___________________________________________________ Pain Assessment and Management, 2nd Edition
Processes in the brain trigger the personal response to recogniz- ing pain. The brainstem receives painful impulses from the ascending spinal pathways (Frediani & Bussone, 2019). From there, three areas of the brain are prominently involved in processing pain signals: the thalamus, midbrain, and cerebral cortex. The thalamus, where nociception is perceived in the brain, acts as a relay station and sends the nerve signal to the cerebral cortex. The midbrain sends messages to the cerebral cortex concerning awareness of the stimuli, and the cortex interprets the pain experience and determines if it is localized (McGuire, 2006). PAIN PERCEPTION The sensation of pain is not the same for everyone, and it is not the same from day to day or even hour to hour. In order for pain to be perceived, nerve signals must reach the brain for interpretation and integration. Many factors including sensory, cutaneous somatic and visceral, and visual and other sense organs contribute to the cognitive definition of the situation and affect how clients feel pain and the degree to which they perceive its intensity and duration (Frediani & Bussone, 2019). Sometimes this has to do with environmental and emotional circumstances. In cases of severe battle injuries or sports mishaps, the person may not feel pain until much later. In these cases, descending inhibitory systems modulate or limit nociceptive input. This response is thought to have an evolutionary advantage because it enables the person to ignore pain in critical situations. There is an adrenaline response (fight or flight), which overrides the perception of pain in that moment (Kuner, 2010; Merck Sharp & Dohme Corp., 2011). Louw (2013) illustrates this phenomenon with the example of an individual who sprains their ankle while stepping from a curb into the street. The person would feel the pain immediately; however, if they simultaneously saw a bus coming at a high speed, the person would spring to safety before feeling the discomfort in the injured ankle. Gender differences may exist with respect to the perception of pain (Aufiero et al., 2017). Keogh (2022) reports that women generally experience more pain across the lifespan when compared with men. The reasons for these gender differences may include genetic factors, hormonal effects, differences in anatomy and physiology, psychiatric comorbidities such as depression, psychosocial factors (roles, coping strategies), and differences in the response to drugs and other treatments (Schopper et al., 2013). For some pain problems, however, the clinician’s gender stereotypes, as well as the clinician’s gender, seem to have some influence on how they perceive and treat an individual’s pain (Bartley et al., 2015; Emerson et al., 2022; Fjellman-Wiklund et al., 2016). Mateos-Arroyo et al. (2024) report that male nurses more often reported using some form of intervention to manage the pain during arterial blood gas testing and were more likely to have specific train- ing in the techniques to best manage pain when compared to female nurses.
Sociocultural factors affecting pain include ethnicity, family history, and cultural factors (Al-Harthy et al., 2016; Shavers et al., 2010). Saba et al. (2024) found that socioeconomic dis- advantages were positively associated with pain in American Indian/Alaska Native people. Culture has much to do with self-image and the desire and ability to express emotions. Pride, embarrassment, or shame may prevent a client from acknowledging or expressing pain. Self-image plays a role in a client’s pain perception and expression; a person who thinks of themselves as being proud and tough or having a “stiff upper lip” may mask verbalizations and postures that signify pain. To this type of person, pain may imply vulnerability and a loss of personal control. According to Shavers et al. (2010), “culturally specific attitudes and beliefs about the origin, role, and meaning of pain not only influence the manner in which individuals view and respond to their own pain but can affect how they perceive and respond to the pain of others” (p. 193). Saba et al. (2024) found that visiting tribal lands was negatively associated with pain with those less socioeconomi- cally disadvantaged supporting the use of culturally informed strengths-based intervention. These authors, along with Krupic et al. (2019), identify several “dimensions” in which ethnicity and culture can influence the pain experience. • Individual pain-related behavior, sensations, emotions, and expectations • Interpersonal relationships and individual beliefs about pain and pain management (e.g., roles of family, healthcare professionals, support people) • Intergroup relationships and the beliefs, expectations, and social meanings of pain of both the provider and the patient • The societal environment, which encompasses health culture, ideology, quality of life, and socioeconomics (Shavers et al., 2010). There can also be anticipatory fear of pain—that is, thoughts or emotions that underlie an individual’s fears that engagement in certain physical activities will increase pain. These thoughts are called fear avoidance beliefs. Pain-related fear may contribute to the nocebo hyperalgesia when pain is experienced (Thomaidou et al., 2021). This phenomenon did not occur when pain was only anticipated. Anxiety is greater when the situation is vague and when the client perceives that they have little control over pain. One study used functional magnetic resonance imaging (fMRI) to identify the effects of pain expectation on task per- formance. This method was chosen to capture the differences in blood flow in the brain while performing different tasks. The authors reported that pain expectation does change the effect pain has on task performance and the connectivity in the brain areas that process the experience of pain (Sinke et al., 2017). Bubble-blowing and ball squeezing activities have been shown to decrease children’s anxiety, fear, and pain dur- ing and after painful procedures (Sarman & Tuncay, 2024).
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