The National Council of Psychotherapists
PAIN MANAGEMENT OVERVIEW
Characteristics of Pain:
Location and distribution:
Pain that is confined to site of origin (examples: arthritis, tendonitis)
Referred pain: Pain that is referred to a distant structure (e.g. visceral pain such as caused by angina or appendicitis) – More simply put referred pain is a painful sensation in a region of the body that is not the source of the pain stimulus - Heart attack victims often feel pain radiating from the left shoulder down the arm.
Transmitted (Projected) pain:
Pain transferred along the course of a nerve
Peripheral Neuropathy is common, often distressing, and sometimes disabling. Population prevalence increases with age from about 2,400 per 100,000 (2.4%), to 8,000 per 100,000 (8%).
Duration and frequency of pain:
Quick pain such as a needle insertion
Pulsating pain: examples migraine or toothache
Longer-duration rhythmic pulse phase:
Example Intestinal colic (IBS type symptoms)
So called because the pain rises to a plateau where it remains for a prolonged period until resolution (example: angina)
Neuropathic pain (along the nerves)
Continuously fluctuating pain:
Such as pain caused by musculoskeletal disorders
Quality Superficial somatic (cutaneous) pain:
Associated with a sharp pricking or burning sensation/s
Deep somatic pain:
Associated with a dull or aching sensation of pain
Associated with a dull aching or cramping
Associated signs and symptoms and complicating factors
Nausea, vomiting, autonomic symptoms
Hyperalgesia (a condition involving altered perception. Commonly a stimuli which would normally induce a trivial discomfort could now cause significant pain to the sufferer)
Allodynia (Again pain caused by stimuli which are not normally painful and the pain may occur in other areas that the location of the stimuli, not generally associated with transmitted or referred pain)
Complex regional pain Syndrome:
Hyperalgesia – see above
Hyperesthesia (A condition of morbidly increased sensibility of the body, or of a specific part of it)
Allodynia – see above
Trophic changes (changes to skin, hair, nail)
Millions of people suffer from chronic pain at some point in their lives. Arthritis is one of the most common causes of disability in the UK.
All pain, whether acute or chronic, is a message carried to the brain by nerves near the surface of the skin or deep within the body. It is natures way of telling you that something is amiss and that a visit to a medical practitioner is essential. From the psychological practitioners point of view this is essential when treating people suffering from pain. The golden rule must always be to first eliminate pathology. Unfortunately I have spoken to several therapists over the years who have agreed to treat clients for pain related conditions while only taking the clients word for it that the condition had been properly diagnosed. Exampled include IBS and migraine.
Recently I spoke to a lady who had been treated for IBS, when I encouraged her to attend her doctor she was subsequently referred to a gynecologist who diagnosed and treated fibroids. The error in the earlier treatment was entirely the fault of the therapist for failing to respect the golden rule of treating physical symptoms, namely always first eliminate pathology. In this case no harm resulted.
Many therapists would be tempted to treat migraine patients – have you had a letter from their doctor to confirm that they have been properly diagnosed?
The objection that a doctor won’t have time for a therapist and won’t write to you is old hat. In any case if the doctor does prove to be one of those retractable individuals who will not respond to you then you have no mandate to treat. This becomes a problem between their doctor and your client.
The pain message is not something to be ignored or to be taken lightly. It is often a warning of injury, organic disorder, or of the cumulative the effects of stress on the body.
Acute pain is a sudden onset pain normally of brief duration. It may be caused by an infection or an accident or may be the result of surgical incision
Chronic pain may be the result of a specific condition. Chronic pain does not lessen with treatment and does not go lessen or away with the passage of time. As chronic pain develops it can have adverse affect’s personal relationships, professional commitments, self-image, resilience and can lead to depression.
A bit on pain theory
An understanding of how pain happens is essential to developing existing and to finding more effective ways in dealing with it.
There are billions of sensory receptors both on the surface of the body and within it that keep the brain informed about such thing as temperature, condition of organs, unusual changes and anything else that may be going on within the contained environment of the body.
These receptors and the brain communicate in a complicated code through the body’s network of nerves. Every nerve consists of bundles of fibers that are categorized as large and small bundles.
The large bundles carry impulses related to touch (sensory perception).
The small bundles carry messages slower than the large ones. It is via the smaller bundles that pain messages are sent.
Both of these sets of bundles meet at the spinal cord. Many Scientists believe that there is a ‘gate-like mechanism’ in the spinal cord that can be shut against the pain messages carried by the smaller bundles.
It is believed that the relief achieved by established methods of pain control such as electrical stimulation (TENS Machines) and acupuncture may be as a result of these methods somehow shutting this gateway.
An overview of the literature finds that in general pain specialists agree on six main categories of pain source. These include:
1. Joint and muscle pain - which account for the majority of patients seeking medical treatment
2. Causalgia – the burning pain that follows a bullet wound or some other sudden shock to the nervous system
3. Neuralgia - which originates in the peripheral nerves is triggered by cold air, chewing or stress
4. Phantom limb pain - after an amputation a mild sensation of "pins and needles" may develop that can sometimes that turn into shooting pains
5. Vascular pain - most commonly associated with dilated blood vessels around the brain – leads to migraine headaches
6. Cancer pain - the result of destruction of tissue. Blockage of major organs by a growing tumor. Spread of certain cancers that reach the spine and press on nerves.
