P HHD - Describing, Assessing, Managing Pain (PDF)

PHHD – Describing, Assessing, Managing Pain Lecturer, Psychology Department School of Medicine Click to edit master title style Learning outcomes: 1. Define pain as a complex perceptual phenomenon, influenced by biological, psychological & social factors 2. Describe the gate-control theory...

PHHD – Describing, Assessing, Managing Pain Lecturer, Psychology Department School of Medicine Click to edit master title style Learning outcomes: 1. Define pain as a complex perceptual phenomenon, influenced by biological, psychological & social factors 2. Describe the gate-control theory of pain 3. Outline approaches to pain assessment 4. Identify major psychological approaches to managing pain BMF Case (HIP FRACTURE) – link to the Pain lecture "Lisa is an 80-year-old woman, living with her husband Joe who is 79. She has always enjoyed reasonably good health. She is due to see her GP (Dr. Sam Johnson) soon who has been sent the results of a DEXA scan (to assess bone mass) that she had recently" "Lisa's husband Joe’s condition deteriorates considerably and he needs almost constant supervision and eventually requires end of life care and planning, a more sustainable management plan is also required for Lisa’s own health care needs". BMF Case (HIP FRACTURE) – link to the Pain lecture  Lisa falls at home and suffers a significant lower limb injury. She is taken to the Emergency Department and it is determined that hip surgery is necessary. The surgery is uncomplicated and successful, as are the initial stages of rehabilitation.  However, towards the end of the rehabilitation program, Lisa begins to have pain in her left knee (opposite side to the hip injury) and also her lower back.  LEARNING OUTCOME 1: Define pain as a complex perceptual phenomenon What is pain? The puzzle of pain Injury without pain Pain without injury Pain disproportionate to injury Pain after healing: phantom limb pain Success of multimodal treatments Definition of pain An unpleasant sensory and emotional experience associated with actual or potential tissue damage Subjective Sensation and emotion Pain without injury Injury without pain Pain: an important social issue Peter Gøtzsche - Prescription drugs are the third leading cause of death: https://www.youtube.com/watch?v=KpDzB8uYHgY  The Cost of Pain Affects approx. 20% adult European population 80% of all doctor consultations in US relate to pain. Prevalence of chronic pain in Ireland – 35.5% (48% in UK) Associated with extended hospital stay, lost working days and increased use of social welfare benefits Cost of pain - €200 billion annually in Europe ; US$560-$635 billion [4,5] Pain statistics underestimate human cost Fayaz et al., BMJ Open 2016; 6: e010364 – Pain often most debilitating and Raftery MN et al., J Pain 2012; 13: 139-45 distressing aspect of a chronic Van Heck O et al., Br J Anaesth 2013; 111: 13-18 disease Institute of Medicine. Relieving pain in America. DOI: 10.17226/13172 Smith & Hillner., JAMA Network Open 2019; doi:10.1001/jamanetworkopen.2019.1532  Acute vs Chronic Pain Acute pain - a useful biological response provoked by injury or disease, which is of limited duration. Responses are usually adaptive. Chronic pain - pain persisting for six months or more and tends not to respond well to pharmacological treatment. Responses are often maladaptive.  LEARNING OUTCOME 2: Describe the gate-control theory of pain Gate control theory Ron Melzack and Pat Wall Melzack R, Wall PD. Pain mechanisms: a new theory. Science 1965;150:971-79 Gate Control Theory of Pain: Periphery Pain sensations transmitted from site of injury to the spinal gate by nerves known as nociceptors: A delta fibres – myelinated pain afferents – very strong noxious stimuli related to potential or actual damage to tissues; the experience lasts for a short time. C polymodal fibres – slow conducting, non-myelinated – carry information about dull, throbbing, pain; experienced for a longer time period “Anti-pain” fibres: A beta fibres – myelinated mechanically (touch) sensitive afferents – activation (e.g., through rubbing, massage, heat) inhibits perception of pain These different fibres transmit information at different speeds. As a result, usually pain is experienced in 2 phases: 1. The first, mediated by A delta fibres, involves the experience of sharp pain 2. This is followed by a more chronic throbbing pain mediated by the C polymodal fibres Counteracted (at least in part) by A beta fibre activation  Gate Control Theory of Pain A-beta fibres not present in diagram Figure 16.1 Transmission of information along A and C fibres to the substantia gelatinosa in the spinal cord and upwards to the brain Source: Adapted from Biological Psychology: An Introduction to Behavioural and Cognitive Neuroscience (Rosenzweig, Leiman and Breedlove 1996: 272). © 1996 by permission of Sinauer Associates, Inc. Gate Control Theory of Pain: Psychological influences on Pain perception: Cognition & Mood Mood – Anxiety and depression - pain tolerance and reporting of pain Cognitions: – Attention: focusing on pain increases experience of pain – Expectations of increases or reductions in pain can be self- fulfilling. Types of thought that influence the pain experience include: Attributions of the cause of pain Beliefs about the ability to tolerate pain Beliefs about the ability to control pain Expectations of relief from pain – the placebo effect.  Gate Control Theory of Pain A-beta fibers not present in diagram A schematic view of the gate control mechanism postulated by Melzack and Wall Combined Gate Control Theory inputs 1. Peripheral pain receptors transmit information about physical damage to a series of ‘gates’ in the spinal column – these nerves link to other nerves along the spinal column that transmit information up to pain centres within the brain. 