For decades, it was believed that pain, especially chronic (long term) pain, is not real. The sufferers were wrongly told that it was all in their minds. Now studies clearly show that pain can have a serious impact on one’s quality of life.
Pain is defined as “an unpleasant sensory and emotional experience associated with actual or potential tissue damage, or described in terms of such damage”. It can be separated into two broad categories: acute pain and chronic pain. This distinction is not perfect — cancer pain, for example, may have components of both.
ACUTE PAIN: Acute pain is the symptom of a larger disease process, and usually an unpleasant event stimulates the intact nervous system to produce the sensation of pain. Examples include a surgical incision, labour pain, acute pancreatitis or a heart attack. Acute pain can be somatic — arising from skin, muscles, tendons, joints or bones — or visceral — coming from internal organs or its covering — or neuropathic — due to injury or abnormality of nerves or brain — in origin.
Physiological and psychological responses to acute pain are directed toward escape from the painful situation. Acute pain usually triggers a neuroendocrine stress response proportional to the intensity of the pain. Catecholamines (stress hormones) are released, increasing heart rate, blood pressure and systemic vascular resistance.
The predominant emotional response to acute pain is anxiety and anger. Acute pain usually responds well to non-steroidal pain relievers and/or narcotics (opioids/morphine-like medicines). Frequently, neural blockade (injection of medicine around selective nerves which cause pain, for example epidural for labour pain or post-operative pain) can effectively relieve acute pain and decrease the likelihood of developing a chronic pain syndrome.
CHRONIC PAIN: Chronic pain persists beyond the expected time of healing. The time course for the development of chronic pain is variable, and the ongoing pain itself becomes a significant disease process, not just a symptom. The transition to chronic pain is marked by changes in both physiological and psychological responses. Instead of trying to escape the painful situation, the patient is now trying to adapt to the ongoing pain. Acute pain, if treated inadequately, may develop into chronic pain syndrome.
In the state of chronic pain, vegetative responses predominate, including sleep disorders, irritability, depression and decreased motor activity. Withdrawal and depression are common, causing severe strain on social and family support systems. Narcotic tolerance is frequent, complicating the treatment of this patient group.
While chronic pain can be somatic or visceral, it is often neuropathic in nature. Nerve tissues are often damaged and the sensation of pain persists without any external stimulus. Neuropathic pain is usually associated with some form of sensory deficit and is described as typically raw or burning in nature. Treatment of chronic pain involves the use of antidepressants, anticonvulsants, and/or corticosteroids. Additionally, diagnostic and therapeutic nerve blocks can be helpful.
Healthcare professionals often fail to routinely assess and document pain. Due to inadequate training, they often lack knowledge and skills to assess and manage pain effectively. There is also seen to be a lack of practical and effective treatment protocols, besides lack of sufficient knowledge to employ safe equianalgesic principles.
Healthcare professionals may have exaggerated concerns related to the side-effects of opiods, especially about tolerance and addiction. They may under-treat pain because of belief in common misconceptions regarding pain.
Some common myths about pain are:
* A patient’s pain perception can accurately be correlated with vital sign changes and evidence of injury.
* Patients readily express their pain to healthcare providers.
* Patients of certain backgrounds consistently underreport or over-report their pain.
* Opioids are addictive and a treatment of last resort because of unmanageable side-effects.
* Patients experiencing chronic pain over-report pain because they are addicted to opioids.
* Older patients and cognitively-impaired patients do not perceive pain as intensely as other patients.
* If a patient is able to sleep, they must not be in much pain.
* The goal of chronic pain management is to keep the dose of medication as low as possible.
* Patients with a history of substance abuse who require IV opioids should never be allowed to control their own dose of medication.
PATIENT BARRIERS: A patient may be reluctant to report pain probably because of a belief in these myths:
* Severe or chronic pain cannot be effectively controlled.
* Opioids are always addictive and a treatment of last resort
* Pain is always an evidence of disease progression.
* it is more socially acceptable to ignore pain.
* Pain is an unavoidable result of aging or disease.
* Pain is a deserved punishment.
DIAGNOSIS OF PAIN: There is no way to tell how much pain a person has. Sometimes the best aid to diagnosis is the patient’s own description of the type, duration and location of pain. Physicians, however, do have a number of technologies they use to find the cause of pain. Primarily, these include:
* Electrodiagnostic procedures include electromyography (EMG), nerve conduction studies, and evoked potential (EP) studies. EMG can help physicians tell precisely which muscles or nerves are affected by weakness or pain.
* Imaging, especially magnetic resonance imaging or MRI, provides the pictures of the body’s structures and tissues.
