Lecture 8 - dissecting pain: from measurement to management

why should we focus on pain anyways?

pain is the symptoms of greatest concern to patients → most likely lead to use health services

pain is heavily influenced by psychosocial processes

what is the primary purpose of pain

warns self or others of tissue damage/injury/disease; evokes care

what are some negative consequences of pain

poor health behaviours

loss of employment / income

depression, fear, anxiety

social isolation

sleep disorders

martial and family dysfunction

what is the specificity theory of pain

pain is directly proportional to the amount of tissue damage

describe how the specificity theory of pain works

1. upon injury, pain messages originate in nerves associated with damaged tissue and travel to the spinal cord

2. a signal is then sent to

   1. a motor nerve, and

   2. the brain, where pain is perceived

describe the problems of the specificity theory of pain

assumption of one-to-one correspondence to injury/disease

unfortunate practices

focus on pharmacological, surgical, or other medical interventions to control pain

what are unfortunate practices as specified in the purely biomedical approach to pain

blaming the patient

assuming psychiatric disorders

intentional faking of symptoms

what is the gate-control theory of pain

pain is not directly proportional to tissue damage

describe how the gate-control theory of pain works

a neural neural pain gate in the spinal cord opens or closes to modulate pain signals in the brain

• involves inhibitor and projector neurons that respond to sensory input and send certain signals to the brain

what is phantom limb pain

phantom limb pain is pain experienced in an amputated limb; classified as neuropathic pain

what is the neuromatrix theory

an extension of the gate control theory of pain

a widespread network of neurons (distributed throughout the brain and spinal cord) generates a pattern that is felt as a whole body possessing a sense of self

for physical pain, what opens the gate

extent of injury

inappropriate activity level; inactivity

for physical pain, what closes the gate

medication

counter stimulation (massage, heat)

for emotional pain, what opens the gate

anxiety or worry

tension

depression

relationship problems

for emotional pain, what closes the gate

positive emotions

relaxation

social support

for cognitive pain, what opens the gate

focusing on pain

boredom

for cognitive pain, what closes the gate

distraction

concentration

involvement and interest in activities

describe the evidence that support the gate-control theory

in studies with multiple pain conditions, objective findings have no clinically significant correlation to pain levels

AMA: in up to 85% of individuals who report back pain, no pain-producing pathology can be identified

describe how the neuromatrix theory works

a network is responsible for generating bodily sensations including pain (pain is produced in the CNS)

pain can occur in the absence of signals from sensory nerves

various parts of the NS work together to respond to stimuli from the body and/or environment to create the experience of pain

each sensation is marked by a unique neurosignature or patterns of activation of the neuromatrix

what is the current state of the research on the possible etiology of phantom limb pain

may be triggered by other types input, lack of normal sensory input, or incongruence between types of input due to lack of limb

what are the theories of pain that are more supported by evidence

gate-control theory of pain

neuromatrix theory of pain

what is the definition of pain

an unpleasant sensory and emotional experience associated with actual or potential tissue damage, or described in terms of such damage

what is the main problem with trying to define pain or trying to detect pain

it is impossible to definitively know whether another creature’s subjective experience is like our own

what are the ways we can measure pain

self-report measures of pain

nonverbal measures of pain

what are the types of pain rating scales

graphic rating scales

verbal rating scales (adjectives)

numerical rating scales

what are graphic ratings scales like

what are verbal ratings scales like

what are numerical rating scales like

what is a valid tool for assessing pain specifically in young people

wong-baker faces pain rating scale

what is the significance about the phantom limb pain

pain cannot originate from the tissue that is supposedly causing the pain

what are the nonverbal measures of pain

look at pain behavioursw

what are pain behaviours

observable behaviours that occur in response to pain

what are some examples of pain behaviours

• facial and audible expression of distress

• distortions in posture or gait

• negative affect (mood, anxiety, depression)

• avoidance of activity

how do emotions affect pain

positive emotions appear to reduce pain

negative emotions tend to worsen (and result from) pain

people with chronic pain tend to also experience… what types of emotions

high levels of depression, anxiety, and/or anger; high levels of these emotions are associated with high levels of subsequent pain/disability

how are pain and stress linked

1. pain is stressful

2. stress and produce pain and worsen the pain experience

what are some ways to cope with pain

maladaptive coping

catastrophizing

adaptive coping

acceptance

what are the good ways to cope with pain

adaptive coping

acceptance

what are the bad ways to cope with pain

maladaptive coping

catastrophizing

what is maladaptive coping

destructive thinking; helplessness

what is catastrophizing

frequent, magnified negative thoughts about pain

magnification, rumination, and helplessness

what are the consequences of using catastrophizing to cope

catastrophizing increases as pain intensity increases

plays a major role in transitioning from acute to chronic pain

what is adaptive coping

relaxation

distraction

redefinition of pain (reappraisal)

readiness to change, taking an active role

what is acceptance

being inclined to engage in activities despite the pain and disinclined to control or avoid the pain

what are the benefits of having high levels of pain acceptance

pay less attention to their pain

have greater self-efficacy for performing daily tasks

function better

use less pain medication than those with low pain acceptance

how does social support affect pain

social support attenuates feelings of pain

describe the importance of social networks in pain coping

the health and well-being of one’s social network affects pain outcomes

• if close people have depression → increased chance to experience pain

what is a solution for the negative consequences that come with one’s social network having negative health

treat the social network of that individual

what is social pain

the experience of pain as a result of interpersonal rejection or loss

what are some examples of social pain

• rejection from social group

• bullying

• loss of a loved one

is social pain adaptive and explain why or why not

yes

signals when social relationships are threatened

how is social pain and physical pain described linguistically

“hurt feelings”
“broken-hearted”

describe the social communication model of pain

when there is one or more person present how does pain unfold, caregiver is some sort of individual that brings care or comfort

person in pain: trauma → ← personal experience of pain → expression of pain →

caregiver: pain assessment → ← pain management → personal experience of pain

all factors are influenced by intrapersonal and interpersonal factors

what is the goal of the communal coping model of pain catastrophizing

to manage distress in a social context rather than an individual one

describe the communal coping model of pain catastrophizing

in a social context…

pain → person in pain: pain catastrophizing → more pain

caregiver provides…

• proximity

• support

• empathy

• assistance

what is the primary treatment option for social pain

acetaminophen (tylenol)

what are the clinical interventions for pain

surgical interventions

chemical treatments (pharamacological)

stimulation therapies

physical therapy & rehabilitation

what are some examples of pharmacological interventions for pain

peripherally active analgesics (tylenol)

centrally acting analgesics / opioids (morephine)

local anaesthetics (novocaine)

what is the problem of using just medical methods for controlling pain and especially chronic pain, and why

not enough

psychosocial factors play an important role in pain experience and in the transition from acute to chronic pain, therefore treating psychological factors and challenges can be essential

is social pain the same as physical pain? describe evidence for and against

similar but not exactly the same

negative social experiences rely on the same neural system supporting the affective component of physical pain (dorsal cingulate cortex dACC and anterior insula AI)

dACC is associated with the degree of distress / pain; the AI is assoicated with emotional processing

describe the best approach to treating chronic pain

a combination of pharmacological and non-pharmacological methods

what are the purposes of psychological treatments for pain

aim to help clients…

• reduce pain frequency and intensity

• improve emotional adjustment to pain

• increase social and physical activity

• reduce use of analgesic drugs

describe the multidisiciplinary approach to pain treatment

treating chronic pain with just one method is less likely to succeed than a combined program

what is the significance of the multidisciplinary approach to pain treatment

further underscores the importance of a biopsychosocial approach