Principles of Pain Management

PRINCIPLES OF PAIN MANAGEMENT Pharmacological action: 1) Prevent or minimize the occurrence of peripheral sensitization and central sensitization 2) Peripheral sensitization can be suppressed with: local anesthetics and NSAIDs (COX1 or COX2) 3) Central sensitization can be suppressed with: Opioids (morphine, pethidine, fentanyl) and m agonists (tramadol) 4) Combination of both (analgesia balance): NSAIDs + opioids à synergism Nonpharmacological Actions. 1. Cutaneous Stimulation and Massage. The gate control theory of pain, as previously explained, aims to stimulate the fibers that transmit painless sensations to block or reduce the transmission of pain impulses. Several non-pharmacological pain relief strategies. Including rubbing the skin and using heat and cold, is based on this mechanism.Massage is general cutaneous stimulation of the body, often focused on the back and shoulders. Massage does not specifically stimulate the same receptors as pain receptors but can have an impact through the descending control system. Massage can make patients more comfortable because massage relaxes the muscles. 2. Ice and Heat Therapy. Ice (cold) and heat therapy can be an effective pain relief strategy in some situations, however, its effectiveness and mechanism of actionrequire further study. It is thought that ice and heat therapy works by stimulating non-pain receptors (non-noniceptors) in the same receptors as those in the injury.Ice therapy can reduce prostaglandins, which increase the sensitivity of pain and other subcutaneous receptors at the injury site by inhibiting the inflammatory process. To be effective, ice must be placed on the injury site immediately after the injury occurs. When ice was placed around the knee immediately after surgery and for 4 days after surgery, analgesic requirements decreased by approximately 50%. 3. Transcutaneous Electrical Nerve Stimulation (TENS) Transcutaneous nerve stimulation (TENS) uses a battery-operated unit with electrodes attached to the skin to produce a tingling, vibrating or numbing sensation in the area of pain. TENS has been used in both acute and chronic pain. TENS is thought to reduce pain by stimulating non-pain receptors (non-nociceptors) in the same area as the fibers that transmit pain. This mechanism is in accordance with the gate control theory of pain. Nonpain receptors are thought to block the transmission of pain signals to the brain in the ascending pathways of the central nervous system. This mechanism will determine the effectiveness of cutaneous stimulation when used in the same area as the injury. Other explanations for the effectiveness of TENS are the placebo effect (patients expect it to be effective) and the formation of endorphins, which also block pain transmission.Research has shown that patients who have received real or sham TENS (placebo) treatment in addition to standard care, report a similar amount of pain relief greater than the pain relief obtained with standard treatment alone. Some patients, especially those with chronic pain, will report as much as a 50% reduction in pain using TENS. Other patients do not feel the benefits. Which patients can be helped cannot be predicted. 4. Distraction. Distraction, which involves focusing the patient's attention on something other than the pain, can be a very successful strategy and may be the mechanism responsible for other effective cognitive techniques.. A person, who is less aware of pain or pays little attention to pain, will be less bothered by pain and more tolerant of pain. Distraction is thought to reduce pain perception by simulating the descending control system, which results in fewer painful stimuli being transmitted to the brain. The effectiveness of distraction depends on the patient's ability to receive and generate sensory input other than pain. Pain relief generally increases in direct relationship to the individual's active participation, the number of sensory modalities used and the individual's interest in the stimuli. Therefore, visual, auditory and tactile stimuli may be more effective in reducing pain than stimuli from one sense alone.Distractions can range from just monotonous distractions to very complex physical and mental activities. Visits from family and friends are very effective in relieving pain. Viewing widescreen films with “surround sound” through headphones can be effective (provide what the patient can tolerate). Others may find relief from games and activities (e.g., chess) that require concentration. Not all patients achieve relief through distraction, especially those in severe pain, the patient may not be able to concentrate well enough to participate in complex physical or mental activities.Someone who does not benefit from distraction should be thought of. Patients using an ADP pump, during the time of effective distraction may not be using any analgesia. Distraction techniques usually end abruptly (yi, the activity ends or the movie ends) and the patient is left with subtrapeutic serum opioid levels. When intermittent distraction is used for pain relief, a baseline opioid input via an ADP pump may be prescribed, so that when the distraction ends, there will be no need to chase serum levels. 5. Relaxation Techniques. Skeletal muscle relaxation is believed to reduce pain by relaxing muscle tension that supports pain. There is a lot of evidence to show that relaxation is effective in relieving back pain. Some studies, however, have shown that relaxation is effectivein reducing postoperative pain. This may be due to the relatively small size of the skeletal muscles in postoperative pain or the patient's need for such relaxation techniques to be effective. The technique is impossible to practice if it is only taught once, immediately before surgery. Patients who already know about relaxation techniques may only be reminded to use these techniques to reduce or prevent increasing painA simple relaxation technique consists of slow, rhythmic abdominal breathing. The patient can close his eyes and breathe slowly and comfortably. A constant rhythm can be maintained by counting silently and slowly with each inhalation (“inhale, two, three”) and exhalation (exhale, two, three). When the nurse teaches this technique, it is helpful to count out loud with the patient at the beginning. Slow, rhythmic breathing can also be used as a distraction technique. Relaxation techniques, as well as other noninvasive pain relief measures, may require practice before the patient becomes skilled at using them. 6. Guided Imagination. Guided imagination is using one's imagination in a specifically designed way to achieve a certain positive effect. For example, guided imagery for relaxation and pain relief may consist of combining a slow, rhythmiccomfort.are instructed to imagine that with each exhaled breath, muscle tension and discomfort are slowly released, leaving the body relaxed and comfortable.. Every time you inhale, the patient should imagine healing energy flowing into the uncomfortable area. Each time a breath is exhaled, the patient is instructed to imagine that the exhaled air carries away the pain and tension.If integrated imagery is to be effective, it requires a lot of time to explain the technique and time for the patient to practice it. Typically, patients are asked to practice guided imagery for about 5 minutes, three times a day. Several days of practice may be required before the pain intensity is reduced. Many patients begin to experience the relaxing effects of guided imagery the first time they try it. Pain relief can continue for hours after imagination is used. Patients should be informed that guided imagery may only work in some people. Guided imagery should be used only as an adjunct to proven forms of treatment, until research has shown whether and when the technique is effective. 7. Hypnosis. Hypnosis is effective in relieving pain or reducing the amount of analgesic needed in acute and chronic pain. This technique may be helpful in providing pain relief especially in difficult situations (e.g., burns). The mechanism of how hypnosis works is unclearbut does not appear to be mediated by the endorphin system. The effectiveness of hypnosis depends on the individual's hypnotic ease. In some cases hypnosis can be effective as thefirst treatment; its effectiveness increases with the addition of subsequent hypnotic cells. However, in some cases this technique will not work. In most situations hypnosis must be administered by a specially trained person (often a psychologist or nurse with special training in hypnosis) and can be effective in addition to the use of standard analgesics