is widely used in treating two highly prevalent chronic pain conditions: arthritis and low back pain.
PAIN CLINICS
Nowadays people with chronic pain can receive effective pain control through pain clinics (or pain centers) which are institutions or organizations that have been developed specifically for treating pain conditions.
MULTIDISCIPLINARY PROGRAMS
Multidisciplinary (or interdisciplinary) pain clinics–those that combine and integrate several effective approaches–are likely to succeed for the largest percentage of patients and provide the greatest pain relief for each individual. Clinics that use multidisciplinary programs generally use assessment and treatment methods for each patient that involves medical, psychosocial, physical therapy, occupational therapy and vocational factors and approaches.
Although the goals and objectives of different multidisciplinary programs vary, they typically include:
- Reducing the patient’s experience of pain
- Improving physical and lifestyle functioning
- Decreasing or eliminating drug intake
- Enhancing social support and family life
- Reducing the patient’s use of medical services