WHAT IS PAIN?

Definition of Pain

In dictionaries, pain (ICD-9: 780.96) is defined as a sensation of hurting or of strong discomfort in some part of the body, caused by an injury, a disease, or a functional disorder and transmitted through the nervous system. A nurse, Margo McCaffery, who worked for years with clients in pain and conducted extensive research in the field of pain, defines pain as whatever the experiencing person says it is, existing when he or she says it does. This definition is perhaps the most useful because it acknowledges the client’s complaint, recognizes the subjective nature of pain, and implicitly suggests that diverse measures may be undertaken to relieve pain.

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The IASP and the American Pain Society (APS) define pain as an unpleasant sensory and emotional experience arising from actual or potential tissue damage or described in terms of such damage. Again, this definition further confirms the multiple components of pain in a person’s psychological and physiological existence. Pain is the most common complaint of persons seeking medical attention.

Acute Pain

Acute pain (ICD-9: 338.1x) is a warning that something is wrong in normal body functioning. It warns of inflammation, tissue damage, infection, injury, trauma, or surgery somewhere in the body. Acute pain is often accompanied by anxiety. It comes on suddenly and can last for hours or days, perhaps even months. Such pain may be manifested as an increase in heart rate, blood pressure, and muscle tension and a decrease in salivary flow and gut motility. The primary goal of treatment is to diagnose the source of pain and remove it. Acute pain disappears once the underlying cause of the pain is treated.

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Chronic Pain

Chronic pain (ICD-9: 338.2x) most often starts as an acute pain but continues beyond the normal expected time for resolution. It may also be described as a pain that recurs. Chronic pain is no longer useful or beneficial. It is frequently debilitating, exhausting an individual’s physical and emotional resources. It is often difficult to manage. Complete relief of chronic pain does not always occur. The treatment goal of chronic pain is to minimize the pain and maximize a person’s functioning. The intent is to decrease the level of pain so that everyday activities can be performed. Because of this goal, a multidisciplinary approach to treatment is often necessary. This approach blends physical, emotional, intellectual, and social skills.

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Chronic pain can further be described as

  1. Nociceptive pain
  2. Neuropathic pain

Nociceptive pain is sometimes called tissue pain. It is derived from damage to tissues rather than nerves. The nerve cells (called nociceptors) carry the pain sensation to the spinal cord where it is then relayed to the brain. This pain is well localized, often has an aching or throbbing quality, and is constant. The pain is called somatic if it is the result of damage or injury to muscles, tendons, and ligaments. Somatic pain may be further classified as cutaneous if the pain comes from the skin or deep if the pain comes from deeper musculoskeletal tissues.

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Neuropathic pain comes from a nervous system lesion. It may be further identified as neural pain if the lesion is in the brain or spinal cord. It is referred to as peripheral neuropathic pain if the lesion is along the cranial or spinal nerves. Neuropathic pain is often described as severe, sharp, stabbing, burning, cold, numbness, tingling, or weakness. Some individuals feel the pain move along the nerve path from the spine to the extremities. Neuropathic pain does not usually respond to routine analgesics.

It is quite possible for individuals to experience nociceptive and neuropathic pain at the same time in certain conditions. Specialists in pain management define additional types of pain. The most common are listed here:

  • Angina pain (ICD-9: 786.51) occurs when the blood supply to the heart muscle is disrupted. It is often described as crushing or tightness and burning pain in the chest.
  • Breakthrough pain (ICD-9: 338.x) results from the reoccurrence of chronic pain that earlier responded to pain management.
  • Malignant (cancer) pain (ICD-9: 338.3) comes from the disease of cancer (tumor, abnormal growth) or the treatment for the cancer (surgery, radiation, chemotherapy).
  • Phantom limb pain (ICD-9: 729.2) is the pain felt from an amputated body part. Military personnel who suffered the loss of a limb often describe this pain as squeezing or burning. The brain mistakenly interprets the nerve signals as coming from the missing limb.
  • Psychogenic pain (ICD-9: 307.80) is often experienced by individuals with psychological disorders. They have very real pain but without a physical cause.
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The Experience of Pain

How pain is experienced is based, in part, on several variables:

