Assessing and managing pain

Pain is oftern categorised as acute or chronic, but it is a complex physical, psychological and social phenomenon that is uniquely subjective and individual.

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

Pain is experienced in different ways by every individual. 

Acute pain:

• is short term and is reversible. Commonly it is experienced suddenly with a physical reason for its existence and with appropriate interventions is reversible.
• Cutaneous and deep somatic pain
• Visceral pain
• Referred pain

Chronic pain:

• is pain that has lasted longer that 6 months and is related to an initial injury or disease but persists long after the initial cause has been treated.
• Recurrent acute pain
• chronic malignant pain
• chronic non malignant pain
• myofascial pain syndromes

Nociceptive pain:

• Pain caused by stimulation of peripheral or visceral pain receptors.
• It is generally localized and responsive to treatment
• Otherwise called as physiologic pain
• It referes to the normal functioning of physiologic systems that leads to the perception of noxious stimuli (tissue injury) as being painful

Neuropathic pain:

It results from injury to the peripheral nerves that leads to abnormal impulse processing by the peripheral and central nervous system.

Transduction:

Noxious stimuli activate primary afferent neurons called nociceptors, which are located throughout the body in the skin.

Transmission:

It generates an action potential that is transmitted along fibres (A- delta and C) which are responsible for a rapid reflex withdrawal from the painful stimulus

Perception:

It is the result of the neural activity associated with transmission of noxious stimuli. It activates the higher brain structures for the occurrence of awareness, emotions and drives associated with the pain

Modulation:

Modulation of information generated in response to noxious stimuli occurs and involved different neurochemicals like serotonin and norepinephrine

Age

Gender

Sociocultural influences

Psychological influences 

Respiratory:- Tachypnoea (abnormal fast breathing), sputum retention, hypoxia (deprived of oxygen) 

Cardiovascular- Tachycardia (Fast heart rate), hypertension (High blood pressure), ischaemia (Inadequate blood supply)

Genitourinary- Urinary retention

Endocrine- Poor wound healing, changes in function

Psychological- Anxiety, fear, insomnia, reduced cognitive function 

Musculoskeletal- reduced mobility, muscle spasm

• A concise history, examination and biopsychosocial assessment, identifying pain type (neuropathic/nociceptive/mixed), severity, functional impact and context should be conducted in all patients with chronic pain. This will inform the selection of treatment options most likely to be effective.
• Referral should be considered when non-specialist management is falling, chronic pain is poorly controlled, there is significant distress, and/or where specific specialist intervention or assessment is considered.
• A compassionate, patient-centred approach to assessment and management of chronic pain is likely to optimise the therapeutic environment and improve the chances of successful outcome.

• Assess pain by taking pain history
• Check for facial expressions
• Assess pain when breating deeply
• Assess factor that increases the severity of pain
• Assess pain on movement 
• Ask about anaglesics (pain relief)
• Fill in and document the pain score.

• P= Provokes- what causes the pain
• Q= Quality- What does it feel like
• R= Radiates- does the pain go anywhere else
• S= Severity- How bad is the pain
• T= Time- when did the pain start, How long does it last

Supported self management 

Pharmacological therapies- 

• NSAIDs= Non-steroidal anti-inflammatory drugs
• Opioids= morphine, tramadol, fentanyl, methadone, diamorphine, alfentanil
• Anti depressants
• Combination therapies= treatment in which a patient is given two or more drugs (or other therapeutic agents) for a single disease.

Psychologically based interventions= Behavioural therapies, Unidisciplinary education

Physical therapies =Exercise, Electrotherapy (TENS)- Transcutaneous electrial nerve stimulation is a pain method involving the use of mild electrical current 

Complementray therapies= Acupuncture