* A neurological examination to tests movement, reflexes, sensation, balance, and coordination.
* X-rays produce pictures of the body’s structures, such as bones and joints.
CONCEPTS OF PAIN MANAGEMENT: It is very important to know and recognize the patient’s physiological, psychological and emotional responses to pain when developing a pain management plan. Do not rely on vital signs to determine the severity of a patient’s pain.
Patients with pain, even severe pain, can be distracted from thinking about their pain. Don’t trust that a patient isn’t having pain because he “looks comfortable”. The doctor should believe the patient’s assessment of his own pain. He should not just treat the pain but also reassess frequently and continue to treat until the patient is comfortable or side-effects prevent further treatment. If this occurs, a pain expert should be consulted.
A history and physical examination of the pain is very helpful. Details of the pain’s location, duration, radiation, and character often provide valuable clues about how to treat the pain most effectively.
Medications are best given orally for long-term management of pain. For short-term management, like postoperative pain, the IV route is preferred (especially with severe pain). Most pain medications have side-effects so the side-effects of opioids have to be treated too if they occur. A balanced approach to pain management combines non-pharmacologic and pharmacologic therapy, and frequently utilizes multiple analgesics which work by different mechanisms.
Chronic pain patients are usually on a specific regimen of pharmacologic and non-pharmacologic therapy. This regimen must be continued during their hospitalization. Superimposed acute pain (e.g. acute postoperative pain) should be treated with additional opioids.
Tension headaches
Although not too often treated by doctors, tension-type headaches (TTH) are the type most frequently experienced. It is estimated that over 95% of people suffer from occasional tension-type headaches and 75-90% of all persons who complain of chronic headaches suffer from this variety. Like migraines, TTH seem to be more common in women than in men. Unlike migraines, they usually begin in middle-age.
Very little is known about the precise causes of this headache, though there are several postulated theories. And it is important to dispel misconceptions. TTH are not ‘all in the head’, they are a neurological condition for which several triggers have been identified. These include missed meals, lack of sleep, bright lights, smoking, anxiety and stress.
Muscular contraction is commonly associated with TTH. There may be muscular tenderness in the areas of neck, at the base of the skull, shoulders, upper arms, and the jaw and face. Some people show signs of clenching teeth. Scalp and forehead may also be painful. Researchers have found that patients complaining of frequent headaches which are generally not migraines also exhibit varying degrees of depression, anxiety and worry. In short, it can be described as a response by the body to strains and pressures, be they emotional or physical.
The typical tension headache is one that produces a dull, steady, achy pain on both sides of the head. However, sometimes the pain develops a pulsating quality when at its worst. The pain usually starts gradually and may last from 30 minutes to several days. Difficulty in concentrating and a heightened sensitivity to light or noise is experienced. Neck and shoulder muscles may be tightened.
Unfortunately, as with other headache disorders, there are no definitive diagnostic tests for tension headaches. Since physical and emotional strain is considered the major cause of TTH, management too is directed towards relieving these. There are a number of ways of doing it:
Posture: Do not sit with rounded shoulders or slump over your desk for long periods. This can make your body tense. Occasionally stand up and shake out your limbs.
Rest: Take a break from work, even for a little while. Avoid rooms that are noisy or brightly lit.
Eat: Missing a meal may be the most potent trigger.
Sleep: Get adequate hours of sleep everyday.
Walk: Regular walk or other forms of exercise can do wonders. Exercise results in release of endorphins in the body which have postulated rolls in pain relief, lowering blood pressure and creating a sense of well being.
Massage: Massaging tense muscles is the best way to release their tension. Applying heat or ice-pack may also be very effective.
Laugh: Laughter is the best medicine and a great way of venting tension.
Take medicine: As soon as you feel the discomfort take an analgesic. Simple medicines like paracetamol and aspirin can do wonders if taken at the right time.
When to see a doctor
* If the headache is sudden, sever and the worst you have ever experienced.
* The headache follows a fall or blow to the head.
* The headache is associated with fever, vomiting, drowsiness or a stiff neck.
* When the headache is worst on waking up in the morning.
* There are neurological deficits associated with it such as weakness, paralysis, numbness, visual disturbances, slurred speech etc.
* When the headache increases in severity or frequency.
People who have been diagnosed with tension-type headaches and are taking analgesics, should also consult their doctors if they are requiring more than 10 pills per month. Drugs should be used with the doctor’s advice only. Healthy eating, sleeping and working habits, however, remain the mainstay of the management of tension-type headaches. — Dr M.H. Khan
