INTODUCTION TO PAIN
The International Association for the Study of Pain (IASP) defines pain as a highly unpleasant physical and emotional experience related to actual or potential tissue injury (Kumar and Elavasari, 2016). Pain is very subjective and specific to every individual person. Nurses are invited by McCaffery and Beebe (1989) to recognise that ‘pain is what the patient says it is’ providing they are able to express or verbalise this.
Pain is a distressing experience that affects everybody at sometime in their life and is completely unique to each person in that everyone has a different tolerance to pain. Acute pain is short acting, with a sudden onset, and a definitive pathology, usually tissue damage and is treated easily. In contrast, chronic pain is gradual and is usually lasting more than 6 months, this pain serves no purpose and has unclear pathology and is difficult to treat (Mirchandani et al., 2011). The British Pain Society describes chronic pain as the ‘Silent Epidemic’ (The British Pain Society, 2014), with more than 8 million of the UK population suffering from chronic pain with the main complaint being back pain (Fayez et al., 2016).
Pain is often described as nociceptive or neuropathic. Nociceptive dividing into visceral pain relating to internal organ; and somatic pain relating to tissue and musculoskeletal, while neuropathic relating to central nervous system (Goudman et al., 2020).
Total Pain originates from Dame Cicely Saunders idea of a ‘whole-person’ interpretation of pain, incorporating Physical, Spiritual, Psychological and Social elements that are the key aspects of the Total Pain encounter. Taking this multidimensional approach into consideration when assessing patients can give a more accurate and adequate assessment of their pain (Dobson, 2017).
Pain is usually a protective function and is commonly in response to a disease or injury. The sensation of pain involves both peripheral tissue and the central nervous system (CNS), with the CNS controlling other responses. There are four main processes involved in the pain pathway, Transduction, Transmission, Modulation and Perception. Transduction begins when nociceptive receptors in the free nerve cells found in peripheral tissue respond to the stimulation caused by noxious stimuli such mechanical, chemical or thermal injury, their response is releasing chemical mediators (prostaglandins, bradykinin, serotonin, substance P and histamine) which ‘fire’, transmitting the pain impulses to the brain via the dorsal horn in the spinal cord. The dorsal horn being the managing centre for pain fibers (Lodhey, 2015). The pain signal is carried by two different types of fibers to the brain, A-Delta fibers; these are myelinated and carry fast signals are C-fibers; these being unmyelinated and responsible for slow pain signals. The dorsal horn in the spinal cord is the managing centre for and pain fibers enter the spinal cord via dorsal spinal roots, this is where the complex process of Perception takes place, including interpretation and expectation of the specific pain. Modulation mainly takes place in the dorsal horn and can either enable or curb pain (Briggs, 2010). The body modulates the pain experience by emitting endogenous opioids (endorphins, enkephalins and dynorphins) at the end stage of nociception, inhibiting noxious stimulus by curbing neurotransmitter such as Substance P, therefore producing a natural analgesia, known as the descending pathway. Our natural opioids can be released by doing everyday activities like exercise, sex, laughter and mediation (Swift, 2015). This type of concept was highlighted by Melzack and Wall in 1965 who introduced the Gate Control Theory suggesting that psychological factors play a role in the perception of pain. Using the concept of “gates” in the central nervous system to describe how some pain messages are allowed get through and reach the brain, while others are blocked and losing the nerve ‘gate’ to painful stimulus. Although there are many pain theories out there including Specificity, Intensity and Pattern Theory, The Gate Theory revolutionised pain management (Moayedi and Davis, 2013).
PAIN ASSESSMENT STARTEGIES
Pain is a highly subjective multifaceted experience and requires objective standards of care. Accurate pain assessment is crucial, as a suboptimal assessment can be detrimental to pain management. All pain assessments/tools must be appropriate to the individual and should be adapted to specific age, cognitive state and type of pain. Emotion (Fink et. al., 2010). There is an extensive number of pain tools available which include unidimensional and multidimensional approaches
PHARMALOGICAL AND INTERVENTIAL PAN MANAGEMENT STRATEGIES
The stagies of the WHO pain ladder
- medication- analesics and adjuvanta analgesia
- Routes of analgesia and rationale
- Interventional strategies
NON PHARMALOGICAL PAIN MANAGEMENT STARTEGIES
- Pain management programmes and members of the multidisciplinary team
- Supported self management
- Physical- physio exercise heat and col
- Psychological based interventions
- Complementary therapies.;[#
- Briggs, E.. (2010). Understanding the experience and physiology of pain. Nursing Standard. 25 (3), p35-39.
- Dobson, J.. (2017). Dame Cicely Saunders – an inspirational nursing theorist. Cancer Nursing Practice. 16 (7), p31-34.
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- Mirchandani, A., Saleeb M., Sinatra R. (2011) Acute and Chronic Mechanisms of Pain. In: Vadivelu N., Urman R., Hines R. (eds) Essentials of Pain Management. Springer, New York, NY
- Moayedi, M., Davis, D. K.. (2013). Theories of pain: from specificity to gate control. Journal of Neurophysiology. 109 (1), p5-12.
- McCaffery, M., Beebe, A., 1989. Pain : clinical manual for nursing practice. C.V. Mosby, St. Louis.
- Swift, A.. (2015). Transmission of pain signals to the brain. Nursing Times. 111 (40), p22-26.
- The British Pain Society. (2014). The silent epidemic – chronic pain in the UK. Available: https://www.britishpainsociety.org/mediacentre/news/the-silent-epidemic-chronic-pain-in-the-uk/. [Last accessed 28th March 2018].