  1. Early experiences of pain. Did management of pain in the past have a positive or negative impact? Generally, a person’s fear of pain increases with each pain experience.
  2. Cultural backgrounds. Research shows that culture generally does not influence how a person perceives pain but does influence how a person responds to pain. Early in life, children learn from those around them. For example, children may learn that a sports injury does not hurt as much as trauma from an automobile accident. Further, they learn what behaviors are acceptable or unacceptable. These behaviors vary among cultures. Rarely are these expectations changed; in fact, these perceptions are believed to be normal and acceptable.
  3. Anxiety and depression. Does anxiety increase or decrease pain? Is depression the cause or result of pain? Some believe there is a relationship between anxiety and depression and pain. The longer the duration of pain, the greater is the occurrence of depression. It is important to address anxiety and depression when treating individuals in pain.
  4. Age. Pain perception does not change significantly with age, yet the way an elderly person responds to pain treatment may differ from that of a younger person. For example, as a person ages, a slower metabolism and greater ratio of body fat to muscle mass dictates that a smaller dosage of analgesics may be required.
  5. Sex. Recent research suggests that females and males experience pain differently. In fact, females demonstrate a greater frequency of pain-related symptoms in more bodily areas than do males. In addition, when pain-free individuals were exposed to a variety of painful stimulus, females exhibited greater sensitivity to the experimentally induced pain than did males. It also was evident that women attach an emotional aspect to the pain they experience, while men concentrate only on the physical sensations they experience. This sensory focus for men allowed them to endure more pain and suffer less than the women.
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GATE CONTROL THEORY OF PAIN What occurs at the cellular level when pain is experienced? The gate control theory of pain, by P. D. Wall and Ronald Melzack, offers a useful model of the physiological process of pain. Gate control is recognized as a major pain theory. According to the gate control theory, pain is a balance between information traveling into the spinal cord through large nerve fibers and information traveling into the spinal cord through small nerve fibers. Without any stimulation, both the large and small nerve fibers are quiet, and the substantia gelatinosa (SG) blocks the signal to the transmission cell (T cell) connected to the brain. The “gate is closed,” and there is no pain. With pain stimulation, small nerve fibers are active. They activate the T-cell neurons but block the SG neuron, making it impossible for the SG to block the T-cell transmission to the brain. The result is that the “gate is open”; therefore, there is pain. In other words, pain is experienced whenever the substances that ...
Back Pain History Taking an accurate history is the most important part of the initial consultation when one is dealing with any medical or surgical problem. Unfortunately, when the mechanical lesion is involved there is still lack of understanding regarding the nature of the questions that should be asked, the reasons for asking them, and the conclusions to be drawn from the answers. I will set out step by step the stages that should be developed in history taking, and the questions that should be asked at each stage. Practitioners will already have their own method of history taking, and I do not suggest at all that they should alter their routine. However, I believe that the following questions must be included, if one is to reach a conclusion following the examination of patients with mechanical low back pain. INTERROGATION As well as the usual questions regarding name, age and address, one should enquire as to the occupation of the patient, in particular his position at work which provides us ...
Spine Health. PROCEDURE 14 — FLEXION IN STANDING The simple toe touching exercise in standing does not need much elaboration. The patient, standing with the feet about thirty centimeters apart, bends forward sliding the hands down the front of the legs in order to have some support and to measure the degree of flexion achieved. On reaching the maximum flexion allowed by pain or range, the patient returns to the upright position. The sequence is repeated about ten times, should be performed rhythmically, and initially with caution and without vigour. It is important to ensure that in between each movement the patient returns to neutral standing. Fig. Flexion in standing. Effects: Flexion in standing differs from flexion in lying in various ways. Naturally, the gravitational and compressive forces act differently in both situations. In flexion in standing the movement takes place from above downwards, and the lower lumbar and lumbo-sacral joints are placed on full stretch only at the end of the movement. In addition, the lumbo...
Spine Health. PROCEDURE 9 — ROTATION MOBILISATION IN EXTENSION The position of patient and therapist is the same as for procedure 7. By modifying the technique of extension mobilisation so that the pressure is applied first to the transverse process on the one side and then on the other side of the appropriate segment a rocking effect is obtained. Each time the vertebra is rotated away from the side to which the pressure is applied — for example, pressure on the right transverse process of the fourth lumbar vertebra causes left rotation of the same vertebra. The technique should be repeated about ten times on the involved segment and, if indicated, adjacent segments should be treated as well. Fig. Rotation mobilisation in extension. Effects: Also here the external force applied by the therapist enhances the effects on derangement and dysfunction as described for the previous extension procedures. The reasons for adding therapist-technique are the same as for procedure 7. In general, unilateral techniques are likely to effect unilateral...
Examination of Back Pain Having digested the information supplied by the referring doctor, extracted as much relevant information as possible from the patient, and checked the radiologist’s report, we may proceed to the examination proper. If the patient is able to do so, we should make him sit on a straight backed chair while taking his history. During this lime he will reveal the true nature of his sitting posture. When the patient rises to undress after the interrogation we should observe the way he rises from sitting, his gait, the way he moves, and any deformity that may be obvious. We will record the following: I. POSTURE SITTING If the patient has been sitting during history taking, we already have a good impression of his posture. We now ask him to sit on the edge of the examination table with his back unsupported. In the majority of cases the patient will sit slouched with a flexed lumbar spine. Some patients are more aware of the relationship between their posture and pain. They have discover...