Nonstandardized assessments There is some objective evidence that may suggest when pain is being experienced. The sympathetic nervous system, with its fight-or-flight reaction, becomes involved when there is pain. Pain causes increased production of epinephrine, which results in increased heart rate (tachycardia), increased respiratory rate (tachypnea), and increased blood pressure caused by peripheral vasoconstriction (McGuire, 2006). Pain may also cause nausea, vomiting, perspiration, or pallor; occasionally, clients may faint. Because the client is not necessarily in a position to fight or escape, differences in these measurements can be used, cautiously, to gauge the degree of pain and whether it is increasing or decreasing. However, these measurements must not be the only method of pain evaluation (McCaffery & Robinson, 2002). Indicators called pain behaviors should be observed in conjunction with other assessments. Communicative pain behaviors include facial and verbal expressions (grimacing, grunting, words used, and sighing), and protective pain behaviors, which include guarding, holding, touching, or
rubbing (Leung, 2012). Significant associations between pain catastrophizing and physical intolerance to stimuli have been found with both types of pain behaviors (Leung, 2012). Pain catastrophizing is a concept that describes an “exaggerated negative cognitive response to actual or anticipated pain experience” (Engel-Yeger & Dunn, 2011, p. e1). Pain catastrophizing involves: ● Magnification : “ I wonder whether something serious may happen .” ● Rumination : “ I cannot stop thinking about how much it hurts .” ● Helplessness : “ There is nothing I can do to reduce the intensity of pain ” (Sullivan, Bishop, & Pivic, 1995). Most rehabilitation professionals become keen observers and constantly ask a client during treatment if he or she is comfortable. In addition, pediatric practitioners may consider using the face scale shown in Figure 3 with children after treatment so that they may indicate the level of pain they felt during their treatment.
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
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. 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
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