Perception of Pain
Obviously some people will be more sensitive to pain than others, and within that different people will respond differently to different kinds of pain.
It has been found that in many cases that loud music (perhaps because of its direct link to emotional state?) or that intense physical effort can override the pain messages.
The intensity of pain can increase during fatigue, depression or periods of anxiety. People suffering from arthritis pain for example are encouraged to stay as active as possible. This not only helps mediate the physical pain but also helps to maintain a persons mood. Which, as psychological therapists we know are intrinsically linked.
Experiments have shown that the pain threshold can be raised not only be activities such as those mentioned above (encouraging clients to play loud music may have inevitable social consequences), but by such techniques as hypnosis or meditation.
Studies on the chemistry of pain indicates that men are less sensitive to pain than women (contrary to popular opinion). Older people appear to be less sensitive than the young.
Responses to pain can be learned through cultural or parental patterns, and individual character traits have a great deal to do with susceptibility to chronic pain syndrome’s.
Some common methods of pain relief:
Although still a source of skepticism among the western scientific community, there is some evidence to indicate that the technique stimulates the release by the brain of endorphins.
Acupuncturists use very fine gauge stainless needles that can sometimes combined with electrical stimulation. This stimulation is done at specific pressure points in the body said to be directly linked to other areas of the body. Therefore a person having work done to alleviate back pain may have the needles inserted in the shoulder and arms as one example.
This is a form of therapy that has is uses with people with established chronic pain.
In therapeutic setting it is also an effective method for helping those for whom their pain has become a way of gaining control over others and getting their own way.
Behaviorism is based on the assumption that many symptoms that may have begun as ‘authentic’ pain have become an established habit that now needs to be unlearned.
People closely involved with the pain patient are often requested to take an active part. Behavioral modification is usually one of the many approaches used in pain control clinics.
Biofeedback means to learn from ones own responses. It is a technique that requires practice in concentration during which the pain patient learn how to predict and to control certain involuntary body processes such as constriction of blood vessels.
By mastering this method, patients can reduce the chronic discomfort of migraine headaches and stress-induced muscular tension. Self-hypnosis may be highly effective in these cases.
Electrotherapy seems to either shut the pain doorway or to stimulate the release of endorphins. TENS machines are compact and easy-to-use and can be operated by the patient as necessary. It been reported to be helpful with neck, shoulder and lower back pain. The present author has used a TENS machine and can vouch for it’s effectiveness, even over self-hypnosis!
Chronic lower back pain may often be alleviated by strengthening particular muscles. Exercise such as swimming is often recommended for arthritis sufferers. Swimming is a very low impact activity. The fact that exercise (any form) provides distraction, increases its effectiveness as an antidote to certain kinds of pain. Exercise also produces endorphins.
Self-hypnosis is useful in helping patients learn to control their pain. Many hypnotherapists also offer specialist services in pain management. The literature is replete with negative mentions, unfortunately by authoritative but uninformed sources. However in this author’s opinion hypnosis is probably one of the least understood, and consequently most under utilised of the pain management treatments.
People who suffer from acute pain are rarely free of anxiety and tension. They readily benefit from the relaxing results achieved by a competent manipulation of tight muscles.
The surgery of last resort
One of the oldest procedures for surgical relief of pain is a chordotomy during which certain nerve pathways are cut or sectioned off. This is certainly considered the treatment of last resort and is usually reserved for certain types of neuralgia.
This article makes little mention of medical treatments for pain control as those methods are best left to medical experts. As stated previously in all cases the duty of the psychological therapist is clear, first and foremost eliminate pathology!!! There can be no excuse for ever discouraging a patient from seeking a proper medical opinion. Imagine how you might feel if after treating someone for one condition it turned out that they actually had another?
A quick word on ethics
When training I was told that under no circumstance was I ever to work using my hypnotic skills with someone I knew or with a family member. This was considered to be unethical. Personally I consider its horses for courses. Recently a loved one underwent major surgery – being asthmatic the morphine dosage afterwards was reduced (morphine suppresses breathing) and consequently she was in a lot of pain. Did I use my skills to help her manage the pain? Absolutely!!!
My old tutor is probably turning in his grave. My own view is that I would have serious reservations about the mind set of an individual with the skills to relieve pain that refused to use them.
A quick point on medical experts
It is worth reading the literature that comes with any prescribed medication. Recently a loved one took some hospital prescribed medication which was contra-indicated for asthmatics, and suffered a noticeable increase in breathing difficulties during the following seven day period. Our own GP immediately substituted another medication.
This paper if the framework of a document that I will be preparing on various aspects of pain and pain management. Although not yet a complete document I thought that it would complement the other articles in this edition on pain and pain management.
If anyone has any information or research information to offer I’d be very grateful…
Michael O’Sullivan FNCH