2. At same time as experience of physical damage, we experience related cognitions and emotions – results in activation of CNS nerve fibres taking information from the brain down the spinal column to the gate at which the incoming pain signals enter the spinal column. Gate-control theory  Factors that open or close the pain gate Tend to open the gate Tend to close the gate Physical Physical – Injury – Appropriate medication – Inactivity/poor physical use fitness – Heat/cold – Long-term drug & alcohol – Massage use Behavioural Behavioural – Exercise – Poor or too little pacing of – Relaxation training activity, i.e., doing too much – Sleep hygiene – Poor Sleep Emotional Emotional – Laughter/humour – Anxiety, depression – Optimism – Stress distress – Engaging in enjoyable – Helplessness/hopelessness activities Cognitive Cognitive – Focussing on the pain – Distraction – Worrying about the pain Ayers S &–De Active Vissercoping R. London, Sage, 2018. p Questions?  LEARNING OUTCOME 3: Outline approaches to pain assessment  Pain assessment “Pain is what the patient says it is” Sternbach (1982) Holdcroft, A. et al. BMJ 2003;326:635-639 Copyright ©2003 BMJ Publishing Group Ltd. Think, Pair, Share Is it true that pain cannot be objectively measured? – how might you know clinically that someone is in pain? Is patient reporting of pain a good indicator of pathological processes/bodily injury? Give examples Can you find any useful mnemonics to assist with pain assessment?  LEARNING OUTCOME 4: Identify major psychological approaches to managing pain Pain management: Historical aim: to eliminate pain Modern aim: – Reduce pain perception – Improve coping ability – Increase functional ability – Decrease drug reliance and distress – Respect for attempts at self- management  Pain management - Acute First line generally pharmacological Psychological intervention forms second-level – Increasing patient control e.g., patient controlled analgesia (PCA) – Teaching coping skills, primarily: Distraction Relaxation – Hypnosis  Pain management - Acute: distraction VR Pain Management https://www.youtube.com/watch?v=lG17khsHfeg https://www.youtube.com/watch?v=jNIqyyypojg  Pain management - Chronic Causes Complex and multifactorial – e.g., may be influenced by interactions within social environment: Primary (intrapersonal) gain: expressions of pain result in cessation of aversive consequence, e.g., going to work, household chores Secondary (interpersonal) gain: pain behaviour yields positive outcome, e.g., expressions of sympathy, care Tertiary gain: feelings of pleasure/satisfaction experienced by person helping person in pain  Pain management - Chronic Results So-called “five D’s”: 1. Dramatisation of complaints 2. Disuse through inactivity 3. Drug misuse through over-medicating 4. Dependency on others 5. Disability due to inactivity  Pain Management (chronic) Behavioural Strategies: Cognitive Strategies: – Based on operant learning: – Cognitions are central to the contingency management experience of pain and reactions – Reinforcement of adaptive to it – Help patient alter beliefs about behaviours such as appropriate unmanageability of pain levels of exercise and ignoring – e.g., address catastrophising pain behaviours or negatively biased thinking – Withdrawal of attention or other – Helps identify and challenge rewards that were previous distorted thinking and helps responses to pain behaviours restructuring of cognitions – Providing analgesic medication Information provision - at set times rather than in reduces anxiety Distraction, re-directing response to behaviour attention Rare to use this approach only: Relaxation - target muscles in problems with generalization area of pain  Pain management programmes (PMPs) Multidisciplinary Teams (MDT): doctors, nurses, physiotherapists, psychologists, occupational therapists and counsellors. Underpinned by cognitive-behavioural principles (CBT) Provide education on pain physiology, pain psychology, healthy function & self-management of pain problems Delivered in group format to normalise pain experience & maximise learning Patient receive: – Full assessment – Education – Skills training – Exercise schedules – Relapse prevention – Family work  Summary Pain perception is influenced by biological, psychological, social, and cultural factors GCT provides good basis for understanding complexities of puzzle of pain Pain is a subjective symptom - pain assessment tools therefore based on the patient’s own perception of the pain and its severity Appropriate management of chronic pain requires a multidisciplinary perspective, addressing the interplay between physical & psychological factors & socioeconomic context  Reading Relevant Reading: – Morrison & Bennett. Chapter 16: Pain. http://proxy.library.rcsi.ie/login?url=http://www.myilibrary.com?id=23 1741 – Alder et al., 148-149 – YouTube clips 1. “Understanding pain in less than 5 minutes”: https://youtu.be/5KrUL8tOaQs 2. “Ronald Melzack - Pain Pioneer”: https://www.youtube.com/watch?v=KRFanGInvlc If interested in reading/viewing more, these are recommended: – Ayers S. & De Visser R. Psychology for Medicine and Healthcare. London, Sage, 2018. pp. 92-101. – Mendell LM. Constructing and deconstructing the gate theory of pain. Pain 2014;155:210-16. – BBC documentary: The Secret World of Pain. https://www.dailymotion.com/video/x4bs4ne (60 minutes) – Pain assessment: https://www.youtube.com/watch?v=5S-TtcJXsx0 Questions?