MECHANISMS OF PAIN RELIEF
There are many influences on the ability to adapt to chronic pain. Craner, Sperry, Koball, Morrison, and Gilliam (2017) found that when clients have a higher level of catastrophizing, they will likely perceive a higher level of pain compared to those who have a higher level of acceptance. The effect on pain of a client’s belief is related to the placebo effect, described as “the positive clinical outcomes caused by a treatment that is objectively without specific activity for the condition being treated” (Puhl, Reinhart, Rok, & Injeyan, 2011, p. 45). A systematic review of the placebo effect on low back pain found a significant change in pain following the use of “sham oral medications” (Puhl et al., 2011, p. 45). There is still much to be discovered about the power of placebo effects, but what is important for practitioners working in pain management to consider is the connection between the Therapeutic intervention methods Methods of therapeutic intervention include removing a pain source, decreasing the pain stimuli, blocking the pain pathway, decreasing perception, modifying interpretation, and decreasing the reaction. Good practitioners stay vigilant as to how their intervention techniques are affecting the client throughout the treatment session. The source of pain can be addressed by relieving skeletal or muscle pressure through stretching, exercise, and massage. Practitioners can be instrumental in instructing clients how to progressively improve flexibility and strength through specific exercises and by using soft tissue mobilization, myofascial Pharmacology Commonly used medications for chronic pain management include: ● Analgesics. ● Over-the-counter: acetaminophen and aspirin. ● Prescription: codeine, oxycodone, hydrocodone, and morphine. ● Nonsteroidal anti-inflammatory drugs (NSAIDs): ibuprofen, ketoprofen, naproxen sodium. ● Anticonvulsants. ● Antidepressants: tricyclics, serotonin and norepinephrine reuptake inhibitors. ● Counter-irritants: creams and sprays. (National Institute of Neurological Disorders and Stroke, 2014) The types and amounts of medication are dependent upon pain severity, pre- or postsurgery status, and comorbidities. Park et al. (2016) found opioids to be the most commonly prescribed medication; accounting for one-third of all pain- related prescriptions. These authors identified antidepressants, anticonvulsants, nonselective NSAIDs, miscellaneous analgesics, topical agents, and COX-2 inhibitors were all used for management of pain. In 2016, the Centers for Disease Control and Prevention (CDC) released guidelines for prescribing opioids. The recommendations include that nonpharmacologic therapy and nonopioid pharmacologic therapy be the first method to treat chronic pain. Opioids should be considered only if the expected benefits for pain and function outweigh the risks (Dowell, Haegerich, & Chou, 2016). While opioid prescriptions increase with increasing pain severity, prescriptions for NSAIDs decline (Taylor-Stokes, Lobosco, Pike, Sadosky, & Ross, 2011). Narcotic medications act on the central nervous system and are typically reserved for severe pain. There is evidence that opioids and NSAIDs reduce musculoskeletal pain in the short term, less than 12 weeks, with a moderate effect size (Babatunde et al., 2017; Tompkins, Hobelmann, & Compton, 2017). Recent analysis of the literature indicates no significant difference in analgesic benefit between opioids and nonopioids compared with a placebo (Reinecke et al., 2015). These authors feel that these results support the belief that chronic noncancer pain (CNCP) is highly dependent on other variables, including psychological and social factors, thereby limiting the potential effectiveness of the narcotic.
mind and the body. Practitioners should include in their clients’ management plans what the clients themselves believe might help their pain. An open-minded health professional can do much to help clients manage their pain. According to Cadden and Orchardson (2001) “the neural pathways serving pain are not passive conduits, but part of a dynamic system that can result in different levels of pain from similar injuries under different circumstances. The passage of signals in these pathways may be inhibited or enhanced at almost any level” (p. 359) – from the nerves that come into contact with the original stimuli to the deepest areas of the brain. The control of pain can target these various levels. release techniques, and massage. Several modalities including heat, ultrasound, transcutaneous electrical nerve stimulation (TENS), and electrical stimulation can be used to manage pain (Glaviano & Saliba, 2016; Grover, McKernan, & Close, 2018; Király et al., 2017; Petrofsky, Laymon, Alshammari, Khowailed, & Haneul, 2017). In addition, basic comfort needs may be met by ensuring that the client has visited the restroom in a timely fashion and has thirst, hunger, fatigue, loneliness, and boredom under control. Information given in a way the client comprehends can relieve anxiety and consequently modify interpretation of the pain. Although NSAIDs such as aspirin and ibuprofen are not typically used for severe pain, NSAIDs have been employed to treat mild to moderate pain – both acute and chronic (McCarberg & Gibofsky, 2012). They should be given with food to minimize gastrointestinal complications such as ulceration of the gastric mucosa. Other negative effects of NSAID use include adverse events in the cardiovascular system and the kidneys (McCarberg & Gibofsky, 2012). Because NSAIDs can interfere with nociceptive input during the pre- and perioperative periods, resulting in diminished perception of postoperative pain (Dionne, 2000), pain control may be best achieved through the administration of NSAIDs during the preoperative phase. This strategy minimizes central nervous system sensitization by interfering with the expected cascade of inflammatory mediators that are released when tissue is injured. More recently, Penprase, Brunetto, Dahmani, Forthoffer, and Kapoor (2015) systematically reviewed the literature and found that gabapentin and COX-2 inhibitors were more effective preemptive analgesics for postoperative pain. Use of a long-acting local anesthetic to sustain pain control through the critical first hours post-surgery is also an effective practice. Finally, a well-defined pharmaceutical regimen over the anticipated normal cycle of postoperative pain can diminish central sensitization. Healthcare practitioners can support clients in their pain management strategies by inquiring if they have remembered to take their medication prior to the treatment session, creating strategies or embedding cues into daily routines to support adherence to medication usage, and educating clients about possible altered response during days when they are not taking their prescribed medication. Combination therapy, which targets a variety of pathways and mechanisms, can be an effective approach (Gilron, Jensen, & Dickenson, 2013). Prior to the introduction of NSAIDs, a combination of aspirin or acetaminophen with an opioid such as codeine had been the drug of choice to control moderate to severe pain. NSAIDs used in conjunction with acetaminophen can provide pain relief that is more effective and consistent over the period of the administered dose. Use of this combination also avoids the deleterious side effects associated with opioid drugs. Clients should always be referred to their physician and pharmacist with questions about potential drug interactions.
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Book Code: PYMA2024
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