Course overview In response to the American Pain Society Quality of Care Committee (1995) suggested designation of pain as the fifth vital sign, various studies have looked at how well this “vital sign” is being assessed. Ruben, van Osch, and Blanch-Hartigan (2015) systematically reviewed the literature and found differences in the accuracy based on the provider’s clinical experience, the timing of the assessment, the intensity of the pain, and for populations considered vulnerable. Despite the increased appreciation of pain and attempts to improve its assessment and treatment, pain continues to be difficult to identify and treat. Multiple studies have attempted to measure the percentage of Americans experiencing pain. One study by Nahin (2015), estimated 126.1 million adults in the United States reported some pain in the previous 3 months, using the data from the 2012 Survey (NHIS). Of those, 25.3 million (11.2%) reported chronic pain and 23.4 million (10.3%) categorized pain as significant. The cost of pain extends beyond physical debilitation. The value of productivity lost to pain can be estimated based on days of work missed, hours of work lost, and lower wages. In the United States, lost productivity and medical expenses cost as much as $635 billion every year (Institute of Medicine, 2011). A study that looked at estimating
the cost burden of chronic pain, calculated the annual total cost for all pain conditions was $386 million. This translates to approximately $31,692 per patient for healthcare resource utilization (Park et al., 2016). Demographically, females, older adults, and non-Hispanics are more likely to report pain (Nahin, 2015). Anxiety, depression, pain catastrophizing, and pain- related fear are identified as psychological risk factors (Clay, Watson, Newstead, & McClure, 2012; Rosenbloom, Khan, McCartney, & Katz, 2013; Vranceanu et al., 2014). Studies show that women, minority populations, clients with addictions, and older adults are likely to be underserved when it comes to adequate pain management (Denny & Guido, 2012; McGuire, 2006; Shavers, Bakos, & Sheppard, 2010). Although health professionals frequently work with clients who are experiencing pain, there is evidence that supports a biopsychosocial interdisciplinary approach when treating clients with chronic pain. The purpose of this basic course is to elaborate on the definition of pain and its perception, factors hampering pain management, assessment of a client for pain, and interventions to improve function in clients with pain. The goal is to provide evidence-based practices that the health professional can use when working with clients who have pain..
OVERVIEW OF PAIN
Pain is defined as “an unpleasant sensory and emotional experience associated with actual or potential tissue damage, or described in terms of such damage” (International Association for the Study of Pain Task Force on Taxonomy, 2018). McCaffery (1968) offered a useful definition: “Pain is whatever the experiencing person says it is, existing whenever he/she says it does” (p. 95). Pain is complex, and the effectiveness of treatment depends on a “constellation of biological, psychological, and social factors” (National Research Council, 2011). Over time, the pain paradigm has shifted from a medical model to one with an “increasing emphasis upon cultural and psychological components and the need for a multi-disciplinary approach” (Bendelow, 2010, p. 25). In addition, when we approach pain intervention, we need to respect the interaction of the mind and body by “focusing on the person rather than the pain” (Bendelow, 2010, p. 25). Pain can be categorized not only by source or severity, but also by duration. Pain may be acute or chronic. Acute pain is usually short-lived and is usually linked to a specific injury or illness (National Research Council, 2011). In contrast, pain is defined as having no biological purpose, having a longer than usual healing time, not responding well to standard treatments, and having a duration of at least 6 months (Katz, Rosenbloom, & Fashler, 2015). Chronic pain may result from an underlying medical condition such as cancer, an injury, medical treatment such as surgery, inflammation such as that experienced with rheumatoid arthritis, neuropathic pain, or unknown causes (e.g., fibromyalgia and chronic headaches) (National Research Council, 2011). The exact mechanisms involved in the pathophysiology of chronic pain are poorly understood, but changes in the central nervous system are thought to occur and to involve the transmission and modulation of pain following injury (Fornasari, 2012). There are several distinct types of pain, as shown in Table 1. Physiology and pain characteristics In most cases, pain is elicited by the activation of numerous free nerve endings in the body called nociceptors , which are stimulated by thermal, mechanical, or chemical factors (Basbaum, Bautista, Scherrer, & Julius, 2009). These nerve endings are located within the skin, joint surfaces, and bone periosteum. When the nociceptors are stimulated, nerve impulses carry their signal to the spinal cord and up to the brain, which may interpret the impulses as pain. Figure 1 shows the pathway that pain takes from the site of injury up to and through the brain.
Table 1: Types of Pain Somatic
Somatic pain is localized, described as achy, throbbing, or dull. It is caused by injury or inflammation of joints, muscles, or bones. Also known as musculoskeletal pain .
Visceral
Visceral pain is poorly localized and diffuse. Described as a deep ache or cramping. This type of pain is associated with internal organs. Psychogenic What is now described in the DSM-5 as somatic
symptom disorder was previously referred to as psychogenic pain or pain disorder in the DSM-IV . This type of pain can be difficult to diagnose and can relate to unexplained symptoms or an actual physical diagnosis. Frequently associated with psychological distress or psychopathology, but not always. Nerve, or neuropathic, pain is injury to the central or peripheral nervous system. The client feels sharp tingling, burning, or numbness. Central pain is a product of “central sensitization” or generalized CNS hyperexcitability combined with reduced inhibition of pain due to chronic nociceptive input. Contributes to conditions such as migraine, fibromyalgia, IBS, and TMJ.
Nerve
Central
Note : From:American Psychiatric Association, 2000, 2013; Douglass, 2006; Latremoliere & Woolf, 2009; The Pain Clinic, 2013; Pickett, 2010).
However, not all pain is localized to the area of injury, and the pain a client feels may seem to be in a location that is different from the site of the actual tissue damage; this phenomenon is called referred pain . For example, a heart attack can produce pain in the jaw, neck, or left arm, or may manifest as a toothache or even sinusitis. Also, referred pain elicited from myofascial trigger points in head and neck/shoulder muscles can be reproduced and felt in the orofacial region in women with myofascial temporomandibular pain or fibromyalgia syndrome (Alonso-Blanco et al., 2012).
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