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Thangamani ramalingam PT, MSc(PSY),PGDRM, MIAP
syllabus
Pain psychology (briefly) [2 Hours]a) Define pain, physiology of painb) psycho – social factors of painc) pain management (Psychological methods)
Pain
“An unpleasant sensory and emotional experience associated with actual or potential tissue damage, or described in terms of such damage” ISAP (1979)
One of the most common health problems that causes people to seek medical attention
Pain is actually beneficial to long-term health and survival
DEFINITION Pain is a noxious unwanted perception in which
the patient seeks medical intervention. “Pain is subjective, individual and modified by
degrees of attention, emotional state and the conditioning of past experiences.” (Livingstone 1943). The intensity of the pain is not directly proportional to the degree of suffering. Because it is basically a psychological experience and depends on how it is interpreted or experienced
TYPES Acute pain – shorter duration up to six months
Acute monophonic pain Recurrent acute non-malignant pain
Chronic pain – longer duration > six months Chronic malignant pain - progressive Intractable-benign Chronic pain associated with non-malignancy disease – identifiable
pathology Chronic non-malignant pain syndrome Recurrent acute – migraine
Chronic and acute pain may have different causes – behavioral factors may be involved in acute pain
PAIN RECEPTORS
PHYSIOLOGY OF PAIN
Influenced by Limbic system & Reticular formation
Gate Control Theory
Gate control theory –Melzack & Wall (1965) severity of pain sensation determined by balance between excitatory and
inhibitory inputs to T cells in spinal cord C & A-delta nociceptor afferents give excitatory input to dorsal root
ganglion of spinal cord– A-delta (myelinated) about 40 mph and C fibers (unmyelinated) about 3 mph, other sensory information travels at about 180 -240 mph
Substantia gelatinosa, large diameter A-beta non-nociceptor afferents give inhibitory input
Increased firing of non-nociceptor afferents causes presynaptic inhibition of T cells and the spinal gate from excitatory cells to the brain is closed. –
Physical agent modalities and physical activities believed to close the gate by activating the non-nociceptor afferents
Central Control Mechanisms of Pain
Theories of pain Pain gate theory (Melzack& Wall) Pattern theory (Sinclair) Chemical theory (Neurotransmitters) (Encephalin /β-
endorphins) Descending control theory (PAG /Raphe nucleus
Inhibition) Substance ‘P’ levels Serotonin levels Central Control Mechanisms (by brain) Specific theory (Unique theory)
The same part of the brain – the anterior cingulate cortex – responds to physical and emotional pain.
Pain in the brain
Chemical processes involved in pain
Substance P Chemical mediator thought to be
involved with transmission of pain.Associated with inflammatory painIt excites pain transmitting neurons
when releasedIts mechanism is not fully
understood Glutamate – release affects
amount of pain experienced
Prostaglandins, bradykinin – released when tissue damaged
Chemical processes involved in pain Endorphins
Pain perception modulated by these opiate like neurotransmitters
The endorphins bind to certain sites on the nervous system including peripheral nerves
They suppress pain transmission at the spinal cord level by inhibiting the release of the neurotransmitter gamma aminobutyric acid (GABA) in the periaqueductal gray matter (PAGM) and raphe nucleus of the brain
High concentration of opiate receptors in limbic area of brain explains the stress relief and euphoria associated with opiates
Limbic system involved with emotional component of pain
Pain assessment
Physiological measuresEMG – muscle tensionHeart rateSkin temperatureEEG and brain imaging
Behavioral pain measuresPhysical symptomsClusters: guarding, bracing, rubbing, grimacing, and sighingSymptoms can be misrepresented: report and unobtrusive
observation differences – Kremer et al. (1981)Self-report measures
McGill Pain Questionnaire - sensations- feelings- intensity
Pain Rating Scales
Visual Analog Scale(VAS)Graphic Rating Scale(GRS)Simple Descriptor Scale(SDS)Numerical Rating Scale(NRS)Faces Rating Scale(FRS)
Pain Rating Scales
Pain Discomfort Scale
Chronic)
Injury / Insult
Treatment
Failure of Treatment
Loss of Control
Dependence
Reliance on Medication
Pain
Psychological & SocialConsequences
Adapted from Gill (1997)
Pain Cycle
FACTORS AFFECTING PAIN Physical Factors: Pain tolerance Body constitution / Genetics Age Sex Temperature Climate (Humidity, Cold, Winter) Light, darkness Noise level Avoidance of physical activity
Social Factors: Relationship with family Social Norms Politico-Judicial Factors Cultural effects (occupation, Social interactions Hobbies
Psychological Factors: Personality (Introvert / Extrovert) Social Context or role (e.g. – Soldier vs Civilian) Attention Ecstasy Attitudes, past experiences Anxiety /
Depression Learning / Memory (Education) Dependency / Conditioning Avoidance behavior Judgment, Ego, Expectation
Psychological factors
Learningmodelingsecondary gain financialculture
Personalityanxiety and depressive disordersextroversion is associated with higher
pain thresholdsinternal locus of control is associated
with better coping
Cognitionanticipation of pain is often
worse than pain itselfexpectations of their ability to
cope coping strategiesStress
Sixteen Pain Behaviors
Asymmetry Slow response time Guarded movement Limping Bracing Personal contact Position shifts Partial movement
Absence of movement Eye movement Grimacing Quality of speech Pain statements Limitation statements Sounds Pain relief devices
(under use)
Physical methods for controlling pain
Medications
Opioid analgesics: substance P release into dorsal horn regulated by endogenous endorphins and exogenous opioids.
Inhibit substance P release
Medications
MorphineOxyContinSynthetics opiatesLocal anesthetics
Medications
NSAID’s - Non-steroidal anti-inflammatory drugsAspirin, ibuprofen, naproxen,
phenylbutazone, ketoprofen, diclofenac
Acetaminophen (Tylenol)has analgesic and antipyretic (fever
reducing) effect, but no anti-inflammatory effect
Surgery
muscle/ nerve repair
Physical methods
Physical therapy
Exercise
Counter irritation – irritating body tissue to ease pain
Transcutaneous electrical nerve stimulation (TENS)
Acupuncture –
Massage therapy
Chiropractic therapy
.
Psychological methods for controlling pain
HypnosisBiofeedbackRelaxation and
distractionCognitive - Behavior
therapyBehavioral Medicine
Behavioral/Cognitive Approaches
• Distraction Music and pain reduction –
Anderson et al. (1991)
• Relaxation• Progressive technique• Autogenic technique – use of self
instructions of warmth and heaviness
Behavioral/Cognitive Approaches
• Guided Imagery • Systematic
desensitization• Reframing• Meditation• Stress management
techniques – not as effective as other techniques
• Thinking about the pain and expectations
Placebo
Classical conditioningPatient’s may change behaviorsPhysiological changes which inhibit the
experience of pain